LEGENDS IN UROLOGY

My interest in urology began in college—waking up one day with flank pain that worsened over a few days, followed by the onset of a fever. Because it was the start of a weeklong spring break vacation, I decided to tackle the 3-h drive home, and two days later, I met a urologist for the first time. An IVP showed a unilateral ureteral obstruction, and a day later a stone was removed from my right ureter by blind basketing. On returning to school, rather than fretting about my ruined vacation, I went to the bookstore, bought a urology textbook (Smith’s Urology, paperback edition) and read it cover to cover over the ensuing weeks. In medical school I had enjoyed my core rotation in general surgery but had not been hooked by it. Just after the halfway point of that year I was strongly considering both family practice and psychiatry, and by March my desk was piled high with applications to those types of residencies. Luckily, the University of Pittsburgh offered a 3-week elective in urology, which came along later in the year. At the end of the first week of that rotation, all the applications sitting on my desk got dumped into the trash. I was completely taken by urology—office and OR, major and minor procedures, and the good-natured personalities of the faculty, notably Fred Schwentker and Tom Hakala. This time I was hooked. After that rotation, my interest in the Cleveland Clinic grew, as every month the Journal of Urology and the Urologic Clinics of North America were filled with interesting articles authored by the faculty there. I applied to 6 programs (Northwestern, Indiana, Penn, Pitt, Case Western Reserve, and Cleveland Clinic) and interviewed at each of them. I remember being impressed by all of them and feeling that all would provide solid training, but I was really taken by the program at Indiana, where John Donohue and Larry Einhorn were in the midst of making testis cancer a curable disease by the combination and sequencing of chemotherapy and surgery. My wife-to-be was interviewing in the same cities for Pediatrics, and while she liked the program in Indianapolis her heart was set on training at Rainbow Babies and Children’s Hospital at Case. And so, in May of 1981 we moved to Cleveland and began our training in July.

The first year of training was hard on us both—I have written elsewhere on these challenges and about a seminal event from my internship that gave career-long shape to my relationships with both patients and families, and refer the reader to that piece for a deeply personal account of that time (see Mrs Hattie Jones, DOI: 10.1200/JCO.22.02405). Every department at the Cleveland Clinic in the early 80’s was a hotbed of innovation, filled with physicians trying to push the envelope both medically and surgically. One of the lost pleasures of that time, beginning during internship, was getting to have lunch every day in a doctor’s dining room with the junior and senior faculty and absorbing their verve and ideas for overcoming shortcomings of whatever the current paradigm was in each specialty, focused on improving outcomes for patients. My career goal at the start of training was to become a general urologist and return to my hometown of 65,000 people to set up practice in suburban Philadelphia; after 2 years of listening and operating with visionary faculty who wanted to change the world, I decided I did too. I really enjoyed the clinical and surgical challenges in oncology and decided then to focus on that, seek out fellowship training, and pursue an academic career.

The Urology faculty were all supportive in fostering my goal. There were only 6 at the start of residency, and all of them were or were soon to be luminaries in the field: Ralph Straffon, Bruce Stewart, James Montie, Andrew Novick, Robert Kay, and Karl Montague. All of them were mentors and taught me something about being a good doctor and surgeon; Jim Montie stands out as someone who also taught me (and many others) how to be a good human.

In that era medical advances (new drugs) were scarce and the order of the day in oncology was the development of new surgical techniques: partial nephrectomy, radical nephrectomy with vena caval thrombectomy, radical prostatectomy, continent urinary diversions, and post-chemotherapy RPLNDs, all of which were becoming routine. The residency was organized such that we spent alternating days in the outpatient department and clinic; while many complained that meant we missed out on half the surgical cases, I found being able to work-up surgical patients that I helped operate on the next day to be extremely valuable. In the latter half of my chief year my two co-chiefs often opted out of being in the OR so they could train on a new-fangled device for treating stones called the lithotripter, so I frequently operated 5 days a week in the months leading up to graduation.

In July of 1986, we moved to New York City to begin fellowship, I at MSKCC and my wife at Einstein. Although we lived directly across the street from Memorial Hospital, with a 2 min walking commute, during the first week of fellowship I left home in the morning and did not return until after midnight, brining to mind the advice that one of my colleagues heard from Eugene Braunwald, the famed Chief of Medicine at Brigham Hospital, when he started his Medicine internship: “If you cannot finish all your work in 24 h you may have to stay late.” I spent 2 years working in a nascent genomics lab at the dawn of the RT-PCR era and then one very busy clinical year learning the nuances of the surgical techniques of the day. I remain indebted to the many great faculty (Willet Whitmore, Harry Herr, Mike Morse, Pram Sogani, and Bill Fair) and to fellow trainees I worked with and enjoyed collaborating with and subsequently watching their careers blossom (Joel Sheinfeld, Paul Russo, Ian Thompson, Peter Carroll, Vin Laudone, Cora Sternberg and Howard Scher).

In 1989, we were recruited back to Cleveland to the institutions we trained in for faculty positions. I spent the first part of my career trying to master the operations I learned in residency and fellowship and trying to improve them for the benefit of patients. In that era return of continence after radical prostatectomy could take as long as a year, and so there was general amazement when my very first prostatectomy patient was continent from the moment his catheter came out 3 weeks after surgery. Convinced this was due to some modifications in the apical and urethral dissection, I submitted a paper entitled “Early Continence after Radical Prostatectomy” detailing a similar outcome in the first 24 patients. It was summarily rejected but ultimately published when the total reached 60 patients. A defining moment in my career came about a year later, when at the annual AUA meeting a urologist I did not know thanked me for publishing that paper, as it helped him understand the anatomy and improve outcomes for his patients, a moment I have described in detail elsewhere (10.1016/j.urology.2007.11.089). A plethora of subsequent publications on surgical technique and cancer biology followed, all with the hope that some observation about a disease or tweak to a surgical procedure made things easier for the surgeon or better for the patient, channeling the focus and energy I experienced in the doctor’s dining room during training. It’s been my hope that at least some of these papers have made someone’s life better.

In the fall of 2008, I was privileged to be named as Chair of the Glickman Urological and Kidney Institute, a unique structure that included overseeing both the Departments of Urology and Nephrology. It was a tumultuous time, as the stock market had crashed, the economy was in recession, my predecessor Andy Novick died suddenly and unexpectedly, and the then chair of Urology decamped for another opportunity. I viewed the opportunity to recognize and promote the talented faculty and trainees in both Departments with excitement. My philosophy was to point them in the right direction (i.e., be focused on improving outcomes for patients), give them the tools they needed to succeed, and get out of their way. My proudest achievement has been watching the success of these individuals, of whom there are too many to call out by name but are familiar both in academic circles and local communities. I began wondering about retirement many years ago when a cardiac surgeon colleague called it quits at age 59. When asked why, he answered emphatically “10,000 hearts are enough” and it got to me thinking about what a post-surgical life might look like. During dinner at a meeting in Indianapolis (of all places) Eila Skinner’s husband told me about a program he was enrolled in called Distinguished Careers Institute. The program was the brainchild of Phil Pizzo, former Dean of Stanford Medical School, that allowed individuals who’d had long careers spend a year on campus at Stanford University, meeting people from a variety of fields (very few physicians were part of the program) and focusing on wellness, forging a new community, and defining a new purpose in life. One of the attractions was the opportunity to take classes alongside undergraduate and graduate students across all the schools at the University and participating in two-way intergenerational learning. Having reached the “10,000 hearts are enough” phase, in 2021 Susan and I both retired from medicine and spent a remarkable year at Stanford making new friends, expanding our horizons, learning new things, and pivoting to a new life.

I’ll close with some observations about careers and life:

1.    Academic careers can be immensely competitive, but unlike many others I encountered, I never saw my career as a zero-sum game, recognizing that others’ success did not diminish my own (and vice versa). There is plenty of room for everyone to succeed. When one competes with others, what can be achieved is limited because you are focused only on being better than your competitors; when you compete with yourself to be the best you can be, the sky is the limit on what can be accomplished. The latter path is the more enlightened one.

2.    Always aim to be better at something today than you were yesterday—be a better spouse or partner, a better parent, a better doctor, a better surgeon, a better leader. The desire to continually improve keeps the heart beating and the brain engaged.

3.    If you want to enjoy life, take big bites.

That’s my story and I’m sticking to it. I am grateful for the opportunities that have come my way, for the lives I’ve touched, and the lives who have touched me back.

And thank you, Susan, for wanting to train in Cleveland. That proved to be wise decision.

Eric A, Klein, MD

Emeritus Professor and Chair, Glickman Urological and Kidney Institute and Lerner College of Medicine, Cleveland Clinic

January 2025