The critical reader may come to the opinion quickly that I am only a plastic surgeon and probably know little about training horses or football players. While this is essentially true, I don’t believe it disqualifies me to comment on other fields of endeavor that require many of the same complex skills that are inherit to the plastic surgeon.
The training of surgeons is unlike any other field of endeavor. One can read massive amounts of material, study diligently for four years of medical school, memorize the indications for an operation, actually study the pertinent anatomy and how to perform an operation and yet know virtually nothing without taking the final exam by incising the patient’s skin and performing an actual procedure where the stakes are as high as they can be. This discipline is entirely different than any other medical specialty as the requisite study of disease is not the endpoint of training, it is the ante that allows one in the real game which is the application of knowledge to perform a mechanical skill (surgery) which is basically unnatural and requires skills that are not genetic but entirely learned. Since surgery is learned behavior, there is no way to be graded except by the subjective appraisal of a competent surgeon. As time evolves and the surgeon becomes independently proficient, the grading of results requires continuous, honest self-assessment of one’s results. The built-in weakness of the surgical training paradigm is the quality of the “on-the-job” training. This is the primary reason why surgical, and more specifically, Plastic Surgical training, can lead to widely diffuse results in the quality of the surgeon. These facts became self-evident to me and led me to seek the most talented and well known surgeons of my era of medicine. Since we learn surgery by watching and imitating others, it makes perfect sense to seek the best to emulate. This quest is how I came to know John Kirklin, M.D, Ralph Millard, M.D, and Paul Tessier, M.D. For those who are unfamiliar with the names, these are the best of the best in surgery.
Let me begin by admitting that I am a hero worshiper. It happens that I have a small but unique set of personal heroes that I have accumulated over a lifetime. These men have excelled in their respective fields which happen to include the thoroughbred racing business, the aircraft industry, the National Football League, and the field of plastic surgery.
Those who only know horse racing by watching the Kentucky Derby the first Saturday in May every year are not privy to the complexities of thoroughbred breeding, training, and racing. You may notice the atmosphere in Louisville, KY at Churchill Downs includes beautiful hats and the unfettered consumption of Kentucky bourbon in the form of the ever present Mint Julep. This pageantry belies the complexity of horse genetics and gene pools as well as the training of these extremely fragile animals. Additionally, they are trained to race beginning as a two year old animal. The three year olds that race the Derby are still adolescent animals and behave in many ways the same as our teenaged children. Yet, the results of their early races can lead to a multi-million dollar horse, both as a racer and later as an addition to the thoroughbred gene pool.
Dr. Ruel Cowles is a veterinary physician/surgeon whose practice and life is dedicated to the healthcare of these majestic animals. One of my mentors, John Kirklin, MD, was an established horseman and was convinced that race horses were essentially untrained whereas gaited, dressage, and jumpers were the only horses truly trained. Dr. Kirklin also opined that a good jumper must be at least 10 years of age. Racing 3 year-olds in packs of 10-20 over a mile long course against the best 3 year-olds in the world would probably be a daunting task for a 10 year-old thoroughbred. It’s like training a 15 year-old to pitch in the major leagues – you can never be sure exactly what you will get.
Dr. Cowles embodies the best of clinical veterinary medicine as well as the intellect to excel as a horse breeder. Dr. Ruel Cowles is one of my heroes.
I have more than a passing interest in the sport of American Football. I was, as many of my colleagues were, a high school football player. I managed to keep my NFL dreams alive through my first year of college where the physical and mental rigors of the game caused me to turn in my shoulder pads to pursue academics full-time. As such I developed an almost unhealthy respect for those players who made it to the NFL. I particularly liked linebackers as that was my chosen position. The day I met Kevin Greene, at the time playing for the LA Rams, I realized who I would have become if I had the fortitude to continue playing. Kevin was a walk-on at Auburn University in the early 1980’s under Coach Pat Dye. He showed early on his pass rushing prowess, but only a few NFL scouts agreed and was chosen by LA in the sixth round of the draft. From his first training camp, Kevin’s coaches and teammates understood that going easy on the veterans was not part of his game. All Pro offensive tackle Jackie Slater found out Kevin was a “maniac” on every play, pre-season or not. Kevin was soon inserted in the line-up for the Rams and there he stayed. After leaving the Rams for Pittsburgh, he truly found his identity, grew his hair to his shoulders, married a beautiful Alabama girl, and became a favorite in Pittsburgh because of his aggressive and relentless style of play. He was known for sacking the quarterback but in fact was a complete linebacker in the 3-4 scheme. I cannot remember a single time that a running-back or receiver managed to even fall forward after he got his hands on them. I was privileged to be Kevin’s friend through the entirety of his 16 year NFL career including multiple Pro Bowls and defensive linebacker awards. His intensity and dedication to his craft were unparalleled. Ten years after his retirement from the NFL, he still holds the career sack total among linebackers. Today, Kevin is imparting his knowledge to younger players as the outside linebacker coach for the Green Bay Packers. Kevin is also one of my heroes.
I’ve known but a few fighter pilots and one submariner personally. There are a few common traits these people have that separate them from the rest of us. First, they all have very acute and agile minds that can assimilate knowledge quickly and apply it so that they are constantly evaluating their performance and improving by self-evaluating and reflection. These traits are similar to those needed for plastic surgeons with the added immediacy of going Mach II or being thousands of feet under water.
As a first-year resident under Dr. Ralph Millard, I became acquainted with Dr. Gregory Lovaas senior resident under Millard. Greg was like a xenon light in a room full of candles. He shown brightly and was a wonderful teacher to me. Knowing Greg as I did it was not easy to imagine the government putting him in a single seat F-104 fighter with nuclear weapons. As I learned more about Greg, I realized he was the perfect personality for such a dangerous, in-your-face profession. Greg, as most intelligent people do, had a wondrous sense of humor that may or may not have served him well over the years. My most vivid memory of Greg is the fighter pilot/Plastic Surgeon maniac. He taught me the fighter pilot credo – “sometimes wrong, never in doubt.” Greg Lovaas is one of my heroes.
A young boy and his twin brother grew up fatherless during the Great Depression in rural Griffin, Georgia. Times were tough for everyone and the twins did the best they could for themselves and their family. As they became teenagers, sports helped fill their days. It was an accident playing baseball that knocked out the two front teeth on one of the boys causing a speech impediment and a lasting impression as he did not have enough money to receive the necessary dental care. The twins with no prospects on the horizon lied about their age and enlisted in the Army and the Navy. The story goes that the twins couldn’t understand why the new recruits were homesick and even cried at night while the twins were elevated from their Hell to three square meals a day and they weren’t worked very hard. The addition of free dental care made WWII a life altering experience, all for the good.
New pair of shoes, one suit, two new teeth and training in electronics were enough to start a new life several years after the war with a new wife and further training in repair of the new-fangled American commodity – the television set. The younger of the twins was desperately trying to live the American Dream. Fixing the notoriously unreliable TVs and their vacuum tubes was a decent job. Utilizing his military training and hands-on electronics experience, twin got a job with Lockheed Aircraft in Marietta, Georgia where he taught electronics to the new hires needed to build the C-130 “Hercules” and the new super airliner – the L-1011. The younger twin learned he had a knack for teaching and especially training people to do a job. He eventually parlayed this experience into industrial training programs for four Southern states eventually having a training facility posthumously named after him in Montgomery, Alabama. Twin number two, and one of my heroes, was George L. Howard, my father.
The training of plastic surgeon is a long grueling process due to massive amounts of material to learn, but more importantly the aptitude, mental acuity, and complex decision making necessary. Most students of plastic surgery realize that the training is so long (± 6 years) because the depth of knowledge necessary is vast and by necessity practicing plastic surgery requires a malleable mind to attack each challenge with freshness, intensity, and thoughtfulness. These attributes are not something one can read about, but can only be obtained by acquiring the knowledge from others who already have it. This is why it is so important to ask the credentials of a plastic surgeon so one can surmise the quality of his/her education in plastic surgery. In plastic surgery, it makes perfect sense that truly the best plastic surgeons are the best teachers. My final heroes are two of my plastic surgery mentors that encompass the best that our field has ever created. D. Ralph Millard, Jr., M.D., and Paul Tessier, M.D. are also my heroes.
Recent history has taught us the penalty to be paid by the consumer of plastic surgery who is swayed by the exquisite marketing of doctors who believe for financial reasons that the least amount of education in the intricacies of plastic surgery is somehow better than the full training program that has been in place for 30 years. There is no other example of attenuated training in any of the surgical specialties. Neurosurgeons are required to train in all aspects of neurosurgery and even take a year of basic neurology training even though few neurosurgeons practice all of the aspects of the specialty. This is mainly because for the last 100 years it is clearly shown that almost all specialists benefit from a wide and diverse basis of knowledge leading to calmness under pressure and the ability to elicit a laser-focus required of the expert. This is true for training many kinds of endeavors and one will never find a short-cut to the training of the best race horses, NFL linebackers nor in the making of aircraft or the training of plastic surgeons. Hippocrates said it best in his aphorism “Life is short, and the art is long; opportunity fleeting; experience perilous, and decision difficult.” The first time I heard this warning was from the great cardiac surgeon John Kirklin, M.D. in his famous surgical “blue-book” to help train young cardiovascular surgeons.
To learn more about Dr. Paul Howard, please visit his web sites: