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Reinventing surgery

Yale Medicine Magazine, 2002 - Spring


Robert Udelsman left one of the busiest medical centers on the planet to lead Yale’s Department of Surgery out of its doldrums and into national prominence. He’s a man on a mission.

Third-year medical student Jennifer Schutzman was acing the middle-of-surgery quiz administered by Robert Udelsman, M.D., M.B.A. She had already correctly described the three causes of primary hyperthyroidism, listed the three veins and two arteries that supply blood to the thyroid gland, and named the two main vocal cord nerves near it—all while holding a retractor steady on either side of a small opening in the patient’s neck. As Udelsman and third-year resident Steven Williams, M.D., probed and cut their way toward the patient’s diseased thyroid, Udelsman threw his medical student a curve: What famous 20th-century opera singer had undergone thyroid surgery with disastrous results?

Schutzman was silent.

“Amelita Galli-Curci,” Udelsman told her. “In 1935, the story goes, Dr. Arnold Kegel removed a goiter, and in a single day, two careers were forever changed.”

Schutzman knew her anatomy well enough to understand what Udelsman implied: the surgeon had cut an important nerve controlling the vocal cords. By cutting the nerve, the surgeon had damaged both Galli-Curci’s voice and his own reputation. That was the nerve that Udelsman and Williams were painstakingly protecting during this thyroidectomy.

In telling the story, which he’d heard from his mentor 20 years before, Udelsman was continuing the tradition of passing on knowledge to a new generation of surgeons. Yale’s new chief of surgery is always teaching. In the operating room, he peppers residents with questions, coaching them as they cut and telling them stories that teach anatomy. When another surgeon steps into the OR to say hello, Udelsman explains his minimally invasive approach to parathyroid surgery, in which the parathyroid gland is removed while the patient is awake. (It’s an innovation that allows the patient to go home the same day, leaves a scar on the neck that’s only an inch long and cuts hospital fees in half.) Outside the operating room, Udelsman remains a teacher—presenting cases at the standing-room-only grand rounds in Hope 216 (attendance is mandatory), painstakingly describing to patients what will happen during surgery and explaining to house staff why white coats are required in the lunch line (scrubs are unprofessional). In all of this, Udelsman is perhaps even more intense and focused than your average intense and focused surgeon.

It’s nothing new for a department chair to guide young surgeons and to help senior staff keep current. But Udelsman is on a mission. In his soft-spoken, persistent way, he is determined to help transform surgery at Yale. He aims to help make Yale, long known as a research powerhouse, into one of the world’s top clinical centers as well. Udelsman came to New Haven last June to head a department that, despite a distinguished past and many strengths, does not have a national reputation and hasn’t turned a profit for several years. Recruited from Johns Hopkins, where he helped develop the new techniques for parathyroid surgery and made laparoscopic adrenalectomy standard, Udelsman says he wants Yale to become the kind of innovative and profitable surgical center that he left behind in Baltimore.

“The Mayo Clinic, Johns Hopkins, the Cleveland Clinic. That’s the level we want to play at,” says Udelsman. “I do not view our referral base as southern Connecticut. Our referral base is the world.”

“If Mrs. Jones can’t park… ”

Udelsman believes Yale will draw patients from far away if they hear that it is simply the best in certain specialties. Udelsman [pronounced YOU-delsman] is still getting to know a department with 300 employees in 13 sections running the gamut from trauma to transplantation, otolaryngology to urology. He already has a few ideas for what Yale’s areas of surgical excellence should be: kidney transplantation and perhaps surgical oncology and heart surgery. “You don’t have to be great at everything. You have to be spectacular at some things. It doesn’t even matter what they are,” he says. He will strengthen research that complements key surgical subspecialties, though research is already strong; Yale surgery ranks seventh in the nation in funding from the National Institutes of Health.

The breast center Udelsman imagines exemplifies the kind of comprehensive care he wants Yale to provide. It would offer diagnostic and therapeutic radiology, surgery, chemotherapy and counseling, all in one place—and fast. “In a typical scenario, a woman has an abnormal mammogram, and she thinks she has breast cancer and that she’s going to be dead in three years. What women want is service, and they want that service in 24 hours or less. It can’t be you’re called [about an abnormality] and two weeks later, you get an appointment.”

Udelsman is determined to make sensitivity to the patient’s experience central to the jobs of medical center staff—the first priority for nurses, facilities planners, doctors and custodians alike. He tells the galling story of a woman who drove hours to reach New Haven for a scheduled appointment and was told to return the next week because the doctor wasn’t there. Inconvenient parking and shabby buildings convey a similar message, says Udelsman. “You can be as empathetic as you want, but if Mrs. Jones can’t park, then she can’t come to the clinic and the whole system breaks down. If there’s dirt in the hallways at the medical center and no one cleans it, the message is, we don’t care. If the phone is answered by voice mail, we don’t care.”

Ralph I. Horwitz, M.D., HS ’77, says Udelsman’s focus on patients is right on target. “We have not made quality of clinical care a strong-enough focus of the institution,” says Horwitz, chair of the Department of Internal Medicine and head of the search committee that nominated Udelsman. “I think Rob is going to focus the attention of the entire medical center on clinical care.”

Udelsman also contends that clinical medicine at Yale won’t thrive until the medical school and Yale-New Haven Hospital cement a partnership that is truly based on a common vision. “They are not,” he said, “competing institutions.”

His chief of cardiothoracic surgery, John A. Elefteriades, M.D. ’76, HS ’83, said in December that he had already seen dramatic changes in Udelsman’s first months as chair. “The department is already revitalized by his arrival. It’s palpable in many different ways. He clearly has great determination, energy and insight, and I think everyone feels that. The weekly grand rounds is revitalized, there’s active recruitment to fill needs the department has had for a long time and there’s a general sense of energy and direction and forward momentum. I think that’s all new,” said Elefteriades, an expert on aneurysms and cardiac arrhythmias who has spent his career at Yale. “I can feel that Rob is committed with every fiber of his body to making this the best academic department that he possibly can. He’s very savvy in terms of the finances of running a department. In this era, that’s critically important, because all the fat has been trimmed from reimbursements.”

Elefteriades reads Udelsman correctly where finance is concerned. Udelsman thinks constantly about efficiency, schooling those around him to understand an operating room as a profit center. “We’re a nonprofit organization, but that doesn’t mean we don’t have to be profitable,” he says. “At the end of the day, if we can’t balance our books—if we’re spending more than we’re taking in—we’re going to have to close the doors.”

Udelsman even campaigns for fiscal efficiency on the fly. He had just completed a thyroidectomy one morning when he was told that his patient could not be moved to the recovery room; it was filled with overflow patients from intensive care. Udelsman quietly fumed. With the operating room now serving temporarily as a recovery room, the next case could not begin. Doctors, nurses and technicians were being paid to mark time. Patients anxiously awaiting surgery would wait longer. As he headed up the hall to visit three patients—two in line for surgery and one recovering—Udelsman buttonholed the nursing director for perioperative services. Had she informed anyone of the bottleneck? Yes, the associate medical director. Had she also written to the hospital’s chief of staff? No, she hadn’t. Udelsman asked her to write to him about the wasted time.

As he walked briskly away down the hall, Udelsman turned back and called to her: “I want so many letters on his desk, he goes nuts!”

Until a few years ago, high finance for Udelsman had been limited to buying a house and car. Then he went back to school at night, earning a master’s degree in business administration and another in business in medicine at Hopkins. “I don’t want some administrator running circles around me, someone who has no concept of what it is to be a surgeon running the show.” Udelsman now knows enough about profit-loss statements, spreadsheets and business plans to guide a department with an annual budget of $40 million.

Efficient billing is so important—“the blood of our system”—that Udelsman wants same-day billing. “I want a billing and collections person right in the OR,” he joked. In one sense, he means that literally: he invited clerks from billing to gown up and witness surgery “so they can experience the magic of what we do.”

Pat Napoletano watched Udelsman and a resident operate. “We deal with pieces of paper. We don’t deal with the patients,” she said, adding that what struck her most about her experience in the OR was “seeing the enjoyment they get out of helping someone.”

That is precisely how Udelsman views surgery. “Surgery is fun. You get to fix things. It’s a technical tour de force. If you ask surgeons what the best part of their day is, it’s when they’re in the OR, by far. … There are few things in medicine where we can so dramatically change a person’s life. Diabetes gets a little better or a little worse, hypertension gets a little better or a little worse. In surgery, in a half-hour or an hour interval, a patient comes out a different person than they went in.”

“If you can’t cut, you’re not part of the group”

The evolution from surgical acolyte to priest is gradual, says Udelsman. When young surgeons face a decision, they ask themselves, “What would so-and-so have done in this situation?” For every surgeon, there eventually comes a day when “there’s no one to ask. There’s no one better at this than you. That is a maturational moment when you really are on your own.” Now that he is a mentor himself, Udelsman trains surgeons in part by quizzing his assistants, by telling stories, “by teaching them the tricks.” Udelsman hopes that the surgeons he and his colleagues train “will always hear our voices.”

He schedules two days a week in the operating room and wants to increase it to three, both because he enjoys surgery and because his reputation depends on it. “As a chairman, it’s very important for me to operate. I’m in the trenches like everyone else. My colleagues, the nurses, the medical students—everybody is testing my skills every day. If you can’t cut, you’re not part of the group.”

Elefteriades made a similar observation: “If a chairman is simply an administrator, he doesn’t gain the respect that he does if he is up there at the plate along with the faculty he’s leading. Rob is not only up there, but he is an extremely accomplished, respected and experienced clinical surgeon.”

Udelsman is fascinated by what he calls “the operating culture. It’s very much a ‘captain-of-the-ship,’ military model.” Surgeons may feel frustrated when they find they can’t recreate this system outside of the hospital. “When a surgeon goes home to their family, they want structure,” says Udelsman. He says his wife, Nikki Joan Holbrook, Ph.D., a distinguished cell biologist at the medical school, will jokingly call his bluff when he tries to apply the surgical model at home in Woodbridge. “My wife certainly has said, ‘I’m not your scrub tech! Forget it!’”

He brings his life as a surgeon home. “I never let go of the hospital. I carry the hospital with me.” His children—eight-year-old daughter Kelly and sons Andrew, 13, and Brooks, 14—have a general idea of what’s going on at the hospital. One of the boys will answer the phone and tell his father, “Oh no, so-and-so’s got another calcium problem.” Last Halloween, Udelsman had to cut short trick-or-treating to return to the hospital for an emergency, to the disappointment of a small witch.

In surgery things do go wrong. Surgeons have a long tradition of gathering to examine their failures, a weekly morbidity and mortality meeting that “has almost religious connotations. … We publicly discuss our worst problems. It takes on an almost confessional aspect. We take our failures very seriously. People do die. You have to ask: Was that a preventable death or not?”

Udelsman moderated when about 40 physicians met for the general surgery morbidity and mortality meeting in Fitkin Amphitheater recently. Residents reported on problems with patients: one who developed a postoperative clot in his heart, another whose hand was mysteriously burned during surgery. For each case discussed, the doctors proposed various ways the complications might have been handled. Udelsman orchestrated the exchanges, occasionally complimenting a resident, repeatedly asking leading questions: Why is it that using a gastrograffin enema may be therapeutic as well as diagnostic? What treatment is available for an obstructed gall bladder in a patient too weak for surgery?

Udelsman talked about a close call with his own patient, who had developed a rare bleed following removal of cancerous lymph nodes. A few hours after surgery, the man’s neck had swelled, a sign of internal bleeding that could block his airway. Udelsman rushed the patient back to the OR and found the source of the bleed. The patient recovered.

“Why you, I don’t know”

The most intense and exhausting work of Udelsman’s week is clinic. Patients referred to Udelsman usually have complicated cases. He reviews their histories, explains illnesses, describes surgeries, confers with family members and reassures patients. He leans forward, one foot tapping, while the clock ticks. He pretty much keeps to his schedule, doing a biopsy, calling a colleague in another hospital, scrutinizing MRI films, seeing one patient after another ushered in—and out—by Patricia I. Donovan, R.N., who came with Udelsman from Hopkins to be the department’s manager of patient care and quality assurance.

Among the patients at a recent clinic, the last faced the most serious illness. The man, a musician in his 30s, hadn’t expected to be back; Udelsman had removed one lobe of his thyroid three weeks before in what is usually a curative procedure. But the pathologist had diagnosed medullary cancer, a rare thyroid cancer that spreads quickly. Udelsman felt sure that it had invaded the man’s lymph nodes. When last tested, the man’s tumor marker was at 97; a normal reading is below 3.

“It’s such a rare disease that many endocrinologists haven’t seen a case,” Udelsman told the fit, dark-haired man who had come to the clinic with his wife and 4-year-old son. “Why you, I don’t know.”

He would need a central and lateral neck dissection to remove the rest of his thyroid and 20 to 50 lymph nodes that Udelsman believed contain tumors the size of specks of pepper. Surgery would take all day. “This operation is 10-fold what you had before,” Udelsman told him.

Two factors complicated the case. Udelsman explained that it was possible that this cancer was genetic. If testing showed that it was, then each of the man’s four children would have a 50-50 chance of developing the cancer and would need preventive thyroidectomies. And the man is a professional singer. As did Galli-Curci, he faces surgery, again, that will put his voice at risk. Udelsman told him the chance of damage to his voice was 2 percent. “I expect you to do great. But let me give you the picture. This is serious business. You can have big problems” if the cancer spreads, he told the man. His wife listened silently.

The man was upbeat, well informed from research on the Internet. “I’m still in a good place about it,” he said. “I am not in any kind of denial, but I’m not going to accept that this is going to take me down.”

“I’m not saying it’s going to take you, but you’ve got some hurdles to jump,” Udelsman replied. “Our goal is to keep you alive for a long, long time.”

“If it comes back malignant, then we’ve done a really good thing”

It’s a Tuesday, the first of Udelsman’s two days in the OR. His first case is a parathyroidectomy, removal of one of the (usually) four raisin-sized endocrine glands on or near the thyroid. The parathyroid glands are intimately involved with the hormone that regulates calcium metabolism. Udelsman is talking to his patient—who is awake.

“Barbers and surgeons were in the same field back in England,” Udelsman tells the patient, a retired business executive in his 60s, as he shaves his upper chest. The man has a parathyroid adenoma, probably not cancerous, but causing him problems with calcium levels that leave him weak and up at night urinating. Udelsman will use the minimally invasive technique.

As Udelsman and Chief Resident Rabab F. Hashim, M.D., begin working through an opening in the man’s neck the size of a half dollar, Udelsman explains to Hashim: “This is very unusual. Most people would put this patient to sleep.”

He teaches Hashim about the benefits of this minimally invasive technique for parathryroid surgery. By keeping the patient awake, sedated a bit and injected in the neck with local anesthesia, Udelsman tells her, they gain two things: they can ask the patient to speak from time to time, a method of checking whether the surgery is affecting the recurrent nerve crucial for speech; and they minimize the effects of anesthesia for the patient, reducing risk and speeding recovery so that the patient can go home the same day. (In this case, the patient will go to a hotel. He and his wife drove up from Maryland for the surgery because they heard that Udelsman is “the best.”)

The man’s parathyroid is hard to find, and the surgery is taking longer than the anticipated hour. “We’re getting there,” Udelsman tells both Hashim and the patient. “It’s a very posterior parathyroid. You see that little mother now?” he asks Hashim. “That’s what we’re after. It’s a very tricky one.”

Udelsman shows Hashim that the parathyroid is enlarged. “It’s a little bit more stuck [to the thyroid lobe] than I like to see,” he tells her. He can’t tell for sure where the parathyroid ends and the thyroid begins, which might indicate that the parathyroid is cancerous. Statistically, the chance of malignancy is only 1 percent, but Udelsman tells Hashim that they will remove the thyroid lobe as well, to be sure the parathyroid is completely out. (With the rest of his thyroid intact, the patient will feel no effects of losing a lobe.)

“In my heart of hearts, I think it will prove to be benign,” Udelsman tells Hashim, “but the time to make the call is in the operating room, not later. If it comes back malignant, then we’ve done a really good thing.”

“Say ‘E’ for me,” he tells the patient.

“Eeeee,” says the man, from behind the drape over his face.

“That’s so good,” says Udelsman. “It makes me so happy to hear that!”

Udelsman pulls off his latex gloves and writes notes about the case. Leaving the operating room, he lowers his mask to reveal a trim graying beard, grabs his briefcase, and walks quickly down the hall, through the surgeons’ lounge and into the cramped transcription room. He picks up the dictation phone and spits out the details of the case without checking his notes or seeming to pause for a breath. The dictation complete, he takes a yogurt out of his briefcase and phones his office. For a promotions committee meeting later that day, he wants to know, “Am I leading this committee this afternoon, or am I going for the ride?” He asks about plans for the department holiday party at his home and reminds his administrative assistant about a problem with his computer. He finishes his yogurt, tosses the container in the trash and pricks his finger to check his glucose levels. He has type 1 diabetes, diagnosed less than two years before at age 43, and he wears a glucose pump. He chomps half a glucose tablet, snaps closed his briefcase and heads out to greet the next patient. After two more operations, he will attend committee meetings for admissions, promotions and fund-raising and meet with the dean of the School of Medicine. If he can find time before heading home at 8, he will work on his article for the Annals of Surgery, “656 Consecutive Explorations for Primary Hyperparathyroidism.”

“My biggest problem is time management,” he says.

But for now, he is heading back to where he wants to be: in the OR, teaching a resident and a medical student how to do what he does.

“It’s not how many thyroids can I do in my lifetime. Isn’t it far better if I teach another generation to do it well?” YM

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