G. Tom Shires—A Personal Remembrance

In Memoriam G. Tom Shires, MD 1925–2007 1 G. Tom Shires passed away at home on Oc- tober 18, 2007 at 81 years of age, surrounded by his devoted family. The cause was carcino- matosis from an unknown gastrointestinal pri- mary tumor. His accomplishments and legacy have been documented widely in the lay press [2] and professional publications [3,4]; they are known to this readership and shall not be re- counted in detail. Rather, this message is one of personal reflection about my 15 years as his resident and as a member of his faculty. Tom Shires arrived in New York City in Sep- tember, 1975 to became the fourth Lewis At- terbury Stimson Professor of Surgery and Chairman of the Department of Surgery, Cor- nell University Medical College, and Surgeon- in-Chief at The New York Hospital (NYH), having been preceded by Frank Glenn, C. Wal- ton Lillehei, and Paul Ebert [5]. Despite a long tradition of producing surgical leaders [6], the NYH/Cornell surgical services by 1975 had been without stable leadership for nearly a decade; traditions of care for critically ill and injured patients had been largely supplanted by the provision of elective surgical care by a cadre of voluntary surgeons. Shires’ vision was to transform not only the institution and its fac- ulty into a true tertiary-care academic health center, but also to modernize the care of criti- cally ill and injured patients everywhere. Play- ing a crucial role in his recruitment was P. A. Peter Dineen (a founding member of the Sur- gical Infection Society), who recognized the need and opportunity. Shires brought with him from Seattle Peter Canizaro, P. William Curreri, Joel Horovitz, and later Malcolm Perry. The “Chief” focused at first on regional in- jury care issues while studying first-hand the internal workings of the department. Working closely with Walter Pizzi, who chaired the New York-Brooklyn Committee on Trauma of the American College of Surgeons, and with offi- cials of the city Department of Health and the Health and Hospitals Corporation, the 911 emergency ambulance response system was transformed from a disorganized amalgam of three different “systems” into a single coordi- nated system that eventually came under the aegis of the Fire Department, City of New York (FDNY). Response times decreased and processes of care were standardized, yielding improved outcomes and patient safety. Plans for an institute for reconstructive surgery evolved to meet the pressing need for modern burn care in New York City with the creation of a burn center that was accepting pa- tients within months of Shires’ arrival. Crucial to the enduring success of the William Ran- dolph Hearst Burn Center of NewYork-Pres- byterian Hospital/Weill Cornell Medical Cen- ter, one of the nation’s busiest, has been the generosity of the New York Firefighters Burn SURGICAL INFECTIONS Volume 9, Number 1, 2008 © Mary Ann Liebert, Inc. DOI: 10.1089/sur.2007.9974 Editorial G. Tom Shires—A Personal Remembrance PHILIP S. BARIE “ . . . the emergence of surgeons as surgical biologists in the past three decades is and should be recognized as truly the fourth surgical renaissance.” G. Tom Shires [1] BARIE Center Foundation, a vision shared by Shires and the fire fighters of FDNY. Also among Shires’ goals was the recruit- ment of academically oriented faculty and res- idents, so as to restore the Department’s his- toric tripartite mission-teaching, research, and clinical excellence. The first class of NYH/Cor- nell surgical residents recruited by Shires (July, 1977) included Anthony Antonacci, William Mackey, Carolyn Reed, and yours truly at the PGY-1 level, and David Herndon, Bruce Wolff, and Roger Yurt at more senior levels. Notable faculty recruitments included Stephen Lowry in nutrition and metabolism in 1983. This crit- ical mass of surgical talent engendered numer- ous new and expanded clinical programs, in- cluding the opening of a Level I trauma center in 1987, now the busiest in New York City. Cornell was my first choice for surgery resi- dency training, but on the strength of its inte- grated program with the Memorial-Sloan Ket- tering Cancer Center (MSKCC), for I was planning to become a surgical oncologist. Trauma and critical care were not on the radar. I was aware of Shires’ greatness, but only in the abstract. Two early rotations at MSKCC dis- abused me permanently of the notion of on- cology, but Plan B was not apparent immedi- ately. I took great interest in a critical care rotation in the cardiothoracic ICU (under the direction of William A. Gay, Jr.; we had no gen- eral surgical ICU, it having been converted into the Burn Unit), but was I infatuated with car- diac surgery, cardiac surgeons, or critical care? There was no longer a “pyramid” at Cor- nell, but in my resident class 11 of the 14 of us were interested in completing the general surgery residency, and the program finished seven chief residents each year. What would become of us? So, we asked for and received an audience, during which Shires offered to support four of us fully, to pursue two-year research fellowships of our choice, anywhere. Coming in to the meeting, we hardly knew what to expect, and perhaps even wondered (I did, anyway, as a second-year resident) whether he really knew any of us. Cordiality and generosity emerged, the likes of which was unbeknownst to us beforehand, but that were the hallmarks of how he treated the peo- ple in his charge. Not only did I avail myself of the opportunity to train in the renown De- partment of Physiology at Albany Medical College with Tom Saba and the late, great sur- gical physiologist Sam Powers, but once I made my interest known to him, to say that my application was “facilitated” by Shires would be the understatement of the century. However, still undecided between trauma/ critical care (which really didn’t exist yet, it being late 1978) and cardiothoracic surgery, I decided to work in respiration physiology in part because it would be useful regardless of the direction my career took. That early work in acute respiratory failure was stimulated by a 1978 paper in the Journal of Clinical Investi- gation [7], which showed me the way to my first successful animal model of injury-in- duced pulmonary dysfunction. Combined with work ongoing at the time in host defenses and inflammation after trauma, my life-long interest in organ dysfunction had begun. Returning to New York City in 1981 to be- come a senior resident, life and work were ut- terly transformed. I found myself welcomed into Shires’ inner circle, treated more as faculty than as a resident. Operating with him was a revelation-he was a master of operative expo- sure, although handling the brittle cotton su- tures he insisted upon was challenging. How- ever, Thursday at 3:00 PM still was a weekly test of survival. The Shires morbidity and mor- tality (M&M) conference was legendary. The conference ran as long as it needed to; the cof- fee was bad, the “brownies” resembled ma- sonry material. Several hours of work awaited when we finished at 6 PM (or later). The third- year resident was responsible for the presenta- tions, and prepared meticulously if there was any instinct for self-preservation. However, some things had to be reported that had no plausible explanation, and it was just “your time” to take the hit. “You did WHAT?” We all learned surgery; how could we not, for there was nothing in surgery that the man did not know. Some of us learned more deeply that a private pre-conference audience and confes- sional could make M&M conference go a bit easier. “Yeah, I’m like you, I wouldn’t-a done that” reverberates to this day. It was while at Cornell that Shires’ own career reached its zenith. Already having served as the 2 EDITORIAL Chairman of the American Board of Surgery (1972–1974) and been elected to the Institute of Medicine of the National Academy of Sciences (1975), he served as Chairman of the Surgery A Study section of the National Institute of Gen- eral Medical Sciences, National Institutes of Health (NIH) from 1976–1978. From 1979–1980, Shires served as President of the American Sur- gical Association, giving the Association’s cen- tenary address “The Fourth Surgical Renais- sance?” [1]. Doctor Shires’ lifelong commitment to the American College of Surgeons also cul- minated during the Cornell years. He was Chair- man of the Board of Regents from 1978–1980, President-Elect from 1980–1981, and President in 1981–1982. Also in 1982, Doctor Shires became for 12 years the editor of Surgery, Gynecology & Obstetrics, the forerunner to the Journal of the American College of Surgeons. Writing in 1985 [5], Claude Organ concluded that Shires was the sin- gle most productive and influential American surgeon of the preceding 40 years. The Shires laboratory was highly productive in the 1980s, with publications in the Journal of Applied Physiology, Journal of Clinical Investiga- tion, Journal of Experimental Medicine, Lancet, and other esteemed journals. In 1986, Shires re- ceived one of the very first R37 (Method to Ex- tend Research in Time [MERIT]) awards from NIH in recognition of his long track record of meritorious research proposals. This produc- tivity and longevity would continue long be- yond the Cornell years, to his laboratories at Texas Tech and The University of Nevada, Las Vegas; he was funded continuously for more than 30 years until his death. Working with Tom Shires at the zenith of his own career was heady stuff. In 1982, when Cor- nell hosted the meeting of the Society of Uni- versity Surgeons in New York, it was we resi- dents who were the centerpiece of the local program presentation. In late 1982, I was sum- moned to his office by Pete Dineen (“No, he wants to see you NOW” was the response to my naïve suggestion that I would make an ap- pointment at my first opportunity) to have a matter-of-fact (but decidedly one-way) discus- sion regarding my role when I would join the Cornell faculty 18 months hence. There was re- ally no other way it would be, which was fine with me. I began re-creating a surgical inten- sive care unit in 1983 as Administrative Chief Resident, and never looked back. Perhaps the most important legacy of the 16-year Shires era at Cornell is that he trained not only clinical surgeons and surgical biolo- gists, but that he fostered leadership [8] among his people. To the surgical chiefs at affiliated hospitals he provided crucial support and guidance. To his academic division chiefs he provided a firm hand as they combined inno- vation and programmatic development with fiscal and financial prudence. Junior faculty members were provided with a clear under- standing of their goals, and the resources they needed to achieve their objectives. Shires, as a visionary and decidedly not a micromanager, allowed us to grow and develop as leaders through our accomplishments, and made sure that those who did the work received the credit. Tremendous loyalty was engendered and rec- iprocated. Testimony to the success of his ap- proach is that more than 40 of Shires’ Cornell- era faculty and residents have gone on to assume major leadership roles in American surgery (Table 1). 3 TABLE 1. SHIRES’ CORNELL-ERA FACULTY AND RESIDENTS WHO BECAME DEPARTMENT CHAIRS, DIVISION CHIEFS, OR DIRECTORS OF CENTERS OF EXCELLENCE. Gabriel Aldea O. Wayne Isom Nasser Altorki Norman Johanson Anthony Antonacci Wilson Ko Michael Banbury Karl Krieger Philip Barie Stephen Lowry Peter Canizaro* Andrew Lowy H. Ballentine Carter Arnold Luterman Jonathan Cohen William Mackey P. William Curreri Michael Madden John Daly Michael Osborne Jerome Finkelstein* Malcolm Perry Henri Ford Stuart Pett William Gay, Jr. Alan Reed Jeffrey Gold Mark Silen Cleon Goodwin Valavanur Subramanian Robert Grant Kenneth Tanabe Richard Greenberg Kevin Tracey David Herndon E. Darracott Vaughan Lloyd Hoffman Giles Whalen Eddie Hoover Roger W. Yurt Joel Horovitz *Deceased Numerous other individuals have achieved professorial rank. The author extends his apology to anyone omitted inadvertently from this list. BARIE One of my most fond memories is of Friday afternoons at about 4:50 PM. The chief would emerge from his office, drain the dregs of the coffee pot in the reception area, and sit down to converse with whoever happened to be sit- ting there at the time. Whoever usually hap- pened to be there was some combination of John Davis, Steve Lowry, Roger Yurt, and yours truly. We were happy to have his ear; in retrospect, a lot of important work got done. As a resident, I was influenced powerfully by a 1982 publication of Shires and Dineen in Archives of Internal Medicine entitled Sepsis fol- lowing Burns, Trauma, and Intra-abdominal Infec- tions [9]. I was awestruck that Shires knew about that, too, and that he would publish in an esteemed internal medicine journal. Little did I know at the time that the paper would be a crucial foundation for my life’s work. In 1985, Shires made the crucial introduction that led to my first experience consulting with the phar- maceutical industry. Thus sanctioned, I knew that such work was appropriate. In 1987, the opportunity arose to sit for the then-new examination in surgical critical care. I wasn’t sure that taking the examination would be worthwhile, nor was I certain that I was even eligible, given that I wasn’t doing critical care full time, nor did I have four years’ part-time expe- rience working in the field (I had been on the fac- ulty for three years at the time). The Chief as- sured me that it was worthwhile obtaining any credential for which I was eligible, and assured me further not to worry about my eligibility. I sat, I passed, and I hold certificate number 027. Later in 1987, while continuing to serve as the Stimson Professor and Chairman, Shires became The Stephen and Suzanne Weiss Dean and Provost of Cornell University Medical College, positions he held until 1991. It was a challeng- ing time for the medical center, which was in fi- nancial distress owing to the advent of managed care and the prospective payment system. Working with David Skinner, recruited from the University of Chicago to be President of The New York Hospital in 1989, a powerful but con- tentious partnership was forged to prepare the institutions for the transition to their current po- sitions of pre-eminence. It was a challenging time for us, too, in that we no longer had the same kind of access we once enjoyed. Leisurely chats by the coffee urn became “walk and talk” as Shires moved from one office to another; for- tunately his assistant did everything she could to let us know when he would be on the move, so we could join him. Fortunately also, the de- partment was arguably at its zenith. Shires’ departure for Lubbock in 1991 to be- come Professor and Chairman of Surgery at Texas Tech University was a shock, and the fac- ulty meeting where he announced it made time stand still. We knew as a faculty that he was growing weary of his dual role, and of the daily battles with Skinner and the hospital. Shortly beforehand, there had been a chest pain scare when Henri Ford was the chief resident on his service. Henri managed everything to a good outcome, but in retrospect the writing was on the wall. In the end, he gave me two gifts as he departed. First, he did not ask me to go to Lub- bock with him, an offer that would have been difficult to refuse, but that clearly would not have been right for me. In fact, he asked none of the surgical faculty to accompany him, to my knowledge, choosing instead to rebuild with graduating residents of exceptional merit. Sec- ond, he gave me the funding for a research nurse, to begin the transition of my research ca- reer from bench to bedside. Seventeen years and one hundred twenty-four publications later, Lynn Hydo works with me still. Several years later, on a cold, rainy Saturday afternoon, the Chief called me and said he was coming to the hospital, and could he stop by my office for a visit? We chatted upwards of an hour, talking about everything and nothing at all. Part way through it dawned on me. I was sitting in the big chair, and it was he who was across the desk. In his way, perhaps he was telling me that I was a “big dog,” too. Tom Shires published his last peer-reviewed paper in these pages [10], fewer than four months before he died. He called me and asked for a favor. He asked if I could arrange for ex- pedited peer review of an original manuscript, assuring me that it was “good.” He needed a publication before the end of June, otherwise he would not have enough continuing medical education credits to renew his Nevada medical license! Amazing! Somehow the journal was able to accommodate him. 4 EDITORIAL “. . . protection of scientific and technologic advances to promote the art of healing to the highest degree will have to come from us, from organized surgery and the societies of surgery. We must create the environment for recruit- ment and productivity. We must eliminate gaps in care while narrowing the voids in knowledge” [1]. Rest in peace, Tom Shires. You gave us full measure, and the skills and tools to carry on. We shall. REFERENCES 1. Shires GT. The fourth surgical renaissance? Ann Surg 1980;192:269–281. 2. Dicke WG Tom Shires, 81, Trauma Expert, Dies. NY Times 2007;October 22. 3. Oransky I. G. Tom Shires. Lancet 2008;371:200. 4. Barie P, Maier RV, Perry MO, et al. G. Tom Shires, MD, FACS, 1926–2007. 5. Fahey TJ III. Department of Surgery, New York Pres- byterian Hospital-Weill Cornell Medical Center. Arch Surg 2006;141:435–436. 6. Organ CH Jr. The interlocking of American surgery. An analysis of surgical leadership in the United States, 1945 through 1985. Am J Surg 1985;150: 638–649. 7. McKeen CR, Brigham KL, Bowers RE, Harris TR. Pul- monary vascular effects of fat emulsion infusion in unanesthetized sheep. Prevention by indomethacin. J Clin Invest 1978;61:1291–1297. 8. Barie PS. Leading and managing in unmanageable times. J Trauma 2005;59:803–814. 9. Shires GT, Dineen P. Sepsis following burns, trauma, and intra-abdominal infections. Arch Intern Med 1982;142:2012–2022. 10. Shires GT, Fisher O, Murphy P, et al. Recombinant ac- tivated protein C induces dose-dependent changes in inflammatory mediators, tissue damage, and apopto- sis in an in vivo rat model of sepsis. Surg Infect 2007; 8:377–386. 5