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No 'Maybes' Allowed
Brennan Is 'Socratic Surgeon at Work'

By Carla Garnett

Photos by Bill Branson

On the Front Page...

Remember squirming in your seat back in school when a particularly fiendish instructor gleefully issued a pop quiz? Now make the exam oral in front of hundreds of curious spectators including your mentors and boss, consider that your performance is being evaluated by arguably one of the best teachers in the field, and imagine your responses determining someone's life or limb. That was the scene June 16 in Lipsett Amphitheater at "Caution - Socratic Surgeon at Work," the 2003/2004 season finale of the Great Teachers lectures, part of the Clinical Center's Grand Rounds series.


Introduced by a longtime friend, NCI chief of surgery Dr. Steven Rosenberg, as "the preeminent surgical oncologist of his generation," guest speaker Dr. Murray E. Brennan, chair of Memorial Sloan-Kettering Cancer Center's department of surgery and Benno C. Schmidt chair in clinical oncology, presented an NIH version of the interactive conference he has held weekly for 20 years with his clinical fellows.

Dr. Murray Brennan
"It's an attempt to get people to think," he said, describing the exercise in which two real medical cases would be thoroughly dissected from start to finish within an hour's time. "We're going to have the clinical associates seated in the front row to help us learn something.

"It's very straight forward," he continued, playfully addressing the 15 or so participants. "If you are confused about the ground rules, do not — do not — try to avoid eye contact, because then I will just walk right up to you. If you don't have an answer just pass the microphone to the left or the right, but you will have to answer the next time around...and when in doubt, agree with me — it's faster."

In the first case, the patient presents with a tumor mass presumed to be a soft-tissue sarcoma. As the physician, what do you want to know next about the patient or the history? Brennan asked.

"Age," replied the first associate.

"Good. Why do we want to know the age?" Brennan asked the next in line.

"Because age can determine prognosis," the associate responded.

"Is that true?" Brennan queried, immediately prodding the next person.

And so it went. Within minutes, Brennan had elicited both answers and new questions from the associates regarding relevance of the patient's sex and predisposition to sarcoma. In addition to a surgeon's up-close perspective of tumor diagnosis, treatment and prognosis, the audience got a glimpse not only of Brennan as a teacher, but also of how physicians think through cases and how quickly decisions must sometimes be made. Following Rosenberg's recommendation to invite Brennan to speak at Rounds, Dr. Udai Kammula of NCI's Surgery Branch helped organize the presention's unique approach.

"I recently completed my surgical oncology fellowship at Memorial Sloan-Kettering Cancer Center," Kammula explained. "As fellows we would have a weekly conference called 'Chairman's Conference,' where the fellows would present a case and Dr. Brennan would discuss important aspects in a very Socratic approach. The surgical fellows would be the target for his questions."

A recent survivor of Brennan's surgical fellowship program at MSKCC, Dr. Udai Kammula (r) of NCI's Surgery Branch helped organize the presention's unique approach.

Brennan's renown in the world of surgery, and his history here, made it fairly easy to get NIH's current crop of surgical associates to take part in the rather rigorous Rounds.

"Since Dr. Brennan was previously in our branch and he is a very prominent figure in American surgery," Kammula said, "I had no trouble recruiting all of the participants. They were quite excited to meet him. I believe their performance was quite good. As far as preparation, there is no way to truly prepare for Dr. Brennan's questions — I know this from experience. I did arrange for a general review session to get them up to speed."

Dr. Cary Hsu, who will return to the laboratory following his rotation in the surgery department, found the experience rewarding.

"I enjoyed Dr. Brennan's lecture," he said. "The Socratic teaching format kept everybody extremely focused on the questions being presented and the questions always seemed to center on the major points being made in the lecture. The exercise was not particularly difficult. As a group, we've been engaged in the study of this topic for some time now and we were well prepared by an advance lecture from Drs. James Yang and Kammula. I think our answers were often tentative because we were forced to answer directly to one of the world's experts on the topics being discussed. It's hard to be completely confident in your answers when the person questioning you has infinitely more knowledge and expertise in the subject."

Another participant, Dr. Gerald Gracia, who recently completed a year-long immunotherapy fellowship in the surgery branch en route to starting a 2-year surgical oncology research fellowship there, said Brennan's presentation was designed to be challenging.

In the hot seats: Drs. Cary Hsu (top row, r) and Gerald Gracia (top row, second from r) are among more than a dozen NIH clinical associates recently quizzed on surgical diagnostics and treatments by Great Teacher Dr. Murray Brennan of Memorial Sloan-Kettering Cancer Center.

"The Socratic exercise was difficult," he pointed out, "but that was intentional. Typically the lecturer would keep asking the same person questions until the person gets one wrong. Most individuals will never forget the answer to a question they got wrong. Dr. Kammula's prep discussion was key. He provided insight into certain specifics that Dr. Brennan likes to focus on...Although it was a different approach than the lecture formats here, I really enjoyed it. Of course, Dr. Brennan is a phenomenal speaker. Most of us were simply excited to hear his view on certain topics, since he is an expert in the field."

Brennan also hoped to share his enjoyment of the process.

"The first case presentation was mine, so I knew what to ask," he explained, after the lecture. "The second was from NCI, so I knew nothing of it. The goal was to show the same process can work — either with a prepared case or with a totally unknown. With the second case, I was as likely to stumble as were the clinical associates. It is okay to be 'wrong' as long as you learn. I hope I conveyed [that] I want people to learn. I want them to enjoy continually learning. I was pleased no one fell asleep!"

A former senior investigator at NIH who spent 6 years here from 1975 to 1981 as chief of the surgical metabolism section helping to develop endocrine surgery programs, Brennan also delivered a few NIH history lessons during the presentation.

"What observation was made in this institution about familial associations of sarcoma?" he asked, coaxing a somewhat hesitant associate into a discussion of Li-Fraumeni Syndrome. In 1969, Dr. Frederick Li and Dr. Joseph Fraumeni, both of NCI then, identified the syndrome that bears their name, a disorder in which a genetic component was found to explain unusually high occurrence of several site-specific malignancies in a number of families. Discovery of the syndrome (also called "SBLA syndrome," for sarcoma, breast, leukemia, and adenocarcinoma) laid the foundation for further research on the role of heredity, environment and cancer that is still conducted today.

Dr. Steven Rosenberg, who recruited Brennan to NIH in 1975, introduces his friend. The two had completed their surgical residencies together at Peter Bent Brigham Hospital in 1974.

Later, when Brennan moved to what questions should be asked during patient examination, the clinical associates were prompted to recall that it was a pioneering clinical trial conducted at NIH by Rosenberg that determined that amputation was not always necessary for site-contained sarcomas. By the end of the hour, the assembly had also learned that a study standardizing use of an imaging technique called selective venous sampling for endocrine tumors had been led at NIH by a former CC director of radiology, the late Dr. John Doppman.

"This was someone who was really special," Brennan mused aloud about Doppman, who died of cancer in 2000. "He would have been a great surgeon, but he went for radiology."

Sprinkling personal observations in among his promptings, Brennan also questioned a standard of patient care that he said ought to be reconsidered, the benefits weighed against the risks of new disease.

"We are now creating an environment that predisposes both to radiation induction [new cancer caused by radiation therapy] and to lymphedema with the very liberal use of radiation therapy for breast cancer," he said. "I could be a cynic, but in my opinion the medical profession has seduced the women of this country, that every woman with a 1-centimeter breast cancer with negative [lymph] nodes needs radiation and chemotherapy to improve the survival from 90 percent to 92 percent. There isn't anything in biology that says you can deliver 1 percent with accuracy, no matter how big the clinical trial.

"What's the price of improving survival from 90 to 92 percent?" he queried, showing a slide of a mastectomy survivor badly burned from radiation and suffering from grossly disfiguring lymphedema.

Answering his own question, Brennan said, "If you improve from 90 percent to 92 percent, 8 percent still recur and you didn't help them, 90 percent weren't going to recur anyway. So you've treated 50 patients for the potential benefit to one and yet that's standard therapy in the United States. That means 49 people will be treated with no chance of benefit.

"Sooner or later we have to come to grips with that kind of problem," he continued, showing a slide documenting the rising number of angiosarcomas developed by women who underwent radiation therapy after breast cancer surgery. "As surgeons, radiation therapists and medical oncologists, we are very reluctant to address this issue, but it will come back to haunt us, in my opinion."

Dr. Richard Alexander (l), head of the surgical metabolism section in the Surgery Branch of NCI's Center for Cancer Research, greets Brennan, who held a similar position at NIH nearly 30 years ago.

Perhaps one of the best lessons Brennan taught that day — delivered offhandedly, as a reminder to the associates, certainly, but also to the audience of onlookers — was about the nature of surgeons, their responsibility and the potential consequences of their often difficult choices.

"You're a surgeon," Brennan stressed during a particularly long pause between question and answer. "You make decisions on inadequate information. You either do the test or you don't do the test. You can't have Grand Rounds on maybes."

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