Multiplier Effect

Few leaders in academic medicine have made a greater impact on the practice of surgery than U of L's Dr. Hiram C. Polk Jr.

By Dale Greer

Photos by John Lair

The residents have already been awake for hours when Dr. Hiram Polk walks through the doors of the surgical intensive care unit at University Hospital for morning rounds.

Dr. Polk speaking with residents

It is 6:47 a.m., and they've been preparing for the questions they know will come. They would tell you--if they had a moment to spare--that a surgical resident has to get up pretty early in the morning to meet Polk on his own terms.

"I realized that when teachers have a good idea, they can pass it on to their students and get a multiplier effect. If I knew something and practiced it all my life, I'd still have contact with a finite group of patients. But the multiplier effect spreads that knowledge out, and your good ideas get passed on. I find that very gratifying," says Polk.

But Polk, chairman of the department of surgery at the University of Louisville who is retiring in June, may be the hardest-working man in academic medicine. He has been awake just as long--if not longer--and he has been doing rounds like these for more than 33 years.

As Polk walks from patient to patient, nearly 25 medical students, surgical residents and faculty move in concert. They stop at each bed, and a resident steps up to explain the patient's history and course of medical treatment. Then the questions begin.

They come slowly at first, like sprinkles of rain, before escalating into a steady downpour. Each question from Polk solicits a response from the resident, but that only spawns more queries: Why did you decide on this course of treatment? Why was the medication used? What alternative therapies have you considered?

One patient in particular--a young man who lost a considerable amount of blood in a motor vehicle accident but whose religious faith prevents him from receiving whole blood or certain blood products-- has Polk concerned. Because of his condition, the patient's heart rate has exceeded 120 beats per minute for several days, and Polk is worried about the stress this is inflicting on his heart.

After five minutes of queries, responses and open discussion with his residents on how best to proceed, Polk expresses his reservations but counsels them to keep a close eye on the patient and continue treatment as planned.

The group then moves to the next bed for another shower of questions from the man who has trained more general surgeons--more than 230--than any other surgery chair in America. It is a scene that has been playing out on a weekly basis since 1971, when Polk accepted the chairman's post at the relatively young age of 35.

Dr. Mark Pfeifer vividly remembers being quizzed by Polk as a U of L medical student in the early 1980's. "As a student or resident, you had to think through every type of question he might ask in order to prepare for rounds," says Pfeifer, who is now chief of staff at University Hospital. "That kept you sharp on the front lines, but more importantly it improved the care of the patients because you were always trying to consider the many possibilities for treatment."

Dr. Michael Edwards, who completed his surgical residency at U of L in 1986, describes Polk's famously Socratic teaching method as "a mixture of inspiration and intimidation." "Hiram inspires you by example, but he is never hesitant to let his residents be intimated by the potential consequences of an adverse outcome for a patient," says Edwards, who is now chair of the surgery department at the University of Arkansas.

He demands that you always put the patient first, and that means you must have an honest reckoning--you have to ask what you could have done differently to satisfy the goal of obtaining a superior outcome for the patient."Hiram understands clearly that satisfaction with mediocrity is a cancer that invades your mind and destroys your pursuit of excellence. He's never allowed that to exist in the care of any patients at U of L or among any of the residents he's training."

Polk's pursuit of medical excellence extends to more than just teaching, however. He is a world authority in surgical wound infections, based in part on his landmark research into the use of perioperative antibiotics. He also is widely regarded as one of the top administrators in the country, having shepherded U of L to national pre-eminence in areas like trauma care, bariatric surgery, cardiac implants and surgical oncology.

Such accomplishments are remarkable by any standard, but they're even more impressive when you consider that Polk almost didn't finish medical school. He says he dropped out three times because he loathed some of its more tedious demands, even as he reveled in the "wonderful intellectual stimulation" it provided.

Of course, this wasn't just any medical school--it was Harvard. But the Ivy League institution didn't offer all that much allure for the young man who grew up in Mississippi. In fact, Polk initially turned down the chance to attend Harvard on scholarship while he was an undergraduate at Millsaps College in Jackson, Miss., preferring to stay home or perhaps attend Tulane for a medical degree.

Since Polk wouldn't go to Harvard for a candidate-screening interview--he'd only applied there as a favor to his Millsaps chemistry professor--Harvard came to him, dispatching the late Dr. Arthur Guyton. Guyton, still regarded as the world's premier physiologist, spent an hour talking with Polk about his plans and about how his vision beyond life in the Deep South.

"That was probably the most important hour of my life," Polk recalls, "because he sort of changed my whole view of the world. He said, "Son, we're going to offer you a position and a scholarship to Harvard Medical School, and you're going to take it." "And I said, 'Yes, sir!'"

Polk describes his Harvard years as an "intellectual roller coaster," but they also were eminently rewarding. "It was a wonderful environment in which to learn--a constant opportunity to excel and be surrounded by talented people who are trying to be the best they can be," he recalls.

A talent for surgery

It was in this environment that Polk discovered a talent for surgery. Upon graduation from Harvard in 1960 he embarked on what has become a distinguished surgical career, beginning with an internship and residency at Washington University in St. Louis. "It's a pretty sacred trust when somebody tells you they're going to let you operate on them," Polk says. "It's a big deal."

One of his Washington instructors, Dr. Carl Moyer, was such an outstanding teacher that Polk soon found himself considering academia too--in part because of the impact it would allow him to make on future doctors. "Dr. Moyer was amazingly good at what he did, and as I spent time with him I began to realize that I also wanted to be a teacher," Polk recalls.

Following residency, Polk began his academic career in earnest as an assistant professor of surgery at the University of Miami and director of pediatric surgery at Jackson Memorial Hospital. By 1969 he had risen to the rank of associate professor and was directing the hospital's tumor clinic, having developed an interest in malignant melanoma.

We didn't know at the time that sun exposure for people with fair complexions and light hair creates melanoma later on," Polk recalls. "We were just beginning to see what we now recognize as an epidemic of melanoma, and it was pretty clear nobody knew what to do about it. My department chair suggested that I look into it and find a better way to treat these people."

The protocols that Polk and his colleagues subsequently developed were soon adopted worldwide and remain the standard of care today. "We stopped treating the patients by cookbook and began to individualize treatment based on a patient's needs," Polk says. "Instead of treating everybody aggressively and sometimes destructively--amputations, unnecessary node dissections and a variety of treatments that didn't consider the evolving biologic behavior of melanomas--we began offering limited but effective therapy for the curable melanomas.

"Other melanomas--the ones that were likely to spread--were carefully stratified so that we could treat some aggressively with surgery and we could treat the rest aggressively medically." Polk's Miami years also piqued his interest in the nature of infection, and he began to conduct a study on the use of so-called perioperatie antibiotics to prevent bacterial infection during surgery. This approach--giving antibiotics to a patient about an hour before surgery, to that the medication is flowing through his tissue during the operation--is now the most common use of antibiotics in the world. But when Polk first proposed it in the late 1960s, no one had given it much thought.

The study, which Polk began at Miami and continued during a nine-month fellowship at the Lister Institute of Preventive Medicine in London, is still regarded as a landmark in clinical research, says Dr. Mark Malangoni, chairman of the surgery department at MetroHealth Medical Center in Cleveland and a former U of L faculty member. "That was truly a groundbreaking study because it really established the principles we use today in treating patients," he says.

Polk's research into the dynamics of infection continues today, including multiple studies on molecular mechanisms and therapeutic agents like gamma interferon that hold promise for temporarily "supercharging" the body's immune system. (Since 1963, he has authored or co-authored nearly 400 papers and journal articles, 152 textbook chapters and 11 books.)

When Polk concluded his fellowship at the Lister Institute--a time he calls "grand growth phase-- he returned to the University of Miami with thoughts of seeking more academic responsibility.

An opportunity for growth

Several schools had been courting Polk to assume the role of surgery chair, but U of L seemed to offer the most exciting opportunity. First, the university has just made the transition from being an under-funded municipal school to a reasonably well-supported state institution. Second, a new health sciences campus was under construction near Jewish Hospital, and both soon would be joined by Norton Hospital. Third, the state had committed to providing U of L with a modern university hospital in which to train its students.

It also didn't hurt that Louisville was near the heart of the thoroughbred industry. Polk had been an avid horseman for years--he worked summers at Suffolk Downs during medical school, writing occasionally for the Daily Racing Form--and he still runs a successful broodmare partnership that boasts the bloodlines of several well-known grade-stakes winners.

Dr. Polk with yearlings
Polk, shown with three of his juvenile thoroughbreds at Hermitage Farm in Goshen, Ky., has a passion for shaping young minds.

"This was, I thought, the best possible kind of job," Polk says. "We had a great university president, Dr. Woodrow Strickler, the school had new money coming in from the state affiliation, and they were willing to put some of that into building a surgery department. I said, 'Why not?'" It was a decision he has never regretted. Since Polk's arrival in 1971, the surgery department has grown from a staff of five and almost no research funding into a dynamic collection of more than 70 faculty surgeons with $5 million in annual research grants.

The department also is a leading provider of top-flight clinical services, including more than $100 million in free care for indigent patients since 1971. Procedures that either were developed or significantly improved at U of L include minimally invasive techniques for treating diseases of the pancreas, novel bariatric procedures like gastric banding to surgically treat morbid obesity and microsurgical techniques that maintain blood flow to tissue so it can be moved to other parts of the body in a process called "free flap."

Other landmarks include advances in trauma care that reduce the need for major surgery as well as two successful hand transplants and the world's first implantation of the AbioCor artificial replacement heart, both of which occurred at Jewish Hospital.

I had two main goals when I came here in 1971," Polk recalls. "I wanted to make U of L a really good training program for students and residents, and I wanted to attract some faculty who would grow up and amount to something. I think we've succeeded on both counts."

early photo of Dr. Polk
Dr. Hiram Polk in 1971.

Many of the students who've trained here under Polk, including Edwards and Dr. Donald Fry, chair of the surgery department at the University of New Mexico, have gone on to national prominence as leaders of their own academic programs. In fact, almost one-fifth of U of L's surgical alumni have found lasting careers in academia.

Meanwhile, the remaining 80 percent are practicing with distinction at hospitals from Paducah to Pikeville and across the United States. Finally, there are the numerous academic surgeons who have made U of L home, like Dr. Kelly McMasters, or those who have worked alongside Polk in Louisville before moving on to positions of leadership at other institutions, like Malangoni and Dr. Kirby Bland.

"I learned a great deal from Hiram," says Bland, chairman of the Department of Surgery at the University of Alabama-Birmingham and a U of L faculty member from 1977 to 1983. "He's one of the best surgical teachers I've ever met, and he's also an excellent surgeon. He's the kind of surgeon who has a passion for doing the most challenging procedures, and he does them well.

"But most importantly, he was an excellent mentor. He gave me and the faculty sound advice about fiscal matters, he strongly supported our professional development. Even today, I still treasure his input and advice on the deliberations I have." Bland, a nationally respected surgical oncologist with more than 15 textbooks to his credit, says Polk's former students and colleagues feel an obligation to follow their mentor's example and do for others what he has done for them.

"That's probably the most important thing we do--pass down to the residents and staff our knowledge about patient management and professionalism. It's the greatest gift we can offer." Polk clearly would support that multiplier effect. "Somewhere in the business of trying to discover and communicate truth, you really get about as big an emotional lift as you can out of anything," he says.

"I can't tell you how many nights in this job over 33 years I've gone home brokenhearted over something that turned out badly," says Polk. But there were a 100 times more nights I went home with my heart singing because of the good experiences I've had with smart people--sometimes faculty colleagues, sometimes patients, sometimes students and residents. I can't imagine having done anything else with my life."

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