Asked by a Resident: Dr. Efe Chantal Ghanney Simons interviews Dr. Mark S. Litwin

In this first installment of Asked by a Resident, Efe Chantal Ghanney Simons, MD, spoke with her mentor, Mark S. Litwin, MD, MPH, about the important lessons that he has learned throughout his career. Spanning personal successes, memorable patients, and influential role models, Litwin describes his lengthy and rewarding career in urology and advises others on how they can succeed in the field. Ghanney Simons is a PGY-6 urology resident and Litwin is professor and chair of urology at University of California, Los Angeles.

Efe Chantal Ghanney Simons, MD

Ghanney Simons: It's such an honor and a privilege for me to have this conversation here with [Mark S.] Litwin[, MD, MPH]. My name is Efe Chantal Ghanney Simons. I'm a PGY-5 resident at UCLA in urology. Dr. Litwin, who's the chair of my department, has served as a mentor and as a sponsor, even preceding my time as a trainee. So, today, we have the opportunity to ask him some questions that we typically wouldn't have the chance to ask an attending in a busy clinical or OR setting. Dr. Litwin, thank you again for your time.

We're just [going to] jump right into it, because we have quite a few questions today. The first question I'd like to ask is, what do you wish you had known when you began your career?

Mark S. Litwin, MD, MPH

Litwin: I wish I'd known how incredibly rewarding it would be. I think I viewed going into surgery and a surgical subspecialty as something that would be highly disciplined and highly demanding. Of course it is that, but I don't think I had a good sense of just how incredibly rewarding it would be. And not just the end game of being an attending and working my way up the academic ladder, but even in the course of residency, in the course of my training, it gives me pause to think back on that now as to how pleasant it's been so far.

Ghanney Simons: I'm really glad to hear that that's been your experience thus far. Speaking of the highs, I'd like to get a sense of the lows as well. Have there been any barriers that you've experienced in urology? Have there been instances where your identity may have played a role in those barriers?

Litwin: Let me answer it in 2 ways. First of all, overall, my sense is that the biggest barriers are those that we erect on ourselves. Not to say that society doesn't also erect barriers that we have to navigate, but I think the biggest ones are those that we put on ourselves in life and in general. On a personal level, as a gay man in urology, I think that the fact that I identify and live my life pretty openly with a husband and 2 kids is something that I perceive might have caused issues or problems for me. I was a surgical resident and urology resident among the Harvard programs in the late 80s, early 90s. It was a very different time, socially, and I was closeted at the time. It didn't really feel like it would be okay to be an out gay person in urology. It's the nature of the field, dealing with men's health, etc. Turns out that patients want the best doctor and the best medical care, and they don't really give a hoot about anything else, most of them. I think that's true for any individual in urology who may perceive that they have an identity difference in some way. I've counseled a lot of women urology residents about this in the past, as to how they would navigate men's health issues as a woman in urology; it's the same for men in gynecology. It cuts across a lot of different specialties. So, I think that that identity played a role in terms of [being] a barrier that maybe I erected, to some extent. And then, I found that just by simply being honest, living my life openly and candidly, no one's really interested in anything in my life other than if I can take out the prostate in a good way, or if I can treat the testicular cancer in an effective way, or if I can manage their urinary tract infection. That's really what it's all about.

Ghanney Simons: Now, can you speak to us a little bit about some of the greatest shifts you have seen in the field of urology over the course of your career?

Litwin: There have been a lot of shifts over the course of the past 30 years. I finished residency in 1991, so 30 years ago, and finished fellowship 2 years later. I would say that the biggest tectonic shift that I have viewed is the change in the administrative aspects of medicine and the demands that we have in order to practice, [as well as] the financial complexities of medicine and those challenges that are created. Administratively, the electronic medical record has been phenomenally great in many, many ways. And it is also soul-crushingly challenging and difficult in many, many ways. I'm not sure people really realize that when we made this mass shift to the electronic medical record, that's been challenging. The way that health care is organized or disorganized in this country is also extraordinarily challenging. I think that's gotten worse over the past 30 years. Patients who need prior authorizations and have formulary restrictions and you name it—it can really put a lot of barriers to practicing medicine. PET CT scans, [prostate-specific membrane antigen] for example, over the past few years required immense amounts of time of the physician to do administrative, financial clearance, and that kind of work. So, I've seen that increase a lot over the last 30 years. I think that is a good reason to really focus on what we like in medicine and what’s effective and what's gratifying, because the negative stuff definitely gets to me sometimes.

Ghanney Simons: Speaking of focusing on the things that are gratifying, what would you say has been your biggest accomplishment? If you thought about your career as a movie, what would earn you your Oscar?

Litwin: That's a great question. It may disappoint you to hear that what I would consider my greatest accomplishment is actually not in my professional life, but my marriage to my husband, Adam, of 32 years so far, and my 21-and-a-half-year-old twins graduating college this year, Rose and Max. I think at the professional level, the accomplishment that I would say is most important to me, and what makes me feel inspired or like my best self, if you will, is seeing my mentees—both current and former—pay it forward, and seeing them take lessons that they've learned during the course of their training, some of which I may have helped them understand and some of which I may have just been a bystander, and begin to mentor their own mentees, be that a medical student [or] some high school student who's going into a STEM field. As mentees get more senior—I’ve been around long enough that some of my former mentees are pretty senior now—seeing them mentor people who are junior faculty, mid-level faculty, and even senior faculty, to me, is the greatest contribution that I feel like I have tried to make. The value of mentorship and trying to model that in a way that's valuable for anybody who needs it—for people who have particular challenges, as well as for people who come in without a lot of obvious challenges—everybody needs mentorship.

Ghanney Simons: Absolutely, and that's just music to my ears. That certainly resonates—all the points you made about mentorship. Congratulations to your kids with their graduation as well in college. If you weren't in medicine, what would you be doing with your life?

Litwin: I think I would be a rabbi. That may be not the response you're expecting. My affection and respect for people of the cloth is immense, and I think that the position that they play, the role they play in helping people through crises and challenging times, as well as being there to witness happy and celebratory times, is extraordinarily powerful and valuable. I have a sideline that I've been doing for the last 25 years or so, occasionally as a mohel, which is the ritual Jewish circumciser. Basically, [it is] just a neonatal circumcision done under local anesthesia in the home with a few prayers added for good measure. I do maybe one every month or two. So, it's not a busy practice, but I so enjoy doing that. I so enjoy being able to serve as the instrument of making the occasion important and meaningful for people who are going through that. If I were in medicine, but not a urologist, I don't know. I can't imagine doing anything else. You don't really choose urology, it chooses you. Once you're chosen, you know, you have to step up.

Ghanney Simons: So, we're [going to] switch gears a little bit to basically get a sense of some of the lessons you've learned along the way. What would you say is your most memorable patient encounter?

Litwin: Over the course of a career, there [are] so, so many memorable patient encounters. The one that came to mind was a young man on whom I was set to perform a post-chemotherapy retroperitoneal lymphadenectomy, RPLND. He was about 30, as is often the case in these patients, and after platinum-based chemotherapy for widely metastatic testicular cancer, he had a large residual mass on his retroperitoneum, just completely wrapped around everything—around his aorta his vena cava, his urinary structures, and it was just a case that I was really bracing for. It was one of these things we look at as an all-day surgery, and you know you're not going to get lunch that day. And it was during the time when we would sometimes admit patients the night before surgery. It's a very foreign concept today because it so rarely happens anymore. I remember going by his room in the evening on the way home from work the night before the surgery—he was doing his bowel preparation—and sitting down on the side of his of his bed. He didn't really understand the gravity of everything he was going to be going through, at least not in the way I did. But he understood that he was undertaking something big and that our lives were crossing at a very important moment for him in the course of his journey to health. As I sat on the side of the bed with him, I took his hand and promised him to do the best I could, to take excellent care of him. I wanted to inspire confidence in him. He asked me if I'd ever done a case like this before, and I thought about whether to answer completely candidly and decided to do that. I told him I had done many cases like this, [and] this was the biggest one I had ever done, but that the entirety of my career thus far was meant to bring me to that moment with that patient and doing that surgery. I think it's true for many of the surgeries that we do, but I really felt a connection with him, a human connection, so that the next day in surgery, it wasn't just removing a mass from around the ureter and the aorta. It was operating on Mr. So-and-so and making sure to hold true to my promise to him. At the end of the day, it was one of these really long days that you just come out totally exhausted. And fortunately, [with] a combination of technical skill and good fortune, we were able to get everything cleaned out. He is now many years post-op. He keeps in touch with me periodically. He went on to a good career, he has great appreciation for what he went through and for the role that I was able to play in helping to get [them] back to health. Now, certainly [for] the patient you see once for a bladder infection or a kidney stone, it's hard to have a long-term meaningful relationship with them. But certainly, in oncology, where we do get to know our patients over long periods of time, and it's very much helping manage them through a crisis, it is really, really meaningful.

Ghanney Simons: Thank you for sharing that. And again, that's an illustration of the blessing that we have as providers to be able to care for patients in that capacity. What would you say the greatest lesson has been from a patient?

Litwin: Patients take it as a given that we know what we're doing, intellectually and technically. But the lesson that's really powerful has been that what they need, in general, is more than that. What they need is some kind of human connection, to know that they're not only having a tumor removed, or a stone cured, or incontinence treated, or erectile dysfunction managed, but that they are themselves being viewed as the complete real human being that they are, and that the human connection with their doctor is part of healing. So, it's more than just technical, intellectual activity that we train for so many years to do, not to disparage the importance of that, but that it really is largely also about healing. Healing happens both at the physical level and at the mental, emotional, and even spiritual levels. And to the extent that we can be instruments of success in advancing all of that and getting them back to health, I think that's the most important lesson. And it is with every single patient, whether they acknowledge it, or you acknowledge it, or not, and it's more in some and less than others, for sure. But that human connection is what's so important.

Ghanney Simons: As we discuss this human connection or connections that you've made over the course of a career, who would you say are the 3 individuals who've impacted your career the most in the most capacity?

Litwin: Number 1, my mother, Sheila, who taught me from an early age the importance of interpersonal interaction and communication and attending to the right brain as well as the left brain, the importance of feelings, [and] the importance of connecting with people, as I was saying earlier. She continues to be an inspiration for me. As a single mother raising 3 children, she turned me on to a book called Love, Medicine, and Miracles by Bernie Siegel, which I highly recommend to anybody at least into oncology, about extraordinary patients and what makes them extraordinary.

The other 2 are perhaps a little more conventional. They would be William DeWolf [,MD,] who was for many years the chief of urology at the Beth Israel Hospital in Boston, and one of my senior professors when I was a resident at the Brigham. He passed away, unfortunately, from metastatic pancreatic cancer not long ago, and was a guiding light for me. He taught me about the importance of thinking big, dreaming big, and using that as a guidepost for my accomplishments. Nothing's impossible is what he taught me.

The other, I would say, to round out the list of 3 also recently passed away actually in the last month or so, is Hardy Hendren[, MD]. Dr. Hendren was the chief of surgery at the Boston Children's Hospital for many years. He was trained as a pediatric surgeon under Dr. Robert E. Gross, and he was at the Mass General for many years and then at Boston Children's for many years. Although he's trained as a general surgeon, his work was all in pediatric urology, and he was widely known as the individual who changed the face of management for kids born with cloacal exstrophy. I did many, many cases with Dr. Hendren that lasted 12, 18, 26 hours sometimes. We would even scrub it out to get a meal. But he taught me the incredible value of pursuing technical perfection in everything that we do. He was a reconstructive surgeon working with teeny, little patients, and so it was especially more important. So, I guess I would say he inspired my technical left brain and Dr. DeWolf inspired my passionate right brain.

Ghanney Simons: Wonderful. This is a trickier question—may not be for you—but what's the most important thing you've learned in your life? What was your life like before learning it? What was your life like after learning it?

Litwin: Easy question for me. The most important thing I feel I've learned in my life so far is the value of human interaction and human connection. I'm not sure I can remember back early enough to before I really knew that, but certainly, since I've come to that realization a number of years ago, it's guided every interaction that I have. I think it's the pathway to happiness for people, not just physicians, but for people in general. And it's really what makes life meaningful. There's a song that was popularized in the 1980s by an acapella group called The Flirtations led by a singer named Michael Callen, [who] died of AIDS. One of the lyrics in the song goes something like this: The only measure of your words and your deeds is the love we leave behind when we're gone. That comes from human connection, and I believe that with all my heart.

Ghanney Simons: I've definitely felt and experienced that time and time and again every time I've interacted with you. There've been moments where I've texted you to meet. You made space and time, and I felt heard, seen, and appreciated. And so, again, having this conversation with you today is such an honor and a privilege. Now, my last question for you is, if you could turn back the hands of time and talk to your 18-year-old self, what would you tell them?

Litwin: Relax and enjoy the journey. Our 18-year-old selves are concerned with getting into the right college to get the grades to get into medical school, to get the grades to get into residency, to get the fellowship or the post-training job. The focus on the destination is significant. And what I can tell you, from my perspective at this point in my life, is that it really [isn’t] about the destination. We all have the same ultimate destination, and I'm not sure we want to get there quite as fast as we may think we want to, but it really is all about relaxing and enjoying it. I think the journey really is actually better than the destination. If I had to complete this sentence: The most important thing residents need to know today is...the challenges of residency are finite, and it does get better. The role that you play as a resident is critical. It is not a job; it is a profession, and that patients and peers, and yes, even faculty, even senior faculty, really do care about your input on a particular case. Some people are more able to show that than others, but I think the reason that any academic went into academic urology, they will tell you, is because of the collaboration. Some of that's with peers, with other faculty, but really most of it is about collaboration with trainees, with residents, with the next generation. I trained in the Harvard system where one didn't really challenge one's superiors, but I think it's healthy. So, relax, enjoy the journey, life really does get better, and make human connections.

Ghanney Simons: Thank you, Dr. Litwin. Again, this has been an honor and a privilege. I know I keep parroting this because over the past 5 years, I've had the opportunity to learn at your feet, if you will. And just being able to share that with the rest of the world has been incredibly important and just really a joy.

Litwin: Thank you very much, Chantal. I would change the metaphor a little bit and say that any teaching I've done hasn't been with you or anybody out to my feet, but it has been walking side by side into the future. Thank you for that.