An Interview with Tirone David: A Master Surgeon’s Reflections on a Life in Surgery

Tirone David

Tirone David continues to be extremely active, operating two days per week, completing 3-5 reviews per week for 5 journals, travelling, and speaking all over the world. He says 2-year-old Leo misses his grandfather. The David perspective on Canadian cardiac surgery is an interesting one: “clinically cardiac surgery is performed reasonably well, and cardiac patients are given better than average care, though talents vary. We aim for the stars and get to the moon. I believe we have too many cardiac units in Toronto. Consolidation would lead to improvement in expertise.”

“I came to Canada as a surgical resident 5 or 6 years after the nationalization of health insurance. It has changed steadily over the past 40 years. The blended culture of Canada is less homogeneous than in the United States. Newcomers (and there are some 300,000 of them each year in Canada) bring energy and new knowledge to the country, but not at the same level as in the United States. Look at MIT or the California Institute of Technology. The math leaders may not speak English well, but the stars in those institutions are mostly newcomers.

The explosion in information and expertise is daunting – so many papers from so many sites. For instance, 1% of the world population has bicuspid aortic valves: 8% are probably genetic and 92% are developmental errors. Ten years ago, there were less than 1,000 scientific papers on this subject to review. There are now more than 2,000. “Health expectations have changed and education and research are strong, not just in one center, but in many different centers. The University provides an ideal mechanism for this expansion in knowledge. St. Michael’s Li Ka Shing Institute excels in atherogenesis. The University Health Network excels in regenerative medicine and transplantation. It would be best to concentrate these efforts to achieve excellence.

I am against unrestricted competitive medical practice, and even more so to having insurance control quality and volume. Concentration of Centres of Excellence require that patients have to travel, but that is a worthwhile price to pay for higher quality of care. The Cleveland clinic is a good model of collaborative practice. Perhaps we could consolidate three hospitals into one in Toronto to achieve this goal. We are not so good at planning for the future. Just look at the urban development of the City of Toronto. Couldn’t our politicians have predicted what is happening with our infrastructure before so many building permits were issued?

Q: What would be your advice to grandson Leo when he is 18 and trying to decide what to do in life?

A: “I’d ask him: ‘What is your passion? What do you want to do in the pursuit of excellence?’ I had to decide at age 18 and since I was undecided my father made the decision for me: “you are going to be a doctor”. It was a lucky decision. I fulfilled my father’s wish and I discovered that medicine was a very fulfilling career. So, I would tell Leo: ‘Put your heart and soul into whatever you chose.” Parents and grandparents shouldn’t make those decisions, but we can help our offspring avoid a mismatch between their characters and a career. Mentorship is very important. I loved neurology in medical school, but my mentors guided me toward surgery, and then vascular surgery, and then cardiac surgery. One of my very influential mentors was Giocondo Artigas, a general surgeon in my home town in Brazil. He said: “It’s innate in you to do surgery’, and he had me assisting him in the operating room as a medical student. At the Cleveland Clinic, Edwin Beven, a Chilean surgeon, and Caldwell Esselstyn, George Crile’s son-in-law were important mentors as well as was George Crile himself. Bill Bigelow was my principal mentor here. He guided me to seek a niche in cardiac surgery and excel in it. He had a major influence in my life and practice. He introduced me to the famous Irish surgeon Denis Burkitt whose outstanding work on bowel cancer, appendicitis, and inflammatory bowel disorders and the role of diet, became a reference standard in medicine. Bill Bigelow sent me to visit Magdi Yacoub, Alain Carpentier and Donald Ross in Europe. I gave a talk at a course sponsored by the American College of Cardiology titled “In Search of Excellence” and described the importance of mentorship and guidance in our professional development. All those individuals influence our lives. Maxwell Wintrobe, a famous haematologist, gave a lecture at the Cleveland Clinic when I was a resident and said that just about any coagulopathy could be corrected by the transfusion of fresh whole blood. I never forgot that coming from Dr. Wintrobe. This led me to donating my own blood to an exsanguinating patient after an extensive open-heart procedure soon after I started practicing. Too bad we can’t do this any longer.

Teaching

“I am more of a model than a mentor. I started out doing one operation and assisting the resident to do the next operation, but my curiosity toward innovation and the referral of more complex cases made this more and more difficult. My true progeny are the fellows who have come and spent 6-12 months with me after their training. Most of them are international surgical stars like Gebrine El Khoury in Brussels, Marc Gillinov in Cleveland, Glen Van Arsdell in Toronto, and others. Irving Kron introduced me at an international meeting by saying: “Tirone taught us to think and how to make things better.” That has always been my goal. I published my failed ideas as well as my successful innovations. I am proudest of the new procedures I have developed that changed the lives of so many patients. John Kirklin named it ‘David operation’ –a procedure whereby the aneurysmal aortic sinuses are resected but the aortic valve cusps are preserved. This resulted in young patients being able to resume full activity on no medications after surgery. Other innovations include techniques of mitral valve repair, operations for endocarditis, an operation for ruptured ventricular septum, and techniques for repair of aortic dissection. Editor Dick Weisel asked me to write a “how to do it” article for The Journal of Thoracic and Cardiovascular Surgery on acute aortic dissection. It has received 10,000 hits because it is a simple step –bystep guide on how to do the operation safely. I should do more of that in a book about the 15,000 patients I have operated upon. I have the data on all of them, but I need more time to complete the follow-up.”

M.M.