The Making of a Plastic Surgeon: Two Years in the Crucible Learning the Art and Science

Chapter 2- The Interview

(For those readers who expected this yesterday, apologies. The day got away from me)

Chapter 2- The Interview

“Houston, we have a problem.”

James Lovell, Apollo 13

On a warm summer morning in 1986 I walked up to the cafeteria entrance at the University of Miami/Jackson Memorial Hospital in Miami, Florida for a face-to-face meeting with Dr. D. Ralph Millard, Jr., Chief of the Division of Plastic Surgery and head of the two-year residency program in plastic surgery. He was to interview me for a position in his program starting in the summer of 1987. As a backup, I had also arranged to interview in Norfolk, Virginia the following day in a residency at the University of Virginia run by Dr. Bill Magee, another well-known plastic surgeon.

I had applied to the Miami program largely because of my time in medical school and superficial familiarity with the program from a brief two-week exposure to it as a fourth-year student. By the end of our time in Okinawa, Sally and I wanted to return home to Miami. The Norfolk program was my backup. Unbenownst to me, this was one of Dr. Millard’s principles of plastic surgery- to always have a backup plan B in case plan A goes awry. I chose it only because I became aware of it while in the Navy. The plastic surgery program at Norfolk reserved a place for one Navy resident each year. The Navy resident would incur several additional years of obligated military service after completing the residency. In my application, however, I specifically asked to interview only for a civilian position since I did not want to remain in the Navy beyond my current enlistment.

Dr. Millard was waiting for me outside the cafeteria. As I walked up and we shook hands, I had no appreciation for how limited my knowledge was of the storied history of plastic surgery or its breadth, or of the program at the University of Miami. I certainly did not fully appreciate the stature of Dr. Millard within the specialty. It is to this that I attribute the fact that I approached the meeting with an uncharacteristic degree of calm and composure. Truly, ignorance was bliss.

 “You know, you are our top candidate.”  Dr. Millard said, as we shook hands. He was not one to beat around the bush.

Having flown half-way around the world for this interview, those words were as welcome as they were unexpected. The joy of the moment was sweet, but short-lived. I did not then know that Dr. Millard had boxed at Yale University and was a lifelong devotee of the sport. Within moments, he would deliver a verbal uppercut that would leave me, figuratively, on the canvas dazed and confused, desperately struggling to salvage my candidacy, and wondering how I could so quickly snatch defeat from the jaws of victory. But I am getting ahead of myself. A little background is in order.

The application process for nearly all residencies is similar. Residency programs sift through the applicants who submit a resume and invite the top ones for interviews. Later, both applicant and program submit their list of selections to the National Residency Matching Program (NRMP) ranked in order of preference. Applicants and programs are computer matched such that each is matched with the other who ranked them highest. Of course, unless the applicant and program each rank the other number one, some compromise is inevitable. The residency program at the University of Miami did not participate in the NRMP. Dr. Millard would not cede control over the resident selection process to anyone else and he personally selected every resident he ever trained.

This would be an appropriate time to provide some background on Dr. Millard, as his influence infuses the rest of this book. He was one of the major figures in plastic surgery, along with other luminaries such as Sir Harold Gillies, Paul Tessier, and Harry Buncke. Dr. Millard’s claim to fame was his pioneering work in cleft lip and palate surgery and remains the standard for this.

The program at Miami had an unusually eclectic mixture of personalities and backgrounds. Among his residents was a 60-year-old surgeon, a resident who happened to be a world class carver of duck decoys, and a wheelchair-bound paraplegic. Every aspect of the program carried Dr. Millard’s imprimatur.

Any honest account of training under Dr. Millard must at times paint him with an unflattering brush. He was demanding and difficult to please, mercurial, irascible, and, at least to me, tremendously intimidating.  At times, he was, quite frankly, difficult to like. Without him, however, the program at Jackson would have been like most any other program in the country with little to distinguish it. All plastic surgery residencies had to satisfy the same basic requirements, but Millard’s presence made the Miami program truly unique.    

Born in 1919, the same year as my father, he was 68 when I returned to Miami from Okinawa. While many of his peers were winding down their careers or already retired, he maintained a full schedule of surgery, was fully engaged in the residency program, was a popular invited lecturer around the world, and remained active in clinical research. He was an imposing figure, over six feet tall with a powerful, athletic build. He was always nattily dressed. He had a thick shock of white hair against a perpetual Florida tan and eyes that could project an intense, steely gaze. His large hands belied their deftness and gentle touch in surgery, especially when operating on tiny infants. It sometimes seemed to me that he could magically coax living tissues to do for him what they would not do for a lesser surgeon.

He was a study in contrasts. A supremely innovative surgeon, he was also a creature of habit in many things, his weekly routine unvarying. Many of his operations followed a set plan with which we became very familiar. At the end of each day, he left his office, stopped at a gym on the way home, and did a full Nautilus circuit. His knowledge of plastic surgery was encyclopedic. He knew more than just the literature of plastic surgery; he personally knew most of the principal players in the history of the specialty. Cold and aloof at times, he could also be charming, and, on occasion, he exhibited a droll sense of humor. The latter could pop up at unexpected moments.

Despite his age, Dr. Millard did not wear glasses. His one concession to age was that he liked a very bright operating field. His operating room had four ceiling-mounted articulating surgical lights shining on the field. In addition, the resident assisting him always wore a surgical head light. One resident before me was a former Air Force fighter pilot. He modified his pilot’s helmet and affixed to it a powerful flashlight, much brighter than the surgical headlight we routinely used. He wore the outlandish headgear during an entire day of surgery. To his surprise, Dr. Millard did not rise to the bait and never once commented on the unusual accessory. Disappointed, he left the helmet home the next day. As they scrubbed at the sink for the day’s first case, Dr. Millard dryly asked, “Where’s the light?”

In 2000, the American Society of Plastic Surgeons, the world’s largest organization representing the specialty, named him as one of the top ten plastic surgeons of the millennium.   

Dr. Millard trained under some of the greatest pioneers in plastic surgery. In his era surgical training combined elements of indentured servitude, apprenticeship in a guild of master craftsmen, and a college fraternity hazing. The hours were long and arduous, the demands great, vacations essentially non-existent, and the pay meager. Program directors of the day did not take into consideration a resident’s lifestyle or quality of life. A product of his time, he carried some of this over to how he ran his residency program. One resident made the mistake of inquiring when he could take some vacation time so that he and his wife could make plans in advance. Dr. Millard saw this entirely reasonable request as evidence that the resident cared more for his vacation time than his training and it soured their relationship for the duration of his residency.

Of all the people who contributed to his training, none was more important than Sir Harold Delf Gillies. A plastic surgeon in England, knighted for his work in reconstructive surgery during and after World War I, Gillies is regarded as the father of modern plastic surgery. His time under Sir Harold’s tutelage forever influenced his career and he remained a devoted Anglophile all his life. I once made the mistake of referring to his mentor as Dr. Gillies. He immediately corrected me. Surgeons in England to this day proudly go by the title of “Mr.”, not “Dr.”, to distinguish themselves from other physicians. This tradition dates to the 18^th century, when the practice of surgery was eschewed by most physicians. One of Dr. Millard’s proudest achievements was his induction as an honorary Fellow of the Royal College of Surgeons in 1986. His accounts of training under Gillies sometimes mirrored my own residency experience.

The defining moment in his career came when he was in the U.S. Navy Medical Corps in Korea in 1953, just after the signing of the armistice between North and South Korea, and was assigned to a U.S. Marine Corps field hospital. Once hostilities ended, part of the mission of the Marines was to assist with rehabilitation of the civilian population. Dr. Millard resolved that reconstructive plastic surgery should be a part of this process. He began with reconstruction of Korean citizens ravaged by the war with traumatic deformities, but could not help but notice the numerous children with unrepaired cleft lips in the local population.  

Surgery to repair cleft lips remains one of the enduring challenges spanning the history of the specialty. Countless operations had been devised, from very simple, straight-line repair to complex, geometric flaps, but none of the early efforts produced a result remotely approaching a normal lip. The problem interested him, and he began to study it in his spare time. One day, while staring at a board on which he had posted photographs of children with cleft lips, he fell asleep. When he awoke, he found himself looking at the board from a slightly different angle and viewing a photograph that was slightly askew. That was the moment he saw what had eluded surgeons since the dawn of cleft surgery: the true nature of the deformity. It was a true “Eureka!” moment.

Contrary to conventional thought, nothing was missing from the cleft lip. All the elements of the lip were present, but they were distorted and out of position. The solution to solving the puzzle of cleft lips was to restore these elements to their normal position and secure them there, a principle he had learned from Gillies. From this epiphany came his signature contribution: the rotation/advancement repair of cleft lips. Once he had formulated his plan for the repair, he needed a patient. Callouts to the local communities by Korean interpreters failed to produce a single patient although he knew there were many out there.  He drew on his skill with a lariat, something he had learned as a young man, to attract a crowd of children and literally rope in a ten-year-old boy with an unrepaired cleft lip. Although you would never see such older children with unrepaired lips in the U.S., it is a common situation in developing countries to this day. Subsequently, he repaired the lip under local anesthesia using this new technique in one of the surgical Quonset hits with his corpsmen assisting. The happy result produced a steady stream of families coming to the Marine camp with their children for free surgery to repair their lips. 

Better than any prior technique, Millard’s technique restored the lip to its natural appearance with scars that were hidden in the natural shadow and contour lines of the normal lip. It was a seismic advance in cleft surgery. He introduced his new technique to the world at the 1^st Congress of the International Society of Plastic Surgeons in Stockholm in 1955. It was a sensation, both on its own merit and for Dr. Millard’s presentation. He was only given five minutes for his talk and, try as he might, he could not whittle it down to less than seven. Seeking to find a way to extend his time, he remembered that the timing process did not commence until the speaker was at the podium. He therefore began his talk at the back of the auditorium and took two minutes to walk slowly up to the podium at which time his five minutes officially began! The response to his presentation was mixed, in part because many of the senior plastic surgeons regarded his ploy to extend his time as brash and impertinent. Even so, the superiority of his operation over all others was not to be denied and it was rapidly adopted. To this day it remains the gold standard for repair of cleft lips and is often referred to simply as the Millard repair.  This contribution alone would have been enough to cement his place in history, but Dr. Millard was not one to rest on his laurels and continued to contribute to the specialty throughout his career.

Dr. Millard was a prolific clinical researcher and writer. He authored or co-authored hundreds of papers published in medical journals, contributed chapters to numerous textbooks on plastic surgery, and wrote several books of his own. In 1957, he co-authored the two volume Principles and Art of Plastic Surgery with Gillies. At the time, it was the definitive work on the specialty. This was followed by his magnum opus, the three volume Cleft Craft: The Evolution of Its Surgery, which was published over 1976 through 1980. To this day, it remains the definitive work on surgery for cleft lips and palates. The first volume was awarded the 1976 R. R. Hawkins Award of the American Publishing Association for excellence in books in the category of medicine, technology, and science. It was reviewed by Time magazine and nominated for a Pulitzer Prize.

In November of 1986, the year before I began my training, he published Principlization of Plastic Surgery. The unusual title was more than matched by the unusual book. It codified 33 principles to guide plastic surgeons in their practice of the specialty (appendix I). Some of these dated from Dr. Millard’s time with Sir Harold. The rest were drawn from his years of practice. I have never seen a medical textbook like it. Each chapter expounded on one principle. The book was lavishly illustrated with numerous photographs and drawings drawn from plastic surgery and, surprisingly, other fields such as entertainment and sports as well. The chapter on perfecting one’s craftsmanship, for example, included a photograph of a Chippendale chair and a Stradivarius violin. In some chapters, he even suggested specific mood music to listen to while reading. The margins of many pages included hand-written notes by Dr. Millard, as if added as an afterthought.

By emphasizing principles rather than specific techniques and procedures, Dr. Millard ensured that Principilization of Plastic Surgery would be relevant long after many of the operations described therein were obsolete. In addition, many of the principles could be applied to other fields of human endeavor. The book had something in it for anyone, from the reader with no medical background, to the most experienced plastic surgeon. It, too, was nominated for a Pulitzer Prize.

Now, back to my interview that fateful morning at Jackson.

As we shook hands, his greeting took me by surprise and filled me with a warm sense of optimism about obtaining a position in the residency. After settling in at a table in the cafeteria, surrounded by some of his residents, he inquired about my training and experience on Okinawa. He spoke fondly of his time in the Navy. I felt the interview was going very well until he asked the one question I should have anticipated. What I could not have anticipated, however, was how much hinged on the answer. The question was simple enough.

“Where do you plan to practice when you finish your training?” asked Dr. Millard. I had not really thought that far ahead; my primary concern was getting into a residency, not where I would practice afterwards.

 “Well,” I said, “I grew up in Miami and both my wife and I have family here so I suppose I might just stay here to practice.”

It would have been entirely appropriate at that moment for a klaxon to have gone off and a big sign stating, “Wrong answer!” to have dropped down from the ceiling.

 “In that case, I won’t accept you here,” was Dr. Millard’s immediate response. “Go on to Norfolk for your interview. You can train there and return to Miami to practice if you wish.”

It was clear that the interview was over. I was dumbfounded.

From breakfast, I accompanied Dr. Millard and his resident to the operating room where I observed a couple of operations. I have no recollection today of what they were, lost as I was in a black fog of misery that my candidacy had been torpedoed so unexpectedly and completely. Dr. Millard’s operating room contained a large white board. Among the many stories that were part of the lore of the program was that of one hapless applicant who made the mistake of mentioning his artistic talent. When they arrived in the operating room. Dr. Millard directed him to the white board and told him to draw a horse. At least I was spared that.

Dr. Millard said little to me after breakfast and it seemed clear that any chance of a residency position had evaporated. Incredibly, from there things went from very bad to lots worse. I had scheduled my interview in Norfolk for the next day and was to fly up that evening. As I mentioned earlier, the Norfolk program reserved one residency slot per year for a surgeon on active duty in the Navy. I had very specifically requested to be considered for one of their civilian slots as I did not want to remain in the Navy once my obligated duty was completed. At midday, I called to confirm my appointment and asked to verify that I was interviewing for a civilian position only. The program secretary informed me that the civilian positions for 1987 were already filled and my interview was solely for the Navy position.  I canceled my interview and hung up. Ironically, there were no other Navy applicants that year, so the position would have been mine to refuse. Even today, this decision seems inexplicably foolish, but I was adamant about not staying in the Navy any longer. 

I had interviews with several other attendings in the Division. All confirmed that the final decision on a residency position was Dr. Millard’s alone. At the end of the day, I sat down with him in his office. He told me that he wanted his graduates to leave Miami and make their mark elsewhere, not stay in the saturated plastic surgery market there. He told me to go to Norfolk and wished me well. When I informed him of my decision to cancel the Norfolk interview, his eyes narrowed.  I returned to Okinawa with the dismal conviction that my plastic surgery career was dead in the water before it ever began. On the long flight home, Dr. Millard’s final words echoed in my head.

“Well, it seems that you have put all your eggs in one basket.”

I spent the entire return flight to Okinawa composing a letter to Dr. Millard and told him that I was not committed to staying in Miami. I asked him to consider my application on its own merits and trust me to make good use of my training wherever I settled. When a letter from him finally arrived weeks later, I could not open it fast enough despite my fear that this would be the final nail on the coffin. He said he would accept me in 1988, but that if I wished to begin training in 1987, he had arranged for the plastic surgery program at Georgetown University in Washington, DC to hold a position for me. Georgetown? There was no way I could refuse to at least check out this unexpected option, necessitating a return stateside. Fortunately, I had to go to Boston to take my oral examination for board certification in general surgery and arranged to make a side trip to Georgetown. The co-directors of the program were Drs. William Little and Scott Spear, both highly regarded in the plastic surgery world, and both trained by Dr. Millard. They informed me that they were not actually holding a position for me but assured me that I would be considered along with their other candidates, based on Dr. Millard’s recommendation. The Georgetown program was an excellent one and I came away impressed and encouraged by the interviews.

After thinking things over, I informed Dr. Millard that I would rather start my residency in Miami in 1988 than begin in Georgetown a year earlier. I reasoned that I could earn some extra money that year to tide me over what I knew would be two financially lean residency years.  I still have his letter of reply, its first sentence indelibly imprinted in my memory. It began, “It has now become possible for me to offer you a position to begin your plastic surgery residency here in July 1987….” What had changed? Had another resident given up his starting position in 1987? This seemed highly unlikely given the intense competition for the few available positions. I believe I was being tested and had passed. It would have been completely in character for the man. I never learned why my application process, interview, and acceptance played out in this unusual fashion. I know of no one who had a similar experience. I asked him this decades later and his only recollection was that he liked the discipline instilled in the military, felt I was mature and serious about my training. Regardless, I had made it past the first hurdle in my path to becoming a plastic surgeon.

Richard T. Bosshardt, MD, FACS, Senior Fellow at Do No Harm, Founding Fellow at FAIR in Medicine

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