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LEGENDS IN UROLOGY


(19) 4 Aug 2012

Mostafa Elhilali, MD, PhD, FRCSC
Professor of Surgery Jarislowsky
Chair of Urology McGill University
Montreal, Quebec, Canada

When I was originally asked to contribute an article to this section I declined, because I did not consider myself to be a legend. However, I later agreed to share my life experiences, since hopefully a few of the lessons that I learned—sometimes the hard way—might benefit someone planning a career in academic urology.

I started by looking up the meaning of the word “legend.” I found an interesting description: “A story concerning the life of a saint.” This did not apply very well. I found a second description: “A person whose fame or notoriety makes him a source of exaggerated or romanticized tales or exploits; synonyms fable or myth.” Maybe!

I will share my story as best as I can, highlighting how careers are influenced by many variables, many of which are outside our control.

I was born and raised in Upper Egypt where my father worked as the director of income tax offices for southern Egypt. Our family is deeply rooted there, and I was surrounded by a very politically oriented family of lawyers, landowners, farmers, and others who wasted large fortunes. I learned a lesson or two from each that forever influenced my decisions in life.

At age 15 I finished high school in the American college and was faced with the most important decision of my life: choosing my career path. Most of my family members with higher-education were lawyers, because this was seen as the natural path to being politically involved. My father wanted me to study medicine, but I was leaning towards law. He took me to see my uncle who had the largest corporate law office in Cairo and was the last Prime Minister of Egypt under King Farouk. My uncle told me that I could become a lawyer, but he advised me to study medicine and then if I still wanted to be a lawyer, I could become the first qualified malpractice lawyer in Egypt.

I applied to and was accepted by the medical school of Cairo University, the oldest of the three universities in Egypt. I failed two subjects in my first year—the first time I had ever failed an exam—and I was ready to throw in the towel and switch to law. After few days of reflection, however, I decided to rewrite the exams, which meant a summer of studying in Cairo while the rest of my family was enjoying the beach. I learned a lesson from this—to never give up after a bump in the road—and I never failed an exam since.

The next turning point in my career occurred during my internship when we had to choose a specialty and obtain a residency position. Since I had graduated with high grades, I could choose any specialty. My first choice was gynecology. The stumbling block was that three of my classmates with lower marks were children of professors who would receive preference. That is when urology became my first choice, and I never regretted it. The lesson here is to never cry over spilt milk, since it may lead to better things, which is what happened in my case.

I trained under a talented group of pioneers in Egyptian urology (Fawzy, Badr, Safwat, Fam, Zaher, and Moro). I fell in love with urology. My first year, when I was the only urology resident and responsible for 100 beds, clinics, and operating rooms was the experience of a lifetime. My second year was even more enjoyable when my intern, the future Prof. Mohamed Ghoneim, became my junior urology resident. We became and have remained inseparable friends. The lesson learned here is that the residency training years form the most influential period of your life. Your residency will shape you into the urologist you will become, and the friends you make will last a lifetime.

After my residency, I was appointed to a staff position in the Urology Department at Cairo University—a highly coveted position that became available infrequently. At the time (the Nasser era) it was almost impossible to get an exit visa to study abroad. For a very short period, authorities allowed the Educational Commission for Foreign Medical Graduates (ECFMG) exam to be taken in Egypt. I jumped at the chance, crammed for the exam, and passed. The next challenge was to get a scholarship to a foreign university. I applied to McGill University and UCLA. Ken McKinnon, the Chair at McGill, answered first and this is how I started my Canadian career. At the time the emphasis was on acquiring surgical skills, but I chose a research fellowship and my PhD thesis was on LDH isoenzymes in prostate cancer. I loved what I was doing and those 4 years colored the rest of my life. The lesson learned here is that early on, you should choose what you would love to do for the rest of your life. It is much harder to change course later on.

The question I am frequently asked is “How can you divide yourself between clinical practice and a research career?” It is very difficult, and most often research gets the short end of the stick and is abandoned. As a clinician/scientist, if you choose to do basic research with a potential clinical application, you have to divide your time equally between clinical practice and research (at least for few years), associate yourself with a basic scientist you admire, and identify the right student (who will be your interface between the bedside and the bench). The lesson I learned is that it is imperative that you collaborate fairly with the basic scientist. That is, you need to talk the same language, spend the time needed to develop the research concept, hypothesis, and methods, and provide the clinical perspective and materials necessary to conduct the study. Only providing patient material and expecting the researcher to do all the work is a recipe for failure. I started my academic career in Canada as an assistant professor at Sherbrooke University and stayed there for 14 years before coming back to McGill as Chair of the Department of Urology. Over this long journey I always had an excellent post-graduate student or a post-doctoral fellow maintaining this bedside-bench link, and I kept the interest and the respect of the basic scientists, which is essential for success.

It is often said that we rise on the shoulders of giants that mentored us. While this is true, my students and trainees have also played an important role. Each one filled in a piece of the puzzle in urology research. The lesson learned is don’t give up on research too quickly; persevere, and it will reward you in the end. It is true that income is important, but scholarships are available to help compensate for income. I was blessed by being part of a practice plan at Sherbrooke University that encouraged research and removed financial penalties. This is why, when I joined McGill as Chair of the Department of Urology, one of my priorities was to create a similar faculty- wide practice plan that encouraged research and innovation and removed financial disincentives for those who chose a clinician/scientist career path.

The successful research from the Department of Urology came from my conviction that we need to have a very close collaboration between clinicians and scientists who preferably should work in the same department under the same leadership. I was fortunate to have a very understanding Dean, Richard Cruess, who believed in me and supported this concept. We started in 1984 with a laboratory with three full-time professors fully dedicated to research in the Department of Urology. They eventually became tenured professors. The research laboratories are now much larger under the current leadership of Dr. Armen Aprikian, and we are very fortunate that we now have eight full-time professors who are researchers and we are recruiting others. The ability to recruit so many basic scientists requires a lot of financial support and we were very successful in convincing many friends and philanthropists to believe in what we are doing. Without their help we would not be where we are today. The lesson learned here is that community involvement in what we do is essential for success.

We should also not lose sight of our role as educators, and this cornerstone of academic life has been front and center throughout my career. I am very proud of the many students who touched my life and moved on to become recognized and established clinicians, researchers, educators, and department heads.

Taking on administrative tasks is another challenge in urology. My major concern when I was asked to become chief of the Department of Urology at Sherbrooke University in 1975 was “What will I have to give up?” As department chief, you often work longer hours, travel, and are away from home. While I missed my family while I was away, I made sure to keep prime time dedicated to them. Lessons I learned as chairman of different departments at McGill University is that you should have clear objectives, surround yourself with the right people, and then do what you feel is right and assume responsibility for the consequences. In many ways it is a thankless job, since your accomplishments may not be recognized until much later. I maintained administrative duties for 34 years.

The other important part of my career was becoming involved with national and international urology organizations. This is another nonpaying job that urologists do for the love of our specialty, the eagerness to “spread the word,” and the attempt to accomplish personal goals in a larger arena. Getting involved has to start from the bottom. You need to show interest, enthusiasm, and dedication to move up the ladder of the organization you are serving. I started from the bottom at the Canadian Urological Association and the Northeast section of the AUA and through many years of participation became the president of both organizations. The time commitment was manageable and the camaraderie was very rewarding.

On the international scene, my involvement with the Société Internationale d’Urologie (SIU) was very different. After organizing the 1997 meeting in Montreal I was parachuted into the top administrative position of General Secretary of the SIU in 1998 as an emergency replacement. I accepted the position on the condition that the central office be moved to Montreal, which was done, and it has remained here ever since. I have to give credit where it is due. Having Luc Valiquette as my adjunct was instrumental in any progress we made over the years, and for that I am forever grateful. The time commitment and the challenges were much more involved. The society evolved from having a part-time secretary in France and an externally-managed congress held every 3 years to having a central office with nine employees and an annual congress that is managed in-house. Very importantly, the society became financially stable and able to fulfill its primary commitment of promoting urology training in developing countries and playing a significant partnership role with our two big-league, sister organizations, the AUA and the EAU. I am very proud of this accomplishment.

I would be remiss if I do not say a few words about the impact of innovations in urology. This is what keeps me going at my age, which is a few years beyond retirement age! We are blessed in urology with the rapid evolution of new and exciting developments. It is happening so fast we are frequently short of breath trying to keep up. I am very proud of being an active participant in many of these developments. When endourology started to become popular, I felt we needed to get involved. With the help and support of Arthur Smith we were among the first centers in Canada to become recognized as a major player in this field, and this remains. When neuromodulation was in its infancy, we teamed up with Emil Tanagho and Richard Schmidt from San Francisco and started the first phase III trial that led to the introduction of the technology worldwide. In 1997 one of our younger colleagues, Denise Arsenault, came to me requesting a holmium laser machine for management of stones, but she tried to convince me to get involved with the BPH component of using holmium laser machines to enucleate prostates. I told her I am too old to learn new tricks. She was persuasive and I went to learn the technique and evaluate the prototype of morcellation with Peter Gilling in New Zealand. I have not done an elective TURP or retropubic Millin prostatectomy since then. It is safe to say that this last venture of getting involved with laser prostatectomy is what will be remembered from my long journey in urology and what will leave the last impression. We now have one of the largest patient series with the longest follow ups worldwide. This constitutes a major part of what I do today. The lesson here is that you are never too old to learn new techniques if you are enthusiastic enough and devoted to reaching the top of a new subspecialty.

For my close friends in Canada I would like to close by first alluding to my nickname among friends and colleagues as being the godfather (the Don) of urology in Canada. It is mostly because of my voice that resembles that of the godfather and maybe because I see no limit in what you can accomplish if you put your will and energy into achieving it. I can reassure everyone that I have no underworld or mafia connections! Finally, being appointed as an officer of the Order of Canada (2001) and an officer of the National Order of Quebec (2009) have been two highlights of my career and life.

Mostafa Elhilali, MD, PhD, FRCSC

Professor of Surgery
Jarislowsky Chair of Urology
McGill University
Montreal, Quebec, Canada

© The Canadian Journal of Urology™; 19(4); August 2012 6327

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