LEGENDS

Richard J. Macchia, MD, FACS
Glickman Urological and Kidney Institute
Cleveland Clinic Florida

Given those who have been honored in the CJU Legends series I consider my contributions, which were mainly in the field of education, to be modest in comparison. However, I gratefully accept this recognition as a urology educator.

After graduating with a BS in Physics I decided to go to medical school. My dad, a gastroenterologist, was thrilled, but my mom, a “hospital widow,” was less enthusiastic. Dr. George Nagamatsu, chair at New York Medical College, (NYMC), sparked my interest in urology. After graduation in 1969, I completed pre- urology general surgery training at St. Vincent’s Hospital (SVH). Andrew McGowan, chief of urology at SVH, recommended me to Keith Waterhouse at the State University of New York (SUNY) Downstate for residency. In 1975, Dr. Willet Whitmore accepted me as a New York Academy of Medicine (NYAM) Ferdinand C. Valentine fellow at Memorial Sloan-Kettering Cancer Center (MSKCC). Brian McCaffery, my former chief resident and predecessor fellow at MSKCC, paved the way for me. I had much less surgical experience than my co-fellows Harry Herr,1 Skip Holden, and Rich Egan, each of whom helped me make it through the fellowship. Pram Sogani and Winston Barzell, both superb surgeons, taught me how to do a radical cystectomy. It was the most wonderful year of my medical career.

In 1976, I joined the faculty of SUNY Downstate Medical School. In 1982, I was appointed professor, chairman, and Accreditation Council for Graduate Medical Education (ACGME) program director. I served in those capacities until 2010. I was greatly honored when Peter Scardino appointed me Consultant, Department of Urology, MSKCC, in 2003. I also worked closely with other chiefs of urology at MSKCC—Pram Sogani, Bill Fair and now James Eastham and Joel Sheinfeld, the fellowship director. MSKCC contributed greatly to the education of our residents and our ability to attract excellent medical students.

I chaired the Section on Urology of the NYAM and was a member of its Advisory Council for 6 years. I also served on the NYAM selection committee for the Ferdinand C. Valentine Medal for career achievement in urology for 6 years and chaired the committee for 1 year. I was also a chairman of the Edwin Beer Fund Committee. The NYAM was the scene of one of my first (of many!) academic disputes. Several members of the selection committee did not want to award a fellowship to one of my residents who wished to take his fellowship outside of AUA-NY Section region. I presented the case for this resident and he was granted this fellowship. That resident was Tom Lue.2 This experience led me to become somewhat obsessed with the concept of providing a level playing field. I fought for blinded submission of manuscripts and abstracts. I also lobbied for the inclusion of an academic integrity clause in the AUA urologist’s oath (which was subsequently adopted).

When I became chair at SUNY Downstate, three giants were chairs in Manhattan: Mike Droller, Darracott Vaughan,3 and Carl Olson. They were role models and treated me as an equal, an undeserved courtesy I will never forget. I think collegiality is one of the hallmarks of urology. I have greatly enjoyed my interactions with and learned from colleagues throughout the world. Recently, Leonard Gomella called me one of his mentors, but I suggested it was perhaps the other way around. Ken Glassberg, Gobind Laungani, and I were all Keith Waterhouse’s residents. I was very fortunate that they agreed to stay when I became chair. After our fellowships, the three of us worked together for about 25 years. Ken has had an outstanding career with very significant contributions to pediatric urology. Gobind, a superb surgeon, took on many of the clinical tasks to free me up to work with students and residents. I restructured our residency program into a multisite, 4-year program, in which our residents were chief residents for 2 full years. Our faculty members included Mark Horowitz, Vic Nitti, Jack Mydlo, Andy Combs, B. Mayer Grob, Nick Karanikolas, Ivan Colon, Aizid Hashmat, Ciril Godec, Ivan Grunberger, Llew Hyacinthe, Jeff Weiss and many others. At Kings County Hospital Center (KCHC) Lynette Boissiere was our dedicated cystoscopy suite head nurse. Except for my time at MSKCC, I spent July 1971 through May 2009—38 years—at SUNY Downstate and KCHC.

As chair of SUNY Downstate, I appointed the first women, African Americans, and Hispanic Americans to our residency programs and faculty. I also appointed the first Hispanic urologist as vice-chair and the first African- American urologist as a chief of service. It was a special coup to recruit Erich Lang to Downstate as part-time, vice- chair for uroradiology in 2005. A shortage of funds was a constant, enormous, and overriding challenge in running our department. I only had control over the finances of our small group at University Hospital-Brooklyn. Voluntary contributions from faculty allowed me to fund basic resident educational activities.

Many years ago, Adley Raboy, a former student, resident, and then faculty member at one of our hospitals, walked into my office and casually informed me that he and his colleagues had performed the world’s first antegrade extraperitoneal laparoscopic radical prostatectomy.4 I was astounded and excited.

One of my great pleasures occurred after Marc Goldstein—who had graduated from SUNY Downstate Medical School and our urology program—was granted an Honorary Doctorate in Biological Science, not clinical science, by SUNY Downstate in 2008. I nominated Tom Lue for the same award the next year, and he won it. One of my great disappointments occurred when Irwin Goldstein, who was leaving Boston University presented a compelling case to me to initiate the first fully independent Department of Sexual Medicine in an American medical school. I fully supported the concept, but it was ultimately rejected by the university.

The story of Chuan-Guo Xiao, a former member of my faculty, is one of enormous highs and lows. As a result of his experience with catastrophic trauma in China he embarked on a decades-long search to find a cure for the urologic effects of spinal cord injury and meningomyelocele. The result is the “somatic-autonomic reflex pathway” procedure, also known as the “lower urinary tract refunctionalization by somatic/autonomic nerve root transposition” procedure, or simply the Xiao procedure. Xiao did much of his pre-clinical work and won all his NIH grants, in excess of $3 million dollars, while working in a hospital in my department. I tried to obtain funding for him from my institution, but despite his winning huge grants, my requests were denied. I believe Xiao’s concept will be proven to be correct. If so, he deserves enormous credit for his dogged persistence. For full disclosure, please note that several years ago, after leaving my faculty, he invited me to come to China as a visiting professor. I observed him performing the procedure several times and talked via an interpreter to patients’ parents who had tears of joy as they described their experiences. Medicine is replete with cases of eventual vindication. I hope this occurs for the Xiao procedure.

I have been a career-long member of the NY Section AUA and it was an honor to be its president 1995-96. My colleagues granted me the Russell Lavengood Award (an award that I originated and Darracott Vaughan named), nominated me for the AUA Robert F. Flanigan Education Award (I didn’t win!), and nominated me for an AUA Distinguished Contribution Award (I did win!). The AUA and the SE Section have allowed me to remain a member of the NY Section after I left New York in 2010. I was the first representative of the New York Section to the Society of Urology Chairpersons and Program Directors.

In 2003, Andy Novick offered me a position at Cleveland Clinic, where I was to work with Steve Jones, who remains a good friend, colleague, and supporter to this day. To decline that offer was very difficult, but I decided that I didn’t want to move from Manhattan to Cleveland. Andy understood and, thereafter, we had dinner together many times in NYC. We lost a great leader when he died in 2008. Before he died, Andy had appointed Larry Hakim, my former student and resident, as chief of urology at Cleveland Clinic Florida (CCFL) in Weston, Florida. He and Andy invited me to take a look. I started what was intended to be a 6 month sabbatical in June 2009, but I loved it so much I have been there ever since, serving in a part-time, outpatient-only, non-leadership position. My former student and resident is now my boss! We are an integral part of the Glickman Urological and Kidney Institute with Eric Klein as our director.

I was privileged to have Bob Furchgott, professor and physiology chair emeritus at Downstate, as a friend. Bob won the Nobel Prize in Medicine or Physiology in 1998 for his co-discovery of the role of nitric oxide. He took me with him when he went to accept his award. Being in Stockholm during Nobel Prize week with a laureate was the thrill of a medical lifetime! Ray Damadian, another colleague at Downstate, should have been awarded the Nobel Prize for his co-development of the MRI. In my opinion, he was unjustly denied.5

I have disagreed with several policy decisions made by the ACGME. Then editor of the CJU, Gabriel Haas, allowed me to vent my displeasure at the ACGME’s imposition of the Outcomes Project.6

My contribution to medical literature has been modest. I co-authored about 135 papers, published abstracts, and textbook chapters, with a student or resident as co-author on most of these publications. I am the senior author on Tom Lue’s first paper! My colleagues and I did win second prize at the AUA in 1980 and 1982 for our early work on androgen receptors. More recently, our paper on fluoroquinolone-resistant post transrectal prostate biopsy infection was, I believe, the first to document this increasingly important phenomenon. Joe Feliciano, an outstanding resident, was first author.7 I have greatly enjoyed serving as an abstract reviewer and frequent moderator for the annual AUA meeting and as a manuscript reviewer for many journals.

Many years ago, I was in line to become the president of the NY State Urological Society. I declined, realizing that I did not possess the even temperament that is needed to be effective in influencing politicians. I appreciate the efforts made by urologists who toil on behalf of the rest of us in the political, social, economic, and legal arenas, whose work frequently goes unrecognized.

The focus of my career has always been education. I am most proud of my students and residents. I estimate that about 130 of my students have pursued urology residencies during my tenure at SUNY Downstate.8 I was a strong, early, and persistent proponent of fellowship training. Former residents are or have been core faculty at Weill-Cornell, UCSF, UCLA, NYU, Mt Sinai-NYC, University of Georgia, Cleveland Clinic Florida, Duke, SUNY Downstate, SUNY Stony Brook, Harvard, University of Indiana, Beth Israel Medical Center-NYC, University of Illinois, Brown University, and University of Florida. Former students are on the urology faculties of medical schools across the USA.

Sadly, my career-long friend, mentor, and role model, Bob Wickham, a former president of the NY Section, died in February 2013 at the age of 90. He was the recipient of 2 Bronze Stars and an inductee into the French Legion of Honor for his bravery in WWII. He was the finest gentleman I have ever known. My brief tribute to him appears in the April
2013 issue of AUA News.9

In 1994, I was named an honorary alumnus of SUNY Downstate Medical School and was awarded the Medal of Honor by the NYMC Alumni Association. In 1995, I was elected a faculty member of the Alpha Omega Alpha medical honor society (AOA). In 1997, I received the Gender Equity Award from the SUNY Downstate chapter of the American Medical Women’s Association, and I was an honoree of the Daniel Hale Williams Society, an organization of African American and Latino medical students. In 1998, I was designated Master Teacher in Urology by the SUNY Downstate Alumni Association. In May 2003, the Arthur Ashe Institute for Urban Health presented me with its Leadership in Urban Medicine Award. In June 2005, I was presented with the first SUNY Downstate College of Nursing Excellence in Clinical Teaching Award. In 2006, I was named as the physician honoree at the celebration of the 175th anniversary of the founding of KCHC. In 2007, I received the first Golden Apple Teaching Award from the SUNY Downstate Medical School chapter of the AOA. I was very honored to be the first physician from Downstate to be named Physician of the Year by Bikur Cholim of Boro Park. Early on, I received a physician award from the ECHO-National Jewish Institute for Health. Since I am an Italian-American, many of these awards have special meaning to me.

In summary, I have been very fortunate in my career as a urologist. I owe an incredibly large and unpayable debt to my patients, mentors, colleagues, residents, students, friends, family, parents, and country.

Richard J. Macchia, MD, FACS

References

1. Herr HW. Legends in Urology. Can J Urol 2010;17(1):4972-4974.

2. Lue TF. Legends in Urology. Can J Urol 2012;19(1):6070-6073.

3. Vaughan Jr DV. Legends in Urology. Can J Urol 2009;16(2):4533-4535.

4. Raboy A, Ferzli G, Albert P. Initial experience with extraperitoneal endoscopic radical retropubic prostatectomy. Urology 1997;50(6):849-853.

5. Macchia RJ, Termine JE, Buchen CD. Raymond V. Damadian, M.D.: Magnetic Resonance Imaging and the Controversy of the 2003 Nobel Prize in Physiology or Medicine. J Urol 2007;178(3):783-785.

6 Macchia RJ. A urology program director ’s view of the ACGME outcome project. Can J Urol 2008;15(4):4139.

7. Feliciano J, Teper E, Ferrandino M et al. The incidence of fluoroquinolone resistant infections after prostate biopsy—are fluoroquinolones still effective prophylaxis? J Urol 2008;179(3):952-955.

8. Kutikov A, Bonslaver J, Casey JT. The gatekeeper disparity--why do some medical schools send more medical students into urology? J Urol 2011;185(2):647-652.

9. Macchia RJ. In Memoriam: Robert D. Wickham, 1923-2013. AUA News 2013;18(4):36.

© The Canadian Journal of Urology™; 20(4); August 2013 6819