D (3:33)

Well, I'm Roger. Ann. Mike. The story is true, except he did call me up, I think reinforced that he wanted to come while I was still pondering things, because I know. I talked to Joan about it, and I said, they want to do this fellowship. And she says, what's that? So anyway, that worked out. And as it evolved, there was no problem getting fellows. So we used to get 25, 30 people applying for each fellowship position, which made me very uncomfortable because that means I had to turn down a bunch of people. So. And you only get to interview them once. So it's just a matter of using your gut reaction as to who's going to be a good Fellow for you. So it worked out fine. But housing is a problem in the Bay Area. It's terrible. The first couple of fellows had trouble finding a place to rent for six months, and the prices were high, their pay was low. And so we finally, one day, I was leaving surgery, and there was a condominium for sale near one of the hospitals. And I walked in and it was reasonable, so I bought it, and that's where the fellows would stay. And that worked out very nicely because it was cute, because the fellows would put things on the wall and about themselves and things and about their experiences. And every fellow had a different little setup. Some of them brought a dog along. One fellow, J Oates, who's unfortunately passed on his wife didn't want to come and didn't want his Dog left home in Texas and he brought his dog with him and the dog lived out of his car for six months. And we used to giggle about that all the time in surgery. But anyway, it was wonderful training fellows. They truly interested in what you have to say. They really want to learn and that's basically what we did. And as I mentioned earlier, my wife Joan was just such a wonderful lady. She would meet the fellows wives and teach them, show them where the markets are and where to shop and if they needed any services, where to go and then she'd have them over for dinner. And it was just wonderful. It made for a very, it was a very home, family oriented type of situation. So I think everybody, except for maybe one or two fellows had a very good time. And that's what happened. Just went on and on. They just kept going for what? 70, 74. 74 fellows, yeah. So by that time my practices started to dwindle. So I finally just packed it up and said, that's enough fellowships. And so now I just see patients half a day a week at a clinic from the University of California they run in Berkeley. And I go there with this Dr. Tullier who's the now the chief of foot and ankle surgery at uc and we see patients together and I don't contribute that much, but it's fun to sit there and listen to them and I can learn things from them. And that's basically what I do now. I sit there and play with my Labrador and I haven't been able to teach her anything. She can't operate this, she doesn't have a thumb. But overall it's a good, great life. That's all I can say. The one thing that impressed me with this legacy pillar is that I'm the only one living of the group, which is a shame. Ken Johnson and I were very close friends. So Ken and I always enjoyed putting courses on together because we'd always argue about everything. He was a real character. Ken was a wonderful person and we were very close. And if I said it was white, he said it was black. If I said it was black, he said it was white. And we would just go around in a circle. But we'd always get our points across, usually.

C (7:44)

So the academy let us do an instructional course and Ken and Roger would argue back and forth and I was just coming along at that point. And so Ken and Roger brought me on and then Ken would just make fun of me. And it was sort of two against one, but Ken would usually win. But it added this camaraderie that just expanded. And we probably did that for about 10 years and the crowds were huge.

A (8:09)

I just remember my first meeting was 1987 when I first put an ankle meeting. And my first exposure was that I thought maybe they weren't good friends, but didn't make sense because as his fellow, I'd been there when I'd listen to conversations between the two of them and then I realized they were just baiting everybody in the audience to stir up the pot to make people think. And that was really, it's of kind, kind of the genius of the whole way this thing went down. Well, I'll tell you one story about Roger that probably to me is the most meaningful and I think speaks to his character. And when I was his fellow, my wife was pregnant and they told us we had to, if she was going to deliver back home, we had to go back home. And so Roger would always go on these trips and these speaking engagements and like he'd take a four day weekend. And so, okay, well, when you were a fellow, that meant you could go and go travel and do stuff. So we decided we would take that four day weekend and fly back to Philly. And we got home and unfortunately, Sunday night, June's water broke. She was 10 weeks premature. And I take her to the hospital and I had almost eight weeks left of my fellowship. And I called Roger and I said, she's in the hospital. He just said, well, you just stay there and call me in a couple days and let me know what's happening. And it wasn't like he had residents on the same, it was just Roger and I was the only person there that could help him. And I called him a couple days later and the babies had been born, they were preemies, they were in the icu. And I called Roger back and he goes, you just stay there and call me in a couple days. And I stayed back almost two weeks and finally they were a little bit stable, but they were still on the nicu. And I flew back to California and I had six weeks left of my fellowship to complete. And when I got there, he had rearranged his entire schedule so I could go back early almost every week so I could spend a four day weekend back in Philly. And I flew back and forth and I went to thank him and he goes, well, I just figured you'd be useless anyway. But I mean that to June and I, that was such a tremendous thing that allowed us to get through that. But that just speaks to the type of person that he is.

C (10:22)

I think that we should speak just a little bit about the innovation that you brought with lots of things. And I think the premier story is we look back and I was actually a fellow at UCSF and they had a total ankle experience that was about 30 or 40 cases. And I was a senior paper and I was going to go into foot and ankle and I looked at these and they all failed. And and I decided who wants their name on an article that has 40 failures of something that just has a dismal record. And so I passed on that and chose to do infected total joints because they actually did better than these total ankle procedures that were a bad design and bad exposure and bad everything because they were total knee and total hip surgeons who were doing ankles and they had no clue what was going on. So things went really rest there for that was in the mid-1970s or so, until about 1998 when Roger came back from actually it was Denmark and he'd been to a total ankle conference and Keith talked about that this morning, that he had an idea that he was actually impressed with the fact that they'd been successful with this three part total ankle. And of course Roger could sell ice to Eskimos. And he just said this will be just a chip shot, we can knock this out in about a year and just get this authorized. And it only took seven or eight years. But the interesting point I want to make and have you speak to Roger was that I think if you hadn't done that, that they were doing the agility at that point and it was going to die and there been so many amputations with it. And I'm not sure that the total ankle roll revolution would have happened without your visit to Denmark and the innovation that you brought in. And granted the star is an older prosthesis and has been eclipsed in popularity by other ones. But the fact that you led the team that got FDA approval opened the floodgates for insurance payment and for the technology to change. And I want you to speak to that a little bit because I think it changed foot and ankle care in America. I mean, if you look at these meetings, half the talks are on total ankles.

D (12:42)

Well, that's correct, Mike. I didn't like total ankles because I kind of divide surgeons up into the ones who were thinking and the ones that are slashing. And I never liked that concept. I shouldn't say what area of the country that happens in. But anyway, that used to bother me. I grew up, biomechanics was my main theme. And I felt if Something wasn't biomechanically correct. It's not going to work. And they were putting in agility ankles and patting themselves on the back, and the results were not good yet. They kept saying they were good, and I didn't like that. I wouldn't do it. They asked me to do it and I said, no, I won't do it. So anyway, after I had a chance to see the star in Europe, this Hakan Kofoid, who developed it, I said, that's pretty good prosthesis. His results were good. It's biomechanically correct. I said, I'd like to try that. So after I got home, I found out who distributed it in the US and phoned him up and said, I'd like to be able to do the star. Well, I will have to call you back. Had to pass a sniff test in order to be able to do it. So they called me back a couple weeks later and said, yes, we'll let you do it. I said, okay, but there's one other thing. I get to name every surgeon who doesn't until we get it through the fda. I said, otherwise it's going to go out and people are going to mess it up. And I said, I don't want that to happen. He said, well, that's a tough one. So they called me back again a couple weeks later and said, okay, we'll let you do that. So that's what we did. I worked with Mike and put together a group of 10 surgeons for the prosthesis and 10 surgeons to do the arthrodesis as a comparison group. And it was a real battle, I mean, because nobody else was really doing them to any great extent. Insurance companies would not pay for them. Fortunately, being part of a surgery center, we could take patients there and do them. They weren't really done as outpatients there. They keep them overnight. So that worked pretty well. And we built up a group of them and we realized this works. And anyway, it was great. Really enjoyed that. I guess we did about 500 or so, and then we had to get it through the fda, and that was impossible. They just kept throwing Roblox in front of us. That wasn't good. This isn't good. So finally, I think it was eight or nine years until. Until they said, okay, we can go back and make this presentation to the fda. Even that got screwed up. We couldn't find the place. One of the cars went all the way. I don't know, missed the FDA place all together. And Mike ended up being the Lead person in front of the FDA trying to present this thing. And we weren't even there yet. And finally he came in here as a shaking Mike. He said, what are you guys doing? So we turn it over to Mike, and when he saw us all there, he felt better.

C (16:04)

This actually is pretty funny because you realize how things happen. And so we were at the downtown lawyer's location, and we were all going to get ready to go out to Bethesda to the fda. And so the lawyer had his Lincoln Town Car, and he took all the important people who were Roger and the statistician who had a computer. I didn't even have a computer at that time. And he just said to Dr. Kofoid and the salesman from the company and me, just go down, get a taxi and go out there and here's the address. So we got out there and the lawyer who was driving the car got lost, and so they were not there. And I went up to the person who was the moderator for the fda. We only had an hour and there was no one there, just the three of us. And I had a sheaf of paper we'd printed out with all the stuff. I didn't have a computer, but I had all this stuff, and I knew it pretty cold. The real key here was you want to. When you're going to get in a battle, you want to know what the enemy is going to do. And so the night before, I talked with Roger and I said, you know what they're going to do? And he goes, no, what are they going to do? And I said, they're going to ask for a blind, randomized, controlled trial. That's what they're going to ask for. And he said, well, you mean where we take a pill out of a vase and it's either going to be an arthrodesis or a total ankle? And I said, yep, that's exactly what they're going to ask for. He said, well, I can't put somebody to sleep, and they come up with a fusion instead of a total ankle. And I said, well, I understand that we just have to have a comeback. And so our comeback will be the agility, which is being used off label and not cemented and should be cemented. And people are doing it all the time. That's the elephant in the room versus ours. And we just say we take one of the capsules out and it's either an agility and an uncermitted agility. That's what they're doing, which the FDA hated, but they just didn't want to recognize it versus the star. And Roger said, well, I'm not going to do an agility. And I said, well, don't worry. They're not going to accept this, but we just have to have a comeback. And I thought to myself, I bet they're having the same talk. And they're going to go, we're going to say this, and they're going to say, this is like a chess game. So I come in there and I say to the leader of the pack for the FDA, Dr. Mann's not here yet. Can we just defer 30 minutes? It's like senior psychiatrist. He said, well, Dr. Coughlin, you have 60 minutes. You can use them any way you want to. If you want to wait for 30 minutes, you'll have 30 minutes for your presentation. I said, well, we're ready to go. Let's go. And so we went up and I started with all this, and I was not shaking. Roger, how would you know? You weren't there.

A (18:39)

You were in the car.

C (18:40)

And so they were still circling around on the ring Road in D.C. and I started out, and I think it's like when you go before the Supreme Court, where you start a presentation, they immediately interrupt you and start throwing questions at you. And I would say that very few people in our whole cadre of foot and ankle have ever been before the FDA and had this experience. It's a seminal event in your life because you're going, this is really a big deal, and it's all on this. So I started in. They immediately interrupted me, and they said, do you know what we want? And I said, what do you want? He said, we would like a blind, randomized controlled trial. And I said, well, Dr. Mann and I have really thought about that, and we'd like to do that. But we realized that everyone that we fused, we're going to get sued because they're going to get something they didn't want. So we've got something better. Everybody's doing the uncemented off label agility ankle, and we'd like to do a blind randomized control trial with that. You're letting that go, and that's like telling them they have a mortal sin on board and they're very bad people, but they're letting it go versus the star and let the winner take all. And there was silence in the room. And then I realized the night before, they probably had the same talk and said, what if they say this? And they said, okay, we'll let you do this trial, and you can actually just do a historical review of ankle arthrodesis if you want to. You can do whatever you want to. And we got the okay. And then they said, now let's talk about statistics. And I knew then that I was dead. And then all of a sudden, the doors burst open. And I turned to Roger. He goes, well, have you got it okayed yet? And I said, well, it's closed. And then I said, why don't you take over? I'm going to slide out, and I can probably get home to Boise tonight and catch an early plane and you finish it up. And it was after that, it was duck soup.

A (20:29)

Yeah, I wouldn't say it was duck soup. It went on for eight years instead of two years. It was a very interesting experience. Dealing with the FDA hasn't gotten any better, I'll tell you that much in coming forward. I think the other thing is just Roger's impact on all the fellows that he's trained. But now it's like all the grandchildren that we talk about. So many of his fellows have gone on and started their own fellowship programs. And even the people that didn't train like Ryders back then, there was no match. And so you basically went out and interviewed, and you had no idea when you were going to hear anything. And I remember I went out and interviewed in January, and like, every month I would call and talk to a secretary. Has he decided yet? And she goes, no, he hasn't decided yet. And then you. There weren't that many more fellowships. When I did that was in 85. It was only four. Joss had his, Roger had his, Ken Johnson had started his, and then Bill Wagner had his. But you still had no idea what was on, going. Going to happen. Claudia would say, well, Roger always feels so bad because he doesn't want to say no to anybody. And he's got all these other candidates. And it was almost like this war of attrition. Like, you're going to finally get worn out and eventually find out that you've got it. But you see what's happened now with his fellows starting their fellowships and even people that didn't train with him. I mean, that's how my fellowship started, because Roger had too many spots filled. And tomorrow, Tom Lee had applied to the fellowship, and Roger really liked him, and he was filled for, like, the next two years, because what you would do, I don't know if you remember this thing, he would wait, and then all of a sudden, he would just pick, like, two years worth so that he didn't have to deal with it anymore because he didn't want to say no. So if you got in that time you did, it was like Bob Anderson, same situation. Bob ended up. Roger was already filling. He went on and did it with John Gould. But I remember Roger coming up to me at the Foot Society meeting in Boston, and I'd only been in practice for like, three years at the time. And he comes up, he goes, hey, I want to introduce you to your new fellow. And I'm like, I don't have a fellowship. What are you talking about, new fellow? He goes, yeah, no, I got this guy and I'm filled up and I can't take him. And you need. I said, roger, I've only been in practice for three years. He goes, that's all right. You're good enough. You can do it. And it's like, well, what do you say? You can't say no. That's how some of these things start. But it's really your influence kind of.

E (22:44)

Along the same line. And thank you so much. It's almost surreal to be sitting here with legends like all three of you guys and residency. We grew up on Coughlin and man, like, we had to read the volumes. And I'm not really sure how the residents are learning now, but those were kind of our bible. That was what you read. Preparing for surgery for every rotation. And so I thank you so much for putting that out there for us. We have in our audience for the podcast, a lot of it are our young listeners, medical students, students, residents, fellows. And this is kind of like the new way that they learn. And for the ones who aren't able to be directly touched by you and your kind of your lineage, what advice would you offer to our young listeners, our future orthopedic foot and ankle surgeons? It sounds like you've taught people very well through their professional life, but also kind of taught Dr. Coughlin and Dr. Wapner here how to have a good, like, family life balance. So what kind of advice could you offer our listeners through everything that you've learned?

D (23:41)

Well, I think the bottom line is biomechanics. That's how I did it. I spent my first year of residency in biomechanics, and at that time it was a four year residency, and the first year is a year of general surgery. That's masochistic if you're not going to become a general surgeon. So I went to Dr. Vern Inman, who was the chairman of our department and the one who gave me my residency. I said I'd like to spend a year with you in the biomechanics lab. He said, well, Roger, that'd be wonderful. Nobody's ever asked me before. I said, well, I'll be there. So he took me, and I just spent the whole year learning about how the mechanics of the foot. And then when I started to get into practice and doing more, I realized foot surgery was just done too much by the spine, by the seat of their pants. They didn't have any basics for a lot of things they did. And what I tried to do is try to turn the whole thing around and make biomechanics the basis of it. And by doing that, it worked pretty well. I essentially went through every section of foot and ankle surgery and applying biomechanics, hone the surgeries, and then would get together a group of, oh, eight or ten patients and publish a paper on it. And that's what I did. I went through almost every major topic of foot and ankle in order to show how to do it, what I thought would be the proper way to do it, and that's the important thing, is to learn the mechanics of how it works and then apply the surgical procedures afterwards.

C (25:24)

It was interesting. As the first fellow, Roger really didn't know what to do with me, and so he wasn't very comfortable in letting me do anything. And I understand that because they were his private patients. And so it was very interesting. Residents and fellows now expect to take an active role in doing part of procedures as part of their training. But I actually had so much experience that you ucsf. I just wanted to hold retractors and just watch his moves. You really can learn so much by just watching someone. And that was a huge part of my training. He was the best surgeon, really, that I'd encounter during my residency. And so just watching him and his economy of scale and just the way that he would do things, and he already had figured out what he was going to do. And of course, people don't understand. They say, well, how can you sing music when you're doing surgery? Because we're sort of multitasking or whatever. Well, you can talk to somebody while they're doing surgery, and he could tell you what he was doing as he was doing it. And it was so fun just learning why he did things the way he did.

A (26:30)

That was really the key in learning. He had this innate ability to take the most complex problems and just distill it down. And I used to always laugh because it was like painless learning. Our program at Penn was kind of, kind of the old school, very punitive. They were always calling you out and embarrassing you and that sort of thing. And I remember flying out to interview with Roger. I literally copied every article he had ever written and memorized them because I was not going to allow him to ask me a question that I didn't know the answer to when I was out there and totally expecting that same type of attitude that I had in my residency. And I got out there and here's this like, totally low key guy. Never asked me a question, just explained things, hung out with him for three days, had a total blast, and it was just totally unique. And then when I became his fellow, every problem would be distilled down, like you say, back to the biomechanics of it. And I would go home and like you say, you take out the textbook, that's your bible, you go back and you read it and you try to be prepared. And it was just this ability to look at a problem. And he taught you how to distill it down to, okay, this is now abnormal. How do I get it back to being normal? And is that going to then work? And then to Mike's point, we would watch his skill. And it's one of the arguments I would have with residents. Now, surgery is not a paint by number set. If you come into the OR and I tell you cut here and you don't understand why you're doing that, you're not going to be able to do that on your own. And if you had that preparation and understanding the biomechanics, the way he talked to you and then you watched him in the OR and then you went back to do it on your own, it became so much easier. And I'll never forget kind of coming back to Philadelphia. I was the first fellowship trained person to come back to Philly. And I'd been a medical student at Temple in the city. I'd done my residency at Penn, and I was coming back to Jefferson. So I knew everybody at the three institutions. And so everybody was sending me their quote, unquote, really difficult cases. They had been holding up for the year to dump on me when I got back. And I just remember being so amazed at how easy these things were because of the way Roger taught me and the things that he taught me and the ability to analyze these things. And it was just one of those experiences where you go, oh, my God, I cannot believe what I've learned from this man. And so it was really a unique experience.

D (28:48)

Let me just say one more thing. The textbook I worked initially with Henry DeVries, who was a podiatrist. He shared a space in the office that I went into. And starting off, you're not that busy. So I used to go in and watch what he did and things like that. So he had written this book on surgery of the foot, and so that was fine. So he turned it over to Dr. Inman, Vern Inman, the chairman of the department at the uc, to do the second edition. And I wrote the biomechanics section in it. And I don't know what else I did, but anyway, Dr. Raymond called me in his office one day and said, roger, he said, I will never do this again. He said, either you do it or that's the end of the book. So I said, that's interesting. I mean, here's somebody who flunked subject A and got into Berkeley, my subject. A teacher in high school told me, asked me what I was going to do. I said I was going to go to Cal. She said, you'll flunk out in six months. That's my writing skills. So here Dr. Inman is handing me this textbook to write. So that was interesting. So I wrote it and got other people to help me with the chapters. And I think I published the next three editions, two editions. And it just eats up all your time. It's just terrible. I mean, I was working many hours a day. I'd come home at night, finish my dictating, because that was the number one thing. And then at about 11 o', clock, 12 o' clock at night, I would start to work on the book, which got me to about 2 in the morning. Then I had to get up at 7 in the morning. So you worry yourself out eventually. So anyway, realized I can't keep doing this. So Mike Coughlin came along and I said, do you want to take part of this? And Mike never turns down a task. I would call him. I would finish my work at home about 11 at night. And if I had a problem or something I wanted to discuss, I'd call Mike. The problem is, Mike is an hour ahead of me, so I would be calling him at midnight. I hear Mike here. A very groggy yes that went on and on. So finally I stopped doing that. But anyway, the textbook just sort of kept evolving through wonderful editors. And it's really, I really am very proud of it. It's a wonderful book. It contains everything you need to know about foot and ankle surgery. And anyway, I think I've said enough.

C (31:39)

Thank you just to finish up on the book because Roger started at ucsf. And as his career has evolved, he's now returned back to UCSF as a professor there, which is really, really sweet conclusion to his career. The book has now I wanted to make sure, as I faded out, that Andrew Haskell, who's a professor at ucsf, has brought the book back to UCSF as well, which is where it started so many years ago. And then on top of that, Roger and Joan have financed a professorship for foot and ankle in the department of orthopedics. So UCSF gave a lot to him, but he's given a lot to UCSF and back to it. And that's indeed what this is all about, is getting something, but also giving back. And I think that Keith and Roger and I believe very strongly that giving back is what makes all this a better place.

D (32:40)

I have to add one more thing. The video textbook was revolutionary. That was revolutionary. I realized that foot and ankle surgery is all done in one spot, so you can easily videotape it. And it's a great way to teach. So I wanted to do that. And the publisher for our textbook wanted nothing to do with it. He said, this is a written book. We don't want any video in it. I said, but this is the best way to teach it. I don't care. So we went to Alice Burgess, who published the ophthalmology book, and talked to her and she said, oh yes, this would work fine. So she did. And we put together the textbook, a video textbook of foot and ankle surgery. I had it all outlined and I called Mike and I said, this is a piece of cake. We can knock out the. We can knock out the written part in six months and then we'll get the videotapes as we go. Poor Mike was on the hook again. And anyway, it worked out very well. It came out well. The publishing company, Mosby, still would not touch it with a ten foot pole. And we finally got it to the point where I think they were starting to get interested in it. Was it the third edition or the fourth?

C (34:07)

Well, about the eighth edition.

D (34:09)

Eighth edition, Yeah. I thought it was before that. But anyway, we finally sold it to them and got them to put that in the textbook, which is really a great way to learn. I mean, you don't have to do a fellowship. You could just sit and watch the videotapes and read it.

C (34:24)

What's so funny and ironic about this is we got about 20 video clips in this. And of course it was evolving from VHS to digital things, and it totally changed. And so when we went back for the next edition. I said we still like to do video clips in the textbook. And they go, well, that's the standard. I mean, we are totally sold on video clips. I mean, you have to do video clips. And I'm going, dear God. I mean, because there's always a new generation of editors that don't remember what happened before. But that was revolutionary too. So, Nick, I'm going to hand it back to you.

B (35:01)

Well, the one thing I think I've learned is that you are an optimist. So thank you so much for everybody for sitting and talking. This was a lot of fun. This is one of my favorite conversations and thank you. Congratulations on your legacy. It's great to be able to sit here with you all and I really want to thank you all for joining us.

C (35:27)

Thank you.

A (35:29)

Thank you for listening to the AOFAS Ortho podcast, a Convey Med production. To learn more about joining our dynamic community of highly skilled orthopedic specialists, visit aofas.org.