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An Interview with William F. Hoyt, MD

2002; Lippincott Williams & Wilkins; Volume: 22; Issue: 1 Linguagem: Inglês

10.1097/00041327-200203000-00010

1536-5166

Lanning B. Kline,

History of Medicine Studies

William Fletcher Hoyt, MD, professor emeritus of Ophthalmology, Neurology, Neurosurgery, University of California, San Francisco, celebrated his 75th birthday in 2001. Born and raised in Berkeley, California, and the son of a physician, he had his undergraduate education at Berkeley and his medical education across the Bay at UCSF. After a 1956–1957 Fullbright fellowship in the Augenklinik of the University of Vienna (Austria), he spent a formative year in Baltimore at the Wilmer Institute, Johns Hopkins University, as Frank B. Walsh MD's second neuro-ophthalmology fellow. He returned to UCSF in 1958 to found the neuro-ophthalmology service, launching it on a counter at the nurse's station of the neurosurgery ward. During his 36-year academic tenure—all of it at UCSF—he authored 266 journal articles, co-authored (with Frank B. Walsh, MD) the biblical 3rd Edition of Clinical Neuro-Ophthalmology, and trained 71 neuro-ophthalmology fellows (half of them coming from outside the United States), 48 of whom have become professors of neuro-ophthalmology, eight who have become chairs of neurology departments, and six who have become chairs of ophthalmology departments. Widely acknowledged as one of the giants of 20th-century neuro-ophthalmology, he received the title of Honorary Doctor of Medicine from the Karolinska Institute in 1983. NANOS inaugurated an annual lectureship in his name in 2001. This interview was conducted in New Orleans on November 12, 2001. LBK: How did you become interested in ophthalmology? WFH: We had some family friends who were ophthalmologists. My father was encouraging in that ophthalmology is one of the specialties in medicine that had really defined limits. I looked at ophthalmology as an opportunity to do something I was good at—manual work. I thought it would be an ideal combination of working with my hands having an intellectual challenge. LBK: You were a medical student at the University of California? WFH: Yes, I was part of the first medical class after World War II. LBK: How did you do in medical school? WFH: I wasn't at the very top. There were people in my class who were so good that I didn't even feel competitive with them. LBK: You've told me that Fredrick C. Cordes MD was the chairman of ophthalmology at that time. Did you have any contact with Dr. Cordes before you became an ophthalmology resident? WFH: I certainly impressed him by showing up and having him hear good words about me from his resident staff. I did not give presentations. He was one of the last department chiefs who was based in private practice–a "dollar-a-year man." He received a token payment for running the department out of his private office. But he was strict disciplinarian, and he certainly looked after the resident training program. LBK: I have heard that as a resident (1953–1956) you were known for performing many cataract surgeries. WFH: I liked the manual part of ophthalmology. I set the University of California record for the number of cataract extractions done by any one resident during my tour. LBK: So if you hadn't seen the light in neuro-ophthalmology, you might have turned out to be one of the "phaco kings" in the United States? WFH: I doubt it. I don't think I would have ever been fulfilled doing just operative work. LBK: So how did you become interested in neuro-ophthalmology? WFH: My first exposure was through Dr. David Harrington, who was the perimetry teacher at the University of California. I thought it rather interesting that you could work with a tangent screen other simple tools and actually achieve some kind of localization of brain problems. LBK: Was the tangent screen the gold standard? WFH: It was. We didn't even have a Goldmann perimeter. There were some old arc perimeters around, but the tangent screen was the method. I remember that other residents didn't like the visual field room. LBK: Did you set the record in doing visual fields? WFH: I'm sure that I did. And I gave my resident papers—we had to do two a year—on topics related to perimetry. I would do pen drawings of the brain and localization (of the lesion) based on the visual fields. That so charmed Dr. Harrington that he had his artist at the Veteran's Hospital draw up these pictures with visual fields and a little brain down below and an arrow pointing down at the lesions. Those pictures ended up in Harrington's books. FIGUREFigure: First article in a peer-reviewed journal, co-authored with Dr. Harrington (Arch Ophthalmol 1955;53:870–881)LBK: I remember that arrow in the temporal lobe. I always felt sorry for the patient! WFH: I only learned later that what happened to the brain was not like an arrow piercing it. By the way, I didn't have any concept of how much neurologic material you could encompass within the field of ophthalmology. But I was aware of Walsh's book (Clinical Neuro-Ophthalmology, first second editions), and I had a chance the meet the man when he came to the University of California in about 1956. I was a senior resident when he gave the Proctor Lecture. I was assigned by Dr. Michael Hogan, the chief, to look after Dr. Walsh and prepare the clinical conference. I was supposed to find the patients and drive Walsh back and forth to his hotel. That exposure in 1956 with Walsh changed my life. Here was this professor who very clearly liked residents, related to residents, had great medical stories, and loved an audience. More than that, he had information, the amount of which I had never been exposed to in my life from one man. He knew where you could find it in the library, who wrote it, and how long ago. How he could handle an audience—particularly the neuro-surgical part—and command such respect! Dr. Ed Maumenee, the chair at Wilmer, wrote a letter to Dr. Hogan saying, "It's a shame that Walsh is here (at Wilmer) and doesn't have fellows or people to whom he can pass on this information." Hogan gave me the and letter and I decided then and there that I would make an arrangement to spend a year with Walsh. LBK: Was that the major career direction change for you—meeting Dr. Walsh? WFH: Absolutely. I had already made a plan for my postresidency period to go to the University of Vienna and spend a year as a Fullbright scholar in the eye clinics. So I had to work out this fellowship with Walsh for the period after I finished in Vienna. LBK: What about your year in Vienna? WFH: I like mountains, skiing, and music, and I wanted the experience of speaking a foreign language. Ophthalmology was about fifth on that list. I wouldn't say that the intellectual, medical experience of Vienna was important to me. That came later when I got to Johns Hopkins. But the Vienna experience laid a background for me. It followed me through my entire professional career: the language, the associations that I had made, the viewpoint that ophthalmology was much bigger than what occurred in the United States, that there were good specialists all over Europe, speaking all kinds of languages. Communication with these people would be a deep personal and professional satisfaction for the rest of my career. LBK: Let's talk about your fellowship with Dr. Walsh. WFH: He would work directly with me, frequently having me see the patient first in his office, then discuss the case with him. Then he would go in and see the patient and do some additional things to elicit the information that he needed. It was just he and I. I don't recall a resident being present. He treated me like a son. Sometimes we would be working on a weekend he would look across the desk say, "Doctor, you look a little tired. Why don't we go down and have steak." LBK: Would you frequently work on the weekends? WFH: Sure. The weekends to Walsh would consist first of all of the Saturday morning conference. It was absolutely the best show at Hopkins on Saturday morning. LBK: Who were the major players at that show? FIGUREFigure: Initial first-authored article, published with Dr. Walsh (Arch Ophthalmol 1958;60:1061–1069)WFH: Frank Ford (Franklin Ford, MD) was his favorite pediatric neurologist. He was always there. Richard Lindenberg was Walsh's friend and neuropathology expert. There were a couple of neurosurgeons. One was named John Chambers. The front row was always occupied by Ford, Chambers, and Lindenberg. They would be the consultants on the material that Walsh brought to the audience. LBK: Were the patients themselves there? WFH: Yes. Part of my job was to usher them in and out of the room. The Wilmer Institute was a good place to be on Saturday mornings. There was not much competition with sailing or golf or horseback riding. LBK: How was the case discussion run? WFH: The fellow was responsible for presenting the clinical details. But others did too. Walsh was very good at getting people to participate. For instance, if a practitioner brought a case in, he would have the practitioner present the case. He would coach ahead of time on how to be brief, and he was wonderful at cutting people off in a nice way. He was also wonderful at recognizing the expertise in the audience and extracting useful comments from various people, not just from his regulars sitting up front. He played the conference like an orchestra. The audience loved it, and he loved it. He loved it so much that he would be angry when holidays interfered with the conference. And of course, the kinds of clinical cases that came through were just extraordinary. People would drive patients up from some pretty remote areas. LBK: It is well known that during your career you became part of the neurosurgery department at UCSF. Was it your experience with Dr. Walsh that led to this? WFH: Yes. I saw how Walsh was treated by and how he treated his neurosurgical colleagues. It was such a fruitful medical and intellectual exchange that I wanted to reproduce it in San Francisco. LBK: Any other particular educational activities during your fellowship that you want to share with us? WFH: Two things: one was neuropathology. Richard Lindenberg was being supported as a neuropathologist in an academic setting by his friendship with Walsh. Hopkins wasn't doing it. Richard Lindenberg was the city examiner of Baltimore. But Walsh realized his value as a teacher. One of the major events in the fellowship was going on a Tuesday night to the city morgue and watching Lindenberg hold forth to a whole group of white-suited residents standing around the morgue table, looking at these brain slices that had been prepared before the evening event, listening to Lindenberg's stories about neuropathology. LBK: What was the other highlight of the fellowship? WFH: The interaction with the Wilmer residents, particularly the senior residents. LBK: Anyone in particular? FIGUREFigure: William F. Hoyt, MD, Assistant Professor of Ophthalmology, University of California, San Francisco, 1959.WFH: Dr. Lawton Smith a, senior resident. He was a phenomenon and a fascinating, entertaining, redheaded southerner. Unbelievable. Lawton would go into the doctor's dining room with four cups of coffee gripped in one hand, sit down and start talking to the whole table. Lawton was also the fastest typist I had every observed. No secretary could keep up with him. Lawton used to carry a typewriter around with him on ward consultations, he would dash off two pages of consultation, stick them in the chart and walk on to the next case. LBK: Tell us about your return to UCSF in 1958. WFH: I started out in part-time private practice in Dr. Cordes' office. I would drive from the private practice office back and forth to the University. At the University, the first people I made contact with were the neurosurgeons. I had a counter and a stool and a place by the nursing station on the neurosurgery ward, that's where I started my teaching. For material, I used the inpatients on the neurosurgery service and the adjacent neurology service. I did not have a neuro-ophthalmology clinic. LBK: Tell us a little about neurosurgery at UCSF then. WFH: The chief of neurosurgery was Dr. John Adams. Dr. Adams had met Dr. Walsh during his visit in the 1950s, and he was aware of the kind of fellowship training that I'd had. Within months after I started, Adams came to me and said, "Hoyt, we want to make you an official member of the neurosurgery department, and I'm going to put in an application to the University for a joint appointment with ophthalmology." I remember thinking at the time, "Wait until Lawton Smith hears this!" LBK: This was a very visionary decision by Dr. Adams. WFH: I think he knew what Walsh meant to Dr. Walter Dandy (professor of neurosurgery) at Hopkins. Here he had the opportunity sitting right in front of him—somebody trained from Hopkins at no cost to his department. All he had to do was make an official position for me. I saved that old appointment letter because I thought it was historic. It was certainly the first time in the United States that a board-certified ophthalmologist had become a joint member of a neurosurgery department. LBK: Did your office space expand? WFH: The place that I occupied by this nursing station slowly changed to a little office, a few doors down on the same level, where I actually had a desk. It was a cubby hole. Sometimes I would have three residents and one fellow crowded into that little space. I guess it just exemplified that crowding isn't always evil; as a matter of fact, it helps people work together. Never in my career did I have an office where I sat back away from fellows. Instead I had a large table, all my fellows and residents sat around the table and did their work there. I enjoyed this kind of community relationship with the young doctors where conversations and questions were always open. I lived in a fish bowl, but I enjoyed it. It also meant that the neurosurgeons that walked through the corridors outside my office could stop in at any time, interrupt what was going on, and tell us about a patient. Walsh always had a chair in front of his desk, and if somebody walked in, he would say, "Sit down, doctor. Tell me a story." LBK: Did your relationship with neurosurgery become a little more formalized when Dr. Charles Wilson became chairman of that department? WFH: Yes. Dr. Wilson came in 1969, and one of the demands that he made for accepting the professorship was that Hoyt would get a proper office in which to sit down and train his fellows, and that it would be on the hall opposite his office. His second demand was that my salary at the University be picked up by neurosurgery. LBK: Dr. Frank Walsh was the first big influence on your career. Where would you put Charles Wilson? WFH: What I owed academically to Charles Wilson was his absolute insistence on excellence. I also owed him an unending debt of generosity towards neuro-ophthalmology. The neurosurgery team gave me and my fellows free access to every patient they admitted to the hospital. Wilson's administrative secretaries would give us anything we needed. There was never a question, if it was copy machine money or typewriters. Wilson ran a first-rate department. A dynamo of energy, he operated multiple cases per week and thereby provided a source of clinical material that was unsurpassed for my fellows and me. LBK: What did you learn from the neurosurgeons? WFH: I appreciated how hard neurosurgeons worked. We would always have jokes about it, that the poor neurosurgeons stand at the operating table for so many hours a day that they get inadequate perfusion to their brains, and that they need all the help they can get. It was my job to pro-vide some of that help. But really, I learned to respect those young people who were going into neurosurgery, and I enjoyed presenting the residency group in neurosurgery to the residency group in ophthalmology. You see, the eye residents had to come to neurosurgery to learn neuro-ophthalmology, and at the same time, neurosurgery residents had this continuous exposure to ophthalmology residents and began to realize that they were smart. It went both ways. LBK: Let's talk next about your fellowship-training program. WFH: Dick Sogg was my first one-year neuro-ophthalmology fellow, and he was coming from Cleveland and Boston. Dick was a very lucky happenstance for me. He was an absolutely delightful person—wonderful with people. Everything ran smoothly when Dick was around. Nurses liked him, and we liked him. After Dick, I took a few fellows whose background and intentions I hadn't investigated very thoroughly. I found that they were often coming to get a foothold in West Coast ophthalmology so they could start a general practice in the Bay area or somewhere in California. I didn't think that is what I wanted to do with my fellowship. I wanted to teach them to be teachers in other universities. LBK: So how did you change the screening process? FIGUREFigure: Hans T. Newton, MD, UCSF neuroradiologist (left), and Charles B. Wilson, MD, UCSF chair of neurosurgery (center), with Hoyt at Dr. Wilson's retirement gala, 1994.WFH: I told applicants that I wanted letters of support from the university professor at the department and school where they intended to do their neuro-ophthalmologic teaching. I wanted academic support for them at a professorial level before I would accept them. I never had local funds to pay fellows. Fortunately, the National Institutes of Health had special clinical fellowship training grants that helped me get started. Fellows had to earn the financial support that was going to carry them through the fellowship. LBK: How many fellows have you trained? WFH: 71. 48 of those 71 have become professors of neuro-ophthalmology. So obviously I wasn't completely successful in the education of teachers. But eight became chairs of neurology departments, and six became chairs of ophthalmology departments. A couple even went further in the administrative level, into management of an entire academic health enterprise. Bob Daroff (Robert B. Daroff, MD, executive director, University Hospitals, Case Western Reserve University, Cleveland) is an example of someone who moved that high. LBK: Tell us a little bit about your method for training fellows. How did you make certain that they really learned neuro-ophthalmology? WFH: That is hard to answer. I always felt that if we could find common ground, and if we could expand that common ground through examination of the patient and reading of the literature, it would be a very satisfying mutual interaction. The fellows who were psychiatrists would teach me things that I did not even know about my own interactions with the patients. If I had a fellow who had a background in neurophysiology, we would get into the neurophysiology of nerve conduction, nerve block, myoneural junction, and higher visual function. Then we would develop publications. I didn't feel that I was trying to mold fellows. I was just trying to have a period of interaction with them in which, if anything, I showed them how much fun it was to run and to do your work as hard as you can. Daroff used to say, "When I worked with you, we were walking at full pace." FIGUREFigure: Robert B. Daroff, MD, (left) and Michael Sanders, MD, (right) with Hoyt (center) during their fellowship year, 1967.Figure: Frank B. Walsh, MD, visits Hoyt in 1966 during their collaboration on Clinical Neuro-Ophthalmology, third edition. Left to right: H. Stanley Thompson, MD (as a fellow), Hoyt, Walsh, and Robert S. Hepler, MD (as a fellow).Stan Thompson (Iowa City) came to me with all this information on the pupil, which frankly I didn't care much about before he got there. He showed me how this subject could be expanded. He became my lifelong "pupil consultant." Daroff came with an interest in the brain stem. This intimidated me some. I wondered, "How am I going to teach this man anything? He already knows more than I do." LBK: You were intimidated? WFH: Yes. A neurologist like Daroff, an ophthalmologist like Michael Sanders (United Kingdom), a neurologist like James Keane (Los Angeles), an ophthalmologist like Myles Behrens (New York) working side by side. They generated a lot of very interesting information, and I stood by learning it. LBK: Didn't you work at times to put fear into those young fellows? WFH: I will never admit that I worked to make them fear me. I didn't. I certainly made them aware that I was demanding, and that they should read relevant literature and bring it to their discussions. I required that they see the new patients that came into the hospital in the evenings and that they call me at home every evening to tell me what they had for the next morning's rounds. I insisted on that so I could tell them what to read before they presented that case so I could bring in material from my literature collection. You might say we did a little "pre-thinking" before daily rounds. If that was intimidating ... I guess it was at times. And it kept them reading rather late in the evening! LBK: How did you manage, year after year, to draw outstanding people from all over the world? WFH: I started very early in my career with another language and with respect for ophthalmologists in the European community. Dr. Walsh directed my first foreign fellow to me. It was Michael Sanders, and he came from National Hospital, Queens Square, in London. I couldn't have been more proud that the British would send their choice for a neuro-ophthalmologist to San Francisco. Michael opened many doors for me to London, and so I had a little string of people coming from the UK to San Francisco. I even set up a sharing program as a reward for my fellows. When they finished my program, they could go to London for two months work with Michael. I slowly acquired applicants from South America, Australia, Scandinavia, Japan, each time with recommendations from a professor. In the 1970s the immigration laws changed my foreign applicants had to take these medical examinations that inhibited my ability to get them. Even so, I've trained 29 foreign fellows for a full year and 28 for at least four months. The placement of one really well educated neuro-ophthalmologist in a country like Venezuela was a bigger accomplishment for me than placing ten people in the United States. The impact they would have was huge on teaching of young residents. That is what Rafael Muci-Mendoza, MD, has done in Caracas, Venezuela. The same is true in Barcelona, Spain with Jordi Arruga, MD. And I could mention many other important people abroad. LBK: You've said that you regard your fellows as family. WFH: Here's an example: Rafael Muci-Mendoza, MD, from Caracas. Muci was an absolutely extraordinary cardiologist, already past president of the Venezuelan Cardiology Society when he came to me. He took on neuro-ophthalmology as a hobby. But I wondered how I could help somebody who knows so much. He stayed two years, brought his whole family. The children went to American schools. Muci taught me medicine a lot more. For example, once when I expressed impatience over a fellow who was not performing well, Muci took me aside and said, "Bill, you have to remember that these fellows are your family, and as in every family, different members have different requirements and so you can't expect the same of all of them. You have to help the ones that are a little weaker do the best they can." I was always grateful to Muci for being so politely critical of my behavior. LBK: Have any of your fellows surprised you with their accomplishments? WFH: Yes, many. For instance, Jim Keane was a quiet person, and I just couldn't assure myself that Jim was going to do anything with neuro-ophthalmology. I was absolutely dead 100% wrong! From the time he got an academic position at the University of Southern California, Jim started publishing good observations, and I just became more and more proud of him. I apologize to Jim for not recognizing all his qualities when he was with me. He was a beautiful example of my incapacity to properly judge everybody that came to me. I think every teacher has that experience. LBK: Let's talk about the third edition of Clinical Neuro-Ophthalmology that you authored with Walsh. WFH: In the early 1960s, Dr. Walsh was becoming committed to a third edition. He was looking for somebody to help him, and he didn't ask me. He asked Lawton Smith. It was logical because Lawton was at Hopkins, and they were good friends. But Lawton did not want to become involved, so I was next in line. I was shocked by the invitation. I never considered the magnitude of the decision to write something on that scale. You walk through a library and you see all these big books, and you say, "Those were each done by other doctors over the years." Some are done by one doctor, not by a team, so it is possible. But when you ask yourself, "Could I do that?" you simply have to decide you are going to try, and you start. No one can tell you what you need to do to get organized to do such a thing. No amount of conversation with Walsh would answer that. You literally have to reorganize your life so that the only satisfaction you are going to have during that period is to see the manuscript grow. And the only way it can grow is if you work at it every night and every weekend. LBK: How did you and Dr. Walsh divide up the work? WFH: That was easy. We decided which chapters I would take and which chapters he would take. So I acquired the visual system and the ocular motor system right at the beginning of the book. He liked some of the genetic diseases myopathies, and I said, "Fine, you take those." I took the tumor chapter. I also took the trauma chapter and asked him to help me with illustrations. I didn't know anything about trauma at the time, but that is what happens to you in a book. With a good outline, and some good library information and a lot of subdivisions in your outline, you can put together a pretty good summary of the knowledge about a certain subject in book form without every having been an expert in that subject. You become better at it when you finish. Finally, the last chapter in the book was drug reactions and toxic substances. Walsh had a lot that he was doing, so I said, "Okay, I'll try that." It was another subject in which I had no expertise, but I slowly worked through it, ending that chapter, amusingly, with a subsection on snakebite. I did that with a huge smile, thinking here's this huge text that we've written, it ends discussing the neuro-ophthalmology of snakebites. FIGUREFigure: Walsh and Hoyt meet at the Wilmer Eye Institute in 1967 upon completion of their textbook Clinical Neuro-Ophthalmology, third edition.Figure: Frontispiece (left) and Table of Contents (right) of Clinical Neuro-Ophthalmology, third edition, 1969.LBK: How many years did it take to finish the book? WFH: We started in 1963 and by 1967 the manuscript was ready to turn over to the publisher. There is a learning curve to creation of a manuscript; you get more and more efficient at getting more and more data. So the beginning was a kind of agony, and towards the end, things were moving more efficiently. LBK: How did you handle communicating your progress with Dr. Walsh? WFH: At first he was a little doubtful that his junior author was going to be producing, and he made a trip to San Francisco and sat with me for a week, working on the visual system and part of the ocular motor system. After that we would meet once every six months. I would fly to Baltimore and sit with him for a week, reading and writing, and going over the manuscript that I had already written. Those were killer days because Walsh could sit in one place for more hours than any man that I ever knew. I would squirm around and get fidgety, but he could just bend over that desk and keep on working. In addition, I could call him day or night, and he was always there to pick up that phone. He knew I was working, and I knew he was working. LBK: Did you have any contentious times with Dr. Walsh over the book? WFH: When it came to the contract and royalties and so forth, he was generous. It was right down the middle. When it came to opinions on a subject, he would always listen to me. For example, he was not of the same opinion that I was about optic nerve gliomas. I wondered how we were ever going to write the chapter on optic gliomas when we didn't agree about how aggressive you should be in treating them. Walsh solved it very simply. He said, "Look, this is what we will do. We'll write one little section that says one of us believes the following, and then we will write another little section and say the other believes somewhat different. Time will tell which one of us will prevail in this yet-to-be-settled tumor problem." LBK: What was the feeling like after you turned the manuscript over to the publishers? WFH: First of all, there was agony. We gave the book to the publishers in 1967. The publishers didn't even start working on the manuscript for six months—they were so intimidated by the size of it. Then when they did get going, they only devoted a few people to it, it took them two solid years to publish it. That was not what they had promised in the beginning, and I never really forgave them for putting us through that two-year wait. I was of course glad in 1969, thrilled actually, to see the book appear. I was thrilled with the reviews. LBK: How about the work that Neil Miller has done now Neil Miller and Nancy Newman, in continuing the book through two more editions? WFH: The question came up in the 1970s of redoing the book. By this time, Neil Miller had taken over the Walsh chair at Hopkins, frankly I was not inclined to go through this monastic experience again! Neil, bless his heart, took on the project. Walsh was right there to encourage him, and it could never have been turned over to a more capable and successful person than Neil Miller. He is efficient, and he writes better than I do. He collected his material for the expansion of the book very much in the same way