COMMENTARY

Life and Times of Leading Cardiologists: Robert Guyton

Interviewer: E. Magnus Ohman, MD; Interviewee: Robert A. Guyton, MD

Disclosures

April 19, 2018

E. Magnus Ohman, MD: Hello. I'm Magnus Ohman. Welcome to another edition of Life and Times of Leading Cardiologists. I'm very honored to have with us today Dr Robert Guyton, who is professor of surgery and former chief of cardiothoracic surgery at Emory. He was very instrumental in developing guidelines for revascularization a number of years ago that really shaped how we practice medicine. Welcome to the program.

Robert A. Guyton, MD: Thank you very much, Magnus.

A Father Like No Other

Ohman: Depending on your persuasion, your family is either the Bushes or the Kennedys of medicine, in the sense that your father wrote a very famous textbook, Textbook on Medical Physiology, or "Guyton's," that I read when I was a medical student—even in another part of the world.

My parents raised us on a little sibling rivalry. There are 10 of us, all in medicine. I'm not sure that more than two or three of us can live in the same state.

Obviously, you grew up in a family with a lot of medical background. Where exactly did you grow up?

Guyton: I grew up in Mississippi. My father was a surgical resident at the Massachusetts General Hospital and contracted polio in 1946. I was born on the eighth floor of the hospital while he was on the twelfth floor in the polio ward with ascending paralysis. The paralysis ended at his left shoulder, which meant that he did not need to go on the heart-lung machine which was associated with a 70% mortality rate.

We moved to Warm Springs, Georgia, for rehabilitation, and then moved back to the family home in Mississippi. When I spoke to my father about this, he did not express bitterness and said it brought him back to physiology and research. He said that he'd had a great life.

The other really interesting perspective is that when I was 18 years old, someone asked me, "What is it like to have a disabled father?" I said, "What?" I thought he was a talented, incredibly productive person, and I had never in my life thought of him as disabled.

Ohman: I can speak for the hundreds of thousands who have read the textbook that we would never have guessed it. It is an incredible textbook.

Generations Dedicated to Medicine

Ohman: You grew up in Mississippi; where in the pecking order of the family are you?

Guyton: It's interesting that you use the words "pecking order," because I think my parents raised us on a little sibling rivalry. There are 10 of us, all in medicine. I'm not sure that more than two or three of us can live in the same state, but otherwise we do enjoy each other.

My father felt that there were all kinds of opportunities in medicine—whether or not you wanted to see patients—because there were all kinds of intellectual possibilities. Medicine offered incredible opportunities that were relatively free of political and other conflicting issues; you could be a servant to society in medicine in a way that was not possible in other fields.

Ohman: I was not far off by calling this a Kennedy/Bush of medicine. I didn't know that all of your siblings were in medicine. Where in the order are you?

Guyton: I'm the second child. There are 23 years between the oldest and the youngest.

Ohman: That's obviously a big family. When you grew up, how much did a competitive environment contribute to this goal of going into medicine?

Guyton: We saw that my father had great esteem from the community, and he was always home for dinner at 5 o'clock. He would work on his book from 7 to 8 o'clock or 7 to 10 o'clock at night in the living room with five or six children crawling around his feet. We saw how much he enjoyed his work. I think that led us to feel like this was something attractive and appropriate for us.

We were always around medicine. After finishing tennis during high school, I would go to my father's office to drive home with him and watch him tinker around in the laboratory and so forth.

My grandfather was an eye, ear, nose, and throat physician in Oxford, Mississippi, where we lived before the medical school move to Jackson. At about age 4 or 5 years, I would go to his office and watch him see patients. I remember him cleaning somebody's glass eye once. So being a young child, of course I tried to figure out how I could get that thing out. It was a little painful.

A Dash of Divinity

Ohman: I am glad you did not succeed. What did your mother do?

Guyton: My mother was a unique and special person. Her father was dean of the Yale Divinity School for 27 years. In his retirement, when he was 65 years old, he was chair of the Committee for the National Council of Churches, which wrote the revised standard version of the Bible. When we were growing up and on vacation in Sunapee, New Hampshire, we would hear my grandfather and grandmother discussing at the lunch table what word should be used in a certain part of the Bible. There were fairly heavy academics, maybe even stronger on my mother's side than on my father's side.

Ohman: Medicine and divinity is a very unique combination. Did any of the children get the ability to preach—that is to say, to speak with a certain level of conviction?

Guyton: I think that penetrated all of us in our public speaking. My father's writing has also been passed along. Johnny, the brother younger than me, has embraced that activity in particular.

Ohman: Let's have a quick run-through. What areas of medicine are your siblings in?

Guyton: David is an ophthalmologist at Johns Hopkins Wilmer Eye Institute in squint and strabismus surgery, operating on those little tiny eye muscles. John is at Duke. Steve is a cardiac surgeon in Seattle. Cathy is an internist in Pittsburgh and married to a radiation oncologist. Jeanie, a rheumatologist, moved back to Oxford, Mississippi, and is married to the most interesting spouse of all, who is a history professor at the University of Mississippi. He is the one that we all prefer to talk to when we get together. Douglas is an anesthesiologist. Jimmy, another orthopedic surgeon, is at the Campbell Clinic in Memphis. Tom is an anesthesiologist in Memphis. Greg is a foot and ankle surgeon in Baltimore, Maryland.

Ohman: It's fascinating that most of the areas are very grounded in physiology.

Guyton: Yes. I think most of us used Daddy's textbook in medical school. The physiology professors wanted me to use the Patton textbook or something else. They present five different ways that things might work in the body; my father's textbook presents one way and that was much more suitable for medical students. I studied my father's book.

Medical Education Started Early

Ohman: You finished high school in Mississippi. Where did you go next?

Guyton: Seven of the eight brothers went to the University of Mississippi. It was partly financial—it cost $115 per semester and we lived with my grandfather. That's one way that you send 10 children to college. My two sisters went to Radcliffe and my youngest brother went to Vanderbilt.

Looking back at his records from the Depression, he [physician grandfather] might be paid with a quart of stew or a couple of rabbits.

All eight brothers went to Harvard Medical School. Cathy went to Miami for a PhD-to-MD program, and Jeanie went to Duke.

Ohman: That is an incredible pedigree there. Did you feel pressure to go into medicine or was it purely spontaneous that you all had this gift for the field?

Guyton: I was captured by it very early with going to my grandfather's office. I would see how patients revered him and sometimes waited 6-7 hours to see him. I saw how he treated all people, black and white, the same. Looking back at his records from the Depression, he might be paid with a quart of stew or a couple of rabbits. I thought it was really neat.

I think I got captured by surgery because, growing up, we all worked in our father's shop. My father invented a number of medical instruments. In the summer we would work from 8 AM to noon producing medical instruments that he sold for measuring the arteriovenous oxygen difference. Some of his machines were used in the early astronauts to measure their continuous cardiac output as they did various things. We, as his children, actually built those in the shop.

Ohman: Harvard back then was very different from Oxford, Mississippi. How did that move feel? Which years were you at Harvard?

Guyton: I was at Harvard from 1967 to 1971. It was a rebellious time in the Northeast, in particular. It was a culture shock for me. The cultural liberation had not fully penetrated the University of Mississippi. While other people were protesting, there was a statement that the University of Mississippi was a hotbed of apathy. I was also there soon after it was integrated, and I think that that was a very positive phase for the University of Mississippi. Things were handled well over that 5- to 10-year period. I think the institution thrived and became stronger because of that progress.

Mentors Along the Way

Ohman: Were there any mentors along the way besides, obviously, your father? Did any other mentor, either in Mississippi or Harvard, get you thinking about things in a different way?

Guyton: I think the pivotal person was Willard Daggett, who was a surgeon at the Massachusetts General Hospital. Dr Daggett was from middle America. He was in the surgical group and was the most prominent research individual in the group. I went to Dr Austen, chief of surgery at Massachusetts General Hospital, and expressed to him my interest in cardiac surgery; he referred me to Dr Daggett.

In medical school, I began working in Dr Daggett's laboratory during the summer. I worked on a research project that led to graduating with a focus in a special field from Harvard and an award from the Massachusetts Medical Society for the best research by a medical student for that year. I thought about taking an extra year to get a doctorate or masters in physiology but decided to go straight into surgery.

When I was a medical student at Massachusetts General Hospital, I met Douglas Behrendt, who had just come back from the National Institutes of Health and worked with Dr Morrow. This was somewhat serendipitous, but it was a positive thing. He was short a resident on the cardiac service, so as a senior medical student I substituted for a resident on the cardiac service.

Ohman: Talk about early graduation.

Guyton: The learning curve is pretty fast when you step in like that. He was certainly one of my early mentors as well.

A Growing Family and Growing Career

Ohman: Did you have a family along the way?

Guyton: Yes. I was married and had four children during my medical school days and residency over a 10-year period between 1970 and 1980. My first wife and I separated after 22 years. I remarried, adopted Beth's two children, and we had two children. We have a total of eight children between the blended family and 15 grandchildren. I've carried on my father and mother's tradition.

Ohman: Yes, very strongly so. You finished your training and became a real surgical resident. How did it feel to become an attending?

Guyton: I was eager to come back to the South because I had roots there. They offered me a position in Boston so I asked my wife what would keep her in Massachusetts. She said she needed an electric driveway, which they did not have at the time.

Two of my colleagues, Joe Craver and Willis Williams, had come to Emory. Dr Hatcher at Emory was looking for somebody to start a research laboratory. I was fortunate to be able to write an NIH RO1 grant with Dr Daggett, who was on the study section at the time, and take an RO1 with me to Emory and start a research laboratory.

Ohman: What year did you start at Emory?

Guyton: I started on July 1, 1980. I had trained with Dr Castaneda at Boston Children's Hospital as well as the Massachusetts General Hospital. My first few years had a heavy congenital cardiac focus. I was in the operating room with Dr Willis Williams, doing my first operation at 12:30 AM on January 1. It was a Waterston shunt and was the last Waterston shunt that was ever done at Emory.

Ohman: What is a Waterston shunt?

Guyton: It's a connection between the right pulmonary artery and the aorta. It's a fairly large shunt that you have to be careful not to make too large.

Ohman: You were at Emory at the time when this fellow, Andreas Gruentzig, showed up. That must have been quite a change for the whole practice of medicine.

Guyton: It was very exciting. I think Dr Hatcher was the head of the Emory clinic, and even as a cardiac surgeon, you have to give him great credit for understanding how important Dr Gruentzig was. Emory was able to compete with the Cleveland Clinic and Dr Gruentzig came to this country to work at Emory. There were some politics involved. You remember that Jimmy Carter was President at the time and Griffin Bell was the Attorney General. Some of those things impacted the ability of Dr Gruentzig to come to this country as a radiology resident, never take an examination of any sort, and start to practice medicine in the United States.

If I was going to be a competitive congenital surgeon, I needed to do it full-time, which probably meant giving up the lab...I chose to be an adult surgeon and continue the laboratory work.

Ohman: That may be a piece of history that is not well known, but I'm glad you're pointing it out to us.

'Fantastic Journey'

Ohman: Looking back at your career, is there anything that you would have done differently? It sounds almost like a dream journey.

Guyton: Yes, it has been a fantastic journey. Like everybody's pathway, you prepare yourself and when forks in the road come, you need to choose which way you are going to go. I began by doing congenital and adult surgery but realized that if I was going to be a competitive congenital surgeon, I needed to do it full-time, which probably meant giving up the lab. After 5 years, I chose to be an adult surgeon and continue the laboratory work. I think that was the right decision. The pathway at Emory was great. I had great support from Dr Hatcher and superior colleagues. We all really enjoyed teaching and we had some fantastic residents. I've been involved in the teaching now of about 140 residents, and most of them are practicing cardiac surgeons. About 4% of the national cardiac surgeons are our graduates and they are still an extended family. They, as much as anything else, have brought me joy that I've gotten from my pathway.

Ohman: Did any of your children go into medicine? After this track record, one would expect at least one or two.

Guyton: There are now 36 grandchildren from my father. Four are in medicine and none from my side. I am concerned that the time I spent in the hospital and the time I spent away from the family may have been an important part of that decision for them.

What Were Important Changes in the Field?

Ohman: You have seen a lot of change in surgery and cardiothoracic surgery over the years. What are the most important things that you observed?

Guyton: Cardiac surgery is very special in that we work hard, we develop unique skills over a long period of time, and then we apply those skills patient-by-patient for patient benefit. In cardiac surgery, we take people who are disabled and we enable them. They go back substantially to a very good life with the ability to do things. Many other fields of medicine help people along and restore them partially, but in cardiac surgery, the patient benefit is almost palpable.

It's also a team effort. Working with other people, such as nurses, technicians, operating room staff, and anesthesia teams, has been a great reward of cardiac surgery.

It remains very special to me as a profession as we now begin to embrace innovation and retool ourselves to meet the challenges ahead. We have done a good job of it. We struggled a little bit in the early 2000s when we were grieving the loss of coronary bypass, but we have really overcome that and we are on a very positive pathway forward in cardiac surgery.

Ohman: Extraordinarily well said. The reality is that you have been very much a part of a field that changed a lot in the face of medicine. Many patients have a lot to thank you for, including all of your residents. Four percent of the US cardiothoracic surgery population—that is a big step forward. I want to thank you for sharing your life with us. It's been terrific to hear.

Guyton: Thank you so much, Magnus.

Ohman: I want to thank you, the audience, for listening to this wonderful story.

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