Life After Surgery: A Different Road
My name is John Holman. I was a general surgery intern/resident at the University of Utah from 1977-1982. Following residency I did an NIH Post-doctoral fellowship and kidney/pancreas transplant fellowships. I then transitioned to industry work. So as Jeffrey Saffle said is his essay, everyone probably has a different take on what ‘life after surgery’ means. Mine will be different as well.
When I hear the phrase "life after surgery," I do not think first of retirement, or of slowing down, or of the conventional image of a surgeon putting away the scalpel and moving into a quieter life. I think of leaving the clinical practice of surgery. That is a different matter. I left the operating room in 2004, but I did not leave patients, transplantation, or the general problem of how medical ideas become useful to real people. The life that followed was not retirement. It was a second career. In some respects it was a continuation of the same career by different means. So first a bit about how I got to my ‘life after surgery’.
As long as I can remember I wanted to be a surgeon. I found an anatomy book in the house when I was young. Then at 6 or 7 years old I took the ‘appendix’ out of my sister's large doll. Predictably, I got into trouble with my parents. I am not sure this should be held up as model childhood behavior, but it did demonstrate my curiosity about things and how they worked.
I attended UT Southwestern Medical School from 1973-1977. My interest in general surgery continued during this time and for the summers between medical school years I was a scrub nurse and surgical assistant at a small local hospital to the general surgeons on simple cases. I also developed an interest in immunology then following lectures by Rupert Billingham, a postdoctoral student and later research collaborator with Peter Medawar, before coming to UT Southwestern Medical School. It seemed that organ transplantation was a good combination of general surgery and immunology. But I swore I’d never re-learn the gluconeogenic or coagulation pathways. More later.
I was lucky to match the University of Utah general surgery program. My medical school mentor, Robert McClelland, had told me I could learn general surgery at Parkland Hospital in Dallas between 6pm and 6am or I could go to Utah and learn general surgery between 6am and 6pm. Seemed like the best choice. My first rotation was Blue Surgery, and the chief resident was Clif Kwan-Gett. Cliff had been raised in Australia so in the early afternoon he’d take us ‘downtown’ and we’d go on ‘walk about’. Pretty cool so far. Next was Barr Coleman. He shard a love of golf so when Arnold Palmer and Jack Nicklaus came to SLC for an exhibition we took the afternoon off to watch the show. Still pretty cool. Next was Burn-Transplant. These two disciplines were a combined service as although the burn unit was busy, transplantation really wasn’t at that time. But in August 1977 the team transplanted 14 patients….and removed 7 of the grafts for acute rejection. Those were the early days of immunosuppression. But the experience solidified my passion for transplantation.
Surgical training shaped me in several ways, but above all it taught me technical discipline and problem solving. One episode from early residency says more about my formation than any formal description could. I was caring for a patient who had undergone common bile duct exploration with placement of a T tube. During the night in the ICU, the patient began putting liters of bile through the T tube. I reasoned that instead of replacing the loss with intravenous fluid, I could elevate the sterile collection bag and let the bile flow back into the patient, presumably into the duodenum where the fluid could be reabsorbed. The patient developed shaking chills and mild hypotension, but it resolved quickly.
When Frank Moody heard about this on morning rounds, he did not scold me as I recall. He challenged me to understand why it had happened. That challenge led me to the literature on early experiences with ERCP and development of renograms in many patients. Subsequently literature showed that contrast agent was not absorbed from the gut but rather refluxed into the hepatic venous system. That lead to a review of the University of Utah experience with sepsis in complicated biliary disorders and ultimately to a third-year research project on reticuloendothelial function in biliary obstruction. Bing Rikkers was my faculty mentor. I remember spending hours with Bing at his house on the weekends going over my project data and papers we were writing. That sequence - a mistake, a challenge, a literature search, a clinical review, and then an experimental project - was an early lesson in how clinical events can become scientific questions. At this point I had decided not to go into private practice but to be an academic surgeon.
Following residency I journeyed to Albany Medical Collage for a post-doctoral fellowship and renal transplant fellowship. My wife Nancy and I also had our first son during this period. I do not really recommend writing a PhD thesis, doing a transplant fellowship and having a new baby all at the same time. My thesis work required I re-learn the gluconeogenic pathway.
I then joined the general surgery faculty at University of Utah in 1986. Everyone then practiced and took call for general surgery in addition to their specialty. Ed Nelson and I worked together on the donor organ recovery and transplant part of the practice. In 1987, the Centers for Medicare and Medicaid Services mandated there to be only a single organ recovery agency in a given geographic area. With help (only a little) from the University of Utah and Intermountain Medical Center I initiated the formation of and became the first medical director and president of Intermountain Organ Recovery Services (IORS), serving Utah’s two transplant centers and others nationally. IORS was later reorganized to Intermountain Donor Services and subsequently to Donor Connect to reflect the growing mission of the organization. Organ transplantation grew at the University of Utah and nationally throughout the late 1980’s and 1990’s. Our organ transplant program was also increasingly successful in attracting pharmaceutical industry clinical studies of new immunosuppressive agents. During this time, I became very interested in clinical trials and everything about their design, execution, data management, analysis and hopefully publication.
By 2003 and 2004, pharmaceutical companies were developing new immunosuppressive agents and were beginning to hire academic transplant physicians to augment their clinical development groups. Pharmaceutical companies had well-funded projects and fully built-out clinical research infrastructures. For someone whose academic interests included transplant immunology, immunology more broadly, and clinical trials, that was attractive. The decision to leave clinical surgery was not made lightly. I was pulled toward industry more than pushed away from academic surgery. I did not feel that I was leaving "real medicine." I saw it as another form of patient impact.
After leaving clinical surgery, I worked in four principal companies: Astellas Pharma Global Development (immunosuppressants, vaccines and anti-coagulants), Myriad Genetics (biomarkers for non-oncology areas), Quark Pharmaceuticals (acute kidney injury) , and Transplant Genomics (biomarkers in organ transplantation). Each taught me something different about medicine, science, organizations, and myself.
At Astellas I learned the discipline of drug development. I had to learn regulatory language, Good Clinical Practice standards for clinical trials., safety reporting, global development processes, corporate decision-making, clinical operations, and the discipline required to conduct studies intended for FDA review. Surgery had taught me decisiveness, ownership, and tolerance for imperfect information. Astellas taught me that those habits had to be joined to process, documentation, and team-based execution. In a development team, statisticians, regulatory experts, clinical operations professionals, safety physicians, commercial colleagues, and project managers all have real expertise. The physician contributes something essential, but not sufficient. I also had to re-learn the coagulation pathway. Never say never.
Astellas also taught me about failure. Early in my industry career I served as the primary medical lead on a project into which I invested about half of my time and effort. The project ultimately failed after years of work and the Phase 2 trial. I knew intellectually that most drug development programs fail before submission to FDA, but it still bothered me. A senior colleague told me that I needed to learn to "date these projects and not marry them." I have remembered that line ever since. It was not an argument for indifference. It was an argument for resilience.
At Myriad Genetics I learned that biomarkers are not small drugs. They have their own logic. A therapeutic drug program must establish safety and efficacy. A biomarker program must establish analytical validity, clinical validity, clinical utility, and often economic utility, while also navigating reimbursement to a greater extent than new drugs, clinical guideline inclusion, and clinician adoption. Myriad also taught me that evidence must be constructed for several audiences at once: physicians, patients, payers, guideline committees, regulators, and commercial teams. A test that is scientifically interesting is not necessarily a test that changes care. At Myriad I also learned the perils of working for a public company, ie, downsizing when the stock price falls significantly.
Quark Pharmaceuticals was an Israeli company developing a drug to inhibit the p53 gene and mitigate acute kidney injury following renal transplant (delayed graft function) or cardiopulmonary bypass (AKI). At Quark I returned more directly to renal physiology and translational medicine. The lesson there was that promising biology is only the beginning. A plausible mechanism, even one that is elegant and compelling, still must survive the practical tests of dose, timing, patient selection, endpoint selection, safety, and execution. Quark reinforced a lesson I had already begun to learn. Clinical development is an exercise in translation, but translation is often unforgiving. What works in concept must still work in patients.
At Transplant Genomics I returned, in a sense, to where I had started: transplantation, immunology, and the clinical problem of rejection. Noninvasive serial monitoring of immune status and rejection risk in transplant recipients connected back to the questions that drew me toward transplantation in the first place. The lesson from Transplant Genomics was that biomarkers are most valuable when they address a clinical decision that matters. The challenge was not simply whether a test could distinguish signal from noise. The challenge was whether the test could inform care in a way that physicians would trust and patients would benefit from.
Across those companies I learned that industry can be a serious form of medical work. But industry can also lose sight of the patient if one is not careful. Large programs, market projections, regulatory pathways, and corporate milestones are necessary, but they can obscure the individual person whose life is affected by the decision. Surgery gave me constant awareness of the patient. Industry taught me the rigor required to generate data one can say is real - as real as clinical data can ever be.
Leaving clinical surgery did not create grief or disorientation, and I never felt the need to justify the move to myself. I miss taking care of pediatric patients. I do not miss the long hours. About ten years after I left practice, I realized that I was no longer a surgeon in the usual sense. That recognition did not trouble me. I had found a new professional community and a new identity. Surgery gave me discipline. Industry gave me scale.
Roger Federer's commencement speech at Dartmouth College in 2024 contained messages of life. One of his messages, "life is bigger than the court," resonates with me. Although family had always been an integral part of my life, the years after I left clinical surgery have also been defined by the growth of family. My wife and I have two sons, both married to remarkable and accomplished women. Each family now has three children, giving us six grandchildren. They have become one of the most vivid parts of my life after surgery.
I admit that mostly I did not experience my children’s early day to day, hour to hour lives as I have my grandchildren. The oldest two, now seven and nine, are already skilled negotiators, capable of presenting arguments for what they want with the confidence of seasoned trial lawyers. The three-year-olds are, in the fullest sense, three-year-olds: unpredictable, emphatic, funny, and entirely certain of their own priorities. The one-year-old twins have taught me something different. They speak what I have come to think of as "Babylish," a foreign language with its own grammar, urgency, and emotional precision. Learning to communicate with them has required me to enter their world rather than insist that they enter mine. In that sense, grandchildren have become another form of education. They remind me that attention, patience, interpretation, and humility are not only surgical virtues or scientific virtues. They are family virtues.
In surgery, I was trained to read subtle signals: a change in color, a shift in pressure, a lab value moving in the wrong direction, a patient who simply did not look right. In industry, I learned to read different signals: endpoints, regulatory language, assay performance, clinical utility, and the behavior of teams. With grandchildren, the signals are different again, but the lesson is similar. You must pay attention. You must enter the other person's frame of reference. You must understand that communication is not just speaking clearly; it is learning how the other person receives the world.
To a mid-career academic surgeon who is genuinely curious and whose current work is no longer satisfying their curiosity, I would say this: do not hesitate to consider industry. It is not necessarily easier. It requires tolerance for slow evidence generation and for failure. But it can be a deeply serious form of medical work. The question of whether my post-surgical work has reached more patients than my work as a surgeon is not the right comparison. The two forms of work are different. The connecting thread for me is curiosity.
‘Life after surgery’ does not necessarily mean entering a descending recovery phase after a great ride. The ride can continue, just on a different road. Surgery never left me, but my identity evolved. The court was important. It shaped me. It gave me discipline, standards, and a way of thinking. But life was bigger than the court: bigger professionally, bigger intellectually, and certainly bigger as a husband, father, and grandfather. For that, I am grateful.
P.S. My new leadership team….
