Nicholas Fogelson, MD
Remembering Paul Underwood
Updated: May 4
Last week marked the passing of one of my early teachers and mentors, Dr Paul Underwood.
Dr Underwood was a professor emeritus at Medical University of South Carolina, where I attended a residency from 2001 to 2005.
I was fortunate to get to train in a residency that was full of extraordinary people. Little did I know that not every department was like that. MUSC was an incredibly caring environment that looked after each resident like a member of family. Paul Underwood was a big part of that.
I can also say that without Dr Underwood, I would not be an endometriosis surgeon today. There is no question that he is the one that got me started on this path.
One day in my third year of residency Dr Underwood and I were doing an abdominal hysterectomy. We unexpectedly found stage IV endometriosis. While most attendings would have been concerned about the complexity of the case, Dr Underwood was utterly unfazed, being a very experienced gynecologic oncologist. At the same time, he never took the case away from me. He always encouraged me to keep operating even when the case was just outside of my normal comfort zone, giving me a few pointers here and there. He was also one of those surgeons who might let a resident go a little too far and get into trouble, knowing he could fix it.
In that particular case, the patient had severe endometriosis of the anterior rectal wall. With a lot of guidance I was able to get the colon off of the uterus and complete a hysterectomy. When we were done, there was a huge knot of endometriosis still there. He looked at me and just said "go cut that out". At that point in my surgical career the idea of intentionally cutting a hole in the wall of the rectum seemed like a sure path to losing one's medical license, so I asked "you want me to cut a hole through the bowel on purpose?". And then he said the one thing he always liked to say - "Nick if you can't do it.... I can".
That line was his favorite. He was always very complementary of my surgical skills as resident, but would tell other faculty "Nick's a good surgeon, but sometime she gets a little scared. You just have to tell him that if he won't do it that you will, and then his ego gets bruised and he gets pissed and starts operating again!" He had a very funny way of intoning what he said that I cannot replicate in writing, but it communicated a real passion and excitement both for medicine and for teaching.
So on that day I cut a huge knot of endo out of the rectal wall and was dismayed that it resulted in a huge hole. To my inexperienced eyes it seemed we had made a huge mistake, and that this could not really be repaired. Dr. Underwood just said "now just sew it up!".
Huh? How the hell could you sew that up?
"If you can't do it.... I can!"
So I got pissed, asked for a 4-0 vicryl and started sewing it up. "Inside to out, outside to in" he told me. "Do the edges first and work towards the middle, and it will be perfect!". Sure enough that huge uncloseable hole closed up just fine. These days I do the same laparoscopically, or I use a stapler to do the same thing.
Its entirely possible that if I had not happened to be with Dr Underwood that day that the idea to pursue endometriosis surgery as a career would never have come to me. In 2003 he showed me that things the other surgeons would call impossible or ill-advised was actually the best way to treat the patient.
He actually asked me to write up that case as a case report. I never did it, because I did a lit search and found that there were lots of series of the same thing. He was always disappointed in me that I didn't do it, and sometimes expressed that. I hope the fact that I published videos on how to do that long after I left MUSC satisfies him know. Not sure if he ever watched those videos. Probably not.
He was an incredibly good surgeon himself, and had no qualms about telling that to anyone that would hear.. but he did it in a very sly way that never seemed arrogant. I remember one time that I had done a vaginal hysterectomy that had a postoperative bleed. Always one to wear my heart on my sleeve, I was moping around the GYN floor, upset about my complication.
"What's wrong Nick?' he said. "You're sad! I can tell when you're sad, so what's wrong?"
"Well what did you do today?"
"A vaginal hysterectomy" I said.
"Somebody told you?"
"oh no nobody told me. But I figure that Nick did a vaginal hysterectomy, and now Nick's moping around the floor all upset, she must have bled!"
"Yes she did. But Dr. Underwood I did the case perfect! I walked out the OR thinking I had done a great case, and that every knot was good!"
Dr Underwood said "Well you tied a bad knot!"
"BUT THEY WERE ALL PERFECT!"
"Well Nick you tied a bad knot..... because if they had all been perfect......she wouldn't have bled!"
"Don't worry Nick. About 1 in 50 vaginal hysterectomies are going to bleed. That's just the way it is....... At least that what other people tell me!!!"
He also had a bizarre way of dictating charts. Most doctors would dictate a very detailed medical description of a surgery. Dr Underwood would dictate a casual conversation with the transcriptionist, as if he was telling her about the case over a drink.
Procedure: hysterectomy for ovarian cancer
Surgeon: Me.. Dr Underwood
We opened up and there was o' lots o' cancer. The bowel was just super stuck. We starting taking it down and it was like worms out of concrete in there! It took a while but we got it all unstuck and we didn't even make a hole in anything which is a miracle. Then we saw the big tumor on the right ovary. I found that ureter and I got the tumor out. There was a' lots o' bleeding. I thought for a moment that she was going to bleed to death. But we got it stopped! And then we took out that uterus and the other ovary. Then we got us some omentum. And then we took some nodes. That was it. I came over here to dictate while the resident closed, which is what they're doing right now as I'm talking at this moment.
This is perhaps a little embellished in my memory, but honestly not very much. My fellow residents and I actually kept a log of the funniest dictations he had done, and occasionally we would pull them up and read them together, cackling with laughter.
Like all people, he was a complex person. Having grown up a rich white man in the Deep South, he occasionally would say something that we would consider untoward. I remember hearing him refer to MLK day as "Martin Luther Coon Day" once at a party among a couple of other white guys about his age. At the same time, I never saw him treat anyone with anything but compassion or care, no matter what race they were, and I believed that was entirely genuine. So whatever racist ideas he picked up in his youth, he didn't seem to actually act on them, as far as I could see. I've always believed you are what you do more than what you think or what you say. And he did a lot of compassion and care for people irrespective of race.
Of all things, Dr Underwood was the epitome of passion for medicine. He was in his late 60s when he taught me, and he continued to teach for more than a decade after I left. I think he really only stopped when he became more severely affected by an autoimmune condition he had and no longer had the stamina for the job.
Not a resident went through MUSC without leaving with a true love for the man, and I think he had a real love for each resident as well.
MUSC was really a special place, because a lot of the attendings felt that way about the residents. It was a relatively small program, only 5 residents a year. At the time I thought that in all programs that tight personal connection between residents and faculty, but really that wasn't true. I worked in several other academic departments after MUSC, and really at no other place were the residents so cared for by faculty. Dr Underwood was a huge part of that.