Susan Mackinnon and Alec Patterson—our August 2007 cover subjects—have blazed remarkable paths since they began their medical careers in their native Canada more than 30 years ago. Both are the chiefs of their surgical divisions at Washington University''s School of Medicine; Mackinnon''s specialty is plastic and reconstructive surgery with a focus on nerve transplantation and injury, a field she helped pioneer, and Patterson is a thoracic surgeon known worldwide for his groundbreaking lung transplant work. In this wide-ranging, Web-only interview, the couple talks about the challenges of medical school, raising four children, and choosing a career that means frequently having to cancel dinner plans (in order to save a life).

I''d like to start with a big question: Why did you go into medicine?

Dr. Alec Patterson: For me, it''s because they accepted me. I could not possibly get in now.

Dr. Susan Mackinnon:Why''d you apply, though?

Patterson: Because I thought they might accept me.

[Laughter]

Patterson: It''s a rewarding profession. It''s tremendously exciting—particularly academic medicine.

Mackinnon: I wanted to do history. And my best teacher ever was Mr. Bob, who was a history teacher. I thought that if you could really understand history that you could predict the future and you could stop all the bad things that happened in the past. And he said, ''You know, you''re pretty naïve,''—he was a real cynic; I think that''s why I thought he was such a good teacher. So he said don''t go into history. And I thought, ''Well, if I''m not going to do that and save the world that way, then at least I would have a job where if I did my job well I would help other people.'' And that was my motivation: to be able to do something with my life that was useful.

When you were kids, did you want to be doctors? You know, every kid has their little play stethoscope.

Patterson: I don''t think I thought about it one way or the other ... I think when I was in high school I wanted to be a doctor.

Mackinnon: I think if you want to do service for other people, it''s a pretty easy choice. There are lots of ways to serve other people, but they are not quite as straightforward. And both of us did well in school. I think another question is, ''Why did you go into surgery?'' I imagine you''re going to get to that. But going into medicine was a pretty simple thing to do.

So leading off of that question, why surgery? Specifically nerve, cardiothoracic, thoracic. What led you in that direction?

Patterson: I think for both of us the surgery question came early in medical school and what flavor of surgery came much later. It''s interesting now how students are asked what flavor of surgery or flavor of medicine they want to do very early. Initially as a medical student I wanted to be an orthopedic surgeon. When you''re in medical school, the people who you interact with as teachers act as mentors. So you''re kind of cruising through medical school thinking that what these guys do is really interesting. Or these guys are really interesting people—they''re nice to me, they don''t shout at me, they taught me, they were interested in me—so you automatically want to pursue that. And that happened to me. I was going to be an orthopedic surgeon, a general surgeon, and then I was going to be a vascular surgeon and then I met the final group of guys that made a big impact on me, who were thoracic surgeons.

Mackinnon: But even after that, halfway through thoracic, you were thinking cardiac.

Patterson: Yeah, well that''s what happens, some guy who you admire, you admire what he does, how interested he is in it, and that person puts his hand, his arm over your shoulder and slaps you on the back and tells you what a great guy you are, how great you would be at doing what he does. It''s almost like an illegal drug or something. That''s mentorship. I had tremendous mentors while I was training.

Do you feel like you''re now fulfilling the same role as they did in your profession?

Patterson: I like to think that we have a fantastic program and gifted people who are all committed to the same means and ends. We''re blessed at the opportunity to be able to train outstanding young surgeons. Doing what I do, I''m not so much involved with medical students. Wash. U.''s a huge place and our little compartment is tiny, but yeah that''s what we do day in and day out—mentor people and teach people to do what we do.

And what about you, Dr. Mackinnon?

Mackinnon: When I went into medicine I was very interested in neurology, the brain and the central nervous system. And as a medical student I did all the electives I could find: neuroendocrine, neuroanatomy, neuroradiology, neuro, neuro, neuro everything. I really enjoyed the mystery of it and as I got to the end of my medical school training I began to see that you could diagnose these hideous neurodegenerative problems or where a stroke exactly was by these little physical exam tricks. But there wasn''t anything to particularly do about it. I mean there are lots of things you can do to help people in neurology, but I was beginning to think it was self-serving, intellectually fabulous—but then what are you doing for the patient?

At that time, at the end of medical school, was when our first child was born. I was signed up to do internal medicine and planned to do neurology. I went to the chief of medicine and said, ''I just had this baby; I''d like to request a week vacation in August to go up to our cottage in northern Canada.'' And he gave me a little talk that I''m sure he thought I needed about the seriousness of medicine—you just couldn''t pick and choose when you take a vacation, and you needed to put aside the personal part of your life. I thought to myself, ''I don''t see myself working for this guy for the next four or five years.'' That''s how intense medicine is, and that''s how important people in it are—either positive or negative. Because there''s no time for fluffy stuff.

At that point in time we were into general surgery and we were doing well [at Queen''s] where we''d done medical school. We were both offered jobs if we''d come back to [Queen''s] and they''d send us to the University of Toronto, which is the big training program in the country. I would do plastic surgery and Alan would do vascular surgery. So that''s not particularly what we were interested in, right? But we were interested in a job and we loved the community and the people there, and so we bundled up our two kids then and drove out of Kingston to Toronto. And I can still remember to this moment going down the hill out of Kingston, across that little flat– remember that, Alec? Up and around the corner. We''d been there since 1959 and that was 1978 when we were leaving. We were going to the big city. And we had two little kids. To go head to head with the department of surgery—University of Toronto. Two hundred and fifty people on staff there then. Now, here in our department of surgery, there are 112. I mean, it was a gun of a place.

How far into your careers were you then?

Mackinnon:We were just starting our training. Alec had completely finished general surgery; I''d done three years of general surgery. And then I was going into plastic and he was going to do vascular. And then he drifted, as we were talking, into thoracic and then into cardiac and then into thoracic.

So when I did my plastics it was hysterical for me because I started my first rotation with this gender reassignment surgical rotation in Toronto. It was then 1978, and was before AIDS, and it was just a great place if you were transsexual or gay. And that was pretty interesting surgery.

But I was very interested in micro and the beginning of the tissue transplantation, which is kind of taken for granted now. If you lose a breast they go to your belly and take tissue from the belly. Or if you have a finger cut off they replant it, if you have facial palsy they take muscle from your thigh and put it in your face, if you have a traumatic injury and lose all the soft tissue in your lower leg they''ll take muscle from here and move it there. Well that wasn''t done when I started my training. And it was just starting to be done.

Do you both like the research or the actual surgery?

Mackinnon: We both have very parallel careers, which is kind of interesting. Our clinical and our research questions are tight. So everything that I do in the lab has immediate translation into the clinical, and the questions we get to ask are always posed out of the clinical problems that we see in the clinic or otherwise with our patients. The word they use now is "translational" research—they coined that in the last few years—that''s what we''ve been doing, sort of walking that tightrope act back and forth.

So you met in school in Canada. Mackinnon: Yes, in medical school—

Patterson: Well, actually in pre-med. They sort of had a kooky program in Canada at that time whereby you could come out of high school, do two years of pre-med college courses and then go directly to medical school. So we both went from high school to two years of pre-med to medicine. I was in the class of ''74 and Susan was in the class of ''75 at the same school.

Mackinnon: We had pre-med hazing then. In my class there were eight women, who all certainly didn''t make it through the two years—

In a class of how many there were eight women?

Patterson: Well, the pre-med class was 50 and the graduating class was 70. I was the class president; it was my job to make sure that everybody got appropriately oriented.

Mackinnon: So that''s how I first met him, and we didn''t have much to do with each other for a year or two.

And when did you marry?

Patterson: 1972.

Mackinnon: Together for 35 years.

And when did you have your first child?

Patterson: 1975. Susan was nine months pregnant when she graduated from medical school. It was funny because as a graduate you climb up and the chancellor is sitting there in some sort of big chair with a little kneeling thing in front of him so you can kneel down. He hoods you and announces you doctor, doctor of medicine or something. So Susan got down on her knees and she couldn''t get up by herself, so we had to jump up and help her up.

Tell me about your kids, your family.

Mackinnon: Yay, we get to talk about our kids.

Four kids?

Patterson: The oldest is Lachlan, who is now 32. He was an athlete as a kid, a very artistic guy interested in photography, music and things like that. He went to school in Colorado, ultimately graduated in art history from Wash. U., and decided he wanted to be a chef. So he went to France for two years, to culinary school and then worked at some two- and three-star restaurants around France. It''s quite analogous to the surgical residency program. I mean you start out chopping carrots and pretty soon you''re cooking fish and meat. So he worked for two years and met a friend who is a talented sommelier, one of the 50 master sommeliers in the U.S. The two of them decided to open a restaurant themselves in Boulder, Colorado. It''s been quite successful and won a bunch of awards.

Mackinnon: The first year he opened it he was one of the top 10 chefs—

Patterson: You''d be doing him a big favor to put the website in this article, frascafoodandwine.com.

Mackinnon: This will be three years this year. In the second year, July 2005, he was on the cover of Food & Wine, and in the October 2006 Gourmet his restaurant was listed 33 of the top 50 in the country. He opened it on $240,000.

Patterson: He was nominated for a James Beard Award—didn''t win it, but it was kind of fun to go to the ceremony.

Mackinnon: It''s like he''s famous.

Patterson: We''ve reached the stage of just being "Lachlan''s parents."

Mackinnon: And he''s married and having a baby in October.

Patterson: Our second, Megan, is an orthopedic surgeon; she was born in ''77—

Mackinnon: Just as I finished my first year internship?

Patterson: Something like that. Megan is the smartest person in our family, many think. She''s a great student and went to undergraduate college at the same school Susan and I did in Canada and—

Mackinnon: Ran for them—

Patterson: Yes, a student athlete. She then came back here to go to medical school and decided she wanted to be a surgeon—and thoracic and plastics were immediately ruled out as options. She became an orthopedic surgeon, went into the training program here and just finished that program a couple weeks ago. About a month ago, she married another trainee in that program, Ganech, who is a bright young orthopedic surgeon. And our son Brendan was born in 1980.

Mackinnon: Just at the end of my plastic surgery training. Three of our kids were born in June. I got pregnant in October to span the June and July transition so that I could take vacation both years to have the baby.

Patterson: He was also an athlete in high school and became a very good rower. He rowed on the U.S. National Development Team and went to the University of Washington, where he was a Husky for four years rowing. After he graduated, he spent a year working in a laboratory of a colleague of mine, where he learned a bit about science and a bit about laboratory work and became interested in that. He did an MPH [master''s of public health] degree at Saint Louis University, where he did very well, he sort of committed himself to that academic program and got very—

Mackinnon: Stopped rowing.

Patterson:Yeah, he stopped rowing and—

Mackinnon: He coached the girls'' team, though, he liked that.

Patterson: He did very well then and was accepted to Wash. U. medical school, so he''s now starting his second year . Caitlan''s our youngest. She was born in 1982 and is a very bright kid. Brendan and Caitlan actually grew up here. Lachlan and Megan kind of got imported into St. Louis when they were teenagers. Caitlan really grew up in St. Louis and went to Clayton High School and went to Washington University. She was furious about the prospect of going to Wash. U. because it''s right around the corner from our house. But the fact of it is, it was the best school she got accepted to, so she went on the advice of her older brothers, who told her what to do basically. We had to sign a pact that we would, you know, never visit her, or if we ever passed her on the street we''d have to look the other way.

Mackinnon: She got her psychology degree and now she''s interested in women''s health and she''s in Chicago. She has this interesting notion from when she was here at Wash. U. and she was studying women''s health. Basically it''s the notion of equitable distribution of health care that is not equitable at all. And there''s all kinds of women who are trampled under the system, homeless, single moms, no health care, all that.

How did you do it? Four kids, research, clinicals, intense jobs? With a family—and obviously a close family. How did you find the time?

Patterson: You know what''s interesting is that largely, probably because of the fact that we weren''t there all the time, our kids are remarkably close. My kids are a heck of a lot closer to their siblings than I am to mine. But we had great help; we had a wonderful woman that looked after our kids during the day while we were in Kingston. I think it was also easier to do it due to the fact that we were medical students in a very small school—we knew all the faculty, we knew all the teachers. When we decided to stay there and train there and Susan became pregnant, everyone was very supportive of that. Which is sort of an unusual thing, I think, in the mid-''70s or late ''70s—

Mackinnon: We didn''t have any preconceived ideas of women surgeons. Because I never saw a woman surgeon until I was one. Canada''s taxes are high, and they put that money back into all the systems. The country will look after you from the day you''re born until the day you die. I remember these little checks, these baby bonus checks—do you remember that? Like $14 or something that my mom would get because you had a baby.

Patterson: Socialist.

Mackinnon: [Canada is] a socialist country. And they have this idea that if a woman''s pregnant it doesn''t just benefit that woman but the whole society—somebody has to bear these things. It''s just a kinder country than the United States. Then and even now.

Patterson: The most right-wing politicians in Canada would make good Democrats.

Mackinnon: That''s a good way of looking at it. Another thing is that both of us doing the same thing made it easier. There was no discussion about stuff. It''s so time-consuming that if you''re not in [the medical] business you can be angry and jealous and ... it doesn''t mean that I''m not angry and jealous when he''s doing something. We were supposed to go out for dinner last night, but we didn''t because he had to do a transplant. So oh, either we get to go for dinner or he''s going to save someone''s life. There''s a lot of understanding—even if you don''t like it, you understand it.

Patterson: I also think that we were very well mentored. I think we were raised right. I work for some of the world''s most academically generous people; when the sun would shine on them, they would reflect directly on me.

Mackinnon: And we worked really hard.

Patterson: We worked hard.

Mackinnon: We worked very hard. We loved it, but we still worked hard.

Patterson: We were in a good environment where academic productivity was expected and rewarded.

I just have two more questions for you, and they can be packaged into one question: What do you think is your greatest medical achievement, and what do you think is your greatest personal achievement?

Patterson: Well, I think our greatest personal achievement, my greatest personal achievement, is our kids. Having four fantastically productive, great kids, none of whom has been in jail or been arrested or something. I would say that''s my—our—biggest personal achievement. And I''d say my medical achievement is always being part of a fantastic group of productive surgeons. I''ve never worked by myself. I''ve always worked in an environment where I thought I was part of a group all headed in the same direction. I never ever felt that I was kind of hanging out there on my own. And it''s not easy; it requires a kind of subterfuge of your own. It''s pretty easy to trample all over everybody else. I''ve done truckloads of transplants and we''ve had a great program in transplantation and had a great program in general thoracics, those are nice things to be a leader of, but I don''t think those things are my major accomplishment.

Mackinnon: So my personal accomplishment is [that] my husband of 35 years is still married to me—I''m sure that''s not easy for him. [Laughs] Oh no, it is. And our four kids. No question. And that''s way more important than anything I''ve done clinically.

What I''ve dedicated my career to is advancing peripheral nerve surgery. There''s lots of different other specialties, like if you were bleeding from your uterus you''d go to a gynecologist, if you got a lump in your breast you''d go to a breast oncologist, if you break a bone you go to an orthopedic surgeon. But if you have a nerve injury, you would maybe think, ''Oh, I should go to a neurosurgeon.'' But they actually are more expert in brain and spinal cord, and they don''t do much of the periphery with the nerves left. Orthopedics do nerves, so do plastic surgeons, thoracic surgeons, general surgeons. So bringing it into a specialty—for heaven''s sakes, why isn''t it a specialty?

I think the general management of nerve injuries in the United States is an embarrassment. So what I''ve done with my career is try to advance peripheral nerve surgery into an area of expertise that patients and physicians looking after them would recognize. The Internet has helped that, to know that there is such a thing as a nerve surgeon. And within that, with my research and my clinical work, I''ve developed a technique of nerve transfer that quickly moves nerves into damaged muscles to get better, faster recovery. So if you have an anatomical injury up in your neck, we used to fix if up there. Sometimes we do. But now what we try to do is come down to where the muscles are that have been unplugged from the electrical disconnect up here, in the neck, and do little nerve transfers down here to get better faster.