Interview with Dr. John Zitelli

Zitelli.J.XXXX_04.28.2022

Okay, perfect.

Emma Helstrom 00:04

Great. So maybe we could just start by hearing a little bit about when you worked with Dr. Mohs or when you knew him.

John Zitelli 00:15

So I, I knew of Dr. Mohs when I was a dermatology resident, because Mohs surgery was beginning to be well known throughout dermatology, more so than any other field. And I liked doing surgery when I was a dermatology resident. So my chairman, Dr. Harry Wexler suggested to me that I go to University of Wisconsin and try to learn this technique and bring it back to Pittsburgh, so that this procedure would be available in our area and in our department. So I called, I remember I was in the pediatric dermatology clinic one morning, and I called the University of Wisconsin expecting to get a secretary and have her send me an application process, like is done in all of the postgraduate medical education. And instead, Mary Jane, the secretary, answered the phone, and I introduced myself and said, I would like an application for a fellowship, and she said, Hold on, I'll get Dr. Mohs, a click. I'm like, No, you know, I don't want to talk to Dr. Mohs, you know, he's too famous, I just want an application. And Dr. Mohs came to the phone, and I explained to him what my, who I was and what I wanted, and, and he said, Well, why don't I meet him in Chicago in, in a few weeks at the American Academy of Dermatology meeting -- and this was in the beginning of December. So this was the first week of December, I get to Chicago. The, the, we agreed that I would come to his room at nine o'clock after his events that he had going on at the American Academy of Dermatology. So I go to the, to the hotel and knock on the door. Now, I'd never met Dr. Mohs. In my mind, Dr. Mohs was a giant. I was expecting to see a big stately, distinguished man answer the door and instead, instead, there was an older gentleman in his pajamas. And I thought, Oh my God, I got the wrong room. I said, I just said sheepishly, Dr. Mohs? And he said, Yes, John come in. So, we, I came in and we had a long conversation, and he said, John, I really only have six months left at the University of Wisconsin, because they have a mandatory retirement age of 60, I mean, I'm 70, and I'll be 70. And he said, So if you want to train with 00:03:00me, you'll have to start in three weeks, January 1st. I'm like, Dr. Mohs, I'm still a resident. So, I said, I don't know, let me talk to my chairman. And I, I spoke with my chairman, he says, Sure, you take the last six months of your residency, you learn this procedure, and you come back to Pittsburgh. So I did. And in that six months, I moved my family up there, found a furnished apartment, met all of the people in the Mohs Clinic at the University of Wisconsin. And those people consisted of two technicians that were experts in the field of cutting the tissue, Bob and Mary, and Rachel, who was his head nurse, and she ruled the world. Rachel ruled the world in the Mohs Clinic. If you wanted to have a good fellowship, you had to befriend her and do what she said -- and then she was, she would have your back.

John Zitelli 04:11

And then of course, Dr. Mohs. And Dr. Mohs was a very quiet man. So, I'll tell you more about him. Very quiet man. He was not warm and fuzzy when you would first meet him. With, with patients, he was all business. He would come in, numb you up, do what he had to do and get out. There wasn't a lot of talk. There wasn't a lot of explanation. It was all about getting it done and getting things done efficiently. He taught me efficiency, for sure. But in that six months, we did an enormous number of cancers. He saw everything that other people would not even attempt to treat, like cancers invading the brain, cancers invade, skin cancer invading the bladder, cancers invading the sinuses, things that nobody else would attempt, and this is all done under local anesthesia. I saw him remove an eyeball under local anesthesia in the office, because it had to be done -- tracing out these, these cancers. Dr. Mohs was a very brave man. He did things no one else would have the guts to do. He was not easily intimidated. He would, when he knew that he was right, he did not let other specialties influence his decisions at all. So, for example, other specialties like plastic surgery, might say, Oh, you know, you shouldn't be doing that. Because they didn't understand what Mohs surgery was, and it was easy to judge and ridicule 00:06:00when you don't know. He didn't let, let that dissuade him from doing what was right. And, and he taught his fellows that. He taught them, don't turn away cases because you're a little bit afraid. When you know you can do it, you go ahead and get the job done. He, he taught us -- all of the fellows that he trained in all those years -- taught us so much more than just how to do surgery. He taught us to, how to take care of patients, taught us how to believe in yourself, have confidence in, in your specialty and what you're doing and how to stand up for yourself. He was a, an amazing man that way.

Emma Helstrom 06:56

That, that sounds really incredible. Could you just remind us of the year that you did the six month fellowship with Dr. Mohs?

John Zitelli 07:04

Sure. I started my fellowship in January of 1980. I was, what that time, what was called the Brittingham fellow. The Brittingham's were of renowned family in Wisconsin. They, they had a foundation at that time then that donated money to promote education at the University of Wisconsin. And so one of the grants was for the, the training of Mohs surgery fellows, and that, that was a stipend that paid my salary. I was the Brittingham fellow. And that was a six month fellowship from January of 1980 to the end of June of 1980, when I returned to Pittsburgh.

Sophie Clark 07:09

Wow. Yeah. So, um, can you talk a bit about what your role was day to day? So, like, what did a typical day as a fellow with Dr. Mohs look like?

John Zitelli 08:03

So, a typical day in the fellowship was, we started doing cases at 7:30 in the morning and most of the fellows followed Dr. Mohs around. And, at that time, this was sort of the beginning of formal fellowship training in Mohs surgery in the country. Before that period, there, there were many people that would come to the University of Wisconsin, they would follow Dr. Mohs around for a day or a week, sometimes a month. They were very informal fellowships, as opposed to the fellowship that I had. And they might just look and see what he did, and then try to do it on their own when they went home. But the six month fellowship that that we had was more formal. So we started the day following him around, after you might be there for a few weeks or a month, he might let you take the scalpel 00:09:00and take a layer of tissue on an appropriate patient in an appropriate case and, you know, and learn to do the Mohs surgery. Most fellows would follow him around and watch and do probably maybe one or two cases a week on their own. And depending on how he, what kind of confidence he had in the fellows, he might let them do more. I did more than most of the other fellows. I think I did close to 200 tumors in the six months that I was there, that was considered a lot by the standards in those days. But, but I say most of the time it was you would watch. You would see how he handled cases. You would look under the microscope with him at a double-headed scope, so we could see what he saw. And you would go home. And that was five, six days a week, because he worked Saturdays as well. So, we did surgery from 7:30 till 3:30, 4 o'clock in the afternoon -- usually probably about 16 cancers every day.

Sophie Clark 10:21

Wow. And we're all of those using the fresh tissue technique. Did you do any fixed tissue?

John Zitelli 10:29

That's a good question. At that time, Dr. Mohs did the fixed tissue technique on all melanomas. Because even then, there was the fear that cutting through viable melanoma cells might promote its spread. We've learned a lot since 1980 about how tumors metastasize. And most people no longer use the fixed tissue technique for anything. We used it for all melanomas. We used it for very difficult, large or bloody cancers. He treated gangrene with the fixed tissue technique, but almost everything was with the fresh tissue technique. You know, maybe, not even one case everyday would be fixed tissue. But I learned to do that, you know, we learned to fix, use the fixed upon bone, ways to remove bone. That's very rarely taught anymore.

Emma Helstrom 11:31

Yeah, we've learned a little bit about the two techniques when we interviewed with Rachel and Mary Jane. So it was great to hear from them.

John Zitelli 11:46

Yeah, that was a way different method. The important thing that tied them together is the microscopic control. The mapping, and the microscopic control. Using the fresh tissue technique was a tremendous advance because no longer did 00:12:00patients have, have that painful paste applied. And more importantly, it allowed immediate post operative reconstruction as soon as all of the tumor was removed. So the cosmetic results were enormously better when you could cut it out and then do the reconstruction. So in the time that Mohs surgery evolved from fixed tissue to fresh tissue technique, the Mohs surgeons also evolved as the group of physicians who were the facial reconstruction experts. Nowadays, the Mohs surgeons do far more reconstructive surgery than plastics, for example.

Sophie Clark 12:48

Yeah. Interesting. So can you talk a little bit more about how he delegated his work with the fellows that he had?

John Zitelli 13:01

Well, like I said, there was very little delegation of work. Most, most of the, most of the, the fellowship was an observational fellowship, with just a dabbling and doing cases on their own. He would allow me to do some of the reconstructions because he didn't do very many reconstructions at all. His reconstructions were mostly doing, putting a few sutures across a wound. They weren't anything like flaps and grafts, like we do now. So he would delegate some of that to me, occasionally. He would let me do some cases, you know, maybe one or one case a day, something like that. More that's, but the usual fellow, like I said, maybe did one or two cases a week, and the rest was observation. But sharing everything under the microscope, that's a very, very important part of the training -- learning to see what cancer looks like under the microscope. And then how to deal with wounds. One of the things that he taught us and taught the world was how well wounds heal, even if you don't do reconstruction. It's a true art form, because I get a lot of specialties, plastics and ENT tend to believe that everything must be, if you make a wound it must be sutured. If you make a wound, you must repair it, close it primarily or do a flap or a graft. And he taught the art of which wounds heal. Well, if you do nothing at all, except dress the wound and let nature take its course. And taught us which ones do well and which ones don't.

Emma Helstrom 14:57

That's really interesting and kind of carrying on with the idea of specific kind 00:15:00of patients, and I know you mentioned some larger procedures that Dr. Mohs had done, were there any standout patients when you were working with him during your fellowship or later in your career?

John Zitelli 15:19

Standout patients? I guess some of the standout patients were the large tumors that I mentioned, watching him remove a tumor that invaded a woman's genitals all the way into her bladder. It was an enormous case. Watching him anucleate an eye and trace a squamous cell carcinoma back in to the sphenoid sinus -- it's a skull based surgery. And watch him remove tumor through the skull and into the Dora, of the brains of the patient -- had to be admitted to the ICU and use the fixed tissue technique. And sometimes those patients had seizures. Some very, very large cases on the trunk that invaded deeply into muscle and bone. Some things that most people nowadays, most, even most, Mohs surgeons, wouldn't have the guts to attempt to do.

Emma Helstrom 16:23

Wow. Yeah. Those sound, yeah, that's incredible. Those are very rare cases. So maybe changing directions a little bit, then. Could you tell us a little bit about the work environment? Kind of what was your relationship with the other staff members and just, yeah, the environment at that time.

John Zitelli 16:47

The, the Mohs surgery clinic was a very close knit family. There were, like you said, Dr. Mohs, Mary Jane was the lead secretary, Rachel was the nurse. There were other, other nurses, the two technicians in the lab. We always stopped at 10 o'clock and volunteers would, would always bring in little snacks that we would have at 10:30, like the coffee break time. When it was lunchtime, it was lunchtime when Rachel said it was lunchtime. It was lunchtime because she would, stopped bringing patients back. And there was nothing else to be done. So there's no patients. Dr. Mohs went into his office, and he ate the lunch that he brought from home by himself. And then, we the staff, would go down to the cafeteria, usually, or when it was nice outside, University of Wisconsin often had grills and things set up. I remember Friday was always Bratwarst Friday, a special day. And then everybody worked until the work was done, and it was time 00:18:00to go home. But it was very professional. It was, there was a sense of confidence and a good feeling, cause we all knew that we were doing things for patients that nobody else could do. That, that, you know, not every patient was that way, but many patients were just, had, had cancers that just couldn't be done or couldn't be cured anywhere else. It's a tremendous feeling of satisfaction to be able to, to see and take care of people like that. You knew you made a difference.

Sophie Clark 18:45

Yeah, sort of going off that. How do you feel like, or did Dr. Mohs ever share anything about sort of the, like, the process of coming up with this and sort of some initial challenges he faced? Or what do you know about some of those initials challenges?

John Zitelli 19:09

Mostly from, mostly from what I read, no, he, like I said, he was not very talkative. He didn't ever express his innermost feelings. He talked about how we, as fellows and trainees, needed to be evidence-based and, and not, not let others intimidate us. You know, look at the evidence for this, you know, he would, he had favorite subjects like the treatment of melanoma and surgical margins, and that sort of thing. But he wasn't a warm, fuzzy guy who said, This makes me feel like this, or, we didn't talk about that. He was stoic.

Sophie Clark 19:59

Do you think that he, I mean, from some of our other interviews, something that's really shone through about him is sort of how humble he was about his achievements. But do you think that him and his team, but also you and the other fellows, understood the gravity of the technique that you were learning and just how life saving it was?

John Zitelli 20:26

Absolutely. Absolutely, and you're right. Dr. Mohs was very humble. And it was, we all knew his achievements. We all knew it by reading about it. We, you know, he was, we knew that he had lived through a long period in his life when everyone was doubting [unclear]. You know, people didn't believe in it. He had people that backed him, and he had people that thought he was a charlatan. He had people nominate him for the Nobel Prize. He had people that said he should 00:21:00lose his medical license. I mean, he weathered a big storm of controversy, mostly because people misunderstood the use of the fixed tissue paste and misunderstood what he was really doing -- and that's the use of microscopic control.

Sophie Clark 21:22

Yeah. Is there anything else you would like to add about your sort of personal or professional relationship with Dr. Mohs?

John Zitelli 21:33

The only thing I would add, and I've already told you is, what he taught me above and beyond surgery, the things that nobody else ever taught me. He's, one of the, a couple of the scientific parts that he taught were the value of treating high risk cancers, especially melanoma, because melanoma is a very political and emotional kind of, of cancer, and taught us to believe in the evidence and don't allow politics or emotions sway you -- make you make wrong decisions. So he taught that part of the science and, and that little bit of politics, but, most of all, he taught, he taught me to be brave and not afraid in my, young part of my career -- to take on difficult cases. It's always easy for young surgeons to be afraid. It's easy to be afraid. I don't want to fail, so I'm not gonna do this. I'll let somebody else do it. And he taught by example, that, you know, don't do that, you're doing things nobody else can do and don't be intimidated. We, we watched him care for patients when, and one of the fellows would say, Well, don't you think you should get a consult? And he said, Sure, okay, I will, I'll get, you know, we'll have the neurologist come down, and we'll get the consult, so he can see what we're doing here in the brain. And that, and the neurologist came down and said, Oh, okay, you know, and then turned and walked away. And then Dr. Mohs would say to that fellow, Okay, there you go, there's your consult. It was kind of funny that way. But he taught you don't be intimidated, don't let somebody else tell you what to do when you know what's right.

Emma Helstrom 21:44

That's pretty wonderful to get that experience from working with him. And another kind of sentiment we've heard from other physicians that have worked with him is that they really, Dr. Mohs really taught them how to be gentle with 00:24:00patients and how to kind of put the patient before the procedure or the illness. And I'm just curious if you found a similar sentiment with your time with Dr. Mohs.

John Zitelli 23:46

Yes, that's all true. You have to be very gentle with them when you're, especially when you're putting the paste, using the paste. But all I can say is I, I agree with those statements, I'm not sure I could add to them.

Sophie Clark 24:36

Yeah. Well, do you mind telling us a little bit about your career, sort of starting from wherever you would like, and, you know, like talking about how it went introducing Mohs surgery in Pittsburgh, but also sort of what your career has become since then?

John Zitelli 25:02

So I came into our, we were a division of medicine, and when I came back to Pittsburgh in July, that was the beginning of dermatology as a department at the University of Pittsburgh. So we were just began to build. It was an exciting time because we had a new chairman. We had new funding. We had new, a new, buildings, physically, you know, physical plant was new. There was, there was sort of an excitement in the department as a whole. And it was also nice that we had a new procedure to offer. So it was, we have new faculty for this, the whole western Pennsylvania area, and we had a new procedure for Western Pennsylvania. I had the support of the ear, nose and throat department, which was very important in my success, I think, because it eliminated the political problems that a lot of Mohs surgeons had at institutions. If you, I got along well with the surgeons, and that was very helpful. Other places, if there was turf battles, it impeded the progress, so nobody gave me much problem doing reconstruction. Nobody gave me much problem doing melanomas. And those were the problems that other people had in, in their institutions. So, and we also began our own fellowship a few years later in 1983. I started a fellowship program through the American College of Mohs surgery, and I've trained 53 fellows since that time -- very proud of that, as many of those people have gone on not only to private practice but gone on to be chairman of departments throughout the country. Very proud of the research that we've done, and we've added to the fund 00:27:00of knowledge to the specialty. I'm, went into private practice after seven years at the university. And, but I've continued, even though it's not a full time academic position, we still teach the residents in ear, nose and throat, the residents in dermatology, the residents in plastic surgery. And then, like I said, we trained fellows for fellowships approved by the Credit Agent Council for Graduate Medical Education, and then, very proud of that, very proud of all the people that I've trained. I'm very proud of the success of our practice, we're, you know, we're well known we do probably more cancers than anyplace. I know that I've treated well over 120,000 tumors with Mohs surgery in my lifetime. And we have a very large database for our research with melanomas, merkel cells, high risk squamous cell carcinomas. And there's no end in sight. We're gonna keep going.

Sophie Clark 28:19

Yeah. Wow, that's really impressive. That's a very impressive number of cases you've treated. Yeah. So in some preliminary research that we were doing before this interview, we saw that, it says that you've authored over 100 articles and chapters on skin cancer surgery and reconstruction. Is there any way you could tell us a little bit more about that research?

John Zitelli 28:49

Well, that, every, you know, without, with fellows, part of the, part of the, the fellowship training is in academics. And that's a requirement that fellows do a project suitable for publication every year. So that, a lot of our research is guiding the fellows, you know, say, Hey, here's the problem, here's some of the data, put this together. And we would write these papers together and do research together. The stuff that, my interests have always been clinical, and we've always tried to concentrate on answering a question that would help me take care of patients day to day in the clinic. And another thing is trying, um, some of our research has been to prove that what has been surgical dogma in some areas that didn't make sense to me, we've been able to prove that dogma false and replace it with evidence. So I'd say that, that I'm very proud of the papers 00:30:00that we've published and, and how its influenced surgery in the whole country from -- one example was at this year's American Academy of Dermatology meeting they had, they had a competition for, what did they call it, game changers. So they looked at the papers that had been published in the journal, the American Academy of Dermatology, and in surgery, and they have, they picked, I don't know, maybe five different papers that were felt to be game changers. And one of my former fellows, Joy Kunishige, her project was on surgical margins for melanoma in situ and that was felt to be a game changer, that won the competition for game changing research in dermatology.

Sophie Clark 31:04

Wow. That's really interesting.

Emma Helstrom 31:08

That's great. Yeah.

Sophie Clark 31:10

Um, so do you have any, so for someone who's, you know, interested in Mohs surgery or, you know, is just learning about Dr. Mohs, are there any, you know, quick things that you think people should know about? Him and the procedure?

John Zitelli 31:34

I'm not sure I understand that question. Any quick [unclear]?

Sophie Clark 31:37

Or like the, sort of the SparkNotes, like, what is what are some like of the most important things that you would want to tell someone about the Mohs procedure?

John Zitelli 31:48

If I'm explaining it very quick, I'm saying this, that's the procedure that, that has the highest cure rate for skin cancer, by far, and the, most of the people that are trained in those surgeries are also are the best at giving you the best cosmetic result after removing your skin cancer. So, in my mind, I think that, that it would be ideal if all skin cancer was treated with Mohs surgery. But there aren't enough Mohs surgeons in this world. And there, I don't think that that's anytime in the near future. But hopefully in the distant future, all skin cancers are treated by Mohs, because it's the best way to do it. If I had a cancer, it would be done by Mohs.

Emma Helstrom 32:42

Yeah, and I think the results speak for themselves of how successful the treatment has been. And so I'm just a little bit curious about when you were experiencing or doing the fellowship. Through our conversations with other interviewees, we've heard how there was some cross disciplinary work done, where 00:33:00I think Mary Jane knew how to cut frozen sections at one point and stuff like that. So I was curious to see if you learned any of the kind of lab techniques or anything else going on in the Mohs clinic?

John Zitelli 33:22

So part of the part of the training of a fellow is that they have to learn how to cut tissue, because they have to be the one who runs their own laboratory. So when I was the fellow that, Dr. Mohs had two techniques for cutting tissue, one was the cryostat, a machine to do it, and the other was with what's called a freezing microtome, which is, uses compressed carbon dioxide gas to do it -- that's technically a little bit more difficult. That was just the way he had done it for years. Almost everybody, everybody nowadays uses a microtome. So when I was a fellow I trained on, learned how to cut tissue on the microtome, and then I took that with me back to Pittsburgh. Now that's what everybody does.

Emma Helstrom 34:06

Okay. Very interesting. And were you also engaged in, we are a little bit of aware of how much almost mapping he did during the procedures, did you also engage with that while, in the fellowship, or is that something you kind of worked on when you brought it back to Pittsburgh?

John Zitelli 34:27

The mapping? Oh, that's an integral part of Mohs surgery. You can't do it. I mean, the fellow, as a fellow, we drew the maps. You have, you know, that's something you just have to learn to do.

Sophie Clark 34:43

Yeah, that's interesting. Um, and so then, other than sort of the movement from both fresh and fixed tissue, to entirely fresh tissue, have there been any other changes to the Mohs procedures since, you know, the 80s?

John Zitelli 35:08

I'd say the biggest one, yeah, that, I would just mention one and that's immunoperoxidase staining. Staining tissue with, other than hematoxylin and eosin, the routine stains. Now for very difficult tumors, we use a monoclonal antibody that's tagged with a dye. So we were the, I think the leaders in using monoclonal antibody staining to do melanomas. Most people did not like to do melanomas because they were hard to see on routine frozen sections. So we established a method of staining the Mohs sections with this immunostain and made it much easier to see melanomas, much more accurate. And the, it has now caught on to where almost all training centers are teaching their fellows to do, use immuno stains and it's part of the board's now. So that, that's the biggest 00:36:00change I can see in Mohs surgery, which improves the accuracy dramatically for difficult cancers. So I only have like two more minutes because I have to catch a plane, if that's okay. Or if you want to do more, I can do it later, or?

Sophie Clark 36:25

No, that's totally, no worries. Do you have, you know, quick, anything else you'd like to add on, you know, for this record of Dr. Mohs or the Mohs procedure?

John Zitelli 36:42

Not really. I'd say the, like I said, the basics, the most important part of it, which is the mapping and complete microscopic control where you look at 100% of the margin. That is the one unifying thing that has never changed and never will. The minor differences in the way we cut tissue, I think are minor but improved by the use of a cryostat instead of a freezing microtome. And then I think that the biggest change has been the use of immuno stains in difficult cancers like extramammary paget disease, melanoma, [unclear] differentiated squamous cell carcinomas and some other cancers.

Sophie Clark 37:26

Well, great. Um, well if that is it, or, we're out of time, I will end the recording.