DDS Profile: Richard A. Kozarek, MD

Current State

At the time that I am writing this profile, it is June 2023, a consequential month and year personally. The date marks the 50th anniversary of my graduation from medical school and, coincidentally, the 50th anniversary of my marriage to my wife, Linda. Defining events like these give one pause when reflecting on what and where alternative careers and relationships might have led.

So, because I am still trying to make sense of how I got from there to here, let’s start with the current day and work backward. For those of you who prefer linear temporal continuity, you may begin with the date of my birth by starting at the end of this biosketch and reading backward.

I am currently 76 years old, almost two years retired from clinical practice and working as a co-investigator in the NIH-supported T1DAPC Consortium and DREAM protocol [1]—a study looking at the incidence and etiology of diabetes mellitus development following even a mild case of acute pancreatitis. My current formal title is Clinical Researcher in the Center for Interventional Immunology at Benaroya Research Institute (BRI) in Seattle, and the position affords me additional time to continue to mentor residents, fellows, and international visiting scholars as well to complete editing (with co-editors Todd Baron, David Carr-Locke, and Nagi Reddy) the fourth Edition of our textbook, ERCP, arguably the major text on this topic over the past two decades.

Past Tense, Seattle

I worked at Virginia Mason Medical Center (now Virginia Mason Franciscan Health/VMFH) for 38 years before transitioning to BRI. For 16 of these years, I was Chief of Gastroenterology (GI) and, for the last 15, the Director of the Digestive Disease Institute (DDI). The latter is a multi-disciplinary group composed of gastroenterologists, GI providers, surgeons, GI interventional radiologists, GI pathologists, administrators (thank you, Julie Katz), and support staff dedicated to interdisciplinary care, basic and clinical research, and presentations and publications. Most years included up to 100 peer-reviewed publications, a yearly regional Virginia Mason GI meeting, multiple live endoscopy transmissions across the globe, and a plethora of institutional educational events (GI pathology, liver pathology, GI radiology, journal club, GI tumor boards, and perhaps most importantly, regular Morbidity and Mortality (M&M) conferences. There is nothing like a monthly M&M conference to keep you humble and sharpen your focus.

The DDI years were heady ones. I was privileged to work with superb colleagues, not only in GI and hepatology, but excellent hepatobiliary, general GI, thoracic, and colorectal surgeons. It was an unusual week when I wasn’t in one operating suite or another and an unusual day when one or more of my surgical colleagues did not join us in the endoscopy suite. I learned as much pancreatic and esophageal anatomy by palpating and viewing the outside of these organs and reviewing frozen sections intraoperatively as I did when performing ERCP and endoscopy.

Despite what I describe as an “in-evolution” pedigree, I was hired by Virginia Mason in 1983 for an endoscopic skill set to include ERCP and the rapidly evolving techniques to treat GI bleeding and palliate GI malignancies. This was a focus of my practice but included a recognition that proper care required additional colleagues and skill sets. In other words, recruit, share, teach, and learn from one another, and recognize that whichever discipline touches the patient first should not dictate the care they receive.

I was also committed to be more than a technician and, throughout my career at the Clinic, maintained an active general GI practice. In fact, until recruitment of a Director for our Inflammatory Bowel Disease (IBD) Center of Excellence, I maintained the largest practice in IBD at the Medical Center. My contributions included the initial description of the use of methotrexate for refractory IBD [2], as well as countless trials with a still evolving armamentarium of biologics and small molecules.

During my years at the Clinic, four distinct but often intertwined events occurred:

• 1. Therapeutic endoscopy evolved rapidly, thus leading to multiple invitations to speak, perform at Live Endoscopy courses around the world, and collaborate with colleagues (and industry) with similar interests and the performance of multi-institutional studies. I consider colleagues like Todd Baron, Simon Lo, Glen Lehman, David Carr-Locke, Marty Freeman, and the late John Baillie, Walt Hogan, and Stu Sherman, as well as numerous friends and colleagues from around the world, as kindred spirits.

• 2. Often a reluctant “joiner,” I nevertheless found myself on committees, Governing Boards, and ultimately president of three international organizations: The American Society for Gastrointestinal Endoscopy (ASGE), the World Gastroenterology Organization (WGO), and a multi-disciplinary organization of minimally invasive surgeons, interventional radiologists, and therapeutic endoscopists, the Society for Gastrointestinal Intervention (SGI) [3]. These interactions led me to more superb colleagues and friendships, including Emmet Keeffe, former editor of this journal, Eamonn Quigley (Ireland/Houston), Henry Cohen (Uruguay), and Ho-Young Song, an interventional radiologist from Seoul, as well as dozens of others.

• 3. Interaction with general medicine and GI and surgical professional journals has also had a major influence on both my career and critical thinking. I regularly review for more than 20 journals, have been on the Editorial Boards of 13, including Digestive Diseases and Sciences currently, and have been the International Editor for Gastrointestinal Endoscopy.

• 4. Finally, mentoring residents, GI and surgical fellows, research fellows, visiting scholars, and colleagues from around the world who chose to spend up to a full year at our institution, has taught me much more than I imparted to them. Shayan Irani, our first Advanced Endoscopy Fellow and now a colleague, is only one of many examples.

Formative Years

Looking back, all the years have all been formative, but I can’t explain Seattle without talking about my training in Phoenix and Tucson, my internship at Dalhousie University in Halifax, Nova Scotia, and my college and medical school years at the University of Wisconsin in Madison. Regarding the latter, I attended college during the tumultuous Vietnam War era of the 1960s. I have vivid memories of the National Guard on campus for student protests and the bombing of our Math Research building that resulted in the death of a graduate student. I was a Philosophy major who took enough science credits to be accepted to medical school. I met my wife during the first week of medical school in a creative writing course that I was taking on the side. However, I failed to tell her that I was a medical student for almost a year.

The first two years without patient contact at that time were difficult for me—not the courses, but the structured curriculum. As a result, I did an externship in West Virginia after my first year, ultimately doing extended rotations in rural Wisconsin, in Tuskegee, Alabama, and at the Alaska Native Medical Center in Anchorage. It was there that I met a copper prospector on the train from Denali who said, “If you like Alaska, then you would love Nova Scotia and Newfoundland.” I wrote to approximately a dozen hospitals in the Canadian Maritimes and was referred to Dalhousie, where I did a rotating internship, after moving 1800 miles in a Toyota Corolla on the day after Linda and I were married. This was a great experience, and we made life-long friends. However, Linda had no work visa, and we returned to the U.S.A. to complete my internal medicine residency at Good Samaritan Hospital (now Banner Samaritan) in Phoenix in 1974. I was convinced that I would become a primary care doctor in a developing country.

All that changed when I rotated to the Phoenix Veterans Administration Medical Center (VAMC) with an excellent but “difficult” gastroenterologist, Bob Sanowski. Because his gastroenterology fellow was away for an extended period because of a family death, I inherited a 32-bed ward and a mentor who insisted on teaching me, a second-year resident, endoscopy and colonoscopy. It was the most stressful two months of my life. Nevertheless, I subsequently did my GI fellowship at the combined University of Arizona Phoenix VAMC program; I spent one year in both Tucson and Phoenix and finished in 1978.

The latter 1970s and early 1980s saw the advent of endoscopic control of GI bleeding, therapeutic ERCP, and palliation of esophageal malignancy with Nd-YAG laser therapy and homemade esophageal prostheses. It was an exciting time, and I stayed at the Phoenix VAMC and the Phoenix Indian Hospital for an additional five years, teaching residents and fellows while expanding my own knowledge and skill set. Note that I ran the esophageal motility lab throughout this time, and despite our move from “dry heat” to days of drizzle, Bob and I remained friends until his death.

What did I bring with me from Arizona? A five-year-old daughter, Katie, who is an architect now and is back in Seattle, and a six-month-old daughter, Ellie, now a dentist in Los Gatos, CA, and the mother of our two granddaughters, Lyla and Bella. And most importantly, I brought my amazing wife, Linda, who went to Arizona as a teacher and left as an attorney and whose support throughout my career held our family together while I was “St. Elsewhere.”

En Route

I was raised in Tomah, Wisconsin, a town with a population approximating 5000 during my grade and high school years. Frank King was a cartoonist who serialized a weekly strip called “Gasoline Alley,” which pretty much summed up our main street before the Interstate highway bypassed it and the city’s major tax base—speeding tickets for tourists from Illinois en route to the lakes of Northern Wisconsin. Subsequently, David Benjamin, perfectly summed up growing up in Tomah in his novel, The Life and Times of the Last Kid Picked [4]. I was the second of seven kids and had three brothers and three sisters. My father was a general practitioner and delivered approximately half of my high school classmates. I am certain that his immersion in Medicine affected the career choices of my siblings (two brothers became MDs, all three sisters became RNs) and, ultimately, me. For anyone interested in pictures of our family as well as a video interview, please see Reference [5].

Transitions

At the time of my retirement from clinical practice, I summed up what I had learned in my institutional and societal leadership roles in our yearly publication, Gut Instinct.

• 1. Recognize that the patient should be central to all that we do.

• 2. Have a vision and set clear goals for your program—and get buy-in from your colleagues and administration.

• 3. Hire people who are smarter than you and have skill sets that you do not possess—or if you have them, push the people you hire to surpass you.

• 4. Share resources and credit with your colleagues.

• 5. Recognize excellence and performance, not seniority.

And keep in mind:

• 6. Your patients and your family take primacy. Find a comfortable balance. Time and money are secondary. There is never enough of either.

• 7. Avoid stasis. Try to learn something new every day. Knowledge, techniques, and technology will continue to evolve. What you did yesterday may not be what you do tomorrow.

• 8. Don’t be smug. Life is unfair, and your own health and social well-being are tentative.

• 9. Give back–to your community, practice, institution, and church/synagogue/mosque.

• 10. Don’t practice beyond your skill set. Whoops…

• 11. As the old advice goes: Wear clean underwear; you never know when you will be in an accident and end up in a hospital emergency room…or need an emergent colonoscopy.

• 12. Finally, don’t prattle and proselytize at anonymous readers. Have something meaningful or instructive to say. (By the way, is anybody reading this?)