It's 8 o'clock in the evening when Dr. Sean Mulvihill finally walks in the door of his spacious hillside home high above the Salt Lake Valley. He left the house more than 13 hours ago. He was supposed to be home by 6.
"Have you had anything to eat today?" his doctor-TV reporter-wife, Kim, asks?
"A piece of pizza," he says, slumping into the couch next to her.
He has been on his feet all day performing his delicate art, which is removing cancers. His specialty is cancers of the pancreas, bile duct and liver. Even by cancer standards, this type of surgery is a tricky business. They are long procedures, five to six hours. In a dozen hours this day, he operated on just two patients with no breaks during the procedures. He removed part of a pancreas, bile duct and small intestine for one man, and he drained a large cyst into the stomach of another man.
"The one man had had three other surgeries, so there was a lot of scarring, which made it a little more difficult," he says quietly.
Mulvihill, 50, is good at what he does, a star on the Huntsman Cancer Institute's redoubtable team of doctors. "When no one else wants to do it, they send it to Sean," says Dr. Michael Cahalan, chairman of anesthesiology at Huntsman. "He gets the toughest, biggest cases with the most emotional issues. The buck stops with him in that field. He's a special resource for the people of Utah. I see people come from far and wide to see him. I don't think the community appreciates what he's trying to accomplish and what he has done."
In the war on cancer that is being quietly fought behind closed doors at the Huntsman Institute, the organization has brought in big talent. For doctors in the cancer field, it's like playing for the Yankees, and Mulvihill was one of their big free-agent signings five years ago. Huntsman's commitment to cancer treatment and research was enough to lure him from his native California and his sailboat to Utah.
That, plus Huntsman offered him the chance to be the equivalent of a manager, coach and star player. His official title is senior director of clinical affairs and professor and chairman of the department of surgery at the University of Utah School of Medicine. Translation: Besides surgery and patient care, he teaches and oversees research and administration.
Mulvihill was a faculty member and surgeon for 13 years at Cal-State San Francisco, charged with overseeing a group of 15 surgeons, when Huntsman found him and offered him the opportunity to lead its 75-man department of surgery.
"He was sought after (by others)," says Dr. Steve Prescott, who was executive director of the Huntsman Cancer Institute for six years until April. "He was at the top of the list. . . . We were looking for an outstanding surgeon with a great reputation who would be able to convey that to trainees and inspire them; someone who was actively engaged in trying to refine how we practice medicine. He came up A-plus in all of those. He's wonderfully talented."
Mulvihill has literally written the book(s) on cancer surgery, along with more than 100 scientific papers and book chapters. He also co-authored a book for cancer patients and their families "Everyone's Guide to Cancer Therapy" and has helped pioneer life-saving surgical techniques. "He is one of the real innovators in this worldwide," says Prescott. Only a few years ago, patients who underwent surgery for cancers of the bile duct, liver and pancreas routinely lost a lot of blood and had to undergo several transfusions during surgery and recovery. Thanks to techniques developed by Mulvihill and others, most of the operations can now be performed without any transfusions, which means less stress on the body, quicker recovery, the elimination of side effects that can result from transfusions, and a lower recurrence rate for cancer. "It improves everything," says Prescott.
'Part of a team'
Mulvihill crams many duties into 60-hour work weeks. Among other things, he oversees research projects that seek early detection of the types of cancers he treats. He has weekly meetings with a group of doctors to review data and plan experiments and papers. "Right now, 90 percent of the diagnoses we make are relatively late, when there's not a chance to cure the patient," he says. "If we had a better test, we could diagnose them earlier. We're very excited about a new pancreas diagnosis project. There's a new type of test that has potential."
On the administrative side, Mulvihill helps to oversee construction projects, budgets, resources and recruitment of new talent. He also teaches residents and delivers lectures.
"There's no nonsense when he comes to work," says Cahalan. "He has very high standards. I've seen him get after people. He's a tough taskmaster, but in a fair way. He expects a lot from himself and from others."
Says Mulvihill, "I provide the resources for others to do their jobs well. I get gratification from helping others to succeed."
That notwithstanding, Mulvihill feels most at home in surgery. He likes to be in the operating room the way an athlete likes to be in the game or a fighter pilot in a fray. (He was sidelined for a month this spring after breaking a couple of ribs in a skiing accident.)
"There's a saying that surgery is so fun you'd do it free," says Mulvihill. "For many of us, there's no place we'd rather be than in the operating room. It's got a sports analogy to it; you're part of a team working for a goal, it's a physical challenge and you have to go into it prepared, it's technically difficult, and there's just the right amount of stress to make it edgy."
His work in surgery has won considerable respect from those who work alongside him in the OR. The man has skills. "He takes on the types of cases that are sometimes called big surgery," says Prescott. "By that I mean the scope of the operation is really extensive. He must remove a substantial amount of tissue, but the real tricky part is the anatomy. The pancreas is intimately related to the bowel and the liver, and the blood supply is very complicated. To do it is very difficult. You must be very highly trained and have unusual skill."
The reality of the situation is that as good as Mulvihill is, the odds are stacked against him when he takes on the types of cancers in his specialty. The vast majority of patients will die. When a patient comes to him, the surgeon is forced to make difficult decisions, namely whether he can save his life or prolong it significantly and still maintain a certain quality of life. The harsh reality is that in most cases, it's too late.
'We cried together'
Mulvihill has ridden the highs and lows. There was a 75-year-old woman who was diagnosed with ovarian cancer, an especially bad form of the disease. She survived that cancer only to develop cancer of the pancreas. Her doctor told her she was going to die, end of story. She came to Mulvihill for a second opinion. After looking into her case, he thought he could save her. He did, and on the occasion of the magic five-year mark after her surgery, she sent a picture of herself to Mulvihill celebrating the occasion and wrote, "I guess you did the right thing." She continues to send Christmas cards.
Then there was the woman from Wyoming who had liver cancer and was told she would die. She came to Mulvihill for his assessment and, ultimately, surgery. She is alive and well.
"The majority of the cancers I see are incurable, and we don't even try," says Mulvihill. "But we have certain criteria that we use to decide which cases are worth trying. They might not die for months or years, or they might die right away."
There is the inevitable heartbreak. A few years ago, a 40-year-old woman came to him with pancreatic cancer so advanced it was considered incurable. Mulvihill tried new techniques that combined radiation and chemotherapy treatments and a new surgical method that is still not practiced at many hospitals.
"It was great news," he recalls. "The tumor shrank. It was still not curable, but it became potentially curable. She did well for a couple of years. She was in her mid-40s. Everyone was so happy. Then the cancer recurred. And we tried everything to keep her going. She died a few months ago, and that was a very sad time. She was a patient I got close to. I had seen her so much. I got to know the family. She was very appreciative for the time she had, for those couple of years. When she realized it was the end, that was a sad time. We cried together."
Co-workers say Mulvihill's bedside manner is one thing that separates him from many other doctors of his caliber. Which seems unlikely to someone meeting Mulvihill for the first time, given his serious, reserved comportment and his initial aloofness, but he warms to people.
"I've seen people funnier and more charming," says Cahalan, "but he has such devotion to patients."
Mulvihill's warm bedside manner was a revelation even to his wife early in their marriage.
"For me, the one most telling experience was listening to him talk to a friend of mine whose father was dying of cancer," says Kim, a former practicing physician (gynecology) herself. "He was talking about what her dad's last days would be like and how to handle this. I was so moved. It was a side of him I had never been privy to. I had never witnessed his bedside manner. I was in awe. There are so few surgeons who could have a discussion like that with a patient. I was grateful he was there for that family. It struck me that this is what he should be doing."
'A little humility'
Sean Mulvihill addressed the issue of the so-called bedside manner at such length and with such conviction during the course of a recent interview that it became clear that this is an important subject to him and one he has considered carefully.
"I had a mentor at UCLA, Dr. Don Morton, who was a cancer surgeon who had a great philosophy of caring for patients," says Mulvihill. "He had a good bedside manner. I watched him communicate with patients and explain what was wrong, what we might do about it. He inspired confidence and hope, which is a very important part of that relationship to convey a sense of, 'I'm here on your behalf to make things better' and he was a very approachable person.
"That's one of the challenges of medicine, especially when you're caring for patients with terrible diseases. Some doctors are more naturally empathetic, and others are more distant. Then there is also the protective mechanism. There's a tendency to sometimes keep your distance from the patient because it's emotionally difficult to have so many patients
die. In my area of expertise, a lot of them are going to die. These are some of the toughest cancers we face. This is the most defining moment in these people's lives. Most of us don't think about our mortality, but these people are thinking about it.
"When I step back and think about it, here's a patient from, say, Idaho, who meets me for the first time. We talk for a half hour, then agree I'll do this operation that could be life threatening. That is a remarkable trust the patient puts in his doctor. . . . We all need to have a little humility about this thing. One of the joys of medicine is that patients still have that respect. We have to do what we can to maintain that."
Mulvihill worries that such confidence in the profession is eroding, with medicine turning increasingly into a business enterprise. He still visualizes the doctor as Marcus Welby, not insurance plans and profit margins and signs advertising liposuction, breast implants and other optional treatment.
"It breaks my heart to see the ads for health care," he says. "I don't know if it should be advertised like a car dealership. I see the ads for liposuction with the price and the picture it looks like they're selling a product. We're not selling a product. We're trying to help you. . . . There should be some distance between a doctor's advice and him making money on it."
'Keep yourself balanced'
Relaxing in his home at the end of a long day, Mulvihill drags a hand wearily across his face, as if rubbing away the fatigue, while Kim sits next to him. Their union sounds like something out of "ER." They were both pre-med students at USC when they met on the first day of their gross anatomy class. They married at the end of the school year, having known each other less than a year. They went on a backpack trip for their honeymoon. The day before he was to start his surgical clerkship, he shaved off his full beard and mustache, explaining to Kim, "Surgeons don't have beards and mustaches."
Kim was a practicing gynecologist for 11 years in San Francisco, but her career came to a sudden end when she developed an allergy to latex gloves. As fate would have it, she stumbled into a second career as a TV news-doctor who does medical-related stories. She began with the NBC affiliate in San Francisco, then was hired away by the CBS affiliate KPIX. Since moving to Salt Lake City, she has continued her TV job in San Francisco and taken on part-time work with KSL-TV. She spends two or three days a week in San Francisco doing the TV work.
"I miss my patients, but I'm happy doing this," she says. "I feel fortunate I'm doing something else related to (medicine)."
Sean and Kim and their three children are an outdoorsy, active family, given to hiking, biking and sailing together. Once a month Mulvihill flies to San Diego to sail his 40-foot sloop for a weekend.
"You have to keep yourself balanced," says Mulvihill. "It's unhealthy if you're so focused on your job all the time."
Especially one that's as stressful as that of a cancer surgeon. There's a fine line between maintaining a warm, compassionate bedside manner in which the doctor comes to know and empathize with the patient, while still trying to separate it from his own life. As Cahalan notes, "I've seen it wear out doctors because of the sadness. But the chance to cure and prolong life is enormously rewarding."
"About 80 percent of the patients I see are going to die," says Mulvihill. "In one sense you have to be an optimist and convey that with the patient, and at the same time you have to have some sense that it's not you with the disease. You have to have a little perspective. They have the disease, and I'm here to help. But there are some cases, little kids. I had one kid who was 16 years old. That makes that even more difficult."
Early in his career, Mulvihill had what he deems still to be the toughest case of his life. One of his patients died on the operating table. A major vein had to be divided to remove part of the liver, and one of the clamps slipped off. By the time they got the bleeding stopped, the patient was too far gone. Dying as a direct result of surgery is rare, and for Mulvihill it was a crossroads.
"It makes you introspective," he says. "It was a terrible outcome. There was a lot of self-criticism there. What went wrong? It was tough to realize I had failed that patient. . . . In surgery, it's impossible to practice without complications. You have to react. Some doctors decide they don't want to take care of that (particular medical) problem again and move to a less risky area. Another way to deal with it is to become cold and callous. The third way is to say, 'I'm sorry this happened; it's not because I'm a bad person you can't expect perfection' and then you do a critical appraisal of what went wrong and try to be better. Doctors are human and they have those reactions."
Mulvihill has gone on to build a remarkable career, and he is excited about the progress that the Huntsman Institute is making. Inevitably, of course, all cancer discussions lead to the great question.
"No one knows what causes cancer," he says. "That's part of our mission statement to understand where it comes from. What the changes are in those cells. Probably our mission is to understand the beginnings of cancer and to prevent it. The next best thing is early diagnosis, to develop better tests and strategies. Clearly, there will be a lot of people that fails. Then we treat it the best we can. After they have it, it's really too late."We cure about half of the major cancers we see today. And the kind I treat is lower than that. Despite all that effort, it's still disappointing how many patients can't be cured."