Zachary Smith, MD is a urologic surgeon who specializes in urologic oncology (bladder cancer, kidney cancer, prostate cancer, testicular cancer, penile cancer, and adrenal cancer).
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What happened in the course of schooling to influence you to choose your specialty of urologic surgery and oncology?
Early in my training I knew I wanted a surgical specialty because I liked using my hands and being technical. However, during medical school I learned that I also liked primary care medicine a little more than I expected to. So I ended up looking for a medical specialty that allowed me to do both.
Urology is exciting because it offers medical as well as surgical treatments for many conditions – I enjoy both aspects of the specialty. I ultimately chose urologic oncology as a result of clinical and research interests and the opportunity to make an impact in patients’ lives during very tough times.
What brought you to Washington University?
My wife is also a surgeon and we were looking for academic jobs that would fulfill both of our career goals. We obviously knew of Washington University in St. Louis’ fantastic reputation and that it would be a great opportunity. The fact that they happened to be hiring for both a colorectal surgeon and a urologic oncologist worked out great for us. As they say, the rest is history.
Which aspect of your practice do you find most interesting?
The surgical side of my practice is very interesting. I enjoy the cutting edge surgical techniques we can provide our patients.
The clinical trial aspect is the most intellectually interesting piece of my practice. The interdisciplinary junction between urologic oncology, medical oncology, and radiation oncology is very important. This teamwork relationship allows us to offer newer techniques and medications to our patients through clinical trials. This is one of the primary reasons I ended up in academics.
Can you explain the difference between medical oncology and urologic oncology?
Urologic oncology is a subspecialty of urology and deals primarily with the surgical treatment of urologic cancers. Medical oncology is a subspecialty of internal medicine that focuses only on oncology – treating any cancer. Within medical oncology, like most specialties, they often further sub-specialize. Most medical oncologists we interact with are genitourinary medical oncologists – dealing exclusively with urinary cancers.
What new developments in your field are you most excited about?
The improvement in care for advanced bladder cancer patients is the most exciting. It would be an easy answer to say “immunotherapy” as a catchall for the most exciting development, because as a whole, that has moved oncology forward the most in the last 5-10 years.
Specifically within immunotherapy, bladder cancer patients have benefited greatly because, until recently, there had been so few alternatives for them. We now can offer a multitude of options even for a patient with metastatic bladder cancer – where previously the only treatment was chemotherapy. While this stage of the disease is still a severe medical condition, we are seeing remission—and even sometimes cure—in what was once considered a rapidly fatal cancer.
What research are you involved in?
Some of my research interests are improvements in surgical techniques and finding better ways of doing radical cystectomy for bladder cancer (removing the entire bladder).
By looking at different ways to improve the process – before, during, and after surgery – we hope to decrease patient morbidity and decrease the recovery period.
I also have an interest in clinical trials – which sometimes get a bad rap. Patients might think they are being “experimented” on, or that they have no other option. That is not the case at all. Sometimes clinical trials are offered in situations where we have very good prognoses for the patients or we might have a lot of treatment options. Generally it’s simply a situation where we don’t know which treatment is better and we might not know the best answer -- so the clinical trial helps us find that answer for that patient and future patients. It should be thought more accurately as a way for us to compare two treatments in a controlled fashion, not as a way for us to experiment on patients. We only offer clinical trials that are safe and in the patient’s best interest.
What happens after the bladder is removed because of cancer?
With radical cystectomy (removal of the bladder), we have a multitude of options for our patients for urinary diversion -- or ways to get urine of the body.
The most common would be an ileal conduit. This involves taking a small piece of intestine, connecting the ureters (the tubes that drain the kidneys) to that piece of intestine, and bringing it to the abdominal wall. The urine then drains into a bag outside the patient’s body.
We have other techniques where we can reconstruct a new bladder out of intestine (called a neobladder). We take a much longer piece of intestine, reconstruct it to a spherical shaped structure, and reconnect it to the urethra just like the bladder was. This allows patients to urinate the way they normally do.
Obviously the second option sounds better at face value, but there are certainly trade-offs to everything.
In addition to those two techniques, there are other less common techniques that we will sometimes use. We individualize the best treatment for each patient.
Where are you from?
Where I’m from is a very long answer. The short answer is I moved a lot growing up. By the time I left for college, I believe I've lived in 17 houses, five states, and two countries (I lived in the Caribbean for two years as a child).
My father had a few career changes -- which were the reason behind many of our moves. Later in life, he actually left his business to go back to medical school and become a doctor. My dad’s transition from business into medicine added to the number of places we moved for him to finish his training.
I was born in Oklahoma City, moved mainly around the Midwest -- Oklahoma, Missouri, Kansas and Illinois. I went to Philadelphia for medical training, was in practice in Florida after that, and then did some further training in Chicago. I’m not really from anywhere I guess, but kind of a “man of the world.”
I lived in Kansas City the longest, so if I’m meeting someone for the first time, I’ll often just say I’m from Kansas City.
Did your dad’s career change to medicine influence you to become a doctor?
Probably a little bit. My parents were very supportive and encouraging. They wanted us to do whatever we wanted, but also wanted us to have a solid career. There was definitely some nudging and some suggestions early on. I’d like to think the decision to go into medicine was my own, but I also remember my parents “strongly suggesting” me away from going to film school. So they probably had a lot more control than I give them credit for!
Which particular award or achievement is most gratifying?
At the risk of sounding too cheesy, I’d definitely say meeting and marrying my wife, and having our daughter (who is probably the best thing in both of our lives) has been the most gratifying.
Professionally, I received an award at my residency graduation for outstanding teaching and surgical excellence. This award was very humbling to receive from the physicians I respected so much and who helped train me. It was kind of a physical embodiment of their confidence in my abilities as a physician and surgeon.
What is the best advice you’ve received?
If I could only pass one thing along as a parent to my kids it would be to just be honest, nice, and treat other people the way you would want them to treat yourself or your family members. I think if you try to live by that rule, most other things fall into place.
Whether it is professionally or personally, honesty is always the best policy. Those are the qualities that get people farther than they would ever imagine they would go.
If you weren’t a doctor, what would you like to be doing?
If I wasn’t a doctor, I would almost certainly be doing something mechanical and in the automotive world. My primary interest outside of medicine is cars -- working on cars, racing cars, talking about cars. Everything my wife would tell you annoys her about me! So, professionally if I hadn’t chosen medicine as a career, I would have ended up doing something in the automotive realm.
I recently finished restoring a car—with a lot of help from some friends (in case they are reading this interview!). Some of my best friends I’ve met through the car world. Like most things in life, the journey is oftentimes better than the destination.