Abstract
Professor and physician Dr. Ernest L. Mazzaferri Sr. passed away on May 14, 2013, at 76 years of age (1,2). Ernie is remembered as a caring and talented physician, an accomplished scholar and educator, as well as a loving husband, father, and grandfather. He was a luminary figure, and few people have had a greater impact in thyroidology in recent decades. Here we include reflections from a few of us that knew him, as well as commentaries from people who did not. Ernie's passion was caring for patients and how to improve their care. Our goal is to pay tribute and memorialize the person we knew and the impact that he had on patients around the world through his dedication to research, lecturing, and writing that achieved remarkable global influence.
Education and Professional Accomplishments
Dr. Mazzaferri proudly served as a Captain in the United States Air Force from 1964 to 1966, and as a Lieutenant Colonel from 1970 to 1972. He continued to serve in the U.S. Army Reserves and again served his country on active duty status during Desert Storm as a Colonel at Madigan Army Medical Center in Tacoma, Washington (1990–1991).
Ernie joined the Endocrine Society in 1974, the American Thyroid Association (ATA) in 1978, and the American Association of Clinical Endocrinologists (AACE) in 1995. He served on numerous ATA committees, was ATA President (2005–2006), and co-authored two ATA Guidelines on thyroid nodules and cancer that, more than any other contemporary documents, served as the gold standard of patient care (3,4). Similarly, until his retirement from OSU, he served as the first chairman of the National Comprehensive Cancer Network guideline committee on nodules and thyroid cancer (1997–1999). Ernie was elected as a Master in the American College of Physicians (1996), served as Chair of the American Board of Internal Medicine Endocrinology and Diabetes section, and was a Member of the American Board of Internal Medicine Board of Directors (1999–2003). He served on four separate committees or panels for the National Academy of Sciences and Institute of Medicine (1997–2000). Among the numerous awards that he received are the prestigious Paul Starr Award from the ATA (1998) and the OSU Distinguished Service Award (2009) for his advancement of the university's reputation as a world center for the study of thyroid disease.
Ernie the Dedicated Physician
Above all else, patient care was the highest priority for Ernie. He maintained a significant clinic schedule despite his many other responsibilities. Patients sought him out due to his widespread reputation for clinical excellence, but it was his caring heart and confident reassurance that established deep trust and personal relationships between his patients, their families, and him.
On January 1, 1999, Ernie wrote a letter to his patients announcing his retirement from OSU. His own words demonstrate the personal relationship he shared with his patients and how meaningful the role of being a physician was in his life. He wrote: Dear Patient, After many years of practicing medicine, it is with great difficulty that I have made a decision to retire this spring. My wife, Florence, and I are moving to Gainesville, Florida, where we plan to enjoy our retirement years with our family. This is an important part of my life that somehow seemed to have been put aside for many years … I have been truly blessed to enjoy my life's work so much over the years and to be associated with so many wonderful people, especially my patients. There are few things more rewarding than being someone's personal physician and I have been privileged to care for a very special group of people. I will miss our meetings and will remember this time in my life with tremendous warmth and satisfaction. Thank you for letting me serve you in this way.
Ernie recruited me to assume his clinical practice, and he promptly scheduled weekly meetings for us to sit together as he would review the paper chart of one patient at a time and offer advice regarding their clinical status and recommended next steps in their care. It was clear that Ernie knew his patients and their families well, and his concern was obvious for those with persistent thyroid cancer, especially those with distant metastases. It is humorous to me now as I recall my disadvantaged struggle to bring an end to these meetings which pitted my attempts to convince Ernie that I was competent to care for his patients against Ernie's compulsion to do everything he could for the well-being of his patients. It is a wonder that he ever let me see his patients without his oversight. I left OSU after 13 years of caring for Ernie's patients, and it remained common for his devoted patients and their families to warmly inquire about him. I will always be grateful to Ernie for his recruitment of me, a wonderful opportunity to follow in the footsteps of a giant, and a professional endorsement that today continues to open doors for me.
—Richard T. Kloos, MD
Ernie the Educator and Mentor
Ernie Mazzaferri was an eminent educator; anyone who has heard him lecture about thyroid cancer would agree that he had an infectious passion for the subject. Hearing him lecture as a young resident, he kindled my interest to specialize in thyroid diseases. I subsequently read all of his papers that I could find. Given the opportunity to work alongside him, I found that my own passion for thyroid cancer grew exponentially. We spent countless hours talking about our patients, discussing caveats of thyroid cancer management, and reviewing papers. His single-minded focus and compassion while talking to our patients transformed my view of the doctor–patient relationship. He was not just respected, but adored by his patients. He taught me how to write a paper, how to prepare a talk, and how to critically appraise an article. As my mentor, he was encouraging, supportive, tireless, patient, entertaining, devoted, and caring. But of all the manifold things that Ernie gave me, that which I am most grateful for was the gift of his friendship. He was more than just a mentor, he was a dear friend. And he will be profoundly missed.
—Jennifer A. Sipos, MD
Ernie the Administrator and Scholar
Dr. Manuel Tzagournis graduated from OSU College of Medicine 2 years before Ernie and notes that while Ernie is recognized worldwide for his contributions in endocrinology, he is less well known for his administrative skills which were “extraordinary.” They were faculty members together in the Division of Endocrinology when Ernie became division director (1974). Ernie is credited with making a good program an excellent one. He subsequently accepted the Chair of Medicine at the University of Nevada–Reno in 1978. When OSU's Chair of Medicine position became available in 1984, the search committee sought an individual with strong academic credentials, an effective educator, and an outstanding clinician. Ernie easily fulfilled those characteristics.
Dr. Tzagournis recalls that Ernie led the largest department at OSU “with ease and efficiency.” During his 15 year tenure as Chairman he increased the faculty, recruited impressive people, and enhanced the department's reputation. Ernie was a popular mentor and educator who stressed bedside teaching. He authored 163 original articles, 49 case studies and commentaries, 21 editorials, 56 abstracts, and 53 books and book chapters. Ernie was a prolific scholar whose influence in thyroidology has been far-reaching and enduring.
In 1990 Ernie sought to hire a skilled molecular biologist to work on thyroid cancer because he was fascinated by the power of this technology and believed that it could help provide answers for the questions that he encountered in clinical practice. Sissy Jhiang, PhD, who at the time knew very little about the thyroid gland, was Ernie's top candidate for the position. She recalls being told by Ernie “that I can study anything that I want, as long as the study involves thyroid cancer.” She joined OSU in November 1990, and Ernie met with her and her graduate students for a scientific conference monthly without fail. Ernie encouraged and provided guidance for clinical aspects of their research, and he also took personal interest in each of them as friends and colleagues. Sissy recalls Ernie's constant concern to improve clinical care as both strikingly evident and inspiring. As imitation is often called the greatest form of flattery, Sissy strives to emulate the hard work and a gentle heart that Ernie exemplified. “Ernie will always live in my heart, and I hope to honor him by seeking ways to improve care for thyroid cancer patients, and by striving to be the kind and caring person that he was,” comments Sissy. Similarly, Dr. Tzagournis notes that “Ernie was a valuable and unforgettable partner, and will be missed greatly,” a common sentiment among those that knew him.
—Manuel Tzagournis, MD, and Sissy Jhiang, PhD
Ernie's Influence Around the World
Japan
Physician, professor, and researcher Ernest Mazzaferri was an exceptional thyroidologist and teacher whose contributions to medicine have benefited thousands of patients and doctors. Although I was never able to work directly with him, his work affected me greatly. When I read his 1994 paper (5) on the long-term impact of initial surgical and medical therapy on papillary and follicular thyroid cancer, I was astonished at the clear results showing the advantages of near-total or total thyroidectomy followed by 131I+levothyroxine. At that time in Japan, most endocrine surgeons performed subtotal thyroidectomy or hemithyroidectomy for the majority of patients with papillary thyroid cancer, and thyroid ablation was not performed. In Kuma Hospital, we abandoned subtotal thyroidectomy. As a result of Prof. Mazzaferri's studies, we now perform total thyroidectomy for the majority of patients and hemithyroidectomy only for very low-risk patients. In the 1994 paper (5), he also described high recurrence rates in young and elderly patients, excellent survival in young patients, and high cancer mortality in elderly patients. This was a really puzzling and fascinating phenomenon. This age-related phenomenon was demonstrated again in a 1999 update of the cohort, originally published in the Journal of Clinical Endocrinology & Metabolism (6), and reproduced in Werner & Ingbar's The Thyroid: A Fundamental and Clinical Text, 9th edition (7). Prof. Mazzaferri also wrote of the importance of serum thyroglobulin measurements in the postoperative follow-up of patients, and this led me to study the prognostic importance of serum thyroglobulin-doubling time (Tg-DT) in patients with papillary thyroid cancer. We recently found that the advanced disease status in young and elderly patients resulted in biochemically persistent disease, but that Tg-DT correlated only with patient age at surgery (8); a finding that might explain the age-related phenomenon reported by Dr. Mazzaferri. For me, he was a real mentor in clinical thyroidology.
—Akira Miyauchi, MD, PhD
Cumulative percentage of recurrences, distant recurrences, and cancer deaths by age at the time of initial surgery. Reproduced from Mazzaferri and Kloos (6) with permission.
Brazil
My first contact with Professor Mazzaferri's work was in the 1980s. His work on thyroid cancer had a great influence on the way we treat this disease in Brazil. Not surprisingly, at this same time we started to give radioactive iodine on a routine basis. His concepts and thoughts, always based on consistent data and his vast experience, continue to influence endocrinologists in South America. As diagnostic methods became more sophisticated, Prof. Mazzaferri, as an open-minded investigator, incorporated the new trends into his work and always focused on the patient's best interests. I had the honor and the pleasure to watch him in several meetings—Endocrine Society and ATA—and as a great teacher, he was always available for questions and discussions. Certainly, his work and stature had a tremendous influence on the way we train our endocrine fellows and the way we practice endocrinology in Brazil and Latin America.
—Mario Vaisman, MD
Israel
We have all learned from Prof. Ernest Mazzaferri. Just as textbooks are made out of original research, good reviews are like “micro-textbooks.” When I was a fellow, some 20 years ago, I went to the library searching for a good review on the management of thyroid nodules. That was my first acquaintance with Ernest Mazzaferri. His “current concepts” paper on thyroid nodules was published in the New England Journal of Medicine in 1993 (9). It was the perfect tool for an introduction to the field. Concise, clear, comprehensive, and easy to read; that paper became a “must” for all fellows dealing with thyroid nodules. Impressed by the style of his writing, I decided not to miss any of his Meet the Professor sessions at the Endocrine Society meetings. I then realized how great he was, not only because of his knowledge, but also because of his charismatic personality—not that of a showman, but that of a simple, friendly, and modest man. Something religious surrounded his figure, small but giant. The last time I saw him was at the 2010 International Thyroid Congress in Paris. The results of two new studies on low-dose radioiodine ablation for thyroid cancer were just presented. Full of energy, he stood up to say how happy he was that the low-dose issue was coming back. At that moment, from my seat in that room, I said to myself, “If Mazzaferri says so, it must be right.” Last week, when I heard about his death, I went back looking for my 20-year-old copy of that New England Journal of Medicine paper, a masterpiece I kept with me. I read it again and thought how grateful we should all be for his entire legacy.
—Carlos Benbassat, MD
Italy
In 2007, while I was traveling for a series of conferences in the Middle East, I received an e-mail from Prof. Mazzaferri announcing his willingness to offer my name as a candidate for the ATA Paul Starr Award. I could not believe that the person who, in my mind, represented the highest authority in the various aspects of thyroid cancer had been following and appreciating my scientific work. The result was that the subsequent year, 2008, I received this prestigious award at the ATA meeting in Chicago from his hands. But indeed, I should not have been surprised, considering that Prof. Mazzaferri has always been following the work of young investigators and was always up-to-date with the literature, to the extent that in any scientific discussion he was the first to come out with the right reference, even the most neglected. The dedication to science and teaching was so great in Prof. Mazzaferri that he had many contacts with Italian researchers and participated in many conferences. He always accepted our invitations with genuine enthusiasm, and his lectures are still remembered. I will remember, together with the entire Italian community, the lessons of Prof. Mazzaferri as a man, as a teacher, and as a scientist, but most of all as a “Maestro.”
—Furio Pacini, MD
France
I met Ernie for the first time in 1996 at the Rochester airport on the way to the Mayo Clinic for a meeting to which we had both been invited to celebrate 50 years of radioactive iodine use in medicine. He was so clear, cheerful, and positive about my work that without any doubt this led me to continue in the same direction. For a number of years, I had only known him by name through his multiple scientific contributions, which brought major insights into the natural history of differentiated thyroid carcinoma (DTC) and the impact of its various treatment modalities. His retrospective studies were among the first to be so detailed and have stood at the center of global discussions around the use of radioiodine ablation in DTC for many years. Despite these debates, changes in current clinical practice, and even the changing demographics of the DTC encountered by physicians today, his works still form the basis for current prospective clinical studies, including those being performed in France.
Since our first meeting we had many occasions to share our viewpoints on thyroid carcinoma. Ernie had a tremendous capacity to assimilate new concepts and scientific progress such that he remained a valuable clinical expert in the field over decades, and his friendly advice was always well founded. He was an extraordinary teacher and speaker, and perhaps his legend will be best remembered for inspiring interest in thyroid cancer among so many young investigators, including those in Europe, to improve the outcomes of these patients and to raise the level of scientific achievement in this field.
—Martin Schlumberger, MD
The Breadth of Ernie's Influence
Dr. Mazzaferri's influence was wide and encompassed multiple disciplines extending from medical endocrinology to surgical disciplines.
A surgical perspective
I first “met” Dr. Mazzaferri as a fifth-year otolaryngology head and neck surgery resident at Massachusetts Eye and Ear Infirmary by reading his 1981 paper “Papillary thyroid carcinoma: a 10 year follow-up report of the impact of therapy in 576 patients” (10). This took me quite sometime to go through. When I completed my review with multiple pages of notes, I really felt I had begun to understand this disease. Years later, when I started a Thyroid and Parathyroid Surgical Fellowship, I insisted that incoming fellows would at the beginning of the year read this article carefully. I felt it provided a unique insight into papillary thyroid carcinoma. Dr. Mazzaferri's life and work has provided us all with greater insight into papillary carcinoma.
I first met Ernie in person in the late 1990s. I was building my thyroid surgical practice and increasingly interested in papillary carcinoma nodal disease and revision surgery for papillary recurrence. At a national conference, I nervously approached him in the front of the auditorium, feeling with his ponderous understanding of thyroid cancer I might embarrass myself. He was amazingly gracious. He was tolerant of my naïve and preliminary understanding of papillary carcinoma, of me being a surgeon and otolaryngologist. He listened to my thoughts and was incredibly encouraging. He emphasized his belief of how important surgery was in the management of thyroid cancer and in the completeness of surgery. He also appreciated the great risks that surgery could be associated with and the importance of blending cancer treatment with surgical safety. This frankly I took to heart and it has been a central beacon for me allowing my career to focus. This is responsible for much of my current orientation towards the disease. Ernie was responsible for that. His elegant articulateness has served as an inspiration to me.
—Gregory Randolph, MD, FACS, FACE
An endocrine perspective
I first met Dr. Mazzaferri in 1990 as a brand new first year endocrine fellow at Madigan Army Medical Center when he was recalled to active duty for several months during Operation Desert Storm from his civilian position as Chair of Medicine at OSU. At that time, I had no idea that he was one of the leading thyroid cancer specialists in the world, but his dedication and true enjoyment in teaching, clinical care, and research were immediately apparent to all of us. In addition to initiating and stimulating my clinical and research interest in thyroid cancer, Ernie went out of his way to foster my clinical and academic development years after he left the Army and returned to his position at OSU.
Ernie insisted that to be a thyroid cancer expert, we had to learn far more than just the endocrine aspects of thyroid cancer. It was critical that we learn, understand, and appreciate how all the members of the multidisciplinary team must meaningfully contribute to patient management. This was particularly true of our surgical colleagues because he was convinced that one of the major determinants of clinical outcome was the completeness of the initial surgical procedure. As a result, Ernie participated in as many surgical meetings as he did in endocrine meetings, earning the respect and admiration of our surgical colleagues: both by teaching them and learning from them.
From an academic perspective, I will always be grateful to Ernie for teaching me to value the benefit of a truly multidisciplinary approach to thyroid cancer. From a personal perspective, Ernie's insistence that even while I was actively pursuing an academic career, that I remember to value and make time for my beautiful wife and wonderful children is one of the main reasons I can celebrate 31 years of marriage and a wonderful relationship with my children (and new grandson). I will be forever grateful to Ernie for his wisdom, love, and continual support.
The physicians of many disciplines will miss Ernie.
—R. Michael Tuttle, MD
Remembering Ernie: Personal Reflections
I was deeply saddened by the news of the death of my long-time and dear friend, Ernie Mazzaferri. The thyroid community has lost one of its leading giants with his passing, at age 76, on May 14, 2013. Ernie lived his life with compassion, grace, and dignity. My sincerest condolences go out to his partner of 55 years, Florence, four children, 14 grandchildren, six great grandchildren, and his many friends worldwide.
I first met Ernie at an annual ATA meeting in the early 1980s. As we drank coffee and talked, we were both surprised to learn that we had overlapped as students at OSU: I, as an undergraduate, and he, as a medical student. Our discussion led to college basketball and football, and we discovered our mutual loyalty to the OSU Buckeyes, which formed the beginning of a lasting friendship.
I frequently invited Ernie to speak at the AACE annual congresses, the last being in Orlando, Florida, in 2008. He was also a regularly invited speaker at the Endocrine University (EU) course held in Rochester, Minnesota, and Ernie never complained about traveling there during the unpredictable March weather. His lectures on thyroid cancer were always popular and well-received. He would never miss the Sunday evening pizza buffet roundtables, which served as an informal session for Q & A with the faculty. Ernie would be the first to show up and the last to leave. There were always dozens of fellows at his side, more than at any other table, and they would discuss difficult and complex cases of thyroid cancer. He was patient and tireless. At the end of the course in 2009, he told me that he had decided to cut down on his travels and talks, and would not return the next year. I knew he would be greatly missed.
We took several trips together, but one in particular to Italy stands out. Upon driving back from Siena to Rome, I noted his absorption in the beautiful, picturesque Italian countryside landscape. When I asked about his fascination, he proudly replied, “Hossein, my grandfather, Luigi Marianelli, was a farmer from the Abruzzi, similar to what you see here, before he immigrated to the U.S…. You know, I wouldn't mind buying a small house here and live part of the year in this peaceful land.”
In 2002, as AACE President, I was honored to recognize Ernie Mazzaferri by presenting him with the Distinction in Clinical Endocrinology Award of the American College of Endocrinology. He received the award for the following, which bears repeating now: “Ernie is a superb teacher, an outstanding clinician, and a respected clinical investigator. His contributions to clinical thyroid literature have been diverse, abundant, and influential. He is best recognized for his work on thyroid cancer, having published seminal articles on the biology, behavior, and optimal treatment of differentiated thyroid carcinoma.”
Happy times: from left, Drs. Ernie Mazzaferri, Hossein Gharib, Martin Surks, and David Cooper, at the Endocrine Society Awards Reception, San Diego, June 2010.
On a personal note, I am ever grateful to Ernie for his enduring support throughout the years. We collaborated on a seminal review on thyroxine suppressive therapy for benign nodular goiter, which was published in the Annals of Internal Medicine in 1998 (11). In 2002, he nominated me for the prestigious Paul Starr Award of the ATA and, in 2010, for the Distinguished Physician Award of the Endocrine Society. A photo of this event shows the typical happy, smiling face of Ernie that I will always remember. We admired him for his dedication to the profession and to his patients, for his strong leadership, and for his generous spirit. For those of us who had the good fortune of knowing Ernie Mazzaferri, we will remember him as a kind, warm, civil, and unassuming man. He was a source of inspiration for a generation of endocrinologists and I am prompted to ask of the hole left by Ernie's passing that which was asked by the passing of another great Italian, “Here was a Caesar! When comes such another?”
—Hossein Gharib, MD, MACP, MACE
Ernie was a good friend and distinguished colleague for more than 30 years. I first learned about him through his early publications of his extraordinary series of patients with thyroid cancer, then, I believe around 700 patients. He started collecting these patients when he was in the Air Force. He told me that he maintained a database of the patients personally along with his wife, Florence. Over the years, as the more primitive database computer systems evolved into more sophisticated programs, they had to transfer all of the patients' data to the new system manually, a difficult task without any help. Over time, we all know the significant new concepts and knowledge obtained from his extraordinary efforts, based on extremely long follow-up, some patients for more than 30 years.
Over the years, we got to know each other well, getting together at our usual meetings and gradually becoming good friends. We had strong and mutual admiration and respect for one another both professionally and personally. He was an important supporter at times when I needed it, and I did the same for him. I nominated him to succeed me on the Endocrine Board, where he also became Chairman, and for the Paul Starr Award, which he received from the American Thyroid Association.
Ernie was the epitome of a top professional, a fine human being, and a great friend. Our world has become smaller without him. I will continue to miss him.
—Martin Surks, MD
Ernie the Husband, Father, and Grandfather; and the Family Table
My husband Ernie had a huge heart, endless energy, and a quick intelligence that drove him through life with passion and tireless work ethic. He lived and breathed academic medicine. It was our family business with nameless and faceless patients as revered guests at our table. It was understood that taking good care of sick people was a household priority. We deferred to and supported his mission to make an impact on patients, while teaching house staff and students the art of caring through the science of medicine. His goal was to educate young people that holding a hand or smiling with eye contact was as important as the drug prescribed. He made medicine fun and exciting, and watching him with patients and students was like glimpsing a master at his art. He was driven to be the best and was extremely busy, but at the bedside patients felt as if they were the only person in the world that mattered. They recognized the extraordinary efforts he made for them and often sent loving notes of thanks. As a family we were proud to share his life and be part of that magic.
Like most doctors' families, we sacrificed our time with him for the good of others, but when he stopped to relax it was with us. We cherished the moments, particularly the hours around the table sharing stories, often tales of medicine and the long journey it took to be successful. My husband's passion challenged our children to make a difference in the lives of others; to do the right thing, to respect people's choices, to be accountable, and most of all to be compassionate. It was a privilege to love and be loved by Ernie, and for us he will never be gone. We live his mantra every day as clear as the breath we breathe. His torch of compassion and work ethic are the legacy that we are passing to our children who have already begun to pass it to the next generation.
Interestingly, Ernie always said that “death is a special part of life.” To go peacefully with grace, dignity, and love is God's final gift to us on Earth. Since several family members are in medicine, we assumed he was helping us cope with the inevitable death of a patient. But, he was also preparing our family to handle his own death, laying the foundation for dealing with our own mortality. As a teacher, he was the voice of wisdom, and this was his last beautiful lesson to us. In honor of his beliefs, and in unison as a family, we chose to take him home with hospice to quietly exit life his way; quietly, privately, and with his loved ones nearby. On May 14, 2013, Ernest L. Mazzaferri, MD, MACP, peacefully entered the Chapter Eternal. But we shall meet again one day, and there will be many more discussions around the table!
—Florence Mazzaferri, RN, and family
The Mazzaferri family at the 50th wedding anniversary of Ernie and Florence in 2007. Top row (left to right): Michael Mazzaferri and Ernie Mazzaferri, Jr. Bottom row (left to right): Sharon Brown, Florence Mazzaferri, Ernie Mazzaferri, and Patti Atchison.
Conclusion
During his distinguished professional career, Ernie Mazzaferri was regarded as one of the world's experts on treating thyroid cancer. Moreover, he had great influence on the careers and lives of many students, physicians, and scientists locally, nationally, and internationally. He inspired us by his tremendous drive to improve care for patients with thyroid disease. More basically, he taught us about compassion, hard work, and accountability.
Ernie was loved by his family, cherished by his patients, and provided masterful clinical care for thousands of patients whom he treated with dignity; one person at a time. Beyond these fortunate patients, Ernie influenced the care of even more patients worldwide through his passion for original research, elegant lectures, and masterful publications; a powerful legacy that continues today. Ernie, we miss you already, but we will not forget you.