Duke GI Oral History: Peter Cotton, MD


Dr. Stan Branch: All right. Dr. Cotton, good morning.

Dr. Peter Cotton: Good morning, Stan.

Dr. Branch: It's my privilege and honor to be able to have a conversation with you this morning. I'd like to talk to you a bit about the past. That's basically some of your time at Duke and a bit about the future. But before we get started, you have rabbits on your tie. Can you tell me why you have these rabbits on your tie?

Dr. Cotton: Well, yes. When I moved to the Untied States in '86 to come to Duke, people started over laughing because my name is Peter Cotton. They thought somehow, what was your mother thinking of calling you after a rabbit. Peter Cottontail doesn't exist in England. Beatrix Potter, who wrote the Peter Rabbit books, wrote about Flopsy, and Mopsy, and Cottontail, and Benjamin Bunny. But it was an American thing to bring them all together into Peter Cottontail. So I learned that I was called after a rabbit and I sort of inevitably had to embrace it, really. So we collected rabbits, and people gave us rabbits, and that's the end of that particular story. But Peter Cotton and my middle name is Benjamin, so I've got the whole lot actually.

Dr. Branch: Yeah, I thought maybe your parents were Beatrix Potter fans.

Dr. Cotton: Well, I think they might be.

Dr. Branch: So when you came to the GI division, what was the GI division like? What was endoscopy like at Duke?

Dr. Cotton: Endoscopy was primitive. There was one procedure room in a corridor, in a clinic. With no recovery space, patients were put on a stretcher in a corridor. There were two people doing endoscopy with no endoscopy nurses. There were two physician assistants. There was no Glutaraldehyde in the building. So there was a lot of potential for improvement.

Fortunately, there was enough enthusiasm from Ian Taylor and Joe Greenfield to remedy that. So we set about, we built a little temporary unit upstairs somewhere, I forget exactly where, in one of the inpatient wards where we did procedures for a while while we developed the unit that you're familiar with. Indeed, that we're actually sitting in at this very minute, which is now offices. But was our first main new endoscopy unit. I don't remember exactly which year it opened, but it must have been '87, or '88, or something like that.

Dr. Branch: Yeah, it would have been '87. Halloween was the conference, if I remember right, because I was the ward fellow.

Dr. Cotton: Is that right?

Dr. Branch: Yeah. I was running around while the guys were still finishing the cabinets down here. Yeah, but I think it was Halloween you had that ...

Dr. Cotton: I do remember a fancy Halloween party here.

Dr. Branch: Yes, we did have a Halloween party.

Dr. Cotton: Yeah, well.

Dr. Branch: Yeah.

Dr. Cotton: So it seemed to work pretty well. Fortunately, we were able to recruit some good people, like yourself, and it grew from there. 

Dr. Branch: I think I know the answer to this, but I'll ask you anyway. What was the biggest challenge then, when you arrived at Duke? What did you see as the biggest challenge?

Dr. Cotton: Well, there were several challenges. The first was that I became a bachelor in a foreign country, which has nothing to do with Duke. Well, I guess it was because I was recruited here. But my wife, of that time, decided to stay in England. So I arrived here and had to start a new life as a bachelor in a country that I had visited a few times, but didn't really understand.

Then the second challenge, of course, was American medicine in general, which I didn't understand and still don't.

Dr. Branch: It's still a challenge.

Dr. Cotton: Then, of course, setting up the endoscopy was obviously my main job, but that really wasn't difficult because of the enthusiasm. It was a total contrast from what I left in England. I was working in the National Health Service, a university hospital of 500 beds, which had one gastroenterologist, me. I was still doing acute medicine, as well. So I was running everything, GI, and hepatology, and research, and all of that stuff. It was really very, very tough.

What made it even more tough was that the hospital was upset about all the work I was doing. I kept getting letters telling me to do less procedures because I was consuming too much of the budget because I wasn't ... no money came with the procedures. So every time I received a referral, it was costing the hospital money. So when I arrived here, it was kind of a 180 degree change. There was an encouragement to do more, and more, and more, and more. Everyone was happy as the numbers went up, so. I liked that rather well.

Dr. Branch: Yeah. It was a very exciting time. Yeah, I've-

Dr. Cotton: I was very naive because in the British system at the time, the number of "faculty" positions were decided by the government. As I said, it was just me in the middle states hospital. There was one other guy who was supposed to be there but wasn't there much of the time. So you applied for a job that you didn't really want. That had a description that didn't really fit and struggled for years to work within it.

Then, when I arrived to be recruited here, I was meeting with Joe Greenfield, the Chair of Medicine at the time. He said, "Well, Peter, I'm told we'd like to recruit you here. What do you want?" I said, "What? What do you want?" Nobody had ever asked me that question before, so I was so naive. So I said, "What do you mean?" He said, "Well, what sort of salary do you want?" I thought, "What? What sort of question is that?"

Like, in the British system, it was all fixed like that, so there was never any discussion. So I mumbled a number and he said, "Oh, well that's all right. What sort of facilities do you want? "So I obviously messed that up completely. Then he walked me out onto the roof of a building in Duke South and said, "We've got some space here to build an endoscopy unit, would this work?" Which is where we are now. I said, "Yeah, why not. So let's do it."

Dr. Branch: Wow, that's a great story. So following that same line, what was your strategy to build the endoscopy program? I understand you had to have the unit, and the facility, and those things. But how did you take what was a very rudimentary endoscopy program to, I think it was the premier endoscopy program in the Untied States?

Dr. Cotton: I'm not sure I had a strategy, apart from trying to put together a good facility and a great team. Of course, Duke has an incredible reputation, as an institution then, not in GI, but, so it wasn't too difficult to advertise Duke. It was also sort of by coincidence, I'd kept my unit afloat in London for several years by running courses for Americans. So there were several hundred, probably about 200, gastroenterologists who'd been to London and spent a week with me in the early days of the ERCP, sphincterotomy, and all that stuff.

So when I came to the States, there were a lot of people that knew about me. We actually put on a conference fairly soon after I arrived to promote the fact that I was here and brought a bunch of important people together, which I think helped. But none of that, obviously, would work without having decent resources. One of my main concerns in the early days was to hire a head nurse who could run the show. I actually flew in a couple of hot shot endoscopy nurses from other centers around the states to interview them.

During that process, a young nurse came off one of the floors and said, "I'd like to apply for that job." I said, "Have you done any GI or endoscopy?" "Yeah, I've done six months of it in GI out West somewhere." I said, "Well, this is quite a big job and you'd be welcome to join the team, but I need some sort of hot shot really." She said, "I can do that job." She wore me down and you will remember her name very well, Marilyn Schaffner who became our head nurse who was the most remarkable person. She was a leader with people skills, she could fire ... didn't have to do it often, hopefully. She could fire people, but as they left they would say, "Thank you so much. I'm going to my new opportunity. Not quite sure what it is, but I'm leaving. Bless you." She was terrific and built a team, that you'll remember, that was very collegial. To begin with, it was like a family. Indeed, we did family things together. We went off white water rafting and all sorts of stuff.

Dr. Branch: I remember.

Dr. Cotton: It was kind of sad when, after it grew to suddenly got to a level where you realized you couldn't do that anymore. You had to suddenly become the boss and cool it. But as you know, I actually persuaded her to come down to the Medical University in Charleston with me when I left. So she worked for me when I was here, then she became my partner running the Digestive Disease Center down in Charleston. Then, she became the Chief Nursing Officer of the whole university., so I was working for her!  She's retired now, but bless her, she was fantastic. I put down a lot of our success to what she did. I really did. Great partner.

Dr. Branch: Yeah, that's key. Surrounding yourself with people who can make you better.

Dr. Cotton: Yeah, sure.

Dr. Branch: So what did you enjoy the most about being the chief of endoscopy here?

Dr. Cotton: I think it was the team stuff that I was talking about. It became a family. A lot of respect for peoples individual enthusiasms and their professionalism, which was frankly different to what I'd grown up with in England. I remember ... Do you remember Laura [Layall 00:11:39]?

Dr. Branch: Yes, very well.

Dr. Cotton: Bless her. One of our nurses at the time. I remember, she said, I need time off on Friday. I'm going to a leadership ... something about aggressive leadership conference. I said, "Are you on faculty for that?" I said because she was always pretty impressive. But I liked the professionalism and everyone was keen to learn, keen to grow, keen to contribute. I liked that enormously. I enjoyed the fact that I was working with Ian, Ian Taylor, who was supportive at what we were doing. Providing things were going right.

Dr. Branch: Yeah, of course.

Dr. Cotton: As they usually were, not always. I enjoyed the ... you might remember. We did a lot of workshops.

Dr. Branch: Yes.

Dr. Cotton:  Bring people in and show off our skills. I enjoyed doing that, and the contacts it made, and the fact that we could invite other people to come in and help. Other people I respected. One of the things I remember most, really, was the trainees, some of the fellows particularly. But also some of the international fellows. You remember there was a period when we had at least one, sometimes two or three, people from overseas, often from Australia who were pretty mature people, who we enjoyed working with. Some of them have become very close friends of mine ever since, so we enjoyed that international flavor.

I enjoyed living in Durham, actually in Chapel Hill initially, then in Durham. Although, Durham has changed a little bit I've noticed in the last 30 years.

Dr. Branch: Yeah. It's dramatic how much has gone unchanged. So we've had a chance to do some reflecting on things, obviously, Dr. Taylor's Grand Rounds this morning talking about his career and the development of his research interests. Some of his past in the division. If you think back about here, what ... and I may know the answer to this, but I'd like to hear your comments. What do you remember the most about being at Duke? What were you proudest of?

Dr. Cotton: That's a difficult question. I mean, I think I did a good job, so that's always important. I was particularly proud of meeting my wife and getting married here in Durham. It goes back to the team stuff. I think it was all of the relationships we built. Many of which have survived for another 25 years. Obviously, I enjoyed the quality of Duke in general. Although, one of the things that I found difficult was the fact that we were all sort of spread out. It's such a huge institution that surgeons were in a different building across campus.

I found that a little awkward in a collaboration. In fact that's, you may remember, the reason I actually was persuaded to go down to MUSC. Because, Ian went down there as chair of medicine and knew that I wanted to develop a more collaborative environment. So I was invited to develop a digestive disease center, which included surgeons, and radiologists, and ... But talking about radiologists, one of the unique things I did when here, if you remember, was we actually imported some radiologists.

Dr. Branch:  I do remember.

Dr. Cotton:  From England, because they were cheap.

Dr. Branch: I didn't know that was the reason, but I do remember.

Dr. Cotton: Well, that was the reason why the chair of radiology was delighted that we had some really good young people actually within the GI unit. So we actually had our own ultrasound machine in here for a while. They obviously helped with the ERCP. Then, Clive Kay was one of the people that developed CT colonography, kicking and screaming. A lot of good memories, a lot good memories.

Dr. Branch: Let's switch gears and let me just ask your opinion about maybe the future, now that we've talked about the past. So what do you see for the future of GI for academic divisions and maybe for endoscopy?

Dr. Cotton: Well, it's easy to think that endoscopy has sort of peaked. We've been through a really incredible two or three decades. But I don't think that's the case. I think with the new third space endoscopy and all the bariatric type stuff, I think there's still tremendous room to grow and develop. So I think there's certainly a lot of room for innovation. There's certainly a lot of room for clinical research to make sure that what we do is actually what we need to do. As you may remember, I've been working at that more recently.

Dr. Branch: Yes.

Dr. Cotton: Particularly, trying to stop people from getting sphincterotomy for sphincteric dysfunction and getting seriously ill as a result. So I think there's room for cutting edge areas and that should be in academics. As far as the rest of it is concerned, money comes into it in a big way. It's going to be driven a lot by what, unfortunately, by what you get paid for. There's a limit to how much you can do for fun.

You understand the current financial situation, the way things are going, much better than me since I haven't been involved in it for years now. That's gonna drive what's possible, I think. I feel sorry for a bunch of people who've gone into practice and end up doing colonoscopy all day. I mean, although it's a good contribution to GI disease, it must be incredibly boring.

Maybe I'm wrong, but it seemed to me sad that a lot of the patients I saw had actually rarely met their gastroenterologist. They'd met the PA a few times, but the gastroenterologist was too busy doing procedures to actually talk to anybody. I didn't like that at all. So the future, heaven knows. I've never been able to predict anything about the future, I really haven't. Many of the thing I've ...

Well, let me take you back, 1973, I'd been doing the ERCP for a couple of years and thought I was pretty good at it. A lot of people were coming to visit. I was still theoretically in training, but I was a world authority at the time because nobody had died, I couldn't move into the faculty position. But in 1973, I'm doing an ERCP with a crowd of visitors and showed a stone in the bile duct.  There was a Swedish surgeon there and he said, "Why don't you remove it?" I said, "Look, you're welcome to come and visit, you can applaud if you like. But don't make stupid suggestions." I had, obviously, no idea that sphincterotomy was gonna burst onto the scene the following year. So predictions have not been one of my things. What I've tried to do is be aware of new things as they come along and jump on them and sort of pretend I invented some of them!

Dr. Branch: I would respectfully disagree. I think you have been a visionary. But, you're being too humble. What would you advise a young division chief or maybe someone who's not quite so young anymore. What should we be doing for our division for the next few years?

Dr. Cotton: Well, I mean, obviously on a practical side, making sure you stay afloat is the-

Dr. Branch: Yeah, that's important.

Dr. Cotton:   ... is the bottom line. But the most important job apart from that is mentoring people, is looking after the people you've got, and training the new crowd. The details of that, you understand better than me. But encouraging young people to do what they really want to do, follow their dreams. Steering them a little bit to show them how they best can do that. I think that's the biggest role.

Dr. Branch: So following that same thing, I think this will be the last question. What would you recommend to a young faculty member, then, who is interested in endoscopy as a major portion of their career?

Dr. Cotton: Well, follow your dream. I think it's always good if you're passionate about something, if you're really ... Then, you should not be persuaded to do something else. I remember when I started embracing gastroenterology in 1968, that's just 50 years ago. Somebody told me there are enough of those around already, the field is crowded. Obviously, it's not anymore.

To be, and I think for an academic endoscopist, then actually I would recommend people at least think about getting proper clinical research training. An MPH, or whatever you call it now days. Or at least the elements of that. To be able to contribute to the huge necessity to really evaluate what we're doing and to do it really well. So I think if you're pushing quality, and research, and the boundaries, then it potentially remains a very exciting career.

Dr. Branch: All right. Thank you for having taken some time to have a conversation with me this morning. I want to personally thank you. I'm indebted to you for my career and always will be.

Dr. Cotton: I've admired what you've done, Stan.

Dr. Branch: Thank you.