Treatment should match the biological behaviour and seriousness of the disease, that balance is precisely where surgical judgement matters, explains Dr Volkert Wreesmann, MD, PhD, ENT surgeon

Dr Volkert Wreesmann MD PhD is an internationally trained ENT, head and neck, thyroid/parathyroid and facial plastic surgeon with a PhD in cancer genetics. He trained and worked in the Netherlands, the United States and the United Kingdom, including at Memorial Sloan Kettering Cancer Center in New York, UCSF in San Francisco, the Netherlands Cancer Institute, Oxford University Hospitals and several NHS hospitals. He is Chairman of the ANDSURGEONS ENT, Head and Neck and Facial Plastic Surgery team at Centro Médico Teknon in Barcelona, and practises through selected clinical locations in Andorra, Spain and the United Kingdom. Dr Volkert shares his reflections on surgical education, international training, cancer genetics, responsibility and surgical judgement. Interview: Irina Rybalchenko What does it really take to become a top surgeon? Becoming a doctor is only the beginning. For a surgeon, the most important education often starts after medical school. It continues through residency, fellowships, supervised operating, research, difficult cases, complications, reflection and, eventually, the responsibility of making independent decisions. There is a surgical principle I strongly believe in: “A good surgeon knows how to operate. A better surgeon knows when to operate. But only the best surgeons know when not to operate”. Many surgeons can operate well. What separates those at the highest level is judgement: understanding whether an operation is truly necessary, whether it is likely to improve the patient’s life, and whether the risks are acceptable for that particular person. How did your own training shape this view? My career has taken me through several major medical systems: the Netherlands, the United States, the United Kingdom, Spain and Andorra. The Netherlands gave me a strong academic and specialist foundation. I completed my PhD in cancer genetics, focused on the molecular biology and evolution of head and neck cancer, and trained in otolaryngology and head and neck surgery in Amsterdam, including at the Netherlands Cancer Institute. The United States changed my standards. I worked in major academic environments, including Memorial Sloan Kettering Cancer Center in New York and the University of California, San Francisco. Memorial Sloan Kettering was one of the defining experiences of my professional life. After completing my Dutch training, I wanted to train with the very best. To do that, I had to pass the United States Medical Licensing Examination (USMLE): demanding full-day examinations with hundreds of questions under intense time pressure, as well as clinical examinations in which communication and judgement were assessed. When I was selected for a fellowship at Memorial Sloan Kettering, I was the first person from my country to be selected there and one of the first few Europeans. I arrived alongside American co-fellows from major US residency programmes. At first, I felt I knew very little. But I kept going, studied every night after work, learned from every mistake and tried to improve every day. During the final part of the fellowship, I became chief fellow. The United Kingdom added another important layer: audit, governance, multidisciplinary collaboration, transparency and responsibility for outcomes. When you combine these experiences, you develop a broader view of what high-level medicine should be: technically excellent, scientifically informed, carefully governed and centred on the individual patient. What did Memorial Sloan Kettering teach you? Memorial Sloan Kettering taught me endurance, discipline and precision in reasoning. In complex cancer surgery, you must understand the disease, the anatomy, the literature, the treatment options and the reasoning behind every decision. One principle there was: “Let the punishment fit the crime”. Treatment should match the biological behaviour and seriousness of the disease. Some cancers require aggressive treatment. Other tumours require a more measured approach. That balance is precisely where surgical judgement matters. One of my most important teachers was Jatin Shah, widely regarded as one of the greatest head and neck surgeons in the world. Training around people of that calibre changes your standards. You realise that true mastery is not just technical skill, but clarity of thought, courage, restraint, discipline and complete commitment to the patient. Professor Shah used to say that people often think a surgeon’s life becomes easier with experience. In reality, it is often the opposite. As you gain experience, you take on more difficult cases, more complex decisions and greater responsibility. Experience does not remove the weight of surgery. It teaches you how to carry it. What mentality is needed in surgery? In cancer surgery, the first requirement is absolute knowledge of anatomy: nerves, vessels, tissue planes, previous surgery, radiotherapy, scar tissue, tumour behaviour and the consequences of every movement. The second requirement is tissue handling. Good surgery is not only about cutting. It is about seeing, exposing, separating, preserving and controlling tissue. But anatomy and technique are only the first layers. After that comes personality. A surgeon must be humble, because the disease is serious and the consequences of treatment can be profound. At the same time, the surgeon must be calm, brave and, when necessary, fearless. There are moments when hesitation becomes dangerous. You must remain in control, even when the operation becomes more difficult than expected. How important are humility and discipline? They are essential. There is a sentence I like very much, often associated with Johan Cruyff: “Never look down on anyone, but never look up to anyone either”. For me, humility does not mean making yourself small. It means not placing yourself above others, while also not surrendering your own judgement or confidence to someone else. Cruyff came from an Amsterdam culture that also shaped me: direct, creative, self-confident and intolerant of passivity. The mentality was simple: if we do not have the ball, we are going to get it. In surgery and in life, you cannot wait passively for things to improve. You take responsibility, organise yourself, study the problem and act. Discipline is what you do when nobody is watching: studying after a long day, preparing before a difficult case, reviewing complications honestly, making the phone call to a family, and doing the small things properly when no one will praise you for them. What did your PhD teach you? My PhD was in cancer genetics, focused on the molecular biology and evolution of head and neck cancer. Cancer can partly be understood as an evolutionary process. Just as living organisms adapt under selective pressure, cancer cells adapt as well. The cells that survive and spread are often those best able to resist the pressures around them. Over time, this can make a tumour more aggressive and more difficult to treat. That taught me to view cancer not only as something to remove surgically, but as a biological system that changes, adapts and evolves. A PhD also teaches you how to think: how to organise your mind, analyse evidence, write clearly, communicate complex ideas and defend your conclusions. That is extremely valuable in surgery, especially when explaining difficult decisions to patients or discussing complex cases with colleagues. How do guidelines and patient autonomy fit into this? Guidelines and multidisciplinary teams have improved medicine enormously. They reduce unnecessary variability and create more consistent standards. But guidelines are usually written for the average patient. Patients are not averages. Every patient has their own anatomy, biology, psychology, family situation, resilience and priorities. Guidelines should inform your thinking, not replace it. A top surgeon must know the evidence, respect the multidisciplinary process and still ask: “Is this truly the right decision for this patient?”. I also believe strongly in patient autonomy. I sometimes tell patients: “I may have met you today, but you have known yourself for decades. You understand your values, fears, resilience, family and life better than I do”. My role is to explain the disease, the options, the risks, the benefits and the uncertainty as clearly as possible. Ultimately, the patient has to live with the decision. They should feel empowered, not pressured. How did this philosophy lead to ANDSURGEONS? ANDSURGEONS was created around a simple idea: patients should have direct access to senior, internationally trained consultants, with careful communication, high standards and continuity of care. In modern medicine, patients can easily feel as though they are being passed through a system. My aim was to build something more personal: a specialist surgical model in which the patient knows who is responsible, who is making the decisions and who will remain involved throughout the journey. For me, Andorra offers freedom, perspective and the opportunity to build a medical model according to a clear vision. It is small, agile, safe and international, while remaining close to major medical centres in Spain and France. In Barcelona, I am Chairman of the ANDSURGEONS ENT, Head and Neck and Facial Plastic Surgery team at Centro Médico Teknon. The aim is not simply to provide treatment. The aim is to help patients make the right decision. What message would you like readers to remember? Real medical expertise takes many years to build. A medical degree is only the beginning. Specialist surgery requires discipline, research, judgement, responsibility and lifelong learning. A top surgeon is not defined solely by technical ability. What defines the highest level is judgement: understanding the full balance between risks and benefits, knowing how to operate, knowing when to operate and, most importantly, knowing when not to operate. For patients, the most important things are clarity, honesty, experience and continuity of care. For doctors, education never truly ends. As responsibility grows, the learning becomes deeper, not easier. The goal is not to compare yourself with others, but to become better than you were yesterday. That is the philosophy behind my career, and it is also the philosophy behind ANDSURGEONS.The post Treatment should match the biological behaviour and seriousness of the disease, that balance is precisely where surgical judgement matters, explains Dr Volkert Wreesmann, MD, PhD, ENT surgeon first appeared on All PYRENEES.