E03 Tony Gomes on Professionalism in Surgery & Surgical Satisfaction

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Chad Ball  00:15

Welcome to Cold Steel, the Canadian Journal of Surgery podcast with your hosts Ameer Farooq and Chad Ball. The goal of the CJS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike. And most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons. We hope you enjoy it.

Ameer Farooq  00:48

Today we have the absolute pleasure of sitting down with Dr. Tony Gomes. Dr. Gomes, is an extremely busy community general surgeon working in Lethbridge, Alberta. He completed surgical residency at the University of Alberta, and then went on to complete a fellowship in surgical endoscopy at the University of Alberta. He was then recruited to Lethbridge and has been there for over 20 years, Dr. Gomes has been heavily supportive of the Canadian Association of general surgeons over the years with varying degrees of involvement at multiple levels. Dr. Gomes thanks again for agreeing to be on the podcast, we really appreciate it. You know, it’s a big honor to have you on the show. And let’s just dive right in. And I love the two papers that we were wanting to highlight for specifically for you because I think those two papers are very representative of you as a surgeon and your career. The two very interesting publications that you have in CJS one of which was about minimally invasive surgery and setting standards for minimally invasive surgery. What prompted the genesis of that committee to set those standards? And can you tell us a little bit about this paper? And what prompted it and what were your recommendations?

Tony Gomes  02:03

You know, I think it was a very interesting time in general surgery. I mean, for many years, all we really needed was a knife and sutures and we could carry on. And we were really in the early adoptive years of more advanced minimally invasive surgery, and the early adopters, early adopters had figured out how to do the advanced stuff. But most of us were still doing, you know, gall bladders and a few hernias and appendices. But we really didn’t know how to learn how to do the advanced stuff. So, this was a consensus meeting. And as usual, I was one of the token community surgeons invited along. And it was just an attempt to try and find a systematic way to teach, in this case, mainly laparoscopic colon surgery. So yeah, I think it was, that was what really prompted it. And that was my interest in it. I think that, you know, did you want me to talk about the recommendations of it or?

Ameer Farooq  03:15

Sure, yeah, I find the recommendations really interesting.

Tony Gomes  03:21

I mean, I think that it was good to have a formative approach to this problem as a model for the future because surgery is changing so much. And I think everyone who comes into surgery now can expect to have to adopt a new technique, which may be quite unfamiliar. And I think the basic sort of general recommendations were around, from my point of view, the importance of mentoring, because a lot of us, myself included, were trying to learn advanced laparoscopic surgery, simply by degree and learning, maybe hand assisted, doing some of it laparoscopically, and gradually moving into it, with varying success. And, you know, it’s just like being a resident, it’s very hard to make progress if the person teaching you doesn’t know much more than you. So, we all felt that mentoring would be a really important way to make this more systematic. It was one of the first sort of techniques where it became very clear that the whole team was really important because anesthesia had to make modifications. Nursing had to make modifications and even sort of the technical parts of it with monitors and the actual quality of the video and all those other things really matter quite a bit. So the concept of the team trying to learn, not just this surgeon was really important. And then, as you took on these new processes, the other thing that we felt was important was to be able to audit just for yourself to be sure that what you were doing was showing some semblance of being similar in terms of complications and outcomes to, you know, established norms in the literature. So that was that was my interest in sort of the recommendations of that paper.

Chad Ball  05:34

That’s great. I’m thinking, you know, as curious, we’re sort of a decade out over from that, how close we get deal, really, in practice to what you guys had envisioned. And I would probably make the argument that certainly scheduled or elective colorectal surgery is dominantly. laparoscopic, now. So I think from the outside, it seems to have worked. What’s your sense of that?

Tony Gomes  05:58

I think, actually, that the framework is really useful. But the way the whole process fell down was that the mentoring needed some sort of formal structure. And in fact, mentors needed a way to be reimbursed for what they did if they traveled and did teaching. And I think it fell apart at that point, that in fact, we’ve moved forward beyond it. Because the bulk of surgeons, then we’re untrained. And we’re 10-15 years ahead now. And the new people coming into the field, have the training, and it’s been disseminated. I know, my partners and my young partners coming in have taught me a lot about this. And we often do cases together, especially if they’re bigger, minimally invasive cases. So in some sense, it’s been superseded. But that doesn’t mean it’s not useful. I think it serves as a bit of a template for technology and technique adoption in the future, what we’re missing is buy in from organizations like our health services to understand that we need a formal approach to doing this. So I think it was a first stab at technology adoption. But we worked hard, and we had some success getting some funding from industry, but it really wasn’t enough to set up a regular program. And so most of the mentorship was kind of on and off. So I don’t think it was a failure, but maybe not as much of a success in execution as in what we sort of perceived or envisioned as a structure.

Chad Ball  07:54

That’s really interesting. When you look at some of the cancer that’s gone across the country, I do wonder if it’s almost analogous, if you look at Cancer Care Ontario, for example, it’s almost a top down approach in terms of whether it’s reimbursement for a given oncologic procedure or a strict, you know, go or no go institution based or hospital based checklist, whether you can do operation x or y versus an Alberta approach, which has been, at least recently, I know you’re involved in this, for example, rectal cancer, just feeding back outcomes, and looking at your performance compared to your peers, so sort of a top down versus a bottom up approach. What do you think about that, whether it’s oncologic care, or whether it’s technical advancement? Which one do you think works better? And how do you see that going forward?

Tony Gomes  08:53

So we looked at the issue of certification, and how would that would work, and it’s a very hard thing to quantify, and measure. And we have, you know, a legal opinion as well. And we tended to shy away from the idea of certification. I mean, we’re all general surgeons, I think that we understand the aims of what we’re trying to do, and we have good skills. It’s my feeling that if we use a more of a bottom up approach and feedback outcomes to physicians, the ones who are truly interested are going to work to obtain those outcomes, whether that means going away to learn some more, or changing their practice, and the ones who really aren’t interested in it, or don’t feel that they want to put in that time are not going to do it. And I’m not sure that it should be institution based, I think that it’s more important to have, you know, you don’t need to be necessarily fellowshipped trained. But if you have one or two people in a community center who do higher volumes of it, and have some interest in that, they can achieve the same excellent results as in a larger center. So I think it’s a dangerous road for us to go down as general surgeons to start to be certified for all the procedures we do. It’s important, I think that we don’t start creating different classes of general surgeons.

Chad Ball  10:29

Yeah, I completely agree.

Ameer Farooq  10:33

Americans have also really started to go down that route of making everything very, you know, Center of Excellence. But that really doesn’t work for Canada, where, you know, it’s a distributed, a very spread out country, and where you need general surgeons who really can service the needs of their communities that they live in?

Tony Gomes  10:56

Yeah, I mean, I think we should give surgeons a chance to achieve those outcomes. I mean, we’re measuring everything now. And if it’s clear, it can’t be done, then, obviously, some things need to be changed. But I think, you know, a good general surgeon is going to understand what their capabilities are.

Chad Ball  11:17

Tony, the other paper you were on that was really interesting to all of us at CJS, for sure, was the CAGS based paper on a blueprint for professionalism. And, as you know, we’ve done sessions on professionalism a couple times at the Canadian Surgery Forum, and it’s certainly a passion of a lot of ours. How do you think we’ve been doing since you guys wrote that paper over the over the number of past few years? Well, I think we’ve, I mean, that paper was just an I have to say, once again, I was a member of the group, I certainly didn’t write the paper, Dr. Bond, sort of pulled everything together. So I’m speaking as a member of the group that was involved with that, but I think this was a first stab at trying, again, to sort of put together a definition of professionalism, and to just enunciate the components of it. It was, it’s quite general. And I think it’s, it’s kind of an easy read. But I think it was quite prescient because it’s, it’s, you know, over 10 years old now. And since that time, we are now being a lot of the concepts in there are being formalized, and our regulatory bodies are taking those concepts on, and sort of testing us giving us modules and giving us direction on various components of that. So boundary issues, all those sorts of things that that are problems within the profession of medicine. So I think this was a really good thing for us to think about, as general surgeons, it was very general. But it was a few years ahead of its time, because we’re now being legislated to do those exact things. What do you think the challenges are, for professionalism going forward?

Tony Gomes  13:17

I think that the biggest challenge is maintaining appropriate contact with patients, and some connection with them. Without intruding upon your own personal life, that’s one of the challenges. I think, because we need to maintain contact with our patients, that it can intrude into our daily lives. And the work life balance is so important that we have to find a way to disconnect ourselves, even though we may feel uneasy about not being involved in our patients care or communicating with them at certain times. The boundary issues are an issue, the communication issues are an issue because we have so much less confidentiality now, that we’re expected to be more communicative in many different forms. So whether it’s email or texting, and all of those things are scrutinized by our health services and our regulators. So it’s a challenge to be appropriately professional, not intrude on your own life and not step on anyone else’s toes and not let information out that shouldn’t be out, that I think the basics of it, of professionalism, really remain the same. It’s just that the challenges to it keep coming up as we move through our world of easy accessibility and sort of universal work, where we’re contacted even when we’re on holidays, as long as we have our cell phones.

Ameer Farooq  15:18

What do you think would be the definition of professionalism in 2019? For trainees and faculty for surgery?

Tony Gomes  15:30

Yeah, you know, I mean, glad you send me some of these questions, because it’s really difficult. I mean, I think we all know, someone who’s professional when we see them and work with them. And we all have varying degrees of professionalism and the different components of it. And I think the components of professionalism are primarily things like altruism, towards others, honesty, impartiality, being accountable for your actions, collegiality with partners, colleagues, and coworkers, and finding some balance in your life. But I tend to enunciate a true definition. beyond saying that those are all components of it. It’s one of those things, it’s like, you know, I know it when I see it. But to actually tell someone, you know, I can tell when they’re not being professional, I can tell them they’re acting very professional. But I don’t think it’s an easy thing to define, because there are many components to it.

Chad Ball  16:44

And the definition, I would argue, are some of the components are stable, but the definition changes over time as well. There’s no doubt. Tony, if we, if we switch gears a little bit and ask you a little bit about you, it’d be great. We’re curious, what drove your initial interest in surgery, when you were just getting going?

Tony Gomes  17:03

I think that you know, when I started in medicine, it was my first clinical rotation. And I actually couldn’t believe how hard general surgeons worked. And I was living with a friend whose father was a general surgeon, and I thought it was some sort of craziness. So I think, though, that once you’re in it, it is quite all consuming. And what attracted me were really the technical aspects. And, you know, for me, that gratification, and the fairly, relatively instant gratification of seeing success or failure was really what made me most interested in surgery. And you could, you know, do everything right, and things didn’t work, right. So there were a lot of things you could control, but in many cases, you weren’t fully in control of, you know, the patient physiology and all the rest of it. So I think that’s what drew me to it. And I really couldn’t see myself doing anything else in medicine.

Chad Ball  18:14

That’s interesting. Your initial thought was, that’s where that’s crazy, and then and you got sucked in. Was there a particular surgeon or a group of surgeons either in Edmonton or elsewhere that really played a big part in pulling you into it?

Tony Gomes  18:29

Oh, yeah, absolutely. I mean, I think that first rotation was with Walter Yakimets in Edmonton. He was a quintessential general surgeon, he ran the fellowship program, he was chief examiner for many years, and he really, you know, clearly loved what he did. And he was a great teacher. And I think there’s no doubt I think every one of us can point to one person or two people who sort of sucked us into the profession of surgery. And, yeah, I think that was for sure, you know, the reason he was probably the reason that I couldn’t think of doing anything different.

Ameer Farooq  19:10

Were you always interested in doing community surgery right out the gate?

Tony Gomes  19:19

Yeah, I actually looked at you know, I wondered if I could be a GP surgeon. But the more I did surgery, the more I realized how little I knew, and I really felt I needed a very general training, and I did a year and my training of orthopedics and urology, planning to go to a small community and was sort of set up to do that. But circumstances changed and the support for a single general surgeon in the small community can follow from under them if your anesthesiology colleagues leave town. So, I really wanted to work in a stable environment. So that’s how I ended up in Lethbridge because there were already three surgeons there.

Chad Ball  20:10

For those listeners that don’t know, you know, and it isn’t the preamble, but Dr. Gomes works in a very, very busy, very busy Community Hospital in Lethbridge. So I guess my next question, Tony, would be, over the years and that environment, how has working in that, that scenario, that setting changed over your career?

Tony Gomes  20:36

You know, the biggest changes have been, I guess, if I want to be unhappy, I would say the biggest changes have been the changes in healthcare administration, but some, a more sort of personal point of view, the practice has grown busier, but we’ve been able to recruit a lot more young people. So we actually do less call. The spectrum of patients that we now operate on, and the average age of patients that we look after. And actually, that, you know, getting better from surgery is far in a way different than it was in the 90s, like patients that we would not have attempted to deal with them, we deal with routinely now. And we get them through their operations. And I don’t know if that’s it’s partly a testament to surgery, but largely a testament to pre and post-operative care. We do much more group-based work now since we have an acute care group. And we do so much more of our work as shorts day and day surgery, partly because we do so much of the work laparoscopically. So those are the biggest sort of changes. I think in some ways, we’re less efficient, because our what we do takes longer. And the days of sort of running through seven or eight cases in the operating room seem to have gone by it’s more like four or five. But that’s not necessarily a bad thing, it’s just how things have changed.

Chad Ball  22:18

It’s interesting you bring up you know, acute care surgery as a service, we talked to Morad Hameed at length, not only about his passion for ACS or emergency general surgery, but also on process and structure and change over time. How is your ACS changed? You know, your guys’ practice specifically in has it actually changed over the years you guys have been doing it?

Tony Gomes  22:41

We started doing acute care in about 2013. And we envisioned it as a way just to provide better call coverage without destroying your elective days afterwards. Our program has changed in the sense that we have been able to internalize all of it at first we had a lot of local coverage helping us. And we’ve evolved in terms of trying to be more systematic about when we take patients off the acute care service. Because there are certain group of patients that are well looked after on an acute care service. And there’s a certain group of patients that require a kind of ongoing continuity. And so we’ve been quite careful about making sure that patients who spend longer in hospital have some continuity with one surgeon because they often get lost in the shuffle. They’re not quite as acute as some of the active patients. And they get I think they get left behind. But you know, our acute care group has been a lifesaver for our program. Our younger surgeons really feel like they could not carry on with call and then working a full day after call. And at this point, I don’t think any of us would go back to what we did before our lifestyle is much better. And I think in a lot of ways our patient care is better because there are no competing issues when you need to take someone to the operating room. You’re not worried about leaving the office, you’re not worried about leaving your endoscopy day. You’re just there to take care of the patient.

Ameer Farooq  24:47

This sort of builds on a talk that you gave us to the general surgery residency in Calgary, it was a phenomenal talk on surgical satisfaction. And in this talk, you talk a lot about acute care surgery and how that’s improved our lives in the ways that you described. We ought to talk about some of the potential, maybe downsides or limitations or things that you think maybe take away from our surgical satisfaction, can you just for the sake of our listeners, recap a little bit of that talk and maybe highlight some of the things that you were worried about, that you talked about in that talk that you gave to us?

Tony Gomes  25:29

I think that, you know, as we get further in our careers, we think a bit more about what’s our source of satisfaction. And I think that we’re at another interesting time in surgery, where we’re trying to figure out a way to take what is individual responsibility, which was the traditional surgeon, and transfer it to the group, while maintaining satisfaction for every member of that group. And when we think about it, that, you know, our traditional surgeons, they had very long careers. And the reason wasn’t that they were financially bereft. The reason is that they really had great satisfaction from their work. And I tried to get an idea of why that was the case. Because the job’s hard, the administrative burden is high, the sort of factor of all the things that irritate you about your job, is also very high. But what really makes you keep doing it. And I came to the conclusion that really, what makes you satisfied, and your job is the outcomes, it’s how your patients do. And if we deprive ourselves of knowing those outcomes, we’re likely to be unhappy. And I hate to pick on the emergency physicians, but I likened it a little bit to that, because they have episodic care, they don’t get much follow up of their successes or failures. And they have a very high burnout rate. There aren’t many 65, 70-year-old emergency doctors, there are quite a few 65-year-old general surgeons. So, my concern with acute care surgery is just that our episodic care may detach us from the ability to feel good when we see a great patient outcome. And also our ability to really learn from the negative outcomes, because in the end, bad experiences are a huge driver of change in surgical care, I think there are things that your mentors have taught you, and things that we read in all the old surgical books, those didn’t come from controlled trials, they came largely from bad experiences, and sequential modification to make those experiences go away and have better outcomes. So my sort of take home from that is that you really need to have a skin in the game, you have to, when you make a decision about a patient in the operating room or top right on them, you have to follow them. And if you don’t, as a surgeon, it’s going to be as much your loss as the patients, you need to follow your patients, you need to see them maybe as much as they need to see you because that gives you either the satisfaction, or sometimes the heartbreak. But it does allow you to improve your practice. And most of our patients do well. There’s nothing better than seeing a satisfied patient with a great outcome.

Chad Ball  29:05

Tony, I think most of our trainees, you know, sort of on average would have a very receptive and optimistic view of that concept, which, you know, of course, I agree with entirely. But how do you reconcile that with the era of, to some extent, millennial outlook, but also, more importantly, probably more directly work hour restrictions. Which, you know, again, from my point of view are good things and totally reasonable and probably where our collective needs to go. But, you know, the point you bring up is so critical and so important to our evolution and our satisfaction and our training. How do you integrate those two concepts?

Tony Gomes  29:53

Yeah I think that’s the real difficulty is, to feel bad about how things go, doesn’t mean you have to be there at that time, though, that certainly makes you feel worse if you’re watching the actual complication happen or having to deal with it. But the challenge is actually to transfer that individual responsibility to the group, to the acute care group, or to communicate to them reasonably temporarily in time that this has happened to your patient. It is important to find some way to transfer that personal responsibility whether the group gives it to you, or you sit down once a week and you go through things. It’s very powerful to sit around with your colleagues and listen to the story of your own misfortunes with patients. That is a really great way to help people reflect and make changes and with your colleagues around, it allows for some back and forth about was this the right decision? Were there other decisions that could have been made? And how, how has it been managed now, so I don’t think that it’s an absolute, we just have to find a way to transfer that responsibility to that person and make them make it impactful upon them. When they are back at work. It’s not the intent to make everyone feel bad 24 hours a day, even when they’re home. But you need to reflect on these things, whether it’s at home or otherwise. And so there has to be a way for you to know, when your patient does poorly and you’re gone, and you don’t know, when you come back or when your group does rounds, it must be made clear what happened with each of those patients.

Ameer Farooq  31:54

When I was down in Lethbridge, you told me this story that when you used to get back home on Friday afternoons, your children would know that you were going to go mow the lawn. And now is your time to kind of decompress and kind of work through that whole sort of series of emotions that you know that you build up from having to carry that load really that big, emotional responsibility. Do you have any other advice besides going along and Friday afternoons that you have for surgical trainees like me and people who are going forward their career trying to balance this real desire to be professional and to really be there with their patients, but as well as have a really fulfilling, well rounded life, which I know that you, at least on the surface seem to have?

Tony Gomes  32:54

Yeah, I mean, I think maybe my biggest mistake was not insisting that my kids mow the lawn. But you know, I have to say, I still haven’t figured it out. I don’t think any of us really has perfect balance, and it changes it’s a moving target during your life. Because the demands on you from work and at home, and all the other spheres in your life change as time goes on. So, it’s difficult. I mean, I think that there are a few things that I think are important. One is when you start in practice, I think it’s important to work hard for the first few years to gain confidence, technical skills, and really solidify your practice. I think that’s hard to do if you’re not working regularly. I think that when you go away, you need to have a habit, you need to find a way to detach yourself. And that’s why it’s so important to have supportive colleagues. I think that the same thing with the support, if you have supportive colleagues, you need to use them. You need to learn from them and lean on them, especially some of your older colleagues because they have often seen things and they may even just be there to tell you you’re doing the right thing, even though things aren’t going well. And another thing that I think that helps you in your professional life is you must find something in your work that you can pursue with a bit of passion that’s different than every colleague besides you. You can pick an area of surgery, you can be a researcher, you can do surgical education, you can start working doing some administrative work. To be a little bit of an expert in one area is very refreshing. And it gives you some expertise, because when you’re a general surgeon, you feel like you’re a little bit weak everywhere. So, it’s nice to have one area that you really feel confident about. And that doesn’t mean you have to do a fellowship. It just means that you’re more interested in that. I think it’s important to relish in your successes, because there’s plenty of those, most of us have lots of good outcomes. And I mean, I might sound old, but it goes really I’m not finished yet. But it goes by in a flash. So, I think you know, like Ferris Bueller said: “Life moves pretty fast sometimes. You better stop and look around once in a while, or you’ll miss it”.

Ameer Farooq  36:06

You’ve been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So, feel free to email us at podcast.cjs@gmail.com, or connect with us on Twitter @CanJSurg. Thanks again.