E23 Rebecca Auer On Being A Surgeon – Scientist, COVID19 Vaccines, & Work – Life Harmony

Listen to this Podcast

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  00:50

Dr. Rebecca Auer is a surgical oncologist and scientist at the Ottawa General Hospital. She spoke with us about her career as a scientist, her work on developing a COVID-19 vaccine, and her tips and tricks on productivity. Make sure to check out the show notes for links to Dr. Auer’s website, and the papers we discuss in the episode. Dr. Auer, thank you so much for coming on Cold Steel, especially during these crazy times. We really do appreciate you taking the time to come in and join with us and speak with us. Many of our listeners will know you but for those who don’t know you as well. Can you tell us about your training pathway? Where did you do residency and your fellowship?

Rebecca Auer  01:32

Absolutely. And thank you both for the invitation to chat with you today. So, I did my medical school at Queen’s University, which was my parents alma mater, so that of course made them very proud. And then after that, I went to Ottawa to do my residency in general surgery. And during my residency in Ottawa, I also did a master’s degree in biochemistry and molecular biology. And then, after my residency, I went to Memorial Sloan Kettering in New York City and did a two-year fellowship in surgical oncology. And then came back to Ottawa and have been on staff there since then.

Ameer Farooq  02:14

Rebecca, yeah, I would emulate what Ameer said, and thank you so much for being with us. We really do know how busy you are. A lot of us as Canadians go down to the US to do various fellowships, and certainly I don’t know the extended group that that you trained with at Memorial, but I certainly know the HPB guys. Memorial is a really special place. A really neat place. And it’s structured differently. I was curious how you found that experience, what some of the benefits may be of going to a different high-speed place like that, where and what brough you back to Canada? Yeah. So, I mean, I think that my strong desire to go down there was really to experience something different both in Canadian healthcare and then also surgical practice in Canada. And really be with some of the leaders in surgical oncology. And I liked the fact that the training program had a lot of trainees, a lot of fellows. So, there’s 14 fellows at any time, at least when I was there. So, it is really a good camaraderie of people. And it was an incredible experience, of course. You’re living in Manhattan. And so, because it’s prohibitively expensive, the hospital will subsidize an apartment for you. So, one of the only times that you probably get to live in the middle of Manhattan near Central Park, and that, in and of itself is quite an experience. Although I have to admit you experience it a little less than you otherwise would, because the work expectations are pretty intense in terms of hours. But it is definitely a different culture down there. I mean, I learned an incredible amount, academically, surgically. And then just also in terms of, they really emphasize the way a surgical oncologist thinks, and approach problems so that you really develop this framework for looking at a cancer problem that maybe there is no data to support decision making, and how do you break that decision down and try and figure out, you know, whether an operation makes sense. So, I thought those were really valuable. I also brought back a strong sense that we actually have incredibly good health care in Canada. And in some ways, we do things better. Certainly, in terms of better care for everyone as a population. We have that and we have this mentality that everyone deserves good care. And so, we make decisions that are going to be good for patients and for populations. And I think that also made me realize that we have an exceptionally good healthcare system here and I’m proud to be part of it. You know, I couldn’t agree more. As you know, I was in a few places and a few fellowships in the US. And that’s sort of what brought me back to Canada: was the realization that our healthcare system was really comprehensive, really equitable. And, just like these places in the US, where all of us sort of go to train, there is a real passion for great patient care at all levels. I also found that essentially the range and care was really tight in Canada, whereas the variability in my impression in the US was really, really quite broad.

Rebecca Auer  05:34

Yeah, definitely variability and durability, depending on what hospital you went to, what provider you saw. And also, just in terms of what kind of insurance you had.

Chad Ball  05:47

Yeah, for sure. What specifically brought you back to Ottawa? Because that’s a great landing spot, obviously.

Rebecca Auer  05:53

Yeah, so I was lucky in a way that when I left for New York, I already had a job offer in Ottawa to come back. And there were two reasons why I really wanted to come back. And one was a surgical oncologist and colorectal surgeon that many listeners will know, Harvey Stern, who had asked me to come back and and take over half of his practice. And he was really my surgical mentor, and the one who kind of encouraged me to go to New York and bring that skill set back to Ottawa. And the second person was my scientific mentor, who still is, who’s also a world-renowned oncolytic virus expert, Dr. John Bell. And I had done my Masters with him. And he had asked me to come back and consider starting a lab with their group. And so, I really wanted to do some lab based translational research, and wanted to do surgical oncology, predominantly colorectal. And although now I also do soft tissue sarcoma. So, the job really looked ideal. And it’s where my husband was currently living. So that also helped a little bit, although he was interested in, you know, he would have moved. But I think those are the two main reasons. I always was committed to coming back to Canada, I don’t think I ever imagined I would stay in the US. Again, for a lot of reasons, but not the least of which was, I really felt it was important to work in a healthcare system with the kind of equity and global approach to good cancer care.

Ameer Farooq  07:37

My observation, Dr. Auer, from spending a little bit of time in Ottawa on an elective was that your group at the general and more broadly in Ottawa is really fantastic. It’s a very cohesive, very collegial group of surgeons, and one of my favorite things about being on elective there was actually attending M&Ms. And I would just love the discussions that were so candid, and frank between the faculty. I learned so much from those discussions. How do you think that culture has developed at the general? Has it always kind of been like that? Or what has been the deliberate things that you think have happened to make the culture like that?

Rebecca Auer  08:17

Yeah, that’s really good question. Because I’m not sure that it was always like that. I remember M&M as a resident, and I remember being terrified to present and having, you know, feeling pretty demoralized after presenting a case. And so, I don’t remember it as being a positive experience as a resident. So that’s interesting that you have that perspective. But I do think now that we do. We have very open and candid discussions. And I think that’s evolved maybe over the last decade. I know the Ottawa Hospital, like many hospitals has implemented this concept of just culture. And, you know, we have signs all over the OR that say, if you see something, say something, just like in the airport, you know? So, and we also in, in my OR, I’ll say to residents and medical students, if something doesn’t make sense to you, if you think something is wrong, you need to speak up. Everyone needs to be heard, you know? Because it’s the nursing student who will notice that the lap pad is still in the pelvis. You know, everyone has a role to play in terms of making sure that we all protect each other from mistakes. And mistakes happen. And I think just culture means that we don’t go and blame somebody, we look at the system and figure out how is it that this could have happened and what can we do to make sure it never happens again. So, I hope that’s the culture that we continue to reinforce. But I think it has evolved in the more recent time. I remember feeling quite worried about M&M rounds as a resident.

Chad Ball  10:00

Rebecca, you’re in a relatively small group of surgeons in Canada who have managed to persevere and still engage at a very fundamental and core level in basic science or benchtop research. It’s interesting, I didn’t know you had a master’s in biochemistry, and it makes me feel a bit sad, because I do too. But of course, it’s not really something other than the methodology part of things that I engaged on a day-to-day basis. But you clearly are doing some amazing work. How have you done that? What kept you interested in that basic science element? What keeps you passionate going forward, despite all the obstacles and hurdles that seem to be increasing? Sort of by the year?

Rebecca Auer  10:46

Yeah, certainly, hurdles are increasing. You’re right about that. And what I would say is that even if I didn’t have a lab, I think doing a master’s or an advanced degree in the lab would have been and continues to be a very useful endeavor just in allowing you to sort of think through problems and come up with hypotheses and figure out how to solve those problems. So, I really enjoyed my time in the lab. And I always wanted to do some time in the lab, even as a junior resident, I would always go to basic science presentations and wish that I understood more than I did. So, I think that the fact that I was able to do it is solely based on the collaborators and mentorship I had in the lab. I was really fortunate to join a group called the cancer therapeutics program at the Ottawa Hospital Research Institute. And it’s 14 core scientists, but there are actually about 150 investigators in the program and about 400 members: students and research associates, technicians, and that kind of thing. And it’s a fully open concept. So, there’s one floor, but three separate wings, and all the labs are open, so no one has a closed door. The labs are intermixed. So, you might be beside somebody on your bench that is from a different PI’s lab. And all the equipment really is shared between everybody. And that concept of sort of collaboration also extends to helping each other with grants and we even have sort of a fund for common supplies. So, if one scientist is a little bit less affluent, let’s say than another in terms of their grant funding, that they don’t have to pay as much for common supplies. So, it really is this incredibly collaborative group of scientists. There are two clinicians in that group. I’m one of the fortunate ones to be in that group. And I’ve really taken advantage of their goodwill and their expertise. I think I got really, really good advice very early on to get senior people in your lab to run your lab. And so, I have a team of researchers. The person who runs my lab, for example, is infinitely smarter and better trained that I am. He’s got a PhD and two postdocs. And so, he runs the day to day of the lab and then I have a couple of amazing technicians: a veterinary technician who does all the animal surgeries, and a clinical coordinator technician who does all the patient consenting for samples so we can do experiments on the blood. And so, these people really make it possible for me to kind of think about what the next questions are, or the next trial is, and what grants we’re kind of going to shoot for. But they really are the ones that make it happen. So, I think that’s been how it’s been able to work in terms of staying passionate about it. It’s all those people that bring me so much energy, you know. When the students come and they have a new experiment, it’s so exciting and it’s so fun to be able to look at the data and talk about it and think about it. And I mean, they teach me so much every day. And I’m pretty full disclosure. I’ll say, okay, I don’t know anything about mTOR signaling. So, you need to explain this to me. And they’re fantastic. So, it’s like free education for me every week. So, I’ve been really lucky to have a great team.

Chad Ball  14:17

It’s amazing to hear you describe the physical structure. And I think, you know, sure it’s fantastic that you were able to walk into that. But clearly, whoever the group of people were, that had that initial vision. I mean, that’s the foundation and I really feel terrible. I feel bad for folks who are sort of isolated in their own surgeon, scientists, labs. It’s probably not the model for the future. There’s no doubt if you want to be that productive. I mean, it’s also interesting to think about, you know, the science of proximity, physical proximity in our workplace, whether that’s in a lab or whether that’s our colleagues in surgical oncology or hepatobiliary surgery or trauma. That physical proximity, once you leave about 25 feet, you might as well be based in Asia on a phone. You know, it’s such a big deal.

Rebecca Auer  15:11

Yeah, you know, you just hit on two things that ring so true for me. The first is, you know, my good colleague and friend, Dr. Fady Bala, who was our Division Chief for a while. And he used to say, you know, William Oso’s most famous quote about the triple threat. You know, the great surgeon, educator, and researcher. And what he would say is that it’s almost impossible to be a triple threat as a surgeon in today’s society. But as a division, and as a group of individuals, we need to be a triple threat. We need to figure out how as a cohesive group, we can deliver on all of those things. But each person might have one or two roles, that where they really have the expertise, and they cover it for all of us. And I think that is so true. I’m not going to understand the fine details of intracellular signaling. But if I can be on a team where somebody else does, then we can really make some advance there. And the other fantastic thing about our lab group is the cancer center lab is one floor above the chemo unit, two floors above the clinic, right across the turning circle from the OR and the ward. So, like you said, proximity really makes a huge difference.

Chad Ball  16:35

There’s no doubt we could talk all day about the amazing stuff you and your team are doing. But I wanted to touch on briefly some of the very timely and topical work you’re doing in terms of a COVID vaccine, would you be willing to talk about that test?

Rebecca Auer  16:50

Yeah, I’d love to actually. So, this is kind of an exciting project for me. And obviously COVID is not something you know, I would normally be studying, or vaccines for infectious disease at all. But it’s interesting because of course, I work in a biology lab and so many of the people in the cancer therapy program are virologists and have been recruited because of Dr. Bell who’s a virologist and studying cancer killing viruses. So, I have a lot of people with a lot of virology background around me. And my passion and focus has been studying how the innate immune system doesn’t work well in cancer patients. But particularly after surgery. So, we have really clarified that natural killer cells, which are kind of part of the body’s first line of defense, and they aren’t antigen specific. So, they don’t go after specific abnormal proteins or pieces of RNA and DNA, they go up. They go after cells that are abnormal for either their virally infected, or they’re cancer cells and they have particular markers on them as a global unit. So natural killer cell function is really important for cancer prevention, and also cancer outcomes. And natural killer cells don’t work after surgery almost at all. Effectively, we call them paralyzed, and they don’t work for over a month. And so, we’ve been trying to understand why this happens, and how to reverse it for quite a long time. And of course, when COVID came, our lab, like all the labs in Canada really had to sort of shut down and only do essential work. But we’ve been talking and thinking about the fact that natural killer cells really are the first line of defense against infectious disease as is the innate immune system. And there’s some data out there to suggest that the reason why some patients have really attenuated response to COVID, or even an asymptomatic response, and others have this very terrible response really has to do with the ability of their innate immune system to respond early and quickly to viral infection. And what’s interesting is in in veterinary medicine, like in cattle transports and in feedlots they use these nonspecific activators of the innate immune system as vaccines to prevent spread of diseases like bovine viruses, which are responsible for these bovine respiratory diseases that cost you know, $900 million in the US economy every year by making cattle sick in the feedlots. So, this concept of boosting the innate immune system to prevent symptomatic respiratory illness is really quite well understood in other fractions of medicine. So, we started to think about could we use an innate immune booster, and I was thinking specifically in our cancer patients who are at high risk because they have a weakened immune system, and they have to come to the hospital for therapy so they can’t self-isolate like they want to. And I had, through the Ontario Institute of Cancer Research made a connection with a company that had a vaccine that basically could do this. And it’s similar to the BCG vaccine. So maybe some of your listeners have heard some of the data around BCG. They are about 8 trials now going on to determine if BCG can essentially do this. And it does it through a concept called trained immunity. And basically, it trains your immune system to fight better to the next virus infection. And it’s not specific to tuberculosis, which BCG is the vaccine designed to prevent, but it’s actually for any respiratory illness, any infectious illness. So, this other product is different because BCG is a live vaccine, and it can’t be given to cancer patients because they’re immuno-suppressed. You can’t have a live vaccine if you’re undergoing chemotherapy. But this other vaccine, from this company called Immodulon is a heat killed vaccine and it can be given to cancer patients. So, we are in the process of launching a trial to basically vaccinate 1500 cancer patients, either vaccinate or observation with this heat killed vaccine that will boost their innate immune system and see if we can prevent respiratory illness. So that’s what I’ve been working on quite a lot over the last sort of six weeks to try and get that trial to the point where it’s ready to open. We’re hoping to have an opening in early June.

Chad Ball  21:19

I’m just curious, and I realize you don’t have a crystal ball and you’re not a prophet. But you know, the layman question continues to be when does a vaccine come? With your wisdom and your experience? What ballpark do you think that is?

Rebecca Auer  21:34

So I think one of the things that’s kind of becoming increasingly understood about Coronavirus, particularly is that kind of our straightforward approach to a vaccine that we would normally use like for influenza, or even for the Ebola epidemic that happened, we would normally make a vaccine that would generate a really good antibody mediated immune response called a humoral immune response. And so there’s been some vaccines that have been attempted to generate a humoral immune response against the spike protein, that’s the protein that’s on the surface and the most immunogenic protein for coronaviruses. There’s a couple of potential problems with that strategy. Number one is that we have a lot of endemic coronaviruses, so up to 35% of the common cold is a Coronavirus. And what we know is that even though when you get sick you can generate an antibody response to Coronavirus, it doesn’t necessarily protect you from getting the same Coronavirus in the same season. It also goes away fairly quickly. So, for whatever reason that antibody response doesn’t remain, and by the following year, it’s often gone. So, this is one concern about the traditional vaccine approach. The second is that in some studies, in particular in cats or feline coronaviruses, there’s something called an antibody enhanced infection where antibodies in theory could bind and coat a Coronavirus spike protein, but then those antibodies, because they have FC receptors on their other side could get internalized into the B cells and macrophages and actually start replicating in a cell that otherwise wouldn’t have been able to infect because they don’t have the H2 receptors that the Coronavirus binds to. And that can actually increase infection. And the third concerning thing is that patients who are in some cases dying of Coronavirus seem to have an antibody response. And despite that, they are still dying of Coronavirus. So that’s not to say that an antibody based vaccine is not going to work. But it’s not as sure of a thing as it might have been for a different virus. So, a lot of the vaccine developers, the ones that are out now are predominantly mediated towards an anti-spike protein immune response. But I think some of the newer vaccines. So again, my mentor, John Bell has been working on a couple of new vaccines that he imagines will be in clinical trial in early 2021. And they have to also get the T-cell immune response to be effective, because that seems to be the one that is going to be better able to protect people. So, all that to say, the vaccine isn’t as straightforward as we would have maybe liked it to be. Once it’s available, it’s obviously going to have to be tested. And so, I think we have to be realistic that we’re probably looking at about a year before we have something. And then I guess the last concerning piece is this data coming out that Canadians are saying that they may not want to get vaccinated. And so, what do you do with that? People’s general feeling is they don’t want to get a brand-new vaccine. How do you manage that in society? Is it mandatory? And if it isn’t mandatory, what happens if you refuse to get it? Or do we just vaccinate high risk people and let them disease run? So, they’re really tough questions.

Ameer Farooq  25:12

These really are very, very challenging problems, as you outlined for both technical reasons, but also the bigger behavioral problems. And we’ve seen that for everything from just the idea of getting vaccinations, but also like, the distancing piece of it, the wearing masks, etc. So really some big challenges ahead. I’m really impressed that you were able to pivot so quickly. Given, you know, I’m sure that it’s not easy to pivot in a basic science setting. What’s your experience been like in trying to tackle a big rollout challenge like this? And what have the hurdles been in terms of just getting something like this off the ground? And I’m thinking about just the length of time that it takes to develop therapy that can actually be tested and get into clinical trials?

Rebecca Auer  26:08

Yeah, so I mean, I was again, very lucky that I was looking for an immune modulator, because we had this idea that it might work. And I’m talking to a few companies that had things in very early development. So, we were talking about maybe a phase one trial for safety and immune responses. And then, through a colleague, actually the scientific director of the OICR, he had a contact with, again, a company that had a product that had already been tested in cancer patients. And in fact, this vaccine, it’s called IMM-101. And it actually has been tested in a phase two trial of pancreatic cancer patients, metastatic pancreatic cancer patients with an improvement in overall survival. So small study, but really good safety data and some really good new data to support it. So, after I chatted with them, then I talked to a colleague of mine, who’s the senior investigator at the Canadian Cancer Trials group for the GI group, and pitched the idea to him. And it’s really been the Canadian Cancer trials group that has been able to make this happen. They have the infrastructure, they have the resources, the biggest challenge has been to try to find funding, and as of now, we have a few potential funding avenues. But we don’t have any cold cash yet. And cold hard cash yet. But we’re pretty optimistic. But working with the Canadian Cancer trials group has been amazing because they really have the expertise and the know how to get these things off the ground. And fantastic colleagues. So, we’re gonna open at eight sites. And at each site, there’s been sort of a designated site PI, who’s been amazing at you know, we had like a three hour call on Easter weekend to develop the endpoints and the inclusion and exclusion criteria for the trial and stuff. So, people have been really invested and really given a lot of their time and energy towards it. So that’s been fantastic. Certainly, zero chance I could have done this on my own. I just don’t have either the know-how, or really the network to do it. And then, you know, learning about Coronavirus has also been easy because I have this amazing group of scientists that I work with. So as soon as we were all on pandemic, lockdown, we switched our journal club to virtual and we changed it to a COVID Club. So, every week someone talks for an hour about Coronavirus and how it replicates what are the issues with it? So, I get this like amazing slide deck and presentation once a week that keeps me up to date on all the latest and greatest on the biology of Coronavirus, which, again, I can’t tell you how fantastic that was to just be able to participate in those kinds of discussions.

Ameer Farooq  28:59

I think it’s so neat that you were able to you know, really capitalize on that opportunity. And obviously, you were well placed from all your hard work going into this, to be able to do that. I did want to touch on one of your papers that I thought was so cool and so interesting, which was the influenza vaccine and its effect on post-operative metastatic disease. Can you talk us through that paper and the implications from that paper?

Rebecca Auer  29:29

Yeah, so again, as I mentioned before, like what we have been really focused on studying is why natural killer cells don’t work after surgery. And at least in our animal models, the fact that they don’t work after surgery promotes metastatic disease. And whether that’s true in humans or not, we don’t know for sure, but I think that there is there’s definitely good evidence from all of our animal models that dysfunctional NK cells can help metastases to grow in the post-operative period. And so, if we can boost that natural killer cell function right after surgery, we hope that like in animals, we could attenuate and prevent metastases at a later time point. So, because I work with virologists, my first trial that I wrote around this was to use an oncolytic virus after surgery. And that trial enrolled a couple of people (two people), but it ended up getting closed. And I think what I realized was, if you’re going to give something to patients right after surgery, it has to be something that is safe and has been tested in the number of people. And so that there’s less concerns. Nothing happened by the way, in the trial. It closed. Just that there was so much angst around giving an oncolytic virus to patients right before surgery that ultimately just seemed like we needed to change directions. Patients that had it were fine. So, we decided to go with something that was maybe a little bit less or had a little bit more of a safety profile. So, I had this amazing postdoc who’s now a PI and a role model at Sherbrooke. And she basically went to the pharmacy and got every vaccine that’s been tested in humans and has like a really good safety profile and tested them in our animal model. And interestingly, the influenza vaccine was the one that was best at upregulating, or activating rather, natural killer cells and could at least attenuate the suppression that happened after surgery. Although they still did get suppressed, but they were so hyper activated before surgery that they were suppressed less. And so. So, she did all this sort of preclinical work to validate that, and we showed that giving the influenza vaccine before surgery could prevent metastatic disease or attenuate it. And so, we were excited about that. But I didn’t really want to do a trial with just an influenza vaccine before surgery. So, we subsequently did quite a bit of work trying to figure out why the NK cells are suppressed, and ultimately figured out that there’s this population of myeloid cells, we call them surgery induced myeloid derived suppressor cells. But these cells increase significantly up to three-fold. And up to 30% of your blood has these very suppressive myeloid cells after surgery, and they seem to be responsible for this natural killer cell defect after surgery. And we found, again, we tested a panel of things that have been shown to prevent the suppression of the cells and found that tadalafil, which is otherwise known as cialis, (so the erectile dysfunction drug), it was able to prevent this. So, we put them together, basically. And we were able to prevent the suppression and hyper activate the natural killer cells. And this gave us the best response. And now we’re doing a trial. It’s on hold with COVID, unfortunately, but we’ve just over halfway done a trial.

Ameer Farooq  33:09

That’s such a neat paper and I’m really excited to see where that goes and look forward to watching that space. I had sort of a different question, kind of in thinking and looking at your research where you’re looking at some really cool immunotherapies. But also thinking more broadly, as I approach my exam, which should happen sometime. It’s really neat to actually look at the evolution of how we treat what we’ve traditionally thought of as surgical diseases, you think about melanoma or breast cancer. And, you know, the role of surgery in a lot of these diseases is becoming less and less. I’m curious, given your training as a surgical oncologist, but also your background in research. Do you think that surgeons are going to still maintain that central role in those diseases? And sort of the second part of that question is do you think surgeons should have more of a formal oncology training during their training? Like maybe should we be rotating through oncology as a resident?

Rebecca Auer  34:23

Yeah, that’s an excellent question. And, you know, I’ve seen in some cases where, you know, these immunotherapies or targeted agents have actually increased the indications for surgery in patients who have metastases, for example. So, what we often see in our practice, the patient that would otherwise never have been operable, but has had these phenomenal responses to immunotherapy, for example, just has one spot left. And should we do surgery? We kind of don’t know the answer to that. On the other hand, there certainly are other situations where one wonders that the targeted agent might take the place of surgery, although I think that’s happening. I mean, I think surgery is still central, I don’t think we have a lot of examples where that’s completely taken over. But I think your point about having a separate rotation is probably an important one. It’s hard for me to imagine that in 10 years from now, you’d be able to look after a cancer patient if you didn’t understand at least the basics of molecular biology. Because targeted agents, immunotherapies, the way that our cancer interacts with us as a host, the way that it signals inside its cell is paramount to how we treat it. And, you know, we don’t talk about colon cancers, for example, in my space, we talk about the KRas, the BRAF, the MSI high, etc. And these are all what parameters you will decide what types of therapy you get. Now, surgery still is central in that disease, but increasingly may not be. And so, unless you understand at least the basics of molecular biology and how it matters in the surgical and oncological care, I think it’s hard to really join that conversation. But maybe we’re not quite there yet, but it’s moving much faster than it used to be. The number of new drugs and oncology that are being approved year on year is just going up and up. And we’re going to subset divide cancers more and more, certainly, in the US, it’s much more common to have your tumor completely genotyped with sort of a list of actionable mutations. We don’t have that yet in Canada, to the same extent, because I don’t think it’s borne out yet that we have successful therapies based on those approaches. But I think it’ll happen over time. So, my surgeons need to be in the know, when it comes to that kind of cancer management. Because it’s definitely going to change who we operate on. And when we operate on those patients as well. I still think surgery is going to be central for quite a long time. Surgery is the one thing that you can do and then it’s done. You can take the tumor out. And that may be all you need.

Chad Ball  37:20

That’s so interesting. You know, Rebecca, we’ve been lucky enough on Cold Steel to have a lot of really interesting, dynamic and accomplished guests. And you’re, of course, no different. One of the questions that we try and ask almost everybody. And I would argue that maybe that you take this to even a higher level with the basic science and granting side is: how do you organize your life so that you’re so productive? You know, clearly being organized, by definition is the foundation of that, but what sort of tools or tips would you have for maybe a trainee or even subsequent to that someone starting out in their practice? In terms of being as productive maybe as you have been? Again, besides basic organization, and besides, obviously, the inherent genetic, you know, interest in motor that you obviously have?

Rebecca Auer  38:12

Yeah, I mean, it’s a really good question. And I’d seen that you’d asked it when I received the pre call. So I’ve been thinking about it quite a bit. What would I tell my trainees self, for example, I think a few pieces of advice that I got early on that I always think about. One of them is, it’s a marathon, it’s not a race, I think when I first started my practice, you know, the very first year, I said, well, I’ve got to apply for CIHR grants. I’ve got to get some money into my lab. And, and my mentor, John Bell said, no, you don’t actually. You need to start your practice; you need to be confident in the OR. You need to, you know, make sure that you feel comfortable with that. You need to do some experiments in the lab to get some preliminary data and go for a small local grant, you know? Really like, this is not a race, this is a marathon. If you want to do this for your whole career, you need to slow down and take your time and build little by little. And that was good advice. Because I’ve seen other people really try very early on to compete with the scientists, some of them have, you know, these multimillion-dollar labs and it’s an exercise in frustration and failure. Which is why I strongly advocate that for surgeons and for any clinician, really, new investigators should be considered the first 10 years, at minimal. I mean, it’s three years before I felt like I could walk into an operating room and know with confidence that I was the best person to do the job. You know, just that lingering doubt. Like, am I as good as the people that trained me? You know, I think that everyone has that and probably for good reason. You want to be extra careful and extra prepared when you are starting out in your surgical practice. And so, you can’t sort of take anything for granted at that point.

Chad Ball  40:13

It’s truly amazing that you let that advice out of the gate, because it’s a bit contrarian to what we usually hear, right? Which is what have you accomplished at three years? What have you accomplished at five years? If you haven’t, you know, obtained grants and been up to speed, then you’re done. And that sounds dramatic. But that’s really been the narrative in most places, I would say. So that’s remarkable.

Rebecca Auer  40:34

Yeah, I think that narrative can be really damaging. Because, you know, the first big grant we got for a national trial, which was my very first trial, which is still ongoing across Canada. But I was past three years. And we had submitted to 11 different grant competitions. I mean, that’s kind of sad, but you know, I often say to people, I’m below the national average in terms of my success rate for grants. And so you know, you have to keep trying to hit the ball, and eventually, it’s going to connect, and we’re going to get something going. But if you feel demoralized and want to give up every time you fail if the messaging you were getting is that you’re a failure because you failed. That’s the wrong message. You’re only a failure if you don’t resubmit it. I think I’ve had really gotten it in my head, and one of my other good colleagues who I ran this trial with. Who’s the same age as me. And same sort of stage of career. But he also had fantastic mentorship. And he told me about his rejection drawer. He said, have a drawer in your office, or a virtual drawer on your computer, where you put the rejections, as soon as you get them, don’t read them, just put them in the drawer. And then find a time later, when you’re ready to resubmit. And when you’re ready to read, or go back to the drawing board, and then pull them out and look at them and only read the things that he can fix.

Chad Ball  42:13

That’s such great advice, you know. The concept of perseverance, obviously, we all know is important, but in particular in science and I think even more in particular with the bandwidth that sometimes we as surgeon struggle with, given all that’s going on, perseverance is the key. And sometimes you have to, whether it’s a basic science paper, whether it’s a clinical paper, you know, your letter, in terms of the response to the requested edits from the reviewer can be longer than the paper if you do it well. You’re right, it’s painful. And that’s exactly what I do, too. You get this terrible letter, you know, it says not only is your science bad, but you’re a bad person. So, you know, read it once, put it away for a little while and come back to it when you’ve digested it and you’re ready to look at it with an open mind. Because even in some of the really aggressive reviews, there’s always stuff in there that has merit that we can use to improve and enhance the paper. So yeah, you’re right, perseverance in all aspects of life is so important.

Rebecca Auer  43:14

Yeah. And I think you really have to be pursuing something that you’re passionate in and you believe in obviously, and we all know that’s true. You know, how many times have people said to me you’re studying this. Post-op immune suppression, that’s stupid. There’s no way surgery promotes metastatic disease, there’s no way that immuno suppression after surgery matters clinically. That’s just an animal model thing. And, you know, it’s possible that they’re right. But I need to be the one to continuously believe in that even when the naysayers don’t. And there’s lots of examples of people who were told there’s no way. And then eventually, they demonstrated the validity of that. So, I could be wrong. And my whole career might be a bust for trying to figure this out. But that’s a risk I’m willing to take.

Ameer Farooq  44:08

Dr. Auer, I do want to be a bit selfish here and get some tips from you about the whole time management, person management piece. Because it really does boggle me that you can wear so many different hats, particularly with a basic science lab and actually having other students and researchers in your lab as well. What are your maybe top three tips for managing your time and being able to you know, juggle so many different things?

Rebecca Auer  44:42

Yeah, so for sure, that’s a really good question. Another great piece of advice I got really early on was do what you can do and outsource the rest. So, I’m a strong proponent of the outsourcing and that’s really why having a fantastic team helps so much. I have a great lab team. Including, you know, someone who can run the lab and run the day-to-day operations. I also have my own administrative assistant and don’t share her with anyone and obviously have to pay her full salary. But she is fantastic and is able to kind of deal with my calendar and organize my life. Less so now, my kids a little older, but certainly when they were little, she would actually email the teachers directly. And they would communicate with her directly. So, Christmas concerts, you know, presentations. Whatever I wanted to go to – field trips, I’d say like one field trip per kid per term, can you make sure that happens? And she would call the teachers and try and figure out how I can volunteer on a field trip and cancel my clinic on that day, if needed, or clear my schedule. So having that kind of thing is amazing. We have the most wonderful caregiver at home for my family that we’ve had since my son (my eldest) was six months old, and he’s now 11. She has been part of our life and makes the home stuff work. And of course, I have a wonderful partner who’s super supportive and understands how much I love what I do. So having that team of people. In fact, this COVID thing has really made me realize how much of a village my world has, and how I’m missing my village so much these days. Because we’ve been so blessed with having so many people in our lives that help out. And I guess the other thing would be that a lot of people talk about work/life balance, and I have decided that doesn’t exist for me. First of all, I don’t think that balance is achievable. Balance would suggest that you have some equity between those things. And the other thing is it suggests that work is not part of your life. When, as most of us as surgeons, work is a huge part of our life. It’s part of our identity for many people, and that’s not to say that we aren’t anything else, but it’s a huge part of who I am and what makes me, me. And I think that’s okay. So, I prefer to say there’s more “calm harmony”. And sometimes that harmony is completely off. And my kids really will make sure I know it when it is. But I think they also know that I love what I do. In fact, my eldest once said to me, you’re lucky that you love what you do. And I said, you know what, I’m really lucky that I do. I said, whatever you do in life, make sure you love it too, because you spend a lot of time doing it. So, I think it’s not perfect. Let me tell you. There’s lots of bad days. Lots of days where I say I’m a failure in every single place. But then you just kind of brush off, stand up you keep going.

Ameer Farooq  48:05

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.