E40 Melinda Davis On Career Counseling And The Anesthetist – Surgeon Relationship

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Ameer Farooq  00:01

This week on Cold Steel…

Melinda Davis  00:04

You know, setting the tone of the room and establishing that level of communication is really important. So I have had also instances where I have had a surgeon come and do a 10-hour a day and not look me in the eye or acknowledge me directly in any way.

Chad Ball  00:33

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. There are so many jokes about the relationship between surgeons and the anesthetist, often about how dysfunctional that relationship can be. But in this episode with Dr. Melinda Davis, neuroanesthesiologist and current program director of the Calgary Anesthesia Program, we put that relationship on the table, dissect it out and try to think about ways that we can make that relationship better. We also talk about career counseling for medical students, and Dr. Davis’s role as the new program director for the Calgary Anesthesia Program.

Ameer Farooq  01:46

Dr. Davis, thank you so much for agreeing to come on Cold Steel, we really appreciate it and you taking out time from your busy schedule. For those of us who don’t know you as well, can you tell us a bit about where you grew up and where you did your training, and particularly how you made it from all the way down under into this frigid town called Calgary?

Melinda Davis  02:08

Sure, well, firstly, thank you for thinking of me for this. I did indeed not grew up in Canada. So I grew up in Sydney, Australia. And I did all of my medical school training there and all of my anesthesiology training there. And interestingly, I went straight into medical school from high school. So I was 17 in my first year of medicine for the for the most of that first year, actually, which was really interesting because it was a very clinically kind of oriented into clinically integrated medical school. So there I was kind of not old enough to vote or to drink. And there I was kind of on the wards trying to come to grips with all of the psycho psychosocial aspects of these patients admissions. And honestly, I would not recommend this, I think it’s really great that people have some life experience under their belt before they enter medical school. So I did a five year medical degree in Newcastle, Australia. And after that, I went into a two year rotating internship. And to my mind, that is one of the great strengths of medical education in Australia, actually, and I’m happy to kind of chat more about that if if you’d like later on but, but it really gave us an opportunity to you know, hone our skills as generalist physicians, so by the time we chose our disciplines to specialize in we kind of had seen a lot of different stuff at that point. And my move into Australia, actually into anesthesia, sorry, was quite accidental, in that I was in my second year of this rotating internship, and they needed someone to come and join the anesthesia on call roster. Because unfortunately, one of the anesthesia registrar’s, which is what we call residents had had a suicide attempt. And, you know, it was a sign of the times in that we never really discussed what a horrific thing that was, but it was more like well, now we need to put someone else on the schedule. And so I was pulled out at that point, and trained up pretty quickly and wound up taking call as an anesthesia registrar. And as it turns out, that was the right career choice for me, but certainly, that I think has formed some of the interests that I have in career selection in medical students. So following my anesthesia training there, I actually came to Calgary to do a neuroanesthesia fellowship. And that’s then I then I stayed, so I came for a year and I’m here 17 years later. Yep, so that’s my story from down under to the the northern hemisphere here.

Ameer Farooq  05:01

There’s so much to unpack in that little bit, that little snippet of your life. I mean, from, from the fact that something so horrific happened, and we never really talk about these things at all, you know that there’s, there’s a lot to think about there. I’m curious a little bit about how you think about the differences between what you went through in Australia in terms of medical training, versus sort of your impression of the system here. You know, I have lots of Australian friends, and we talk a lot about the differences in training. You know, it’s kind of unique in North America, where people typically do some kind of undergraduate degree often will do a graduate degree and then enter medical school versus in I’d venture to say most of the world people kind of come directly out of out of high school or A-levels and and start medicine. How do you think that changes the way people interpret or practice as physicians, and then and then maybe talk a little bit about sort of the flip side of that, where people have to do a bit more years as a general physician before the sub-specialize?

Melinda Davis  06:13

You know, there’s good and bad, as I was saying earlier, I really think that people need a little bit of extra life experience in order to train in medicine. And it’s interesting, as I get older to like, I’m much more able to appreciate all of the facets of patient-centered care, because of all of the things that have happened to me in my life. And honestly, as a 17-year-old, I just had no idea. When I think back at that I, I cringe. For sure my ability to learn new information was probably better than than it is now. And so I think I could kind of cram all that stuff in and I had fewer competing things going on in my life. So I could focus on, on getting my medical degree. But I think on balance, I think it’s awesome that people here come from all sorts of different other backgrounds to do their degrees. And of course, yeah, the the flip side is that it takes longer here. And I certainly got through my degree pretty quickly in that I finished medical school at 22. And then I was all done all of my training by 30. So that was helpful. But it’s a trade off for sure. I think one of the benefits of the Australian system is this idea that you go off and you do this internship. And there’s no match. And to be fair, it was a long time ago that I went through this process that I finished medical school that I did my intern year, etc. And so I feel like I’m poorly qualified to comment on what it’s like today. But I think the absence of a match is crucial for developing well-rounded physicians. And this is something that, you know, as a research interest of mine, because I think the match while on one hand, is good in that it is a good way to manage human resources across the country, it’s a good way to I guess make things as fair as possible in terms of access to postgraduate training. On the other hand, it is so incredibly competitive, and it drives this very early differentiation, like students really feel like they need to make a commitment to a career choice very, very early. And and that’s some of the data that I’ve been collecting in my research. And interestingly, I was just looking at, at some of the results from this year’s class. So about 30% of students that come into medical school have already committed to a career choice. And I put to you that at that point, you really don’t understand truly the pros and cons of any career in medicine unless you’ve had a chance to really be very deliberate about your exploration. So I think the match here does a disservice to our students and our and our health care system in a way because I think the risk is the unintended consequence that we are not producing well-rounded physicians. And that’s not true of every student. Like clearly there are students who are going to be excellent in all domains. But the risk is that if you put blinkers on and aim for one particular specialty career, you’re going to not adequately I think, learn about all of the other parts of medicine that you may well come up against in your life as that physician. So there are pros and cons of both systems and I’ve been really lucky to be able to experience both of them in various different capacities.

Ameer Farooq  09:59

I mean, such a important point that you’re raising, you know, it’s particularly we see it exacerbated in Calgary, because our medical students only had three years to do medical school. And it’s the same thing in McMaster so that that issue is heightened in terms of having to make a very quick decision without even having rotated through medical school often through various rotations and still having to make a decision quite early on. Do you think that is a disadvantage for those medical students? And how do you see the role of the undergraduate Medical Education Committee and program directors in terms of giving people a wide sort of taste of specialties, particularly specialties like anesthesia that don’t really have a big footprint in the undergrad undergraduate medical education curriculum?

Melinda Davis  10:57

Yeah, yeah, this is a real consideration. And it’s not just true that the three year schools, the four year schools have got the same issues, because they’re needing to choose their electives for their final year, you know, relatively early because of the time lag, or the latency between booking and doing. But yeah, you’re right, like the three years students, really, and this is the craziest thing need to have a bit of an idea about what it is that they want to do for their career, pretty much by the end of first year, because when they come back from summer, for what, what is some of that I do get, they really need to start thinking about the order of their clerkship rotations so that that process can start to take place. And so they need to kind of know, maybe not with any certainty about what they want to do, but they probably need to have a bit of an idea about what they don’t want to do so that they can order their clerkship rotation so that those rotations occur after the columns cut off. So and interestingly, though, the match rate in Calgary by and large is in keeping with the rest of the country. And that’s true of McMaster as well. So something is working for those three schools. This is the reason though, that we’ve developed their career exploration program at the University of Calgary. And so the idea there is to make this process really deliberate, and to bring it way, way forward in the process in the program, so that I’ve already spoken to them once in lecture form to kind of give them an idea of how this is going to look. But our first year students in the fall of first year, so three or four months in, have a individual career coach, and they’re starting to have conversations with them, about what their interests are, what their values are, what they kind of picture that for their future professional lives, and how they can go about investigating various different options for them. Because you’re right, if they wait to see, you know, to be passively exposed to these different crews and medicine, they simply will not be exposed to them in the time that they have in order to make the decision. So it needs to be a very deliberate process. And we have recognized that and we hope to put things in place to help them with that, including sort of facilitated shadowing and connecting them with preceptors, where they can ask some of the really important questions about career choice, which includes questions along the lines of what’s the worst part of this job? And can I live with it kind of stuff? Unfortunately, COVID has put a little bit of a wrench in the system with our plans for shadowing this year, but we’ll see how that unfolds.

Chad Ball  13:44

Melinda, I’m just curious, how many programs across the country have sort of an early exposure tractor or pathway like that, is that unique to Calgary? Or is that typical and 2020?

Melinda Davis  13:55

I think it is unique. I think all schools have some form of career counseling, and most of them had some, you know, access to, to these resources. But as far as I know, we’re the only program that has made a very deliberate attempt to make this early. And to make it conscious that one of the things that we’ve discovered in collecting data is that there are some biases around career choice. And students come into medical school, in some instances with this preconceived notion of what a family physician looks like it does and what a surgeon does, and and sometimes they’re wrong. And sometimes it’s based on stereotype but sometimes it’s based on work experience that wasn’t entirely kind of complete, or, you know, a mentor for their or graduate degree supervisor who worked in that field, where you’ve got like, part of the information but not all of it. So we have felt that this program is really important to try and push up against some of those stereotypes and biases. And just make sure that people really know what it is that they’re signing up for when they decide upon a career in surgery, for example.

Chad Ball  15:15

Yeah, it’s it’s interesting to me listening to you talk about this so eloquently, because you sort of describe my personal experiences to the tee. You know, I did, I grew up in Edmonton, I did an undergrad degree there, I went to grad school at UBC and decided really late, like, almost at the end of my graduate degree, I’m going to do medicine. And I had a sports medicine physician that was on my master’s thesis group. So you know, exactly that my exposure with was sort of like, well, I come from this varsity sporting background, I like sports. This guy’s great. I’m clearly going to do sports medicine. And I remember hitting medical school and and saying why I should just be sure that that that’s the case. I went to University of Toronto for medical school. And in the first half a day, I realized there was no way I was going to do that for a whole host of different reasons that you can probably guess, knowing me. But so I thought, well, the next natural progression of that must be orthopedic surgery. So then I went and looked at orthopedic surgeons, I hung out with them, you know, on weekends for about three or four weeks. And I was like, Oh, no, that I don’t like this either. And I really did spend two full years, every weekend I could, and at least one week night, and I emerge to family medicine to obstetrics, everything walking around. And I just sort of assumed at that time, I remember thinking that everyone else must be doing the same. But you’re exactly right. Nobody was and it seemed me because I because I was older. And because it was a late choice for me as a career path. Maybe my view of it was different. But, you know, I think the program you’re describing is so important.

Melinda Davis  16:52

Well, what you did that was really interesting, like you made an investment, like you decided to actually do this in a really deliberate way. And it that’s hard. And it’s hard to push up against something that you may have had, you may have beliefs, like you had a belief that sports medicine was the way to go for you. And it’s way easier to just kind of go with that and then seek confirmation that you’ve made the right choice. And so I wonder if some of the shadowing that we say is really just an exercise and confirmation bias. Yeah, like, we’re all prone to these sort of decision making errors if you like. And sure if if doing that really truly does confirm that you’ve made the right choice, then that’s awesome. But it’s really important to listen to that niggly feeling as well. And to ask yourself, like, is this sustainable? Like, can I really see myself doing this for 30 years? Like, what is the worst part of this job? And how does that jive with an honest appraisal of myself? And I just feel like this is stuff we haven’t really explored.

Chad Ball  18:01

It’s so true, right? We we don’t talk about it, we’re not exposed to it. And generally, I remember just sort of thinking after the third or fourth patient in this sports medicine clinic, like, these guys are all princesses. There’s absolutely no way I can do this for the rest of my life. And I had absolutely no idea. Like it was remarkable how ignorant and silly I was,

Melinda Davis  18:23

And you know, good for you for kind of going through that process. And clearly you’ve made the right choice now.

Ameer Farooq  18:30

Absolutely. One one kind of, really, I think crucial and interesting part of this whole conversation about career choices is that, it seems like there’s been a bit of a crisis, at least, you know, in the news and on social media about medical students not matching at all in Canada. You know, like, the last couple of years, we’ve seen sort of record numbers of medical students go unmatched I think, not last year, but the year before, it was something like the entire, like an entire medical school class, something like 200 medical students or so it’s never matched at all. And, and to me, you know, like, you could sort of say, Well, many of these people probably chose or some of these people at least chose high risk or highly competitive specialties. And there was always going to be a chance that they might go and match but 200 seems like a lot when you consider that there were many positions across Canada for residency that were unfilled, particularly in family medicine. How do you make sense of that? And how does that change the way that we counsel medical students when when they’re thinking about their career choices?

Melinda Davis  19:44

Oh, yeah, it’s such a good question. You know, the reasons behind that match rate really would be the subject of an entire PhD thesis, and it’s incredibly complex. But certainly it’s fair to say that over For the last decade, the number of applicants to seats has gone down. No other way around. There are fewer seats per applicant available. And that is particularly true, as you say, in some of the more competitive disciplines. So there is a PhD student who may have finished actually in Toronto, who is doing a combined PhD MD degree who has looked at this and published some really interesting data on that. And what he found is that the CaRMS disciplines are one entry disciplines fall roughly into three different clusters, cluster A, B, and C, and cluster A, in that cluster, there are more positions than there are applicants, and the risk of going unmatched in those disciplines. And I’m talking about things like internal medicine, Family Medicine, the pathologies, microbiology, genetics, what else is in that nuclear medicine, in that cluster, your risk of going on matched is about 1 in 40. The cluster B disciplines, well, let me just move to cluster C. So cluster C are the ones that are very competitive. So they’re the ones in which there are far more applicants than there are positions. And you can imagine which ones they are, so they’re ENT, plastics, neurosurgery, orthopedics might fall in there. What else goes in that list, I’m trying to think off the top of my head. But they’re, they’re the classic sort of, you can imagine these are, as you say, the high risk disciplines because your risk in those as a cumulative group is 1 in 4. And what’s interesting about that group is that you are more likely to go unmatched than you are to match to another discipline, which is in contrast to cluster B, which is everything else like general surgery, anesthesia, obstetrics, like all the other ones are in cluster B. And in that group, your risk of going on matched and this was from 20, this was a decade worth of data finishing in 2019. In that group, your risk of going unmatched is 1 in 10. But you are likely to match to something else. So what that says to me is that those cluster C disciplines that are very competitive, are encouraging students to put all their eggs in one basket, essentially. And so what’s changed in the last two years is that students can no longer do all have their electives in one discipline. And so it’s encouraging some diversification, which I think is critically important for producing a nice well-rounded physician, but also allowing people to actually develop parallel plans for CaRMS. So what we really encourage. So firstly, we share that information with our students, I think it’s really important that they have all of the information available to make informed decisions. And we encourage them to develop more than one viable career plan. Because let’s be honest, like, well, I don’t know, I’m speaking to surgeons, but I think most physicians would be generally pretty happy working in more than one discipline. Like I doubt any of us are really only able to work in anesthesiology, for example. And so we really encourage students to look very closely at what another career choice could be that they could thrive in in the future, which is very much in contrast to the idea of a backup, because a backup is just a recipe for disaster because you could match to your backup. And if you haven’t fully explored it and really given thought to what it could look like instead of use time working in that backup. I can only imagine that that is not a recipe for well-being in the resident years and beyond. So basically, we arm our students with all the available information, we encourage them to explore multiple options. And that’s not to say that there isn’t going to be one clear front runner. I absolutely agree with that. But I think the idea that we we being a medical profession, try to get students to put all their eggs in one basket is just a bad plan. So things are changing a little bit in that regard. And I hope that we are responding to that with our program as well.

Chad Ball  24:44

You bring up so many important and interesting points. I’m curious, is there a national level discussion that is this nuanced and this granular that’s going on right now, or is this sort of a few people in a few places discussion?

Melinda Davis  25:01

If there is a national level conversation, I’m not invited to it. I’m talking amongst myself about this stuff.

Chad Ball  25:08

Interesting, interesting.

Melinda Davis  25:09

I feel very passionate about this. I feel like there needs to be some sort of reform.

Chad Ball  25:14

Yeah, yeah, there’s no doubt. I mean, you speak so eloquently to make so much sense. One of the things we wanted to explore, you know, as you pointed out to one of our listeners or surgeons is the relationship between anesthesiology or just and, and surgeons. I would always make the argument, you know, I’ve talked about it a little bit before that, that it’s, it’s a unique relationship across all of medicine. You know, the relationship between cardiology, for example, and, and, or maybe even interventional cardiology and cardiac surgery, you know, again, as a hypothetical is very different from from what we experience, you know, with each other, for example. And I don’t necessarily entirely mean when a patient becomes ill, and we’re operating and you’re looking after them, or we get into a bunch of bleeding, you know, it can be the day-to-day sort of slow or mundane cases as well. I’m curious how on the other side of the curtain, the literal curtain, so to speak, how you view that relationship? Yeah.

Melinda Davis  26:09

That’s such a great question. It really is a symbiotic relationship, unlike any other in medicine, like you say. Like, I really can’t think of another example that’s so close knit. And it really strikes me that we need to make more of that, actually, both in the operating room, but also academically, like in terms of education, and research, as well, because we can’t exist without each other. And when it works, well, it’s great, especially during a crisis, that relationship. And I know that you and I have done many trauma cases together, for example, and to my mind, those trauma cases are a really great example of, of when the anesthesia surgery relationship is really tight and decision making in the moment is not together as a team, which I really think is is critical. But yeah, like it’s an interesting relationship here, like in a way like teeter totter is a bit of an analogy to because there’s this surgical condition. And there’s the things that you are doing, which may involve fairly major exsanguination, depending on the case. And then on the other side, we’re kind of trying to bring everything back to homeostasis. So there’s, there’s this tension between the push pull. But also, I think, that it’s fair to say that we really are on the same team, like we’re both looking towards the same goal, which is a good patient outcome in all domains and fair care.

Chad Ball  27:48

Yeah, exactly. You know, I, I thought about this for a long time, and I struggled to even bring up an analogous relationship outside of medicine. Like if you think of business, or you think of, I don’t know, what a law or accounting like, I maybe I’m just ignorant to it, but I really can’t come up with one. It’s interesting how our two groups are, in general, like most places I’ve been in, visited and trained, quite separate from each other to your points, socially, academically. You know, everything wise, it’s, it’s a bit odd, quite honestly.

Melinda Davis  28:26

It’s true and, it’s not just an, excuse me, a Canadian phenomenon. Like I the places that I’ve worked in now three different countries, this is true everywhere.

Chad Ball  28:38

Yeah. What’s your view or what do you want out of out of a surgical anesthesia interaction? I know it’s a very broad 30,000 foot question. But I guess what we’re looking for is what are the absolute do’s maybe? What are the absolute don’ts? What what drives you nuts?

Melinda Davis  28:55

Well, you know what, I’m going to start with the dos actually.

Chad Ball  28:58

Perfect. We’ll build momentum here. I like it.

Melinda Davis  29:02

I am looking to get some credit before I hit you with the don’ts. Well, here’s the thing. So I’ve given some thought to this. And in part, it’s because I’ve given thought to what I’m looking for when I select an anesthesiology residency candidate, because it’s the same thing. Because at the end of the day, when I yeah, like at the end of the day, it’s really the nonmedical expert CanMeds roles where this is really asked to be honest. So when I think about like a really good day in the operating room, for example, and by that, I mean, it’s personally and professionally satisfying, but also, and it clearly goes hand in hand, it’s been a great day in terms of good patient care and patient safety and it all goes together, right? And when I think about where that comes, when it comes from and how that is exemplified, I think about it starts really with the booking, for example. Like, I think that case, selection and the choice to proceed to the operating room is something that we are never involved with as anesthesiologists. And interestingly, it’s something that we have begun to kind of address with a complex case committee at the foothills and I’m happy to go down that tangent at any point. But it’s really helpful for us to kind of understand what the goal is. Because every now and again, we come to the operating room, our patient comes to the operating room, and we think, oh, like, what are we trying to achieve here? So it’s nice to know, kind of what the plan is, and the thinking behind the case selection. And in some ways, then, in terms of my kind of personal view of this. When I think about the way that the case is booked, it’s really helpful if it’s booked for the appropriate period of time. Now, clearly, you’re not going to know when things are going to go sideways, there’s unexpected things happen in the operating room. But that’s really helpful to have like a good idea of what the day holds, and have that actually pan out as it appears on paper as far as reasonably possible.

Chad Ball  29:23

Well, I think that’s a that’s a really interesting point, right? Because if we put all the cards in the table, and we’re honest in this discussion, you know, when when you guys are assigned or pick your your room, you know, well, before you start that day, you’re gonna be late. Or you or you gonna be early? Right? Like, you guys know, just like, we know, right? Yeah, exactly. That’s the truth of it.

Melinda Davis  31:45

Yeah, it is. It is. So yeah, like, likely, it’s best if there’s a match between those two things. So then, you know, one of the other things I think, is, is really great, that contributes to to a good day is the kind of huddle for the safe surgery checklist. So it’s really helpful if the surgeon is there, at the beginning of the day, we kind of can look at the slides and go, Okay, well, this case is going to be straightforward. This one, I’ve got concerns about these my concerns, you know, and perhaps a little bit more detail. But a lot of that stuff is not appropriate for the safe surgery checklist, which is done on the patient there. And some of the things we discussed, we’re gonna be talking about major hemorrhage, possibly doesn’t need to be in as much detail as we need in front of the patient. So really, what it comes down to when I think about what is a good day and a good interaction with a surgeon that I’m working with, which are the majority. I think what I’m talking about essentially is like really great communication, and collaboration and a sense that we are not technicians and we’re not machines, we are actually members of a team, looking after a patient. Because sometimes I think that is lost. And not just in in surgeons views of us. But I think in general, I think sometimes people don’t appreciate that we are indeed invested in that patient while they’re with us, but also beyond.

Chad Ball  33:22

Yeah, I think that’s a really good point. I mean, I the term that comes to mind when you describe that is operational, right? You often hear that anesthesia is an operational arm or an operational entity, but it really undersells all of the critical decisions and care that that you guys provide all day every day.

Melinda Davis  33:39

Right, I you know, I think of us very much as perioperative physicians, which certainly recognizes that our skill set goes beyond interoperative technical skills. I think we we have a skill set that extends both pre-op and post-op. And I really see us as being an advocate for a patient who’s kind of at their most vulnerable if you think about it. So yeah, I see that role there.

Chad Ball  34:12

Yeah, I mean, I couldn’t agree more. And, again, speaking from personal experience, the pre-operative assessment, that that you guys provide, whether it’s in the clinic as an outpatient experience, whether it’s an inpatient experience prior to you know, a more urgent operation is is always incredibly helpful. And sometimes, you know, we do rely on on you guys to provide a you know, a second look and say, What are you really doing here, bud? I think, probably the, the, you know, the the, the egoless honest surgeon really deeply appreciates that when it happens.

Melinda Davis  34:49

Sometimes it’s helpful for us to know that that’s what you’re asking though. Because occasionally you know, what, you know, we we haven’t not algorithm what’s the word, protocol, for how patients are seen in our pre-admission clinic. And so we go off and we work there, and there are 12 patients booked. But sometimes we don’t really appreciate that what you’re asking is, should we really go ahead with this? You know, I think for the majority of patients, the risk-benefit ratio is quite clear. And that’s the vast majority. But in a very small percentage, it’s not clear like you’re gonna do a thing, there may be other surgical things that you could do that are potentially less giant. There may be medical options and maybe palliative options. And we need to know that that’s what you’re asking us, because we can give you a fair understanding of what the perioperative period could look like for that patient. But we’re kind of doing it with half the equation, because we don’t know what the alternatives are. Which is why we’re trying really hard to develop this complex case committee for patients who are exactly in this category, which is where it’s not very urgent surgery, we haven’t really done any cancer surgery. It’s more elective, but clearly has an indication. And we’re trying to figure out like really, like, is this a good idea? What are our alternatives? What’s the perioperative period going to look like? And is there anything we can do to optimize that pre or internal post? And who else can we bring in? And so we’ve got this committee that has surgeons on it, and physiologists on it, internal medicine, geriatrics, and ICU, and we all get together, and we hear these cases in a multidisciplinary way. And I really feel like that may well be the way forward for those more challenging cases for making surgical decision-making.

Chad Ball  36:48

Absolutely. Okay. Now, tell us what you don’t like.

Melinda Davis  36:52

Oh, okay. This is a risk of being like a laundry list. Yeah. It’s my list of complaints. You know, I, I have to say, I am speaking for myself. And I also need to preface this by saying that 99% of my interactions with surgeons, I’m very positive. Like, I think I have a good working relationship with really all of the surgeons that I work with. And anything that I’m going to say here, I think could equally be directed at anesthesia, or anyone else really like it. At the end of the day, like I said earlier, it’s all about the non, the nontechnical skills CanMeds roles here. So, here’s some specific things that you asked me, what drives me crazy? Here’s my answer. So when at the beginning of the day, or the beginning of the case, we met the patient for the first time in the holding area or equivalent. And we have to form a relationship with that patient very quickly. And again, I think this speaks to a misunderstanding that anesthesia has, you know, our patients are asleep, we have no relationship with them, which is so not true. We do we form rapport very quickly. And we need to form a relationship of trust very quickly. And, you know, I think, if you’ve had surgery, you know how terrifying it can be to kind of put yourself into someone’s hands, whether that’s a surgeon or an anesthesiologist. And so, and obviously, we also need to do a pre-op assessment to make sure that we’re good to go for the case and to plan how we’re going to proceed with the case. So something that does really drive me crazy is if I’m in the middle of a sentence, and the surgeon walks up and starts talking to the patient. So the patient is really excited to see the surgeon as well, they should be because like you guys have got this long-term relationship with them. And it’s great. And they’ve got lots of questions. And I think it’s really important that you make that connection pre-op. Absolutely. But it can be very undermining for our interaction and our record development.

Chad Ball  39:09

Yeah, absolutely. That’s sort of communication 101, isn’t it?

Melinda Davis  39:12

Yes, that’s a good summary of a very specific example. The other thing I would say is that it is very helpful to us, for you to be there at the beginning of the case. And I know that sounds like a no brainer. But it’s super helpful if you’re there, not your fellow for planning, for a huddle, for the briefing and for positioning. So I have had an instance many years ago where the surgeon wasn’t present. And the fellow requested the case to be done in a sitting position. So the sitting position for neurosurgery is very uncommonly done these days because it’s associated with significant complications. And you know, I can say in the 17 years that I’ve been on staff, I’ve done it twice. And so there really needs to be a lot of planning around that. And a lot of conversation about the risks and benefits of that position. So it was really challenging for me to have this asked of me, but actually not have a surgeon there decision of record there to discuss this with. So that’s an extreme example, which ultimately became a surgery that was done in the prime position. It’s very helpful to have you there as part of that initial planning phase. And I think it sets the tone for the room as well, if you’re there, you know.

Chad Ball  40:39

Yeah, there’s, there’s no doubt to and I think, to be fair, as an educational tool for our own surgical trainees, it’s helpful for them to watch us do that model that.

Melinda Davis  40:50

Oh, absolutely. You know, and along the same lines, I think, you know, setting the tone of the room and establishing that level of communication is really important. So I have had also instances where I have had a surgeon come and do a 10-hour a day and not look me in the eye or acknowledge me directly in any way. And, you know, frankly, that has massive implications for patient safety, among other things. But you know, if that’s the time that gets set at the beginning of the day, you can imagine how that unravels.

Chad Ball  41:29

You know, it’s funny, you had mentioned that to me previously, a while ago, and I, I’ve thought about it a number of times since and I still can’t wrap my head around that happening, like, again, pull our work environment into something that’s semi-analogous. Like, can you imagine that happening on a plane? Can you imagine that happening on a on a on a sports team? Can you like, it’s just, it doesn’t happen. That’s, that’s disappointing. Yeah. Unacceptable, I agree.

Melinda Davis  41:58

It’s really strange behavior on every level, really. But when we look at the function of teams and teams in the operating room, they need to be able to function in a way where it’s safe for everyone to communicate freely, honestly. And so that is not a great start for interactions. But it’s extremely rare. You know, I think most of the time, the surgeon arrives, and we have a great conversation about how the day is going to go. So you know, everything I’m saying here is unusual. But there are specific examples that really speak to the same thing over and over, which is communication and collaboration, really. And then, you know, in terms of some other specifics, if you’re going to alter the physiology in any way, you should tell us that you’re going to do it. So for example, if you’re going to clamp something big, or unclamp something, or.

Chad Ball  42:55

Are you perhaps insinuating when we clamp the cava doing a bad liver with, with high venous pressures, we weigh what to tell you.

Melinda Davis  43:04

Yeah, we like to know that we like sure we’ve got venous return, we love it. It’s helpful for us to plan, shall we say, and it helps us interpret what we’re seeing, as well. And again, this is a no brainer. I am sure like things happen in the heat of the moment as well. But it can be quite difficult for us to really appreciate where you’re at in the surgery, we can’t see. Sometimes it can be really difficult to hear, like, do you find that like the operating room is loud? Because bear huggers and suction and it can be very difficult to hear the details of your conversation.

Chad Ball  43:38

Yeah, I agree entirely. And it’s especially bad with N-95s on and and these traumas, it’s just like, yeah, I can. I’m sorry. Can you see that for the third time? I genuinely can’t hear you.

Melinda Davis  43:49

Yeah, that should be its own podcast, I think. Yeah, exactly. Trauma surgery in the era of COVID. And then one final thing I would say is if you encounter an anesthetic, a sorry, a postoperative complication that you think could be attributable to anesthesia, it’s really great to let us know about it. Because I’ve certainly heard instances of this where, you know, many months later on the grapevine you hear about it, and think it’s really important for us to know, medicolegally. But it’s also really important for us to know, for our own professional development, that something wasn’t quite right. So yeah, back to the communication thing.

Ameer Farooq  44:35

What’s remarkable about what you’re saying is that like, it seems like it should be, as you say, a no brainer, like it should be something that that we just intuitively understand. Like that that whole comment that you made about someone not looking in the eye for 10 hours, it seems like something that just couldn’t or shouldn’t happen. Like why do you think that happens like when there is a breakdown in the relationship between surgeon and anesthesiologist you think that’s usually isn’t a personality thing? Do you think it’s usually a one off? Like, what what do you think is the reason for that? Obviously, that’s, that’s a complex multi-layered. Yeah. And specific, probably context specific. But but in your experience, like, why does that happen?

Melinda Davis  45:18

Yeah, I don’t know. It is interesting to me though. And this goes a little bit hand in hand with some of the work that I’ve done in undergraduate and postgraduate medical, medical education. When you see something like that, it’s rarely isolated. Like, there’s usually something going on, and often in multiple parts of their practice. And this is by no means us, like, I’m not saying this, this is a surgeon problem, like this is true in medicine in general. So I honestly do not know. But it is, it is something that’s so important to address. But we have no way of addressing that. Like, I really don’t know how to manage that in the moment, other than to push through and provide the best care that I can under those circumstances. And to be fair, it’s very, very unusual. So yeah, I can’t answer your question.

Ameer Farooq  46:20

And in fairness is it’s a it’s a big, massive, massive question. But I think you’re, you’re so right, that there often is a whole constellation of things going on in the background. Perhaps that’s important to like to just acknowledge, perhaps at the end of the day, if you know that there’s been a bit of a bad interaction. I know I know my dad is famous at his hospital in Fort Saskatchewan, for just directly kind of confronting and maybe this isn’t the best way of going about it. But but but you’ll you’ll just say to his anesthesist, who he knows for many years, because it’s a small community hospital. He’ll just say to them, like, like, why are you being like this, like what’s going on? Usually, there’s a story that kind of kind of spills out of there.

Melinda Davis  47:01

Yeah, and you know, that’s an interesting point in itself, because the system that I trained in, was one where the anesthesiologist and the surgeon have an ongoing relationship. So here, the computer schedules me, and I work with a different surgeon kind of every day. And I can go a long time, a long time between livers. Whereas in Australia, you work with the same surgeon on a Tuesday morning, forevermore, until you decide that relationship no longer continues. And there are pros and cons. But the pros are, you do develop an understanding of expectations and what’s going to come next. And there’s an ability to kind of talk in shorthand. And, you know, I don’t have any evidence for this. But I wonder about efficiency. And I wonder about safety.

Chad Ball  47:52

That that is such that I mean that that’s a dream. You know, it’s interesting, one of our liver colleagues from Toronto, who recently moved to Mayo, was describing to us the way that that Mayo functions, which is very much like what you’re describing. And it’s also what I experienced as a fellow in the US like, not only do you have your one or two anesthesiologists on your in your group, but you have the same scrub nurse, you have the same circulator, you have the same peri-op folks. And it’s incredible, I think how much stress that takes out of difficult operations in general for everybody. But just really not an option to date in, in Canada. And I, we do talk about that quietly in the backhall. And I wonder why it hasn’t happened. But, boy, would it be great?

Melinda Davis  48:39

Yeah, I mean, I think in anesthesia, it’s really important that we are exposed to a sufficient case mix that we are comfortable and safe on call. So it’s really important to not become too subspecialized. But at the same time, like I really, you know, I’ve been thinking a lot about team dynamics and team function. And the team knowing each other is a good start I think a lot of the time.

Ameer Farooq  49:08

I think this is a good segue to talk about one of your new roles, which is that you’re the residency director for the anesthesia program. You know, I’m curious why you would take a role like this, because it’s not an easy role. You know, having now kind of watched my program director sort of thinking about it as a graduate now like, I kind of appreciate how hard it is sometimes to be in that role for a variety of different reasons. But but why what got you into that role? And what do you think are the big challenges going forward for anesthesia education?

Melinda Davis  49:47

No, these are great questions. I you know, in terms of medical education in general, so firstly, I will say that like, I love this job, and as the residency program director, I I see it is as such a great privilege. Like I’m really enjoying watching people develop, because by the time they come into that program, they’re phenomenal like that way better anesthesiologist than I am. And that is something that brings me great satisfaction and joy. But to speak more generally about medical education. For me, this develops quite organically, when I was probably seven or eight years into staff practice, when I kind of found myself thinking, well, this is good. But what next kind of idea. And it was around at that time that I was really kind of understanding the concept that this is really important. Like, I think we have an obligation to teach the next generation. I think this is the right thing to do. Because if you think about it, we are each individually incredible, incredibly valuable resources. Like think about the training that we’ve had. And then this sort of intangible wealth of experience that we harbour within us. And so you’re thinking, well, we’re always going to take that with us, like we have, we have lifespans. And so I really do think it’s our obligation to kind of pass all of this on to the next generation. And then if you think about it, in a sort of egocentric kind of way, albeit, a morose way, it really is a legacy, as well. And when I think about some of the things that I do in my practice today, I can hear in my ear, the voices of the people telling me to do it this way. Maybe not telling me the right way. But, you know, I learned so much from those people. And I bring them with me and the things that they taught me as I go through my practice now. And I had a very interesting experience recently where I had to write an assignment for my master’s coursework. And I pulled a reference that I recognized the name of the author. And it was it a physician in Australia, who was in fact, the preceptor for the first small group that I had in first year of medical school in 1991. And he was, he was a geriatrician, and he was there facilitating a small group about some cardiovascular case. And he was the first person who kind of introduced me to the idea of preload, afterload, and pump. And it was like this light turning on moment. And I still use those constructs today, when I’m problem solving perioperatively, perhaps with a little bit more sophistication, but at the end of the day, that’s kind of the framework. And so he made this incredible impact on me, in terms of enjoyment of physiology, but he also taught me a lot about how to create a really safe learning environment that was full of enthusiasm and curiosity. And so I actually looked him up on the interweb. And I emailed him out of the blue after 29 years, and said, Hey, you are not going to remember me, but I was one of your students way back. And I really wanted him to know what an incredible impact he had had on my career. And to be fair, I hadn’t thought about him in that period of time at all. But when I saw his name, I realized that bits of the things that he taught me, I am carrying with me today, and it was so important for me to close that loop. And so we had this really lovely email interaction backwards and forwards and he was retiring this year and in the process of moving back to Ireland, where he was from. So those sorts of things are the reason why I think medical education is critically important and why I’m thrilled to be in this position as program director.

Ameer Farooq  54:04

It’s such a beautiful and moving description of why it’s so important and why teachers are so important. I mean, you know, I hear things that now I even though I just recently graduated, but I mean I hear Tony MacLean or Chad Ball in my ears all the time. And you know, whenever I feel like cutting corners, I can I can feel Dr. Ball, you know, breathing down my neck and it’s such a beautiful, beautiful relationship like it’s, it’s it’s kind of not something that’s that you can find in the same way maybe outside of medicine. Like if someone teaches you how to do something with a patient with such high stakes, like it’s really there’s nothing there’s no relationship that has that much stakes and analogous, I think outside of medicine, like it’s really a beautiful relationship.

Melinda Davis  54:57

Yeah, it is. I agree.

Ameer Farooq  54:59

Yeah. And, you know, to that point, do you think that people can get better as teachers? Like, do you think that you can actually train someone to be a better teacher?

Melinda Davis  55:11

Oh, absolutely.

Ameer Farooq  55:13

Because it seems like sometimes, you know, people are naturally inclined to it and good at it. And they may not be the people who are, you know, interested in medical education or have that as their research focus. But, you know, it’s clear, there’s something different about the way that they do things, and you can understand it the way that they they teach it to you like, how do you impart that to someone? And how can you make someone a better teacher?

Melinda Davis  55:37

Yeah, great question. You know, I think I want to focus in on clinical teaching and bedside teaching, as opposed to classroom-based teaching, which you know, you can, you can learn about those things through various different coursework. But in terms of the clinical teaching, which I should say, is a really unique mentorship relationship that you do carry with you thereafter. I think we all have the capacity to be excellent teachers. And the first thing I would say is that, I think we need to address some, the biggest fear that I hear articulated is that I hear people say, well, I don’t really know enough to teach. Or, well, I haven’t really thought about that topic in a long time to know enough detail to be able to teach a senior resident. But I think it’s really important to, to actually take a second to go, Well, actually, you’ve got a ton of experience, and you are the expert. And really, the first thing you need to do is to just become consciously competent. So you need to just be aware of what it is that you’re doing, whether you’re teaching a technical skill, which for you guys is clearly critical. But also in terms of your decision making. And I think the residents get so much from just hearing us show our working. Like just explaining why it is that we made the decision that we made, goes a long way to I think creating a learning environment that kind of fosters to and fro and, and good learning in the clinical setting. But it’s also what they need, like they need to understand why you did what you did. So they can decide whether or not that’s a reasonable justification and how it fits with other techniques or other options that they’ve learned. So I think that is the first sort of big overarching step is to become consciously competent. And then I have thought about this too, in terms of whether or not we could really improve our bedside teaching by focusing on the evaluation part. And I don’t mean the evaluation of the preceptor, I mean, evaluation of the resident, because many, I’m sure it’s the same for you, but in it, but anaesthesia, at least we have daily evaluations. And so I think by using the evaluation to kind of reflect and in a farewelled evaluation should reflect the goals and objectives. It helps the preceptor kind of understand what the point of the whole thing is, you know, of the clinical experience of that day. And that’s where CBD has actually been quite useful, because those API’s are bringing them to milestones. And so it’s really clear what it is that you are expecting from your learner. And if you can say what it is that you’re expecting from your learner, I think it really helps drive some of the in the moment teaching around it. So this is a huge topic, could also be its own podcast. But I absolutely think that all of our faculty are capable of being excellent bedside teachers.

Chad Ball  58:51

You know, it’s interesting that you that you frame it in that way, because, you know, I would argue and Scott Gmora and I talked about this on a podcast a year ago, that in surgery, classically, there’s very little, if any direct feedback. It’s sort of like, if no one’s yelling at you, you’re probably doing a pretty good job. And I like you, I think CBD will be a really important construction opportunity to improve the teaching as well as the feedback. I think that you know, clearly that the era is different as well with the expectation of students or trainees is different. We’ve had some really interesting conversations, honestly, on the on the podcast, and most recently, Janice Pasieka talked, you know, at length about some of the things that she tried to do and the people she tried to tap into to improve her ability to teach and it was remarkable to listen to. And I always, you know, I always sort of compare that in my mind to a great story that a guy named Georges Laraque who was a teammate of Wayne Gretzky’s story. A story he told him, you know, there to be fair, you know, in Laraque’s book, he and Gretzky are are very, very close to very good friends. But he sort of said it was interesting to watch the and, and play with the greatest player of all time. But when Gretzky tried to coach for, for Phoenix or in the Arizona Coyotes, he was the absolute worst coach he ever had in his entire life, including amateur hockey and Gretz would skate out in the ice and get really frustrated and say, Why can’t you guys do this? Do this and he would physically show them. And then they would all look at him and say, we we just physically can’t do that. We’re not, we’re not you. And he sort of implied that that Gretzky being, you know, Gretzky, never made any attempt to sort of, you know, improve his coaching and improve his his educating ability. So, yeah, I agree. I think we can all learn it, we can all get better. And and there’s certainly optimism if if the interest in the desire is there. I think one of the last question, we’d love to ask and and, again, before I do, Ameer and I thank you so much for spending the hour with us like, yeah, it’s you’re fantastic. It’s been a great conversation. If you could go back in time and give yourself advice as either a trainee or maybe a junior staff starting out, what would you tell yourself?

Melinda Davis  1:01:22

Oh, well, you know, I am so envious of the residents who are training now in 2020, in our program across the country, like they have phenomenal training, they have exposure to such great stuff. And so what I wish that I knew, and what I would say to them now is I would say lean in, like be prepared to be vulnerable, be prepared to be uncomfortable with not knowing and to really go after the stuff that you don’t know because now’s the time, like don’t be defensive. Just be comfortable with this thing the time that you have to learn. Yeah, I mean, yeah, that’s my summary. Lean in. Be vulnerable.