E50 Ed Harvey On The Canadian Journal Of Surgery And EBM In Surgery

Listen to this podcast on SoundCloud

Chad Ball  00:12

Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad Ball. We’ve had the absolute privilege of chatting with some amazing Canadian as well as international guests over the past year. While the topics have been broad in range, whether clinical, social or political, our aims for the podcast continue to remain the same. We hope to inspire discussion, creativity, scholarly research, and career development in all Canadian surgeons. We hope you enjoy our second season as we continue to highlight some incredible guests, deliver detailed masterclass sessions on a myriad of clinical topics and introduce some fresh new features such as debate and companion formats. We hope you relish the podcast as much as we do.

Ameer Farooq  01:13

This week, we’re joined by the co-editor in chief of the Canadian Journal of Surgery, Dr. Ed Harvey. Dr. Harvey is an orthopedic surgeon at McGill University. In this episode, we explore what it really takes to run a scientific journal, as well as the changing landscape of publishing with the rise of predatory journals. Finally, we get Dr. Harvey’s thoughts on the challenges of evidence based medicine in surgery. Dr. Harvey, thank you so much for joining us on Cold Steel. Can you tell us a little bit about yourself, where you grew up and your training pathway for those of us who don’t know you as well?

Edward Harvey  01:47

Sure, I’m actually originally from a suburb of Ottawa called Nepean. I’m from a fairly large family, four kids, but no one else in health, not in my direct family, or even extended family. I went off to Western University when I got old enough to study bio physics. And it was a fairly small program, we had a lot of hands on research. And that’s really where I got interested in doing research. So kind of carried through life. Then I came on to McGill University to do medical school. And I haven’t left because my wife wouldn’t let me. So I’m married to another physician. She’s here behind me at McGill. And we kind of set up shop here. I was pretty happy being here. It was a time when no one wanted to be here. But I was happy we stayed. I’m actually done three fellowships over the years and a master’s degree. And I’m now a professor at McGill University, and one of my part time gigs is helping the Canadian Journal of Surgery and helping Chad Ball.

Ameer Farooq  02:48

Congratulations on a fantastic career. You know, one of the obvious big areas of your life is research and innovation. Is that something that you were always interested in? Or is that something that sort of evolved over time?

Edward Harvey  03:03

Yeah, good question. I really didn’t know what research was. I had no idea what university was until I got to Western, did bio physics. And biophysics is a lot of hands on research and actually, some of the projects we did when I was in biophysics, similar to what we did in orthopedics: we broke bones, we saw how things wore out. I worked on a sensor so all things have now come full circle, in what I’m doing with my career now. But before university, I had no idea what research was. My father told me I used to take everything in the house apart, we never got it back together. So maybe I was researching things on my life. But I’m not sure if that’s applicable.

Ameer Farooq  03:44

You know, as you mentioned, you’re the Editor in Chief at the Canadian Journal of Surgery, how did that role evolve? And tell us about some of the brightest moments and biggest challenges in that role?

Edward Harvey  03:58

Sure, the Canadian Journal of Surgery I’ve been aligned with for a long time now. Joe Meekins was Editor in Chief when I was a resident. When I became staff, he asked me to come on to do one of the case report sections of the journal and I was on the panel for a number of years. And when Joe Meekins and Jim Waddell were both timing out from the journal, he actually asked me to send him my CV. I thought it was to become an Associate Editor and then all of a sudden, they asked me to become Editor in Chief and I have no idea why. I don’t think I was any better than anyone else on the panel, but I just, I guess I hit my deadlines better than they did. It’s always been a big priority for me to set deadlines. I don’t do a great job at it, but I try. But for brightest moments and biggest challenges as Editor in Chief on a journal, are the several challenges we’ve met over the years. I think, if you go back and look, there’s a paper published in a journal about the former editors. And if you look at the common thread through that paper, everyone says they had trouble getting money to run the journal. And I don’t think that’s changed. We’re still in kind of a dubious position. Economically every year was the discussion at the journal, should we keep doing this journal? And I think it’s important we keep doing it. But it’s become a little easier now that we’ve gone online, and we’ve come out of print, it’s a little cheaper, not much, but a little cheaper. I think one of the biggest challenges also is that this journal is just represented by people from all across Canada. So all the reviewers, all the Associate Editors and all the editors are across Canada. And the journal doesn’t have a lot of money. We can’t have meetings in person every year or every six months, like some journals do. And we’ve been virtual since before there was an internet. So it used to be by phone call, and then email became de rigueur, but now, it’s easier, you know, we can get in touch with people today and it makes it a little easier. I think the best part of being an Editor at the journal is that you get to read a lot, so those are the major points, I think as being Editor in Chief. I don’t know if Chad could add some, but those are my challenges. I’m just honored to be trusted to do this. Actually, it’s a 63 year old journal now. It’s the journal with the longest publication history of all the journals published in Canada over the last 300 years. So I think we’ve got this legacy to keep it going. And I take that seriously.

Chad Ball  06:44

Yeah, I couldn’t agree more. And for sure, it’s an absolute privilege to be sort of the last man in the door, thanks to you, and I’ll always be appreciative of that. It’s interesting, it feels like I’m not sure, and you and I have talked directly about this, but it feels like the media world in the context of academic surgery is changing rapidly right now. Whether that’s surgical journals, obviously that we care about, or medical journals. What do you think the future is for some of these journals? Whether it’s Annals or Canadian Journal of Surgery, or Bone and Joint or whatever? Where do you think we’re going?

Edward Harvey  07:24

Sure, great question. I mean, it’s hard for people to get a good overview of the journals because of what’s going on in publication, because there’s a lot of driving factors. There’s obviously driving factors from our side that we see in academia, you know, published, not so much in Canada, but still exists in the fact that you want to get your message out about good patient care. But then there’s also the top down pressure, you know, the economics of running a journal. I think if you step back and look at why the journal is actually here, there’s those two real dichotomous reasons and I think Chad and I are around on the academic side and trying to drive patient care, but it’s always a fight to get it done. You know, economically. I think Vivian McAlister was really important to this journal. He stepped off just before Chad. But he and I wrote an article in the journal actually, like the 60th anniversary, about the history of publications in Canada. And if anyone wants to look it up, it’s a great read, not because I wrote it, because Vivian wrote it. But it certainly gives you an overview of the history of the journal publications in Canada and how it’s tied to actually medical care in Canada. The publications have actually resulted in the Canadian Medical Association, the Royal College and other long standing institutions being started in Canada. So the people that publish journals and the people that published in the journals have been a driving force in medical care in Canada, not just through the way they publish, but the institution they founded. So you can say, oh it’s just a journal, but I think it really speaks to where we’ve driven medical care in Canada. So I know now we’re we’re at this point with the Canadian Journal of Surgery, we’re 63 years in, the journal was founded in 1957. There’s currently a collaboration between Canadian departments of surgery, the Royal College of Physicians and the Canadian Medical Association. And the founding editorial board was actually 12 chairs of surgery from across Canada. So all the academic centers actually participated next to the President and the Editor in Chief was the president of the Royal College of Physicians and Surgeons at that time, which is Robin James out of Toronto. And it’s kind of continued that tradition of being a cross Canada effort, which is important. So I think Chad’s question was more like, where’s the journal and what’s the overview of what the journal means for publications. So I’ll just give you a little bit of the history about how this journal has changed medical care in Canada. I can talk a little bit about how it interacts with the rest of the kind of big broad rainbow of publications across the world. You know, it seems to be like a little journal in Canada but it’s not. The journal itself now actually has risen on the Impact Factor high enough that the H index is 55. And that might not mean anything to anyone, but the Journal of Surgery, which is is seen as a very good journal, the publishing has the same age factor. So the Canadian Journal of Surgery is in the top 10 List of surgical journals, which people like Vivian McAllister and Chad Ball have been very instrumental in having it happen. I mean, I think we’re a little bit like the Rodney Dangerfield of surgery. It’s very Canadian, we don’t get much respect, but we actually have an impact. So we have an impact on the process of medical care on how we publish. And what happens in the future. And what happens in the future is a huge question. Journals have become consolidated, just like companies are. The actual types of publications that we’re into. I mean, there’s more than 2000 journal publishers globally. And there’s actually 30,000 active scholarly peer reviewed journals in published biomedicines, about 30% in total. So we’re in a big field. We’re seen as a big competition. But the top 10 publishers publish like 1/3 of the journals. So there’s this kind of amalgamation and consolidation of journals that we might have to fight in the future going forward. People are going to try and buy us out, because we’re seeing maybe a desirable kind of topic now, because we’re in the top 10. And that will be one of our challenges going forward.

Chad Ball  12:01

That’s so well said Ed. You know, I think we’d probably be remiss if we didn’t take a moment, in particular, to thank the surgical chairs across the country that still continue to support us from almost every university. They really are the lifeblood, not only as you point out in the origin story, but currently as well. One of the things that I always thought was really great when I was publishing as a resident, and even before that, as a medical student, to be honest, was the the open access nature of the Canadian Journal of Surgery. And I’m sure there was, you know, journals that preceded that, but to be honest, in my little world coming up, I didn’t know of any. And it’s been amazing, personally, and maybe, selfishly, to get feedback from sort of, as you’re insinuating, all around the world, you know? Head over to Australia and hit three cities and give three talks and trainees come up to you and say, “Oh I read your paper on this, this and this, and it’s a little bit striking. So I was curious, do you have any sense of how that initially evolved? And who was the driver to do that? Because it certainly seems to have, you know, like you said, allows to punch over a weight class.

Edward Harvey  13:06

Yeah, that’s a good question. That happened under Vivian and myself. I must say, Vivian was the driving factor, I was the devil’s advocate. So he said, we should go open access. I said, oh my God, we can’t go open access. And so we talked about it over and over again. And finally, I think he convinced me that we have to. I mean, there’s different business models for publications of journals, right? But we were sitting at a very low impact factor back in 2011. What we needed, there’s many ways to increase your impact factor. The reason we were trying to increase the impact factor was because we didn’t have any advertisements and people were not supporting it. And therefore we’re not going to have a journal. This goes back to that 60 year old dilemma of not having money to publish this journal. So Vivian and I and the publishers discussed different models and how to come about and get more eyeballs on the journal. And obviously, full open access is one way and Vivian was instrumental on not just the argument, but also in putting it online. So he had the University of Western Ontario archives, put every journal article online. And they’re all there, right back to the first volume. And it helps, you know, I mean, everyone’s aware of how journals are published. At least they think, you know, everyone’s kind of complacent with the conventional firewalled journal where you have to pay to read it or be a subscriber. And if you’re not, you have to pay $20 to look at the article or maybe your university supplies it for you, but there’s payment going on there. And we’ve considered delayed open access, which means you just delay for a while and then you still have a firewall but not prolong or full open access is what we went on to. And there’s even models like self archiving: you just publish and nobody cares what you publish, you just put it up. Which is another big challenge in publishing – the predatory journal. Which seemed to be similar to self-arching. I think looking at it going forward, the predatory journals are the biggest problem right now, for most publishers. Those are journals that publish anything with no review, or have a model where if you send paper for publication it’ll delay it for three or four years and say you have to pay more money to get it published earlier and some other kind of unethical practice around their publication policies. And so I think in response to that, there’s been a few worldwide organizations, the big one is COPE, which is a group which is set out in ethics, policy on publications, its committee on publication ethics. I think all the surgical journal editors group, about 120 journals belong to COPE and adhere to the principles of COPE. And actually, it’s open to anyone. You can go and look, and it has great algorithms for how to resolve paper publication issues, you know, author issues, when you’re having problems with publishers, etc. So it’s been a great resource. But even with resources, like COPE, or the World Association of Medical Editors and others, it’s still really hard to recognize what’s a predatory journal in some cases. There’s been a famous academician named Beal who put up a list of fake journals and publishers, but was forced to withdraw it from lawsuits from one of the open publisher groups. Other people have the list online. And there are other lists like Cabell’s list of good and bad journals, and the directory of open access journals also that allow us to kind of separate out that predatory group. But I think it’s going to be a big challenge going forward. And it’s totally driven by the fact that the profit margin from the big publication groups is huge. Like the big five have a profit margin of 35% on the author’s backs. It’s definitely not what we have at the CMAJ or this Canadian Journal of Surgery, but because of that large profit margin, there’s been entrance into the market of all these predatory publishers.

Chad Ball  17:13

Yeah, there’s no doubt it’s almost an overwhelming problem and technology is certainly playing a part in that as well. You mentioned the the impact factor of a journal a couple of times, and certainly you and I understand that, I hope, quite deeply. But for the listeners who maybe don’t understand that concept, exactly, can you sort of outline it and what it means to a journal or what it doesn’t, and then maybe just chat about why removing, for example, case reports from a Canadian journal and trying to minimize maybe qualitative surveys that aren’t referenced enough or too much in comparison matter?

Edward Harvey  17:51

Sure, that’s a great question. There’s several impact factors that people use to judge journals. Basically, it is what it says. It’s an impact factor. How much impact is this journal, publication or person having on the community at large? And the most commonly impact factor is actually a private company owned rating system, and it rates. So it’s very hard to get ahold of. You can’t get a hold of it, you have to pay for the current year, but you can get a hold of it when it’s two years older online. But when people say Impact Factor, it’s a numerator and denominator function. So depends on how many papers are published in your journal, and how many times you get quoted. So the journal that has a lot of quotations on the hat will have an impact factor of 70, like the New England Journal of Medicine, and someone who has very few quotations has an Impact Factor is zero. And actually, the Impact Factor in most medical journals is around one. And that’s much higher than other specialties. So if you’re over one, you’re doing well. And if you’re below one you might be doing well, you might just have a super specialized kind of clientele. A good mathematical journal has an impact factor of point two, because people just read their own theory and don’t quote it, I guess. But in medicine, we’re looking for something over one. And when we started in 2011, the impact factor was 0.6, I think in the Canadian Journal of Surgery. And we’ve actually got it up to, at times 2.5, or hovering around two. So I think it’s a good place to be, especially for a journal that publishes very Canadian centric papers. We publish protocol papers from Canada, which are not getting referenced by many more people and Canadians. But we still have managed to keep that impact factor high without any bias, without forcing people to quote us or forcing people to read our journal. I think part of that was Vivian’s move to get the Royal College distributing the journal. A lot more eyes got on the journal. More people were quoting it. But it’s also a factor that we have good science. Canadians do good science. Is that a good enough description of the Impact Factor for you Chad?

Chad Ball  20:22


Edward Harvey  20:23

H index or any thing?  Like I said, there’s almost 24 that are used to describe journals. But I think when everyone says Impact Factor, that’s the one they’re talking about.

Ameer Farooq  20:33

Dr. Harvey, one of the things I’ve really enjoyed about you being the co-editor in chief or the editor in chief is your editorials. They’ve been remarkably frank. And you’ve never shied away from tackling some big issues. I mean, some of my favorites are, like the one where you talk about the way Trudeau sort of holding on to transfer payments or about the fact that you know, surgical innovation seems to happen, but never seems to find its way to the operating room. And I’m just quoting too, you have many, you’ve written tons of editorials. And they’re all excellent. How do you sort of think about the editorial itself? And do you have any advice for maybe some budding editors in chief, I know, there’s a few new editors, for example, like the Canadian Journal of Urology just got a new editor in chief. And, you know, he wrote his first editorial the other day. So do you have any advice for people writing editorials? And how do you think about that particular piece within the journal?

Edward Harvey  21:40

Yeah, sure. Great question. I mean, I think it’s the only time when you have a timely publication in that, people might read. So you can sit on your soapbox at your own center and say, I hate this, or I hate that and we should do this or that. But this is one time when I think I can actually get out to a larger readership. And I try to seize on timely publication of current events that apply to medicine. So transfer payments for health has always been a kind of a bugaboo. Especially being from Quebec, my wife had a great input into writing that one because she said, “you’ve got to write about this”. And I said, okay, I’ll write about that. And I usually bounce them off her because she’s a great sounding board. Plus, if I tend to rant too much, she stops me. But it is a sort of a rant. So you have a mild version of like a Rick Mercer rant where you’re walking around the room and talking about your subject and you put pen to paper. And that’s the way I approach it, you know. Something that’s bothersome that’s going to affect health care, like the debate over private versus public, or the federal government transfer payments, or medical education. I think my next one will be about the next lost generation of medical students, especially at McGill, where no one gets to do an elective anymore. I don’t know how people are going to choose a specialty if you can’t do an elective because of COVID. I mean, this is not the only time that they’re going to deal with a pandemic in their life and they should be able to deal with that and do electives, but our medical schools have decided not to apparently. So that’s the kind of thinking that goes for me behind it. It’s something that is a little controversial, a little current, and that would be better out there now rather than waiting six months for another publication.

Ameer Farooq  23:33

The other thing I wanted to talk to you about is sort of your thoughts about EBM. You wrote this great article about evidence based medicine and you have this paper that’s called “Evidence Based Medicine: Boom or Bust in Orthopedics and Trauma”, which was published in JSPS. How do you think about – especially now in your role as Editor in Chief – how do you think about EBM and the challenges of applying that to surgery? And I’m specifically thinking about the challenges of doing RCTs in surgery.

Edward Harvey  24:07

Yeah, it’s a big deal. I mean, I’m a member, I guess card carrying member of the Canadian Orthopedic Trauma Society. So we were one of the first big world groups to push EDM in orthopedics. We were kind of ahead of the curve. One of my mentors, Marksman Koski was instrumental in doing a functional outcome score for musculoskeletal problems that no one ever done before. We sort of continued that on with a group of like minded researchers across Canada, led by Ross Leighton out of Nova Scotia actually for the last 25 years. But we specialize in doing large clinical trials, cross country borders, and about simple questions that we can answer in orthopedics. Nothing complicated. That’s the best way to get a result right. So we’re very happy with our contribution to literature. We’ve been recognized multiple places as being, you know what’s called great researchers. It’s just a great group of people who are willing to collaborate. That’s what makes great researchers. But as that went on, it became more and more obvious that people don’t really care if you solve a problem, if that’s not what they were trained to do. So I spoke in Washington, just before COVID. But I use the example that we cured avascular necrosis of the hip eight years ago, and nobody cares.  Because total hip arthroplasty is so easy to do, and so well paid, that they don’t want to do anything else. So that’s the kind of thing that goes on in all surgery, I think. You sort of get a toolkit and it’s really hard to make you change your toolkit. So if evidence based medicine is good, I think it’s good. But it doesn’t make any societal change. Why are we paying so much money? It’s a huge cost to do randomized control trials. Mo Bandari ran one that’s very famous about open fractures with 1000s of patients in eight countries, dozens and dozens of centers and cost millions of dollars to do them. It was a great New England Journal publication for everyone involved, multiple other publications in sub studies. But if it doesn’t change the way we’re going to do medicine, why are we spending money on those trials? So our argument with this symposium that we ran was that we need to follow up on these trials. And if we’re not changing the way patients are cared for, then why are we doing it? And I think it’s a little bit tongue in cheek, that I do believe in evidence based medicine. But I also believe in follow up, you know, you can’t do something and not follow up and figure out what the outcome is. And we haven’t done that well in orthopedics. And I assume we haven’t done that very well in other specialties, I haven’t seen those papers come across my desk. So the question then becomes, you know, should you just be doing cohort studies rather than randomized controlled trials, because they are a lot cheaper. And I think that it’s a combination of both. We’re looking at a problem called acute compartment syndrome. So we got access to a huge database in biostatistician and we looked up the results. And we were finding weird results, even with huge cohorts. And we went back and looked at the randomized controlled trials, which showed that tibia fractures had a 10% incidences complication. But the cohort study was showing a 3% incidence and you could reconsolidate that. But it just comes down to the fact that data is not collected correctly, and that people don’t like the code for compartment syndrome because it’s a medical legal risk. And so now you’re stuck. You should have had a better answer with a cohort study, but we know it’s not right. So I think a combination of the two is probably going to be in the future. We’re gonna have to identify problems with cohort studies or identify solutions. And if we haven’t got a definitive answer, we can least verify it with control trials, but make sure we take our control trials to be trials that will change people’s practice. Sorry that was a long answer.

Ameer Farooq  28:17

No, that was fantastic. And I think it brings up a lot of the issues around RCTs and surgery, and I think something that I personally have thought a lot about. But do you think that the issue with RCTs is just that they’re in a select population where the conditions are very tightly controlled? And so the application to your average patient that walks in the door doesn’t apply? Or is it more that you know, people just won’t apply the findings of an RCT until they’re sort of trained to do it? You know, I mean, an example in general surgeries is, there’s a stitch trial that showed that five millimeter by five millimeter bytes for closing fascia was better, but I have yet to see anyone close their fascia like that. And, it’s just sort of one of those things where, you know, I’ve never done it that way. Even the few people who tried to do that said, oh, I had someone do this. And so even though that’s the whole point of randomized control trials or studies is to get away from anecdotes. But what’s your sense? Is it sort of A or B?

Edward Harvey  29:26

No, I think it’s that’s a perfect example. I think it’s both. That’s bad answer. But my daughter’s a lawyer so I can go that way. I think that part of the problem is people’s interpretation of trials. So you’ve got two ways to go. You can either design a trial for the typical surgeon, so a lot of the British trials in orthopedics are designed that way. They had an proximal humerus fracture study, which basically had a couple 100 patients in it. 66 were surgeons and they averaged about two surgeries per surgeon. So the argument against that trial was, well, those guys aren’t experts. Of course, it didn’t turn out right. You know, you can’t publish that. Well, they got published in JAMA because it was extremely well designed to trial, except that it probably didn’t have any implications for our practice, because you’re going to look at that and go, well, community surgeons were doing these tough fractures. Of course, they didn’t turn out as well. Well, in the Canadian side, we really limit our trials that are 53 PIs, which are all trauma, fellowship trained surgeons. And so we realize that, if we did complicated answers, we might get answers. We might have significant results, but they wouldn’t be significant to the community. So we tried to do some simple tests, like: do you use soap or no soap when you wash out an open fracture? Do you leave the ulnar nerve where it is, or transpose when you do a distal humerus fracture? Those are applicable to every surgeon in our readership. So I think you have to be careful about the way you design your trials, and a lot of the stuff and nurture people. Like I said, people look and go, well, that doesn’t apply to me for X, Y, and Z. You’ve got to eliminate the x, y and z when you design your trials. And I think we’ve done a good job of that. But even at that, we still have trouble getting a knowledge translation to the community.

Chad Ball  31:22

Yeah, there’s no doubt that’s a challenge for every specialty and every subspecialty I think everywhere, but you’re exactly right. I mean, you guys have really led the way I would argue, maybe in combination with the Canadian critical care trials collaborative, as the two sentinel groups in this country for a long time. So I think, you know, we’ve just begun sort of an acute care surgery group that’s national, and it’s called the Cannucks group, which obviously is an acronym, but that’s really what we’re trying to emulate. Steal from you guys, and borrow and beg. So hopefully, we’ll get there because you’ve done such great work. You know, one of the other interesting things to talk about in RCTs, and I certainly have heard you talk about it and Moe talk about it. And I’ve talked about it. It’s the idea of data fragility within a typical surgical trial, you know, the usual thing. You take two or three events or people in your numerator and flip them over to the ratio, and all of a sudden your conclusions are very different. How do you evaluate that issue when you’re reviewing a paper? And then how do you consider it or contemplate it when you’re designing the trial?

Edward Harvey  32:33

Yeah, I think it’s important in design trials. Like, I gave this talk at the American Academy last year. And I talked about this. You get like a 50/50 response, you know, the statisticians are rolling over the table and under the table. And then the clinicians are sort of like, oh yeah, that makes sense. So some of my bugaboos are like intent to treat. So you know in an epidemiological, well designed study, if you randomized two arms, that is an intense treat to go on one arm, you’re there. Now, that’s great in a medical trial, like for hypertension, where you’re also changing everything else around that patient and helping them even if they decide to get out of that arm, right. But if you go into a surgical arm and either have surgery, or no surgery, there is no place for intent to treat in design of a trial. And we still do that. I mean, I used a clavicles paper as a great example. The clavicle trial was what really made us famous in that we had an no fixation versus fixation for clavicle fractures. Everybody in the world said, there’s no way you should ever fix those things, even surgeons doing it, thought we were crazy to do the trial. And at the end of the trial, it turned out, no, you should fix them. And it’s really changed the way people practice, at least in the center that did the study. The problem with that study was we had an intent to treat. So the two non unions in the surgical side, were actually people that went to surgeons and said, “oh, no, I don’t want surgery” and then got a non union. And then were treated with surgery and healed uneventfully. But they were still treated as non… Like they’re in the other arm, right? They’re treated as complications for the surgical site. Now, you’ve mentioned fragility, if this is a typical ortho paper, or a clinical trial, three patients in one arm rather than the other arm would swing the whole decision tree, right. So there’s a real danger with that trial, that it would have went the other way. And it would have been like non-ops way to go. You know, still everyone said, of course it is. But it really wasn’t. So we have to design our trials a little better. We have to design how we enroll patients. It’s really hard to do a two arm study where one’s non-op and one’s op. Everyone knows who had the operation. The patient knows, the surgeon knows, the physiotherapist knows. So I think it requires a rethinking of how we design trials. I think that will help a lot.

Chad Ball  35:03

That’s so well said. You know, as Ameer said, we recognize you’re super busy and really want to thank you for being on again. I want to finish though with a selfish question because I marvel at what many of your trainees have told me about you in terms of your well roundedness and particularly your dedicated family life. I’m curious, you know, other than the usual barn fire maybe that most of us live in, how do you manage the editor ship, the clinical surgery, the innovation, private work that you do? And then of course, the surgeon scientists side of things with your family and the rest of your interests in life? What’s the trick to that? I think we can all learn from you.

Edward Harvey  35:47

I’m getting emotional now when you talk about my family, but I can give you a short answer and a long answer. The short answer is my wife’s. And she goes, yeah, it’s because you can’t sleep. And so yeah, like most nights, I sleep three or four hours. And that’s the way I’ve been all my life. But the real answer is, it’s time management. And it’s easy to say. Obviously, your patients are the priority, like taking care of life and limb decisions. I’m a trauma surgeon. But I don’t schedule my day like that. I schedule my day when my family’s the most important thing. So at the beginning of the week, and during the day, my wife continually reminds me of what I have to do for the family. And I’ve always been involved with coaching them in hockey. My kids all played inner city hockey, my girls played AAA hockey, my son’s now going to play university rugby. And I’ve always tried to make every one of the games or been the doctor at their teams. And that’s my priority. But then they all understand that if some emergency happens in the hospital, I’m going to go do that. And then all the rest of the stuff gets scheduled in 10 minute blocks during the week. It’s just really time management. There’s no secret. Everyone’s busy. Absolutely everyone’s busy.

Ameer Farooq  37:08

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.