E60 Andrew Ibrahim On Architecture, Visual Abstracts, And Design In Surgery

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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

It is a human tendency to try to categorize people and to put them into neat boxes that fit our preconceived notions of the world. Dr. Andrew Ibrahim, our guest for this episode defies those conventions. Dr. Ibrahim is a general surgeon at the University of Michigan, and an architect. In this episode, we talk about his path and how he combined those two passions as well as one product of that combination, the now famous visual abstract, we also get Dr. Ibrahim’s thoughts on the concept of design, his vision for the hospitals of the future, and what architects might learn from surgeons.

Chad Ball  01:49

Thank you so much for joining us. It’s a real honor to have you on the show, really and truly. I was wondering just out of the gate here, if you could tell us where you grew up and what your training pathway looked like.

Andrew Ibrahim  01:59

Yeah, great. Well, it’s it’s great to be here. And thanks so much for having me. My story is not super straightforward. I grew up torn between becoming an architect and a doctor. And part of what motivated that interest. I grew up in Cleveland, Ohio. And if you drive along Interstate 90 in Cleveland, and a half hour drive, you could see eight or nine inpatient hospitals. And it was always curious to me, why my family members when they got sick went to one hospital versus another. And I was like, Why are there so many hospitals and who decided where they should go? And I kind of, I don’t know why as a kid started thinking about like city planning at a young age. And I think because family members needed to go to hospital that was kind of like one of the questions I thought about. And when I got to college, I was torn between the two. And I’m kind of classic, type A pre-med fashion, I did all the coursework, did all the things and I got into med school by the time I was about 20. And I went to the Dean of the medical school and I said, Gosh, I’m so excited and flattered but I just shadowed for a day in the medical school and I don’t think I’m ready. And she said, well, what would you do if you weren’t a doctor? I was like, Oh, I’d be an architect. She’s like, why don’t you go do that for a couple of years. And we’ll save your spot. So I moved to London and studied at the Bartlett and did the foundation coursework in Architecture and Planning, which I really got to learn the frameworks for how you think about planning cities and organizing large scale public infrastructure and managing multiple stakeholders. So then I naively went back to the medical school after that, and I said, so who are the architects that plan regional delivery of health care? And I got some chuckles. And they were like, well, what you’re interested in is public health. And so I trained in public health, did the master’s degree in health services research. And it wasn’t till I got to Michigan, I met a person named Dr. Justin Dimick, who has been my mentor for about a decade now. And he was really wise in that he said, you know, there may not be someone who does what you do. But if you arm yourself with enough of the right tools, you could start to forge your own pathway of this surgery and architecture world. And I think that was a huge catalyst to being able to do the work that I do now. So I operate every week on Thursdays, and I’m on clinic on Tuesdays. And then Monday, Wednesday, Friday, I’m either in my research group or an architecture firm thinking about how you actually design and deliver large scale public health infrastructure.

Ameer Farooq  04:46

It’s such a fascinating story that you would, you driving down the Cleveland highway and looking at these hospitals and think, man, I don’t understand why these are built the way that they’re, they’re built. Like that’s such an like a thoughtful thing to sort of think about as a child. And it’s kind of interesting that, that what drew you into architecture was actually healthcare, which is kind of a unique set, you know, path into, into architecture as well.

Andrew Ibrahim  05:13

Yeah, I have embarrassing, I wish I could find him. But when I was in grade school, like fifth grade or something, I used to finish my homework as quick as possible. And then I would turn the sheet over and start drawing the city. And I started to lay out like, well, how many houses do you need? And all those people need jobs? So what ratio of like commercial density do you need to be able to support that population? And then what if those people want to go out of town? Where should an airport go? And so there are these sketches from when I was in grade school, which maybe explained a little bit, why my grade school grades weren’t like, perfect. But I definitely got the work done just so I could use the blank sheet of paper on the other side.

Ameer Farooq  05:54

That, there is this amazing piece that I’m sure many of our listeners have probably read by now, which is the piece in wired about you and and kind of your response to COVID. But I think, you know, honestly, what I took away from that piece was it was more about you and your your journey and how that was sort of emblematic of the types of people really at the highest end of the spectrum who were trying to combat COVID it was really, really quite a beautiful piece. And one thing I wanted to highlight from that piece was really the the tragedies that you had to deal with along the way, particularly, you know, you didn’t match into surgery initially, and then you lost your brother while you’re doing your research fellowship. Could you talk to us a little bit about how those moments shaped you and kind of made you the person you are today?

Andrew Ibrahim  06:44

Yeah, thanks. Well, I owe a lot of gratitude to Elliott Woods at Wired. I didn’t, I don’t know that I had as much insight about all of that until I talked to him as much as I did. I think you know, one of the big disservices that we maybe do to a lot of our mentees, when we mentor and educate them is we set these goals. And we encourage them to be really ambitious. And whether you meet the goals or not is kind of the marker of your success. And I think it’s much more helpful to for our mentees. If we encourage them to be ambitious, set the expectation that failure at some point is inevitable. But then learning how to retell your story where those failures become assets. So I think if you took the average set of people and said, Hey, I want you to make this great story, and have a successful career in academic surgery. I don’t think most people would choose the chapters of failing your boards, not matching into residency, doing a prelim year where you want to quit like three times, having an engagement to the, your person, your couples match with, fall through halfway through. And then kind of having your best friend and older brother who’s your role model pass away. Like no one’s gonna, like choose those chapters, right? No one’s like, Man, I wish those things could happen to me to be successful. But I think the value is in learning how to reframe those events into ways that are meaningful and support you. So I remember Justin Dimick after I failed my boards, I’d called him and he told me, failure is the crucible of great leaders. And I actually didn’t really understand what that meant for a while, until a lot later. And you realize how much those moments both refine and expose you. And I think it’s a lot like one of my COVID binges on Netflix, as in the show called Forged by Fire, where all these swordsmiths kind of do this top chef competition. And I couldn’t help but notice how they would all work on their craft so hard, and they put their sword in the fire in and out in such hot temperatures, sometimes it would break. And the moment of truth though, is when you would get put into the cold water to sort of temper your sword. And I think so much of my story, looking back, of some real good spots and some rough patches has ultimately just been a form of tempering and sort of just getting stronger from it. So I would love that when we talk to our mentees, we teach them a little bit more about how to look back on their kind of weak moments and think about are those ways that strengthened or refine them.

Chad Ball  09:50

That’s such a beautiful description and story to be honest with you and I it makes me think, you know, back to my own experience as well, two of my co residents, one in my year and one, two or three years behind me were interesting folks, and they’ve gone on to do really, really impressive, super high level things on two sides of Canada, two sides of the country. And you wouldn’t have really guessed that from, you know, I frame this they’re two of my very best friend, so I, they won’t have a problem with me talking about this. But you wouldn’t have guessed upfront that the challenges they had with the relatively rigid structure with how we train people within medicine and surgery would have led to their incredibly dynamic, creative and unique trajectory and where they ended up and I think sometimes you’re exactly right, or your implication is right, that we, we try and force everyone into this training model that really is, has historically worked very well for the majority of folks and produced a very good product, but probably isn’t right for everybody.

Andrew Ibrahim  11:07

Yeah, I totally agree. You know, one of the, one of the lessons, I think, looking back at early in my surgical training, it is really hard to enjoy your work if you don’t feel competent. And when you’re in those first rungs of surgical training, you know, the first time you put a central line in and you drop someone’s lung that rattles you for a while. And until you understand why that happened, and you can reproduce it and do it, putting in central lines aren’t fun, you know, until you get to a certain level of competence. And I remember kind of the ebbs and flows of the first couple years of training. And I remember a couple times going to my mentors and being, like, I think I’m just gonna quit. And one reality was like, alright, if surgery is not for me, like, how am I going to pay rent come July. And so what that actually had done inadvertently, is I reached out to my friends in architecture and in consulting, and said, hey, would you have any interest in hiring a one year out surgical trainee who can’t put in central lines. And, you know, I ultimately got back on the horse and got better at my craft and learned to love surgery much more as I got more competent. But the blessing of that is I built this incredibly broad network. So then fast forward a decade later, when I’m thinking about all these healthcare systems delivery and design challenges, there were a lot of people I knew already to talk to who I’ve been talking to for a decade, as initially as part of my like, contingency plan. But now we’re like valuable friends and collaborators. And so maybe one example of like, even when you think you’re sort of just kicking the can and beating up on yourself, you may actually be discovering other valuable parts that will become useful later.

Chad Ball  13:07

Yeah, that’s, that’s so well said. You know, you’ve done so many really, really interesting things in your in your career so far. But one of the things we wanted to really ask you about and go deep on is that the development of the the creation of the visual abstract. You’re widely credited with that concept, and our friend Keith Lillemoe of course, you know, speaks so highly of you and your vision for that. I’m curious where that came from how you sort of came up with that in general. And, you know, it’s, it’s amazing to see the rapid uptake of that concept, technology, whatever you want to call it. I mean, you see, you submit to a number of journals now, including JACC, Annals, you have to submit a visual abstract if it makes so much sense. It’s it’s revolutionary. So where did that come from? And where do you see it going?

Andrew Ibrahim  13:54

Yeah, in our on our last tally, I think we’re well over 100 journals now that have adopted the visual abstract. So the backstory of it kind of fits into what we’ve been talking about. So if you go to architecture design school, you have to learn principles of design. And one of the kinda key deliverables in that world is you need to be able to convince someone of your vision about your work. And you often do it with three or four compelling images that you tell a story around. So before I even got to my research time at Michigan, I had already maybe been oriented this idea that the visuals are essential to telling a compelling narrative. And so when I was in my first few research meetings, with Justin Dimick at Michigan, it only made sense to me to explain my work through a set of images and I cared a lot about designing craft and so it wasn’t just threw some images up on a slide and saw what happened. I tried 20 different configurations. And I showed it to my friends. And I did focus groups. And I said, Hey, which one of these do you think most gets you excited about going to the next slide? Which one of these do you think captures the essence of what I was talking about? So now I was like, telling Justin about how much time I was spending making these slides. He loved them. And he said, would you be interested in taking over the social media account at Annals of Surgery? And I said, sure. And part of what was interesting to me is Annals of Surgery has such great research papers that are published there. And I felt like they weren’t getting the word out like they weren’t…not enough people who I know would be excited about that research, were able to find those papers. And so the first visual abstract I made back in 2016, was very close to home, it was about how trauma in London had been formed into a regional delivery system, talking about like a confluence of all the things I care about, I lived in London at the time, I thought about regional delivery of care. I’m now the social media editor for one of the best journals in the world. And so I tweeted that as just a text alone abstract, and it got shared like eight times. Now, it’s just like, there’s no way this topic is just so good, if only the right people. And then I made the visual abstract version. And I put it in the form that you now see in the kind of, those three window panes. And it made sense to me, I was like, someone could totally read this and get with this papers about. And when that got shared, when that got posted, it got shared 200 times in the first week, and three times as many people went on to read the paper. And so it kind of became clear that like this was an effective strategy. But I will say because we’re people of science and numbers too, it wasn’t enough to me that it was just a good design aesthetic. I mean, I’m formally trained in health services research. And so I prospectively made a randomized trial, does it actually matter if you share as a text or visual, and it was actually a crossover trial. So the articles got shared again in the opposite format. And it was actually able to reproduce the results. And so I think what was exciting to me about the visual abstract, besides maybe developing the concept is that we held the design to the fire of a randomized trial, and hung our hat on outcomes and measurement, as opposed to just it’s a good idea. And then Keith Lillemoe to his credit, very importantly, once this became like a thing, there were some people who said, gosh, you should just patent this and make it proprietary, so that everybody sends their best work to Annals of Surgery just to get a visual abstract, and Keith Lillemoe pushback, and he said, Justin Dimick, too, they both said, they think this would just be good for our field more broadly. And so they were really the forces that really encouraged me just to open source it. And that was one of the best decisions I ever made, because it got adopted broadly. But it improved a lot. The people who adopted it ran with it, and made it better. So like Dr. Chelsea Harris, did the live visual abstracts, added the methods bar, etc, etc. So many people have gone on to evolve it better. And it was great to let it go and let it develop.

Chad Ball  18:40

Yeah, you’re so right. I mean, your your initial vision has evolved a ton. It was interesting, you know, Keith and I were were co-authors in a paper and we were trying to develop a visual abstract that that looked effective and look good. And to be honest, I really struggled with it up front. And hopefully I’ve gotten better over time, like anything, but what what are your sort of 30,000 foot absolute dos absolute don’ts when you’re putting that together as a as an author or co-author on on a surgical manuscript?

Andrew Ibrahim  19:10

Yeah, so I, I have a couple process things that I think about when I’m making a visual abstract. I think the hardest part up front that people don’t spend enough time is, is just clarifying, like, what’s your message? Like? What do you want someone who reads this visual abstract to know, like really. You know a lot of people for as many research papers as they write, sometimes their research paper isn’t clear. So like, what is like the real thing that you care about as your bottom line message to a reader. And then could you get that across in three or four bullets or phrases. And if you can, you are well on your way to a visual abstract because getting the content messaging down is the hardest part, no question. I think the design part is just fun now, because we figured out all the templates and we focus grouped and troubleshot them. And those are kind of baked. So it’s really the content. And then once I make a visual abstract, I show it to a bunch of people. And I asked him two questions. I asked, the first question I asked him is, did you know where to look? When I put this visual abstract together? And I wrote the words the way I did the font the way it was the icons where they are, did you know where to look? Or where you kinda like, doing circles around it kind of figuring out what you’re supposed to read next. So do you know where to look? And the second question I asked people, when I asked them to give me feedback on a visual abstract is, was there any point when you were reading this visual abstract, where you had to stop? Was there something that was confusing? The words didn’t make sense, where you’re supposed to look was counterintuitive. There’s anywhere that you need to stop, then I need to do more work. Because the visual abstract should be so effortless to read, that the message is clear. You can read through it once without stopping. And you know exactly what the author wants you to have. And so I was telling that to my mentor, Justin Dimick, and I said, you know, this is like, what I think the core of a good visual abstract is, and he goes, I wish people wrote that way. I wish that was the core of just writing manuscripts that they were so clear, you didn’t have to pause and it just moved you along. So I think one of the hidden curriculum of visual abstract is actually just clarifying your thinking, and clarifying your writing about what your message is about.

Ameer Farooq  21:44

I mean, there’s so much to talk about just the visual abstract, but I want to back out for a second and a bring us back a little bit to your your combination of architecture and surgery. And it seems to me that the fact that you are interested in architecture and got formal training in the way architects do change the way that you think, obviously about presenting your work. But how else has it changed the way you think? You know, one of the things that I was exposed to, while I was doing my MPH, and participating in hackathons, and things like that is this idea of design thinking. And I know that’s perhaps just one part of what you must learn as an architect. So but but that was such a powerful concept for me personally. And yet, when I try to explain it to other people, I do a miserable job. So I am curious, like, how else has architecture changed the way that you think? And in particular, how has it changed the way that you think about designing things?

Andrew Ibrahim  22:42

Sure. Again, great, great questions, the design thinking movement, kind of from IDEO, and Stanford, and Tim Brown, really kind of brought it to coming of age of helping people understand the value of design. One of the key principles in design thinking that they articulate really well, is this idea of empathy. And I ultimately think that effective design is an expression of empathy. So if you go hang out at a car designer, and they’re trying to figure out the most effective design for this new concept car, they want to develop 80% of the time, they’re going to talk about the user experience in that car. In other words, their design is actually just an expression of empathy. And so when I think about visual abstracts, the reason I’m obsessing about the message being clear, I mean, easy to read and engaging, is because it’s an expression of empathy. I’m trying to empathize with a reader who’s super busy, doesn’t know if they want to read this article or not, doesn’t have time to read the whole volume of Annals that month. And me being able to concisely summarize things for them, is my way of demonstrating empathy for how busy they are. And that carries over, I think, to every phase of design. So I’m currently involved in masterplanning a huge academic health center of a famous place that’s global, and I can’t say, and so much of the conversations, you know, we quickly get in the weeds about, you know, HVACs and mechanical vents and building codes. And the only way the conversation actually usually moves along, is to go back and think about, like, who’s the user who’s going to use this space? And like, what do they want? Like, how would you and your design demonstrate that you understood what’s important to the people who are going to occupy that space? And so I think, if anything, especially for clinicians, like we get it, like we think a lot about empathy, and kind of thinking, well, what are the ways you could express design, that would be a way to express how much you care about the person sitting or standing across from you.

Ameer Farooq  25:02

Whenever I’ve tried to explain design thinking people look at me like I again, like I have two heads, how have you sort of sold this to people? Or how have you sort of been able to articulate this in a way that people can understand, obviously, visual objects has been one part of it. But how else have you sort of shown people that those two things can be merged?

Andrew Ibrahim  25:21

Yeah. So I’ll say up front, the haters are always going to hate and they’re going to be inevitable. But I think one of the most important mentoring lessons I got from Justin Dimick, he often talks about the three metamorphoses that are described by Nietzsche in his early philosophy. And there are these three stages of development. The first stage is being a camel, where you kind of wander the desert, and you just learn all the tried and true history of what people have tried to do before. The next is a lion, where you kind of destroy the conventions, you’ve studied all the things you know, all the past. And then you’re in this lion phase where you are challenging conventions and sort of tearing it up. And then the third phase, which is the most fun is you become a child, where you get to think anew and you have a blank slate to redesign or rethink a new idea, a new way of doing things. And I think the mistake I made early on, is I thought I was ready to be a child right away. So I walked into Dr. Dimick’s office, and I said, hey, I want to be this design guy and rethink the way architecture informs healthcare delivery. And he said, do you know what everyone else has done in healthcare delivery? Do you know the past of health services research? Have you done the 101s of all the things of the people in your audience that they know cold. So I actually spent most of my time up front, with Dr. Dimick, writing some really traditional health services research papers, 30 day readmission rates, evaluating payment policies on cost and quality, and doing traditional HSR. Because I needed to spend time as a camel and kind of do the traditional tried and true stuff. And then I could start to write papers to say, hey, I don’t know if these models work, I don’t know if this is the right thing. And then it kind of opened the door to thinking anew like a child. So there is a little bit of irony that the more creative you want to be, you also need to develop a portfolio of work in traditional things that both reassure people that you’ve kind of put in the time and the thoughtfulness about what you’re trying to do. But it also is important to your development to become better at your craft. So I, it was a little hard to swallow. And that was like first explained to me, but it turned out to be some of the most valuable advice because you really do need to learn your past and the tried and trues before you can kind of start to think anew and get super creative.

Ameer Farooq  28:01

Yeah, I’m curious about how you think about things now, because you know, architecture has, and design is such a different way of approaching problems. You know, they start with, as you say, with the user in mind, right up front, it’s very fast, it’s iterative, you know, you fail fast. And it’s very different than the way that you approach traditional health services research where you, you really, you know, dig into the background, you do your systematic review, and then you make a little incremental change on what’s already out there. And that’s sort of your work. Like, I’m curious how you approach problems…do you have a hat that you take on and off? Like, you know, I’m putting on my design hat? Let me approach it like this? Or do you think it has all sort of come together in a very organic way of approaching problems?

Andrew Ibrahim  28:47

Yeah, I think the part about my life that I love the most is I live in two really different worlds that you just described. One of really rigid, empiric measurement, and another world of really outside the box creative design. And it turns out, those are strengths for each of them and they’re weaknesses, kind of for the opposite. And you know, you wanted creative outside the box ideas, you’d have so much fun in an architecture studio, and people come up with stuff that you’ve never even heard of. But if you asked any of those people, alright, let’s say we build this thing. How are you going to know if it works? How are you going to evaluate the quality of your design and know that this somehow made the world better or made a better experience that you will occupy it? There’s like crickets. Whereas in healthcare, we know how to measure everything like almost to a fault like we have documentation or measurement or methods for everything. And so I think the beauty in approaching any kind of problem is leveraging both. Is being able to have a space where you can be super creative, but then having a a space where there is tried and true measurement where you can hold your feet to the fire a little bit and say, Oh, how does this stack up? If I start to measure the efficiency of patients coming through this clinic and their experience, can I say that this design of this clinic was maybe better? Like, let’s see, like, let’s try to measure it. So I think that’s been a little controversial in the architecture world of how much you should measure the quality of design. But for me, I think that is the way to reconcile both is to try to bring those two together.

Chad Ball  30:33

That makes that makes so much sense. You know, the other thing we wanted to touch on was a paper that Ameer and I loved very much that you and your crew did in Annals talking about the limitations of current operating theatres and how they might be planned in the future. And it, it certainly hit home for a lot of us on the trauma side of things, as I’m sure you’re aware, as we design hybrid OR suites, and we call them RAPTORS. And Andy Kirkpatrick here in Calgary with myself published a whole bunch about constructing and developing and planning those rooms as well as on the user side, how you’ve, the physicality of working, you know, synchronously with an interventional radiologist who maybe embolized in the pelvis while you’re doing the liver NASH, or whatever. So we really love that whole concept. I was wondering if you could talk a little bit for our audience about the limitations that you see and where it may go in the future to your point about users.

Andrew Ibrahim  31:30

Yeah, I think there is…speaking of kind of camel and learning history, the story of Ernest Codman. If there’s kind of anyone interested in this healthcare line of space, they should go back and read Ernest Codman’s story and read it in real time. So Ernest Codman was a late 19th century surgeon at Harvard, in this golden era where ether had just been described. And everyone just started operating willy nilly, because they were like, Oh, my God, someone could be asleep? Like, let’s do all kinds of operations. And Ernest Codman was one of the first people just to kind of say, like, this a good idea, you know, he kind of pretty, eccentrically, would go around the hospital with his little note cards and keep track of if patients were dead or alive, what operation they had, who did it. And then he started thinking about, well, why did things go wrong? Was it a technical err, or was it judgment, and he kind of created like the first real database of kind of outcomes, research and quality improvement, that kind of now is the legacy of the National Cancer Institute database, the reason we have morbidity and mortality conferences. And what’s interesting about Ernest Codman, when he was developing these ideas, he was outcast so hard. At some point, his biography gets sent up to Nova Scotia, he gets kicked out of the hospital. And he’s so poor at the end of his life, he actually doesn’t even have a proper burial. And he famously on his deathbed said, it may take 100 years for my ideas to be accepted. Because a lot of surgeons at that time were private practice, they didn’t want to air out their dirty laundry, they didn’t want people to know they had mistakes. And it’s actually kind of what the architecture world looks like now. So in architecture, there’s this dirty phrase called a post occupancy evaluation. And it’s this idea that after you build a building, and it’s occupied, you go back in there, and you have some really hard questions about your design. Is this building working? Is this room big enough? Are we, are the adjacencies logical to what we thought the workflow is going to be? There’s sparse data, but post occupancy evaluations probably happened for like less than 5% of hospitals. And there’s no real like, standardized way to do it. And so and understandably, the things that architects say is very similar to what people said in Codman’s time. Look, we’re private practice or based on reputation. I don’t want to air out my dirty laundry. But there’s another argument to say like, how’s our practice going to get better? How are we going to improve our design if we don’t go back and figure that out? So I think there’s going to be a shift in architecture where clients are going to drive that differently. And they’re going to say, look, Chad, Ameer, you guys are brilliant, you’re visionaries. We want you to design this hospital, and we’re gonna pay you a billion dollars for it. But hey, by the way, at one year, we’re going to measure these pre-determined agreed-upon outcomes. And if your hospital meets these measures, we’ll pay you 1% bonus. And if they don’t meet these measures, we’re gonna dock you 1% because we really want a building that delivers on certain performance measures. So I think clients soon are going to be driving contracts that are at risk. And I think that’ll hopefully stimulate and motivate a whole generation of architects who measure the quality of their design after space is occupied.

Ameer Farooq  35:14

That’s brilliant. It’s again, whenever you hear a really great concept, you always think, well, of course, why has no one thought of that before, but it obviously takes someone who can marry those fields to be able to actually, you know, see that concept as it should be. And one of the things I wanted to again, take you again, more broadly, you know, again, in that Wired, they profiled the fact that you really had to look at the way that Michigan was operating in order to handle the designs of COVID. And you’re actually now embedded with HOK as well. What is your big vision for the way that hospitals can adapt to better meet the demands and the needs of both patients and physicians going forward in the future? Both, you know, thinking of, of COVID and beyond?

Andrew Ibrahim  36:05

Yeah, great questions, we should have a paper coming out in the next few months, that outline some of these design principles of kind of a post-COVID hospital world. But I’ll give you a couple of kind of tangible examples of some of the ways me and some people that collaborate with it and thinking about it. When you think of like a parking lot, I have yet to go to a big academic institution where anyone has said, we have too much parking, everybody wants another parking building. And some of these campuses, you have, like 10 story parking buildings that go for blocks, you’re like, wow, that’s a lot of parking space. And then you go hang out at Ford, and you realize their autonomous vehicles are pretty darn well advanced. And it’s pretty plausible that within 20 years, very few of us are actually going to be driving, and you’re kind of like, holy smokes, we just built huge parking garages, next to our hospital, what do you mean, we’re not going to need to drive in two decades. And so one of the things you can start to do in your design is to sort of future proof the design and say, well, instead of building this parking garage, for normal parking specifications, why don’t we also build it with load bearing specifications that it could be converted into an office building at some point, and instead of having the slabs on an angle, have them all flat, and all of a sudden, you think, well, this space could readily be adapted, should the times change that we actually don’t need as many parking spots. And I think there are corollaries to that. And many phases of the way we think about and design hospitals where its use and capacity gets much more flexible. I think we, when you go to some of these historic hospitals, you know, you see the entranceway of 200 years ago, and this beautiful stone and it’s usually just a ceremonial building, because it’s not really in use anymore. And I think we’re probably going to move away from these buildings that we design for a century and be much more malleable about our design. And think how do we get much more flexible about a space that maybe we don’t need as many hospital beds anymore, and one or two floors become like a community resource center, as opposed to an inpatient ward. And so I think there’s some good design strategies that would allow you to do that, if you think about it up front. And so we’re starting to put a lot of those strategies into our design from the get go. So that the building has much more adaptability and vitality. Regardless of how the times changing moving forward.

Chad Ball  38:44

Just like everything you’ve talked to us about today that makes that makes so much sense it…you know was sort of laughing off mic there because I was having this conversation with my oldest daughter, who was probably about 10 at the time, about the self-driving cars, whatever that whatever you want to call that technology. And that was the exact point. She was like, well, the car is going to take you to work and drop you off and come back and take me to school isn’t that I hadn’t even thought of that. So you’re exactly right. You know, one of the other stories that maybe I use as a lead in to, to our penultimate question here for you is that, you know, I was on a flight just over a year ago. And it was one of those usual things I think that we all do post call fly across the continent to give a talk get on the plane.

Andrew Ibrahim  39:30


Chad Ball  39:31

That’s why, you know, I remember going to the airport, in the taxi and in Boston thinking, I can’t wait to get on that plane and sleep. And I ended up sitting beside a gent, Canadian gent who was an architect, and he, his sub specialty within architecture, and I’m sure this is not news to you and it makes total sense, but it was news to me at the time was that he designed essentially all of these really beautiful high end car dealerships across the country for all the different manufacturers. And he had done some really remarkable buildings. And so yeah, again, almost a Costanza moment, i was i was so jazzed by, by what he was talking about and so pumped up, I was thinking, how do I become an architect? I have to go back the other way. So we know you and I were curious about your health and design fellowship that you run that seems to be aimed at architects and planners, what what goes into that? Who do you select? How do you see the folks coming out of the other end of that?

Andrew Ibrahim  40:31

Yeah. Great. Thanks. Thanks for that question. And the fellowship has been something that I’ve just been so peaked about. So it is a two year fellowship for architects or planners who’ve been in design. So they’ve been in the weeds, they’ve been in the studios, they’ve worked with clients. And they’ve said, Oh, my gosh, these are the real design constraints, or these are the real problems with why we’re not able to create a better OR, or a better hospital, or a better stadium, or a better public park, or whatever. And what I want to do in this fellowship is immerse them in a world of health services research, where they get equipped with the best and rigorous tools of econometrics, of policy evaluation of healthcare, delivery science, and understand all the tools that many of us in health care or maybe take for granted. Or that a lot of us use in the highest level healthcare, research work, and armed people on the front lines of design with those skills. And it would be incredible to have a decade from now, a whole generation of architects, planners and designers, who all know how to speak econometrics, and hierarchical modeling and difference in differences, and can really start to not only design things that are impactful and beautiful, but can evaluate them and rigorously know, did our design actually do the things that we wanted it to do to actually help the community in the way that we thought it would. And so I’m excited about trying to marry the best of design with some really rigorous empiric research tools. And then let that fellow go out and do whatever they want. If they want to go be a nerdy academic, and write more books, great. If they want to go back to their firm, and start a whole new practice in data driven design, awesome. Or if they want to go start up a data analytics firm, whichever, I’m pretty agnostic to what they do after. But I think it’s really important for us to train people both strongly in design, and in pure quantitative research methods to advance this field forward.

Ameer Farooq  42:46

We’ve talked about this a little bit, but what have you learned from actually trying to teach architects and designers? And how is that maybe different from what people are usually taught in that world? You talked about the fact that, obviously about learning more about empirical measures and actually quantifying the impact of your design, but what are the other things that you think that you could really teach designers from your work as a surgeon and health services research?

Andrew Ibrahim  43:18

Yeah, I think one of the exciting parts, besides just the quantitative analytics, is just immersing in that space. You know, it’s really different. If you want to design a hospital or a building or a space, where you kind of meet with people one or two hours a week who are there. And you know, you’ll be empathetic, you’ll ask a lot of good questions. But what if for two years, you were just totally immersed in that world, or the people you’re interacting with all the time, or just oriented, totally different lead to the world than you are. And I think no matter how good or empathetic the designer is, they will learn a different way to see the world by spending time with a bunch of econometric health policy, health care delivery, clinician science nerds. And so I think just immersing in that different world will challenge a lot of views. Even just beyond the basics of quantitative analytics. And you know, some of the most interesting design work that I’ve seen, when you start to learn the backstory, you realize that the designer and the client have such a deep understanding of each other and that that relationship evolves over the years. And that’s kind of what it takes to pull off some of the best design is really engaging in that space in that world for years. And so I hope this kind of kickstarts another generation of people to immerse differently in a different world.

Ameer Farooq  45:00

There’s so much more that we could ask you about. But we’ll close out our podcast with you today. And hopefully we can get you back another time. And we just absolutely appreciate your time with us today. But one of the questions we ask all of our guests is, if you could go back in time, knowing what you know now about your career and the path that you’ve taken. If you could go back in time and give yourself advice as a trainee, what would that advice be?

Andrew Ibrahim  45:26

Alright, great, great question. Certainly, in that context of the pandemic, there’s plenty of time for reflecting and thinking, I think a couple of things I would tell my younger self is to just be kind to yourself, I think I was definitely the type A pre med up till two in the morning, sweating bullets, wondering if this next test is going to make or break me. And it’s worth stepping back to just be kind to yourself and realize that your test score or your ability to pass an exam, or your career is not your identity, and that you as a person still have value independent of all of that stuff. And I think for a lot of us, who are very ambitious and motivated, and especially in medicine, it’s easy to lose sight of that. So I think I’d tell myself just to be kinder to myself, I think the second part I would tell myself is it’s okay to take risk. And that was lot of these ideas I had even younger than now. And I sort of was shy about developing them because I thought it was too risky. You’re like, who’s ever gonna get excited about that? Or who’s gonna care about those ideas? Well, it turns out a lot of people care about those ideas. And part of me was like, well, maybe I shouldn’t develop that sooner. And so I think being kind to yourself and taking some more risk or when I would leave your, my younger self with.

Ameer Farooq  47:05

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