E62 Andrea MacNeill On Planetary Health In The Operating Room

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Chad Ball  00:12

Welcome to the Cold Steel surgical podcast with your hosts Amir 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 brought 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  00:55

Have you ever stared at the garbage bags in the operating room and thought, “that’s a lot of trash?” Our guest for this episode, Dr. Andrea MacNeil took that thought and decided to do something about it. Dr. MacNeil is a surgical oncologist at Vancouver General Hospital, and is on a mission to improve planetary health inside and outside the operating room. We asked her in this episode to walk us through how the operating room impacts the environment, what we can do to lessen that impact, and how that effort might help cut costs and improve patient care. Dr. MacNeil, thank you very much for joining us on Cold Steel. It’s really an honor and a pleasure to have you and talk about something that’s really neat and really important for all surgeons no matter what specialty they’re in. Before we get to that, could you tell us a bit about yourself, where you grew up and your training pathway?

Andrea MacNeil  02:01

Let me begin by saying thank you, Ameer and Chad for hosting me on on Cold Steel. It’s my great honor to be here. I grew up in a small town in New Brunswick called St. Stephen and did my undergrad at Western, went to Toronto for med school and then moved out west for residency. And other than a brief foray back to Toronto for fellowship have been on the West Coast ever since.

Chad Ball  02:24

Oh, that’s awesome. What kept you in Vancouver? Besides it being beautiful, and a great group? What drew you there?

Andrea MacNeil  02:32

What’s not to love? There’s no one specific thing that kept me here. This is as you know, one of the world’s most livable cities. And for somebody who is particularly drawn to an environmental ethos, this is absolutely the place to be.

Ameer Farooq  02:50

So that leads very nicely and segues us very nicely into your paper. But actually, before we get to that, you did mention that you did surgical oncology in Toronto? Why surgical oncology and what element of surgical oncology excites you the most?

Andrea MacNeil  03:08

Well, strangely, I did surgical oncology because I was attracted to the breadth of it, which was the same thing that attracted me to general surgery. And since then, I have proceeded to specialize in two cancers. And so I’ve gone from being a generalist to someone who really only treats and operates on retroperitoneal sarcoma, and peritoneal malignancies. So I’ve gone from breadth to depth, but I absolutely love the opportunities that surgical oncology affords to be part of a multidisciplinary team, the unique decision-making in tailoring a solution to each individual patient’s cancer and their particular circumstances. And it also affords an opportunity to establish meaningful relationships with people, you know, we don’t see them once and operate on them and then say goodbye, we see them for years. And that’s incredibly meaningful.

Ameer Farooq  03:59

All right, and now I really want to get to the sort of the meat of our discussion, which is about all the work that you’ve done around planetary health. Before we dive into your paper that I think really is a seminal paper in this area with regards to surgery, can you talk a little bit about what planetary health is? You know, I did my MPH in in Boston, during residency, and I had never even heard of this term “planetary health” until I’d done my Masters in Public Health. What is planetary health?

Andrea MacNeil  04:28

Yeah, that’s a great starter question Ameer, because you’re absolutely right, that many people will be unfamiliar with that terminology. And rightly so, it’s a relatively new recognized field of study. And the beauty of the word is that it’s actually a collective term that encompasses both the health of humans and civilization, as well as the natural systems that underpin that. So you don’t have to speak of human and planetary health. It doesn’t simply refer to nature. It actually inherently comprises that inextricable relationship between human and environmental health. The other, I think nice thing about the term is that it comes devoid of any of the political baggage that climate change and many environmental issues have become saddled with for various reasons. And climate change as well is one discrete component of planetary health in that it refers to global warming from emission of greenhouse gases. But it’s by no means the only way that our environment is degrading. So planetary health is a much more versatile term that encompasses ocean acidification and biodiversity loss, mass extinction, ozone depletion, all kinds of other planetary crises, aside from climate change.

Ameer Farooq  05:50

It’s such a fascinating topic, and I had no idea and I never really thought until I did my masters, but all the various ways in which all these these issues in our environment really have a huge part to play in the health of our, our planet and our species and our patients. I’d argue that it’s a pretty unusual thing for a surgeon to get interested in. How did you become interested in the topic of planetary health?

Andrea MacNeil  06:20

I’m not sure that it is that atypical actually. I mean, I’ve had a lifelong interest in environmental stewardship, as I think many of my peers and I’m sure you have, because we just grew up aware with you know, consciousness of the way that we are degrading our environment and some of the consequences of that. But I think what distinguishes my path from others is that I discovered a way to mainstream that into my career, and take it from being a personal consciousness or advocacy work on the side to the core of my academic practice.

Ameer Farooq  07:00

Yeah, I guess, I guess that’s sort of what I meant is that, you know, all of us might profess to love recycling and, and care about the environment, but you actually took it to the next step and, and made it part of your career. So that’s, that’s amazing. And I think this is a good time to talk about your paper that was published in The Lancet, where you looked at carbon footprinting in New York. Can you just walk us through this paper? What sort of, and I know, this was a big, you know, gargantuan effort that you put into actually doing this paper. So can you walk us through a bit about kind of how you came up with the idea for the paper, the methods that you used, and what you found?

Andrea MacNeil  07:38

Yeah, absolutely. This paper represented the output of my Master’s, which I undertook during my residency. I took a research year and did a Master’s in environmental change and management at Oxford. And I did that specifically to look at the environmental impacts of the operating room. And that was born out of just the visible waste that I saw all around me in my professional life. And the underlying belief that we could do better, that it wasn’t absolutely necessary. So I went and did this Master’s. And this paper, ultimately took seven years to come to fruition. So I encourage anyone out there who is on a similar timeframe and trajectory to persevere, it is ultimately worth it. And as you say, it was eventually published in 2017, in the lens of planetary health. Part of the struggles were, firstly, that the scope of study I was proposing and the metrics with which to do it didn’t exist. And so I had to derive those from first principles. And another part of the struggle was the inherent interdisciplinarity of it, made it difficult to publish in a clinical journal. And that is a challenge that all of us in the still small community of sustainable healthcare have faced. It is gradually, actually, it’s significantly improving now, but in the early days, any work looking at the environmental performance or sustainability of anything in the healthcare sphere, was destined for an engineering or some sort of kind of basic science journal within the material sphere. It was not deemed appropriate for a clinical audience. And so it was only when the Lancet started one of their subsidiaries called The Lancet Planetary Health, that we began to have a forum for this type of, at that time, novel, interdisciplinary collaboration, now much more mainstream output. So, yeah, I can walk you very quickly through the study and give you a brief overview of the methods and the results. But if it’s okay with you, it’d be nice to just focus on the actions that have come from this and the real world change that it has engendered. So we we did a greenhouse gas inventory of operating rooms and we compared three very well matched tertiary care hospitals. So we looked at Vancouver General Hospital, the University of Minnesota Medical Center, and the John Radcliffe Hospital in Oxford. And we use the greenhouse gas protocol, which is the industry standard for carbon accounting and reporting. Very briefly, this looks at three scopes of greenhouse gas emissions. And when I apply that to the OR I can tell you exactly what that entails. So one scope includes waste anesthetic gases. I’ll talk more about that in just a second. Another scope encompasses energy consumption in the OR. And then the third scope and the one that’s probably most interesting to surgeons is around the consumables. It’s all the stuff that we use in the OR, and the emissions that are generated from the manufacturer, the use and the disposal of those things. So the interesting findings were that waste anesthetic gases comprise an enormous proportion of the OR footprint, or certainly they did at that time. And this has dramatically improved, and it’s something that I’m very proud of. So the three inhaled anesthetics that all surgeons will be familiar with, which are Sevoflurane, Isoflurane and Desflurane are actually very potent greenhouse gases, the worst by far and away being Desflurane which is almost 2500 times worse than C02 from a climate impact perspective. And when at the time I did the study, Desflurane with the preferred agent of the anaesthetist at my institution and certainly at the American institution we were studying and across North America, it was pretty much the default agent for most anaesthetist because it allowed for a faster induction and emergence. But since that time, it has become widely known within the anaesthetic community that Desflurane has this disproportionate climate impact and anaesthetists have almost universally shifted their practice away from it. And that has made an enormous impact on the environmental footprint of anesthesia. The way this came out in our study was that the UK Hospital doesn’t even have desflurane on formulary, because in addition to being worse for the environment, it’s also significantly more expensive. So they just didn’t even offer it. And we discovered that in spite of having a similar case volume and scope of practice to the other hospitals, carbon emissions from anesthesia in the UK Hospital were 10% of the Canadian and the American Hospital. So it was a really dramatic finding that highlighted the singular role of Desflurane in determining the environmental footprint of the OR. The second scope was around energy. And the take home message from that is that energy consumption due to HVAC requirements, which is heating, ventilation and air conditioning, is responsible for 90 to 99% of OR energy use. So while I would never discourage someone from turning the lights off after hours, or turning the computer off, or being cognizant of their personal energy consumption, because OR’s have such stringent ventilation requirements, the energy consumption from HVAC operations just massively dwarfs everything else. So it’s really helpful in guiding our energy conservation efforts. And then that third scope I referred to was around consumables, around the stuff that we use. And this was by far and away the most challenging scope to capture. But really, the take home findings were pretty staggering. And that is that whenever somebody thinks about sustainability, typically they think about waste management. Surgeons, any citizen nurses, they all want to talk about establishing OR recycling programs because they believe that how an item is ultimately disposed of is really important, whether it’s thrown into the garbage and landfilled, or whether it’s recycled. And what we showed, and what many other people have shown since, is that the vast majority of emissions from a product are generated in its manufacturer, not in its disposal. So far more important than whether you have a recycling program for something is actually, your choice of consumable in the first place. And whenever possible reusable items that can be sterilized, or reprocessed or whatever needs to happen for their reuse is much much preferable to single use items where you have all of the emissions from their manufacturer just thrown into the garbage after a single use. We now know that actually up to 90% of a product’s emissions are generated in the manufacturing phase. So that is far, far more important than how it’s disposed of at the end of life.

Chad Ball  14:31

Wow, that is absolutely shocking. And, you know, to be honest, until we read your peer reviewed publication, I don’t think any of us really understood that. Either those nuances or the take home message. I guess the natural next question to move on to, how do we promote this responsible behavior? How do we actually operationalize this within our own operating room environments and in our own hospitals across the country?

Andrea MacNeil  14:58

Yeah, there are lots ways and one of the things that I loved from this study was that it became apparent to me that every population of people that work within the OR has a piece of this. So scope one anesthesia, that’s where our anesthesia colleagues can make a difference. And they have. They’ve shifted away from Desflurane, they’ve defaulted to Sevoflurane, and even better than that is transitioning away from or minimizing inhaled anesthetics altogether. So strengthening your regional anesthetic program, offering people up surgery under spinal or regional block or whatever the case may be, Tiva. Those are orders of magnitude better from an environmental perspective than inhaled anesthetics. So while that’s primarily the purview of our anesthesia colleagues, it obviously requires collaboration on our part as well, and a willingness for us to consider doing surgeries under circumstances in which we might not have otherwise. And I can tell you that now, we do virtually all of our breast cancer surgery at the BC cancer agency under Petro block and the patients get a little bit of conscious sedation, and that not only are we improving our environmental footprint, but the patients go home sooner, we avoid post-op nausea and vomiting, and their opioid requirements postoperatively are effectively zero. We’ve stopped opioid prescribing their post op analgesia is much, much better with regional. So the reason I say that is because it really highlights the multiple wins. And I’m sure we’ll get to this later, but how we sell this to people. But this is not uncommon for a sustainability initiative – to not only have environmental savings, but to check off all these other boxes to improve patient outcomes or the patient experience or be cost saving or in other ways be better for the system or for for the populations that we’re serving. So regional anesthesia is a way that we are accomplishing all of those things. And then the second scope was around energy. And that’s where you bring in your building, your hospital engineers and the people who manage your infrastructure. So that’s that’s their purview, an area of expertise. And then the third scope around the consumables is really more within the purview of the OR nurses and surgeons. So the decision about what gets opened or used for a case, how we can streamline our picklists, selectively choosing reusable consumables when that option is available to us, when it’s not lobbying our institutions to adopt procurement policies that prioritize reusables. And when they’re not even in existence, engaging with industry to send a signal that we want reusable products. That whomever comes up with these will have a competitive advantage.

Chad Ball  17:43

You know, I love the last part of what you said there in terms of trying to engage our healthcare environments in our ORs into being sustainable and sort of paying attention. What advice do you have for, it could be large networks, or it could be small, rural hospitals, and anything in between, where, you know, a surgeon or surgeons or anesthesiologists are meeting resistance with their, with their managers, in terms of implementing some of this? How would you go about trying to address that, and change the minds and the hearts of those folks?

Andrea MacNeil  18:20

Yeah, there are a couple of things I would say to that. One is to highlight the win-win-win that I’ve just alluded to earlier. And even though the environmental sustainability of something may be what drives your behavior, that may not be the top priority of your hospital administrator. But what we’ve seen throughout all of the studies that have been published and all of our lived experience is that almost every sustainability initiative is ultimately cost savings. Because really, what we’re trying to do is eliminate waste and inefficiency from within the system. So whether you’re approaching it from the ideological bent of an administrator who wants to lean the system and cut costs, or an environmental advocate who just wants to eliminate waste, the outcome is the same. So you have to kind of understand the language that your target audience is speaking or what’s going to resonate with them, and frame it appropriately. What we’ve also found is that typically, these initiatives are also improving the patient experience at very least, and often the patient outcomes. And I’m going to speak more to that in just a second. But the other point, I would say, in response to your question, Chad is to be as data driven as possible. As you’re well aware, there are all kinds of passing sustainability fads, conflicting messages one day to the next as to what is the most responsible behavior, and we want to be as evidence-based and data driven at this aspect of our practice as we are in the more mainstream clinical recommendations that we make for our patients. So the data is ever increasing. We have very good evidence to guide us. And I would suggest that we rely on that and present that, so that our administrators and leaders understand that this is not simply a personal agenda. That there actually is a burgeoning body of knowledge and data to support it. And just to expand on the patient experience and outcomes bent, one of the things that we can do as surgeons, or as other specialists, other practitioners who have a practice is think about the way that we construct our practices, and any inefficiency or redundancy inherent in that. And at heart, this is getting to the principle of ensuring that the care we deliver is appropriate. So what I often see is patients will be referred from a family physician to a local surgeon, who might even not be the right specialty for the problem that they have. They get referred to various other specialists in an attempt to get to the heart of what their problem is. And ultimately, they arrive at a definitive treatment provider, having had many unnecessary tests and treatments along the way. And every single one of those tests and treatments consumes resources, which is material and energy and generates waste. So absolutely everything we do as clinicians generates an environmental footprint. I actually had a colleague, Dr. Sita Ollek, who’s now a surgical oncologist in Kelowna, do a study on this looking at retroperitoneal sarcoma, which is one of the cancers I treat. And we looked at, we process maps, patient journeys in BC, and we found that some patients actually see up to seven specialists before they arrive at their definitive treatment provider, and 27% of them had unnecessary surgery along the way. So obviously, that’s a massive use of resources unnecessarily. But think about it from the patient perspective, the months of anxiety, living in this space of uncertainty, and undergoing all kinds of investigations and treatments that they didn’t need, that didn’t add value, and that actually had the potential for patient harm. Obviously, it also delays their accessing definitive care. So we were proposing implementing clinical pathways that expedite these patients’ arrival at definitive care and eliminates all of those unnecessary steps. And you can imagine that in doing that, we will not only generate cost and carbon savings for the system, but we’ll also improve the patient experience enormously, and potentially improve their oncologic outcomes by allowing them to access care faster.

Ameer Farooq  22:31

Now, you’ve been going sort of around the country and around the world talking about this, and giving grand rounds and really kind of taking forth this message. I’m curious as to what your response has been, you know, as you sort of alluded to, that the whole language around, let’s say, environmentalism, or climate health is often a polarizing one. And, you know, I could sometimes see an individual surgeon saying to themselves, just as we might say, in our in our day to day lives, you know, why should I care about this, you know, I just need to do my job and sort of take care of my patients as best as I can. So I’m curious as to what the response has been, and how you respond potentially to people who maybe push back on the idea that there’s a lot more that we can do to to eliminate waste and improve efficiency?

Andrea MacNeil  23:21

I have to say, Ameer, my experience has been universally good. That this has been very enthusiastically received. And I think this gets back to my geographic location in Vancouver on the west coast, typically surrounded by like minded people. I know, that’s not necessarily been the experience of some of my colleagues within this field, who are in other geographic and political cultures, if you will. What I’ve noticed interestingly, though, is the evolution in the audience reaction over the past decade that I’ve been delivering this message, in that at the outset, I really had to connect those dots for people and explain why environmental degradation is also a health problem. And people were shocked by that: to think that climate change is also a health crisis. And I really had to map out how the collapse of the ecosystems that support human life and health, undermine our health and how this is driving unsustainable demand for health services, etc. And now I start from a completely different point, that is eminently obvious to people. I don’t have to connect any dots at all. In this day and age, people completely understand that climate change is the greatest health issue that we’re facing today, COVID notwithstanding. The other thing, you know, that just occurred to me in response to your question is that this is also, in my experience, this has been a very unifying message, and something that potentially otherwise disengaged or burned out clinicians can mobilize around and it empowers people to take meaningful climate action within their professional sphere. To deliver the message to people that they don’t have to attend a climate rally outside of ours, or in some way, take advocacy to a level that they don’t feel is within their personal grasp at that moment, but to say, you know what, by not ordering unnecessary bloodwork and imaging tests for this patient, or by offering them a virtual consultation, instead of making them drive 16 hours to see you, or by, like I said, implementing clinical pathways to expedite their accessing definitive care and eliminating unnecessary steps, you are taking meaningful climate action within your professional sphere. And that’s been an incredibly empowering and energizing message, I think, for our clinical colleagues to hear. When at times, it certainly feels that we don’t have a lot of control over our environments and our circumstances. And we can be quite disillusioned about things.

Ameer Farooq  25:53

That is a way of circling back to what we were talking about earlier about sort of, you know, how this work that you have done in sort of looking at surgical waste, and how that kind of has translated to your own individual sense of responsibility to the environment. And I get, you know, obviously, I get the sense that this is something that you’ve been very passionate about for a long time. But how do you think this work has impacted how you act and behave out of the OR? And does it change the way that you look at your individual environmental responsibilities? And if so, how has it changed it?

Andrea MacNeil  26:28

I don’t think it’s changed the way I perceive them. But I feel that I have to hold myself to a higher standard, if I’m going to be a messenger for this. I have to minimize my climate hypocrisy, if you will. And to that extent, the pandemic has actually been an enormous benefit in that it has normalized working from home. Virtual communications is obviously completely eliminated travel. And just like any other surgeon, I attended meetings and as you say, traveled around giving grand rounds. And quite hilariously, I gave grand rounds in early February, just before the pandemic was really on most people’s radar screens here. And I delivered grand rounds for the Ottawa Hospital. And they offered me the option of doing it from Vancouver, just in keeping with the spirit of the talk around climate change. So I did and I delivered rounds at 4am, Pacific Standard Time to the Ottawa Hospital group of surgeons and anesthetists. And it was, and it was hilarious how much discussion it generated around the medium. People saying, you know what, I don’t think anything was lost by the fact that she delivered that virtually. And I certainly felt that way too. And it allowed me to just work a normal workday after. And then within about four weeks, the entire world shut down and went virtual, and that sort of thing became entirely standard. So I just think that’s an enormous benefit, that there’s no longer an expectation that we physically place ourselves somewhere to deliver a message, but that we can now do this in a more climate responsible way. So I’m very happy that I don’t have the expectation to travel that I did before, then I can navigate this in a more virtual and environmentally responsible way.

Chad Ball  28:08

You know, Andrea, as you and I talked about, before we started recording it, my experience has obviously been very similar. And, you know, this is amazing. And I think it’s changed the world forever. Why do you think there was such traditional resistance to embracing this concept? You know, in other words, why is it that the old model was the old model for so long?

Andrea MacNeil  28:33

I mean, I don’t have a great answer to that Chad, except to say that it was what spoke to people’s frames of reference or their expectations of normal most. So you can imagine you extrapolate from the idea of an in person meeting within your organization. So you get together with your colleagues. Well, obviously, if you want to expand that conversation to colleagues elsewhere, you know, the default position is that you have to meet with them in person, like it would take some disruption to say, let’s host this virtually, it was easier for people to imagine an in person meeting because it was just a slight modification of their baseline normal, and to imagine completely revamping their communications media.

Chad Ball  29:18

Yeah, I think you’re right. And it was just inertia and maybe lack of vision in some scenarios. But, you know, you really get the sense going forward, both I think personally with those of us that traditionally have traveled a lot, as well as in talking to some of the experts within that sort of conferencing field that, you know, at the very worst hybrid meetings will be the future and probably webinars and web based communication and talks will be even more so.

Andrea MacNeil  29:46

Yeah, and I guess, to further that, the other barrier was that we just didn’t have the virtual communications mechanisms that COVID has leapfrogged into our future. I have given a couple of talks recently where the virtual conference was hosted with a level of sophistication that honestly a year ago I couldn’t have imagined. And the dress rehearsals have involved practicing going from the virtual greenroom to the virtual mainstage and downloading clickers onto my phone to advance my slides, just things that we just didn’t have before. So that was a barrier, the quality of our virtual communications media, certainly were limiting in terms of reimagining how we host conferences and meetings. And now that’s not an issue.

Ameer Farooq  30:31

Yeah, to paraphrase Winston Churchill, “Never let a good pandemic go to waste.” And so yeah, hopefully that, you know, with all the human suffering that this has caused, we can use this opportunity to keep on changing and developing things and keep moving things forward. I’m curious as to where you’re going to take this research program next. You know, you published that paper in The Lancet, where do you see yourself going in the next five to ten years in terms of both a research program as well as, you know, changing things, maybe locally here in Vancouver.

Andrea MacNeil  31:06

I see my research and advocacy efforts as very much intertwined, basically inextricable. So I would say I have three big pillars that I’m working on. One is a net-zero healthcare emissions campaign. So in January of this year, NHS England announced a commitment to decarbonize their health care system in advance of 2050, which was their nationally mandated target. And they’ve since refined that to be much more granular, and they expect to be fully decarbonized by 2040. So we’re trying to leverage that, given that the NHS is the world’s largest health system, to achieve similar commitments from both federal and provincial governments in this country. Because the more powerful the top down mandate, the easier our grassroots bottom up action is. Now complimentary to that. I’m working with my health authority, Vancouver Coastal Health, who have absolutely embraced planetary health as a strategic priority and are putting all kinds of resources behind it. And we’re in the process of mapping out our planetary health strategy. But I can tell you that it includes things like hospital food transformation, implementing a planetary health diet to minimize our food emissions and improve our patients access to healthy nutritious food, and even educate them about the environmental impacts of their dietary choices. One of our general surgery residents, Annie Lalande is doing a two year Master’s looking at this, and it’s really exciting. We’re also working to embed environment, environmental performance in our quality metrics and our quality reporting. And we’re working to expand our stewardship program, which currently encompasses antibiotics and opioids to include stewardship of all healthcare resources, so that there is some consciousness around over-investigation and over-treatment and potentially some institutional protocols to to restrict that and encourage appropriateness. We’re also working on supply chain issues, things like the procurement policies that I alluded to earlier, as well as a community mobilizing campaign that’s actually really exciting. We’re deep into this right now. About a month ago, we launched our sustainability campaign at Vancouver General Hospital, using an online crowdsourcing platform. And many of our surgeons and anesthetists, nurses, PAs or perfusionists, housekeeping staff have posted different ideas that they have for how we can improve our footprint. And we’re now in the phase of evaluating those, refining the ideas, and choosing some to implement, which we’re going to do through the team based Quality Improvement Program. And we’re evaluating the platform and the model to see if this is a reasonable way to drive grassroots mobilization across the entire institution and open this up to other clinical areas beyond the OR. And then the final thing I would say is that I’m also in the process of establishing what I’m calling a planetary health care lab, which is a multidisciplinary collaboration based out of UBC to really fill some of the gaps in our knowledge and answer some of those questions that we have on the ground about what is an environmentally preferable product or process. Because there’s still an enormous void to fill there. So we’re bringing together the appropriate expertise from the engineering side, health economics, a public health perspective, to try to answer those questions so that we can be as data driven in this aspect of our clinical practice as we are in other aspects.

Chad Ball  34:34

That’s absolutely amazing. I don’t think I’m overstating it when I, you know, I really do mean it. We’re lucky to know you, we’re lucky to have you in the surgical world, we’re lucky that you’re in Canada. So thank you. I mean, you’re really going to change the world and we all would like to do that. But I know I see it in your future and it’s incredible. I want to step back just a little bit. You use the term sustainable health care group. I think in terms of probably referencing a core cohort that are really passionate like you – can you tell us more about that, and in particular for listeners that might want to become more involved in some of the stuff that you and others are doing, how do they access that? Where do they look?

Andrea MacNeil  35:19

Yeah, I mean, I don’t really know how to best direct people right now. But until fairly recently, like within the past one to two years, the group of clinicians with any expertise and passion and academic investment in this was extremely small. We actually held a workshop at Yale in 2018. And there were probably 25 of us there. And that really did represent the vast majority of that community. So that’s something that I love, because we’re all very close, very tight, nascent community. But amazingly, what we’ve seen over the past couple of years is an absolute explosion of people who get the vision, and who are jumping on this bandwagon. And coming at it from all different clinical backgrounds, and different aspects of environmental expertise. So it’s still small, still burgeoning. But there are many different pathways to this. And what I would say to people is that you certainly don’t need formal training in environmental or sustainability science. That this is an unexpanded access of healthcare quality, it’s part of high value care, all of those things that we hear about much more frequently. This aligns perfectly with those agendas. And so if you’re interested, you know, get involved with your quality improvement team, and look at appropriateness of care. Get involved with choosing wisely, which is a well known initiative around ensuring the appropriateness of investigations and treatment, there are established mechanisms that accomplish the same things just without an explicit environmental mandate. And obviously, if people are engaged enough to pursue formal training in it, then by all means the field needs more of you.

Chad Ball  37:02

That’s incredible. It’s amazing that the last question that I personally wanted to ask you was, you know, you’ve educated me and our listeners about so much, but I’m sort of curious at a 30,000 foot level: how do you live your life? In the sense that, what are the some of the things that you do outside of the hospital to help limit your environmental impact and your carbon footprint and just sort of day to day things that maybe some of us “head in the sand” busy surgeons across the country might not think, in terms of low hanging fruit?

Andrea MacNeil  37:36

Well, there have been studies showing that the most impactful personal decisions one can make are to refrain from eating meat, and in particular red meat, to avoid or minimize air travel, and to have one less child. So that gets into a very contentious area that I won’t tackle today. But those are kind of the most impactful things we can do. And I’ll be completely honest, I’m not entirely vegetarian, I do try to minimize meat. But that is one of the liberating things about coming at this from an environmental perspective, rather than a purely ethical standpoint, in terms of the consumption of animals in that it’s a continuum. And 90% reduction is amazing. 70, 50%, anything is better than nothing. It doesn’t mean that you have to commit to a lifestyle that you can’t fathom, or a lifestyle of austerity in some way, you know, it is a continuum, and any contribution is worthwhile. The other thing I really tried to do, though, is just minimize material consumption. And that’s where the coming back to the OR example, the emissions from a product are generated in the manufacturing stage. Whereas people typically think if I put this paper in the recycling bin, or if I put this plastic, if I buy the single use plastic pop bottle and put it in the recycling bin, I’m good. You’re not, that’s the take home message here. Single use plastic is egregious, we need to get away from that. And we really need to rethink our consumer behaviors. Like think about giving your loved ones gifts for Christmas, or whatever holiday you celebrate this year, that are non-material, or that are at least not going to end up in some sort of disposal mechanism in the near future. Give experiences, give something something reusable, something thoughtful and meaningful. But don’t just go on Amazon and buy more junk. So I really do try to minimize my material consumption.

Ameer Farooq  39:36

We always ask all our guests to give some advice, if they could go back in time and give themselves advice as a trainee. And I think that is especially important to ask you because, you know, it’s amazing to hear you talk about building a planetary healthcare lab and all these things that I’m sure would have been hard to even dream of when you were embarking on this journey. So If you could go back and give yourself advice as a trainee, knowing what you know now about doing something that’s different, that’s innovative. That’s sort of cutting edge. What would that advice be?

Andrea MacNeil  40:11

Despite how immensely satisfied I am with my clinical career, one of the things I have come to realize, as I’ve gotten older, is that I probably could have been happy in any number of clinical specialties or different careers. And I wouldn’t trade what I do at all. But harkening back to that sustainable health care community that you referenced Chad, I am the only surgeon. And there is a reason for that, that specialties like anesthesia, or emergency lend themselves much more easily to incorporating a significant academic or advocacy component to one’s career. And even within the surgical realm, something that doesn’t necessarily involve practice of your own patients, and especially urgent cancer patients who need timely attention lends itself better to those activities. So I wouldn’t change anything, but I’ve had to accept the consequences of those choices that I’ve made and reconcile that for myself. But if I had to do it over again, who knows, maybe I would have chosen something that facilitated this a little bit more.

Ameer Farooq  41:22

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.