E76 Colin Schieman On Direct Entry Training And Intra Operative Teaching

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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

This week we have a treat for our listeners. Two episodes with Dr. Colin Schieman. Dr. Schieman is a thoracic surgeon at the University of Calgary and the current program director for the thoracic surgery program. We discuss a key issue in modern surgical training – are direct entry programs good or bad for training and trainees? Dr. Schieman also gives his approach for intra operative teaching. Don’t forget to check out our bonus episode this week, where Dr. Schieman is a gives us his approach to lung nodules and lung cancer screening. If you’ve been enjoying the show, please rate us and review us on iTunes. It really helps us out. And also let us know what you think about splitting the episodes up into two as we did with this series this week. Let us know if you like it, you don’t like it, or any comments or suggestions that you have, you can email us at podcast.cjs@gmail.com or tweet at us @CanJSurg. Thank you and on to the show. Can you start us off by just telling us a little bit about where you grew up and what your training pathway has been.

Colin Schieman  02:16

Grew up on the mean streets of middle class Southwest Calgary. I had two loving and supportive parents and enjoyed a fairly typical Alberta childhood playing sports and things of that nature. I was very fortunate to get into medical school at the University of Calgary, where I then went on to do my residency in general surgery, and then followed that by thoracic surgery. I was the first member of my family to get involved in medicine. At the completion of my thoracic surgery residency, I had a very strong desire at that time to broaden my perspectives. And I, I sort of knew I needed to attain some training elsewhere. And so I did an additional fellowship at the Mayo Clinic in Minnesota. As Chad and I have talked about many times before, I think that a year away was incredibly important for me, and it’s something that I I strongly recommend to all of our trainees even even sometimes when they don’t want to hear it, I think it made a big impact on me. Following that I was fortunate to start my thoracic career at McMaster University in Hamilton, Ontario. It was a fascinating and somewhat of an unprecedented time of complete upheaval in that group, which then blossomed into the busiest program in the country really. Finally, in 2016, I was lucky to be able to come back to Calgary and to be closer to parents and grandparents and many of the mentors who taught me as I was learning surgery. And then, just during my career, I’ve I’ve worked pretty hard to do a number of brief sort of visits or observer ships for a few days or a week or two at a time, just to see how different experts do a variety of things. And so I’ve had little visits to friends in Montreal and Toronto, British Columbia and England. And I would say for these, for me, these are sort of formed an important part of my CME and my training.

Ameer Farooq  04:13

I mean, we have heard from so many guests, including your colleague, Dr. Christian Finley about just how formative outside experiences have been and continue to be. And I really liked the idea of you continually trying to go even now and spending a little bit of time in other places. I think there’s so much to be gained from that. I want to ask you a little bit about your thoughts on sort of the whole training pathway for thoracic surgery. You’re the current program director for the thoracic surgery fellowship in Calgary. And my understanding is that thoracic surgery initially actually went towards a direct entry model similar to what the vascular surgeons do now in terms of, you know, right out the gate out of medical school, you directly match in to vascular surgery, and then you train for five years and then you’re a vascular surgeon as opposed to the current training pathway, I think in most places in Canada, at least for thoracic surgery, where you do five years of general surgery, and then two years of thoracic surgery. So I’m curious how you sort of see the interplay of the base general surgery training, and the subsequent thoracic surgery fellowship, do you think there is still a value for that base general surgery training? And what are the synergies if there are any?

Colin Schieman  05:37

Ameer, I think that’s great. And it’s actually an increasingly topical question. You’re hearing rumblings of this concept in many different areas. I actually had a colleague and a friend who participated in that short direct entry trial which took place at the University of Toronto. I also have a few friends in the United States who have participated in one of the the now four different eligibility streams available in the United States which sort of range from 5 plus 6 model on the longer end to the I-6 direct entry route into cardiothoracic surgery for medical school. So they’re, they’re fortunate in their numbers, they’re trying a variety of different I think strategies to see what what works. And as you guys know, the vast majority of general thoracic surgery residents in Canada come as graduates from general surgery and I think for good reason. I personally think thoracic surgery isn’t in a very fortunate secondary residency role. As general surgery provides a very strong foundation for for thoracic training. Residents come with an incredibly strong synergistic skill set related to physiology, sepsis, nutrition, organ failure, tissue handling, and fairly advanced surgical skills. Laparoscopy, anatomic foundations in the neck in the abdomen, and, and it’s, it’s incredibly well suited to help us teach people thoracic surgery. A trained general surgeon has a vast skill set such that I think thoracic surgery program directors are fairly privileged and well poised to, to hit the ground running, so to speak, and to try to teach a fairly different set of diseases and operations, but with a lot of at least conceptual overlaps. And so I would say, currently, I can’t think of a better stepping stone for for us as thoracic surgery teachers in general surgery. It’s not the only exclusive route, but it’s very well suited for it. Just for the purposes of comparison, when I was at McMaster, our program admitted international fellows for additional thoracic surgery training. And we actually got to work with boarded surgeons from a variety of countries that didn’t have necessarily any general surgical training or or had general surgical training in a different environment. And that was fairly evident of that, if you will, in some cases, a weaker foundation than we have in Canada. And, and in many respects, it made it a tougher hill to climb for them. As well as for us as teachers, for sure.

Ameer Farooq  08:25

Obviously, there’s many different training paradigms, depending on where you go. And because the fundamentally the issue is that, you know, the training pathway gets very long. And you wonder how much of this skill sets that you build, specifically with regards to like, specific anatomic understanding or knowledge, you wonder how much of that carries over when you’re now a thoracic surgeon and doing you know, sometimes it’s in some people’s cases, completely different operations than what you spent your five years of general surgery training, doing. So you know, I know, there’s, there’s certainly some talk about having sort of a direct entry model where you do a couple years of undifferentiated general surgery training, and then you go on and you do the rest of your training in your specific field like, you know, you do three years of general surgery and then you move on to do three years of HPB or three years of colorectal, three years of thoracic, etc. Do you think there’s any merit to that concept? Or do you think that the model that we currently have makes sense the way it is right now?

Colin Schieman  09:30

You know, I wasn’t aware that that was a growing movement within the general surgical subspecialties. But I can say that I’m not at all surprised to hear that. As you mentioned in my sort of surgical life vascular surgery split off as a direct entry route and before that it was cardiac surgery and I’m not sure that I think it’s necessarily wise if we look at having these quite subspecialized areas be routes of entry straight from medical school, I have some some concerns about that model. But I can see several reasons why, as you say that concept has merit and is worth considering, or at least variations of it. As you’ve mentioned, I think the depth and volume of knowledge required to graduate, a specialist or a subspecialist today is is immense. Certainly, from my perspective, one or two year programs, and I suspect this holds true of HPB. And core, I have an increasingly difficult task to teach these fairly huge bodies of knowledge in such a short period of time. And then further the breadth and more importantly, the expectation of technical excellence in the execution and outcomes of these procedures is forever becoming a higher and higher bar to reach. And so although some procedures have become chronologically faster and quicker to do, with undoubtedly better outcomes, very few of them have become technically easier or less demanding to perform. And so I think with the move towards less invasive procedures with broader physiologic and oncologic boundaries sort of being pushed every day. I think it’s made things technically more difficult from my perspective. And so, you know, even though a few short years ago, gone are the days when someone could do a few colon resections during a general surgery rotation over several months, even many months, potentially, and then they would be fairly safe and well positioned to go on and do that in practice, I think, you know, that just as a micro example, things are often done now laparoscopically, often with following neoadjuvant treatments. And, and then you couple that with very highly scrutinized outcomes, which should and will be compared to the best of your peers in the business. And I can see why all of us are wanting more dedicated time to our areas of focus. You know, like it, would it be better to learn biliary surgery for four years or one year, you know, like, obviously, I think I would rather have the person that had a chance to learn it for four years. And so I think there’s huge merits to the idea. And as you said, that that obviously pushes up against what is displaced in the process. And so does that mean, you’ll no longer know how to operate on like the breast cancer or trauma patients or, you know, what do you carve out in the quest to make it more efficient? You know, does it mean that we have five or six offshoots of general surgery after, as you say, sort of a core base of training, and I find this sort of fight between ultra specialization, reasonable lengths of training and the breadth and knowledge, a very difficult interface. I, I could imagine programs like general surgery morphing into something, as you’ve alluded to, like, what they sort of call the joint training programs in the United States that use a 4 plus 3 model, or, you know, a potentially a 3 plus 3 model. So for example, as you’ve hinted at your knowledge that not all general surgery entrants are going to be doing elective procedures across all disciplines, and that, and then you sort of given them a chance to gain a critical skill set and have them fraction off fairly early, and then allow them additional time within their subspecialty. I think I think that would be a better method to achieve greater specialization than just simply adding more time at the end. And I get the sense with the new surgical education paradigm with competency-based training. And I think as we see how that unfolds in the next five or six years and, and certain elements get very parceled out that I think more and more we’re going to be asking these questions in the future so that I personally think that model that you hinted at has a lot of potential or value.

Chad Ball  14:15

Certainly, it’s something at the at the HPB fellowship level, whether it’s the fellowship counselor, the HPBA, in our circumstance, for a number of years now have really had some extremely deep discussions. You know, what’s really a North American wide match about some of the in particular technical limitations of our of our general surgical graduates across the continent coming into HPB fellowships. And as you know, HPB fellowships can be super high volume one year or medium to high volume two year fellowships, and just the challenge of trying to, you know, take a graduating general surgery resident who has maybe done one third of the total volume of cases that you did in your general surgical residency and trying to make them an independent, competent, safe HPB surgeon with significant potential after 12 months is really, really challenging. So there’s there’s been a number of notable folks that have wondered maybe some of these fellowships should be a mandatory second fellowship. In other words, maybe you should have to go do surgical oncology or trauma or colorectal or something before you enter maybe some of these more technically advanced fellowships. And, you know, in that conversation, I’m always a little bit uncomfortable, because I echo some of your thoughts. I do like, where are we going with this? How long does this end up being? But it you know, at the end of the day, in many ways, volume is so critically important to develop technical expertise. I just don’t know how you get around that without really altering that the system that we have now, what are your thoughts on that?

Colin Schieman  16:02

Wow, I can absolutely see how and why experts and teachers would be comfortable with that transition and would want that. I’m not sure it’s the best direction for us to go in. It’s undeniably easier and arguably safer to teach a new complex set of procedures or procedure, such as a Whipple or laryngectomy, to a trainee who has a fairly high level of mastery of the local anatomy and skilled hands with respect to tissue handling and suturing. But I can’t help but wonder at some point, if that’s a real net win for programs and for society, just to keep stacking these on top of each other. And, you know, to be super blunt, like somebody has to do the hard work of training the junior residents. And so you know, I, I’ve worked with and witnessed fellows and registrar’s from other countries. During that some of my training opportunities that have, you know, these never ending residency or registrar structures around the world and, and some of these fellows are in their middle ages, like these are guys with gray hair and receding hairlines and their kids are in high school. And I just think, wow, like, I don’t know, if, if this is the perfect time, you know, cognitively, training-wise, for personal reasons for, you know, length of service delivery to society, if that’s really the best answer, but I certainly understand how it evolves. If you gave me a choice, I would counter that. I really do think having, you know, I got the sense when I was going in general surgery that a lot of folks have a fairly comfortable idea with what they’re going to be interested in when they’re done kind of at that three, four year mark. And certainly not everybody does, but but it’s not to say that those individuals aren’t going to benefit hugely from learning thyroidectomy, for example, or, or liver resection, but if they kind of know what they want to focus their mental energies on and their scholarly and energies on, I personally think the 4 plus 3 or 3 plus 3 model is a better trade off. And I think you can split people out it kind of in the six to seven year window with fairly high level expertise, rather than the challenge that you allude to Chad, which is just you got somebody that’s there for 12 months, and you got to build rapport with them, teach them the system, figure out what their baseline level of skill is, and then in a fairly condensed period of time transfer, like a master level of skill. Like I, I get that that’s not ideal. And so I’m not opposed to lengthening that time when you’re when the stakes are high, but I just don’t know if it should be done at the expense of doing it after you know, HPB fellowship one and then HPB fellowship two. That doesn’t quite feel right to me.

Chad Ball  19:10

Yeah, I couldn’t agree more. I mean, you said exactly, you know, summarized really what I said in those meetings for the same reasons. And surely we can prove the quality and the structure of training earlier rather than dumping at the back end for sure. And you know, the other thing that you that you touched on that I think is is particularly relevant is the the innovation and the rapid movement towards minimally invasive surgery, whether that’s, you know, laparoscopic hepatectomies or lipo procedures, we can debate those two all day or whether it’s in laparoscopic esophagectomies, I’m sure you can debate that all day. It’s hard to know exactly you know, how to insert some of these extremely complex MIS procedures into the training paradigm and when to do it as well.

Colin Schieman  20:01

Even thoracic surgery, which is two almost two full years of additional training, we feel a fairly big push to get, I would say, the average person through where everybody in the room feels safe and comfortable. Like it’s, it’s, it’s a high bar to reach. So I, I couldn’t agree with you more.

Chad Ball  20:22

And totally, I mean, I hope our listeners aren’t, aren’t listening to this thinking these guys are talking about the negative and in you know, instability too much. But that doesn’t mean just switch gears one of the things that you and I both know very well both, you know, individually and collectively when we talk to your your trainees or they talk to us behind your back, so to speak, is that you have a really beautifully masterful way of, of grading responsibility and providing opportunities to learners of all different levels. I was wondering how how you framed that, and you clearly have thought a lot about it, and in particular, how you approach it, and maybe how a guy like me, could get better at it.

Colin Schieman  21:04

But it’s very kind of you guys to say that. Thank you. I, I would say that the issue of maximizing the educational value from my clinical experience, or in the case that we’re talking about an operation is something I you’re right, I’ve thought a fair amount about. And I’ve certainly gotten better at it with time. And despite that, it’s still something I struggle with often. And so I guess I’d begin by saying that, sadly, it it really first derives from from the individual’s willingness to put in the emotional energy as a teacher and there’s just no great shortcut around that fact. I think surgical teaching is unavoidably an active process and its work and it, it has a million great things that arise from it that are that are so self-evident, but but it is work. And I think in the least it costs you time and efficiency and that ultimate desire for sort of surgical flow, which underpins a nice safe case. And at its worst, it potentially endangers the lives of the patients. And so on the flip side, it’s really the most lasting legacy that most of us can hope to achieve in this game. And I would say that aside from a world changing research discovery, which I would argue is pretty difficult for most of us to stumble across teaching a resident to learn a new skill, literally has the potential through the multiplier effect to benefit hundreds or 1000s of people. And so it’s, it’s really right at, you know, when Chad, you and I have talked about legacy before, but it’s right up there like guys, for me, it’s the essence of it. And so, you know, to answer your question, my personal approach is to religiously go through a pre-brief discussion before the case with the trainees and so everybody has their own take on this. For me, this is not a time to quiz the resident about the CT scanner, the patient’s history or the latest studies. I think, of course, our residents know that those elements are expected but I don’t waste particular time on that in the moment, I’m rather I’m trying to create an environment that’s nonthreatening that they can bring as much confidence to the case as possible and not be distracted by things like that I, I asked them very bluntly, what their personal experiences with the given procedure, just to gauge how new this is to them. And, and in that moment, and in those few sort of minutes of discussion, you can quickly convey the critical elements of the case in your mind, build a vision for the flow of the procedure, you talk about the most difficult elements and the pitfalls and and what happens is you instill the trainee with some confidence and excitement about the case. And it often opens up a brief and focused set of questions that they have. And and almost always they’ve prepared. And it’s their opportunity to show that to me. And unless it’s literally the very first time that I’ve ever done that procedure with the trainee, I try to tell myself that I regard this as being their case, even if it’s, for example, only the second time they’ve done it with me. And I then let them do the procedure, each step with a ton of sort of moment to moment instruction for sure. And this almost always gets some several steps into the case and always lets them get to their personal limit. And so in many ways, Chad that they set that limit, not not me. And when we start to bump up against a technical wall, or it usually becomes fairly obvious to all of us when they’ve met their limit, and it’s sort of my turn to show them the next few steps. And the really cool thing about that is in many respects, the residents can go to incredible depths within a case just as a result of our collective preparations, almost always further than I think they’ll get and further than they think they’ll get in. And then the flipside of that is that when, when I take over they they get fairly intently focused on why and where they got logjammed. And so, you know, I’ve had residents complete cases, at the beginnings of rotations with me that I literally never got to do till I was at the very final components of my training. And so, if you occasionally have big wins like that, certainly, that’s obviously those were the good times that there’s, there’s sometimes it just doesn’t, doesn’t go very far, the exchange isn’t good, the rooms not good, the case is tough. You know, the first port goes into the lung parenchyma. And the whole case kind of gets derailed before even started and stuff. And so, it’s, but it’s certainly it’s kind of a neat way to start, I think, for me, and that’s sort of how I try to frame it in my brain on my better days.

Ameer Farooq  25:54

You know, as someone who was your your trainee, you know, I can remember this time when, when I was scrubbing with you, and you actually had one of the medical students put in a port, I think, for a vasc, or something like that. And I remember looking at you and thinking, this is crazy, like, how are you letting a medical student put in this port. But I realized very quickly that you knew exactly what everyone in the operating room could or couldn’t do. And I think largely because you know, your mind, you had very specific ideas of what you were going to do in this operation, and you are confident in your ability to, you know, both gaze a trainee and to, you know, clean up after us so to speak. And I think that’s a really underappreciated skill in a teacher. Let me ask you, if you have a trainee, let’s say, who’s struggling and, you know, despite the fact that you shown them a few times, or, you know, you think they should be at a different place than where they are, How do you sort of deal with that? And how do you overcome it?

Colin Schieman  27:00

Yeah, I am. I would say the struggling resident isn’t is an immensely challenging problem as, as, as a teacher. It’s certainly not the fun part of being a teacher. I think it’s, we all feel like superstar teachers when we have our gifted PGY7 residents in their final weeks of residency, you know, doing complex cases with us, we all feel like we’re just wonderful instructors. But I think it’s fair to say that most of us fall down pretty far with the difficult trainee, or the resident who is in difficulty. And I sort of think that there’s a few different flavors or varieties of residents in difficulty, and you have to do a bit of diagnostic work to see what you can offer them. So I sort of think there’s roughly three types. There’s the resident who’s so inexperienced, that every task is difficult and clumsy, just by virtue of not having seen and having done enough. There’s next as the one who doesn’t care and is sort of underperforming as a result isn’t committing themselves to the process. And then lastly, is the one who cares and is working hard, and just isn’t advancing as they should. And they aren’t assimilating concepts, their techniques are awkward, and they just aren’t meeting the standard that you and they would hope to. And I think that we make the mistake of defaulting often to assuming that the resident difficulty is, is that second type who’s, who doesn’t give a darn. And I think that’s potentially a dangerous set of assumptions. It’s it’s absolutely sometimes the case. But before I jump to sort of how I try to deal with that, I, for me, what’s been hugely beneficial is to chat. And so I, my suggestion is, you chat with your fellow faculty to gauge their experiences with that training. And it’s often enlightening to hear their thoughts about where they’ve had frustrations or, you know, they often will come at it from a fairly different perspective. If they’re an off service resident all page their their home program director and just chat about maybe something that I’ve seen and see if that is a pattern of behavior, or if this is just a person’s having a tough time on our service, and maybe we need to kick ourselves in a better supportive environment. And in some of the more difficult scenarios, I’ve had to talk to the postgraduate dean’s office to see what options are, what personal learning supports are available. I think the first resident that’s just inexperienced, and is fairly straightforward. You just need to get it out. You have to haul more of the load than you want to and you have to sort of teach them the beginnings of the craft. It’s not easy teaching a brand new resident, how to suture for example, or how to hold the cautery or how to hold the scalpel when it sort of feels not really where you’re at your mental energies want to focus in that moment. But I think that’s how I approach that, that trainee that. The second i think is is tricky as well. I think as I said, you have to be careful that you don’t misjudge their apathy when it’s possibly something more profound, like a learning difficulty or personal issue. You know, people are complicated, we often forget it as faculty, but residency is an insanely grueling process. And I think most of us started to break at certain points during the strains of residency and had trouble being our absolute best all the time. And I certainly had periods like that. I try with trainees sort of like this, take the time, ask them how they’re doing, try to probe them on, where I think they’ve maybe come up a bit short. And you can fairly quickly tell I think, if they’re engaged, or if they have other things going on, and occasionally, you’ll be surprised, I think. In the end, if they’re just not committing to the process as a learner, you still have to commit to providing them with a bit of a learner with a learning experience, for sure. But I think at least you can temper your expectations and commitments with what’s possible. The last resident is the poor resident who’s busting their butt but isn’t really making the grade. And for me, these are the real heartbreakers I think thankfully, these are rare. In my limited experience, these residents deserve our best. That means talking with your team of teachers, talking to the postgrad office, seeing if they need a mentor, seeing if they just need a bit of encouragement. And I can honestly say that I’ve had trainees that, in the beginnings of their time with us thought they were not capable of progressing to what we thought was a safe and acceptable level. And I’ve been, I’ve been pleasantly surprised with fairly significant investments of energy on their and our part. So even the struggling residents can can often vastly move beyond where you see them in that moment. A very rare few don’t physically have the constitution or the aptitude to do surgery. And if you suspect that these are pretty tough, it’s tough to speak openly about surgery as their correct choice of career and I can distinctly remember a trainee, who I think fell into this sort of categorization. And I spoke with a trainee and I spoke with the dean’s office and when we approached the trainee to entertain, sort of if they thought this was working out for them, through tears of relief, I’ll never forget this in my lifetime, the resident was, was happy that somebody finally just said this limit. It’s something that clearly they had been aware of and had been thinking about for a long time. And they pivoted to a different pathway which I think it was a big win for everybody. But it was a fairly pivotal and challenging sort of circumstance. But so so not everybody, I think is suited to it for a variety of reasons. And, and I think we often forget that there’s this entire university infrastructure that it has like, literally educational and learning experts that have access to a whole world of resources that we don’t typically think of. We I think we we fair, were fairly quick to assume that most of the surgical trainees are, are just really bright, capable, hardworking people, which they are but but they’re still just just young people trying to learn difficult sort of things so.

Ameer Farooq  34:04

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.