E89 Liane Feldman on SAGES presidency, future of MIS, and FUSE program

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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  00:55

We were lucky enough, at the end of June 2021, to interview a true Canadian surgical icon, Dr. Liane Feldman. Dr. Feldman is the chief of the Division of General Surgery at McGill University in Montreal and the newest president of the Society of American Gastrointestinal and Endoscopic Surgeons or SAGES. We really wanted to try to understand from Dr. Feldman, what does it mean to be a minimally invasive surgeon in 2021? Where does Dr. Feldman see SAGES going in the future. And finally, we discussed the work Dr. Feldman did to help create the fundamental use of surgical energy or FUSE program. The FUSE program is now a core part of North American surgery programs and helps residents to understand the actual underlying physics and mechanics of surgical energy devices. In other words, what exactly is the difference between blue and yellow in the bovie? For all this and more, stay with us.  The first question I have for you is, do you think the Canadiens are gonna win the playoffs?

Liane Feldman  02:13

Absolutely. You have to have faith, a thing like that. It seems, last night, not withstanding, seems like there’s something magical happening, for sure.

Ameer Farooq  02:25

Yeah. The price is right and, keep calm and carry on, right? We’re all rooting for them. Dr. Feldman, you’re a Montreal native. Is that correct?

Liane Feldman  02:36

Yeah, that’s right. Born and bred. My mom’s from here as well and my dad was originally from Toronto. But yeah, I was born here and raised here. This is home.

Ameer Farooq  02:48

And did you do medical school and residency in Montreal as well?

Liane Feldman  02:53

Yeah, I’m pretty much a lifer. I did go away from my undergraduate degree, I went to Brown University in Providence, Rhode Island. So just a little bit, 6-hour drive or so, south of Montreal for 4 years as an undergraduate and then, it was always my dream to come back to McGill, come home. And I’ve basically been at McGill ever since.

Ameer Farooq  03:17

Right on. And you’re now currently in McGill. and you’re the Chief of Surgery there. Recently now, the president of SAGES. There’s so many different things that we could talk about but, one of the things that we really wanted to chat with you upfront and congratulate you on, obviously, first of all, is your election as the president of SAGES. So, I just wanted to start off by asking you, how did you become interested in running for the position of being the SAGES President.

Liane Feldman  03:46

SAGES, to me, I always really connected with SAGES as a community of surgeons and an organization. I first was trained by Gerry Fried who was also my predecessor as chair of our department here. I was actually his fellow in minimally invasive surgery. He took me to my first SAGES meeting, where we presented, I think I had a little poster. In those days, you had to type in your, maybe not type it in, but try to print it out in the square. And we had a poster, was in San Antonio. And maybe it was just getting to spend time with Jerry and his amazing wife, Karen, that was really fun as well. But I just really found a community of people interested in the same things that I was interested in. But also really started to connect with other people at my stage. People that were interested in the same stuff. You could connect with people that you’ve read their stuff; you’ve read their books. And SAGES, I just love, it’s a really down to earth organization. Really, really focused on young people, I felt. I still feel. Lots of opportunities for young people. Also, it’s an organization that has a lot of fun. Definitely. I don’t know if you’ve been to SAGES yet.

Ameer Farooq  04:49

I haven’t had the chance to go to SAGES specifically. But yeah, you totally get the flavor that SAGES is a fun event to go to.

Liane Feldman  05:27

Right. So I would definitely, of course, I’m a bit biased, but as President, my meeting will be in Denver, in March in 2022, and I really hope you can come. And then, the meeting in 2023 will actually be in Montreal. And it’s the first time it’ll be in Canada. So, I hope we can attract a lot of Canadians who are interested in GI surgery, improving recovery for patients, minimally invasive surgery, techniques, technologies, and just also a fun organization and definitely… I won’t give away all of SAGES’ fun things, but there is the sing off that is pretty well known. But I hope you can come.

Ameer Farooq  06:13

Yeah, it’s definitely on my list of meetings to attend. Once we can actually go back to in-person meetings. It’s just such an exciting prospect on the horizon to be able to go to these meetings again, in person, to meet everyone. You mentioned that you’d gone with your mentor, Gerald Fried, who is obviously a huge name in Canada and beyond, in terms of minimally invasive surgery. How did you, yourself, get involved or interested in minimally invasive surgery? Clearly, you were a pioneer, and I should mention for our listeners, that you’re really someone who has pushed minimally invasive surgery here in Canada and really helped to bring that and expand that across the country. So how did you, yourself, get interested at a time when, probably, not that many people were doing minimally invasive surgery?

Liane Feldman  06:59

Well, I think it’s probably like a lot of people, what you what you get into, a lot of it had to do with role models. And Gerry was always, Dr. Fried, Gerry Fried, was always a mentor to me and a role model for various reasons. He was, certainly, a well-known pioneer in minimally invasive surgery. And when I started my surgical residency, it was 1993 and the first lap choles in Canada were only done in mid-1990. So, it was really a time of rapid development and innovation. But to me, I’m not really like a gearhead. For me, it wasn’t so much about the stuff. For me, it was a lot about, the patients just look so much better. And it’s a very, very obvious thing. I was always interested, I don’t know why, but I was always interested in proving that. That patients were recovering faster. And actually, that has been a bit of my research interest, ever since I was a trainee. So, a lot of it, I think is just seeing the impact on the patients. And a lot of it was following in the footsteps of somebody who I thought was a good role model. And I thought it looked like they had a good life and were happy in surgery and excited about surgery. That was one of the things about Gerry is that he really loved to operate. And he really loved to be in the OR and be with patients. And he seemed happy. So, I think that was probably a something to emulate as a trainee. I think that’s something that really rubs off on people.

Ameer Farooq  08:41

Yeah, you can’t really underestimate how powerful that mentor’s impact on you. I kind of like the fact that you chose to become a guru of MIS because you liked what impact it had on patients. You know, a lot of surgeons talk about the fact that they like the tools or they’re kind of interested in the technology aspect of it and all that. And I’m kind of like you. I want the tool that will be the best for the thing that we need to do, right? As opposed to being the advocate for the tool. Because sometimes, that’s not the right tool for that particular patient or for that particular condition. This sort of relates to one of the questions we were gonna ask you about SAGES. SAGES stands for the Society of American Gastrointestinal Endoscopic Surgeons. On first glance, it’s kind of hard to figure out what unites that group of people. Especially now that it’s not even just about laparoscopy anymore. There’s robotics. There’s transanal surgery. Obviously, I’m a colorectal fellow, I’m going to bring transanal surgery into it somehow. But there’s all these disparate technologies now and perhaps some things have not proven even the test of time for minimally invasive surgery. So how do you see SAGES as encompassing all those different folds? Or do you see SAGES as really, a society dedicated to figuring out more minimally invasive ways that we can do surgery? How do you sort of think about that as an organization?

Liane Feldman  10:21

Well, I think SAGES is a general gastrointestinal surgery organization. So, I think there’s an evolution that we could discuss of why it’s called gastrointestinal and endoscopic surgeons. But I think the key thing is, for me, the sweet spot for SAGES is about the intersection between innovative new, often they’re new, but innovative, less invasive technologies that improve recovery for patients. And at the same time, the education that’s required to go with that. And I think that’s where SAGES really took off. Just to get into the history a little bit, SAGES was begun by the surgeons, about 40 years ago, who are interested in endoscopy, colonoscopy. So that’s where the endoscopic surgeons came from. And when laparoscopy came on the horizon in 1989, 1990, they were the same group that immediately grasped, and maybe it’s because they were doing image based, they were in that kind of image-based world as GI surgeons, and they immediately grasped the meaning of it. They were very early adopters. And a lot of them became, even in colorectal, in upper GI and bariatrics, became those kind of pioneers in those areas. And they’re in that kind of, and I would say, my generation is more the people that were taught by those pioneers. And so that’s a little bit of why it’s called, it actually was called gastrointestinal endoscopic surgeons, but to broaden the appeal to abroad into the house of surgery that’s really in gastrointestinal surgery, the “and” was actually added. And not that long ago, within the last 10 years or so.

Ameer Farooq  12:18

That’s a neat history that I actually didn’t realize. And it’s almost like, having not been there and only having a very recent kind of insight into SAGES, it’s almost more about a mindset as opposed to anything else. It’s like a mindset of, how do we advance care? How do we innovate? How do we make things better? As opposed to just being about the latest tools or the latest toys.

Liane Feldman  12:43

I think that’s a really good point. And if you don’t know anything about SAGES, I’m very happy that is conveyed. Because at the same time, I think what’s important to me, in thinking about technology, is kind of the… and I think SAGES is definitely interested in the next big thing, there’s a big focus on technology and being ahead of that curve. And that’s really important. So, stuff like, computer vision and helping with looking at AI technologies, looking at robotics, as you mentioned. But at the same time, being aware about the humanistic aspects of surgery, the community aspects of surgery. What’s important in our careers as surgeons to thrive, not just survive. Last year, we started a new task force actually called Reimagining the Practice of Surgery. We call it RPS. And that really has to do with, us as surgeons, what’s important to us in our careers to thrive as surgeons professionally? To get the meaning out of our professional lives that drew us to surgery in the first place. And our career trajectory. So, I think having that community of people, being a surgeon is hard. And in some ways, we have a lot of supports if we’re lucky, in family and friends. But in some ways, it’s our colleagues that really understand and that having around us having excited about the same things that we’re excited about, understand the challenges and the times that things really don’t go well. And that’s normal in the life of a surgeon, at some point. I think that’s another thing that really drives, that you can find in surgical societies. Not only SAGES, but I would definitely encourage everybody to get involved in a specialty society or surgical society. Whether that’s local, provincial organization, national, international. Because they’re our people. Your people. The people that are interested in the stuff that you’re interested in, the people that get you. Having that opportunity to travel. I’ve really made close friends through my work at SAGES and other people have the same, whatever organization they’re drawn to. I think there’s so many aspects of, there’s so many things to do in setting up your career. But I think that’s one thing that, I feel very lucky that I was able to get involved deeply in the surgical society.

Ameer Farooq  15:25

I think I’ve told the story before on the podcast. But when I was doing my masters, one of the residents from Calgary came to Brigham and Women’s to do an elective. And I met up with her while she was there. I think it’s the closest experience I’ll ever have to meeting up with, like, a veteran. Like two veterans meeting from a war. Like, that’s what it felt like. It felt like two veterans. The way that we just caught up on things that had happened in the past and things that were going on. It really did feel like, it’s more than just a colleague. It’s like someone that you’ve really gone to the frontlines with. I feel so delighted when you have this as one of your visions for SAGES. What are the other things that you think about when you’re, now as the President of SAGES, in terms of your vision for the organization, going forward?

Liane Feldman  16:20

Well, you know, it’s such a huge privilege to have that platform, that people will listen to you, for some reason. I’ve thought a lot about how to try to make the most of my opportunity, for sure. I mean, serving in the roles that lead up to presidency for the last several years, on the executive committee. And going through the pandemic for the last year and a half. And going through the reckoning. It’s a North American organization but it’s an American based organization and seeing the reckoning that they’ve gone through with racism and anti-racism efforts. So, DEI, anti-racism, I think, are very key priorities for this year. I think SAGES, because we like to think of SAGES as an innovative organization, I think we’re not new to those concepts. But I think they’ve been brought out in such a striking, emotional way that we will definitely focus in a big way on that this year. That’s definitely a very big priority for other organizations, and I think SAGES hopefully will continue to be innovative in that space. And for us, it’s just a way to continue to be as strong as we can be. To be the most creative, innovative, organization that we can be, by making sure that we encourage leadership opportunities within our organization for everybody. And that everybody feels that they belong in our organization. We, obviously, like every organization, we have work to do to understand those pathways and understand if we have potential blind spots. And that’s work that we will certainly do, in a big way, continue to do this year as well. Actually, the chair of our, we call Diversity Leadership and Professional Development Committee is Alia Qureshi, who is actually also Canadian. She trained in Toronto, she’s now in Boston. So, good Canadian content there. But that’s definitely a big priority for us this year.

Ameer Farooq  18:43

Yeah, it’s certainly a thing that every organization, journal, institution, really needs to think about. What strategies are they going to have, in terms of addressing those issues? I noticed that you had tweeted the other day that you were in discussion with the president of the Society of Black Academic Surgeons, and I know that those efforts are kind of ongoing. What do you see, besides making the leadership opportunities available to everybody, what are some of the concrete things that you think SAGES can do to try to promote diversity and equity in the organization?

Liane Feldman  19:22

Like you said, there’s one thing to commit and there’s things that you need to put into practice. You know, when, a few years ago, we started a taskforce that became a committee that we called We Are SAGES. That probably was more focused on gender equity within our organization. And we did have to put in, not that we had to, but the process was quite strategic in, let’s say, representation at our meeting. Representation, speaking opportunities. And maybe in gender, the metrics are a little more transparent. So we could, without much difficulty, say, it’s going to be 50% of our speakers are going to be women. And when I was the co-chair of the program in 2018, president at the time, Dan Jones, was very fierce on it. And we had conversations where he would ask us, as the chairs of the program, and obviously, the meeting is a really huge central event for us, and planning the meeting is a big deal. And he would say often, what’s the number? We’d say, 46%. He’s like, not good enough. Get me to 50%, I don’t care how you do it, it’s 50%. It’s 51%. And so, I think there are, whether, we need to put in those kind of, how do we know where we’re going in the right direction? Getting the data and the metrics that we need. And I think a part of SAGES that I got a lot out from SAGES, as a committee member, and then a committee co-chair, chair, board member, moving up in the ranks, was really a huge amount of leadership training for me. And that’s something that I feel so grateful to SAGES for. It’s where I encountered things like strategic planning, budgeting, how do you enact a vision? How do you sell a vision to a group of other surgeons or other colleagues? And so, to me, really, this is a part of our leadership development. So, it’s education for our leadership, it starts with education. And then it’s putting policies into it, will likely involve putting some policies. And, you know, looking at needs of our members, through surveys and needs assessments, led by our diversity committee. So, I think there’s a lot of great people involved with that. And I think that we have to be strategic, thoughtful. We have to keep track and we have to make sure that our organization represents the house of surgery. And that are our members gain stuff from SAGES that they’re able to enact in their own communities. And I think that’s one of the big advantages of having opportunities in organizations like SAGES is that, what I learned through the opportunities I was given at SAGES to lead, are a huge part of what we bring back to our own organizations, our home base, to enact in leadership. And it builds on itself. So, I think that that’s a key role for SAGES.

Ameer Farooq  23:01

It’s not an easy task. I don’t envy anyone who’s put in the realm or in the role of being the president of a major organization, because it’s really a big group of people. And, of course, surgeons are not necessarily, they’re not pushovers by any means, or natural followers. So, you really do have to deal with some people who have very strong opinions on how to do things. And who have a variety of different interests and thoughts and opinions on things. So, I’m curious if there’s anything surprising that you’ve encountered during your first initial bit in your tenure as SAGES President, in terms of leadership and that type of activity, in terms of thinking about running a big organization like this?

Liane Feldman  23:54

Well, you know, volunteer leaders. We have an excellent, really, outstanding staff. And that’s one of the things I also think about. Something like SAGES, and other organizations like it, are, I think the main thing is to, for any, it’s almost like, any project that you want to do is, you think of the opportunity that you have and laying out some kind of a vision that’s attainable in the time that you have with that opportunity. I think it’s like any project or any role that we play in our everyday life. I mean, surgeons to me, are all leaders. Surgeons lead every day in the operating room. And I think we have an excellent, excellent group of leaders. I’m surprised every day. I’m amazed every day. I’m amazed by the amount of work that people do as volunteers. It’s humbling. It’s amazing. We had our virtual board meetings and the one that we had not very long ago, about a month ago, maybe a little bit more, in the spring is basically, we have 42 committees and task forces at SAGES. And so, to hear about the amazing work that’s done by our volunteer surgeons. Surgeons are pretty busy. It’s amazing. I’m surprised and just so proud, and in many ways, just like, wow, you’re doing what? Every committee is doing amazing things. So, I honestly, I sometimes am surprised. I’m surprised when people are able to put that time in, but I think it’s really worth it. Because you do have that ability to create something, in some ways, that mirrors what you can do at home, but it’s different. So, not that I’m surprised, but I’m proud of it. It’s exciting and it definitely gives me energy.

Ameer Farooq  26:19

That’s fantastic. There’s some really passionate people out there in the world. And it is really inspiring to see what people do. That’s one of the things that we’ve learned from doing the podcast is, it’s amazing the work that you and so many others have done. So that, it really, really, truly, is amazing.

Liane Feldman  26:36

And it’s amazing what you’re doing in doing the podcast and adding to the journal in that way. Bringing something new. Something that gives a different perspective as a volunteer and as a leader. And that’s what it’s about is, if you have the opportunity, and we all have that opportunity. You know, big, small, every single day, as surgeons in our kind of privileged roles as leaders in our communities and our institutions, whatever level we’re at. You know, I think your example shows you can take something, you have an idea, you’re given an opportunity and you run with it. And then you have something that’s meaningful, and that people learn from, and you’ve created something new. So, you’ve done great with that as well.

Ameer Farooq  27:24

We appreciate that and we’ve enjoyed doing it. One of the, obviously we talked before about SAGES is that, SAGES is this innovative organization that is constantly trying to think about the next best technology. How can we take care of patients better? In a less invasive way, potentially. And obviously, you’ve been doing this for a long time now. You were a pioneer of MIS back in the 90s. Where do you see the future of minimally invasive surgery going?

Liane Feldman  27:56

I think the evolution will continue to be towards this path, less invasive, more personalized, safer. And some of the exciting innovations, I think in safety, will potentially revolve around computer vision, potentially, point of care decision support in the OR, but also in the clinic. So more personalized as we get more into data science potential. None of these things proven to do anything yet, but these are just looking at certain potential. Yeah, so I think that we’re continuing on that path. This is a time of rapid transformation. It’s a pretty exciting time to be in surgery. I think, especially, starting in surgery. We’ve seen this kind of rapid transformation, as you said, with the laparoscopy revolution, that’s something that completely transformed surgery extremely quickly. I think maybe every 25-30 years, and maybe data science has the potential to give the next revolution, advances in robotics and surgical techniques. There might be a role for some of those things to be automated. So, I think this is a very exciting time of transformation. More image-based, also education, augmented reality techniques, virtual reality techniques in education, are very exciting. How do we learn from video recordings in the OR? So, lots of really, I think, exciting stuff in minimally invasive surgery.

Ameer Farooq  29:48

It is an exciting time. It’s also an interesting time. I’m sure you may have seen, there was this paper in Annals that reviewed the robotic cholecystectomy experience in New York, and found a surprising number of bile duct injuries and increased complications. And so, it almost seems like there’s this separation happening now, in some ways. Where lots of surgeons are trying to adopt new technologies and new techniques, maybe with varying outcomes. You know, it’s always hard to say what goes on in these types of scenarios. And then you’ll have the advocates for whatever their favorite thing is. You know, the robotic colorectal surgeons, to give a colorectal example, will just talk about robotic colorectal surgery, and the TaTME-ers will talk about TaTME. So, there’s all these different camps and there’s all these different technologies, and varying levels of expertise with all these different platforms. Do you see SAGES broadly? And perhaps, you personally, do you have any thoughts about how we can perhaps bridge that variation in care and unify these different camps?

Liane Feldman  31:02

Well, I think it’s, kind of the technology adoption curve. There’s extreme enthusiasm when something is new. You know, TaTME is a great example. There’s gonna be a role for it. It enables certain things to be done, probably better than with other techniques. And how do we personalize what’s the best… How do we make sure, as surgeons taking care of a specific type of patient with a specific type of disease, that we have the tools in the toolbox to make that as personalized and have the best outcome for that patient as possible? I think when we bring it back to what’s the outcome for the patient. And even through a value lens of, best outcome, outcomes that are important to patients divided by the cost, as being Michael Porter’s definition of value. I think it starts to simplify things a bit. But they’ll always be… I think another great framework for evaluation of new technologies is called the ideal framework. Where we want to encourage, obviously as surgeons, innovation is critical. And it doesn’t always follow the path of phase I, II, III, trials. On the other hand, it does need to follow some kind of path, and where we evaluate the role, and the effectiveness, and the tradeoffs for different technologies. I think that’s a really good framework to look at that.

Ameer Farooq  32:49

Yeah. I do think, personally, that SAGES is going to have a huge role, in terms of disseminating the best available techniques, and tools, and data around all this stuff. I mean, I can’t tell you how many times I’ve watched SAGES videos in preparation for an operation. Even when I’ve done it many times before. Because I just find it so helpful to look at them.

Liane Feldman  33:12

Me too, yeah. And I think, I’m very happy to hear that. Because I think SAGES is, one of the things is, how do we make that information? I think when we’re looking to watch a video to learn to prepare for a technique and we know that that’s probably the number one-way trainees and surgeons, what they do. You know, learning, you’re doing something you don’t do every day. And we want to make sure that the quality of what we’re watching is, that there’s a quality element to it. And I think that, if SAGES can give that kind of stamp to people who are watching it, that’s exactly what we want. But we want to make it easier for people to find that. So, we are embarking on a whole redo of our educational materials at SAGES, we call our Master’s Program, which is along specialty lines; colorectal, hernia, bariatrics, etc. And a new organizational wide learning system, management system, which will also hopefully help with management of the fundamentals programs of FES, FLS and FUSE. Two of which are mandated programs by the American Board of Surgery. So, trying to make that information more accessible, easier to find for what you need, is definitely also, maybe not as exciting as DEI and anti-racism efforts. But making sure that educational materials, because it goes exactly with, I mean technology. I think this is one of the things learned in laparoscopy, that a technique that’s only doable by a rare few people is not going to be something that changes patient care. And if it’s something that’s really worthwhile, like laparoscopy, then how we train people to do it is critical, in terms of that learning curve and the safety aspects. So they really go hand in hand, new technologies and it’s almost the translational aspect, is that surgical education piece. And I think you’re right, that it’s a lot through video.

Ameer Farooq  35:26

Yeah, even simple things, I think. Like having playlists or things like that on YouTube, so that it’s easy to find the right video and things like that, is going to be super helpful. I think SAGES, one of the things that’s been really cool about SAGES and is so innovative about SAGES is the embrace of social media, Facebook, Twitter. And I would be remiss if I didn’t ask, who is the genius bot that runs the SAGES Twitter account? The SAGES Twitter is, far and away, no question, is the best organization’s social media profile on earth. How did that happen? Who does that? Tell me a little bit about who does that.

Liane Feldman  36:12

Nobody knows who exactly does it. We all have our suspicions. I will convey your compliments. But yes, I agree. It’s great.

Ameer Farooq  36:26

But there must be some level of, SAGES agreed to go down this path. Because it’s totally different than a normal or traditional Twitter account. You know, deliberately, the voice is not super starchy and uptight. It engages in a different way with the audience. And lots of non-surgeons follow SAGES because of that reason. So, what was the thinking around that? Or like, who had the courage to let the Twitter account and the social media presence go in that direction?

Liane Feldman  37:01

Well, I think that’s just how SAGES is. I mean, I think that’s one of the values. We want to be exciting, and we want to be relevant, and we want to engage lots of different types of people. And we want it to be kind of fun also, at the same time, and not take it too seriously. So that’s the mix that, I think, is what we’re happy to have.

Chad Ball  37:39

I want to switch gears here a little bit, Dr. Feldman, and ask you about your experience as the James IV traveling fellow. I think about a decade ago, correct me if I’m wrong. I’m curious, what prompted you to apply for that fellowship? I know, obviously, it’s a prestigious honor and something we watch very closely in Canada. I’m curious what your experience was like traveling through that time.

Liane Feldman  38:03

Like you said, it’s a big honor and it’s not really much of an application, you’re kind of brought forth, you’re nominated by the people at James IV. And I’ve become one of those people that sits around the table, usually we meet at the Canadian Surgery Forum, where we meet virtually. And nominees are brought forward from the various departments of surgery. There’s some amazing, amazing, Canadian surgeons. I think it’s a great opportunity at that tipping point where, maybe at the tipping point between associate and full professor, where making those international connections are important. So, when I went, I had kids who I could travel with. But the youngest, I think, was 6 or 7. So you’re right, it’s about 10 years ago. He’s 18, the youngest. We had 3 kids and there’s a bit of a trail for James IV because it’s great to visit other places involved in James IV themselves, and then a mix of other places as well. So, we got to bring the whole family to Australia, New Zealand. So that was a huge adventure for us at the time, and it’s a great mix of work and play. They still talk about it. Kids, the family trips you take are, even for me and maybe for you guys too, what you remember as a kid are those trips. My parents didn’t take me to Australia, but even road trip, driving down to Florida or something, you definitely remember those. So it’s a great opportunity for Canadian surgeons.

Chad Ball  40:14

Yeah, it’s so true. And it’s such a prestigious honour, you’re right. It’s a small club and it’s a list of some really amazing people. I’m curious both, bilaterally. So how did it change, or maybe alter, or impact your practice when you came back to Canada? And I’m curious, obviously, these relationships, whether they’re through former fellowships or through, we always try to leave some sort of legacy or something behind it. I’m curious on both directions, how you experienced those two.

Liane Feldman  40:47

Exactly right. I think, for sure, I got more out of it than I left behind. But visiting a place like Imperial College in London, a mecca of surgical education, surgical innovation. Having a whole day of meeting with researchers at different levels, hearing about all their ideas, presenting your own work and getting feedback on that. I also made a point of trying to get to the OR every place that I went, just to see different ways that people do things, and also the same ways that people do things. Rounding with the residents and the team as a general surgeon, and I always liked emergency general surgery. So many things are exactly the same wherever you go. Questions are the same. I remember even, “when do you guys use cholecystostomy tube?”, “oh, I hate cholecystostomy tube”, “oh, I love cholecystostomy tube”, the regular stuff that unites us around the world. No matter where. At least in the western world, in the academic surgery world. Yeah, you come home with, I had lots of ideas, new ideas, new collaborations, new friends, and a lot of family memories as well.

Ameer Farooq  42:18

One thing that we definitely need to talk about before we let you go is, the FUSE program. You co-developed the FUSE program. And this has become, obviously, an integral part of training for residents, particularly in North America. Can you talk about what the FUSE program is? How and why you developed it?

Liane Feldman  42:39

So FUSE, it stands for fundamental use of surgical energy. It’s one of those things, it’s a program that was developed by SAGES, an educational program, to teach surgeons some of the basic information that underlines the safe use of energy devices that we use every day in the operating room. The didactics are free, anybody can go through them. It’s stuff that we generally don’t cover in our residency programs or training programs, or we’ve had industry come in and there’s nothing inherently, necessarily, wrong with that, but I think it’s such an important safety issue. We’ve all had safety issue that we should understand the devices that we use, that all have huge benefits, and we couldn’t do surgery without them. And certainly, we couldn’t do minimally invasive surgery without some of these devices, but that we should own the training of those devices and understand the safety issues. And really, that’s what FUSE is about.

Chad Ball  43:56

Well, it’s an amazing program. It’s interesting to reflect, right? Because when we teach trainees about some of these devices. Certain things like say, certain energy instruments, for example, are quite intuitive to use. But there is nuance to all of it. Whether it’s using a stapler, or whether it’s using a negative vacuum suction dressing, there’s tons of nuance. Quite honestly, the companies aren’t great communicators at teaching that nuance, I find, I don’t know what your experience is. And then the flip side of it is, that you know as well, there is variability from place to place and I don’t think everyone reads the engineering manual that comes with a lot of these devices. So, it’s so critical, hey?

Liane Feldman  44:43

I mean, you can just ask yourself, do you know what the basic technology, how does that device that you have in your hand work? And I know as trainees, it’s not just for, all of us as surgeons, I suspect many of us, would have trouble explaining the difference between ultrasonic, bypolar, cut, coag blend. Maybe there’s a bit more education on that in our nursing colleagues. How do you handle an OR fire? A disaster event that can happen, that we need to be aware of and drill down on. And these are things that happen, and they have devastating consequences. I think most of us have been involved in complications of energy devices. Surveys have shown that most surgeons, if not from themselves, have sort of one degree of separation away from, either a colleague or a case that they dealt with, you know, an enterotomy that develops or bowel situation that develops a week later. We’ve all been involved in those cases. I was not an expert in energy in any way, I was brought into it, probably, because of my work in education. And that’s how I got on to the team. So I’ve really had a full education about it and needs a refresher once in a while. But I think I’m happy to have the opportunity to promote the program and encourage it. Also, for people that want the actual certification, there is a certification exam that can be done. But for everybody else, as I mentioned, the didactics are free. They can do CME, there are CME questions built into it. I’m glad you guys like it.

Ameer Farooq  46:44

One thing that comes up every single time someone has a FUSE. I remember doing this as a resident, every resident that I’ve seen after taking the FUSE course, they always come back to their staff, and they’re like, “the FUSE course said that I should use cut when dissecting, not coag, and I never see you use cut” and they’re like, “well, that’s true, but I still use coag”. You know, I still remember one of the surgeons in Red Deer would always use cut and I was kind of shocked when he did that. And then I went away and did the FUSE course and realized that, at least, according to the physics, that seems like the right thing to do. Can you explain for our listeners, why should you use the cut function when dissecting, and not coag?

Liane Feldman  47:30

So, you’ll have to go to the FUSE. But basically, when you use coag at the same power setting. So, what you press, you know, 25-30, you say, “where are my, you know, where’s my bovie settings?”, you’re gonna say, “oh, I have 35-35”. So that’s the power of the watts that are generated. So, if you go back to our physics class, at the same power, the thing about the coag is, it’s an interrupted waveform. So, it’s only actually generating current, maybe, in the FUSE, it says about 6% of the time. So, in order to maintain the same power, you have to really jump up the voltage if you’re only on 6% of the time. Versus the continuous waveform that you have with cut. And I think that every generator is a little different. And it is one case where you want to look at what the manufacturer is recommending. Oftentimes, it will recommend the blend function, which is not cut and coag put together, it’s a modification of cut. So that it’s a little bit of interrupted waveform. So, let’s say it’s on 80% of the time, 50% of the time. And you will have different tissue effects. And it’s a great thing to do for academic half day, or something to do with a piece of meat in the simulation center, where you can really play around with that stuff. And the thing about the continuous waveform is, is you can understand, it’s going to give you a stronger, more effective seal when you’re coapting the vessel walls versus that, kind of, welding that you could have. You know, it’s on for 6% of the time and then off, on, off, on, off. And you get that sticking and carmelization that pulls off your seal. But it is very good for fulguration or that surface coagulation on the gallbladder bed. So, I think there is an art to electrosurgery and there’s some very basic concepts that can be easily taught and remembered, that help us with that art of different tissue effects, when you use the tip of the hook or when you use the heel of the hook, that we all kind of recognize, but it kind of explains why. And it also goes through some of the safety issues. So, if you have, let’s say an implantable device like a pacemaker, if you’re pushing up the voltage to get that tissue effect, you may have more interference with those devices and so forth. So, I think it’s stuff that we use every day that we’re responsible for really understanding of it.

Chad Ball  50:06

I was hoping that we could end with a question. You may know, we ask almost all of our guests. Which is that, if you could go back in time and visit yourself, either as a surgical trainee and/or maybe a junior staff surgeon, what advice would you like to give yourself in hindsight?

Liane Feldman  50:24

I think, advice to my younger self is just to take it easy on myself. As a resident, I think it’s that everybody learns to operate. Somebody did tell me that and it helped at the time. I didn’t believe it, but it turns out to be almost entirely true.

Ameer Farooq  50:51

You 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.