E01 Robin McLeod on EBRS and a life in surgery

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Chad Ball  00:15

Welcome to Cold Steel, the Canadian Journal of Surgery podcast with your hosts Ameer Farooq and Chad Ball. The goal of the CJS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike. And most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons. We hope you enjoy it.

Ameer Farooq  00:50

It is my pleasure to introduce our first guest for the podcast Dr. Robin McLeod. She is an icon of Canadian surgery and is a general and colorectal surgeon. She’s also the visionary and founder of Evidence Based Reviews in Surgery (EBRS). She completed her training in general surgery at the University of Toronto, Colorectal Surgery Fellowship at Cleveland Clinic, as well as training in clinical epidemiology at McMaster University before joining faculty at the University of Toronto in 1985. She is now vice president, Clinical Programs and Quality Initiatives at Cancer Care Ontario. So just once again, thanks so much for coming on board to be our first guest on Cold Steel, the official podcast for the Canadian Journal of Surgery. You’re such an icon for Canadian colorectal surgery and general surgery in general. And so, it’s a huge honour to be able to have you as our first guest and pick your brain and get a glimpse into your contributions to CJS as well as to your career in general. Could you just define what Evidence Based Reviews in Surgery is, just in case anyone who’s listening has never heard of EBRS.

Robin McLeod  02:05

Evidence Based Reviews in Surgery is an initiative that was undertaken by the Canadian Association of General Surgeons, and the idea for it – or the goal – was to teach practising surgeons how to evaluate clinical papers. And so, for this, we had once every month for general surgeons, those were – they were the ones who were involved – that once a month, and we did eight a year and each package each month had a clinical article and then also a methodology article that they could use to evaluate the clinical article. And we had experts that were involved and so that there could be a discussion with the experts. And at the end of two weeks that we would send out a review of both the clinical article as well as the methodological article so that the participants could read what the experts said about it. And we did eight general surgery articles and four colorectal surgery articles every year.

Ameer Farooq  03:50

You know it’s funny, when I was growing up, my grandfather is a general surgeon and he actually used to be on the listserv when EBRS kind of first came out as its first iteration as a listserv. And so, I remember my grandfather reading EBRS. And clearly disseminating research has been a passion of yours for a long time. How did you first come up with the idea of doing EBRS?

Robin McLeod  04:21

Well, it’s sort of a funny story. When I finished my general surgery and colorectal surgery training, then I went to McMaster and there were so many great people there and they were the ones who first talked about evidence-based care. And so, I got really interested in evidence-based care and also in clinical trials. And then when I came back on staff at the Toronto General Hospital, I wanted to do a journal club with our residents because I agreed with the people at McMaster, you know, that they needed to learn how to assess a article and the methodology. So Toronto, being fairly large and multiple hospitals, it was impossible to get all the residents together. So what we did was we had journal clubs at the various hospitals. And the general surgery staff were very happy to chair them. But they didn’t really have a good sense of how to talk or teach about methodology. So, for them, I made what I called in quotes, tutors’ notes, and so that they used them at their own hospital to do Journal Club. And then Ori Rotstein and Bryce Taylor, who are general surgeons here, they thought that it was great and that I should try and get it pan-Canadian. And at that time, Bill Fitzgerald was the secretary of CAGS. And so I spoke to him, and he’s always been a strong supporter of EBRS. And so we also received funding from pharma and surgery technology. And so that’s how we moved from Toronto to CAGS. And when we moved, I should also say, when we moved to CAGS, that we formed an EBRS committee, which had individuals who had a clinical epidemiology background and were spread across the country.

Chad Ball  07:08

That’s fascinating. Really, really interesting. Dr. McLeod, what were some of the highlights and the lowlights that you can remember thinking back to getting it going, in particular, maybe some of the challenges and how you overcame them?

Robin McLeod  07:22

Sure, I think that it wasn’t as bad as you thought it might, you think it might be, because I had these surgeons who, you know, were fairly well known and behind me and Bill Fitzgerald also; he’s always been really supportive. And then we were just lucky to get some funding from pharma. So that really helped us. And then in 2005, I think it was, Richard Finley, who was the – had been the chair of surgery at UBC and was regent on the board at the American College of Surgeons (and I was also a regent) and Richard really liked Evidence Based Reviews in Surgery. And so that’s – we spoke to them and that’s how we got the UCF behind us as well. So you know, it was really pretty easy and support – everyone was very supportive. So it was good.

Ameer Farooq  08:34

How did you actually get people on board? Because clearly, my grandfather, who was a community general surgeon in Fort Saskatchewan had heard of this.

Robin McLeod  08:42

Well, you know, that was a bit of a problem. It’s so – I hadn’t thought about it until I was going to talk to you about this. And it made me think of how we’ve changed over the last 20 years. So one of the problems we had was that none of the articles were really available electronically. And at first, we didn’t – we just gave them the name of the participants. That is, that we just gave them the name of the article we were going to study that month. And then they’d have to go to their library and get it from there, or get it from them. And needless to say that that was – we didn’t like that because we really wanted the community surgeons to be involved and they might not have a library with these articles. So that was a big problem. And after about the first or second year, we wrote to a few of the editors of some of the bigger journals. And we said: do you think that we could download one of your papers, here and there, and that we could then put it on our website? And so I think that’s how we did it, or maybe we just gave it to them each month. But that was a big problem for us. And then we had the listserv, where we tried to get people to discuss things. But that was really difficult, too, because I think it’s much easier now. How you’re doing it is that people can just write something in and they – they’re not as shy to say anything. But that was sort of – and then we sort of just went along and it grew. One other thing I’ll tell you is that this is a good story – that Bill Fitzgerald, as I said, was a real, very supportive. And when we were going to implement this, he said: I think that you guys should do a randomized controlled trial, and one group would be surgeons who just got the clinical article for the month and then the other group – the surgeons – would get the article as well as the methodology article and also the discussion on our listserv. And he said: well, you know, you guys are all about evidence; you’ve got to show us whether this is – whether EBRS is better than just reading the article. And in fact, we got funding for that. And we did show that those people who did all of the works with the EBRS – that they did much better. So that was one of the highlights, really. And then we actually had a second trial that we did. And that was we – we had two groups. These were cluster randomized controlled trials, where we had several universities where the residents would just get the materials electronically and they would just read them themselves, as opposed to a journal club where, you know, that people were in person, and they really talked to each other. And again, not surprisingly, the one where it was a journal club, that the individuals did much better on that. So those are some of the highlights of this. I think that the only thing is, Chad knows this, is that in the last few years that we had difficulty continuing to get some support from our sources. But the new editors have done a good job in that. So we’ve been able to continue.

Chad Ball  08:59

That’s fascinating. Dr. McLeod, the EBRS session at the Canadian Journal of Surgery that you’ve kindly involved a number of us in is always really popular in terms of feedback and attendance. I was just curious for those who don’t know, you know, behind the curtain, so to speak, if you could explain how you select the articles both for the CJS session – sorry, the CJS in general, as well as the CSF in particular for that session?

Robin McLeod  14:02

Sure. So, I think that to get the attention of clinicians that you have to have an interesting clinical topic. And the great thing about general surgery is, you know, there’s a whole variety of different things from breast cancer to hemorrhoids, to, to name it. And so, we really tried to get topics that would be really of interest to clinicians. And most of them were clinical, but sometimes they were sort of more articles about the system and how to implement things and whatever. So, I think that because we chose a clinical topic which was of interest to the clinicians that we got their interest. And then we also gave them a methodology article to read and we hoped that that would help them understand why the clinical article might be a good article or not necessarily a good article, and then we did have the discussion on the listserv. And then at the end of two weeks we would give a synopsis of both – from the clinical side, as well as the methodology side. And when we had the Americans from the ACS on this and it was going out to American surgeons as well, we had two – one person, one surgeon from Canada, the other surgeon from the US, who would do a clinical review of the articles. And I think that really increased the interest, too, because most of the articles we chose that how we do things in Canada was similar to how they do things in the US. But in some, you know, they were quite different. And so that was of interest to the clinicians. But I think the real thing was that the clinical issues grabbed them to sort of get involved. And then they, once they did that, then they also started enjoying or reading the methodology, and then the articles that we showed or that we gave to them that did a critique of the methodology and the clinical paper as well.

Ameer Farooq  16:56

What are your thoughts on how things have sort of evolved over time?

Robin McLeod  16:59

I think it’s great that, you know, it’s come along, as we were discussing, that when we first started this we had lots of difficulties just getting hold of a clinical article that we’d have to ask the editors, etcetera, etcetera. And then we had a listserv, which probably no one knows what a listserv is now. And so I think it’s, you know, it’s adapting to particularly what younger surgeons are doing, you know, looking at their app and Tweeting and having that discussion that way. I think it’s much better, although just having said that, there is still something about getting people together in a room. And, you know, sitting and talking back and forth. And I think that you guys do a great job with the app and tweeting and stuff like that. But there is just a little bit lost by not getting everyone in a room to have a discussion. But, you know, residents and everyone else are busy. So I don’t think that, you know, it’s a little bit idealistic for me to think that we get people together in a room and talk about general surgery. So, I think that I’m very proud of how it’s just continued to be available and that it’s changed as we’ve gone along.

Chad Ball  18:35

It’s fascinating to hear how it’s evolved from you as well to think about how it’ll evolve in the future and where it’ll go in the next 10 years and 20 years. But looking backwards, just one more time. Is there a particular EBRS-related manuscript or series of manuscripts that’s fond to your heart and interested you?

Robin McLeod  19:01

Well, we publish just about every package, you know, that it would have a synopsis of the clinical article and then we do a evaluation of the methodology and then also the clinical article. And so we’ve got all of those out there in hinterlands somewhere. And so we’re pretty proud of that. And I think that you asked me a second question.

Chad Ball  19:37

Yeah, just does any particular paper that strikes your memory in terms of being particularly fun or controversial or enjoyable?

Robin McLeod  19:48

Well, you know, one of the ones that we did was probably 10 years ago, maybe. But it’s a while ago that there was an article, a randomized controlled trial, in the New England Journal of Medicine, that, and they had two groups of patients – one that was treated, I should say they had lung cancer, stage four lung cancer – and one group that received chemotherapy and the other one, palliative care. And so we did that one, even though it’s a little bit outside of general surgery. But what we learned from it was really important to all of us. And that one – that article, too – people really like that because I guess all of us would think that oh, well, if you guys have chemotherapy they’ll live longer. And it was quite striking that patients who were treated with palliative care did live longer. And I liked that also because it just shows that, you know, we weren’t just talking about how to do a hemorrhoidectomy or some ridiculous thing like that – that we were really looking at some of the things that we as clinicians might not know that much about.

Chad Ball  21:24

I totally agree that that paper had such a strong signal and says so much beyond the actual topic of lung cancer; it was a great discussion. I hope you don’t mind if we switch gears now a little bit from EBRS and hopefully talk about you a little bit.

Robin McLeod  21:45

I don’t really want to talk … [laughs]

Chad Ball  21:47

We know, we know. But you’re fascinating. And I’m sure we can all learn from you. Let me ask you what drove your initial interest in pursuing surgery as a trainee, and then in particular colorectal surgery after that?

Robin McLeod  22:07

You know, I was thinking about that. I really don’t know what sort of pushed me towards surgery. I just really always liked it from when I was a clerk. And I really liked gastroenterology. So, I liked sort of the GI part of it. I also had an uncle who was a general surgeon. Oh, and I should say, you know, when I finished medical school, probably before you were born, but anyway. I finished medical school in 1975, and at that time, like no female went into surgery. And my uncle really wanted me to be a surgeon. And then when I was a clerk and then I did a rotating internship and the surgeons who I worked with, they really supported me, so. And so, that’s how I got into surgery; it sort of wasn’t any big thing or anything like that. But I love it. Oh, and I’ll tell you one of the reasons why I like general surgery or at that time is there weren’t, you know, there wasn’t really great imaging around about that time. CT scans were probably started in about 1980 or something like that. And what I really liked about GI surgery is that in ortho or cardiac you put up the x-ray for ortho and then, you know, you don’t, that’s what you – you figure out, that’s what the operation is; in cardiac, not an x-ray but whatever study. And in abdominal surgery, what I’ve always liked is, you know, even with good imaging now you sort of have to think about what the clinical findings are and then use your brain to think about should we operate and what we’re going to do or what may be going on and if we don’t operate what the circumstances might be. So, that’s what I really liked about abdominal surgery. And that’s probably why I did general surgery and then colorectal surgery. But partly I did the colorectal surgery because my partner of many years, after I finished at Zane Cohen, was starting to do cockpouches and then we started doing pelvic pouches and strictureplasties and, you know, the surgery that we did do and then for rectal cancer and, you know, it was very, you know it was, difficult surgery. And then reoperating on patients who had been operated on before, there were real challenges. And so I think that’s why I particularly liked colorectal surgery because of the new things that were coming along. And also just that operating on the belly can be quite difficult.

Chad Ball  25:47

In terms of research, Dr. McLeod, you mentioned that your time in McMaster certainly brightened and focused you with regard to EBRS. But how is it that you got interested in the research component of our practice so out of the gate?

Robin McLeod  26:05

When I was a resident, I actually did some basic science research. And then, as I said, I went to Mac when I finished and I really could not be a bench researcher at all. I just wasn’t as interested in it. But I loved everything that I learned at McMaster. And I think also that, you know, it fit well with the clinical work that I was doing also. And so I am, you know, I’ve really had an interest, sort of an over, over, over sounding or whatever, oversight with evidence-based surgery. And that really is what I would say what I was really interested in. And so I did some clinical trials, clinical ones with the IBD patients, as well as colorectal patients and cancer patients. And, but then I also was interested…so that was what I consider getting the best evidence. But then, as we’ve been talking about, I was really interested in ensuring that people use that evidence. And particularly, I felt very strongly that if we want our residents to use evidence when they’re out in practice, that we have to be teaching them the skills to – as to how to evaluate articles, and that’s where EBRS came in. But also, subsequently, that we had an initiative at U of T, best practice in general surgery, and that’s where we all came together. And we reviewed the literature, but we also came together so that we agreed on the guidelines. And so, the example I use is that I thought that it would be terrible for patients or the residents to come to the Mount Sinai Hospital and we’d use antibiotics A and B for colorectal patients, and then they’d go to Sunnybrook and they’d try – and the antibiotics they’d use were C and D, and then they’d go to another one and they were different ones as well. And so it was a terrific initiative, I think, that it brought us all together in the seven or eight U of T hospitals, that we developed these guidelines and they were evidence based, but also the residents liked them because they didn’t have to learn different processes if they came to hospital 1 and then hospital 2. So that’s really what ties it together, as I really believe in evidence-based care and doing the studies so that you can get the best evidence, but then also implementing it.

Ameer Farooq  29:54

That’s really fascinating, Dr. McLeod. Do you think, like over time, we’ve gotten better as sort of clinicians and residents, at kind of adhering to understanding the evidence behind things and doing things according to evidence base?

Robin McLeod  30:14

Yeah, I think that we’re much more aware of evidence and using guidelines. When we started best practice in general surgery in 2006, it was interesting that the reason that we started it was because we wanted people to use the best evidence, but now we don’t call it that anymore; we call it quality improvement. And I think that with quality improvement, that obviously, you need to have evidence but it’s much, you know, like I think in every province in every hospital there are quality initiatives. And, you know, NSQIP is a good example. And so that it’s come a long way. And so I think because of that – that we’re using more guidelines and also our performances being assessed also. So yeah, I think that we do. I think though that there’s a lot better or a lot of other things that we could do, you know, that choosing the right antibiotics and mechanical bowel prep and DVT prophylaxis, like that’s just sort of the start of things. There are so many other things that we should be doing and we could do better. But we try.

Chad Ball  31:48

What is an average day in your practice? What has it historically looked like? I guess is the first question. The second one would be what optimally would you want it to look like? And, how do you manage that, and balance all that, as well with being, you know, a mom and a husband, sorry a wife, and all the other social things that you do?

Robin McLeod  32:15

Well, I’m not that wonderful. So, take that line out.

Chad Ball  32:18

I don’t know.

Robin McLeod  32:20

But, I wouldn’t change my practice at all. So, I operated two days a week; I was going to clinic one day, and then two days a week I was over here at CCO – one or one and a half of those days at one time and the other two doing research or other things like that. No, it was good. But I’ll tell you really, how this – the best thing. It’s so funny, actually, is when we were – when I was first in practice and we had two small daughters – that my husband was busy, too, that we would come home on Friday night and my husband would say: I’ve got to go into the office this weekend, so I’m going to go in on Saturday. And I said: well, I’ve got work to do also, so you have to be at home on Sunday, and I’ll go in on Sunday. And you know, it was really awful for a lot of reasons, you know, like that we didn’t see each other or whatever. So, I came up with this idea that Monday, it was one of my days when I – my research day and I wasn’t operating. So, I would stay in my office till about midnight on Monday. And my husband knew that he had to be home on Monday night and he’d, you know, give, get dinner for the girls and everything like that. And that was my night. And, you know, you can think of it, it’s all, you know, if I was there from six until midnight or something like that, that’s sort of like a whole day, you know, on the weekend. But I didn’t do anything on the weekend, unless, you know, I had a few little things, but that’s when I would do it. But the funny thing is that my husband loves playing tennis and squash and plays a lot and has a lot of friends. All of his friends were scared to ask him to play on Monday because they knew that I would not appreciate it and they would get a lecture from me. So, that was sort of the big joke in our family that John could not go and play with his friends on Monday night; he had to be at home. So, that is the only sort of thing that, I guess, is sort of a little thing that was good for my research.

Chad Ball  34:56

That’s great. I think that just in terms of closing, is there any parting advice that you would be willing to provide or recommendations or advice in general to any trainees that will be listening to this, at any level, whether that’s medical students or residents or fellows or junior staff or anyone?

Robin McLeod  35:22

Well, I think that I would tell them that we are very, very lucky to be surgeons. It’s such a great occupation, such a wonderful thing. But I think that we always have to remember that it’s the patients that we need to think about, and their care. And we have to treat them like human beings and it’s all about them. And I think that more and more we’re starting to be – have more engagement, more asking patients what’s important. And I think that’s what we need to do. I think that, as I said, that we’re very lucky to be in such a rewarding occupation. And I, for me, I think the academic part of my career and teaching and education were just really important to me. But it’s been a fabulous career.

Ameer Farooq  36:44

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.