E04 CSF edition: Kelly Vogt on the Evolution of ACS & Tips for a Career in Academic 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

Today we are recording live from the Canadian Surgical Forum or CSF. This is the annual conference that brings together general surgeons from across Canada. We had the pleasure of sitting down with Dr. Vogt who is a trauma and acute care surgeon. We talked to her today about her work on acute care surgery, and her early prolific career.

Chad Ball  01:08

Kelly, we’re here at the Canadian Surgery Forum and you’ve been kind enough to engage us on Cold Steel and we’re really, really excited about that. Just to start and sort of stick locally, what do you like about the CSF, you’ve been coming here for a lot of years, and what are the sessions and the content and the things that you seem to enjoy the most.

Kelly Vogt  01:31

Thanks so much for having me, I’m honored to be on the podcast and live at the CSF. The CSF has been such an integral part of how I grew up as a surgeon. I’ve been coming since I was a resident and it’s so fun to go from residency when you get to come and see your peers from across the country and just full of ideas and excitement and go to sessions that are interesting. And I really remember that as a resident. And now as I’ve transitioned into practice and some administrative roles, it’s such a wonderful opportunity to get together with colleagues from across the country, see friends that I don’t see on a regular basis, and be part of not only reviewing what we’ve done, but in generating new knowledge and working towards improving surgical care in Canada. I think the meeting is really cool because it brings leaders from all across our country. And also, people who are up and coming in leadership together to be able to come up with new ideas and take them home, provides an opportunity for us to work together collaboratively, which I think is a tremendous strength of the Canadian surgical system.

Chad Ball  02:41

Yeah, I think we couldn’t agree more. It’s a special place and it’s very Canadian, it feels different than international American meetings.

Kelly Vogt  02:49

It really does. Yeah.

Chad Ball  02:51

You’ve recently taken over the role as sort of the national lead for acute care surgery, emergency general surgery or the newly formed Canucks group. Tell us when you create content for a stream like the EGS acute care surgery stream, what sort of elements go into that? How do you pick speakers and topics? And how do you view that?

Kelly Vogt  03:16

We’re so fortunate in acute care surgery or emergency general surgery, whichever term you prefer, that so many dynamic leaders in the country are really a part of our group. And so, when we sat down specifically this year to develop the content stream for acute care surgery, what we talked about is, how can we help all the general surgeons in Canada. And so, what we landed on was really clinically relevant pearls, tips and tricks our session was all about, if you’re alone in the night, what do you do in those difficult circumstances. And I think we as a group feel that that’s what resonates with most of the surgeons and the trainees that are attending. So, we had a great session yesterday where we had experts in their fields talk about complicated biliary disease and complicated colorectal disease. And really, you know, surgical rescue or this idea of complications in general surgery, all stuff that’s supremely relevant not only to the acute care surgery specialist, but also to every general surgeon who’s operating across this country.

Ameer Farooq  04:22

It’s great to have you here and actually talk to you in person and really dissect out one of the papers that we found fascinating indicating general surgery. And one of that you published in your very early prolific career, a number of papers even in CJS, but one of the ones that stood out to us was the paper entitled beyond just the Operating Room, Characterizing the Complete Case Load of a Tertiary Acute Care Surgery Service, which was published in 2018. So can you tell us a little bit about what inspired you to write this paper and to do the study

Chad Ball  04:22

That’s great.

Kelly Vogt  05:00

Thank you guys for highlighting this paper because I think it’s a really one of the really interesting things that we’ve done. And I should start by giving credit to our medical student actually Tunis who did the majority of the work on this paper is now doing residency not in surgery, but still spectacular guy. So when we sat down and thought about this paper, it really was framed in the idea that we’ve talked a lot and most people listening will know, that emergency general surgery care has changed in the last 20-25 years. And it’s become in many centers, not all but in many centers segregated into acute care surgery or emergency general surgery services. And along with that change, came some research and some publications looking at that concept. But the early work really focused on what were we operating on. And because it’s general surgeons, we operate a lot on appendicitis and biliary disease, there was a lot on how did these services modify the way that we treated those diseases. And I think that’s tremendously important. But what we felt was lacking in the literature at the time was a more comprehensive understanding of what these services do. Anybody who deals with this patient population knows that, first of all, we operate on more things in the appendix of the gallbladder. But also, we don’t operate on everybody. And not everybody is admitted to our service. So many patients come from the emergency department, not all of them do. So, the idea behind this paper was really to take our acute care surgery service and describe everything that we did, every patient that we interacted with, where they came from, and on a macro scale, what happened to them? Did they have an operation? Did they have an intervention that wasn’t an operation? Did they have no operation? And then a little bit about their trajectory in terms of after they were discharged from hospital did, they come back? Or did they end up needing an operation?

Ameer Farooq  06:51

Can you tell us a little bit about the methods of how you actually conducted the study and which patients you chose? And the little bit of the nitty gritty and how you actually did the paper?

Kelly Vogt  07:00

Yeah, absolutely. So again, really helpful to have a medical student who did this as part of a summer research program, because we wanted to capture stuff that you can’t capture retrospectively. So as a prospective cohort study, we did it over a two-month period. And basically, what our student did was go every single day, hang out with the ACS service, and see what they were doing. So, we captured every patient that the ACS service had contact with, whether that was through just a phone call, whether it was through a consult from an in another inpatient service, a consult from the emergency department and interoperative consult. So, every patient was captured. And then we followed them prospectively till 30 days after their surgery to see what happened with them.

Chad Ball  07:45

Kelly, you touched on the reality of a mature emergency general surgery to care surgery service, not operating on everybody? In other words, we tend to look after a real broad range of folks from minor, semi minor analysis right up to critically ill. What was your findings? What were your observations about that cohort that we don’t operate on? What are your overall thoughts? And also, you know, the cuts of clinical part, but then from a system part in terms of who provides the best care? And how do you view that whole segment of the folks we look after?

Kelly Vogt  08:24

That’s a really great question, Chad. So, I think you have to look at people we don’t operate on as falling into two, maybe three camps. There’s the people that you meet, that are consulted to you from whatever way they get to you, that you meet them, and you know that they’re never going to get an operation. And in those people, sometimes it’s the disease process. Sometimes it’s, you know, this person has terrible pancreatitis right now, and their gall bladders already out, and we need to look after them because they’re sick, but they don’t need an operation right this minute. And sometimes it’s this patient is too sick, and they’re never going to get an operation, and whether that’s sick because of the acute illness, or it’s sick, because of whatever they had their comorbidities before, it’s clear that those patients are never going to get an operation. And then there’s the people who definitely are going to get an operation, and that’s the patients who come in with acute appendicitis or perforated viscous or something that we know we just have to do an operation on them. And then the most interesting group, in my mind are the ones who come into hospital, or we get consulted for who have a disease that may be operative, and maybe isn’t. And the classic example of that is an adhesive small bowel obstruction. Do we watch them? Do we operate on them now? Do we operate on them later? What do we do? And so, in the context of who’s the best person to care for all those patients, I really strongly believe that the one of the greatest benefits of this acute care surgery model or whatever you want to call it, is that it takes all those patients with a common problem of derangements in their physiology plus or minus derangements in their anatomy, and have them cared for by experts in dealing with sick patients. I think that what separates the acute care surgery expert from an elective surgical expert, is that the acute care surgery expert focuses all of their time and attention on patients who have derangements in their physiology, on patients who are sick. And I think that that’s what makes us a little bit more aware of the impact of changes in that physiology. And ultimately, hopefully, is providing the best patient care for that group of patients.

Ameer Farooq  10:37

Do you see that evolving over time? Or, of course, this practice varies from place to place. But do you see our role being different, like turning some of these diseases as interests where we can kind of exclusively consulting service? You know, how do you see that playing out?

Kelly Vogt  10:53

I think you really touched on it, that there’s a lot of practice variability across the country, certainly in my place, what the diseases you mentioned, are already the purview of our general surgery service. And, you know, I’m biased in saying that I think that’s good care for the patients. I think the extent to which your hospital system allows for collaborative work between services really is going to define how the patients have the best outcome. If you’re set up that you have a service, that’s going to admit those patients who’s going to provide the same frequent reassessment with an eye to potential need for surgical intervention, who’s going to stay on top of the fluids and the best evidence in managing the care of that patient? Who communicates well with the surgeons, and frequently with the surgeons, I don’t see that as being a problem. I think in fragmented systems, though, you run the risk of running into trouble for patients who have potentially surgical problems managed on non-surgical services.

Chad Ball  11:57

Just to take that concept a little further. Kelly, we know across this country, you know, that being Canada, that the structure of ECS services varies widely, both in terms of resources and footprint, as well as in terms of participants within those services. What’s your overriding philosophy or thought on, you know, one model, which would be really truly we hire six to eight acute care surgeons to run that service, like paddled military service and transplant service, a trauma service, versus a more multidisciplinary group where you might have a colorectal surgeon one week and HPV surgeon another week, and then an endocrine surgeon potentially for a third week, as long as they’re doing enough of those weeks. What’s your senses are one that’s better than the other? Or is it all good? What do you think?

Kelly Vogt  12:50

Yeah, so you’ve touched on a what I would consider probably one of the biggest controversial topics in acute care surgery in Canada right now. And I will provide a little bit of background of when I did train in the US. So, I had the opportunity to see how that system differs a little bit from our system. And I think what I took away from it, or at least one of the main things I took away from that, was how different Canadian departments of surgery are than American departments of surgery. And the biggest difference I noticed, is in the collegiality, and the ability to work together as a group. And I bring that up, because it actually is fundamental to the way that I think about the question that you asked. I think that, as I said before, if your group doesn’t talk to each other, if they don’t work well together, if you’re not able to pick up the phone and call someone who has different expertise than you, from the clinic or from the operating room, that’s where I see the benefit of having an acute care surgery service run by acute care surgery experts only. In Canada, where our colorectal surgeons and our HPV surgeons, and our surgical oncologists communicate within our departments of surgery with our acute care Surgery Specialists, I actually think that diversity in the ACS service in that model, is probably a benefit, not a detriment to our patients. The key there is that if you’re outside of your comfort zone, and whether that be because it’s a complex trauma patient and you don’t manage those very often, or because it’s a terrible gallbladder and you need help from your HPV expert. What matters is that you are comfortable to pick up the phone and call someone to help you. And we see that in our place all the time. You know, and I my sense is that that’s the same across the country. So, in answer to your question, when people work well together, I think it’s valuable to have different sub specialists staff your ACS service.

Ameer Farooq  14:53

One of the other challenges, I think that’s highlighted in your paper is that there’s a fairly high readmission rate and representation rate to the emergency department and readmission back to the hospital after being discharged from acute care services as highlighted in your paper, and how do you see that further follow up, going for acute care surgeons who might not necessarily in many places have a ACS follow up clinic or predefined way of following up, especially with patients that aren’t operated on?

Kelly Vogt  15:30

Yeah, I think that’s probably one of the big things that we need to sort of talk about in ACS. I think there’s two important points to make when you look at the high rate of return to the emergency department and also the high rate of return to the operating room for our patients in this cohort. And broadly, in ACS across Canada. I think the first thing is it highlights, we take care of sick patients, you know, at a baseline, our patients have acute surgical or maybe even non-surgical problems, they have baseline comorbidities, you don’t get to optimize any of that stuff before they come into your care. And so at a baseline, they’re sick. And I think there’s always going to be returned to the emergency department and a later delayed operation, that group of patients for that reason. I think part of it is our fiscal constraints and our desire to get people out of the hospital as soon as we can. And I think for the most part, that’s good for them, we just need to be a little bit more precise and who we’re choosing to do those things in. But I think the biggest thing we took from this is that high number really identifies for us that there’s room for improvement in the way that we’re caring for the acute care surgical patient. I have lots of theories. But the interesting thing about ACS is that, like trauma was you know, 50 years ago, we’re just at the beginning of this. We don’t systematically collect data on these patients, we don’t systematically review data on these patients. And so how we can actually intervene to improve the quality of care that we’re providing, I think is largely unknown. And one of the great things about ACS services is it puts all the patients together; we can capture them much easier than we used to be able to do. And so, one of my big vision things, one of the biggest things that I hope we can achieve in the next five years, is some sort of way of frequently capturing or capturing all the data for all of our ACS patients. So that we can use that to inform practice change research to but also quality improvement so we can reduce some of this readmission.

Chad Ball  17:41

It’s a really neat time to be, you know, I would say either training or, or working at the at the front half of careers, right, like this is, this is crazy. I agree with you. I mean, this is sort of what you think that trauma felt like in the early to mid-80s.

Kelly Vogt  17:57

Yeah, I think it’s so exciting. I feel so privileged to be a part of this at this stage of it, because we really just have so much opportunity. I think we can do so much good for the patients.

Ameer Farooq  18:07

Maybe we can transition talking a little bit more about you and in your career and, but maybe you can tell us a bit about kind of where you grew up, where you did your training and what your practice is kind of like now clinically and academically.

Kelly Vogt  18:23

Sure. So I was born in Edmonton, but my parents moved back to Ontario when I was six months old. So I grew up by in Ontario, mostly in Oakville, just outside of Toronto. I had an awesome upbringing. I lived with my parents and my three siblings, and we were all pretty close in age. So that prepared me well for the scrappiness of surgical residency, I would say. I did my undergrad in Waterloo and that was pretty important. I did an epidemiology course there, which was my sort of first introduction to epidemiology and research and just fell in love with it. So much so that I debated between doing my PhD and going to medical school in the first place. But, you know, I ended up saying yes to the medical school where I went to Western, and I did my surgical residency there are too. Really incredible mentorship from numerous people. Dr. Ron Holliday, who got me into general surgery in the first place. I was, at one point going to be a pediatrician, really glad I didn’t take that career path. And then Dr. Murray Jurati, Neil Perry, Darrell Gray, who really showed me how awesome trauma could be and kind of led me down that path. I was fortunate enough to do my fellowship at LA County with Dr. Demetriatus and Dr. Inaba and a tremendous group of people there and learned a ton in those two years in Los Angeles and then came back on staff at Western

Chad Ball  19:47

Kelly, looking back, you know, five years out from the start. What would you like to have told yourself or what would you have liked your younger self to have known you know, as your transitioned, particularly in the first couple of years and maybe beyond?

Kelly Vogt  20:05

So the thing I tell my trainees now, because I wish someone had told me this along the way, is that the medicine is, by and large, the easy part. You spend so much of your career, all of your career before you start your staff job learning how to do the medicine, the operating, the clinical care. And by the time you finish your training, you’re pretty good at that stuff. I mean, there’s still hiccups, and you know, in your first year, you’re going to see things you never saw in your training, but you have the building blocks to be able to come up with the solutions. What very few people highlight in your training is all the rest of it. The administration, how do you fit the research in? How do you have a life when you haven’t had a life for so many years? Because all you’ve done is train. So, I wish someone had told me that ahead of time.

Chad Ball  20:55

So what’s the answer? How do you do that?

Kelly Vogt  20:59

I don’t know yet. I’ve been doing this for five years. The things that I’ve learned, at least in part, are you can’t figure out all the answers until you start. You can’t figure out all the answers maybe until you finish or maybe never. But certainly, you have to be in those positions before you can start to figure out how to do them. I will say that probably the biggest transition I’ve gone through is the transition to becoming a parent. Because that really has impacted my work life more than I ever thought. And trying to figure out how to balance work and life when life is two small children who depend entirely on you, has been the most challenging, also the most rewarding but the most challenging thing I’ve ever done.

Chad Ball  21:50

You touched on a little bit in terms of mentorship early and influence early but I’d say obviously, it is clear to everybody, your immediate group, your support group at work, your colleagues, can really make or break your initial few years for sure. Tremendously, you know, it can either really set you off on this great path, or really lead to a long period of struggle. And you know, as I say, often as you guys know, your group in London is fantastic.

Kelly Vogt  22:22

I could not ask for more incredible partners. And really, I mean, our division under Ken Leslie’s leadership, and I mean, you just look at who’s in my hallway with me, you know, Ken Leslie’s office across from mine. Mike Ott, Darrell Gray, Neil Perry, Chris Vinden. I mean such incredible people to work with, to run ideas by, to support you, in and outside the operating room, I would be nowhere without that support.

Ameer Farooq  22:52

What does a typical day look like for you? Especially we were talking about the fact you have two kids, and what the typical day is like for you? Or a typical week like for you?

Kelly Vogt  23:02

Yeah, so we’re really lucky in that, you know, myself and a couple others in London actually were really hired as acute care experts. So, we do weeks of acute care surgery, weeks of trauma, and then have other weeks that are more focused on administration and research. In terms of a typical day, our just turned one year old gets up around six. So that’s usually when I’m up in the morning with her and our almost just over two-year-old is up a little after that, which is actually lovely, because I get to spend a bit of time with them in the morning, before the nanny gets there and then I head off to work. My days vary, but I try really hard to, to stick to just short periods of time on my email, because I find that that’s a real time waster. So, my first 30 minutes of the day are usually a coffee and dealing with my email, no matter what my day looks like. And then whether it’s our acute care surgery clinic or trauma clinic or whatever other clinical things I need to do in that day, they get done pretty early. I like to spend my mornings working on research, I find it easier, my brain doesn’t function as well, during the day. So, if I have writing or analysis or things to do, I tend to do them a bit earlier in the day and I leave my administrative tasks, which generally seem to be a bit more task oriented and easier to check off the list more towards the end of the day usually. That’s on a week that I’m not really doing as much clinical work so, and then home for the kids and feed them and give them baths and put them to bed and then either my husband and I get to spend a little time together or we both pick up our computers and have work to do.

Ameer Farooq  24:36

Do you have any advice for someone potentially, who wants to be an academic surgeon? You know, beyond role models, is there anything else that you would have as advice.

Kelly Vogt  24:47

I was lucky in that the way my residency was structured at the time I was able to take a year in the middle and do my Masters which I did a masters of clinical epidemiology at McMaster at that time, working with the group at Mack who were really the you know, founders of clinical epidemiology gave me a tremendous footing to start off on this academic career. The first piece of advice I would give is, do it if you love it, because it’s hard, after a long day to write a paper, it’s hard to keep getting rejected, and have to turn the stuff around and keep working on something, you know is important, but you can’t quite convince the rest of the world is important. So, if you don’t love it, don’t do it. And then in terms of the practicalities, the other piece that has been very helpful for me is I’m currently working on my PhD, which gives me a nice structure to my research program. The biggest two things I can say that have helped me be productive so far in my career. The first is finding a way to protect your time, which sounds easy, and in fact, my contract says I get 75% percent protected research time. Remembering that nobody’s going to protect that time except you. So, for me, sometimes that means turning the lights off in my office and shutting the door so that people don’t know I’m there. But I can actually spend that time writing or doing what I need to do to be productive academically. Or even working off site sometimes, if I don’t have clinical responsibilities that day, finding a coffee shop or somewhere else that I can work. And the second you said not to talk about mentors, but I think it’s really important to recognize that I wouldn’t be where I am without people like Chad, who have helped me along the way. Find people who love what you love, and they will be so thrilled to capitalize on your enthusiasm for it and help you along the way. Even if Chad’s not writing the papers for me, the fact that he supports my ideas, and I can bounce things off of him or he can give me advice, has helped me more than probably anything else in my career. So, working with people who are like minded, who have the same vision and same goals that you do, will make work not only fun, but so much easier.

Chad Ball  27:01

You’re too kind Kelly. I’m going to ask you a bit of a pointed question and then a real fun question to end. Yesterday here at the CSF, there was a group of us talking about a statement that someone who’s well known had made and he sort of said that the era of the triple threat surgeon is dead. And, you know, as we discussed the triple threat concept comes from Hopkins in Baltimore. And I sort of argued that maybe or maybe not that’s true, because the original embodiment of that statement from that group had to do with basic science research, clinical care, and clinical education. And there’s not too many of us doing basic science research anymore. I would argue that those people still exist. And those programs still exist. And it just looks different than it did in Hopkins in the 60s. What do you what do you think of that?

Kelly Vogt  28:10

I agree, and I disagree. So, what I’m gonna say is that I think that there are some exceptional people that choose to be surgeons. And I think what makes the surgeon scientist, however you define that. Maybe the coolest people that I know, is the fact that they take their opportunities and opportunities, I mean, they’re training, the patients that they see every day, the people they interact with every day, and they turn those opportunities into ideas, and know how to ask questions where the answers matter. And to me, that’s the most important triple threat that we can still provide I think in our clinician scientists. They ask the questions; they know how to answer the questions and they know how to take that information and translate it to the broader population. So, I think they exist.

Chad Ball  29:07

Our last question for you is one of your many passions about wine? And you and your husband are rapidly becoming known as important wine connoisseurs, so to speak, or collectors or from an ignorant person on that level, I don’t know what the terminology is. But tell us what you love about the wine world so much why you love it, and why it’s so central to your life and maybe even if there’s anything analogous or not to your professional life.

Kelly Vogt  29:37

Sure. My love of wine started actually with my dad. My dad and I are very similar people which as you can imagine as a teenage girl that meant we fought a lot and when I was early in my training, I got the opportunity to take a trip with my dad and we went to Napa, just him and I which had never happened before and we bonded like we’ve never bonded before over that wine and so it started out as an emotional thing for me. And then the science of it became tremendously interesting and trying to understand the different varietals and how you understood what they were, and I have really enjoyed trying to pick it apart in a scientific way. And then when I met my husband, he jokes that if he had responded, I like white wine to my first question of what kind of wine do you drink, we probably wouldn’t still be together, but and he might be right. But what he did say was Cabernet Sauvignon, which is my favorite, and our relationship grew actually, in the vineyards of Napa, we ended up getting engaged there. And so, the emotional piece of it for me and for us as a couple really has been a tremendously important part of why we love it so much. You open a bottle that you drank at a special time in your life and brings back memories. And other than liking the wine, that kind of stuff really helps. I don’t really link it too much to the job other than to say that sometimes at the end of a long day, it’s probably the only thing that makes me feel better.

Ameer Farooq  31:19

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.