E05 Scott Gmora on surgical training

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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

In this episode, we had the pleasure of interviewing Dr. Scott Gmora. Dr. Gmora is a minimally invasive and bariatric surgeon at McMaster University, we had a blast talking about a variety of topics, but in particular talked a lot about surgical education, almost magical process of producing a surgeon. There’s some real pearls here for surgical residents, and I’m just gonna get out of the way now. And let’s get to the episode.

Chad Ball  01:16

Dr. Gmora, thank you very much for being on the podcast with us. We know how busy you are, and it’s really a pleasure to have you on. In full disclosure to everyone who may or may not be listening, you and I have been friends and known each other very closely for what’s shockingly, almost 20 years now, guess it’ll be 18. I think I know you well. We’re going to try and steer this conversation in a really interesting place. Because I’ve always been enamored with and to be honest, jealous of the way you think. And I really do mean that despite your disdain for the word, you’re an innovative thinker, and we’ve always learned a lot from you. So I thought maybe we would start in just give the listeners a little bit of knowledge about your pathway through clinical medicine. It’s been a little bit different than most, you know, you and I started out as residents together, you pursued a trauma surgery fellowship that you completed at Ryder and in Miami, and then went on to New York City, and did bariatric surgery. So, tell us maybe give us some insight into what you were thinking and, and how that pathway evolved.

Scott Gmora  02:24

Well, firstly, thank you for having me on your podcast, and congratulations on the success of your podcast, with a lot of people talking about it. So, I know you’re a humble guy, but it’s fantastic when you guys are doing. Yeah, I mean trauma, holy cow. There is nothing that beats trauma. I don’t have to tell you that. I missed trauma so much. It’s all I’ve ever wanted to do. I think both of us, I mean, I try to think back, right, 2002. And it was certainly my first rotation on general surgery. And there was just no question. This is what I was good to, funny enough for the rest of my life. There’s this, I don’t know, there’s something that happens when you see when you’re dealing with that. I mean, I’ll be rare, but that’s exsanguinating patients, and it’s you and that patient, there is nothing going on in your head, there is no internal dialogue. It’s so primal, and I don’t know, there’s this kind of, I don’t know, beautiful purity, you know that that kind of happens in trauma in those situations. And, again, I don’t have to tell you this, I think we’re on the same page, but there’s nothing that kind of compares to that. I think for me, at least in surgery or medicine. And I don’t know, it’s kind of interesting, that’s even kind of a purity in not having to focus on surgical technique in a way. You know, I think in trauma, when we talk about technique, we talk about, we really mean efficiency, right? I think, like a really technically good trauma surgeon has that kind of battery of knowledge, and pattern recognition. But it’s kind of speed exposure, it’s not a meticulous dissection, they know their anatomy, well, they know where they have to get to they have to deal with that problem. And I think, you know, in elective surgery, like the scorecard difference, you know, the scorecard is much more of that, “can I attain perfection?” In trauma, the end result is really simple. If you stopped the bleeding, like that’s it. That’s right. You know, and I think like, you know, an elective it’s a little bit you know, not to overuse, the kind of analogy of playing a video game or something but the ability to kind of redo something. You did your first Whipple and I’m sure it was great, but your second level was better, and I know your third Whipple, you’re like, I’m gonna be better than my second level, and then by your fifth 500 Whipple, you’re like that’s gonna be but there’s this constant improvement trying to get to perfection, which you can never get. And so for me, you know, I’m going to be a trauma surgeon and then I had, you know, this idea of like, well on my off week from that I need to have an event skill set. I don’t want to just kind of be a generalist for me. So our mutual friends, Shazia Karmali, you know, I want to do laparoscopic surgery. And he suggested, you know, do geriatrics, which, to me was laughable at that time, it was nonexistent in Calgary. And he gave me really good advice. He said, do bariatric and make sure you do with somebody who does a hands-on and ask the most of them. I didn’t really kind of get it at that time, but I did it, and it kind of changed. It changed everything, I’m sure we’ll talk about it later. But just kind of that ability to kind of hone a small number of kind of surgical procedures and getting to mastery was so appealing and also the patient population. Funny enough, you know, in trauma, the quote-unquote real or the severe, or the unstable traumas are often the penetrating trauma. Now, population, as you know, as you can tell me better than I can tell you, when you crack your chest and stop bleeding, you know, from their heart, they don’t wake up kind of grateful that they are alive, and a lot of ways that they’re really not happy that they got shots, so it’s like it’s a unique patient population. And in bariatric surgery, these patients are coming in, they’re crying, and they’re ‘thank you so much, you changed my life,’ came to recognize them and I think different people. I made a call, you are probably the only person I know that’s been able to kind of balance that wave into both worlds and that’s the kind of man I’m jealous about that you can kind of have a foot in both worlds. I ended up kind of making a decision on going with the latter, becoming a laparoscopic surgeon and kind of giving up the trauma career just as much as I regret or at least miss doing so.

Ameer Farooq  06:49

That is a fantastic, I think, very poetic description of trauma surgery and very cogent reason for the choices that you made. I’m curious how your bariatric fellowship kind of changed your philosophy on learning and teaching laparoscopic techniques.

Scott Gmora  07:09

It’s such a good question. It profound I almost lost my mind during fellowship, it profoundly changed. During the during my bariatric fellowship, it completely changed how I did surgery, you know, like, again, we’ve spoken about this in the past, but it’s always amazing to me, how the heck, we actually train people to dislike, how it works at the end, how is this back in the day, and still to this day, you kind of come in? You’re, we’re doing open surgeries for the most parts from when we were training. And there’s no way to practice there. We have Zoolander, like an atlas where you know, a total gastrectomy is basically three illustrations. And you’re like, okay, like, no, I guess that’s I do a total instructed me, right. And it was pre-YouTube, we had no videos yet. So it’s nothing. There’s nothing right. And so, like, I always kind of think, like, imagine, like, you had like a bad boy, just like one day, like in a major league game, you like the bad boy, like, “Alright, you’re gonna pitch this game.” And they’re like, “I don’t, I’ve never pitched, yeah, don’t worry.” It’s like, “you’re going to pitch and then attention.” And they can’t even get to the you know, to the hitter, and they go, but most of them you’re not ready yet, you know? And then, you know, two months later, like, “Oh yeah, come back up here, try that again.” And it’s like, it would never happen outside of surgery. It’s how we teach residents, we just, they just watch and then one day, you’re like, yeah, to do it, and then they can’t do it. Well, you’re like, you, let me take that it’s okay. This is a hard case, let me do it. And then you do it. And then they go back. And somehow, at the end of that, they kind of get the confidence. But what happened, you know, was at the end of trauma, we had, I had this huge revelation with my co-fellows doing trauma. And that was note, and writer of trauma is like, a lot of the injuries and trauma are rare. I don’t get I don’t have to tell you, you know that some clavey and the cables, and it’s not something you’re going to hit every night or even senior fellowship, you could just not be on call on the night that you have these things. And we were noticing that, you know, I had a run, right, like was doing for economies almost every night and my co-fellow had never done one and my co-fellow had done, you know, a bunch of these vascular injuries. And I had it we had this idea of what happens if we, again, this is what it was our fellowship chat, it was like 2006-2007, something like that. And we kind of bought at that time, it was ghetto, but we bought like this head cam, you know, it was like, I guess, the equivalent of a GoPro or something like that for the time. And we can say like, Hey, we’re going to be on call. What we’re going to do is we’re going to just record the trauma cases. And that way we can have, you know, like I can see with you know, Dan, my co-fellow did and he could go have this like library of cases. Again, pre-you, you had no way, you know, if someone wanted to, if he wants to learn how to do an ER thoracotomy, you read a book, or maybe if you were lucky, you saw once in your residency over and over your staff person shoulder that you had no way of learning that. And we kind of put these cameras on our head and we got these really unbelievable footage, because you’re really looking through the eyes of the surgeon, you know, when, when the phone looked up at the vital signs monitor, you know, obviously the cameras answer that and you kind of see, we had like this great footage, and we were able to teach yourself or at least way better. What, oh, how do you fix the cardiac injury or this or that. And I guess my point is in a long very winded way, when I got to geriatrics, it was similar because we were able to record cases. So, holy cow, to be able to record a master, the person who’s training you doing a case, and to be able to watch it 1000 times, and at that time, the iMac had just come out, and there was iMovie, which was like the Apple, you know, moving kind of, you know, editor and stuff like that. And I just got this huge kind of archive of, you know, Doctor Toshiro, who is training the him doing it. And, and things that look like magic, I realized worth kind of magic, like, you know, he would, you know, my laparoscopic skills in retrospect were very limited when I started fellowship. And I would look at him and he’s just like flipping a needle, like a yo-yo, like, poof, it just lands perfectly. And I couldn’t do it. I could not understand how to load it. And then you slow down the video and kind of look and you’re like, oh, he turned his instrument 10 degrees. And then it just oh, that’s and you realize what looks like magic. It looks like somebody was just born with skills is truly kind of a learnable things that we’re just not able to do in open surgery. But we can do it in laparoscopic surgery, because we can record everything. And everything that you see on a screen you can watch later. Thousands and 1000s of times, frame by frame by frame. And by the end of fellowship, it wasn’t, I could do more than load a needle. You know, I could operate almost indistinguishably I mean, as arrogant as that may seem, when you put up two pieces of video, I just emulated him and modeled him, and I couldn’t believe the learning, like how quickly my skills developed by using video recordings. And it dramatically kind of changed how I view teaching, right? We, when a resident, you know doing a lap colet, or whatever it is, they’re not watching 20 videos or 50 videos of themselves doing a lap coin, they are completely in if they can’t learn on the fly. But when you break it down and you watch the videos, and you’re like, listen, you regrab, you know, Hartman’s pouch seven times, you know, after two times, change to a tooth grasper or whatever the case is, you know, it completely changes the trajectory of learning. And I think especially now with kind of, you know, the work our restrictions, if we don’t have these kind of alternate modalities, I don’t know how you’ve come out, being a good surgeon. You might be like, a minimally acceptable surgeon like yes, you could pick out a gallbladder or not hit the CBD, maybe you got a critical view. But to be proficient and efficient, kind of surgeon, I don’t know how you get that by just kind of practicing for these little spurts of time throughout residency. So it for sure changed how I teach residents now, like they are not allowed to operate with me, for example, if they’re not recording their case. It’s just too painful for me not to be able to correct them afterwards. So that’s a long-winded answer to that question.

Ameer Farooq  13:18

Dr. Ball told me a story about you in fellowship, and I’ll ask you to tell it as well. He told me that when you started fellowship, your preceptor kind of made you he would sit in a corner and he would just go ‘uh’, and every time you made a mistake, and then he would you were forced to do it all your right hand all the … Can you tell that story?

Scott Gmora  13:40

Yeah, you know, he would, he was. He’s a really great guy, you know, and wasn’t so great at teaching you “This is how you do it,” took your hand 10 degrees, but he was really good at showing you how to get to where you need to get to and he would just sit there and it’d be like, one, he would just count the number of times you grabbed it like ‘han’, okay, grab a gun, ‘han’, you just say that in the corner. Then it was infuriating, like what but you realize like, oh, man, like it’s taken me seven times to load this needle. Like that needs to be fixed. He was left-handed, I was right-handed, but he could operate in both hands. I guess obviously, left-handed people tend to be more ambidextrous. I’m right-handed, purely right-handed. And this guy, you know, halfway through my residency, halfway through my fellowship, said “you need to be able to operate with both hands.” “So that we mean like backhanded?” “No, no, both hands.” “No, but I’m right-handed.” “It’s okay, you’re gonna learn left-handed.” “What do you mean learn left-handed, like if you think about if you’re right-handed, you try and write with your left hand.” It’s an impossible task. And he got, you know, one of the reps to give me a simulator from those days and I brought it to my little apartment in New York. And like a madman, like what’s the movie, “Beautiful Mind,” I sat there like a crazy man thinking about this. And just like what, like kids play with a yo-yo for hours and hours and hours, and they could do all these tricks, I just put one hand behind my back. And I’m like, that’s it, I’m getting there. And I just with my left hand, left hand, left hand, and at first I literally could not, it wouldn’t even move. You know, when you turn laparoscopy, you try and grab something and your hand moves the wrong way. You’re like, wow, like what does happen here, I couldn’t do a thing. And then, all of a sudden, it develops to the point that today, my left-handed suturing is far better than my right-handed suturing, which is hilarious. But it was it was a really good lesson. And I could just say one more thing on that, that kind of dovetails nicely. There was this article, but I think it was Atul Gawande. And then obviously, you know, he has been a great surgeon, Boston, and he had this great article, I think, in The New Yorker where he talks about, you know, this guy is, you know, Dr. Gawande, he’s done, you know, 1000s and 1000s of thyroids, right, but he decided, it’s like, well, Michael Jordan has a coach, and you know, these athletes have a coach and he decided to bring in one of the best surgeons who had retired in Boston, you know, who had a very good reputation for being that guy who just had good insight, he’d been retired for 10 years. He said, “Can you just come into my OR and kind of watch me operate and take notes, and kind of coach me?” And, you know, again, Atul Gawande writes in this article, kind of, he thought, “There’s nothing that you’re gonna be able to improve, like, I’ve been A, this person is not an endocrine surgeon, and B, I’ve done 1000s of these. I’m, it was a blast the guy in, and he said, at the end of this, the guy had pages and pages and pages of notes on things that Atul Gawande could improve on, right. So you know, he say, every time you grab the bovee, the cord got wrapped around, you know, your posts, like, so move the posts over. So your cord doesn’t do that, because you think six or seven times you’re yanking on the cord. So you could use your bovie. And we just go down the list of things. And you realize that we have no coaches in surgery, right? I mean, yes, like, occasionally you’ll kind of get a grant or good job or try it this way. But to have someone who really sits there, as in, in sports, and breaks down what you’re doing. Wrong, you know, like that, that kind of degree, we don’t have, it’s a major, major flaw in our training, major.

Chad Ball  17:28

But that’s, it’s so interesting, right to think of surgical training. And you and I, very early in our residency used to talk about the outlook and the need to be a sponge, the need to have the drive that you’re that you’re describing to become superb. And ultimately, hopefully, to become a master surgeon. You know, that your description of using video to help improve the efficiency in the rate of training, is critical. But we also used to talk about the amount of time where essentially you’re waiting the poor use of time, not really on our fault, but that’s you know, in some ways, the waiting game of surgery, right? You’re waiting between cases, you’re waiting on call between ‘see patients here’, all those all those elements. So in a in a 2020 world where you have work, hour restrictions, and you have right or wrong, a different outlook, more millennial outlook, all these sorts of caveats and factors that fall into that outside of video training, to the level of efficiency that you’re talking about. Do you have any other comments or suggestions or thoughts about how a resident can make, or a fellow can make their time more valuable? Or less of it? Less exposure?

Scott Gmora  18:47

Do I have thoughts or opinions? Is that what you’re asking me? I have a lot. You know, I met this, I have a good friend who is an LPGA player. You know, I met her I don’t know, I think actually around the time of fellowship. And we had, it was fascinating to me, I know nothing about that world at all. You had a bit more exposure with hockey, I know nothing about it. But I would have these conversations with her and, and I remember, you know, I remember her asked me once, like, “So how do you guys practice?” And you know, as we were saying before, I was like, well, “You just kind of do it?” And she’s like, “No, no, I understand. But like, you know, how do they teach you to do it like, like, you know, visualization?” And I’m like, “Well, how do you learn how to golf stick?” And she goes through this list of she’s like, “Well, every day I get up, and I start by visualizing my swing.” I’m like, “what does that mean?” She’s like, “No, no,” and she like pulled up this book of step-by-step visuals, “Like this is what you’re going to visualize. They do that for 15 minutes. Then I go and I review my video recordings of my swing from yesterday. And then I practice my breathing so that when I you know, when it’s an important kind of putt, I’m able to slow down my breathing and kind of not kind of you know, lose it in the moment to choke in the moment, as you’re going through all these things and they say, “Well, so what do you guys do?” Like, we don’t do any of that. And what was fascinating to me, so she had recommended this book to me. And it was a book that she said a lot of like the pro athletes call it “Five-minute mental toughness” or something like this. But it’s basically sports psychology. And what’s interesting to me is that we haven’t incorporated it at all into our world. Like, I don’t know, if it’s because surgeons are just so, you know, kind of emotionally, you know, kind of backwards, you know, I don’t know what it is, like, if you said to a surgeon like, “Oh, I’m sitting now with my eyes closed visualizing”, it would look like many I think would look at you like you lost it. But you don’t I kind of think about, I don’t know, you must have gone through this when you were doing your HDB training, I remembered my bariatric training. Again, I almost lost my, I would go to sleep, I would be dreaming about this, bam, gastric bypass and do deals. Like I’m dreaming about it. And it’s replaying it over and over and over and kind of “What’s my next step?” “What’s the next step” “What’s?”, and it translates to real life. And I think that we’re losing a whole skill set. That is very well known, very well researched in sports psychology that we just do not even tap into whatsoever in surgery, right? Like, it’s as simple as that. And I think it’s a big problem. And I think back to like, what’s the one skill that every resident can do with their eyes closed, if the only tool that they could practice, and that’s kind of one-handed not because they can all practice it on the arm of a chair, right? There is no art form that’s like, “I’m not that good at tying one-handed knot”. Everybody could do it, because it’s possible to practice that. And it might take somebody, you know, a month to master, it might take them a year, but they’re able to practice it, we don’t have that. We have these simulators that we could kind of maybe practice some, you know, again, the choreography or some general kind of stuff. I could talk a long time on simulators in general, but we’re just not there. And we probably won’t be there for a long time where we’re able to actually replicate the surgical experience with fidelity like that. Come on, that’s what 50 years away 100 years away. So if we don’t use these other ways, and again, like I know, the residents now they don’t even understand how lucky they are to have YouTube and web search. Like, all of this is out there, you can watch videos and pause it and rewind it, and if you don’t use it, you are crazy. You are crazy!

Chad Ball  22:39

Yeah, it’s so true. You’re exactly right. And you know, I’ve talked about this before as well. Like, when you think about your own experience and my own experience, whether that was elite sports, whether that was training professional athletes, or whether that’s aerospace medicine, and being around astronauts and that whole world. I mean, our training paradigm in surgery just seems so dated and so slow, and sewn on efficient. For all the reasons that you mentioned, it’s a little bit depressing, quite frankly. And I don’t, I’ve never understood for a group of people that clearly are very smart and work really hard and are really quite driven, why that hasn’t evolved at a greater rate, and with more fidelity, and with more, so to speak, than so many other fields. It is interesting. I don’t know.

Scott Gmora  23:31

I couldn’t agree more. But it’s a major problem. You know, and again, people are far more eloquent than I have spoken on this with a lot more thought on it. But the work hour restriction, it’s a scary thing. You know, I just not even that long ago, we don’t do hardly any trauma at our hospital, but we had a drop off lenok an unstable when a lack, you know, that came through. And I was with the our five, what, like, it’s almost at the end of the year, right, obviously are fun and like, okay, like, like, have you seen this or like, No, I haven’t done this trauma, splenectomy, you know, I’m like, wow, I realized like, every generation says this, you know, like, surgeons before, before us and say like, oh, what do you mean? Like, open common balls, like declarations, when you mean you haven’t done them? Or like, we don’t do them anymore? You know, or, or whatever the case may be, every generation thinks that there’s so you know, superior to the, you know, to the one that comes after, but it’s a it’s a big problem to come out without having, I mean, seeing you know, a little no deal but seen like surgical procedures. It needs to be solved or there will be there will be I think, pretty horrifying consequences.

Ameer Farooq  24:41

Well, so what do you, what should training like, put yourself in my shoes, like, what do you think like, I’m, I should be meditating and/or visualizing before every case? Like what should I be doing?

Scott Gmora  24:57

Yeah, okay, so let’s take the word ‘meditating’ out. I could talk a lot of times, I meditate, okay, but if you say the word meditating, you’ve lost 99.7% of surgeons, they just press, they just turn off the podcast. But, you, like there are, you know, if you, you know, I would say like, if you ask, like before you do a lot of calling with a resonance, so it’s like an artery, I’ll say like, okay, we’re about to do a live call, okay? I’m going to step and look at you like, you’re from another planet, like, how do you mean this? I’m like, What are the steps? They’re like, Oh, you mean, like, where do I put the port? I’m like, no, no, the steps tell me move by move what you’re going to do. Because when I do a lap pulley, I have my recipes. I first retract this way, I take, you know, the hook, I buzzed the per diem, I take it anteriorly I take a posturely, I have step by step. And when you ask the residents doesn’t mean like, “Oh, you mean like get the critical view?” Like, no, I know, you know, the buzzwords and the big kind of points of it, but if you can, in your head, play that movie of you doing a gallbladder, in an ideal situation, forget it in real life. So we say “meditating,” I would say more, I mean, again, whatever label you want to put onto it, you have to be able to see in your mind yourself doing a procedure from start to finish. Or you are not able to do it at a master level, period, full stop. Period. You know, and so yeah, I think before every case, and I think all the good surgeons do that. I mean, I’ve no doubt that Chad does this or every surgeon right where you’re like, okay, so I’m going to come in, I’m going to take it this way, and you take it and you have it figured out. So that’d be my first kind of suggestion, is that you need to understand the procedure at that level. Not like oh, I’m going to take the line of pull on a right hemi. But to be able to like, okay, I’m going to grab right here on the bowel, I’m going to pull, I’m going to take my if you’re doing an open, you know, call in, let’s say, I’m going to buzz and right here, I’m looking to see, you know, the frog for that plane open up on it, you need to be able to visualize it at that level. I think that that’s kind of the first step.

Ameer Farooq  27:10

That is fantastic advice. I have to also confess that I was at your talk on the stop the bleeding workshop that Dr. Ball put on at CAGS. And I think you talked about in trying to control laparoscopic bleeding, you talk a lot about techniques, not only kind of mentally visualizing what you need to do to stop the bleeding. But you had a bunch of techniques on just even managing your own emotions in the room and managing your own emotions as well as like, the kind of tenor in the room. How did that, how did your, because I never heard anyone talk about stopping something that happens to us every day and laparoscopic surgery. Kind of that succinctly and eloquently.

Scott Gmora  28:04

Yeah, I think it kind of dovetails with what we were talking about before. You know, I remember being just starting my second year residency, I’m at the law heat and I’m doing again to come back to colorectal case. But it was a little anterior, you know, I’m just, you know, low-life, you know, slowly, second-year resident just starting, I can’t put my shoelaces, barely. And I remember, you know, the surgeon kind of been like, okay, you’re going to do kind of the, you know, you’re gonna start to do the preclinical dissection, and you’re going to kind of go with it. You’re going to start on taking this on the rectum. And I remember starting to buzz and he’s like, “No, no, you’re in the wrong plane.” I’m like, “Oh, okay.” I’m like, “Where do I go?” He’s like, “You need to be a millimeter.” Like, okay, so I start buzzing again. “No, no, a millimeter.” And I’m like, okay, “No, no.” And again, I’m in the wrong plane. And then he does it, and it just opened. I remember asking them like, “How did you know to go there?” Clearly, he saw something, he may not know that he saw, he may not be able to articulate it. But his brain saw something, a difference in color, a difference in texture, something that my eye, my untrained eye didn’t see that told him that. And I remember asking him to like, “Tell me what that is, because then I’ll be able to do what you’re doing.” And with that kind of a half-assed work, he just kind of like, Scott, you’re either born with it, or you’re not. You know, typical kind of surgeon answer, right? But that that moment stuck with me because I realized, and again, coming back to the bariatrics, and being able to record it, all these things look magical when you’re a resident, like, oh man, he’s so calm, or “Oh, man, like, he never gets any bleeding.” Or, “Oh, he’s so efficient,” or “How does he see this perfectly?” Whenever I try and do this, I can see they have just done something differently. And it’s, it’s easy to understand when it’s a technical skill, like yes, this is how you know you colocalize. You place one hand like a master surgeon, probably who does a lot of, you know, Kohler, who does a lot of ACP would do it better than I can do it, because they figured out the recipe: one hand here, one hand there, that gets attention, that plane will open up easier than another. So it makes sense in a technical, but, of course, we don’t think about it in the, I don’t want to say emotional, but the, in the softer kind of world, right? So if you think about it, you know, like, I remember very clearly seeing, there was a few people that I saw, who stuck in my mind and chat with us. But I said them, I’ll leave them anonymous, but who would just be extremely calm, but these are people who I knew at their residence was dear to me, who had no clue what they were doing. But you know, one would just kind of like, you know, just, they were just extremely, and I was like, watching what they’re doing. I’m like, okay, they’re talking slowly. They’re, they have certain mannerisms. And I just copied them. And you realize that a lot of these things is just, if you just kind of are able to break down what the other person is doing, you will get the same result yourself. So you know, in that talk, I say, when you, you know, crap hits the fan, and you get into major bleeding and you get temporary control. For me, my move is to go, “Hmm, interesting.” Because I noticed that, you know, Master surgeons would do that. Our version of that, you know, and my son was like, “Oh, my God, this guy, he has like, a heart like, you know, what’s new, this podcast Cold Steel? He has like, a ball, the cold steel.” It was like, the calmness, you know, I’m like, this guy like nuts. And I realized, Oh, no, he’s really crapping his pants on the inside. But he figured out a skill he may or may not know. I’m just using kind of a trigger word to kind of calm himself down. Hmm, interesting. All of a sudden, the whole room is calm, he’s calm, everybody’s in control, it looks like a magic trick, but it’s not. It’s just the technique. And I think there’s a lot of these and I just know a fraction of them. I wish to go with Tom who would teach me more than more. Clearly that sounds.

Chad Ball  32:10

Yeah, it’s so true. We all have our mannerisms. And, and, you know, I’ve changed from interesting to good. I’ve stolen that from Jocko Willink’s podcast and his two-minute videos. You know, I’d encourage anybody listening if you haven’t watched a podcast by Jocko or I should say a video on YouTube called “Good” by Jocko Willink. You should. It’s fantastic. But you’re right. I mean, when Scott Gmora says “interesting,” or I say “good,” it’s probably pretty serious now.

Scott Gmora  32:42

Well, listen, I know you hate talking about yourself, Chad, but you have very, very distinct kind of mannerisms. You add, maybe anybody I know, you talk slowly, you don’t raise your, I don’t remember hearing you yell. I don’t think in my life, to be honest with you, even when you’re super pissed. It’s a very kind of deliberate, you know, like, kind of inflection and tone and it comes across as competence. And it might be true confidence, I don’t know, maybe confidence is maybe you work backwards and kind of like and figure it out kind of in retrospect, maybe that’s what it is. It’s just kind of, but it’s …

Chad Ball  33:19

Well, you know what’s interesting, I think Ameer could probably comment better than me, and he might disagree with you. But I certainly have different tenders and approaches and interactions. To your point earlier, if I’m doing trauma sinding elective surgery. And that comes from a whole bunch of different places, I think has a whole bunch of different implications on the room and the way the way that you think and so on. But you’re right, and I think you know, no matter for maybe that’s very good at or mean, it’s very poor at it. It doesn’t matter which end of that spectrum you’re on. It’s something that we all need to work on all the time going forward. Because we can flip, we can regress, and we can always get better as you point out.

Scott Gmora  34:02

Can I ask you what were the differences that you have between trauma and elective? I think I know exactly what you mean. But one of the differences and is it conscious or not conscious?

Chad Ball  34:13

You know? Yeah. I mean, for a similar paradigm, training pathways. It’s always interesting to me to take a step back, and to listen to. And I don’t mean necessarily where you and I work, I mean, everywhere on Earth. Listen to I in trauma folks, talk about the elective folks and listen to the high end sub specialized elective folks talk about the trauma folks, and sort of going up the middle of that road. There is merit to both of those stereotypes going each way. And then there’s a lot of untruth, there’s a lot of inaccurate stuff that’s believed in and said, and there’s pros and cons to each and that that’s you know, I think that’s what’s fascinating about your it’s kind of dual training. I think what But hopefully it makes me a better trauma surgeon, for example, the HPV training. But you’re right, there’s different environments. So you know, when everyone’s excited for that injury case, and the blood pressure is low and the patient’s actively dying or just arrested in front of you, I think you just got to be the calmest person in the room every single time. And people respond to that, because what you often what you often see in, say, trauma bay, with many other groups involved, including emergency medicine, in particular, is the opposite of that you see a switch that’s flipped, and the anxiety or the excitement in the room goes through the roof, and it’s very, I don’t wanna call it dangerous, it’s counterproductive, for sure. And it’s potentially risky. But as you know, what an elective scenario, really many of those things are the opposite. So I like to think that I would behave differently in each one. But you’re right. It’s for sure, at least in my case, it’s learned, it’s copied, and it’s very calculated in almost every circumstance.

Scott Gmora  36:03

Can I ask you a deep questions? I know you’re like going deep. But do you, I felt this coming out of their trauma rolled into the elective that I didn’t appreciate. And I’m just curious for you who kind of swing back and forth between both those roles on a daily basis, you know, in the, what, you know, and a lot of people have said it, but I didn’t realize kind of just how true it is, you know, when I felt definitely there was like a tension or stress in a true trauma case, the guy’s exsanguinating. But there was something about it not being my fault.

Chad Ball  36:36

Yeah.

Scott Gmora  36:37

That was, that was very liberating. And in a lot of cases, I don’t care if it’s an appy, you know the patient, you spoke to the patient, you worked up the patient, you know, their family, you joke with their family. And when something happens, or go sideways, that that kind of internal dialogue in your head that you try and kind of suppress, but you kind of you’re like, oh, no, oh, that’s the problem, like, I just cut the ducks, like, that was not intended, that’s going to stricture, this guy’s gonna be like, he just gonna leave, he’s gonna this, he’s gonna that. Whatever the case may be, it’s a different game, or is it not for you? Like when you’re doing a Whipple, does it feel different than when you’re doing even the worst of promise?

Chad Ball  37:20

That’s an interesting question. Right? And I mean, the short answer is, of course, yes. I sort of like your example. So if you if you take something, let’s make it really concrete. So if you take an iliac artery stab wound, right? Close, the guy’s minding his own business, and it’s early in the evening, and all these things and he shows up at your door, he’s sick, you don’t know him, as you said, you have no emotional connection to that person. And then take the patient with a laparoscopic appendectomy for all the details that you described. And the trocar bounces into their iliac artery increasing exactly the same injury. You’re emotional, exactly what you’re saying. You’re emotional, and your, the way your brain processes that could not be more different. So then the question is, why is that? And sure, some of it’s that conversation, but I think that it’s logic would say it’s even, it’s even beyond that. And there’s certainly guilt to it. And there’s, you know, your brain tends to tends to run down pathways both good and bad. And, and I think the better you get out of it, the better you control it. But, you know, you could even make the argument, I suppose that, you know, the patients in laparoscopic elective or semi-elective, whatever urgent scenario, in a better position like you caused the injury, you can see the injury, you know where it is, it’s not like you’re opening someone’s leg or someone’s belly, or we’re both trying to find the injury, they’re not three liters of blood behind. How you approach that, I think, exactly is right in the idea of where you’ve trained and how much you’ve seen that and all those things go into it on the on the trauma side of things I would always credit. In my case, they flew Seattle. And to me is a absolute, technical, technically superb surgeon. He’s a technocrat by the by the definition. And it was interesting to me because he was the first guy I’ve ever met in trauma really anywhere in the world that you and I had gone. That said, this patient is your mother, your brother, your brother, your father, your son. It doesn’t matter that you haven’t met them, it doesn’t matter that they’re not related to you got to assume they are and you better provide them perfect care, otherwise, there’s going to be a problem. And I think he meant, you know, between him and whoever not necessarily the patient, but that’s true, but it’s also a little bit unrealistic because of your former comment. And I think that’s something you struggle with always on the elective side. And it’s something that the electrified like to say about trauma, emergency gentle surgery, right, it’s sort of, “well, I didn’t know that that’s it’s easy stuff. I don’t feel guilt.” You know, that suciana, we’re trying to drive a little bit of that guilting you on the urgent side and emergent side. He clearly thought it would make you better at your job, and I think he’s right. So I couldn’t agree with anything more strongly than what you’ve said for sure. No doubt, yeah. You know, question maybe for you is around the concept of innovation. So again, I, I’ve mentioned that upfront, your maybe, your dislike for that term, but you know, it’s a broad term, it’s a 30 000-foot term, it can mean a lot of things, but what does it mean to you? And how do you apply that? Or how do you think about it in the context of surgery?

Scott Gmora  40:42

Well, so I’m gonna take, I’m gonna hit a fracture of that big topic. When I did my fellowship, Dr. Teixeira, maybe some of you see this a lot more in the US than you do in Canada. But every Thursday was Experimental Surgery Day, never getting there. He’s like, okay, it’s Thursday. I’m like, okay, this is an experimental surgery day. What is that? And we would do the surgery with, you know, a kaleidoscope instead of a laparoscope. And I was like, what is going on here? Like, what program that I come to? We would do the single incision, laparoscopy was the heyday of sills, right-dual incision. And I was furious. I’m like, oh, my God, I can’t load a needle with two hands. And now you want me to start learning how to operate. This is the most ridiculous thing I’ve ever seen in my life. And what I realized was just how wrong I was, you know, that you have to be really, really careful in surgery. On saying that something is a is from from an innovation point of view is a bad idea. Because probably what, you know, at the very least, you have to acknowledge that you might just be on that super, super early part of the curve of the technology curve, you know, so to say that, I mean, if you look at for example, I don’t know endoscopic suturing. You know, so if someone said to you right now, you know, we should be closing the hole in the colon with with the kaleidoscope. Like, are you crazy? What are you talking about? Like, that technology right now is the most ridiculous, complex technology that exists, you know, it doesn’t work well, it takes a lot of pract. …, everything is bad about it. But if you advanced, you know, 10 years, 20 years, what however long it takes, and you had an efficient way of suturing that was easily reproducible with a kaleidoscope, you’d be like, course, I’m gonna close that hole. I just had a colonoscopy, and I proved him I’m not going to be in the OR. I’m just going to properly suture that hole from the inside. So it’s not that surgery is a bad thing. You know, and the example that you and I have spoken about, I don’t know how many times was when we started, not even started, but during our whole residency training, we never did trauma, ultrasound, we never did fast ultrasound, it was always the radiologist coming up to do it. And at that time, you know, this was like, maybe you can answer that question better than I can, but it was on the early part of fast. And the people who had looked into it just five years or 10 years earlier, to see what it was feasible for surgeons to do. They were too early, right? The technology wasn’t there, the ultrasound machines were garbage, you couldn’t see anything. And even if you could see something, you had no idea what you were looking at, there was no systematized way of kind of interpreting. What are you looking for? Are you looking for free air? Or are you looking like, how is the surgeon going to read an abdominal ultrasound, it’s preposterous, it takes a radiologist nears and even they’re not as good as the text, you know, and kind of getting the images. And that person was right, you know, when that person said, you know, ultrasound and trauma is ridiculous. It was right when he was at that time. And then I remember very clearly starting my trauma fellowship. And on the first day, you know, I’m on call and I’m in a trauma bay and the attendings whenever in the call room, and the guy comes in with a stab, you know, in his chest, and the intern, the guy is like, I want to say like six months into residency, picks up the probe throws it on the chest, and he’s like, “Yeah, he has glue around his heart. I’m like, what are you talking about, like, you’re an intern, like, that’s, that’s the craziest thing. Like, let’s get the radiologist out of here, let’s do the guy was right. And I was like, “Oh, wait a second”, like when the person that we respect and it was a bad technology, it was back in the day. But now it’s no longer you know, and so when we look at things that pop up you know like robotics. You know, like I, we all roll our eyes that we were going to do it like a robotic hernia repair but a waste of money only the Americans do you know, all what all kinds of stuff. And that might be true now, but if the cost of it and the technology comes down to docking time and everything, it might not be crazy down the road and when we look at notes, like we’re gonna do a transvaginal extraction of the gallbladder, like you guys make no sense. That might be true now. But as things develop, and technologies evolve, it’s not, and I think if I had to kind of give, I’m very careful on around our residents, not to say that something is a ridiculous idea and to dismiss and specifically because of that fast, you know, trauma, ultrasounds kind of scenario to be really careful to like, Well, right now, it’s not a good platform or good way of doing something. You have to keep your you have to be open. And how many examples do we have in this? I mean, that, you know, that’s, you know, vascular, right? Like, if that’s not the epitome of the example. I don’t know what is, you know.

Chad Ball  45:22

Yeah, I couldn’t agree more. The ultrasound example. It was not only close to you, and I for sure, but in my fellowship, heading down to Atlanta, being trained by Grace Riziki, who is the inventor of the extended and fast examination for trauma. I mean, she doesn’t talk about because she’s, you know, a superb surgeon and an amazing condition, wonderful human, and really tough. But she was an ultrasound tech, essentially, before she went to medical school. And when she started to, you know, fuse that concept in her brain, and then spent really the first 10 years of ever really magnificent career, inventing fast, the ridicule and the pounding that she received, nationally and internationally from other trauma surgeons, including, you know, to be honest, and in some regards to her eventual husband, who I’ve mentioned before Siano, was unremitting an unbelievable. And you look at it now, and you’re like, well, exactly your point. This is not the medical schools, medical students job in many trauma bays like, and it changes what we do with it and center. So I think your advices is sage, we have to be very, very careful, as at all levels, particularly faculty surgeons, not to give that impression and to remain open-minded. It’s easy to say it’s hard to do sometimes for sure.

Scott Gmora  46:40

Now, firstly, I mean to say that I had no idea that background on Dr. Rezeki, that she was an ultrasound tech. And that’s, that’s an awesome story. And you could So see how that happens, right? How the surgeons, you know, the so superior and mighty, you know, are just kind of rolling their eyes and look at us even let’s take the even like, even bigger examples. And like, when we were training, you know, laparoscopy and you know, like the colorectal surgeons who were kind of like, there is no way I am ever doing a laparoscopic colon is ridiculous. And you’re like, yeah, it wasn’t a well developed kind of technique back then. But it’s going to evolve, you know, and to just kind of be in that mode of like, this is stupid, I think really holds you back.

Chad Ball  47:21

No doubt. The last question, I think we want to ask is another broad one, if you’re gonna boil it down to one or two or three pieces of advice that you wish you’d given to the younger you or you wish you had given to, to me, at some point or just trainees in general, what would you say? What would you hit on?

Scott Gmora  47:39

You know, if I had to give advice to myself, it’s gonna be a corny answer. You’re going to be surprised by me of all people saying it, but I’m going to anyway. You know, if I had to kind of go back to myself at the start of whatever, medical school or residency and be like, you need to notice, what I would tell myself is, what we do is so insanely crazy, you know, and everybody talks about what kind of privileges it is. And it’s such an overused word. But think about it, like I mean, can you really sit back and think like, I’m taking a knife, and opening up human beings, not only am I opening them up, I’m going to rearrange their insides, and put them back together and close them, and they’re going to be better. Like, even just think about the concept of, you know, cutting out small pieces, small bowel and putting them together. We don’t think twice about it, you know, and I would tell myself, residency by definition, and also, being a faculty, by definition, and being a working surgeon is going to beat that out of you that sense of this is the most amazing job in the world be so grateful for what you’re doing. Residency, by definition, is going to beat it out of you. Because it’s kind of like, you know, you don’t want the pilot because like, Oh my god, I can’t believe I’m flying. This is amazing. Like, you have to have the plot that’s like, I’ve done it a million times, whatever. It’s no big deal. And it’s human nature that you lose that specialist, I would bet you if you talk to an astronaut, you know, they probably get the right answer. But if they were talking amongst themselves, they probably say like, “Yeah, by day four, I’m like, yeah, that’s the earth through the window. And yeah, I’m floating” and like, it’s easy to lose that all you know. And what we do is such, there is I don’t think no, there is any job in the world that even comes close to surgery. I mean, medicine, sure. But surgery, we a surgeon can kind of understand what that means that kind of that, that weight that’s on you to do it and what and what you’re doing and I would tell myself, just that has to be a small part of your brain, that that always remembers that it doesn’t have to be like, you know, whatever, then you’re this evangelist all day, kind of, you know, screaming how lucky you are, but you have to keep that in the back of your mind, because there’s going to be a lot of crappy days and good days and boring days. So it’s gonna be your 100th inguinal hernia repair or whatever it is that you do, and you’re gonna be like, I’m so sick of the damn job. And you can’t let that happen. I think that’s what I would tell myself.

Ameer Farooq  47:53

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.