E07 Paul Greig On Transplantation, Surgical Education, And Retiring From 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

In today’s episode, we had the opportunity to sit down with a real legend in transplantation. Dr. Paul Greig is a transplant surgeon who worked for over 30 years at the Toronto General Hospital. We talked to him about what it was like to set up a transplant program and to get his insights into residency and education. Sorry for the audio quality in this episode, but there’s some real wisdom to glean here from Dr. Greig. We hope you enjoy.  Dr. Greig, I’ve had the opportunity to talk to many of your trainees and residents who are my friends and normally start the podcast…

Paul Greig  01:27

Don’t believe everything you hear!

Ameer Farooq  01:31

What’s clear from talking to them is that, normally we start the podcast by talking about a clinical topic or reviewing a paper. But it’s clear that we have to talk to you about your career first, as a transplant surgeon. Can you tell us a little bit about where you grew up, where you did your training, and how you ended up in Toronto? And then, the second part of that is, why liver transplantation?

Paul Greig  01:53

Yeah, sure. So, Toronto guy. Was born here in Toronto, did a public school education in Toronto. Actually did my undergraduate at the University of Waterloo in math and computers. Was a co-op student at Waterloo. All along the way, I played in some bands. Then, when I finished Waterloo, I played in a prog rock band for about a year and a half. My girlfriend at the time didn’t want me to be a computer programmer, she wanted me to be a doctor. So I applied to med school and I got in. Toronto was the only med school that accepted me, so I went to the University of Toronto, did my medicine here, and was influenced. Later, I got attracted to surgery. I did my residency, the program in general surgery here in Toronto. I finished that in 1981. I went to New York, I did 2 years of research fellowship at Columbia Presbyterian Hospital, in Manhattan. Some of the best years of my life. And I came back on staff as, I guess we would call it [inaudible] surgeon at the time, in 1984. So that’s my background. So I took an interest in liver disease and liver surgery from Bernie Langer, without question, fairly influential guy in my life. Basically, he just challenged me more than anybody else had challenged me. I just loved what he did. And I had done some research with him along the way. Studying a device called the LeVeen peritoneovenous shunt, that we [inaudible] the acidic fluid through a plastic tube, with a one way valve back into the central vein. So people peed it out. Got some publications out of that during my residency. So I was headed towards a life of liver surgery. And quite frankly, I came back on staff at the Toronto General Hospital in 1984. And I expected [inaudible] and Whipple operations for a living, because that’s what this, sort of, emerging specialty of liver surgeons were doing. Lo and behold, that’s what happened. We started injecting [_____ with glue] and then [inaudible] by the wayside. At the same time, Langer had started our fellowship in liver surgery, and [Leonard McEachern] was one of our first fellows. [Leonard] and Bernie had become aware that liver transplantation was starting to become successful down in Pittsburgh. This guy, Starzl, was transplanting the liver and they weren’t all dying. Some of them were now surviving. And the plan was [Leonard] was going to go down to Pittsburgh, learn how to do liver transplants and come back. But while he was a fellow, Bernie said, “Why don’t you and [Leonard] start transplanting some pigs?” So we went over to the lab and we started transplanting pigs. We got the perfusionist to come over and help us do venovenous bypass. We put pigs to sleep and we transplanted pigs and developed those techniques. [Leonard] left in July of ’84 to Pittsburgh. And later on that year, I guess it was ’85. Later that year, Bernie decided that we were probably ready to start to do liver transplantation. [Inaudible], we had a critical mass of liver surgeons, Langer, Taylor, Steve Stroudsburg, myself. And we did our first transplants in 1985, did a couple more in 1986. And in 1987, he said, “Well, that’s enough for me, Paul, why don’t you take it from here?” So there I was, a brand new surgeon on staff with an outstanding opportunity. And that’s the day I started doing liver transplantation. That’s how it happened. Along the way, in 1986, I did go down to Pittsburgh. I went down for a week. [Leonard] was still there as the fellow and he made sure that I was well taken care of. I saw like, 6 transplants in 5 days. And I actually stood with Thom Starzl on a [biliary] transplant on my last days there. So, that’s actually my [inaudible] transplantation was 5 days in Pittsburgh. And of course, I had the benefit of the mentorship of Bernie Langer, [Bryce Taylor and Steve Stroudsburg]. And so, my forerunners. So that’s how I became a transplant surgeon. [Inaudible] as part of all of that.

Chad Ball  07:07

That’s an unbelievable story. Really interesting.

Paul Greig  07:11

Right place at the right time, man.

Chad Ball  07:13

Yeah, that’s, that’s fascinating. That’s really cool.

Paul Greig  07:15

I consider myself a second generation [hepatectomy] surgeon, but I’m really a first generation transplanter.

Chad Ball  07:22

Yeah, exactly. It was interesting, of course, when you gave the Bill Wall evidential address for the CHPBA, you were referred to in the introduction as a 1.5. And that’s exactly where that comes from, eh? 1.0. Yeah, it was great. In the Canadian Journal of Surgery, you published a couple of really interesting vignettes or stories about Dr. Langer, and Thom Starzl, you’ve touched on as well. How did those guys, how did they not impact your outlook on your career outside of the actual technique of liver transplantation of HPB surgery? And I’m also curious, if you’re willing to talk about it, how Bill Wall may or may not have influenced both yourself, as well as the Toronto program in general, coming out of London.

Paul Greig  08:13

Three questions. So I’ve already alluded to the fact that [inaudible], and when I met Bernie Langer, he just challenged me more than anybody else. In his way, and his mannerisms and everything. He basically said, “let’s see you be this good, Paul”. He challenged me more than anybody else ever did. I think that’s part of the culture of the Toronto General Hospital. There’s a lot of pressure to be excellent. And there’s pressure to be excellent in every hospital, I understand that, and maybe I’m overstating it, because it’s the only place I’ve known. But Bernie did that in [inaudible] made what he was doing just what’s [inaudible] anything else. And Bernie had a couple of statements, “if you don’t stand tall enough, you can’t see far enough”. He clearly was a visionary sort of guy. Transformative toward the vision of general surgery or department of surgery. He started the Liver Transplant Program because he thought he could. And he showed me that you need to challenge yourself and take these things on. Just, sort of, created an atmosphere of excellence that we all emulated. We all aspired to. So, that’s probably the influence that he had on me. Of course, the technical aspects. I operate halfway between Bryce Taylor and Bernie Langer. Those are the 2 guys who influenced my surgical decision making and my technical skills. Bernie just established a standard of care, of excellence, that we all aspired to. So that’s how he affected me. I would have to say, I didn’t know Thom Starzl particularly well. I’m not sure he would have known me if we had seen each other in the hallways. But he showed me what could be done. As you know, he was such a pioneer and a maverick. He wouldn’t take no for an answer. Although I, personally, have not been that creative in my surgical career, clearly he was the guy who showed us that if you’re determined to make something work, you can make it work. He made the best of all of his successes. He had lots of failures along the way, but he’d had enough successes to encourage him along, to make this thing work. And that’s why we transplant the liver today. So those are the 2 people who influenced me along the way. As I said, Bryce Taylor was an important factor as well.

Ameer Farooq  11:03

Talking about your early career, setting up the Toronto Liver Program. I mean, now it’s well renowned, world renowned, really, program in liver transplantation. But looking back, what do you think were the critical steps in creating the program? And what were your most challenging struggles in setting that up? You know, in talking to some of your residents, it seems like there’s a lot of synergy between the Liver Transplant Program as well as the Lung Transplant Program. How do you think that all played out?

Paul Greig  11:39

The Liver Transplant Program first, then I’ll talk about the relationship with the lung. So the liver transplant that Bernie really developed in the early days. I think one of the really smart moves, initially, was to invite every surgeon who dabbled with the liver in Toronto to come and be part of the Liver Transplant Program, if they wanted. Even though there’s a big city, east side of Chicago already had 3 programs, New York had 2. You know, I’m going to have 2 more programs. And in the Toronto [inaudible] university [inaudible] business, he went out of his way to make sure that everyone at the other hospitals, at Sunnybrook, and [inaudible] hospital, at the time, and St. Mike’s, and [the Western], and Mount Sinai, everybody was invited to come and participate. And so what that establishes is a single program, rather than fractious 2 or 3 programs that are fighting against each other for turf in the transplant world. So they were smart. The next battle, quite frankly, was the resources of the hospital. For anesthesia, this is all night work that is really hard, and no one loves doing that. It was technically challenging for them, these patients were unstable. And it was not really easy to develop a cadre of anesthetists who were interested in this. After all, they all want to be the cardiac cases and not the liver cases. You need to know, by the way, that we now have 3, and sometimes 4, liver transplant anesthesia, liver anesthesia fellows now. It’s really, totally changed many years later. It took us a while to develop a cadre of younger anesthetists who took an interest in this. Because quite frankly, we’d get a different anesthetist each night and then you’re only doing a transplant every week or two. It took a while for anesthetists to develop that expertise. A bit of a challenge in the time. It was also a personal challenge to enthuse them and try to, instead of maintain a positive spin on transplantation, speak with the anesthetist that you want to get going at 3:00 in the morning, please, because the liver will be here at 2:00 and we have to get on with things, and that wasn’t going to be easy. [Inaudible] the resources of the hospital. Because this ICU [inaudible]. To do that, eventually, I guess this is more [Bernie] as much as the next. [Inaudible] organ transplant program, because we realized that as individual programs, heart, lung, liver, kidney… None of us are going to have the critical mass to be influential in the hospitals and [inaudible] that then has a cache. So the transplant program has really grown and blossomed, mostly as a priority for the hospital. So there’s sort of what logistical things were important. There’s a lot of groundwork for the first 5 years, we didn’t have any coordinators. We’d get a phone call that there’s [a liver rep] in Ottawa, I would spend the next 45 minutes on the phone. Calling in the anesthetist, the [inaudible] nurses, the blood bank tech, the coagulation tech and calling in the patient and tell the other patient [inaudible] to go. And [jnaudible] make sure the airplane is going. And as well as we’re driving down to [inaudible] the donor, we’re getting another phone call that there’s another liver. It was a lot of personal time until we had individuals who would help us with the coordination of all of this. That was a lot of personal time. This one other thing. The first 7 liver transplants, [inaudible] took turns sleeping in the bed across the way from that patient, overnight, for the first 3 or 4 days. Just to make sure that they were okay. You have intense postoperative care and you’re committed to making it. So there was a staff surgeon or a staff hepatologist sleeping beside the patient for the first couple of days. Due credit needs to be given to [Gary Redman] because a transplant program is very dependent on its hepatologist. That’s for the patient’s [inaudible], and [Gary] had done some training transplantation in Pittsburgh and came back after the summer break, initially, before he moved downtown. So [Gary] was really driven to develop a transplant program. So, the combination of motivated citizens and a particularly motivated hepatologist was quite successful [inaudible].

Chad Ball  17:02

Dr. Greig, your name, I should say your good name, certainly is synonymous with a lot of really, really amazing things. But one of them is clearly the world that surrounds education or surgical education. As Ameer sort of touched on, whether we’re talking to your former residents, your current residents, nationally, internationally, fellowship fellows, whether I’m sitting in a room quietly listening to your sage advice at the HPBA Committee meetings. Really, when I think of surgical education, honestly, I think of you. And unlike a, maybe, 1.5 transplant surgeon, I think you’re a 1.0 surgical educator. So, our questions really surround advice that you would have for residents in surgical training, for HPB fellows or fellows in general. How do you frame surgical education? What do you tell your trainees? I’ve benefited, personally, from a lot of your advice from medical school forward, whether you remember it or not is another question. And finally, what do you think of the shift to competency by design? Does that have any implications, good or bad, from your point of view?

Paul Greig  18:19

Yeah, so don’t let me forget to do the last question. But the CPD thing, I may forget if I just get rattling on.

Chad Ball  18:27

You bet.

Paul Greig  18:28

So, residency has changed, without question. The residents are much more empowered over the past few decades than before, and that’s probably a good thing. They’re much more aware of their situation, much less blind faith. “Oh, if I’m supposed to do that, then that’s what we do. Because that’s the way it’s always been done, that tradition is”. And they are more challenging of more traditional methods. That change, probably a good thing. There’s clearly more camaraderie within the residency. I really didn’t know the other 10 residents in my year, we never saw each other. We were busy being doctors. That clearly has changed and residency education is much more formalized than it was. I think what that does, is it very basically guarantees that you’re going to be able to pass the written and the oral exam. The challenge, I think, for residents these days, is to get the adequate clinical training. They’re very protected from themselves, from spending too many hours in the hospital. And were protected from individuals who would ask too much of them. At the same time, the knowledge base is probably easier than it was before. Because the resources, it’s all on your phone, you can look stuff up. CAT scans are done. If you got a good radiologist, they’ll tell you what’s going on. Although my advice to the residents is, you better be good at reading the X-rays. They don’t test you on that. It just makes you a better doctor. But the technical aspect on the surgical side, I think is an ongoing challenge for our residents. And we certainly recognize that during the first year of the fellowship, there’s a much steeper learning curve now, than there was in the past. You know, there are residents, who have not the open often experience that we used to have 10, 20 years ago. [Inaudible]. And they have to master both open and laparoscopic techniques. And apparently, you have to learn how to do it on a robot as well. So that’s a real challenge for them to get all of that. And that’s just a time thing, you got to do lots of them. I think our real challenge going forward is to get enough open surgery. That’s my bias, of course, I think there still be a role for open surgery. For trauma transplant, the liver won’t fit through the laparoscopic port. So there still is an important role for open surgery. And it may become a subspecialty, someday. Who knows where that’s going. But that’s my challenge. So, my advice to the resident is, jump on every opportunity. To use your hands and to be comfortable with handling tissues. It’s all about handling tissues and seeing [inaudible]. Anyone can cut it, you know, but you have to know how hard you can pull. When you see, that’s where I should go. There’s translation to laparoscopic surgery, as well. I’ve been doing some work with my brother on my car. And metal is a lot harder than tissue. And I said, he’s got this expertise, he knows how hard he can bang the fender and I don’t. But I know how hard I can bang a liver, you know? It’s all about these subtle things that you learn. So that’s my advice. Of course, residency prepares you for your fellowship. And my advice to fellows is to capitalize on every opportunity you can. Because you will end up operating the way your last mentor taught you. And during the fellowship, you need to have your antenna well positioned so that you recognize the strengths and the weaknesses of each of your teachers. You’re going to have some in the operating room who are really going to teach you wrong, there’s gonna be others who challenge you more. Frankly, they’ll be the ones that you’ll probably learn more from, if they don’t help you as much as the others do. You’ll get something from everyone. Now, the current generation is very good at soliciting and seeking feedback. And it’s important to get that. But you can’t get that every time. So, you need to be introspective and take advantage of every opportunity. And like I said, recognize the strengths of each of the different teachers, because they’ll all be different. With the Toronto General Hospital, we have 7 of us. We teach liver transplants, and we have different styles. It’s all similar stuff, but each of them will impart different values and make different emphasis on different parts of the operation. That’s what the fellowship is all about, synthesizing all that stuff. That’s my advice to fellows. With regards to CPD, this is just the educator’s, not the teacher’s, but the educator’s next kick at the cat. I’ll fully acknowledge that we don’t do evaluation well. We certainly don’t do it very objectively. Subjectively, we’re all pretty good at finding the good surgeon. And the challenge, of course, is to help the struggling individual. I think we should come to recognize that not everyone can be a surgeon, and they started out being that way. Not everyone who gets an HPB fellowship is destined to be an HPB fellow. I think we need to acknowledge that. Although, that’s a real challenge to us, a couple of my challenges during my career. CPD is the administrator’s attempt to improve on our ability to evaluate. It adds more structure to the evaluations. We went through structured evaluation tests, OSATs, the Ottawa score and all these things, and they’ve been adopted to different extents by different programs. And CPD, I see as being similar to them with these milestone things. It’s trying to get the surgeons to more objectively evaluate and give feedback to the trainees. Part of the problem is, you get what you pay for. And none of us are paid to do this. You know? And they’re busy individuals. So we’ll see if it makes much of a difference. Instead of CanMEDS competencies, which was the tool of the previous decade, now it’s CPD. We’ll see where it takes us. Part of the problem with CPD is it tries to compartmentalize many of the things we do, and life isn’t like that. You’re starting off thinking this is appendicitis and you end up, up to your eyeballs, taking out the sigmoid colon, because things are not that tidy in life. And so, there is going to be some limitations to it. But it just acknowledges that we’re still struggling with our abilities to effectively give feedback and help the struggling student. There’s my thoughts.

Ameer Farooq  27:10

Those are some really sage and deeply wise comments on some real challenges for our generation. A lot to think about. I think we’d be remiss to not ask you, like we were talking about before we started recording, about some of your passions outside of medicine. We heard that you’re not only just a phenomenal musician, but also a dedicated gamer. Can you tell us a little bit about those outside interests that you developed outside of medicine? And how did you do that as a person who was sleeping beside the patient a good percent of the time?

Paul Greig  27:49

So, I became addicted to World of Warcraft through my sons. Today, we’re serious gamers. In fact, one of his sons took a year off to play World of Warcraft. It was either fight them or join them, and I did the latter. So that when I came home, Kevin would say to me, “Hey, Dad, I got your guy some new armor, I just sent it to you.” So it’s a way to relate to my children. On the other hand, it’s a decompressor. It takes your mind off the rest of the world and in the high stress environment that any surgeon works in, we do need to decompress. Whether it’s an hour at a time with World of Warcraft. Or because you’re off this weekend and you’ve got your bicycle club on Sunday mornings, you go biking for 4.6 km or whatever they do, it’s very important to keep that sanity. It’s difficult to maintain a serious hobby through the formative years of 35 to 55, because you’re so busy becoming an expert at who you are, that most of us jettison our personal hobbies and struggle to maintain our family commitments. But my advice to my colleagues is, don’t lose them entirely. Because they’re very valuable to resurrect in the next couple of decades when you’ve got little more time and you are who you are. And they’ll come in very handy, because when it’s time to hang up the old war cap, you need something else to do every day. And that for me is, as you know, that’s music. It’s really neat because I thought I was an okay guitarist, but I’m starting to take lessons again and I feel huge challenges and I’m learning something every day, and I’m getting better at this. So, you need something that does challenge you. That would be my advice. And so, if you can maintain some of that, then that will be valuable to return to when it comes to retirement times. Emphatically, not playing quite so much World of Warcraft and the new version is going to come out in a couple of months time, we’ll probably sign up for it, I think we’re up to 120. But that seems to have lost its luster, perhaps because my sons have stopped.

Chad Ball  30:35

That’s fantastic. The last question we want to ask you, maybe it’s the most important question, I don’t know. You might agree or disagree with my subsequent statement here. But I think, as surgeons, we see lots of examples of retiring poorly. And by that, I don’t mean that in a judgmental way. But just in terms of challenges, personal challenges moving on to the next chapter in the postsurgical life. It appears from the outside anyway, and talking to you a lot about it, that you’ve done that with elegance and grace and deep thought, as usual. I was curious how you viewed that, how you did that, and what you would tell any of us that are, 10 or 20, or maybe even 30 years out from that time point. But what advice would you have and how do you think about that? I’m going to start before retirement, I’m going to start around 60. And I think it’s very important that an individual be sufficiently self-aware, because we change. I have a naive enthusiasm for life and the excitement and I go too fast and all that business, that was my nature. And we change with time, we become more cautious. We worry more. Yeah, we can hide the tremor, the tremor I can control in the operating room. But we don’t look forward to having to resect the portal vein, the way we used to. “Ah, it’s a good portal vein case”. “I didn’t really want to [inaudible], ah okay I’ll tell you about the portal vein today”. Life changes and you have to be aware of that. And we become more cautious because we take our complications much more seriously. “Oh, we should have done that differently”. I think that’s human nature. And I saw a number of senior surgeons who had lost it, and I was embarrassed for them. I was very aware of that myself. I could see that in myself, that I was much more cautious. And before I made this [inaudible] unresectable, I better make sure I’m not [wussing out] on this because I don’t want to deny someone an opportunity, you know? In the operating room, the same sort of thing. I would call my colleagues. But we do change and I think you have to be aware of that. And some of us change sooner than others. You need to have that self-awareness and know when it’s time. Number 2, obviously you have to have the financial resources in place. I sat with my financial advisor and when I sat down with her, it’s was pretty clear to me that I had more money than time, that any more was just greed or more for the kids when I die, and it’s time to move on. So, you work towards that. So, you develop a goal, because I developed a goal in all that. And you have to have the successions stuff in line and all that. People to replace what you’re doing, all that. Then planning. I remember, I have a number of friends who were my age and retired. I used to say to them, “But what do you do all day? What do you actually do?” “Oh Paul, you’d be surprised how busy you get when you’re retired.” “Yeah, what do you do all day?” They give me these answers. A little bit here and there, and you talk with people and stuff. And advice is free. But I sorta like this advice I got that suggested you should have at least 3 things that you’re working on and one of them should be physical, because we start to lose it. And so I’ve got 3 things. That have enough of a challenge that when you get up in the morning, there’s something you got to do. That’s what you want to do when you’re less at the beck and call, and you’re not going to get called at 3 o’clock in the morning, and I’m not chronically exhausted. It’s quite extraordinary how exhausted one really was and didn’t realize it, you know? But the advice I got to have 3 things, separate from [inaudible] obligations to the house. There’s always stuff to do in the house, work to do in the house. Things to do. So I chose learning music, it’s my number 1 thing. [Inaudible] and work with another guy taking lessons and recording. That’s coming along pretty well. We’re starting to gig. I’m training to do some more mountain hiking because I love being high in the mountains. I look forward to doing more in the Canadian Rockies once I get this other thing under my belt. And I got a project with my brother, which I’m thoroughly enjoying, and at the end of it all, I’ll have a summer car. I was just chatting with him today about what we’ll do next. So that would be my advice. Be introspective, know when it’s time, and put a good couple of years planning to it. Because it’s pretty easy to wake up in the morning and have another drink, because it tasted pretty good.  Thank you so much for this. Thank you, thank you, thank you.

Ameer Farooq  36:17

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.