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 got to talk about a topic that seems to loom over my head a lot these days, examineship. We spoke about this with Dr. Tony MacLean, a colorectal surgeon at the University of Calgary and the new head of the Royal College Exam Commitee for general surgery. We talked about how to prepare for the exam. And we also drew upon Dr. MacLean’s experience as a program and fellowship director, to get his advice on how to get the most out of residency. So, Dr. MacLean, thanks for coming on the podcast, we really appreciate it. And, in particular, we wanted to draw on your experience, having been on the Royal College Examining Committee for a long time. Can you tell us a little bit about how you got into this role? What drew you to the role? And how do you think the exam has changed over the years that you’ve been a part of it?
Tony MacLean 01:43
Sure. So, I was asked to become part of the exam board for the Royal College back in early 2006. At that time, all program directors were automatically invited to become members of the exam board. And so, I joined. Number one, I thought it was good from a program director perspective to have a good understanding of the exam process. So that I was sure that the curriculum that I was delivering for my residents would meet all the needs that they would have in order to be successful at the exam. And then having been involved in that process for a few years, I was invited then to become part of the test committee, which is the group of surgeons who helped put together the actual questions for the exam, put the exam together. And then, through the course of that, I got to work with some really great people and great mentors, like Don Buoy, Brock Verr, and Gord Davies, who then ask me to continue that commitment by becoming the vice chair with a view of becoming the chair, which I assumed this past year after Gord Davies completed his term. I think, from how things have changed over that time period, certainly from my own exam, and since my involvement with the exam board, I think there’s been a conscious effort to really try to ensure that we’ve increased the amount of clarity with the questions that are delivered to the examinees, both from the multiple-choice component, as well as from the oral component. And we’ve also sought to try to ensure that there’s a very fair delivery of this exam to the candidates. That’s been something that’s been an evolution for the last number of years and continues to be an evolution. It’s a challenge to try to provide questions that are both extremely clear, with one clear best answer. But also, that aren’t so easy that it’s not worth giving the exam at all. Obviously, that’s a fine line to balance, but I think we’ve been getting better at it. I think over time, that’s become a much better process.
Chad Ball 04:43
Tony, one of the things that is clear is that, oral exam ability, or talent, or examsmanship, whatever term you want to use, is a real skill. It’s a true talent and it’s certainly, I think, underappreciated. And even for those of us maybe that give lots of talks or can talk to the media, or whatever. And you’ve known me for a long time, since I was your resident. Doing well on an oral exam certainly wasn’t intuitive to me anyway. So it’s clearly a skill. What sort of tips do you have for trainees, really at any level, whether they’re doing a Royal College exam with you guys, or whether they’re doing maybe a fellowship examination? How should they prepare? How should they frame the exam in their mind? And what would you tell them, maybe at a 30,000 ft level, to really think about and try to train in terms of performance?
Tony MacLean 05:34
Sure, that’s great question. I think the most important thing for any exam is having that comprehensive knowledge base that allows you to be able to answer the questions effectively. But the knowledge base itself, as you indicate, doesn’t necessarily translate into an effective answer on an oral exam question. And I think that boils down to a few things. I think, from an advice standpoint, I think the best advice I could give would be to practice. And that means to take every opportunity to do oral exams, right from your very first year of training as a trainee, and to have that become sort of a standard part of the way you think. And to treat each of those exams like they were the real thing. Really, to be hyper focused on what the actual question being asked is. To maintain a sense of organization in answering the question and to answer the question completely, but not to continue the answer beyond what the question that was asked is. There’ll be lots of opportunity to have follow-up questions in any oral exam, whether it’s a practice one at the end of a rotation, in your home institution, or whether it’s at the Royal College. And so, I think, being clear what the question is, in your own mind, and providing a clear, complete, but relatively succinct answer to the question itself, is probably key.
Chad Ball 07:22
I think we’ve all seen this, in friends or colleagues, you’ve probably seen it on the day of these examinations, for sure. But every once in a while, somebody will have trouble regrouping after a difficult question or a difficult performance of the question, whether they have the content knowledge or not. How do examiners, in general, view that scenario? And what advice would you give the candidate in terms of calming themselves and refocusing their ability, going forward within the exam itself?
Tony MacLean 07:55
That’s another great question. The examiners are a very great group of people, they’re volunteers, and they want a good process. But at the end of the day, they want the candidates to pass when they should pass. And there are no examiners that are hoping that a candidate will do poorly and fail. That’s as disappointing for us when we see that. We do see people struggle. And I think the best preparation for that struggle is to struggle in practice and force yourself to follow up a difficult question in practice with another question immediately. That gives you that practice to settle yourself down, to refocus and to do it again. I think, if you haven’t done that in the lead up to the exam, that might, give you the difficulty during the exam process itself. And so, the more you’ve been through that, and had to force yourself to reset your focus and to forget about the question that just happened, the more effectively you can do that, the better you’re going to do. And it’s important to remember that, no one question on an exam of any kind will sink a candidate. This is a cumulative score and most people are actually, probably, doing better than they believe they are. That’s our inherent nature, I think, for most of us to judge ourselves more harshly than the observers or the examiners that are evaluating us. And so, I think that’s another important thing to keep in mind.
Ameer Farooq 09:36
Going in a slightly different direction away from the exam. You were a general surgery program director here in Calgary for a few years or for quite a number of years. What advice would you give current residents about their training and particularly considering the fact that it seems like there’s just going to be more restrictions and limitations on the number of hours that trainees can put into the hospital. How do you think that we’re going to reconcile the two? And how can we get the most out of our training?
Tony MacLean 10:06
That’s a great question. I think that’s a moving target. And I think you’ll get a lot of difference of opinion about what the right answer is there. From my perspective, I felt this way when I was a trainee, and I got this advice from mentors of my own. And I think that, 5 years, though it might seem like a long time, is really a short period of time to gain the knowledge necessary to be an effective practitioner, as well as gaining the technical skills required to effectively carry out our job. I think what we do is such important thing, I would urge people to, from day one, really devote themselves to the time necessary to acquire both the technical skills and the knowledge to perform at your best. I think one pitfall that I see not infrequently these days is with the skills labs, people feel that that’s the venue that they’re going to pick up their technical skills at. And the volume of work done outside of that, for at least some of our trainees, has gone down significantly. Some was trained in the era prior to skills labs, and we basically turned our apartments into mini skills lab. And still remember tying literally thousands of knots. Sewing my furniture, sewing pretty well everything in the apartment, for the first couple of years of training. I was given advice, which I think still holds very true today, that you’ve got to be able to effectively carry out the technical steps appropriate to your level of training, when asked to do so. And if you’re able to do the things when you’re asked to do so, you’re generally given more opportunity to do both that task as well as additional, more advanced things. Whereas if you struggle with being able to do things like sewing or tying knots, the likelihood is that the faculty or the senior trainee that’s with you will assume that you’re not ready for the task at hand and will simply take over, will be less likely to get you to do it the next time.
Chad Ball 12:36
That’s great advice Tony. If we continue down this path in terms of your experience and your thoughts as a long term fellowship director, should say longtime residency director and then also involved heavily, obviously, in the colorectal fellowship world. One of the questions, I think, that all of us get routinely is, how to best prepare yourself at the resident level for applying to a fellowship, and then securing it. What are your thoughts about that, in general? What advice would you give the residents moving through that sort of scenario? And then, is there any specific colorectal surgery in particular, I guess, at the end?
Tony MacLean 13:14
Sure. I think this holds true whether you’re going to do a fellowship, or you’re going to go on into practice. I’d, sort of, view your training as a 5-year job interview and you certainly want to be conveying the right attitude. Somebody who’s got a good work ethic, somebody who takes responsibility, somebody who is honest, hardworking, and takes good care of their patients. As far as deciding on a fellowship and securing a fellowship, I think the most important thing is finding what really you enjoy doing. That can be difficult, especially when you like most of the things that you expose yourself to in general surgery, I think. I was going through my training, I liked most of the subspecialties and there were certain things that I liked less about some, that helped the balance for me about what I want to end up doing. And that’s partly the work and partly the mentors that I was exposed to in training. I think as far as setting yourself up, I think if you have those traits of being a hard worker, and really being committed to the job, the mentors that you have in training will recognize those traits and will be supportive of you and supportive of your applications. To fellowships, things that you can do on top of that, obviously are trying to be involved in research, getting some research done and getting some publication under your belt. I think that, again, shows another level of dedication to the field and dedication to potentially becoming an academic surgeon, that can certainly, in many fellowships, be a more attractive base for the candidates that the programs are looking at. That can help tip the balance in a competitive year, when there’s multiple candidates applying for few spots.
Chad Ball 15:23
I couldn’t agree more. I mean, you sort of said that in a very eloquent way, I’m probably more blunt about it, when I’m asked. I say, you can probably secure a fellowship through either having worked really hard and having that social and career credit with your mentors that are maybe connected to the places you want to go. Or alternatively, you have a CV with very little fluff, that’s a phone book, that they simply can’t ignore and have to invite you for an interview. So, I agree totally. What do you recommend, or what do you do, if you’re the resident who, say, wants to do HPB training and you think that’s your story out of the gate and then maybe you’re close to 4th year and you think, oh, my god, my colorectal rotation was the best, I want to do colorectal now? So sort of a late applicant to that field. How do you think applicants should deal with that? And how would they frame it in interviews, if they actually, eventually get them?
Tony MacLean 16:19
I think that does happen occasionally. The most important thing is being honest with people. I think, if you’ve done the other things, if you’ve been a hard worker, people are supportive of you, and you’ve done research, the research will likely have been in the other specialty, maybe HPB, in the case that you’re bringing up. But I think that still speaks for the candidate and their dedication. And I think, people make a whole field change, there’s always going to be people that are skeptical of that and unsure whether they’ve truly changed or they’re just looking to have a backup to what they really want to do. But again, if you’re able to arrange last minute changes to elective, if you still have some left in your training, that’s often an extremely important component to demonstrating that interest in the field. And then again, with your mentors, telling them the truth, telling them where you were, what you were thinking and how that’s evolved and what you’re thinking now. And we can often make some phone calls on your behalf, that can sometimes tip the balance and allow you to get your foot in the door, to get an interview and put your best foot forward.
Ameer Farooq 17:35
I wanted to switch gears a little bit and ask you to tell us a little bit about your career. Where you grew up and where you did residency and fellowship. Because I know that your journey has been very interesting, even down to going to Australia for a few months in residency. Can you tell us a little bit about that?
Tony MacLean 17:54
Sure. I grew up in a small city called Moncton, New Brunswick. Went to university in Halifax and then stayed there to do my medical school and general surgery residency. In general surgery, I actually very much enjoyed the vast majority of subspecialties that I explored. And so, I went through several different iterations of what I thought I might want to do. Ultimately, my initial plan was that I would try to do something that would allow me to get back to my hometown to work at my local hospital. When I was in early 4th year, I had the opportunity to work with Will Henderson and Bernie MacIntyre, who are phenomenal colorectal surgeons. Both of them are now retired, but they were amazing surgeons and really sparked my interest in the colorectal specialty. When I expressed that interest, Dr. MacIntyre offered to help me arrange for an elective. He happened to be a co-resident at the Mayo Clinic during his fellowship, training with a surgeon from New Zealand. And so, he contacted her and she was kind enough to invite me for an elective there. Dr. Eva Juhasz was her name. And I spent more time there, focused put on my own colorectal surgery and that helped solidify my interest in the field. And then completed my training. I was the first year of direct entry into surgical residencies, rather than a rotating internship. I was on my last year of the rotating internship and so at the end of my training, there was a slight change in things that we were allowed to write our exams a year early. So, I did that. But then completed an additional 6 month training in order to be eligible to write my American board exams, in addition to the Canadian exams. I got both of those. I went into practice in general surgery for the remainder of that year, covering a locum in the practice of a surgeon in Dartmouth who, unfortunately, had died that year. And then I went off to do my fellowship training in Toronto. Had some amazing mentors, including Robin McLeod, Helen MacRae, Shane Cone and Marcus Burnstein. And I think it was really most of my time with Dr. Robin McLeod, that allowed me to see the benefits of working in a more academic center and really struck my interest in having a more academic career. Mostly through her mentorship, I was able to be successful in my fellowship and in securing my job here in Calgary, where I’ve been since I completed my training. I’ve been extremely fortunate. The people that have taught me through the years have advocated for me and allowed me to become successful.
Ameer Farooq 21:16
You’ve talked a lot about how much you actually enjoyed working in Dartmouth as a community surgeon, can you talk a little bit about pros and cons, and what you like about being an academic colorectal surgeon?
Tony MacLean 21:32
Sure, I mean, it’s one of those things that’s hard to know how true some of these things were. You got to keep in mind, my perspective, I’d gone from working in a fairly unregulated environment, fairly massive number of hours a week, to working in a hospital where both the family physicians working in that hospital and the nursing staff had bent over backwards to try to protect us as faculty there, for many nighttime calls or work. So it was, sort of, an amazing transformation from working frequently, all night long, to working all day and into the evening. But rarely getting interrupted at night. So, went from being chronically tired to very well rested. Went from making very little money, to making very good money. And went from, at least, my perception at the time, was being not treated super well by nursing staff in an academic center, to being treated extremely well by nursing staff in a small community hospital. And so a lot of those things made me wonder whether I should go off and do additional training or just stay there and enjoy that wonderful life that was seemingly happening, in that short period of time that I was there. I think some of the things that, again, mentors helped me see was that, for the most part, if you’re going to do subspecialty training, and try to work in an academic center, you’re, for the most part, gonna have to do that out of the gate. It’s rare and difficult to do that later in your career. There are some examples of people who’ve done that successfully, it’s certainly much less common. I think, the other thing that I noticed was that in some community centers that I worked in as a resident, the faculty saw their work as something more like a regular job and didn’t seem to have the same kind of passion for the profession that I could see in some of my mentors in academic centers, and I certainly was concerned that could be my fate, if I did follow that same path. And so, I very much wanted to be in a situation where I continue to have passion for what I did and enjoyed my career throughout its course. You know, training residents and secondary residents, and students, does have its challenges, but it has mass rewards. We get to work with some pretty phenomenal people, we get to watch them develop from novices into outstanding surgeons, and certainly people, and I think that’s a huge part of the enjoyment I’ve had in my career so far.
Chad Ball 25:16
Tony, I think last question we want to ask you, you’ve touched on, highlighted, really what I think from the outside looks like a pretty amazing career so far, and I don’t say that as if you’re almost done. Goodness, I hope you’re not, got lots to go. But if you think about the environments you’ve been in, if you think about your amazing clinical voyage and your expertise, as well as some of these roles, whether it’s been the involvement in the fellowship, whether it’s been the Royal College exam, whether it’s been residency program director and now section head of general surgery, in Calgary. If you put all that together, what are the 1 or 2 or 3 pieces of advice you, maybe, wish you had known earlier on, or that you would throw out there for folks? Really, at any level.
Tony MacLean 26:06
You know, I think that’s a difficult question for me. What I think you’re getting at is, how do you decide what it is that you want to do? And I think, to me, that boils down to doing the things that you think you’re going to enjoy. And certainly, I wouldn’t say that every part of everything I’ve done, I’ve enjoyed. There’s certainly been some things that have been challenges. But, by and large, most of the big things that I’ve taken on, I’ve really got some enjoyment out of it. I think, from a program director standpoint, you really develop some great friendships and bonds with the residents that are training at that time, and those last further, your and their entire career. And there are people that, when you see them at meetings and other social events, they immediately seek you out and want to say hi and reconnect. I think that’s a model opportunity for people who have that interest. It also sets you up to meet a bunch of other really awesome people across the country who are doing the same job at the other institutions. And it really builds a good network from that perspective. From the Royal College perspective, again, an amazing group of people who volunteer their time to help make that process successful and really amazing group of people to learn from. And you often build long lasting relationships, again, that that carry forward in other realms of the profession, and in social circles as well. Yeah, I think that’s probably the most important thing to me is finding the things that you’re interested in, that you truly want to do, and do them to the best of your ability, and people appreciate it. And I think you get real satisfaction.
Ameer Farooq 28:45
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 email@example.com, or connect with us on Twitter @CanJSurg. Thanks again.