E16 Mary Brindle On Art, Ariadne Labs, And Pediatric ERAS

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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  00:51

In this episode, we had a conversation with Dr. Mary Brindle. Dr. Brindle is a pediatric surgeon at the Alberta Children’s Hospital in Calgary, Alberta. We had a unique discussion about the relationship between art and surgery, and how those two disciplines interact and inform each other. We also heard from Dr. Brindle about her work on updating the safe surgery checklist and her work on ERAS in pediatric surgery. Check out our show notes for links to Dr. Brindle’s papers as well as to the paintings we discussed in the episode. We hope you enjoy.

Chad Ball  01:24

Well, Dr. Brindle. Thank you very much and taking time for joining us we really really do appreciate it. Its a pleasure to have you on and we’ve been looking forward to it for sure. We’re just curious, for those listeners that maybe don’t know you. Where did you grow up? And what was your training pathway like in terms of, you know, medical school and making a decision to go into surgery and eventually ped surgery?

Mary Brindle  01:48

Yeah, no, I, I followed a bit of a different route than I think most people did. Certainly at the time that I was going through my educational pathway. I’m from St. Catharines, Ontario. So it relatively small-ish town that is across Lake Ontario from Toronto. I grew up there and I did my undergraduate degree actually in art at Yale University in the United States, and then I went to Dalhousie University in Halifax for my medical school. I did my general surgery training in Vancouver. During that time, I took a couple of years to do research at Stanford, finished up my my general surgical training in Vancouver, and then my fellowship at Sick Kids in Toronto, before coming to Calgary where I’ve been since I finished my fellowship. So that’s, it’s a bit of a circuitous route. But that’s kind of how I ended up where I am now.

Ameer Farooq  02:54

What was the thing that made you want to do surgery and then more specifically, pediatric surgery?

Mary Brindle  03:01

Yeah, no, and it’s interesting I am, I was interested in surgery at the time, I was thinking about medicine in general. So a lot of the a lot of my interest was way back before thinking about medical school was in anatomy and the creative process and the technical process of of actually doing things with my hands. So surgery was very appealing to me both for the the problem solving nature of it, and for the technical side of it. So even when I was first starting out into medicine, that was something that that I was really interested in doing. And pediatric surgery is a is an area particularly neonatal surgery, which is a great passion of mine is very much about about anatomy. It’s often a very creative process, because you don’t always know exactly what you’re going to what you’re going to find in the case. And you have to be able to develop the sort of creative solution sometimes because not everything kind of follows the textbook. So there’s that. Of course, there are other things about pediatric surgery that for me made it very appealing. In medical school, when people were thinking about there’s the specialization, a lot of people would say I would love to go into a pediatric specialty, but I just think that I would find it really frustrating to deal with families. And I’ve got to say it’s one of the nicest things that we do in pediatric surgery is working with families to try and come up with a care plan and the care pathway. I’ve got to say like 99% of the time, you’re all sort of moving in the same direction. We all want the same thing. It’s rare, I think to have big differences between your own overall goal in, in from a parent’s perspective to a surgeon’s perspective. So, there’s a lot of things that I really liked about pediatric surgery long before I started looking at it. And I guess I had one other thing just to get back to the technical side of it. It’s, it’s not a very forgiving specialty when you’re dealing with neonatal surgery in terms of technical error. If, if you do something right the first time, you have great results, I guess this is the same in many other areas of surgery. But neonatal tissues are not very forgiving. So there’s a real pressure to be technically correct right at the outset.

Chad Ball  05:45

It’s so true. Yeah, there’s no doubt. You know, a lot of those elements are what draws us to our particular subspecialties. It’s, it’s amazing how core and central that is to so many of us say.

Mary Brindle  05:57

Yeah, exactly.

Chad Ball  05:58

Mary one of the things that you wrote that a lot of us across the country really, really liked very much was the the piece with Andrew Seal, in in Roscoe about sort of a history of what’s your guys’s history of art and surgery and the intermingling in between those two things. So, you know, we heard you mentioned that you had formal art training. I was wondering if you could talk a bit about maybe that article, and in particular, how you see those two worlds interacting, how it informs your practice of surgery, or maybe it doesn’t, I don’t know, and vice versa. Just a general a general sense of all that amazing stuff that you’ve done.

Mary Brindle  06:38

Yeah, and I really loved doing that article with Andrew Seal. I mean, you know, you know, Dr. Seal. He is he is a really remarkable human being excellent surgeon. He’s a tremendous artist. And I think he has also done a lot of work to try and encourage that creative side of medical students, residents, people in the health care system, so. It was really fun to do and, and he and I have similar and also different perceptions of the role of art in in a surgeon’s life in particular. I feel like doctors, you know, really saw a lot of this as being ability to get away from the sort of the, the stress of surgery something to do, which really takes you apart and takes you in a different direction. And I see that, but I also see them as very much interrelated. And I think that on many levels, he does as well. Some of the things that I think are very similar, is the sort of dedication without clear, external rewards all the time to the pursuit of a craft. And it’s interesting when I was in, in art school in undergrad, at that point, I didn’t know anyone who would come from that background who went into medicine. And actually, no matter did the people who were in the medical system at Yale, it was very unusual. And there was a perception that there was a perception.

Chad Ball  08:22

That’s real interesting.

Mary Brindle  08:25

I know. And I think there’s probably a lot more of that now. But there was a perception of people in art was somewhat flaky. Not really. Yeah, yeah, exactly. But I’ve got to say, like, myself, and my, like, my friends who I worked with, like we were in the studio, one in the morning, two in the morning, like constantly working on this. Not necessarily being able to be confident that the all of that hard work would necessarily come to what we would want it to do to be at the end. But recognizing that without that hard work, we would never would never get there. And I think that prepared me very, very well. It was much less structured than the science programs at the time.

Chad Ball  09:13

It it’s so interesting. You know, I I want to maybe get your thoughts. I certainly you know, and in full disclosure, I live far from the art world. My you know, I, I I’m so impressed by it, and I’m so mesmerized by it and your talent. Now there’s talent in the process. It’s, it’s mesmerizing to invest the word like that I really, really fall back to, just to just to be around and watch. But I gotta be honest, one of the most interesting, actually, like two of the most interesting podcasts I’ve ever heard were Dave Chang when he had Jerry Saltz on. And, and also again, for those who don’t know Jerry Saltz is a Pulitzer recently Pulitzer winning critic-writer in New York. And he talks so deeply and so interestingly about exactly what you just mentioned in terms of process and the lack of external validation. And sometimes when an external validation comes how inaccurate it can be. It’s such a different driver in many ways than than surgery.

Mary Brindle  10:25

Yeah, yeah, it is. It is, I mean, different than, yeah, no, I suppose in surgery, you you see your product pretty quickly. And the value of it is relatively clear at the end. But the process I think, is still to kind of get to this idea of, of excellent to achieving excellence. It’s it’s a difficult process to go through it. And I think that art and medicine, particularly surgery, I think, share a lot in that respect.

Ameer Farooq  10:58

Dr. Ball and I didn’t talk about this before, but I was just thinking about that David Chang podcast, because I think the interesting thing that he does is he interviews all sorts of interesting different types of people, chefs, athletes. But when you get to people kind of at the height of their craft, it’s it’s surprising and interesting how, how much overlap there is when people just pursue their craft, for the sake of their craft? And like, I’m curious, for those people who haven’t read the article, like, how do you think that your art has do you think the fact that you were an artist has helped you become a better surgeon and or vice versa? How do you think the two have kind of interplay?

Mary Brindle  11:45

Yeah, no, I definitely think it has. And I think part of it is, is this idea of the pursuit of kind of individual excellence. And I mean, I do a lot of health systems research. And I’m a huge believer that system performance is incredibly important in giving the very best care to our patients. But there’s another side of that, which I think is the surgeons own personal contribution to a patient’s outcome. And I feel like that is this this pursuit of excellence, which I think shares a lot within art, where we aren’t simply aiming for, for being adequate, but we’re aiming to be, to be to achieve mastery to be better than, than what you basically just need to do your daily work. And that, I think, requires a certain internal dedication. So that you may, you may come to work, and you may do in your training, you may come to work, you may do an appendectomy, and your staff person’s like great, no problems, that’s really good. Or you may have a staff person who sort of narrows down on some of the key areas that you could do better. But at the end of the day, you’re going to move from person to person to person, in terms of the people who teach you. What I think is really important, and particularly when you’re done training is that you have integrated, that desire for self improvement into your daily work, so that at the end of the case, or during a case, you’re concentrating on those technical aspects, and at the end, you can reflect upon them. And you can say, I was happy with this, or I wasn’t happy with this. And I’m going to get better. Musicians do this all the time. But I’d say that painters and artists, we do the same thing. You look at what you done, and you think I really feel like I didn’t really capture that the way I wanted to. There’s the technical side of it, there’s the way you envision it. I think those was really important for me in, in becoming a surgeon and I think actually continuing to grow as a surgeon,

Chad Ball  13:58

Yeah, continued quality improvement, or whatever terminology you want to apply to it is important for all of us, no matter what we do. There’s there’s no doubt. One of the things that Mary that I sort of warned you maybe I would I would bring up was the quote from Michelangelo. I think that it is so interesting when we think of it, at least when I think of it in the terms of the context of surgery, which is that natural power, talent, dedication and self-teaching are not sufficient to carry one to the height of mastery. And essentially, the relationship between the mentor and in the school and the participant are central to the success of of that individual. What do you think of that quote, and how do you relate it to surgery? Because of course in surgery, the training is reasonably regimented. And you do see artists of course that don’t have classic or formal training who are absolute rockstars and amazing and you really don’t so much see that in surgery per se, but what do you think of all that?

Mary Brindle  15:01

Yeah, and usually in this area too and Andrew Seal and I talked a little bit about this. And this is one of those areas where modern art can diverge somewhat from, from the surgical training. In that you take the Renaissance artists around the time of Michelangelo, the northern Renaissance artists, like Hans Holbein. These are people who the the technical aspects and achieving mastery over that was incredibly important being able to depict something in a very precise and certain way. And I do feel like we there’s an area where we have some overlap. I do like that I was glad that you sent that to me, because it really does reflect this, this apprenticeship idea also in surgery. And I think that with the changes in medical education, there’s been a bit of a drawn back from the idea of apprenticeship. Like this, it feels a little bit negative that you put in your time, at the end of it, you come out as a finished product. But there is something very important in learning from in learning from people who have achieved a certain degree of mastery that doesn’t come as easily through didactic learning, or even simulation sessions, there is something about this graduated sort of acquisition of skills and the technical mastery that you can achieve when you’re actually doing surgery that is harder to achieve outside of that. It resonated with me. I was really glad that you sent that along.

Ameer Farooq  16:33

Can you can you teach like the art of surgery or the that dedication by breaking it down? Or like how do you think that competency based design fits within this whole idea of surgery as sort of this technical mastery this art form that we’re all trying to achieve?

Mary Brindle  16:53

Yeah, well, no, surgery is complicated. And being a good surgeon, is certainly not about just someone showing up and doing an exceptional job at an operation. I think we all we all recognize that. And I think that some of the changes in the way we pursue education reflects the fact that the art of surgery is not simply the technical art, but also the clinical decision-making, the problem-solving what have you. So there is certainly I think, a component that the competency by design, does teach and at the end of the day, it’s a little different than if if you are dealing with a musician or an artist. And in most cases, you are really getting a tiny proportion of people who do high performance work and what have you. But we want a you know, we want a large number of highly skilled and trained surgeons and how we go about doing that, unless you have some form of saying that there is competency that we want to instill and measure and achieve in our in our trainees. And I think this mastery, which is a very important part of it has to be something which is integrated into this. But I think it is even more important in in sort of changing your mindset as a surgeon so that after your training, that you continue to try to achieve that because I feel like there’s so much to learn in training, that this is true mastery, the artistry of surgery, is something that you are going to continue to develop yours after you’ve left the training program.

Ameer Farooq  18:39

Speaking of lifelong pursuit, how do you like what advice do you have for trainees who, let’s say are starting or are in the middle of their training? Who have interests that are like arts or other things outside of surgery or medicine? What advice do you have to people to on keeping up with those those passions outside of surgery? And how have you done that in your life?

Mary Brindle  19:07

Yeah, I think that it’s it’s hard because even in art, there can be a lot of traditionalist thinking. Like when I was in school in art school, there was this this pathway that you would go through and there were it was presumed that if you were going to be a successful artist, you would do your degree, then you would do a masters, and you will be a teacher, and then you would on the side work in galleries, and this was just the pathway that you follow. And I think that what’s really important for us, those of us who are interested in art, outside of our medical practices is to find a way of recognizing that the value of the art that we do can be quite different than the way people have traditionally told us we should be valuing art. So you know we don’t like when I was in art school. It’s all about Well, you know, if you’re not showing your art, if people aren’t buying it or looking at it, that it’s, it doesn’t have the value. You have to change that in your head. So that you recognize the importance of the art to you as an individual. And that can be either very, very personal. You don’t show your art anywhere, it’s just for yourself, it’s part of your personal growth, or that there is some component of sharing that. But it doesn’t need to fit any particular measure of success that we’ve been told throughout our life that this is your sign of you as a successful artist. You can do it 100%, you absolutely can. But that’s, that doesn’t have to be the way you do it. And there’s lots of people who I know who continue to pursue art and continue to show and continue to engage with audiences. And if you keep that up, you can go back to a more traditionalist kind of approach to art. And then at a certain point in your career, or even all the way along your career, but I think what’s really important is that you find a way of integrating that way of either seeing the world or or pursuing art for yourself as a deeply personal thing to make that part of you but not necessarily expect that kind of external validation for for what really, I think their internal process.

Chad Ball  21:24

I’m just curious, you know, how I you know, you’re such a, such a busy person administratively and clinically, how often do you paint? How do you how to get get it in, in your life? And and also, what’s your, what’s your process like? I’m always fascinated in asking artists, do you see the end result the painting, for example, before you start, or is it an evolution, and it changes your vision of it changes as you go? How does that work for you?

Mary Brindle  21:51

Yeah, no, it’s a, it’s a good question. And I go through periods of sort of more hour productivity and less hour productivity, kind of depending on sort of everything else that’s going on. But I do try to keep somewhat involved on a regular basis. And when I get really busy with research, or clinical work, or what have you, I try and maintain involvement either through a lot of just engagement with art or sketching. And right now, I’ve been doing a lot of sketching. And I just, last few days, I’ve been sort of, sort of going down and getting my studio ready to do some more like actual studio painting. But that’s more of a, like a bit of a rigorous process to do that. Through an oil painting, which is what I do is the kind of thing where you don’t just sort of go and spend like a few minutes doing it. It’s like the setup is it takes a while that type of thing. But when I do when I do, painting, it can be a few different ways. Either it can be very much like an exercise of just putting ideas down, drawing things, quick paintings or renderings of my larger paintings. I spent a lot of time drawing and redrawing climate competition, that type of thing. And even things like I even things that look relatively spur of the moment, I’ve spent a bit of time drawing and redrawing them before they make their way onto onto a canvas. I think a little bit about that. I went to Madrid a few years back and I saw all of the studies and sketches that Picasso had done for that painting Guernica. And there like he had rooms full of really, yeah, all the elements of this painting that he worked and reworked and reworked and resketched and redeveloped for a painting that feels really immediate. Very emotional, right? It does not process to tell it doesn’t make it stagnant. It makes it living nicer.

Chad Ball  24:05

We are just curious who your favorite artists are and if you have any, particularly favorite paintings? Yeah, and it can be abstract. So we all have to go look them up to be great.

Mary Brindle  24:18

I mean, these are hard questions, of course. Because, like if you if you ask someone like what’s your favorite musicians? What’s your favorite band? It’s, you know, I mean, like, people’s interest in music. I have diverse interest in art, but one I’ve mentioned Jean-Michel Basquiat, I love his art. I love his vision. He’s a guy who’s really interested in anatomy and in in narratives and story. There are many paintings that he does, a lot of them are untitled too, it’s hard to say, like, untitled, but lots of lots of these narrative paintings, but there’s no painting that I that I really quite like and it’s similar and different than then that Basquiat’s work. It’s “The Ambassadors”, which is the Hans Holbein painting. This is a painting, which is a huge painting in the National Gallery. It depicts two ambassadors and there’s kind of surrounded by sort of elements of science and things that they’ve picked up in different places. And it’s, it’s highly, it’s a highly detailed painting, it’s a very well developed painting, it’s highly realistic and colorful. And when the kind of across the front of this painting, there is this, this sort of deformed gold that stretches from the left side of the cross, to the midpoint of the painting that if you look at the painting, you don’t see it. It looks like a smear, it looks like something unrelated, but if you stand in the right angle, that it it turns into this, this skull, which I remember that painting as a kid, and I loved it. And I still really appreciate it, because it’s got this narrative. And it’s, it’s a highly, that you just know, the hours of work that went into it, but also the many ideas that come out from that.

Chad Ball  26:14

I love it. I want it.

Mary Brindle  26:17

It’s a great painting, it really is worth going to see in person. Whenever I’m in London, I try to see that painting.

Ameer Farooq  26:24

I wanted to talk to you a little bit about what your work with Ariadne Labs has been like I had the opportunity to meet Alex Haynes, while he was still there, and kind of explore that a little bit. And it was so impressed by their group and the work they’ve been putting out. How did you get involved with Ariadne Labs? And what has it been like to work with such an innovative group?

Mary Brindle  26:47

You know, it’s so I guess it started when I did my MPH, which was back in 2010 2011. I just had some very small interactions with Atul Gawande, but nothing, you know, nothing significant. But I was interested in the work that he was doing. Then, when I took my sabbatical, I decided that I really wanted to develop more of this kind of health systems research. And I wrote to Atul at that time and said, this is something I’m interested in. What do you think, and he said, Spock just started at the Ariadne Labs be really good said, Let me put you in touch with Bill Berry, who was at that point, the connection, for safe surgery. He said, he’ll he’ll help you out, we’d love to have you. And so that’s, that’s really how it started was back during my sabbatical. And, like, I really wanted to sort of dig in deep to understand how, you know, have these health systems can improve. It’s a fascinating lab, because they’re really, really interested in in changing, changing things. Not necessarily publishing not, you know, not looking at what we typically think of as our academic tick boxes. But to actually say, like, we see a problem, this problem exists all over the world, we’re going to develop a solution that works here in this one site, and we’re going to scale it up, and we’re going to try and make it work everywhere. It’s a really different way of seeing research. In a very much like a, we want to change the world type thing, which is super appealing, I think, you know, it was, it was really, it was really fun to work with those guys. And that’s kind of how that started. And then from that work, I got interested in this case surgery checklist revision project, recognizing that you know, that the checklist itself shouldn’t be a static tool, it should change as the world that we live in changes, it should evolve based on what we learn. And that was kind of sort of the impetus for the project that I’ve continued with Ariadne Labs. And it’s probably the reason why the work that I’ve done with Ariadne Labs is really kind of blossomed into the work that I’m doing with them now.

Ameer Farooq  29:15

When I went there, I really got the same sense that you did. And again, I was just there peripherally. But it almost feels like a cross between, you know, a Google kind of startup type scene and like a hardcore Harvard research. Which is it, I don’t know how they’ve managed to kind of get those two ambiences. But it really does feel.

Mary Brindle  29:40

Yeah yeah it does give you like a feeling of uses intersection of different groups like creativity, a lot of sharing, it’s a big open concept lab, which can occasionally be a little bit exhausting because you’re always, you know, sort of interacting and intersecting with people. But at the same time, it really pushes that kind of dynamic like get bring people together, develop solutions to problems. And then there’s a real push to do things in a way that is relatively quick and relatively comprehensive.

Ameer Farooq  30:15

Can you talk a little bit of what the work that you’re doing with revising the checklists? Like how does how does something like a checklist evolve or change? I think most of us feel like it’s something that you put it on a piece of paper.

Mary Brindle  30:28

Yeah, I think that’s, that’s the thing. It’s, there’s problems, even with the concept of a checklist as a checklist, because it feels like these are the things that I need to do to move to the next stage. And it becomes a bit of a, you know, kind of a tick box exercise where people are more interested in, you know, getting that, you know, that piece of paper completed, rather than actually achieving the concepts that are behind the checklist, which are really those to do with, like improved communication, and improved understanding of what you’re you’re supposed to be doing in the operation to come. I mean, I think that everything that we’re dealing with right now with COVID, has really sharpened our view of the importance of these types of structured communication strategies, so that you have a shared understanding. So from the initial creation of the checklist, which was, at that point, there wasn’t a lot to go on. There were pilot checklists, there were checklists that people were doing in the ICU. There was real push from the WHO to say, what can you create, that’s going to work everywhere. So really, what came out from that first project was something that was, I don’t want to call it a first draft, because it certainly wasn’t, it was very well thought out. But nothing of that scale had been created before. So there’s been a ton of learning since then. And people have recognized the problems that the checklist can drift into this tick box thing and how we can bring it back to something just much more communication based. So we’ve learned a lot from that point. And what a new checklist should look like. And I shouldn’t say a new check of the new approach to a checklist or how we should develop a checklist or what that you know, what a revision would look like. I think it’s been informed by what people all over the world have been seen, in terms of what works, what doesn’t work, places that have used it particularly well, how that’s integrated into something. So we had a meeting in Boston back in early December, where we brought people from the UK, from Australia, New Zealand, United States, Canada, from all over the place, but we really sort of concentrating in high income countries just to keep our scope manageable at the beginning. Although we’re planning a second stage of this, and we brought everyone together and said what’s, you know, what should we be thinking about now? Here’s, here’s the whole slew of published evidence on what works and what doesn’t. And clearly, under the right circumstances, the checklist can work very well. And under poor circumstances, it really doesn’t improve things. And so we brought people together. And we’ve been in the process of collecting information on what will make the checklist better, how do we optimize it? And we’re kind of at that stage now of, to breaking that down into approach to modifying the checklist and approach to implementing the checklist. How do we teach and educate around that? We’ve done a little bit of early preliminary work with the WHO to say like, what’s the next step? In terms of looking at the global WHO checklist? When it’s kind of look at it, it’s it’s an involved process. But I think an important process, the checklist has to feel like dynamic, otherwise, we’re just using a dusty tool that doesn’t really have any relevance.

Ameer Farooq  33:59

In sort of unrelated lines, you’ve done so much work on ERAS in pediatric surgery. Can you tell us a little bit about that, and how you got interested in and why you think it’s so important?

Mary Brindle  34:12

Yeah, I mean kind of fits into some of this, the same idea of how we can create systems to improve safety. I mean enhanced recovery after surgery has a like a clear role in certain areas of surgery, particularly colorectal surgery, which is where it started. And one of the things I really liked about enhanced recovery after surgery is that it is really, really focused on how the the ERAS guideline is used. The timeout itself exists. But so much of the focus of groups that use ERAS is like, Well, how do we actually take these recommendations and put them into practice. Or how do we evaluate how people are putting this into practice and this real sense of like, if you’re not seeing How you’re actually using the ERAS guideline, if you’re not evaluating that, then you’re not doing it right. And I really liked a lot of those concepts. And some of them are just easy wins. Like this, this idea back like 10 years ago that a patient after a colonic resection needed to stay in hospital for a given number of days, just because that’s the way it was always done. Like this kind of turns that around a little bit, it really focuses on the patient and moving things forward. So a lot of ideas that I really liked, and pediatrics just wasn’t at the table for that it just people have been expanding use of enhanced recovery after surgery to all sorts of different areas, it’s really taken off in like gynecologic oncology surgery. But I think pediatrics felt different, because I mean because it was very different children are different, their needs are different. And we decided that if we were going to look at an enhanced recovery after surgery in pediatrics, rather than just sort of going to say, Well, how would it work for adolescents? And you know, what can we use? What can we not use? We sort of said, Well, we love these concepts and how it works, let’s actually go to the most complicated and farthest away patient population neonates. And, you know, here is what ERAS protocol would look like for them. And this was a like, this was a very comprehensive process to go through with, to try and start from scratch and say, what works and what doesn’t work. Let’s like, give ourselves a blank slate, recognizing a lot of the principles of ERAS, want to capture that. But you know, we can’t like getting a neonate up and walking doesn’t happen. So what are what are the what are the neonatal sides of that? What is like, what’s the parents role. And it’s a little bit like, I mean, from doing this work with a checklist, the same type of thing, we got an international group together. And this one’s more, I’d say, international scope. And we have people from Hong Kong and from Sweden and from the UK and everywhere to evaluate as thorough as we could all the relevant, like data that’s out there, to create a bit of a guideline. And then to kind of push that forward. And it’s, you know, it took a lot of work. But it this is going to be the framework that we build from, to do further pediatric, ERAS work to, you know, to kind of come from the other direction. And it kind of allowed us to create some standards for what an ERAS guideline should actually look like. And that’s one of the things that we that we started working on as well, because everyone kind of knows what your ERAS looks like. But the until this past year, we actually didn’t have anything down on paper as to this is what constitutes an ERAS guideline. And we kind of worked on that as well with the ERAS society.

Chad Ball  37:57

Mary, we can’t thank you enough for spending time with us from Cold Steel. It was amazing to hear all this stuff you’re hearing involved in and engaged in moving surgery forward and thank you for that. But most importantly, thank you for the art lesson.

Ameer Farooq  38:20

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.