E21 Keith Lillemoe on Equity in Surgery, Annals, and Bile Duct Injuries

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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

Dr. Keith Lillemoe is the chief of the Department of Surgery at Massachusetts General Hospital in Boston, and the editor in chief of Annals of Surgery. We spoke with him about equity and surgery, bile duct injuries, and the challenges of being in charge of the Annals of Surgery, as well as leadership in general. Check out the show notes below for links to all the papers that we discuss, including the consensus conference guidelines on bile duct injuries.

Chad Ball 01:17

I think we all probably in North America and the world know exactly who you are, of course, but I was wondering for any listeners who may not know you closely, if you could sort of give us a sense of your training and career path and tell us how you ended up where you are now.

Keith Lillemoe 01:33

Okay. First of all, thanks for the opportunity to be part of this. I’m excited and look forward to you having some challenging questions and some good discussion. So I guess I’ll start with the very beginning. I’m a farm kid from South Dakota. I actually went to college at the University of South Dakota and did my first two years of medical school there. I then transferred to Johns Hopkins in Baltimore, which obviously was quite a culture shock for my last two years of medical school, but we seem to like it and so I stayed there for the next 29 years. I did my general surgery training at Hopkins. I joined the faculty there and stayed there until 2003. I finished my training in the days before there weren’t a lot of fellowships. So I consider myself a general surgeon. But over the course of time, my practices sort of migrated to mainly pancreas and biliary not that much hepatic surgery. I don’t do any colorectal anymore. And other than bread and butter, general surgery, hernias and lap Kohli’s, I guess pancreas is become my ditch just because of this the way referral patterns develop both at Hopkins and then later at Indiana and now here in Boston. I left Hopkins in 2003, I was at Indiana University from 2003 till 2011. That’s where I obviously had the pleasure of working with you Chad as our fellow a few years before I left, and then in 2011, I moved here to Boston and to the Mass General Hospital and everything was going great until about two and a half, three months ago. And now we’re facing what for most of us is the biggest challenge of any kind we’ve ever seen Medical Society. Economic, it’s, it’s a it’s an interesting time. It’s scary. But, you know, I’m confident our technologies will catch up with this disease and the day will come soon where, you know, we’ll be back to some normality, but it may be a new normal.

Chad Ball 04:01

You’re such an international leader and I would even say icon for sure. You know, like you said, with regard to pancreas surgery with regard to bile duct injuries, and probably now COVID as well, but maybe avoiding those topics, at least for the for the start here. You’ve also clearly achieved the pinnacle of surgical leadership, whether that’s, you know, at Indiana and then subsequently the Harvard system as the chairman of surgery, or of course the president of the American Surgicals so many examples. When did you know you wanted to pursue that aspect of your profession.

Keith Lillemoe 04:40

So my first role model in surgery was a private practice solo practice general surgeon in this little town in South Dakota. And I came to Johns Hopkins, having never been around surgical residents or been in an academic medical center. And so, it was a, you know, it was what I grew up with was at Hopkins and I have to say you emulate those who are your role models. And I was very fortunate at Hopkins to have lots of great role models, but probably the number one person that was John Cameron and you know, John instilled a lot of things in us. A lot of tough love. But, you know, one thing he instilled upon us is that we should be leaders and leaders, not just national leaders or department chairs or anything like that. But no matter where you are, you should be a leader. Whether you’re the leader in your community surgical group, whether you’re a leader in your local state chapter of the American College of Surgeons or whether it be a leader of national organizations or major academic departments, you should strive to be leaders and, you know, the track record at Hopkins of leadership going back to the products of Halsted and then Blaylock and then more recently, the products of the Cameron residency has shown that something about the institution instills the desire and maybe even the expectation that you will become a leader of a Department of Surgery and so when the opportunity came to go to Indiana, and to be a leader, I certainly took it and very much enjoyed the opportunity and certainly there was a way I would say that the job was done but you know, the move to Boston, the MGH added another layer of complexity to the leadership and another set of challenges and so that’s sort of the pathway of leadership that I’ve had the national leadership opportunities. A lot of these come again from, from people helping mentor you and direct you and opening doors or crack for you here or they’re getting you on a committee or getting you an entry level appointment as a as one of the worker bees in the organization. Not you know, I was Secretary of the SSAT I was Secretary of the society University surgeons both which ultimately culminated with being a president and same with the American I was the recorder which gave me the opportunity to, you know, get to know the organization, serve the organization and to develop the connections in the organization that led to the opportunity to be president. And I’ve said this many times, and it’s not original, but when you see a turtle on top of a flagpole, you knew the turtle had a lot of help getting up there and I am the turtle and I have had a lot of help along my career in every facet and you know, just consider myself very fortunate.

Chad Ball 08:08

It’s interesting that you, you highlight your bring up, you know, essentially mentor pedigree because I was sort of thinking of exactly that earlier today, as you know, being a football fan like Don Shula died, and I was looking at his coaching tree, and then thinking in the context of Bellichick and Andy Reid, and these guys, and then of Dr. Cameron, and you and it’s amazing were quote, unquote, Dr. Cameron’s offspring, including you have ended up and so on, because the generations of leaders are underground for a long time the impacts going to be felt for probably forever. One of the really interesting things that I that I always thought about you in particular was the groups of people that you’ve had around you and sure enough, I mean, it sounds like you walked into some of it at Hopkins, and we’re certainly a participant in developing it, but how did you develop such an amazing group in Indiana, and then at MGH you know, these are some of the absolute best of the best folks, and they’re amazing conditions and also meeting humans.

Keith Lillemoe 09:13

In Indiana, I followed a real giant in in American surgery, Jay Rosefeldt and he had set the bar of quality very high at Indiana University and it was a small department and we took the opportunity to grow it and with the opportunity to grow, I was able to recruit some good people, again, many with Hopkins pedigrees that made it like bringing family and friends in to help me grow it and so that was that was key there. And then I think coming to MGH, again the place was a tremendous program, it was tremendous faculty, tremendous residents, but, you know, it gave me a chance to institute a, perhaps more of a cultural change than any major transition in any other aspect and it was timing, because, you know, if you look at the culture where everything was in America and in surgery and things like the Me Too movement, and things like that, that have come along in the last five years, I think your traditional surgical departments would be really struggling now, if they hadn’t made cultural changes. And I think that changing the culture has allowed us to recruit great residents. Many have gone on to become great faculty members with us or elsewhere. And it’s also allowed us to recruit people from outside the MGH to come in and, you know, be exceptional contributors. It’s been fun to recruit a couple of division chiefs over the last few years that were from outside of the MGH and that was good, a little, introducing some new blood is always a good thing. And, again, for junior faculty, too, we’ve got a pipeline of some great junior faculty that have come from other institutions to again, help us round out our culture.

Chad Ball 11:25

That’s a that’s a perfect segway to your presidential address. I know when you were the boss of the American Surgical Association and talked about a number of things, of course, but you know, the two dominant issues that you that you demanded attention about and really talk eloquently about were equity and quality in surgery. I was just curious what led you down that path, and then if you can comment on what was clearly had become a passion for you and some of those improvements moving forward, including the document that you guys published about some of the inequities in research itself.

Keith Lillemoe 12:04

So I guess I would say, being the father of a female surgeon changes your perspective on it a little bit. So I have that going for me. You’ve met my daughter, Chad, and you know that she’s headed the lines of surgical oncology and so again, maybe the apple doesn’t fall far from the tree. But I had grown up in a program where there was very few women, residents, even less attendings and it’s seem as the shift in medical students becoming least 50% of that greater percentage women, that surgery was going to shoot themselves badly in the foot if we didn’t find a way to make our life more attractive to people of all genders, all persuasions, all ethnic backgrounds and I just thought it was time that someone spoke up about some of the things that had been viewed as inequalities. And the American surgical as great an organization, was very slow to make the transition. And I gave my presidential address, there’s only been one woman president, the percentage of women in the organization was in single digits. And, you know, you could say, well, the pipeline isn’t there, you know, people have to progress to get to be members of an organization like that. But, you know, we had to overcome, you know, those unconscious biases that do exist. And less somebody would bring out the bring these to our attention, whether they be on search committees, whether it be on promotion committees, whether they be on membership committees for prestigious organizations, you know, somebody just had to say, look at we have to make sure that we have a open and level playing field across all factors and although I gave my presidential address on really gender inequalities, I did open the door for the next year when Ron Mayer was president to extend this beyond just gender into all areas of inequalities and lead to the document that you refer to that, I think, is a very nice tool for anyone who’s looking to establish programs in your own department.

Chad Ball 14:53

Yes, I think you’re right. I think that document is going to live on for a long time and it’s really changed perception and process and structure in lots of places. You know, one of the things that is clear to everyone in the world is the impact you’ve had on our field through peer reviewed publication. You know, again, having spent time with you in Indiana, I was always impressed by the productivity of that group, in addition to Hopkins, and of course, Harvard, but I was curious, how do you how do you ensure that productivity is at the chicken or the egg? Is that the people you’re hiring? Or is it the structure? I mean, I finally remember as a fellow getting to sit in on the monthly research HPB meetings, which were fantastic. But which, and how I guess is the question.

Keith Lillemoe 15:43

Life attract, and you want to go to a place where you have a high level of productivity and, you know, the driving point behind the good clinical care is asking, the questions that need to be asked to me that make the clinical care better. And if you come from an environment where you’re stimulated to ask questions and translate the answers of those questions into research and academic productivity, I think you can find that adds another layer of success to our careers and it does help in areas of promotion and recognition. But again, it really is all about advancing the knowledge that helps us take care of patients better and I have been very fortunate to be surrounded by people at all three of my institutions that sort of shared that love of academic productivity and in sort of been along for the ride a little bit, here at the MGH. I’m not doing too much original research myself, but we do have a very productive group here and it’s fun to have that stimulus to keep your eye on the ball.

Ameer Farooq 17:08

One of the things you’re clearly an expert on and have done some really fantastic work not only on researching it, but also talking about it his bile duct injuries. I think as a resident, listening to and reading, stuff that you’ve put out has been incredibly useful in understanding this problem. I was hoping you could give a short overview of some of the pitfalls in actually what goes into causing them about injury, and then talk us through how you would approach that if that happened.

Keith Lillemoe 17:46

So first of all, it has happened to me, you know, I cut a bile duct and, you know, recognized it and had to make those decisions. I’m going to do a little self-promotion here. In the July issue of Annals of Surgery, the safe Cholecystectomy group, which came out of stages and then expanded into all the other major or surgical organizations is finally publishing the proceedings of the excellent all-day symposium and consensus conference that was held at the American College of Surgeons in October of 2018. And that goes through all the major questions and decision making points related to prevention of bile duct injuries, recognition of bile duct injuries and management about a duct injuries so I don’t know when this will actually hit the airways or the podcast will become public but if the people will wait until the July issue of Annals comes out, I think everyone will be far more, have a lot more knowledge, instilled with him that and what I will talk off the top of my head on it. But I’m very pleased that group has worked so hard on it, I have to give credit to Mike Brunt past president of the SAGES for really making this a passion of his presidential address, and then keeping it going and enlisting all the other organizations. So that being said, obviously, you know, like anything, the best way to treat up a bile duct injury is to avoid it. And I think we’ve learned a lot through the years about how to do the operation more safely, new techniques such as a critical view of safety, which isn’t so new anymore. It’s 20 years old now, but it is, you know, a technique I think, if done properly can do just about everything necessary to ensure avoidance of an injury. And it’s really most valuable in those easy cholecystectomy because if you get in there and a cholecystectomy is too easy, you kind of let your guard down. I think everybody gets very concerned on a tough cholecystectomy and then really says, oh, we really have to be careful. But I would guess if you really could analyze all the lab chole injuries that are done in America, more of them were probably done on easy, straightforward, lap chole and we’re on, you know, the tough acute chole cases. So the nice thing about the critical view of safety is that it should be achievable in just about every patient and if you just take that little extra time, and we’re really talking about a matter of minutes, and check and double check, to be comfortable with the anatomy and know that the structures that you’re cutting and dividing are going to the gallbladder and the gallbladder only you think are about the safest as you can be. Other things that have evolved over over time is recognition that not every gallbladder that you tackled, particularly those who do the acute care surgery of the world. They’re doing the gall bladders that come in and they’re really getting tough now during COVID people are sitting home with bad cholecystitis for three or four days because they’re afraid to go to the hospital and come in on day five or six and the gallbladder is all matted in the concept of partial vholecystectomy hardly existed 10 years ago. Most people would do whatever it took to get the gallbladder out and now I think recognizing that due to partial cholecystectomy or even a cholecystectomy if the case is too tough is a way to avoid that injury. As you know, we’ve become aware, actually the open COVID cystectomy, particularly in those cases that are tough to do laparoscopically is perhaps become the most dangerous operation in America now because most everyone who trains says is grown up doing lap coli and very few open coli and so again, unless you’re in a program where you really have a busy emergency room with a lot of acute cholecystectomy coming in, you’re not necessarily cutting your teeth on the tough open coli and so I do think recognition that injuries can take place and taking every step to avoid them is the most important thing. Once you recognize you’ve had an injury and in the data, we show that the majority of bile duct injuries are not recognized at the time of the actual laparoscopic cholecystectomy, they’re recognized in the post-operative period. If you do recognize it at the time of surgery, the best time to repair it is if your situation allows is that at that time, The first thing that you do is you look around where are you and who might be there to help you. And if you’re in a situation where you’re in an ambulatory surgical Center and the patient was going to go home and you don’t have all the big retractors and the instrumentation to do a reconstruction, you shouldn’t be trying it. Whereas if you’re in an academic medical center, or even a community hospital and there’s a more experienced surgeon, particularly someone who’s had surgical oncology or HBB or transplant training, you know, always get help, you know, you can’t let your ego stand in a way of doing what’s best for the patient and if doing what’s best for the patient involves asking a senior surgeon to come in and help you do the case or help you recognize the nature of the injury or just offer advice, I think is the first thing that can be done. And finally, if when you do go about the repair is follow good concepts of surgical technique, debris, damaged tissues avoid tension and then your anastomosis, which in most cases for bile duct injuries involves not trying to bring the two ends of the bile duct back together as a end to anastomosis but to bring roux-en-y limb up there which is attention free anastomosis with healthy tissue, which I think is important. You know, follow good surgical principles, external drainage in case there’s a leak, and again, kind of my personal bias again going back to the days of Hopkins training was, if there’s a way to put a stent across an anastomosis for that immediate post-operative period to control the balik that’s not a bad thing to do. I don’t think a stent is required but it’s certainly a safety net. It’s sort of the belt and suspenders that one can use to make sure that if you do have a leak, that it’s a controlled leak and doesn’t lead to worsening consequences after your repair. So getting recognition, get help make the proper decision as to is this the time in place, and am I the surgeon to fix it and if all those things, check the box that you can do the repair is again, follow good surgical principles. Since most injuries are recognized in the post-operative period, the decision making of the surgeon when they identify whether it’s in the emergency room, or after the patient’s been readmitted that they have a bile duct injury, again, to look around and say is this the institution where we can provide the best of multidisciplinary care? Do I have the interventional radiology backup? Do I have the endoscopy backup? Do I have my own surgical skills to allow me to do that, and if if not, maybe the best assessment is to transfer the patient to a center where they do have all of the teams to be able to take care of the patient and provide the kind of care that ensures good results. There’s very few cancers that we treat that have a 90% survival, but you know, bile duct injury should have about a 90% success rate and if it’s done in the proper institutions, that those numbers have been classically reproduced many times, at least in five year follow up and so I think, again, thinking to where the patient would be best managed is oftentimes more important than just trying to take care of your own complications.

Ameer Farooq 27:11

Dr. Lillemoe, someone who has, obviously a bird’s eye view of how this topic has developed over the last few decades. I’m curious, and this might be a spoiler for your Annals of Surgery July edition, but I’m curious as to where you think the management or prevention of these injuries is going to go? Like, as you said, the critical view of safety has been there for 20 years, do you think the issue is going to be just ensuring that everyone knows it? Or do you think there’s still things that are on the horizon to make us better at avoiding this never injury?

Keith Lillemoe 27:48

You know, I’m, there is extensive discussion about alternative techniques, interoperative ultrasound, there’s Di tests that you can do, particularly with a robot that helps you better identify structures and the like. So, I do believe technology will catch up with us. The one that I like to tell the story about and again, a little bit of self-promotion to group that we have at the MGH is really machine learning. And, Chad probably drives a Tesla but I don’t, but I do have a car that when I crossed the lane, my steering wheel shakes a little bit and if we could train our laparoscopic equipment, the camera to process the performance of a procedure and through having studied hundreds and 1000s of lap chole that if I could get a little, like dog collar shock on my hand to my Maryland dissector when I’m about ready to encircle the common bile duct thinking it was the cystic duct that would probably differ determine from wanting to proceed. So, I do think technology will come along and I would like to think that it would be available without the expenses of robots and just be applicable through machine learning techniques that get applied into the camera system that we have right now and I know companies I do not have any personal conflict of interest with this but companies like Olympus are working on these techniques to try to make for safer surgery.

Chad Ball 29:52

If we switch gears here, just a little bit Dr. Lillemoe, you’ve been a mentor to dozens and dozens, probably hundreds have us now and you continue to be so I have very a very close level, I was curious sort of 30,000 foot view, what is the term mentor mean to you? How do you approach it? And what advice would you have for junior staff all the way through in terms of being a great mentor.

Keith Lillemoe 30:22

So I think mentor is someone who really cares as much about advancing their mentees career as they do their own. And they’re willing to put in the time and effort to listen and to talk and to guide and to provide feedback at every stage of your career. And I still believe I have mentors now, that helped me. And so I think you never are too senior to not have mentors. I, again, as I alluded to, being a mentor is a way of paying back to the people who mentored me all the way through my career, and provided opportunities for me. So, I always consider myself very fortunate if someone seeks me out to be a mentor and having been a program director in the chair now 17 years and program director for 10 years, on top of that, I do get placed in the opportunity where I do get a chance to talk to, medical students, residents, trainees, and faculty and fellows, mentoring from everything about where they should match in an IRMP to where they should do their fellowships to their first jobs and the like. But there’s also mentoring in terms of how you conduct yourself professionally and the example that you set, I think, we all are exposed to a lot of people who could be mentors, and I think, as you as a young person, are looking for anyone who’s looking for a mentor, they should try to look at the characteristics and the qualities of the mentor and say, that’s really where I’d like to be in X number of years. My first mentors were first and second year residents at Hopkins, when I was a medical student, I just want to be like them and then when I became a junior resident, I wanted to be like, my chief residents. When I became a faculty member, that’s when I started recognizing that I had to have mentors that will help take me to the next level, and again, fortunately, there were several around during that period of time. So, the good thing about mentoring is, even though you know, your focus is really on the mentee, that, again, I hate to come up with all these corny statements, but light shines brighter off of when it’s reflected off someone else. So, if you have success as a mentor and your mentees rise to levels of success, people will figure that out, and you’ll get some credit for it. So it is mutually beneficial. But really, the better job you do in helping the people you’re trying to be a mentor for, in achieving their goals, the better you will be.

Chad Ball 33:51

You know, one of the other many jobs that you that you do offer your desk is, of course, the editor in chief of Annals of Surgery and certainly this audience knows in the field that clearly the preeminent surgical journal in the world, I was curious to three rapid fire questions about your role in Annals, how do you view that job? Will be the first question. The second question, it’s a bit biased because I’ve spent enough close quarter time with you that I have seen how you actually fit it into your day but for our listeners, maybe describe how you do that. And the third thing, both you know, selfishly from the professional side of things as well as curiosity, how do you deal with an upset author who maybe didn’t like one or two or three or four of the of the reviews and send you that terse email?

Keith Lillemoe 34:45

So, let’s go from the last question first, because I dealt with that today. Paper that was rejected, generated a polite email of pointing out why they disagreed with his decision. So, the first thing I do is I listen to him and I look at what the reviews said and what their response is and then in the case today, it was a paper that we had had three reviews on, and one review was pi, except one review was flat out reject and one was sort of intermediate. So it wasn’t as if this was a slam dunk, either direction and I said, so I sent an email in response to the email that I had received, saying, I’ll resend be send your decision, and I will send it out to someone who has not seen it before. Let them take a look at it and give me a new fresh set of eyes. And fortunately, one of the good things about COVID there are a lot of us who’ve had a little bit more time on our hands. But I’ll get into that in a minute to your second question, but I send it to a very well-respected surgeon in that area and he said, I’ll look at it now and within two hours, I had a response from the fourth reviewer that the paper should be rejected. And I had established with the authors, I said, I’m going to send it to one person and if that person says accept will accept and if he says reject, will reject. And in this case, the decision went along the lines of our original decision and at least I gave the person the chance. Now sometimes, look at it, and there was two or three very solid rejects and I just have to say there’s not much you’re going to do that’s going to overcome this decision. I don’t go to quite as much work as we did today but still, I think you should at least listen to their arguments and go back and look, rather than just flat out say the decision is a decision.

Chad Ball 37:12

Just out of curiosity, that given the massive number of submissions you get how common is that scenario where you have an upset author sending that email back to you?

Keith Lillemoe 37:25

I would say probably a weekly occurrence. We’ve on pace right now for well over 3000 submissions and again, that’ll get into the second side of your question or second question. But if we’re getting 50 or 60, so we accept roughly around 10%. So, 10% of 3000, who keep the numbers? Simple. We accept 300, we reject 2705, all to get deemed 50 to 75 requests for reconsideration, I think we must be doing a pretty good job. So, the time, we’re not going to talk about COVID very much but the thing that’s been most noticeable for me is that there must be a lot of people having time on their hands because the manuscripts are just pouring in. So, the numbers are up and I don’t know whether this was a smart thing or not a smart thing that I threw out there. I said if you want to send something to Annals of Surgery that’s COVID related, we will promise a rapid turnaround and immediate publication online. So, at last count, we were up to 400 submissions just on COVID related topics in the last six weeks. It’s has really increased the workload dramatically and I give a lot of credit to the panel’s production staff. Because when I accept something and send it in the next morning, if I’ve done it at night, I will usually expect it will be available on the website and available through e-pub within 48 hours, which I think is remarkable. We’ve accepted I guess of 400 or so papers that we’ve submitted, I think we’re pushing about 50 that we have put into press. So again, these are all available on the Annals of Surgery website and we’re now moving from papers that were all about the disease. It was a paper published in Annals which really set up the first question about the role of laparoscopy and aerosolized I don’t say this word very well, but, you know aerosolized particles. And whether it really happens or not, has been debated whether the particles can be in smoke associated with calories has been raised. And so, I think it was good to get that paper out right away. We’ve looked at a lot of papers, one of the ones we published was from the University of Pennsylvania and how to safely do a tracheostomy in these patients who, when you’re cutting into their airway, you could get a blast of viral particles. So how to go about that. So, the first few weeks, were all about treating the disease and how to strategize and shut down your programs to safe surgery and safe decision making and those we’ve sort of run out of topics there, there’s still a few that come through. But in general, most of what we’re looking for now is how do we deal with the next phase? What are the steps for ramping up? How do we deal with education now? There’s no, I just got a memo, Harvard is not going to allow visiting students to come rotate it at the MGH this year or any of our hospitals. How do we appeal to that group, which is oftentimes a strong opportunity for us to get to know the candidates who have an interest with us and have them audition with us and for us to the chance to impress them. So we’re focusing our most of the papers that are being accepted now aren’t about how we treated the COVID epidemic, as if we were on the peak of the crisis, but how are we going to manage it now that we’ve flattened out and we’re moving into other areas, although there is now an opportunity for people to report their actual results. At first there was case reports of this or a case report of that, or guidelines or how I do it, or how we’re doing this or that I think there will start to be accumulating data on what happened to the transplant community. What are the true risks of transplantation in the COVID era? Do we determine that and organs and not bringing in patients who are well to get transplants. I do think there are some results that are going to be reported beyond just we treated patients who had COVID and this is how many died, I think there will be information that’s gained and perhaps registries that are accumulated. But this step that I did or misstep that I did, that opened the door up for 400 submissions on one topic, in six weeks is changed my workload a bit since I do most of the decision making myself. So, I have done a lot of time. Chad, referred to the fact that I do multitask pretty well. So I can generally assign and review a lot of decisions that have come from my outstanding associate editor group putting in the recommendation comes from the editorial board and ad hoc reviewers that I can oftentimes multitask and doing that when there happens to be a sporting event on in the background or the like or even a break between my biggest activity now is zoom calls, every hour to end it, if it’s the wrong zoom call, you can kind of check out a little bit and review decisions or do assignments while somebody babbling on about whatever the topic is, this sort of direct the camera away from your face so they don’t see that you’re looking at your computer screen, audio only. So those were the second and third question. The first question was?

Chad Ball 44:17

I was just curious of your overview of how you view that job because I think certainly the majority of us in the rest of the world look at it as a really, really important and obviously prestigious job. I would say that you clearly in so many ways, but in particular to the journal direct the way that surgery is going.

Keith Lillemoe 44:44

I do view it is important. I think that I have a lot of impact on 60 or so residents and 100 or so faculty and maybe an association here or there outside of our home base. But this is an opportunity to have a great impact on really the entire world and practices surgery. It’s too big a job for one person and that’s why having a great associate editor team, a great group of people on the editorial board a huge stable of people who are willing to put in the time to volunteer the time to review manuscripts is so important. And so, I think that it’s sort of like service to our profession, if you’re going to write papers, if you’re going to read papers, I would hope people would always be willing to review a paper. Now, of course, if you’re an acute care surgeon or a critical care surgeon this time of year, I just prefer not this time of year, but this crisis going on, I try to avoid sending papers, to people who I know are up to their eyebrows with COVID patient care, but there’s a lot of us who have not been on the front lines of treating patients who have really stepped up during this period of time. And reviews are coming faster. I’ve even had people who said that they’ve been quarantined because they had an exposure and said, Send me some extra manuscripts to review. So, I never turned down that opportunity.

Ameer Farooq 46:31

Dr. Lillemoe, one of the things I’ve been most impressed about with the Annals of Surgery is just how on the forefront you have been, it was sort of pushing what the journal does. I mean, I think in an era where journals sometimes struggled to find relevance, I think, Annals has actually been leading the way in terms of embracing new technologies. So, for example, I think the visual abstracts has been largely, something the Annals has really pushed and then lately, particularly the COVID analyst has been instrumental in really collating things on social media. Can you talk a little bit about how you sort of navigated that very tricky water of embracing these new technologies, and keeping something like Annals not only relevant, but really pushing the frontiers of how journalists can interact with the readers.

Keith Lillemoe 47:32

So, when you’re sort of un tech savvy as I am, and on social media savvy, and to know that most of the people do agree with you, that Annals is sort of set the stage for social media for surgical journals, I have to give all the credit to this string of great young, bright individuals, starting with Andrew Abraham, who is our first creative director and who actually sort of came up with the idea of the visual abstract. We’ve had a great series, our most recent person, Karen Chava, was very social media focused even as a medical student, I remember we tried to recruit him as an intern applicant, he went to the dark side, he matched at the Brigham. Now he’s working more closely with me because he’s been in our creative director for the last two years, he’s done a great job of taking it to the next level, this whole thing with a COVID site was really his idea. So again, surrounding yourself with great creative minds, I can make anybody look good.

Ameer Farooq 48:58

Well, I do definitely think that it takes some bravery to take a journal that’s well respected, like, like Annals and put it into some uncharted waters. I definitely think you deserve some kudos for that. What I wanted to also ask you, if you had some advice for authors who wanted to perhaps publish their manuscript in the Annals one day, after having read so many different manuscripts, what are the absolute do’s and don’ts for any prospective author?

Keith Lillemoe 49:37

Well, first of all, it comes down to the subject matter. You got to find something that’s new and innovative, and interesting, I think the days of my series of the largest number of this or that getting published is not happening as much as it used to. I mean, or at least not been happening quite as much in the top flight journals, although Annals probably has still publishes a fair amount of those, I think, you’ve got to tell a story that says more than just I’ve done a lot of these, this is what my results are, you’ve got to try to find what’s important out of your results and translate that into a message which, again, advances the care of patients. So that’s number one. Number two, construct a manuscript well. You need an interesting introduction; you need to well define. methodology, you present your results in a combination of words and figures and tables, so that they’re very clear. You don’t try to do too much. But still give us as much information that’s important to tell the story. And then finally, wrap it all up with a strong discussion of the relevance including whatever might be viewed as is limitations of your study, and use proper, you’ll have it if it’s, you know, one of the best things about for me was my South Dakota education background, my best friend was a Princeton grad. Every time I had a manuscript that I would write, Charlie Yo, would generally, coauthors, Charlie would always correct my English and make sure my senses were constructed properly or Dr. Cameron we just spoke, what’s the key points of the paper. The best way to write a paper is to do it collectively with getting the opinions of multiple coauthors and make sure that things are said in a fashion that may seem perfectly clear to me because I know the data and I’ve written the data, but someone who doesn’t know quite as well will say, this doesn’t make sense, you need to go back and rephrase this sentence or represent this data or look at this differently. I know, the solo author, manuscripts are just not going to work.

Chad Ball 52:30

Dr. Lillemoe, we can’t thank you enough for spending time with us again on Cold Steel. I just want to close with this maybe two softball questions. And then again, thank you. The first thing I think we all know that after your family and your professional career, that maybe the third thing that comes into that is your love of sports, and certainly having seen your memorabilia collection and listen to your stories and some of the amazing events you’ve been to. I just curious what your what your top one or two or three of those would be.

Keith Lillemoe 53:03

Well, again, blowing my cover here in Boston, I’m a I’m a Yankee and Ravens fan. I’ve got a lot of things that are Yankee related and a couple of my favorite pieces are, number one, when Andy Pettitte and Derek Jeter went out and took the ball away from Mariano Rivera on his last appearance at Yankee Stadium. I have that signed by all three of them, that’s a favorite. I also have a picture of Ray Lewis, his last home game at the Ravens stadium where he does his little dance in front of the whole crowd and signed by Ray in the team. Those are a couple to jump right out. Then I have a few that are important. Because I was at the event like Cal Ripken is 2131 game when he broke the record of Lou Gehrig, four consecutive games and I have something signed from him from that day and then I have some to from people I’ve taken care of. Maybe you have to be a pretty deep sports fan to know there was just a Baltimore Orioles baseball player who had colon cancer in his 20s, 27-28 years old, just had colon cancer surgery and some very hard-working beat writer for the Orioles published some stories about two previous Oriole greats who had colon cancer. One was John Boog Powell and one was Eric Davis and I just happened to be the surgeon on both of them. This was back in the 1996 and to have those stories retold related to this young man and actually had my name actually brought up in the article that the sportswriter wrote. I’ve told this story again, many times. There’s this great line that your kids don’t read your CV. But all my kids watch the day that I was the lead story on sports center announcing, about Eric Davis’s operation and his diagnosis. He was sort of pre-HIPAA days but actually holding a press conference, live on sports center kind of made it for me. That sort of puts your statement, Chad, that sports is pretty important.

Chad Ball 55:48

Wow, I love it. I love it. I’m just hoping you’ll close this out with maybe providing us with a single or one or two of the most important pieces of advice you would have for both trainees in a surgical residency and maybe even a fellow and then as a junior staff.

Keith Lillemoe 56:08

Well, again, I’m not sure that these are unique but and I’ve sort of alluded to them is get good mentors. Watch how every surgeon acts in every situation, whether it’s a tough case, or an easy case, whether it’s how they interact with nurses and students and try to make yourself a composite of all the good qualities of people you see. I think that it doesn’t matter whether you’re a medical student or resident or a faculty member, you need to sort of take the best from everyone and also learn from what isn’t good about people. So, make yourself a composite of the good things that surround you. And secondly, get applicable to anyone at any stage, it was a line that the great John Tarpley still probably says is get in the habit of having good habits. Which means, whether it’s kind of a stitch, you always drive your finger down to secure the knot flat and do everything, rather than get in the bad habit of doing it when it’s maybe that is important because if you don’t have that tendency to have good habits, when it is important, you may make a mistake. So those are two generic things, work hard. Look for the right opportunities. Always think ahead. I never have done anything thinking about what my next job was going to be. But you always want to position yourself so that whatever you do, you’ll be there when the right opportunity will come along. I think had I not gone to Indiana and not done some of the things that we did at Indiana, when the opportunity to come to the Mass General came along, I probably wouldn’t have been a candidate. So never stop looking for new opportunities. In the Annals of Surgery story, I was asked by Dr. Sabiston to write a review article on pancreatic cancer, who had ever turned David Sabiston down. I wrote it and submitted to him, and he probably just read it himself wrote me back a nice handwritten letters, or at least hand signed letter, long before the days of email saying, thank you for such a nice review article and oh, by the way, would you like to be on the Annals of Surgery editorial board? I just blown him off and said, No, I don’t have time to write a review article. Who knows what would happen my whole life with respect to Annals of Surgery may never played out. You know, you can’t do everything, and you need to know when to say no. But you know, as I look at the clock, it’s 10:15 here on the East Coast, but I would never say no to you. You have to do something like this because I think it’s important and you just have to be selective but if you see a good opportunity, you should take it.

Ameer Farooq 59:33

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.