E27 David Feliciano On Trauma And Culture Building

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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

It’s not an understatement to say that Dr. David Feliciano is a true giant in trauma surgery. He literally wrote the textbook on trauma. Now in its eighth edition. In this episode, Dr. Feliciano gives us his insights on leadership, recruiting star faculty, research and the future of trauma. Check out all the show notes for links to papers we discussed in the show.

Chad Ball  01:13

Dr. Feliciano, thank you very much for for spending your time and meeting with us on on Cold Steel, our podcast we really, really, truly do thank you for it. We know how busy you are and how crazy the world is right now. And it’s it’s amazing to have an icon on called feel like like yourself. I guess my first question out of the gate is, you know, all of our listeners, of course know who you are, but few of them know you. So we just curious where you grew up and what took you down the pathway towards medicine.

David Feliciano  01:50

I was born in New York City, grew up briefly there. And then when my dad left for World War Two, my mother moved to northern New Jersey about 15 miles from New York City. Because that’s where my father’s large Italian family was stationed. So I grew up there. My interest in medicine was almost completely due to my father, who was a community surgeon, again, in a city of about 25,000 people and almost exactly 15 miles from New York City. I rounded with him when I was five years old as a start. And he later had me working, doing urine analysis in the lab on Saturday mornings when I was in high school. And then of course, I got my first job as an operating room technician in my father’s hospital and then spent a total of five summers working at hospitals in the New York New Jersey area as a technician. So I had a lot of exposure to medicine. And secondly, my dad was one of these even keeled, likable human beings who was really revered in our town. He was the board of education doctor, the board of health doctor, industrial consultant, did all the physicals for all the high school athletes. So I was kind of really immersed in medicine from a young age, frankly, I owe it all to my dad.

Chad Ball  03:28

Wow, that’s amazing. Yeah. And immersion is probably the right word. Did you ever consider doing anything else at any point?

David Feliciano  03:36

Briefly, I really wanted to stay at Georgetown for residency. But my father was who was a Georgetown graduate classes of 39 was really opposed to that and he thought I ought to get out and see other academic centers in the country. I found out that the Mayo Clinic was now accepting interns. They had previously only accepted residents and I eventually matched at Mayo for my surgical residency. The thing that struck me when I interviewed at Mayo was that they did 120 cases in the operating room in one day, in thier are two hospitals when I interviewed and it looked look to me like they did more cases in one day than Georgetown University Hospital did in several weeks. There was also a large variety of cases and a lot of high-end cases. So I discussed that again with my dad. And that was my first choice. And I matched there and I’m eternally grateful for his advice and for the training I had at the Mayo Clinic. I went to Houston right after that, to do when those days was a vascular fellowship. And that came about because I wanted to go on staff at the county hospital in Houston now called Ben Ben Taub Hospital. But Dr. DeBakey and the faculty at Baylor College of Medicine said, I couldn’t want faculty unless I took either cardiac or vascular training, because everyone in quotes, has that kind of training there. So I started, I did a six month vascular fellowship, all of it on Dr. DeBakey service and then became an attending at the county hospital. After that six months, when I got interested in trauma, it appeared that I might need some more training. So I took a leave of absence from my residency at the Mayo Clinic, and eventually spent my time as a trauma fellow in Detroit, with Charlie Lucas and Anna Ledgerwood. So I’ve trained in a few different places. And I’ve trained with some really good people, obviously DeBakey and his colleagues in Houston and Ken Mattox in Houston and Charlie Lucas and Anna for trauma in Detroit. I really encourage people to not be afraid to take a look at places that perhaps wouldn’t fit their mold. Be aware that places with huge volumes and lots of experience can teach you a lot.  No it was always medicine or science, but my one of my vivid memories is when I was filling out my college paperwork to go to Georgetown in Washington, DC. There was a line you had to fill in, which was what what is your projected major. So my father was sitting next to me at our home in northern Jersey. And I turned to him and I said, Well, what should I put? He said yoy put biology because that’s pre-med. So that was a very short discussion.

Chad Ball  04:09

Short and direct. Can you can you tell us about your your training pathway through medical school and then all the way through the end of your training.  Yeah there’s no doubt. I mean, your your training and mentor list is sort of the hitlist of that, well, you know, that 1.0 generation of trauma surgeons. It’s remarkable. You clearly, you know, I would say at least from the outside, major name at Ben Taub in Houston was your partners Birch and Mattox, and then moved on to Grady Memorial Hospital in Atlanta, where I think, you know, I think it’s really honestly safe to say you took it to a whole new level level. And I would say, I would say iconic. What was it like walking into transferring over and walking into Grady Memorial Hospital, given the the history and the weight of that place initially led by Harlan Stone, and of course, then you How did you feel and how was that experience?

David Feliciano  07:58

I really campaigned actively to become a surgeon in chief at Grady. My predecessor, the late Roger Sherman was nearing the end of his time there. And it looked like a perfect place for me, I would be in a leadership position. I would still have a huge volume of general trauma and vascular surgery that would be affiliated with a nice private university i.e. Emory. When I got there, and I was aware of some of the issues, they have really not had a very large number of full-time faculty there. A lot of the faculty historically rotated down from Emory University Hospital to help cover. There were no attendings in house at night. Many of the cases during the day were performed by senior residents without supervision. Three things I really tried to change quickly. One, we took back the trauma resuscitation for emergency medicine, we got a stat page system, the attendings had to answer. And later the fellows so we quickly reestablished ourselves as the trauma resuscitation team. Secondly, we did not have an ICU service when I got there. And eventually all the partners in our group were double boarded. So we had a surgical intensivist in place every day and then eventually a full time surgical critical care service that fellows residents and students could rotate through. And then I think the biggest decision was, I told the faculty they would have to come in at night on every case. But I did not in the beginning mandate that they had to sleep in and I sort of learned some lessons from watching other leaders and about nine months later I said exactly, aren’t you tired of coming in at night? Why wouldn’t you sleep here, it’ll be a lot easier. And interesting enough, nobody objected. And it really, really changed. I think the hospital’s perception of our our group that we were really committed to taking care of the patients. Because remember, we weren’t getting paid for night call those days, we just slept in our own volition.

Chad Ball  10:21

Wow. You’ve certainly trained a lot of Canadians and you know, the three of us that comes to mind would be right, you know, in order, Lorraine Tremblay in Toronto, Neil Perry in London and myself here in Calgary. And we all talk about it, you know, the institution of Grady and Emory. And of course, you guys as a group, as being a really unnatural, almost almost, like beyond superstar like, like a truly globally impressive group of faculty that we got to interact with. We realize parts, you know, change here and there. But I’m curious, how did you how did you create that, that group upfront? And what do you like, in terms of leadership style? How do you how did you get there? How did you do that?

David Feliciano  11:13

I think you have to be very honest when you’re recruiting people. So when we sent out a call for people to apply for faculty from time to time, we didn’t gloss over the problems. We reminded people this was a public hospital. The salaries were sort of restricted to double AMC levels for academic rank, that night call was unpaid. And then we told them the positives that there was a huge volume of general trauma, vascular intensive care for them to work on and to study. We told them, the Emory residency was elite for a lot of great residents at the time spending 35 to 40% of their five years at Grady. And then after interviewing people who we felt were really interested in coming, we always met as a group to see if the other partners thought the new person would fit in or not. That’s very interesting. We had several occasions where we had highly qualified candidates who just didn’t appeal to everybody, as a co-worker. We were very busy clinically, as you well know. And we had to cross cover one another at night, we had to cross cover one another during the day in the ICU. And even though the group was not all lovey dovey, we had to get along professionally. And it was really important for everybody in the group to have a say in who came in. I’m really was looking for highly energetic people who understood the hospital and wanted to be part of something that was clearly going to get better over time. We had one person who interviewed with us who had done trauma, but was mainly interested in advancing his laparoscopic career. And when the group met, we agreed his interests were not really in line with ours perfectly a very good person. Interesting, I know what happened to him over his career, probably would have been of great benefit to our group in terms of developing laparoscopy. But we were primarily interested at the time in acute care surgery, and people who would, you know, make a run with us while the group is intact.

Chad Ball  13:40

If we shift gears a little bit here, Dr. Feliciano we, and we sort of look at the concept of, especially for trainees, you know, selecting a fellowship. And I don’t think I ever told you this although maybe in the last 24 hours I did. One of the there’s many reasons that you know, I came down to Grady to train with you guys, but one of the reasons, quite honestly was I spent a significant amount of time almost six months in South Africa. And the volumes were similar. And my observation of how deeply and profoundly you and your faculty cared about the patients and were willing to go to any ends no matter how described to provide optimal care. You know, I remember you saying to me early, every patient’s your brother, your mother, your father, your sister and treat them as such. That was a huge reason why, why we showed up and I think Lorraine and Neil would say the same sort of thing. So outside of things like that are obvious, like high volumes, what should a trainee be looking for for a high quality fellowship experience?

David Feliciano  14:48

I think there are a couple things. One is you have to get a sense when you interview on whether the person who leads the group whether it’s division cheif or a hospital cheif, or whatever is really committed to mentoring and supporting somebody’s career. I’ve worked with several chairs, for example, where their goal was to continue their notoriety, but were very terrible mentors. And that doesn’t help any young fellow or faculty person. So a strong leader who’s clinically active, who will be supportive. Secondly, the vibrations in the group is everybody on the same wavelength in terms of caring about the patients and committing themselves to always doing what’s right? Oh is he getting up at the M&M and telling the truth in front of the fellows and residents? I think those were really the important things for somebody to consider when looking at a fellowship or a job. Is the group functioning well together? Are they committed to the same goals? Do they look like they will support a new person? Most of my choices for faculty were really good. And a couple couple glitches along the way. And in retrospect, I had funny vibrations about the people eventually turned out to be somewhat troublesome. And I always became much more sensitive to my inner vibrations with people rather than looking just at their CV. That was part of the process of everybody in the group saying is this somebody who I want covering my sick patient, who will cover me when I have to run home because my child is sick? Who will come in and help me on a busy call night. Groups are really critical to academic development. Because the more smart people you’re putting the room, the better the abstracts, and the studies and the papers and the presentations are going to be. A few individuals can do this alone, very bright, highly motivated people. But I think the thing about our group was that we’re pretty much on the same wavelength. We all believed in the academic process. And we all pretty much wanted the other people to succeed, which is really critical.

Chad Ball  17:15

There’s no question the academic productivity that had come out of Grady, you know, under, obviously, your leadership, and also Dr. Rozycki’s leadership was absolutely remarkable. And it’s changed the field forever over and over and over again. You did mention the term mentorship and I realized mentorship and teaching are are different but but certainly perhaps related. You won the Teaching Award, General Surgery Teaching Award at Emory University, I don’t know how many years in a row and I remember it was absolutely ridiculous. You can remind us but not so much how do you do that, but what advice do you have, in particular for maybe junior faculty that are trying to get better at teaching and engage as mentors in their in their practice and in their careers?

David Feliciano  18:01

Well, my wife’s the expert on mentorship having given given a presidential address or two on it. The biggest thing about being a leader or a mentor, from the mentor side is you’ve got to be willing to take the time to listen to the fellow or junior faculty and get a sense of their motivation, what their problems are, what problems they’re confronting with any projects and all in how they perceive how their own career is going. One of the things I learned early as a surgeon in chief at Grady he was to keep my mouth shut when someone came in my office at a junior level, and not try and respond to every point. But just listen and get a sense of if they were satisfied with the way things are going or not. And the other thing I learned and was that when faculty come to you with problems, and you’re their mentor, you do not have to tell them in the first conversation that you’re going to solve their problem. I learned very quickly not to make those promises. And to say to people, let me think about it, or let me talk to some other people. And we’ll get together in two weeks or something. Let’s make an appointment now. I found that a much better way to mentor and supervise or whatever, because it gave me time to think out a good solution. And if I didn’t have a solution, I would tell people two weeks later, I don’t think we can solve this problem that you’re having. But here are some options to maybe work around it. So good mentors, listen, good mentors show interest in the production and advancement of their mentees. It’s time consuming for the mentor. It’s hard work sometimes. It can be frustrating. And particularly for someone like myself who’s not really extroverted people person, it’s a learning process, you certainly get better at it. My relationship with a fellows at the shock trauma center, in terms of mentoring is really good, because I think I understand the process better. I can sympathize with the fellows as they’re getting ready to take a job, I can sympathize with them, in terms of the things they don’t get during the fellowship in the modern era. But it is a process where you get better at it. But in the beginning, you have to be a believer in academics. And mentorship is, of course, one of those things as part of it.

Chad Ball  20:48

For sure, the natural next question then is, and you sort of bring it up there is what sort of factors should go into the equation and evaluating and then selecting your first job out of the gate or out of fellowship?

David Feliciano  21:02

Yeah, hard thing to do.  Yeah, basically, it’s, it’s similar to what I mentioned previously. You should have a set of criteria that you think would be necessary for your first job. For example, if you have been in a fellowship, where you had 85 or 90% blunt trauma, you have never operated on a gunshot wound or the femoral artery, but you’re really interested in that injury, then you probably should not go to a center that does 85 to 90% blunt trauma again. You should know yourself a bit as you finish your fellowship, and say to yourself, these are the things I really enjoy doing. I love clinical high-end trauma surgery. I love writing papers. Therefore, am I going to a place that has mechanisms available to help you with data collection, data retrieval, statistics, editing. Thirdly, I think you need to say the salary progress. Do they go by the double AMC guidelines? Do they go beyond it or are there bonuses for night call? There’s a whole list of things that I give fellows if they ask me on things to look for in your first job. But I think you do it logically, it’s not a random. And certainly you should have some criteria, as I mentioned, and then finally, in the your inner vibration. Do I feel like I would fit in here? Or are there clearly several young faculty who are disgruntled and talking about leaving? That’s not the kind of situation you want to go into.

Chad Ball  22:49

That’s superb advice. I mean, sometimes that can be hard to figure out. And sometimes certainly, it’s it’s not hard to figure out. But in due diligence is key. You’ve touched on a lot of the things maybe that surround the answer to the next question I’ve asked you. But just to put it in a cohesive package. If you are starting out your first year, second year, third year, what are your concrete advisements for either starting a clinical research program, or even maybe more challenging a laboratory research program? And I think it’s certainly an increasingly relevant question at least is in Canada, because the funding mechanisms are poor, you know, our provincially led health care systems really don’t more and more so care about research at all. All they care about is, you know, high quality clinical delivery. And that has a trickle down effect not only just because of the money, but also just the general environmental milieu that we experienced up here.

David Feliciano  23:55

I really just did a little bit of laboratory work early my career, so I should not speak on it at all. But my advice would be in any decent academic center and often in your same department, there are other people who are funded, you have active labs. And it’s often very helpful to join one of those labs first, where they have PhDs to help the science. They have technicians to monitor the animals. They have, again, a mechanism to collect data, retrieve data, etc. I think to start a de novo lab as a new faculty is very, very difficult these days, particularly if you only have a starter grant from your own departments. I would, you know, consider joining with others and some of my colleagues in academic surgery have been very effective in going other departments in medical school when they have interests similar to let’s say an immunologist or somebody like that. That really helps getting involved with established people. Lab clinical studies, you need a certain number of criteria you need volume of the thing you’re going to study. I always use example, if the only trauma, you get your trauma centers, traumatic brain injuries, then that’s probably what you’re studying again, instead of gunshot wounds do. I mean, it’s not complicated, you study what you have. And then there’s a series of components. Getting through the IRB is one of the big ones these days. Secondly, once, once you’re approved, it’s a question of whether you will have people to do the data collection or as I did in Houston, and Jane Moore has done repeatedly in Denver, we had the residents fill out, you know, data sheets on certain injuries, after they came out of the OR and engineer to have them put it in a mailbox or a slot in the door, that I would collect a morning report as you send. So I had a continuing stream of data coming in and you can these days load it into a computer online. And then you should just, you know, as science questions, clinical science questions that are realistic, you don’t have to reinvent the wheel. And the final thing is to have the support that I mentioned, do you have a good track system where you have a registrar who can pull charts from this data later? Do you have somebody who can help you write? Do you have somebody who can help you get an abstract ready for submission? You’ll you’ll hear this theme recurrently that all these processes in an academic career, are collaborative in some way. Many of my studies were incredibly simple. Just comparing splenectomy versus splenic repair. You know, we had two groups. This is the way they presented. This is what their associated injuries were. This was how bad this spleen was. I mean, I presented two papers in major meetings on splenic repair. Because, you know, we were doing when I came to Ben Taub, we were doing 50 splenectomies a year. You know, in five years, that’s a couple 100. It’s incredible. So look at what you have, you had people to help you with the data collection, etc. and be collaborative in the study, include your colleagues, if they’re, you know, submitting patients who study.

Ameer Farooq  27:39

You know, we we’ve all learned so very much from you. But there was sort of three things that I that I think that you profoundly drove home in myself and a lot of us that have come through there. And the first thing is, as you point out asking that simple question. Your your questions in your in your publications are always extremely clear, is extremely focused and extremely direct. And I think that’s something that our brains tend to overlook. And we we try and overcomplicate it sometimes when the when the basics aren’t answered. The second thing that that was really helpful, at least for me at the time was like, I would come to you and I’d say, I have this idea. I want to look at A versus B, what do you think? And I don’t know if you remember or not at this point. But you would say, well, that’s a great question, Chad. And then you would proceed to tell me how it fit into the last 100 years of history of that of that question of that concept, or that area of of surgery. And that in itself, is something I don’t see around a lot. A complete command of the literature so that I’m not spinning my wheels, and I am trying to produce some sort of paper that contributes to moving the field forward. So I think finding, you know, that one or two or three people maybe in your department that has that historical understanding is, is is amazing. The the third thing was, you know, and I hope maybe you can comment on it, is the actual process itself. So, you know, the contemplation and the conception is one thing, but in terms of sitting down and writing an abstract and then targeting a particular meeting, and then writing that abstract editing that as I should say, writing that manuscript, editing that manuscript and submitting that manuscript to a given journal. What do you have any any thoughts you can share about that sort of more definitive end process?

David Feliciano  29:36

You really get better at the process, like everything I’ve mentioned previously. Meaning when I first started writing abstracts, I would put in conclusions that really weren’t justified by the data. Or I’d make gratuitous superfluous comments in the conclusions, when again, the data just didn’t support it. I think when you first start go to the program book of the society that you’re submitting the abstract to and look at the abstracts in the previous year or two. And you’ll see, you’ll gain a lot of wisdom from seeing how people are able to condense their thoughts, not putting too much data, and then draw a limited number of conclusions from the available data. And then honestly, I was pretty careful t Grady about reviewing almost all abstracts that went out to major meetings. I know that offended some people but you know, I’ve done it for a long time I’ve been on program committees. I’ve been a program chair for several societies, I just sort of had a sense of when things were just unclear unreadable. When you write an abstract or a paper, I think it’s really important to write an outline ahead of time for both, like what exactly why did we do this study what’s what’s what was the main hypothesis. Secondly, just list the methods if they were retrospective, or concurrent current or just say it and don’t apologize for it, it is what it is. And then some people put so much results in abstracts or in papers that it overwhelms the reader and I certainly in the abstract can only be very, very limited. But then finally, they need to correlate to the conclusions that are drawn. I don’t think an abstract should state more than one or two significant conclusions. When you write papers, after you get the outline, you know then it’s honestly a matter of doing it over and over and over again. Ask any academic surgeon about a paper, he or she wrote, you know, 30 or 35 years ago, and compare it to their most recent published paper, and they’ll all notice a change in the style of writing. It’s much more direct, it’s clear, conclusions are probably better justified. One of the things I learned at Baylor when I was a young faculty was I got to know, Dr. DeBakey’s sisters, Lois and Selma who edited all of his publications. And Lois was a bit crusty, but she took an interest in me because I took an interest in her. And one of the things she said to me early in my career was write like you speak. Meaning many surgeons really write in a flowery fashion, when they have an abstract or a paper accepted to a meeting. The first thing I always do is if I’m editing is take out all the flowers and just boom, boom, boom, this is a scientific paper, people’s time is limited. And you want to get your, your points across in a relatively rapid and clear fashion. So I go through a lot of edits for chapters and papers. I’ve, I’ve had chapters where I’ve done 18 drafts, I just couldn’t, couldn’t get it right. And I kept moving paragraphs, changing words. And if you’re not willing to commit, you’re not going to get things accepted and published, because people will not be able to get your ideas if you’re a bad writer.

Chad Ball  33:29

Yeah, there’s no doubt that’s so true. I think we all know your, your editing red pen well. And we all appreciate it both at the time but even more so as time goes on.

David Feliciano  33:40

Well, some some people appreciate it Chad.

Chad Ball  33:45

I don’t know, I think both I think most. Now I know you didn’t want me to ask you this, but but I’m gonna make the comment and ask you anyway, because everybody you you’ve trained is essentially has been telling me to ask you, which is the you know, the the statement is, you are a technically gifted surgeon full stop non non-discussable non-negotiable. And I think the world knows that. The question then is, whether you start that way, which is probably very few or whether you get good to that level or close to that level, how do you get better clinically, as, as you go through your career? You know, and I don’t know if you think about it in terms of junior, you know, mid-career, senior or, or how you think about it, but we’re all curious how you how you put that together, how do you get better on the clinical side?

David Feliciano  34:38

Well, just just to be frank, I was very average when I finished my training at the Mayo Clinic. It was a different kind of residency in those days and a lot of complicated stuff that the faculty did a lot of. So I was considered average, I’d be in the grey middle of the bar graph. I didn’t recognize that when I went to Baylor where the residents were very technically gifted many of them because they had this huge set of hospitals where they operated, you know, the county hospital, Ben Taub, private hospital, Methodist, the VA, a children’s hospital, another private hospital. And when I did, and this sounds crazy now, but I told my wife at the time that I was going to sleep in the hospital as a new attending and take call with my team at the county hospital every third night. I mean, no one told me I had to do that no one paid me. But I slept in every third night on my own without getting paid for about six months. And just watched and assisted the chief residents at Baylor College of Medicine. And I learned so much both good and bad. And second thing I think it really helped was, there was a tendency many years ago for faculty not to cover all cases in public hospitals, as I mentioned before. But I really love operating like most surgeons, and I just found that if my team was going to do a patella amputation, for example, and the chief resident really wasn’t interested because he or she was going into cardiac surgery, I would happily scrub with the intern. And I still do at a shock trauma. I mean, I just do, you just keep operating every day. There’s some academic surgeons who are so busy traveling and lecturing, writing grants, whatever that they’re, you know, they end up doing 100 cases a year or something. The usual two two cases a week, you will not get better at that volume. So almost every year in academic side, despite you know, the other activities, made sure I did about 350 to 400 cases, which is eight cases a week. It really helped me get better and better because I operated on everything as we used to in those days. You know, the general surgery cases, the vascular cases, thoracic for trauma, endocrine. You know, if you do a broad base and maintain a high volume, you just get better technically, and you get smarter in terms of your interoperative decision-making. The other thing I’ve done is, this isn’t done much anymore, but I used to go watch people operate. I used to go back to the Mayo Clinic about every year or so. And pick one of the surgeons there it was usually Jon van Heerden, who I had tremendous respect for as an endocrine surgeon. I would just stand behind John, every other day, the Mayo Clinic way of operating and just watch him do cases all day and ask him questions and take notes. I went to MD Anderson, within the past four years, to learn how to do a retroperitoneal adrenalectomy. One of my fellow Mayo trainees is chief of endocrine surgery there. I called her I just went down, spend my own money and watched her do cases. And I’ve done that all over the country. There were people I wanted to watch where I never got there. But I’d really recommend that. And the fourth thing is, don’t be afraid to talk to people in your own institution. If you want to learn how to do open peripheral vascular or an open  thoracotomy, then go talk to your local vascular thoracic surgeon. So you know, I’ve got a slow week coming up next, would you mind if I sat in or scrubbed in or whatever observed you on any open cases that you do? So I’ve been watching surgeons my whole career, and you get a sense of I can learn something from this person they can. So it’s a multi-step process, including all the things that I mentioned, but the big ones are get volume, stay with it. Don’t advocate the OR, to advance yourself academically.

Chad Ball  39:23

And that’s such great advice. You know, it also requires humility, and it requires persistence. And yeah, that’s, that’s amazing. That one last question that I want to ask you boss is you’ve always said to me time and time again that you should reevaluate your own career in a very honest way. Maybe every five years or so. And whether that’s setting new goals or reassessing your immediate environment, just figuring out how to move forward. Can you can you talk about that for for the benefit of our listeners and what you’re really meant?

David Feliciano  39:59

When you start your career as probably a small subset of people who really had an idea that, you know, I want to be a chairman, or I want to be the highest billing surgeon in whatever department I’m in or whatever. But most of us have to be in a place for a couple of years to see, for example, what the case mix is, how referrals occur, what comes in on night call. But in the end, you want to find what really is a passion, what really gets you excited in the OR. And outside the OR, those two things. I mean, some people are terrible teachers. And other people are gifted teachers. Some people are great leaders and other people are not. And at some point, your first year or two, you ought to sit down with yourself at a desk and say, these are the two or three things I want to accomplish in the next five years. Meaning I will need 40 to 50 publications to get promoted to associate professor. Okay, how do I get there? How many papers is that a year? What topics am I going to write on? Who am I going to have help me? Or I want to be the greatest teacher ever in the history of the med school. Let me go talk to the person who runs the Student Program. Let me talk to the program director for general surgery. Where can I get involved in teaching? It’s sort of like a business decision, you’ve made a choice on what you think are the things that really get you excited. Now, next step, while you’re sitting at your desk is what are the 3or 4 10 steps you have to take to get to that goal. Many people find if they’re in a trauma career, that after the age of 40, it gets very difficult, you don’t recover as quickly. If you’ve been up at night. A lot of the patients are so sick in this era of geriatric trauma, that it’s not always enjoyable. And some people feel when they have one of these conversations with themselves, they want to branch out and say I’m going to start moving towards becoming a leader in academic departments, or in my med school, or in one of the surgical societies. And its the same process. How do I get there? And you just have to be prepared that it’s like life, you’re not going to get everything you want out of an academic career. So with hard work, and planning, in good mentorship, you’re going to get a lot of what you desire. But reevaluation at least every five years is critical. And if you have to change paths, you change paths, it’s just like life. It’s not a crisis.

Ameer Farooq  42:43

I have two questions for you. One is when did you sleep? And the second question is, you know, as someone who really has a command, as Dr. Ball said, of the history of trauma over the last, you know, however many years, where do you really see trauma care going in the future? And what do you see is the big challenges for trauma care for my generation?

David Feliciano  43:10

I think this is an individual thing. But I’m a napper. There isn’t a Saturday or Sunday that went by when I was active in practice that I didn’t take some naps. I’ve learned that from my father, by the way. In terms of the history, it really helps when you’re writing papers, or even planning studies or giving presentations, to have a sense of where we all came from as surgeons, particularly in trauma. And the history is, you know, unfortunately goes back about 2000 years if you’ve done some reading. But I will encourage people to do the reading from history books, I’ve got, you know, majors history book of all the first descriptions of medical diseases. I have any number of surgical books from the 40s and 50s, reviewing the history of surgery up to that time. The materials out there for Christmas, I gave three of my colleagues around the country, one one outside shock trauma, and two inside a book on the history of vascular trauma from a resident at Duke who was kind enough to send it to me. So I mean, the material is out there, it’s just a matter of, instead of watching another episode of something on television is just picking up a book and committing yourself to 15 to 30 to 60 minutes a night when you’re not tired and just learning about these things. Annotating in the margin, taking some notes, so that when you go to write something, you have this material available and you’re very familiar with it. I’m very disappointed in the journals that now say we don’t want any references before the year 2000. I’m particularly sensitive about that, because it’s about 60% of my CV. You know, every everything I wrote is disappearing, but the biggest challenges in trauma care I think with the availability of acute care surgery for people in trauma, a lot of our concerns about recruiting our successors have been alleviated, frankly. Now, it’s a question of getting people to tackle the questions that we have never been able to answer, right. Like, simple question. When do you do with fasciotomy? You know, we can’t answer that. Whether you’re talking about a therapeutic or prophylactic fasciotomy. We know there’s a lot of individual variability and help people tolerate a higher compartment pressure. That just absolutely speaks to the need for a prospective study in many centers. Should you anticoagulate as you put in a PTFA graph for trauma? I have no idea. I know what I do. But we need to study that. There are a bunch of people going around saying you don’t need to use heparin while you’re doing a peripheral vascular repair. Oh, really? How do they know that? Well, they did some retrospective data collection and wrote a terrible paper. So I think there are a lot of questions that should keep people interested and active for many years to come. And I would encourage people to pick one of those questions early in their career and say, I’m going to spend the next 30 years studying, operating and writing about this topic. For example, you’ll never see my name as a first author on a paper about colon injuries, why? I can’t explain it, but I don’t have that great an interest. So my partners have always written. You, I’ve picked areas that are really of interest to me like vascular trauma. And trauma, as an acute care has a pretty bright future. Keeping people in the profession as they get older, requires a division or a chair to allow people that make some of that adaptations to the physical constraints and things like that. But right now, as long as we have men, and testosterone, and alcohol, trauma will not go away in the United States.

Chad Ball  47:27

I just want to end by asking a very, I think, simple question that we asked a lot of the guests, which is very simply, you know, thinking back over, in your case, an extraordinary, long, productive and amazing career. What advice would you give trainees or what advice would you have wish you have gotten earlier than that maybe it didn’t?

David Feliciano  47:51

I didn’t recognize early on how important the, if you will, the old boys network was in controlling a lot of academic activities outside the medical school meaning getting into societies, joining committees and societies, getting to present at the college, presenting at major meetings, being asked to write chapters. There is a network of people in each specialty that, in a way control many of the activities and it took me a little while, again with an introverted personality. But I did learn to go up to people at meetings and say, you know, I really admire your work. And I just had a few questions. And by doing that, you know, I got to meet some really great people from all over the world. And I got some really great advice. And then they knew my name. And then I was interested in their field. So I would not be bashful. I tell people I tell fellows this all the time, they never listen. If you see Gene Moore at a meeting and you have some issue or, you know, academic or career wise or whatever, he can find the time. You just have to approach a person like that appropriately and say, what I said. I met Leon Pachter at New York University on a tennis court, I went up to him, I said, I have read all your papers. And I said, I just love them. And he is now you know, all these years later, it’s 38 years later, we’re close friends. And that kind of contact really helps you. So a big one is branch out, make good contacts in your field. It’ll be mutually beneficial over time. And the second thing really is, you know, find your passions if you can early and really commit to them, as I mentioned previously, and you’ll get better at writing about them, studying them or even operating on them. You can’t be a rubber ball in academics, some people are but you want to have a few things that are really true to you that you’re interested in and pursue those.

Ameer Farooq  50:21

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.