E29 Sean Gregg On Creativity, Entrepreneurship, And Advocacy In Surgery

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Chad Ball  00:15

Welcome to Cold Steel, the Canadian Journal of Surgery podcast with your hosts Ameer Farooq and Chad Ball. The goal of the CJS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike. And most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons. We hope you enjoy it.

Ameer Farooq  00:50

Dr. Sean Gregg is a practicing general surgeon in Red Deer, Alberta. Dr. Gregg has a fascinating life story and is a superb surgical educator. In this episode, we get his thoughts on creativity, entrepreneurship, and advocacy in surgery. Dr. Gregg, thank you so much for coming on Cold Steel and joining us on the podcast. Can you tell us for those listeners who don’t know you as well, where you grew up and what your training pathway was?

Sean Gregg  01:17

Yeah, you bet. So I’m an Alberta guy. I grew up barely just south of Calgary, kind of on the edge of kind an outskirts country. My dad trained horses, so we had a bit of a farm. And then my first degree was in Edmonton at the U of A. And that degree was actually in in physics. And then actually I started a master’s program. But I never finished and some other detours along the way before doing my MD at U of C. And that’s where I finished my general surgery residency as well. And then I practiced for about three years. And then I went back and joined Chad Ball and Elijah Dixon, Francis Sutherland and Oliver Bathe for some remedial work in hepatic biliary surgery. And then came back to work in Red Deer, and I’ve been there well, ever since. So about eight years since then.

Chad Ball  02:25

Sean, we know you’re, you know quite well in Calgary. And I think we talk a lot and we always, always appreciate all your contributions academically, clinically, and so on, that you give to us. But, you know, I’m not going to let you sidestep the word detours without telling us about some of those detour stories. And and I think, you know, at the end of the day, you’re such a remarkable guy. And you and you think I think about life and you think about surgery, maybe a little differently. I mean, that as a compliment to most of us were pretty linear. That’s why if you could tell us some of those stories and maybe how they impacted your your career, either a good or a bad way.

Sean Gregg  03:07

Yeah, you know, I, you know, I, like all of us, I often get patients asked me, Why I became a surgeon, why I choose to do what I’m doing. Usually, I’m doing a colonoscopy at the time, they ask me. But, you know, my answer is always the same. I just tell them I was I wasn’t good at anything else. You know, I tried all kinds of things. So, as I say, my first degree was in physics.

Chad Ball  03:33

And I know, that’s not true. My observation has been you’re good at everything.

Sean Gregg  03:38

But my first degree was in physics, which is a fascinating discipline, right? Theoretical physics, not useful or applied physics. And, you know, it wasn’t long into my first degree that I realized that there was no career path in physics that was interesting or exciting to me. You know, I think you could you could teach physics to other people, or you could be in an underground lair in Switzerland or something like that. And, and none of those really appealed to me. But at the time, I was interested in international development, and I had done a development project as a student in, in South America in Guyana. I spent a summer down there. And I applied for a scholarship in my third year of my physics degree. It was a great scholarship. I’m sure nobody else applied. It was sort of back of the book. But it was funded by a Canadian Development Agency, and it would pay for me to study anywhere in the world for a year, as long as it was the developing world. Wow. And it was a killer opportunity. Right? And so I got the scholarship and they flew me out to Ottawa with some other Canadians and what I did was I applied to the University of Zimbabwe and apparently out of an interest of the program, one of the programs they have there, but also was excited to see Africa. And not long before I left the University of Zimbabwe closed, it was about 1998-1999. And there was just a lot of civil unrest. And they they closed the university as most universities are a hub of dissenting thoughts.

Chad Ball  05:25

So just to be clear, you personally didn’t close the university.

Sean Gregg  05:31

Well, the story is just beginning.

Chad Ball  05:32

Just stay tuned.

Sean Gregg  05:33

No, no. So then, you know, I had to detour and so I, I enrolled in a master’s program in Durban in South Africa. And that was, was, like a master’s degree in managing development projects. Right? So the study of an industry, I suppose, that I’d never really had been been aware of or appreciating prior to. And so, you know, I headed down there. And I mean, it was pretty formative years for me, right? I was about 19. I remember arriving in the Johannesburg airport catching a connector to Durban. And this little old lady was sitting next to me. And she kind of took an interest in me. And I told her what I was up to and why I was there. And she said, Well, the first thing you need to do when you get to campus is buy a gun. And, you know, I was visibly taken aback. And she sort of realized that, maybe I wasn’t ready for that step, right. And she said, Oh, well, you know, if you don’t want to buy a gun, they’ll show you how to make one. And I was not at all reassured by that. But in fact, I did learn two different ways to make a gun at home while on campus in South Africa. But I I did this semester, I, you know, I did a semester studying development. And I just became disillusioned with the field of development. And I had a lot of philosophical objections. I was more philosophical at the time. So that carried more weight, I guess. Anyways, like, I was going to leave the program. But through another bizarre sequence of events, I ended up on the university chess team. And they were paying for me to travel around playing chess, in tournaments, and eventually I lost the nationals and had to decide what I wanted to do. So I, I bought a car I bought an old Volkswagen Beetle and loaded it up with camping gear, and I, I set off across the African savannah and drove around in between semesters, so for a few months, put about 30,000 kilometers on that car. It broke down, and we’d fix it. And, you know, we drove through rivers and under drafts, and all over Africa, and I ended up in Zimbabwe, when the university opened. And basically talked my way into medical school there because, you know, I had my own funding, and they let me audit courses. So I did a semester, like first year of medical school in Zimbabwe. And they followed the traditional Oxford curriculum that was very science heavy, right? And we did histology and a full cadaver lab. And you know, I get to know the professors a bit and they let me write exams, and I did okay, and so they asked me if I wanted to stay and I’d love to Zimbabwe was a great place to be at that time. Just a gem in Africa, right, a very stable country literally was held up in the world as probably one of the most successful countries one could find at that time. Unfortunately, I didn’t realize that was really the beginning of it unraveling. And so I did stay on I stayed on another semester. And by the end of that semester, it was clear that I was not going to be able to complete a degree there because there was just more and more violence and instability. So eventually I had to leave. Interestingly though, I was collecting my scholarship in American dollars and the rate of inflation was such that I was still paying all my expenses in Zimbabwe dollars. And so I would go to the bank with a with a backpack and get these bricks of Zimbabwe and cash out to pay my tuition but wow, I left Zimbabwe with way more money than I came with because it would have opened budgeted in in US dollars but paid in Zimbabwe a month. And then just the the way, I had booked the cheapest flight in the world. I went the other way around the world to get there and so I had to fly back through Singapore. And the the flight allowed me an indefinite layover. So I thought great, you know, get off the flight and Singapore and I wanted to travel up through Malaysia and through Thailand and Burma to Bangladesh. But, you know, I met this artist in northern Thailand. And, and I thought his he was just a street artist, you know, and he thought his work was so incredible. You know, he had never seen anything like it in my life. He he just did charcoals, right, like a use of powdered charcoal and calligraphy brushes and applied it to watercolor paper. And it was such realistic work, right? It was amazing. It was just photographic reality. This guy was incredible. He’s just working in a in a street market in northern Thailand. And I asked him if he would teach me. And then he said, No. But I kept bugging me, I came back the next day. And eventually, maybe on the third day, he said, Well, how long do you have? And I said, Well, you know, I’ve got about two weeks. And he laughed in my face. You know, he said, You know, that’s not even a start, we will barely even make your brushes in two weeks. And so I said, Okay, well, I have two months, then. He said, Well, we can probably get started in two months, but it’s not nearly long enough. And so, the next day I, I started work, I showed up and worked every single day weekends, you know, Monday to Sunday, for actually about three months with that guy. And, you know, the first week, we, we just made my brushes. And, and the next week, and I’m telling you all this because it is I think it is relevant to how I think about surgery. So I’m hoping that this will have some relevance as we, as we chat this morning, but but you know, one of the first tasks he gave me was to draw an eye, right? And the eye is very detailed, and we’re all very sensitive to the appearance of an eye. So it does have to be fairly perfect to pass muster. Right? In my first, I was terrible. I did a second eye, and I was pretty happy with it. And, you know, it had taken me probably two days to do my two eyes. And he look at it, he said, Okay, do a 100 eyes. Right? He wouldn’t even talk to me until I finished my, like, 100 of them. And, and it took me a couple of weeks. Right? It just repetitively doing eyes. And some were good, and some were terrible, and so forth. But you know, there’s no question, I definitely learned all the components, you know, and every now and then he would, you know, kind of point something out. And I, you know, I finally finished and presented my eyes to him. And he didn’t even really look at them, you know. Two weeks of work, I was crushed.

Chad Ball  13:00

That does sound surgical.

Sean Gregg  13:02

Threw them in the corner, because he didn’t actually care whether I, I, you know, was doing a good eye or bad eye. Because, you know, that’s my concept of how you would teach them. Right? You know, give them the practice and show them what they did wrong. But he wasn’t teaching me how to how to do an eye. Because it wasn’t about the task of completing 100 eyes. Right? Because in my mind that was that I was going to get a 100 done. And that was like a landmark. To him it was it was teaching me to just be absorbed in each eye. Right? And it’s not about completing a 100 eyes. It’s about being absorbed in the process of each brushstroke of every part of every eye. And it doesn’t matter if it takes two weeks or two years. You know, you just try to lose yourself in that moment, right where the rest of the world melts away. And you’re, you’re just kind of all you see is, you know your eye and your hand and envisioning how to bring what’s in your mind into reality. And eventually, you know, one of my friends at the time who owned a bar, he took all my pages of eyes and he put them up. He owned a bar he put them up in his next to the urinals in his in his bar, which is hilarious at the time. Anyways, that you know, and I did spend three months there. And I think I gained some technical proficiency there. I’m far better now than I was even leaving Thailand back then. But I think the lesson wasn’t about you taking the boxing I completed this or I completed yeah. It was about just being present and pursuing excellence with each brushstroke. Right? And that the end result will be good if you concentrate on the details right? And you know it’s still, it’s still a hobby. I always have something on my easel that’s unfinished. And I, you know, I don’t spend as much time with it as I used to, but I’d love to get back to it. So from there, I came back to Canada. And I finished my degree in physics and I kind of thought, geez, well, now what? And I decided that, you know, of the things I tried, I really did enjoy medicine, and I wished that I could have carried on in Zimbabwe. So I’d written my MCAT and applied to medical schools. I would have applied that year, and I had a friend living in Taiwan at the time. And I, I flew over to join him. And that year, I actually applied to medical school from, from an internet café in, in Taiwan. And for anybody that traveled at that time, internet cafes were sort of hubs of traveler culture, right. And, you know, people smoked and so I applied to medical school in a smoky internet café next to kids playing Starcraft. And I worked in Taiwan that year. I actually taught kindergarten and the English immersion school in the mornings. And I worked as an artist the rest of the time, right, so I would do mostly portraits and various other commission things. And that was a good time. I worked really hard trying to learn Chinese, but really didn’t stick. But a good time for me, right. I tried on some different hats. I saw a different side of the world. My girlfriend at the time was living in Peru. And so I left Taiwan. I came back to Canada and did my my medical school interviews, and then joined my girlfriend in Lima. I studied Spanish at the University of Lima. And that relationship didn’t work out, obviously. But when we, when we broke up, I hit it off on my own. And in retrospect, I can’t think why why this seemed like a good idea at the time. But, you know, I had been traveling all over the world, and I felt pretty comfortable in my own shoes, and so I decided I would cross the Andes in the north of Peru on my own, and there really isn’t any roads up there to get over the Andes. And at that time, which would have been about, say, 2000, it’s where the sort of the remnants of the Sendero Luminoso and NRCA paramilitary groups resided, right? That’s the eastern slopes of the Andes is his perfect climate for growing cocaine, right. It’s got a high elevation and lots of rainfall. And so it’s mostly populated by farmers. But it took me about two months to get across the Andes. And every day is a story. You know, I went village to village and a lot of the people had never seen a white person. And eventually, I didn’t get far enough over and down the eastern slope that the rivers got big enough on me I could climb on a boat and head down the Amazon. When I arrived in Iquitos in the Amazon, I phoned my mom and she she said I was in medical school in Calgary and I had to come home. So yeah, so I flew back to Lima and then and then headed home and started medical school that summer.

Ameer Farooq  18:52

One of the highlights for a lot of surgical residences is coming down to Red Deer and spending time with you and hearing these stories. And no doubt I think we all hear these stories and can see like the impact it’s had on you and even your your teaching style. I did want to ask how you ended up in Red Deer and why why Red Deer and why community general surgery practice?

Sean Gregg  19:17

Yeah, you know, I I guess there’s an idealized answer and probably the real one as well. So you know, the real answer is in my fifth year, jobs were hard to come by and I suspect they still are. And I’d worked in Red Deer and I’d met the group in Red Deer and I liked the idea of a general practice. You know to head out and be able to do everything I felt comfortable doing. But also work with a supportive group that was willing to expand my skills right so that you know, I could do everything I felt comfortable doing and then do some things I didn’t feel comfortable doing but do them with a colleague that was keen on helping me expand my scope. So it was an offer I couldn’t refuse. I’d also met the love of my life, and was pretty happy to find a place to settle down. I was weighing that against pursuing a hepatobiliary fellowship. And, you know, in retrospect, I wouldn’t do it any other way. Right? I came and worked as a generalist for three years, I did thyroid and breast and APRs. And I learned bariatric surgery with my colleagues in in Red Deer. And then I came back and did my time in Calgary and hepatic biliary surgery to add that to my practice. And then, you know, you have to, you have to make some practical decisions. So I did give up some aspects of my original general practice so that I could focus more. But but yeah, in retrospect, for me, it was, it was a great choice. At the time, one of the things I really valued was autonomy in my practice, and, and so I think, at the time Red Deer offered a lot of that, outside of what I might find, in an academic setting.

Chad Ball  21:23

Sean, one of the really impressive and interesting things you’ve done in terms of citizenship work more recently, as has been our advocate of, you know, in terms of general surgery, with the Alberta Medical Association. And without putting a target on your own back what are some of the things been that you’ve really enjoyed about that process, and maybe you’re able to share some of the biggest struggles as well.

Sean Gregg  21:50

Yeah, I’m the General Surgery rep to the AMA. And it was clear, say 10 years ago that we needed a more consistent presence at the AMA. And then for the listeners, that’s the Alberta Medical Association, our professional body. Partly because general surgery as a section was just being outclassed in advocacy in that body and many others. There were sections that were just more engaged. And you know I think the ones that were most effective, did have a consistent presence there that understood who was who and how things worked, and was able to be more effective. And so I took on that role. And I started with the executive right? I think I was the secretary when Paul Hardy was the president. And and then tried to maintain more consistent president presence because our executive changes every two years. So attending the rep forums, it’s interesting, the minutes are available to everybody. What what isn’t available to everybody are the conversations that happen at the breaks or on lunch or a dinner. And, you know, general surgery in particular, is really insulated. I think, you know, we’re we’re so hospital-based and absorbed in our work that we don’t necessarily appreciate how other sections have structured their practice models, and modernized them. And being able to see and compare and contrast how general surgery functions against other groups. Well, I guess it gives you a new perspective, right? A new idea. And general surgery is clearly a laggard in innovating its practice models. And that’s not necessarily a criticism because it comes from a sincere place. We genuinely love our work and we revere the the practice models that were that we inherited from our, our teachers. But I do think that there’s a role to challenge them. You know, and see what other people are doing and try some different approaches. So for me, it’s, you know, the greatest benefits have just been eye opening and, and sharing and, and learning from some of the other groups. The greatest challenge for sure, is just engaging surgeons, right? Because they love what they’re doing and they’re busy. They’re happy to be supportive because they want an advocate. But, you know, it’s a genuine challenge, like there’s a reason that other sections have been somewhat effective at that level.

Chad Ball  24:53

You’ve done an amazing job of walking that fine line in terms of advocacy, and education and come on guys sort of spirit. It’s been really great. It almost sounds like the your AMA experience to some extent maybe and correct me if I’m wrong has been a bit of a of another educational detour so to speak. Because I, you know, you and your as you, as you mentioned her not by name your lovely, lovely wife, Bonnie, you guys, I think of both of you as entrepreneurs for sure. And we all know, that’s in many different areas. But you recently it sounds like transitioned into a little bit more focused on maybe the business side of general surgical practice, and certainly by your description today pushing the envelope or or looking at efficiencies and restructuring. You know, you and your partner’s collective practice, and I’m not implying it’s all you by any means. I don’t want your partners to have a sense of that. But could you go through how you look at, look at that app element to that aspect of it for us?

Sean Gregg  26:00

So, you know, I think we inherit some biases when we come through training. And there’s a long list of those, but the first is that that money or business is, is, I guess, is almost beneath the purview of a surgeon, right? The surgeon looks after the patients does surgery, and the money will sort itself out, we try to put our patients ahead of ourselves. And, and so for sure, when I hit it out into practice, I subconsciously downplayed the, the value of economics of this job. But as time goes on, you start to realize a lot of things. One is that principles in entrepreneurship or business, though from a surgical perspective, it might seem like it’s money oriented, or focused, and in a lot of ways it is, but it has so much more to offer that we that we might have dismissed. So, you know, as my, as my wife pursued her business, she runs a yoga studio, that’s extremely multifaceted. It’s been a very successful business, by any measure, right? It’s repeatedly award winning. Yeah, financially, it totally stands on its own feet. And it has, it has brought a lot to the community. And it is a marvelous creative outlet for my wife. Right? So it is constantly innovating. There’s new programming and new ideas, and it’s it’s an exciting place. And, you know, I found that even from medical school, that a large part of medicine is a bit stifling. Right medical school, it starts out there’s really no room for creativity or creative thoughts. In in medical school in particular, right, you’re really just assimilating knowledge. And then residency is is, is about learning from others, learning other people’s way of doing things, and acquiring some familiarity and experience and the the intangibles of our profession have to be assimilated in in those years. But it’s a bit like learning an instrument, you know, you start out doing scales and, and then you get some technical proficiency. So you play the music other people wrote. And you have to do that for a long time, until you’ve really mastered your medium, and then you can go and create. And that’s the exciting time of surgery, right? Where you have really mastered your medium. And now you can, you can see where it takes you you can innovate. Just like a musician would. However, that’s increasingly difficult for surgeons, right? We seem to practice in these ever shrinking boxes. And we’ve lost a lot of autonomy that would allow us the space to improve and innovate. And, and you know, to list those boxes, we’re all familiar with them. Some of those boxes are fee structures. Some of those boxes might be our access to resources. Some of those boxes seem like they should be challengeable, like working in, in, in big systems. If you want to change a form, there is a huge amount of process and diversity and and stakeholder input and so forth. If you want to change a form it’s a multimonth or even multiyear process. It’s very difficult to rapidly innovate and so often we bend instead of trying to bend the system around us. Entrepreneurship is not like that. Right? You are you’re totally your success is contingent on how hard you want to work. And your innovation. It is it is really about innovating and setting yourself apart. And I can guarantee that when any of us applied to medical school, we were never setting out to be the best algorithm followers or the best appliers of evidence, because that’s not, that’s not what inspires people. We really wanted to help people, work hard, and at the end of the day, look back, reflect on what we’ve done. And and be reassured that we had made some personal impact some difference, that that we left our mark there that had somebody else been there, they would have had a different or worse outcome. And those opportunities are harder and harder to find. So I have always looked for creative outlets. And, and, you know, now 10 years into practice, I feel like the steep part of the learning curve is behind me. And it’s an exciting time to try to innovate and improve. But there are a lot of barriers to doing it. And so trying to look at business structures. It’s not necessarily about money, or, or getting more money than my other roles would would have supplied per hour. It’s about finding a place that I can express myself where I can have some more autonomy, where I can create a system and look back and say, I made that I made that difference for people. And so it is an exciting idea when you start thinking of it that way. And in truth, if you really want to pursue excellence, it is a real challenge to pursue it within public institutions because of the sand in the gears. If I want to, if I want to change a process or form in the hospital, it’s a matter of almost learning to not try. Because it is so difficult. But if I want to do that in my office, it’s a different process the next day, right, your ability to rapidly iterate and innovate processes is far greater. So I have been inspired by my wife’s experience to see what we can do to remake models of care. And I don’t want to keep them speaking in in the abstract, but a simple example was perianal clinic. So nobody, nobody is passionate about perianal disease. And, unfortunately, patients suffer for a long time with perianal disease, because access isn’t great. And what I want to do is kind of examine why that is? Why why are we not meeting what patients are looking for? Right? Because, at least for central Alberta, people could wait over two years to see a surgeon for a very simple complaint. And, you know, some things we can control some things we can’t. Like access to the operating room, right? Those are very difficult resource management issues. And as a group we can’t really affect our total access. However, the vast majority of people with periodic complaints don’t need the OR. They just need some of my time. And yet they were still waiting two years. And so I started looking at your where’s the bottleneck? Why is this happening? And, you know, part of it is it was not well-paid. And it’s not glamorous, and nobody really enjoyed it. So they didn’t set aside time for it. The third thing, well, well, how could I make it more attractive? Right? Could I build a business model where it was better paid? Could I build a business model where it was more enjoyable to deliver? And then Better yet, can I build a business model where patients get better care, right, where they’re seeing faster, and they get, I guess, more service or or more things that the patient would want. And I actually didn’t take me long to realize that, that that’s a very achievable goal, right? The first thing I had to do was take all of those disease processes out of the public system into my office. And of course, you know, this is still publicly funded. But under under our office, we suddenly have huge amount of autonomy, where we can change processes, we can set the scope of practice for, for nurses, etc. So we just iteratively improve the process. And so now, I’m in to help you understand we we had people with a periodic complaint, they fill out their history in physical form. At home, and that gets auto populated into our electronic medical record, we have our nurse who is dedicated to this problem, right? Her understanding and knowledge of perianal disease is as good as my own, because there is an attainable knowledge set. But I couldn’t train the the nurses in the hospital to that level, because it would be a different nurse every week, and I don’t pay them. And it was difficult to change their scope of practice, because I don’t really define their role. But in my office, we could easily define that role. And we bought the equipment, we bought met with vendors. And, you know, I wrote the business plan, which again, was a totally foreign thing for me, but not difficult to do. You sit down and follow the formula to come up with a business plan where you would make as much or more working in the office looking after hemorrhoids as you would any other activity. And then you have to pay for the nurse and you have to pay for the equipment and so forth. And then I tried to see how we could tweak it to make sure that we’re viable. And then, and then we can adjust the volume and how we run it. So a nurse focused clinic that actually has the surgeon there to do procedures for an opinion and leave. It’s far from innovative, right, it’s what the dentist does. It’s what a large group of other sectors do where they, they apply an expanded scope of practice for a nurse and train them into a role. And now the patients get 20 minutes of an expert nurse’s time instead of five minutes of my time.

Chad Ball  36:50

Its so true you know, there’s so much unintentional inertia, you know, in myself and in our general surgical colleagues, for the most part that I wouldn’t, you know, you’re I’m sure your story is not unique, but it’s darn close to unique, like we we just don’t engage in this kind of innovative thinking, right, like we should have, I think, you know, personally with with the way that our particular province in Alberta is moving. I think it’s it’s our duty to do so and to really put thought into it at this point.

Sean Gregg  37:20

Yeah. And you know, when when we realized how successful it was, because the patients are getting better counseling and care to get way better access. Because we cut our wait times from two years to three months. The referring doctors are much happier because they get way better turnaround. And the surgeons are much happier because we have removed some of the onerous portions of that care from them. Right. So the nurse is now able to do the documentation. They read the letters and so forth. Whereas now the doctor can sign off rather than spending a large amount of time dictating or writing. And so you realize a lot of efficiencies, everybody in that system wins. We just never examined what we were doing before. And so it’s actually an exciting prototype, and it’s hard to get excited about perianal disease. But when you see what can be achieved with actually a minimal amount of effort, and certainly a minimal amount of financial outlay. It’s exciting to see it because I’d love to apply those principles to other problems.

Ameer Farooq  38:32

You know, what you described sounds a lot like what they’ve done in Edmonton in terms of making a central referral process. And that has they came actually to give us a talk here in Calgary not too long ago. And it’s been impressive what they’ve been able to do, and how much inefficiency they’ve been able to get rid of by doing that. And of course, it sounds like you’ve taken that even in even further into the next level.

Sean Gregg  38:59

Yeah, so you know, I I was catching up with a mutual friend that Chad and I have the other day on the phone, Scott Gamora. And Chad and I were contemporaries with Scott in residency. Scott was in the same year as Chad a couple years ahead of me. And Scott is a bariatric surgeon in Ontario. But, you know, I’ve always felt like Scott was at his heart nonconformist. You know, and he just has a small, small piece of that nonconformity in there.

Chad Ball  39:42

That’s a perfect description. Absolutely.

Sean Gregg  39:46

And, you know, I’m sure it’s been his greatest gift and curse various times in his life. But, you know, one of my fondest memories of Scott was a talk he gave us a he could have only been maybe an R3 in residency. And it was a research proposal. And I was probably one of the most practice changing research proposals. He never even did the study. But I think most people that were in attendance still remember the talk, it was about bowel sound. So he wanted to prove that bowel sounds really had no clinical validity. And, and just by proposing the concept and demonstrating that there was no evidence behind it, I think, and in such a rhetorical way, that without even doing a moment of original research, I’m not sure anybody in Calgary ever listened to bowel sounds again, it was so compelling. But you know, it’s challenging sacred cows. And so when I was chatting with Scott, on the phone the other day, it’s interesting how convergent our opinions have become. Because he works as a bariatric surgeon, but he has encountered the same frustrations, where it is very difficult to pursue excellence in patient care and process within a big machine, and so, he, he has started to provide some bariatric services outside of the public system. And, you know, he and I would agree that there’s not a lot of financial motivation to do that, right. It’s, it’s so expensive to deliver. And it’s so much work that it’s, it’s hard to ever argue that there would be a financial reason to do that. Really he did it is because it is so satisfying, so rewarding, to regain your autonomy, regain your control over the processes, so that you can actually look after patients, you can give them what they want. You can give it when they want. It a silent source of dysphoria in medicine, these days where we we are constantly in a position to fail patients, whether it’s poor access and various frustrations that we can’t address, that he’s realized that it’s very exciting to pursue an entrepreneurial, bent to things. And, you know, I don’t know how successful it will be from a business standpoint, time will tell. But I can say for, for the for Scott is already successful. It’s already a great creative outlet.

Ameer Farooq  42:34

Dr. Gregg, it’s incredibly uncertain time, obviously, with the COVID pandemic. But also, I think, in Alberta, even preceding the COVID pandemic, there’s been a lot of change in the political climate. And I think you have definitely been kind of at the center of of trying to navigate that. What do you think the future holds for surgeons in Alberta?

Sean Gregg  42:59

Yeah, yeah, I guess the the crux of that question is, it’s sad that it’s so hard to answer. Right, the future is uncertain, and none of us have a crystal ball. And I think the political events of the last few months were entirely unpredictable. Right? The cancelling of the master agreement is unprecedented in any province. The the changes that this government impose, were so obviously poorly considered, I don’t think anyone took them seriously. Nobody believed they would actually be foolish enough to do it. And then they did. And then of course, they realized it and had to walk it back. But it is extremely difficult to, to predict. What what made maybe I’ll reframe your question, and say, well, what’s the current trajectory? And how would I like to see a change? I think, the trajectory of medical practice and surgery, I do find somewhat concerning, I find it concerning in how we have maybe allowed ourselves to lose some of the control some of the autonomy, and some of the best parts of being a surgeon. And it’s insidious, and we did it partly because we were busy enjoying our time with our patients and because as surgeons, we often value knowing we we did a good job, you know, over pursuing the political side of things or the administrative landscape. And, and maybe we have allowed ourselves to be sidelined a little bit, but we really have become increasingly divorced from control and autonomy despite being the experts, and often the best resource in the room. Our opinions I think have become marginalized. And so we are we are frequently controlled by access to resources by very specific limiting fee structures, administrative pyramids that we don’t necessarily get to contribute to, like, even even guidelines and evidence. Well, they’re clearly revolution for patient outcomes. They are, they are barriers to innovation in a lot of ways, right? They do shuffle us all towards the mean. And then and then politics, right, we we are so influenced by it. And it’s so difficult for us to impact it. So, you know, I think one of the frustrations that surgeons see is that despite losing control, we carry no less responsibility than we did 10 or 20 years ago, right? We, we are still morally responsible for poor outcomes. And we still carry that moral injury when we have unhappy patients, even if their discontent is related to things beyond our control. I think, you know, most surgeons have a certain learned helplessness where they are happy to continue focusing on the aspects of their job they can control in that they do enjoy. But the trajectory I do find concerning that there’s a lack of engagement, and we are maybe losing a battle that we didn’t even know we were in. And so how would I redirect that trajectory? I think, I think it does come down to critically appraising the system and the trajectory of it, and then seeing what you can control what can we take back? And where can we express ourselves and express our autonomy and and to be excited about those things right to, to have a little bit more unity and engagement, and build each other up? I think there is ways that we can change the direction of things.

Ameer Farooq  47:25

I think that term learned helplessness is such an apt one, because people it’s like a favorite pastime in the operating room is to complain about, you know, various problems with with how patients see us and how patients get to the operating room. But very rarely do you find anyone actually, you know, going out and setting out to actually change those processes. And we need it so desperately.

Sean Gregg  47:52

And since I started thinking this way, like with a more entrepreneurial bent, I actually see a world of opportunities. I see opportunity everywhere to improve it. The barriers that I imagined there, they’re not necessarily barriers, there’s, there’s more opportunities than one might guess.

Ameer Farooq  48:12

Dr. Gregg, I think one of the things that I also wanted to touch upon before we kind of close things out is just talk a little bit about your group in Red Deer. I really enjoyed my my rotation when I came down there and I it’s consistently one of the best rotations for Calgary residents and Edmonton residents who come down to Red Deer to join you. How have you guys maintained such a fantastic group in Red Deer? And what do you think it is that makes you guys such a great group?

Sean Gregg  48:43

Well, I mean, I’m, I’m flattered you think so. I, I think we do take a fair bit of pride and in trying to maintain a strong group, we are actually a very integrated group. So we have a single office together, we are very into reliance on find overs for call. And so having good colleagues is, is probably the number one most important thing for my quality of life. It allows me to trust others with my with the care of my patients, and and we, as a group, when we’re unified, can accomplish far more than then a bunch of individuals. I think it’s, it’s got to be about a long term principle of building a strong surgical culture. Once you have a good group, and good philosophy, it becomes one that people do want to join. And so we probably do recruit a bit above our, our weight class. For that reason is because we we have a good quality of life because we’re a unified group because we get along Because we support one another. And for me, that was probably one of the the most constructive parts of my career was those first few years here where Dr. Farris would scrub with me where, you know, that was that was almost my first fellowship, you know. And, and our ability to get residents rotating through. It would be extremely difficult to recruit well, if, if you don’t get residents routinely, right, where you, you don’t get exposed to new people, and vice versa. Because those are all job interviews, then they’re two-way job interviews, when a resident comes through.

Ameer Farooq  50:39

In closing, Dr. Gregg, I was just wanting to get your advice for trainees, particularly, I’m being selfish now, as I’m about to go out into the great, great wilderness and the great blue yonder myself. What advice do you have for trainees going forward that you wish someone had given you when you were starting out?

Sean Gregg  51:03

I mean, so, you know, I do think about my time as a trainee, and from my perspective, now, I do try to improve things for them. And so this isn’t your question at all. But I’m going to answer my own question. You know, how can we make things better for trainees and so we have tried to do better long term manpower studies, or at least planning, right? So we identify a community need, and then we identify a good person with an interest, right? So we, we think that they can serve our community and then we help them get the training that they would need to serve the community and be a good fit. It’s, it’s a tough place to be when you’re a trainee, and you’re trying to pick a fellowship, uncertain of where you might end up. But you might be happy in any number of fellowships, or types of practice. It’s very difficult to pick one. But that’s the advice all trainees get it’s, you know, do what you love, and never workout. But in truth, if you had the commitment and support of a group, and the job offer, and they wanted to help you find that training, that’s a much better place to be as a trainee. And so we’ve tried to create that scenario, and I think we do recruit a bit better for it. Thinking about you know, the advice I give the trainees, you know, we have medical students, and I usually usually tell them, if they could be happy in a different profession that wasn’t surgery, they should do that. Surgery is for people that couldn’t possibly be happy doing anything else.

Ameer Farooq  52:56

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.