E35 Christian Finley on Quality in Cancer Care

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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. Christian Finley is a thoracic surgeon at McMaster University. In this episode, we talked to Dr. Finley about his unique training pathway and his provocative work demonstrating the disparities in surgical cancer care across Canada.

Chad Ball  01:03

Dr. Finley, thank you so much for joining us on Cold Steel today. We really, really do appreciate your time. You’re a really interesting guy to certainly, a lot of us and you’ve had an interesting path. I was curious if you could tell our listeners where you grew up, what your training pathway was like, maybe even why thoracic surgery as a fellowship and a career. And then how did you end up at at McMaster, Hamilton in particular?

Christian Finley  01:27

Sure, I’ll tell you my whole arc. Although, I think the word interesting as cover for weird, but I like it, I like the way you posed it. I am a thoracic surgeon, I’m actually a third-generation thoracic surgeon. My maternal grandfather was a thoracic surgeon, my dad is a thoracic surgeon and I am a thoracic surgeon. I was born in London, Ontario and come from a medical family. My granddad, who was a thoracic surgeon had eight children, and four of them became doctors, two of them became surgeons.

Ameer Farooq  02:02

Wow.

Christian Finley  02:03

He bought a cottage and he would take all eight children the day after school up to this cottage and leave them there for the entire summer and bring them back the day before school started again and leave them with a non swimming Mennonite nanny. So it’s a wonder I am even around. And so, out of this medical family, my mom married my dad, who was a medical student in London at the time and then became a thoracic surgeon. So my roots are deep into London. When I was about 13 years old, my dad got the job as the head of surgery in Vancouver and so we moved out West, which was both traumatic for a 13-year-old to move across the country, but also eye opening and opened a bunch of doors to the outdoors, into BC, which which I loved. And really developed a lifelong passion for the outdoors. I did engineering at Queen’s, after I’d done high school in BC, which was wonderful. Which is still, I would say, the best four years I ever had. And then I got into medical school back out West and went back out West, and loved it. I absolutely loved medical school and I absolutely loved the general surgery residency I did at UBC. I’ve never been so tired in my entire life. You know, I think we started with five residents and I think we finished with three, and as people left the program, we just got to do more call. It was back in the era when you would do call all night and work the whole next day and I loved it. I’ve got 12 cavities, I think, through that time because I ate nothing but gummy bears and Swedish Berries from the vending machine. But I worked so hard and loved it. I absolutely adored it. And to this day, think back on that training as such a wonderous time and part of the greatness of BC at the time was, you got to one, rotate to rural communities. And so I went to Whitehorse, I went to Prince George, I went to Bella Coola when I was a medical student and I really developed a love of those rural places. At the time in my life, I thought I would be a rural surgeon. And the other great thing was that they had a six-year residency of which one year was a research hearing, and you could really do whatever you wanted. And so I went to Harvard and did an MPH at Harvard, and had a wonderful time there. And I think that’s where I met my wife, which I think probably adds to how much I loved it. But it was the type of place where everybody was interesting. All your classmates did phenomenal things. I keep in touch with them to this day and we still do hiking trips every year. And every time we’re walking along these trails, you hear what people are doing and it blows you away. And Al Gore would come and talk, and all these high-level people that would really get you thinking beyond what was right at your feet. I also took some leadership courses at the Harvard Business School and some other courses at the Kennedy School of Government, which I think really opened my eyes to how things are done in business and how things are done in government and how it differs from medicine and public health in particular, which is very telling in today’s environment. After that, I went and did my thoracic training, at Toronto. I interviewed, actually, at Mass General and a bunch of different places across the United States, and eventually chose Toronto. I remember vividly going to Boston, largely because I’d been to Boston for that MPH and thinking it would be nice to go back there and talking with one of the fellows there at 4:30 in the morning, when I was rounding with him. When I asked him what he thought about Boston, he said he actually had never seen Boston, he had only seen within 50 meters of the hospital. And so, that was telling as to what the training was like. And so I settled in Toronto to do my fellowship and again, worked very hard, but really, really enjoyed my training there. It was a sort of place that was on an upward curve, which I think is a good place to be. They were in a growth. I ended up doing lung transplants with them and flying all over the country and participating in all these innovations. The first ex vivo, the first awake person who is on pulmonary venous bypass pumped only by the right heart. So, there’s this 13-year-old girl awake with pulmonary hypertension, whose pressures were high enough to pump it through a circuit, awake with this oxygenator externally just sitting there.

Chad Ball  06:44

Wow.

Christian Finley  06:44

So to see a 13 year old with that, to do all these transplants, to run and go stuff, to put people on the first, you know, take these lungs and do this first ex vivo, was really amazing. Again, it was a bit telling that my wife was an emergency physician and has worked in Iqaluit and the South Pole. And has had a far more interesting life than I, came and was working in the emergency department at the Toronto General. And so, on the day we did the first ex vivo lung transplant, I came home to tell her how we had taken these lungs and they were by themselves on the OR table on a pump, and we were resuscitating these lungs by themselves. And it probably cost about $100,000, she had been downstairs in the emergency department someone came in with a broken leg and they couldn’t even find a pair of crutches for the person to go home. And so that was the telling nature of our health round and how you can spend $100,000 on a pair of lungs and can’t find a pair of crutches. As part of the training, they allowed us to do electives. And we’re all trained in a very tight circle in thoracic surgery in Canada. And so, I thought it’d be important to go away and see how it was done differently in other places. And using some connections from mentors, I went over to Leuven, Belgium, which had one of the premier thoracic units in Europe, and did some time with them and absolutely loved it. Again, just a great time to seek a completely different way of doing the same thing. And they were great technicians and I learned a lot, also learned a lot about humility. I think a lot of the European surgeons have a much more humble way of doing things. And you would have these absolutely world class surgeons doing what we would not consider typically within the scope of a thoracic surgeon. And then also, if they’re having trouble with a pump on the transplant, they would call cardiac surgeons, because the cardiac surgeons were doing it every day and their ego didn’t get in the way of patient care, which I really valued there. I then went over to England and did some training in minimally invasive esophagectomies, which was novel at the time. And here was a relatively medium sized hospital doing cutting edge surgery, they would still use cloth drapes on the patients, it was very British. At the same time they would be doing this cutting edge surgery, we’d be doing laser dopplers of the flow of our conduit before we put it back in and do all sorts of really novel innovative stuff. But then you’d go to the cafeteria and they’d have roast beef in Yorkshire puddings for lunch at the cafeteria. So a very British experience. But I came back with those skill sets, back to Canada. At the time was trying to look to where to work and there’s only a few jobs available at the time. One of them was here in McMaster and at the time, McMaster was undergoing some significant difficulties and they, essentially, changed the whole staff out for thoracic surgery. And so I came down here with Yaron Shargall, who is my partner, and joined one of the surgeons who was here for about six months until he was gone. And then it was the two of us, but simultaneously they had undertaken regionalization in Ontario and so they closed down St. Catharines, Burlington, and a few other places. All of a sudden, we were the busiest center for elective cancer surgery in Ontario, all in the first year of my practice, and it was two of us. They had these criteria for what meant a large volume center, and I made the criteria for a large volume center myself in my first year of practice. I’ve never worked so hard and been so tired in my life. I would go to bed at night thinking about all the procedures that I would be doing because, someone once told me when you just start practice that it’s a great time because you’ve never had a complication and you’ve never had someone die. And sadly, in thoracic surgery, those things don’t last very long. And it’s a real contact sport, sort of like pancreatic surgery or other sorts of significant surgery where the morbidity rate, if you’re being truthful about it, is probably in the 40% to 50% range. And so, I always had 15 patients in the hospital. I operated three days a week. There was one week, I did seven esophagectomy in one week, myself. And I was exhausted. I worked from 5:30 in the morning, I was here, and I’d be here until eight o’clock at night every night. So, for those first few years, until we hired some more people, it was real hard work, but it was good testing ground to get real good at your craft, because I do believe in that 10,000 hours. There is a real learning curve after you’ve been on the staff becoming even better I my experience, both from myself and my junior partners. And there’s nothing like being thrown in the deep end to get through those experiences. So I’d say I agree with you that my career, clinically, was not typical, but has been very rewarding. I think it’s amazing sometimes that, I think our training in Canada is wonderful. In particular, because we work with a bunch of different people. I still pull out moves that I learned in Prince George or in Whitehorse from very different rounds. They’ve pulled me out of the fire. And then the same thing about, I got called into a retrohepatic caval injury and I was pulling out some moves from general surgery. Grabbing it with some allises and trying to suture it with these backhanded stitches, and that was all moves I learned in different places. I think that’s the advantage of training in Canada, is that we get that broad training and good training. Like, I can’t think of a place in Canada that I don’t really respect because I’ve seen great surgeons come out of all the centers.

Chad Ball  12:42

You know, it’s interesting, your pathway has so many elements that are so critical. And you know, sometimes it’s just serendipitous and we’re lucky we fall into these, and sometimes it’s planned for sure. But your volume-outcome, your volume-comfort, your volume-performance, obviously is one element. But the other element, as you pointed out, is traveling to other places. When I think of me, as well, my experiences that were prolonged in places like South Africa and Columbia, Indiana and Atlanta. I mean, you’re exactly right, we’re all a compilation of what we learn. And I almost feel bad sometimes for our friends or our trainees or whoever, who just stay in one place through all their training pathway. Because they’re missing out so much.

Christian Finley  13:28

If you’re not there working, I found that being there, showing up, putting my all in, I got experiences that were wonderful. And you worry for people that don’t, that aren’t there as many hours. I don’t want to jump into the deep end that is work hours, because I do think that too much in some ways, and there were great personal and health, probably, costs to it. But by being there, I saw and did things that made me the surgeon I am today and without them, I don’t know what I would have learned in some ways. So, you’re right. We’re all just compilations of what we learned and some of it is just by dumb luck and just being around.

Ameer Farooq  14:07

Dr. Finley, you’re the lead physician for CPAC, which is Canadian Partnership Against Cancer. Can you tell us about CPAC, what it is, how it was formed, and what are its goals and mandates? And then, CPAC has been having some really significant impacts and some real achievements over the last few years. Can you tell us what you think have been the big achievements of CPAC up until now.

Christian Finley  14:43

I’m not sure if I’d call myself the head physician, I think there would be a few people that would contest that one. But I do lead in the cancer surgery realm for sure. But my path to CPAC, equally was serendipitous. I think it’s equal parts showing up and trying hard, and equal parts dumb luck. Certainly in all those busy years, I went into it having had a good basis for research. And I went into it through my residency, often developing my own research questions. I’m not sure Chad, again, what your experience has been. But certainly coming from Vancouver, there wasn’t always huge research projects to jump onto. And oftentimes, you would sometimes be handed a bunch of charts to review that weren’t necessarily, the research question hadn’t been really thought through. So I would start crafting my own research questions very early on, and then trying to find ways to make it happen. Even in Vancouver, I learned how to query the National Trauma Registry. I learned how to get through a graduate student access program, get access to CIHI data for free. And then I used that data in my time at Harvard to ask my own questions and write my own papers, Such that, all of my work on volume-outcomes was really stuff that I generated, and found ways to get data for and then found statistics people to work with. And it was a lot of hustle. But because I came up with the question, I liked the question and I was impassioned by the question. My dad would always say that there’s 100 hours that goes into a paper. And you better like it, because spending 100 hours doing something you’re not enjoying is a tough slog. And so, from those questions, I was looking around and I saw that CPAC had put forth a review for proposal to look at how cancer surgery was going in Canada, like high-risk resource-intensive cancer surgery. And so I put in an application and I was careful about reading what they wanted. I made sure I made collaborations with people that were outside my typical comfort zone. I made contacts with geographers to plot out how things were done. And I’d learned to do that because I had watched Morad Hameed do it in BC trauma, the power of good geography that can help tell a story. So I made that contact to Simon Fraser, I learned the power of getting a voice from the patients. So I found at McMaster, Julia Ableson had this very amazing group looking at asking citizen panels what they wanted from healthcare, and so they would inform them and then you’d get feedback from a patient group. So, adding on top of the quantitative aspect of that I think that we’re good at doing in surgery or binding ourselves with epidemiologists and quantitative numbers, I tried to add in things that were atypical and I found that in my career, by looking to the interfaces in that Venn diagram, or looking to where two different types of science meet, you get to ask interesting questions and people are really willing to collaborate. And so, I put forth this review for proposal. And I won it against people that, by all rights, had more right to that money than I did. But I read the question, and I tried to think of it in a interesting way. And my experience, and asking my own questions to that point, has allowed me to ask interesting questions there. And I guess it resonated with the people handing out the money. So with that money, I found a very smart student, Saud, who came to work with me. I recognized that he was intelligent and I gave him the support he needed, and he ran with it. So, by finding a good person and trusting them to do the work, we were able to pull that thing off. Which I don’t think, again, a more established group would have given those opportunities. And I think that it has allowed him to flourish and allowed the project to flourish. Through that, those collaborations, we were able to come back with a document that has affected real change. So we were able to show quantitatively what the problems were in the country, to the point where there are some regions and jurisdictions with quadruple the mortality of others, or double the length of stay. But I also, because I was a surgeon, was able to identify that if all we did was beat on outcomes, that the best way to have good outcomes is not operate on anybody who’s high-risk. And I think that we all know that surgery for many of these diseases is the only way you’re ever going to be cured. And so that if you rob people of their chance at cure by perseverating on only mortality and length of stay in those outcomes, you’ve missed your chance to help people. And I think that’s why, when I came out with that report, I really tried to balance that access to care with the outcomes. And I came forward with a number of different key findings, but I also came forward with a number of different recommendations which were to benchmark, to set standards, to be respectful of geography. What works in downtown Toronto does not work in Newfoundland. And my job at CPAC has really been, I wrote that report, and then they hired me to really implement the recommendations. And that’s what I’ve been doing for the last five years is really looking at standard setting, benchmarking, and trying to understand how things are different in rural Nova Scotia versus, you know, Quebec. I think that, that job at CPAC has really been a lot of relationship building. That, in the Canadian system, we don’t have authority at the federal level to change things, that everything is done at a provincial level in terms of making stuff happen. And so, when you want to affect change, you can’t tell anybody to do anything. That you have to learn to work with everybody and help them to accomplish their goals. To understand where they might be lagging, where we can provide them some structure, some support. I think a lot of times, Ontario does some wonderful things. But in reality, there’s places like Manitoba which has the best breast cancer program I can find. Their re-excision rates are low, they’ve got the highest immediate reconstruction rate. So, that’s something that’s scalable and transferable to a lot of provinces that might find digesting an Ontario approach impossible. And so that, using BC, or Alberta, or Manitoba, or whatever is good in one place, and creating these networks where you can disseminate those best practices has been what I’ve been trying to do. And when you only got soft power, you learn how to work with people really well. Part of it is, I think, trying to understand where you can get data. Because data, I think, in this day and age is what we all need, and trying to get in a contemporary manner has been the tension, right? It’s always trying to find information for people that can help them do a better job, but if you show up with something that’s five years out of date, the first thing you get is, “well, everything’s changed, we’re much better now.” But it’s been my experience, you then get that data that’s updated and you realize that things haven’t changed. But you keep going through the circle with people if you don’t have contemporary data. So, those tensions of being contemporary, topical, and practical, using what you can get your hands on, have been themes I’ve been using and trying to cross-pollinate between sides.

Ameer Farooq  22:35

So to take this step back Dr. Finley, for our listeners who don’t know the work that CPAC has done as well. Can you tell us a little bit about what was involved in really answering this monumental question, and really doing this monumental task that you were working on? So if you can tell us a little bit about what was in that initial report and what you found about cancer surgery in Canada?

Christian Finley  23:03

I should answer your first question. Which was, CPAC is a federally funded organization that’s mandate is to reduce the number of people getting cancer. For those that do get cancer, try to make sure that the mortality is going down. And for those that have had cancer, improving their lives. I think that what we found is variation. I think that it’s not surprising to everyone that there’s a lot of differences. Despite the fact that we’re in Canada and we have, what you would expect to be, the most homogeneous of systems. That we have very good comprehensive training that’s pretty similar, that we have relatively similar resources, especially as it comes to cancer surgery. But in fact, the number of people who get access to even the decision to have a cancer surgery varies dramatically. And that the flow of patients is very complex but the end result is that, if surgeons aren’t involved early on in the decision for operability and resectability, that you get a whole group of people that don’t even get a chance to be cured. So to give a specific example, when I came to Hamilton, there was a group nearby that was part of the regionalization that didn’t fully understand the implications of what a PET scan did. And so, would not do biopsies to confirm PET positive nodal disease, which for those non-thoracic surgeons, really means there’s a false positive rates to PET scans and those people weren’t getting optimally evaluated. So that you lose 25% of people that actually were curable. But you see that everywhere. That when CPAC did work looking at single fraction radiation, for palliation. So if someone’s got a painful bony met, you don’t need to bring them 10 times to the hospital and radiate it, you just give them one blast of radiation that’s equally effective. But when they started looking at it, there was a couple of provinces where it’s actually that piece of contemporary information had not made it into clinical practice. And so the fact that we looked at it changed things. Or day surgery for breast surgery. The chance of getting a day surgery for a mastectomy varies from 0% in one province, to 35% in another province. There are many factors like that in terms of access to care, or mortality, that we found varied across the country. And I have worked in a lot of places that are not the ivory tower, and I love them. I have the utmost respect. So when it came time to interpret these results, I went to each province before I publicly released them, to work with them. Because I think none of us like to be sideswiped, nobody likes to have their data thrown in their face, and particularly if you’ve not had the ability to vet it. So before I released any of this information publicly, I went and talked with every provincial leadership. In fact, even when I was going through the process, one of the avenues that I didn’t speak to earlier was, I had a structured questionnaire and would try to find out who was in charge of cancer surgery in the province. Really, the questions I had for them were, can you get data about what’s happening in your province? And can you use that data to affect change? It’s really the most simple of an audit and feedback loop. And in most of the time, I’d say, “are you in charge of cancer surgery in your province?” And in about 25%, I’d get an answer, “I think so.” Which is never what you want to hear from somebody. And almost nobody had the ability to get data and act on it. And so one of the fundamental recommendations was that every province has to have somebody in charge that has a budget to get data, and then able to affect change. Because cancer surgery often sits out of the silo of the cancer agencies. That, we have a system where cancer, in our historic context, was medical and radiation oncology that sits in a standalone building away. And that some surgeons had cross-appointments or had some experience there. But largely, there was significant barriers to MDTs, or to working with them, that we were trying to overcome. So again, one of the recommendations in the report was that you have to have someone in charge and they have to be able to do something, even in the most basic sense. And we’ve really, I think, seen significant changes in the last five years in that, I can think that almost every province now has a person in charge who can get data and then acting upon it. So I think that, at the most fundamental, that’s what I’m most proud of in terms of the body of work is that is I think that we’re moving forward and that surgeons are being integrated into the cancer agencies better, and that we’re able to get data and work with it. Because we are always going to have some variation, but we need to try to minimize it. And that was what led to the work in standards is that, I think we all know that the volume-outcome relationship is really about everything except the volume. That it is having good people who work together with nurses who know what they’re doing and have the right equipment. And I always liked that Amir Ghaffari paper in the New England Journal, that the complication rate between a high-mortality and a low-mortality hospital is exactly the same. It’s really how you rescue someone once they’ve had a problem. And I think that’s what everything else is about.

Chad Ball  28:57

There’s no doubt Christian, it’s incredible how much work and how much traction, and how much structure you’ve created in less than five years. It’s quite awe inspiring, quite honestly. And it’s something that will, I hope, change the country in cancer care forever. It’s interesting that you bring up not only failure to rescue, but sort of dance around a little bit, I mean that in the nicest way, the different methodologies that various provinces have implemented in terms of trying to unify quality of care and implementation of care and outcomes of care. So, if you look just as an example, of course, you look at Cancer Care Ontario, and as you alluded to earlier, creating strict volume threshold, case volume thresholds. You’re in or you’re out, you’re going or you’re done. Versus say, Alberta and the rectal cancer world, which was more of an educational sort of endeavor as opposed to a tough love endeavor. How do you view those different processes at the government level? How do you view it in terms of the interpretation and the abilities of CPAC?

Christian Finley  30:07

Guys, it’s such a multi layered question, isn’t it? Because I vacillate back and forth. Because ideally what you would have is a situation where somebody looked at the province and made sure that people didn’t have to drive too far to get good care. And that’s actually one of the things we did in our report, was map one and three hour driving radiuses from cancer surgical centers, and tried to plot that out. But ideally, you would measure how Christian Finley as a surgeon did and be able to, in real time, evaluate my results in risk adjusted way, against my peers. And in thoracic surgery, we’ve actually largely done that. We have another body of work that I’ve done with Andrew Seely, who’s a surgeon in Ottawa, is look to start a national database in thoracic surgery where we capture all of the complications. All the minor and major complications. Everybody does it with strict definitions, and it’s what drives our M&Ms. And so our M&Ms are no longer, what can I remember my problems being two months ago? It’s driven by hard numbers saying, our atrial fibrillation rate is up. It is higher than it is in Ottawa. What practices can we bring in place to improve that? I think that’s the ideal model where I as an individual, and us as a center, and us as a country, for that matter, compare ourselves to peers and try to make sure that we do it in a positive deviant method. And so that’s, again, what Andrew Seeley has really advocated for, and I think is a good Canadian way of doing it is, it’s not about punishing those that are two standard deviations below. It is saying, you are two standard deviations below, here’s what the people who are two standard deviations above are doing, how can we do that? The other aspect of that is, I think, making sure that everybody has the basics of what they need to do a good job. And that was the standards. So I wanted, in my ideal world, and to some extent, we’ve been successful, we’ve benchmarked. Either at a administrative database where that’s necessary, or at a very micro level or nano level at the individual center. But I also think that we constructed these standards to make sure that everybody had what they need, they were constructed in the most positive of ways. And so we tried to make sure that we had good geographic and practice setting representations. So we had, for breast cancer, we brought Alex Poole from Whitehorse. We tried to make sure that we had people from downtown Toronto and Grand Prairie or, have good representation by geography practice setting, so that we had the right people at the table. And then we tried to say, what do you need to do a good job? What is a standard that needs to be there? And a lot of the time, we would break it down by who the people are, where they’re working, and then what quality processes need to be wrapped around them. Because I agree with you, I don’t think setting a number of 150 is useful. I think that if you had 149, doesn’t make any different than 151. So we took the evidence of the literature to be that you needed to have standards, and have the things in place. So we actually had a librarian go, Laura Banfield, who really helped us go and get all the published and great literature and we educated our representative group of surgeons. And then we sat down and we constructed what the people had to have, what they had to have wrapped around them, and then on a go forward basis, what type of data they had to capture and the quality processes. Because I think all three of those elements are key. And I think we tried to pick the disease sites where we saw the most heterogeneity in the country or variability. And pick off thoracic surgery, gyne oncology, rectal cancer, and then we tried to pick off big disease sites like breast cancer. Because, as good as we are, and I sit on this international clinical benchmarking, where we compare ourselves internationally, Canada does very well at many things. But there are certainly some things that we lag on and knowing how you lag is important internationally, nationally and locally. And I do think that those standards are fundamental to your original question. I think it’s a combination of the Ontario and Alberta and BC for that matter models is that, we need to capture data and act upon it, in particular if it’s if it’s struggling. But that a positive framework where you’re trying to pull people up and mentor them and keep things managed locally that can be managed locally is key. But that you do need to be watching in some capacity. And you can do that in a responsible manner by having communities of practice where everybody has the opportunity to comment on what they think needs to be captured, and then get their data in a protective and safe environment. And you saw that with urologists and margin positivity in T2 prostate cancers. And so for all, memorize the pathologic staging of prostate cancer, if the cancer is in the prostate and you’re removing the prostate, you shouldn’t have a positive margin. But they had the positive margin like 40% of the time. In talking to some neurologists, it should be more like 10% of the time. That there’s some aspects of how the pathologist cut it, and some of the nerve sparing nature of it, that you’re gonna have some positive but they identified the problem, they got the data, they acted on it, and they dropped their numbers dramatically. So I think that you can have a combination of many of the methods, and that you have to use your local circumstance that, when I talked to Newfoundland about the standards we developed for thoracic surgery, they sat back and said, we got eight cases of esophageal cancer, if we sent them all to Nova Scotia, there are lots of times in the wintertime that we cannot get people out. And what are we gonna do with the perforated esophagus if we don’t have any esophageal skills? And so I think there’s some practicalness to it, that we’re able to get into the document that really as reflected in pragmatism, but I think that all of us have different methods. Ontario has a very micro method. But I think that they’re all good. We just need to have someone in charge.

Ameer Farooq  36:57

Dr. Finley, one of the things I think that you tried to really drill down on in your guidelines was the whole question around surgeon performance. Because I think one of the things that’s hard to quantify, and yet we all know intuitively is so important, is that quality surgical training and quality surgery is really what underlies a lot of what we want in terms of good outcomes. I mean, we all talk about hospital volume, and that we need a good team but fundamentally, underlying all of this is the performance of the surgeon. For example, you talk about in the guidelines, that someone doing rectal cancer surgery should have specialized training in it, or that they should have sufficient volumes of it. What are your thoughts about that? Does this mean that everybody should have done a colorectal fellowship? Or a surgical oncology fellowship to be able to do rectal cancer? Or, like you say, there are practical considerations in a country like ours that’s so geographically spread, that maybe that’s not realistic. And then the second part of that question is, should there be some way of monitoring our performance as surgeons? So, should we be having coaches in the operating room or intermittent video assessment of our cancer surgery? What are your thoughts on that?

Christian Finley  38:35

You ask these very tough questions. So hopefully, you edit me and make me sound brilliant. But the training one’s an interesting one, right? So that is the most contentious issue when you bring it to a group of people. And I think that there are things like when we had that conversation at the breast table, the feeling very much was that everything needs to be done that can be done close to home. That breast surgery, largely can be done close to home, but there are aspects of it, that if you don’t do a lot of it, that you cannot be aware of. And I think sometimes in surgery or in medicine, in general, the most dangerous things are the things you don’t even know you don’t know. I always think that about junior residents on-call, they don’t even know that they’re walking into a dangerous situation, because they’re not even aware of it. And I think that as surgeons, we can walk into danger not knowing it and there are ways to get around that. Certainly when you come out of your training, you are the closest to contemporary training you’re going to be and that we all have maintenance of certification. And if you try to stay on top of everything in the world, it’s not possible. You know, my wife is an emerge doc and trying to stay on top of what’s new in stroke, heart attack, appendicitis and everything else in between is an almost herculean task. And in surgery, and particular in general surgery, I think that we’ve crossed the Rubicon, as it were, that things are getting really complicated and even in things that we used to think of as not that complicated. And so there’s a balance of getting enough training, so being ultra specialized in something, and doing enough of it to stay contemporary. And I think as you commit to something, that you don’t necessarily have to have three fellowships in it to be good at it. I think that we can all think of rectal surgeons we worked with, who were really, really good. And they came from an era when there wasn’t fellowships, and they just did a lot of it. Nowadays, I think that we do have to do fellowships, just because the world is not as forgiving on that learning curve. And so I think that if you want to do a specialized thing, like Whipples or lower third rectal cancers, or transanal excisions, you should really have training and be staying up to date. And I think that that is trying to quantify how much time a year you have to spend being committed to something to be competent at it is difficult to know. But I do think that the reason that we structured our standards that way is that I do think that there are levels of training or commitment to the proportion of your practice or case volume that is necessary to be good at a job. But I also think that you need to, on a go forward basis, know how you’re doing and compare it to something. There is always an international collaborative or benchmarking undertaking in every disease site. And relying on things like NSQIP, which looks at wound infection rates, really doesn’t tell you about your margin positivity for low rectal cancer excisions or margin positivity of a Whipple. And so you need to do disease site specific monitoring, to know if you’re on the fairway. And you certainly see that, and I saw that in my data, is that when you work in a really niche area, and you live in an a small province, you don’t even know if you’re two standard deviations below until someone shows up and tells you. That was the case when I showed up with the data from my report and it’s like, you guys are two standard deviations off of the mark. And they would have no idea because no one was keeping track of it. So I do think that there is a component of training, and a component of ongoing maintenance of certification, slash, knowing how you’re doing that is important. So I think that there needs to be an assessment and there needs to be a level of training. How authoritative you have to be, and oh you have to do three extra years of this, I think that the Royal College is quite good at things like gyne-oncology defining what it means to be a gyne-oncologist. But it don’t necessarily think that you have to do the Canadian training. And in many cases, I think that there’s very good training around the world. So we tried, into our standards put into a methodology that people’s training should be comparable, and go through the Royal College assessment as necessary. But I think that in all disease sites, you just have to sit there and look at what you’re doing and make sure, it was exciting to do all disease sites in all areas. I remember doing that in Prince George. You do an esophagectomy, then a transanal excision, and then you do a thyroid, and it was awesome. But I think that those days are waning. There certainly are areas where people are still able to do that. But I think as it goes forward, it’s increasingly less the case.

Chad Ball  44:02

It’s interesting, Christian, that you touched on NSQIP in particular. Henry Pitt and some others within the HPV world have developed HPV specific NSQIP. For a lot of those more nuanced HPV relevant outcomes and markers, quality indicators that we would be interested in. Outside of potentially bringing in a very public, a very expensive QI platform like NSQIP, how else can the community general surgeon or even us at the Foothills Hospital or you at Mac, how do we accumulate that data? How do we access it if we want to act on it as a collective outside of CPAC?

Christian Finley  44:48

Yeah, you’re right. All the administrative databases or even NSQIP in general, not the disease site specific NSQIP variables are useful information. but I would think that at its most basic, we need to have healthy M&M rounds and have partners. And if you don’t have partners who do what you do, you need to make a partnership with someone somewhere else that does what you do. Because we all need to phone a friend now and again, and that we all can do better. We had an M&M two years ago, maybe, where we were looking at our lymph nodes, we looked at data that’s at hand. So the pathologists in Ontario at least, capture synoptic pathology. And you can go a long way on synoptic pathology, because you can look at how many lymph nodes take, your margin of positivity, which are really the two fundamental aspects of most surgeries. And so you can get, within your institution, under the protection of quality improvement, data that takes a little bit of work and you can get. But I think that you need to have a functional group of people that can talk, you need to get some data on a regular cycle, and compare it to something. There are cheap and easy ways of doing that, like looking at your wound infection rate. Those are usually captured by somebody in the hospital. Even on the discharge out check database, and usually your hospital can get that data for you. The pathology is, again, a low hanging fruit where you can find out what your nodes look like, find out what your margin positivity rates are. But I think at the baseline, we just need to have functional M&Ms. I’ve participated as a trainee in a lot of M&Ms that didn’t adhere to the spirit of it. Which is to be, not canceled every other one, to come in with actual data to talk about, and with an openness to discuss results. And I think that we, as surgeons, sometimes struggle with those aspects of it. But I do think that we need to come into that process with an air of humility, and trying to improve. One of the stories that I keep meaning to write down is, we’ve seen a reduction in mortality in cancer surgery in Canada of 35% in the last decade. Show me another disease site that’s reduced their mortality by 35%. We’ve done an amazing job. Largely, I think, driven by the fact it’s a team sport, we have better intensive care, we have better anesthesia, we have better minimally invasive techniques. And all these things have resulted in a massive improvement for our patients. And yet, no one’s crowing from the rooftops about that. So clearly, we’re doing a lot of stuff right. But I do think that we need to keep those fundamental processes intact. And I think that the busier you get clinically, the harder it is to do. But by laying those out in advance, I think you can still protect them. I think this coronavirus has been devastating to a lot of surgeons. But what it has done is allow a little bit of free time to sometimes go and look at things you weren’t looking at before. And one of them may be how we deal with referrals and dealing with domestic group, or how we evaluate ourselves that are things that we can spend some of this time doing that are productive.

Ameer Farooq  48:20

Dr. Finley, it’s really been a pleasure to talk with you today. And I think it’s been a really important conversation and some really challenging but important topics. One of the questions we’ve been asking all of our guests is, if you were to go back and give yourself some advice as a trainee, maybe during dental surgery residency or even during your fellowship, what would that advice have been?

Christian Finley  48:46

I think number one is to stop eating out of the vending machines. Number two, I think you need to find good trainers, to ask around and really do your due diligence to find out a place you want to train. And then I would go all in. I think that by committing yourself to the undertaking of surgery with your heart, you can come out of it with a wonderful career. I love my job. And I think part of that is because I really took all the opportunities that came my way and may have created a few for myself, but most of it was just working hard and enjoying it. I think that that’s what makes it a great job. When you ask surgeons about their quality of life, even into later years of practice, they love it. When I think of myself in my CPAC job, I still am a surgeon four days a week and I’ve looked at other opportunities. I sit back and I go, I love being a surgeon, it’s the best job ever. So I think by being a surgeon and getting that good training and savoring the experience of it, is wonderful. I’m a third generation thoracic surgeon. When I read my grandfather’s operative report from 1945, I can sense his joy, his terror in doing that first pneumonectomy. You can read through his operative report and try to think back to doing a pneumonectomy when no one knew how to do pneumonectomy. To do an MIS chole when no one has done an MIS chole, or you haven’t done one before. It’s a great job with lots of challenges and rewards and sorrow, but my recommendation would be, enjoy it. Because it is fleeting. You think back, even talking with you guys today, how fast that all went down. I feel like I just started the other day, but it’s been a few years.

Chad Ball  51:05

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.