E45 Undergraduate Surgical Education With Andreana Butter And Geoffrey Blair

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Chad Ball  00:12

Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad Ball. We’ve had the absolute privilege of chatting with some amazing Canadian as well as international guests over the past year. While the topics have been brought in range, whether clinical, social or political, our aims for the podcast continue to remain the same. We hope to inspire discussion, creativity, scholarly research and career development in all Canadian surgeons. We hope you enjoy our second season as we continue to highlight some incredible guests, deliver detailed masterclass sessions on a myriad of clinical topics and introduce some fresh new features such as debate and companion formats. We hope you relish the podcast as much as we do.

Ameer Farooq  00:55

In this episode, we have the pleasure of speaking with Dr. Andreana Bütter and Dr. Jeff Blair, both pediatric surgeons, and both very involved with the Canadian Undergraduate Surgical Education Committee, or CUSEC. We talk about a wide range of issues surrounding undergraduate surgical education, as well as their efforts through CUSEC to promote surgical education across Canada, and their upcoming conference called C-CASE. Links are in the show notes below.

Chad Ball  01:46

Well, welcome to Cold Steel. You know, we can’t thank you guys enough. We always think our guests we know how busy surgeons are in general and you two have your hands in I think many many pots and certainly we appreciate your time and your ability to do this. We’re really, really excited about the conversation. I was wondering if each each of you and maybe we can start with Andreana and then move on to Jeff and ask you about where you grew up and what your training pathway was like to lead you to here and now.

Andreana Bütter  02:18

Sure. So I was born in Ottawa, then grew up in Aylmer, Quebec across the river. So lots of bilingualism right from the beginning. And I was the first one to go into medicine in my family, I decided as a teenager, I really enjoyed working with children and figured I would become a pediatrician as I think a lot of pediatric surgeons start out. And then I got into medical school at the University of Ottawa and decided quite late that I enjoyed surgery, I did surgery first to get out of the way, figured I’m never going to be a surgeon and got through clerkship and realized actually, that was the most fun rotation of all of them. And in particular, any kind of pediatric surgical specialty I quite enjoyed. And I had a mentor who was Dr. Mary Jean Duncan, who is a pediatric plastic surgeon and I any chance I had I would sort of sneak out a class and go hang out with her and, and so yeah, so I decided, you know, surgery was for me and a bit of a circuitous route finally sort of got to Western and general surgery and, and then got into fellowship at Sainte Justine in Montreal and became a pediatric surgeon and came back to Western on staff. So that’s sort of my path here. Yeah.

Geoffrey Blair  03:43

I grew up in southern Ontario in a city called Guelph. And I was intrigued by the concept of being a surgeon that sort of went into limbo during high school years as I, I grew enamored of mathematics and physics. And then at the very end of high school, like, like a flash of realization, I realized I wanted to be a doctor. My parents were not doctors, my grandfather had been one but he died before I was born. So I, I set my course to get into medicine. I could see myself as a surgeon, because I I thought that was where I could maybe have best effect. And then I started I got into medicine. I was fortunate in that regard. And I started to volunteer at Toronto Western hospital emergency ward, as a as a very young medical student. At a busy section of Toronto, they were overwhelmed and very quickly, I was given the responsibility of sewing up scalp wounds and things when I was a first-year medical student, and they would just let me sew these wounds. You know, you can’t go wrong too much with a with a scalpel wound, the scars are going to show and it heals no matter what you do, but I got a taste of surgery very, very early and fell in love with it. Paradoxically, however, upon graduating I went it family practice because I was actually truly interested in everything. But then during my second year of family practice, again, based in Toronto, I was in Northern Ontario, and working with the surgeon in a town called Dryden, there, and I had the opportunity once again to wield the knife, and I pinned a hip, I took out an appendix, I did hernia repairs, sewed up chainsaw injuries and so forth. And I felt absolutely head over heels in love with surgery. Applied and I got in in Toronto. And after a while realize that pediatric surgery like Andreana, I guess you realize it had everything. It was head, neck, chest, belly, colorectal tumor, trauma, it had the works, and the joy of working with children. So pediatric surgery was, was my goal and I was allowed in, I was the only Canadian actually that year that I applied. So they I maintain they had to accept me. I trained in Toronto, and then subsequently moved over to Vancouver. And it had a wonderful time practicing pediatric surgery that I just retired actually, from that clinical practice. But I carry on in medical education realm.

Ameer Farooq  06:38

Congratulations to both of you. And I always love hearing the stories of how people get into surgery. Because, you know, it ranges from your experience where you kind of didn’t think surgery was an option or you know, really didn’t have it highly ranked to Dr. Blair who kind of always knew that he wanted to surgery and then you know, both of your have fantastic careers and, and are enjoying doing surgery. So it’s it and we’ve heard the story many times from, from our other guests. So it always is enjoyable to hear how people find their way to surgery. Could you know both of you are involved with the Canadian Undergraduate Surgical Education Committee, or CUSEC. Can you tell us about CUSEC and how it got started and sort of what the purpose of CUSEC is?

Andreana Bütter  07:26

Well, I think Jeff should comment first about how it got started because he has the he’s been with it longer than I have. So I’ll let him start that conversation.

Geoffrey Blair  07:37

Well startled morning, so I’ll try I wasn’t that well was a medical student back then, or probably a resident but more than 30 years ago, I think that the exact number would be 33-34 years ago, it was started as a committee. It still exists officially as a as a committee, the Canadian Association of Surgical Chairs. The surgical chairs of Canada realized that they needed to have a committee to help with the concepts of curriculum and teaching surgical undergraduates. In order to make sure that our undergraduate medical students would be attracted to surgery, and the appropriate things were taught for any graduate, whether they go into surgery or not. So the committee the Canadian Undergraduate Surgical Education Committee was started by a cadre a very dedicated individuals back in the day. And they looked at such things as what should be taught in the curriculum and so forth. And they, they agreed to meet every two years. And it was actually not until 2009 or 10, 2010, actually, that I got involved. And I didn’t know what it was. But it I got to go to the 2010 meeting of CUSEC. That wasn’t run like any committee meeting that I’d ever been to it was really a symposium. And as I said, it still had that cadre of committed individuals who, who sponsored papers and discussions, both free and formal discussions were had, again, talking about how best to teach the concepts of surgery to our Canadian medical students. And it just has grown from there. Andreana you got involved, not too long after that, in 2000 and teens. And both of us, Andreana currently and me in the past, have been touched upon to be the chair of the committee. And we’re beholding beholden to the Canadian Association of Surgical Chairs who continue to be to show their commitment to undergraduate surgical education by not only sponsoring us financially but sponsoring us philosophically and spiritually as well. So it thrives CUSEC is alive and well and doing. Andreana do you want to comment?

Andreana Bütter  10:12

Yeah I became involved a few years ago when I became the director of undergraduate surgical education here at Western. And so my first meeting, I think, was in Ottawa a few years ago. And I really enjoyed in, in a lot of ways, it’s a bit similar to pediatric surgery in that there’s a lot of collegiality, it’s, it’s a smaller group of people, you know, very like minded. You know, everybody wants sort of, how can we be the best teachers we can be and tips and tricks and things like that very practical. And, and I really quite enjoyed that, rather than some of the big surgical meetings where you know, 1000s of people and you’re kind of feel, you’re just this little person with these 1000s of people around in dark suits. So I really quite enjoyed, enjoy that. And so I sort of kept returning. And, and there’s also a few pediatric surgeons have been involved with CUSEC over the years. I’m not quite sure why that is, but I guess maybe we particularly enjoy teaching or we, we grab, you know, people who are similar to us, so we grab our other pediatric surgery colleagues, into the organization. So, so Jeff, kind of, you know, grabbed me and, and, and eventually, yeah, yeah, that doesn’t sound right or the grab, but like, spoke to me about it and, and got me more involved. And I’m very happy to be here and be part of it.

Chad Ball  11:47

Those are those are great stories, and really interesting, you know, one of the podcasts we had a few months ago was a great interview with Richard Reznick about surgical education, and some of the performance metrics and exams and the history behind them over time. And, and, you know, in, in certainly listening to you guys now, and previously, I sort of had a three part question, maybe for either or both of you. And that’s really, you know, surgical education at the medical student level is clearly different than the resident level. And it was interesting to, you know, hear Dr. Reznick, you know, I don’t know, sort of progression from fellows to then focus on residence, and then as the dean, medical students, so I’m curious, one of the challenges at the trainee level to make this transition smoothly, as well as the educators themselves. I’m also curious, how has it changed over time, both in form and function?

Andreana Bütter  12:45

Well, I’ll start, I’ll say, the, the challenges, I think, you know, at the post grad level, you have already differentiated individuals, physicians who, you know, have, they’re more focused in their specialty. So I think you, you have maybe even more like minded people, as opposed to medical students who are still undifferentiated. And, you know, in most of them will not go into a surgical discipline, however, most of them will probably at some point have to deal with a patient who, you know, who becomes a who needs an operation or he needs to be referred to a surgeon. So it’s trying to make the content relevant for them, as surgeons know, what, what do they really need to know. But with that very broad lens and not being sure which way they are going to go. So I think that’s definitely been a challenge for us for undergraduate surgical education. And so I don’t know if Jeff wants to add it.

Geoffrey Blair  13:53

I think we’re just realizing every day I realize that the challenges that occurred to me the other day, that wasn’t that long ago, when I went hiking and I’m still an avid hiker, I would take a compass and a topographical map. And now I take a GPS. It’s, it’s similar in medicine. It doesn’t seem to me or although I’m an old man in this business, it just seemed to be that long ago, that we didn’t have CT scans and ultrasonography was in its in its infancy, and other high tech techniques, laparoscopic surgery was just like not even considered. back then. And yet, look at us now look at where the technology has taken us. So medicine and healthcare delivery has changed remarkably. And we have to make sure the challenges we have to make sure that our surgical education is keeping up. There’s a danger of seeing it dehumanized. There’s a danger of creating the impression in medical schools that that the ultrasound machine or a CT scanner has all the answers. And that things like physical examination, touching the patient is not necessary, compounded by the current COVID era, my gosh, when everything, including this episode right now is, is over Zoom, you know, the concept of actually relating in our personal physical way to a patient seems to be on the wane. And yet, in surgery, of course, that’s, that’s the end point is we have to be physically in contact with the patient to operate to rearrange what God put there, as you said Ameer. That’s a challenge. And we, I think we’re a little bit behind now in realizing the need to employ cognitive science. In our methodology, we’re stuck still stuck with the concepts that maybe we can inculcate surgical knowledge of surgical concepts by means of lectures. And I think we’re beginning to realize that no, we just can’t do that. But how to do it. What is the best way to teach in the operating room? What’s the best way to teach using simulation? Does it have to be high resolution simulation or low resolution simulation? These huge challenges are daunting. And it’s a bit scary, actually. And we don’t really know the answers to these things. But we have to keep looking at it. And that’s one of the things that and I’m sure Andreana is the same for you that things keep changing. And there’s a huge vista of challenges ahead of us that for the most part, surgical educators being mostly interested in postgraduate education, aren’t thinking about, but we’ve got these neophytes, these newbies that aren’t that much more knowledgeable than the general public coming into our medical schools. And we have to start thinking surgically at some point. And that’s a huge challenge.

Ameer Farooq  17:30

You’ve touched on so many different challenges that I think are facing undergraduate surgical education in 2020. And, and hopefully we can get back to some of them. But I wanted to just zoom in on one of the things that you picked up on, which was sort of the increasing specialization and the complexity of the surgeries that we do and how do you think about educating medical students who come up on the on the surgery rotation? Who, you know, some of which most of which won’t go into into surgery at all? Like, what is the point of medical students coming on their surgical rotations anymore? I mean, you know, in, in an era where every bit of the curriculum is kind of sort of vying for more time, you know, even at the family medicine level in Calgary, they actually have gotten rid of a general surgery rotation for family medicine residents so that they no longer rotate on general surgery. And you know, we’re all biased in that we think that that’s probably a loss and probably something that people still need, but like, what is the value anymore for let’s say, the person who is not going to go into general surgery of doing in a surgical rotation? And what do you sort of see as being the important things to get out of their rotation?

Andreana Bütter  18:48

Um, so I think that, you know, of course, I’m biased, but I think there’s a huge value to medical students doing a surgery rotation. I think surgery is really one of the few areas in medicine where most of our specialties are really team based. And for a lot of medical students, they will comment afterwards how much they enjoyed surgery, even though they don’t want to go into a surgical specialty. But they really enjoyed that team approach, feeling like they’re part of something and they’re not just you know, going to a random clinic here and random clinic there and, and be feeling like they’re really sort of taken under the wing of their senior resident or junior resident, they’re attending and working with residents who are much closer in age to them and who, who just been through it and really can be mentors for them. So I think there’s huge value. There’s also value in I think surgeons in particular, I know you know, most physicians, although we never get any formal training to be teachers, medicine in general lends itself to teaching just the nature of it. You know, the old adage see one, do one, teach one. And surgeons I think are really good at that because it is technical, very it is procedure based. So the medical students really thrive with that if they’re in the right environment. And even if they will never become surgeons, they need to recognize for most of them, they will need to recognize when is this a surgical patient? Why is this a surgical patient? What is a surgical abdomen look like? And and recognize that, you know, this is this is important. And I need to, you know, speak to a surgeon and get this patient looked after. And then pediatric surgery in particular we talk about, you know, like APSA’s motto, our American colleagues is, you know, we’re not just saving lives, we’re saving lifetimes. And for students to recognize when a baby with bilious vomiting, you know, that is a surgical emergency. And that’s not the kind of thing you should just go back to bed and just forget about it like that is, you know, get your surgeon on the phone. And so, to me, I think it’s very, very important. I think the the students really get out a lot out of their surgery rotation, even if they won’t go into it. Jeff, what do you think?

Geoffrey Blair  21:05

Yeah, I yes, ditto to all that that’s very important. There are a couple of things that surgeons are particularly good at, however. And these two things that they’re good at, are things that are rife throughout medicine, whether it’s surgical issues or not. One of them is dealing with uncertainty. There’s uncertainty all the time. Now, medical students are actually an interesting breed for the most part, they emerge from an undergraduate degree or undergraduate course in, in sciences, they come forward from what I call the temples of accuracy. I think all of us remember in the chemistry lab that those scales that were so sensitive, that you had to close the doors on them in case a passing whiff of air would throw off the reading. Remember the mathematics classes where the answer was the answer? And being close to the answer wasn’t good enough. The math professor didn’t give you marks if the answer was 352. And you got 351. You got it wrong. Okay. So they emerged from that and they go into medical school, but nobody ever tells them that they’re going to be dealing with uncertainty. And I think that really shakes up a lot of students. Or even worse, there are students that don’t realize that they’re not dealing with certainty. They talk about confirmatory tests, there is, there’s hardly anything like that a confirmatory test. They think the CT scan or ultrasound or other techniques, lab tests will confirm the diagnosis. And then they’re somewhat flabbergasted when they find out that no, the test was wrong or it may be only a certain degree of accuracy. So surgeons are very good at dealing with uncertainty, they face it every day. And other things they are good at, by their very nature is they’re good at acting. I teach the students there are three things a doctor has to do in order they have to care, truly care, truly give a damn about the patient. They have to think and then they have to act. Okay. Care, think, act. And that last thing surgeons are pros at. We’re action Jacksons, we actually do things. Now I’m not saying that our nonsurgical colleagues don’t. But come on. In that’s in a talk I gave a number of years ago that you were at Ameer, it’s been shown that from a personal personality characteristic and treat point of view that surgeons tend to be action oriented individuals. And we can teach that. Furthermore, we can combine the two we can teach how to act for the patient’s benefit in the face of uncertainty. There isn’t a surgeon alive, who hasn’t done a laparotomy not really knowing exactly what they’re going to find inside that belly. But knowing by God, they’ve got to cut that belly open to find out. These are dra are drama-filled decisions and thought processes and actions that students have to learn about. And surgeons are particularly adept and able to teach the concepts underpinning how to deal with uncertainty and how to act in the face of uncertainty.

Ameer Farooq  24:42

I am reinspired by hearing your description of surgery and you know, we’re all nodding our heads as you as you made that description of surgery and I think that’s such a beautiful explanation from both of you of why surgery is so important at an undergrad undergraduate level, but I want to push back a little bit. I mean, you know, I think many medical students do enjoy their surgery rotations, but a lot of them don’t. And it can be for a variety of reasons. One of which I think is just the intensity of surgical rotations. Like you said, we start early, and we go late. And, you know, one of the things that shifted a lot, and there’s been a lot of talk about this on Twitter, in particular, and other social media platforms, is actually kind of getting rid of call 24 hour calls for medical students. And that, in fact, has actually happened in Calgary for our medical students, because of the shortness of their rotations, they will only go on till 11. You know, and, you know, I have mixed feelings about that. I mean, I think I’ve done a lot of a lot of cases between midnight and 6 am in residency, and I’m sure you both have done way more than me, how do we make that experience better for those medical students who find the rotation quite intense and demanding, and they know that they’re not going to ever do this in their career? How do you sort of walk that line?

Andreana Bütter  26:13

Yeah, so I think the the call issue and other things, we’ve had this at Western too. We switch to electronic medical record, and then the medical students couldn’t put orders in anymore. You know, over the years, and particularly, I’ve noticed in the last five to 10 years, there’s been a very gradual erosion of experiences for the medical students. And we’ve, we keep progressively and I say we, you know, everybody, keep taking away things from them. And, you know, there’s medical legal concerns, and, and all this kind of stuff, but I think and, you know, trying to, like we do with our kids, you know, sometimes you’re trying to protect them. But unfortunately, and we see this with the younger generation, where if we protect them so much, we could result we’ve seen like more anxiety and more mental health issues than we’ve ever seen before, because the thing is we can’t snowplow everything away from them any difficulty, because unfortunately, that is not life. I mean, life is full of challenges. And those challenges, you know, often can end up being opportunity. So I think we for like to address like the call issue, you know, we the night before their half day, because it’s later in the afternoon, they only take call till 11 here at Western, but the other nights, it’s the full 24 hours. And you know, the students are a bit nervous about starting surgery, they’ve heard all the rumors, you know, we try to tell them put the rumors aside about mean surgeons yelling at you and throwing things. And, you know, I would hope in this day and age that we’re beyond that now, um, but they come out of it, and it is intense. But they come out of it saying like, wow, that was like I’m tired. And it was really intense. But I learned so much. And it was such a gratifying experience. And so I think we really need to not keep diluting things for them. I think this is life. This is just as if they were on any other rotation. This is actually what we as surgeons, what happens for general surgery and pediatric surgery, a lot of our stuff happens at night. I mean, patients don’t get sick between nine and five. We do a lot of stuff at night. And I think it’s really important for them to see that. And again, it’s being part of the team and and doing as much as possible. So I would argue we need to just like with our kids, not try to snowplow every difficulty away from them, and let them have that full experience. What do you think, Jeff? Yeah.

Geoffrey Blair  28:52

Yeah. No. I come from an era and maybe you do too, Andreana. Maybe even you are Ameer. A generation or generations whereby we thought that the trouble with doing call in surgery one and two was you miss 50% of the good cases, you know, there are those of us who go into this business because we’re really passionate about it. And we actually we want to spend a lot of time doing it. And, and that way, sometimes we gloss over the difficulties of being on call and being tired. But come on, I realized now that the experiences that I went through as a resident and even as a medical student, and even as a staff surgeon were ridiculous in terms of the fatigue I felt. So we have to get real and realize that being up all night is equivalent to being legally drunk. And you know, you’re really not capable of operating both cognitively and physically actually after being up all night and tired so, and that doesn’t, that doesn’t bode well for learning either. So we want to get sensible about that. But at the same time, as you say, Andreana, we don’t want to take away every experience, there is something dare I say it magical about operating at two o’clock in the morning. I don’t miss it. But, you know, there is something to be said for the on-call experience. And I regret the fact that some students, some learners won’t get that experience. So we have to find that balance. And whatever that balance is, I don’t know. But one of the things we can do that I think we feel that up until now is that the literature is filled with something that we know already, and that is that many students are intimidated, the first time they’re on a surgical service. The first time they’re on surgical services when they do their first surgical clerkship rotation. Now in most fourth year programs, that’s a third year rotation. And our school, actually, in the first two years has little surgical related teaching, and little teaching by surgeons, and certainly bang, they’re on, say, a vascular surgical service. And they’re oh you going to assist that femoral popliteal bypass. And students are afraid they’re intimidated by that. Now compound that if they have to stay up all night, and they’re maybe dealing with sick patients, and so forth. So we’re, we’ve got to take away from them that intimidating aspect and to do that, I think we have to, we have to start, as surgical teachers start making better inroads into those first foundational years of medical school, which in most fourth year programs is years one and two. So that when the student hits their first surgical rotation in clerkship, it isn’t an intimidating experience. It may be a tiring experience, but we can take away some of that intimidation aspect by preparing them conceptually. For what surgery is. Its lingo, its its paradigms, it’s the way surgeons mindsets are. So while we’re taking away some of the on call drudgery, we should give them some benefit of having a better conceptual framework for surgery.

Chad Ball  32:44

That’s a, that’s a very interesting way to frame it. And I, you know, I would ask both of you as master surgical educators a pretty simple question. And it’s reliant on the the viewpoint, you know, that there is some controversy of controversy about the intersection of fatigue and technical performance. And there’s also clearly tremendous human variability from person to person in terms of their ability to, to be functional and do well, you know, an hour whatever of being up, and I always worry a little bit about painting everybody with that same brush. And, you know, without getting into the nuances of it, I do wonder at the medical student level, and the resident level, to some extent too, you know, the importance of recognizing that variability. So what do you do if you are a medical student in Vancouver, Calgary, London, and you’re super motivated by your rotation, and you do want to pursue those experiences, but maybe the format of your particular, you know, immediate geography or your media program doesn’t necessarily structurally allow that. What would you recommend to those, those folks?

Andreana Bütter  34:01

We have the added challenge of COVID. You know, Western’s policy for medical students as if they get less than four hours of sleep, that they can be excused the next day, from duties. You know, and the resident of course, the residency is variable. It’s, it’s difficult if you’re a medical student, like I think back when I was a student, and I would try to go to any kind of surgical thing that I could on my off time. Unfortunately, that seems to be discouraged a bit at the medical school level. I’m not quite sure why there’s some concerns about medical legal coverage. And students being on one rotation but doing stuff on another rotation and kind of not doing what they’re supposed to be doing on the assigned rotation. So I can understand that. On the other hand, they feel like you know, if you’re really interested in something thing and you’re trying to explore that, especially with how competitive some of the specialties are, you know, I feel like there should be some leeway in the system. But I’m not. I’m not sure why it’s a bit more rigid, which I think is a little bit unfortunate. And again, a bit detrimental to the medical students. And now with COVID. I mean, they can’t go anywhere else in Ontario, they can’t go anywhere for electives, so that that’s made it more difficult for them.

Chad Ball  35:31

I mean, that that’s a great point in particular is the impact of, of COVID. And it’s been interesting. Again, I’m sure you guys certainly know infinitely more about it across the country in terms of national trends than I do. But it seems like the variability from school to school and from province to province is is significant. And I think we all worry very much about, you know, the current medical student clinical, rotational experience, you know, your University of Calgary again, we’ve had this outbreak at the foothills. So, again, last week, all the medical students were pulled out whether they wanted to or not. I do wonder going forward, you know, the reality is, I think in their careers, not only as as faculty, but probably as trainees, if they’re in long enough residences and fellowships, they’re going to have another pandemic, and it’s going to impact their educational environment again, so I worry about it. Jeff, do you have any comments or thoughts about the COVID reaction?

Geoffrey Blair  36:31

Yeah, what you’re saying actually brings up another topic, which is of interest to any surgical educator, and that is the transitions in one’s career. There is this big leap that students learners take when they graduate from medical school, and when they go into residency, and it’s this leap is a wall. And that wall has manifest in various ways, such as the wall between undergraduate surgical educators and postgraduate surgical educators. And we’ll get to that later on, I hope, when we mention the Canadian conference for the advancement of surgical education. But one of the things that we’re going to have to I think, see, in this COVID pandemic, is we’re going to have to come to the realization that students graduating might be deficient in some of their skill sets, whether it be history taking or physical examination, or whatever. And I think that the postgraduate programs, not only surgery, but all of them have to realize that there’s going to have to be foundationally in the PGY one and two years, perhaps more attention paid to those basic skill building. Things that here too, for the medical schools, ostensibly looked after, that is the basic stuff, history of physical examination, and just dealing with patients. I worry about that. Because I don’t think there’s enough conversation between the undergraduate educational realm and the postgraduate realm. And I think there has to be in especially in these COVID times, because as you say, you know, well, first of all, we don’t know when it is exactly going to be over and then it could hit again. So I’m worried about that. Andreana?

Andreana Bütter  38:44

Yeah, I totally agree. And, you know, we just recently at Western like now we were having a little more conversations between like, I’ve, I’ve started attending the post grad surgical education meetings, that are run by our one of our vascular surgeons and trying to have more connection with post grad. Because, again, I think we have built these silos, unfortunately, in surgical education. And it’s, it’s unfortunate because, you know, medical student becomes a resident, it’s, it should be sort of one continue on. So hopefully, and maybe COVID will force us to be better with that to be better communicators between those silos, and try to transition more seamlessly. We have for the clerkship issue, Western is just developing a course on that transition to clerkship at the end of their second year to try to get them into the hospital meeting surgeons at least by the their second year. So when they hit clerkship in third year, it’s a lot of that anxiety of all the unknowns will be taken away for all the rotations in the hospital. So different things like that. I think we’ll have to continue developing to assist the students.

Ameer Farooq  40:00

It’s an as we’ve been talking about, it’s an absolutely crazy time to be involved in, in surgical education at particularly at the undergraduate level. When I actually won an essay contest for CUSEC, at where I first met Dr. Blair in 2013. And I, the essay was about rapid communications technology, like basically talking about how I never read a textbook when I was in medical school, and I would just watch YouTube videos, which maybe I shouldn’t say in front of Dr. Ball, but anyways, the I wonder, like, how much of our, the education for our undergraduate students is really going to be conducted virtually. And I’m curious how you both have navigated that, you know, like I recently saw on Twitter that there were there are places in the US offering virtual vascular surgery or general surgery, electives, whatever that means. So I’m curious about how you both foresee that going forward. And in some ways, maybe that’s better. You know, like, I’ve always hated when I was in medical students being treated like a little kid that I couldn’t, you know, read, listen to things at home if I wanted to, if that’s what I chose to do. So what are your thoughts about how, how much virtual education is going to take over undergraduate surgical education?

Andreana Bütter  41:26

Well, I think when the when the pandemic started, Jeff and I were in communication. And you know, we’re and other surgeons as well across the country about, you know, what can we offer the students, while they’re sort of stuck at home. And, you know, the good thing is we sort of, you know, I had a little bit more free time, so I was able to kind of scour YouTube and various sources. And we actually, were able to put together a virtual surgical curriculum, which we now can give to the students on their surgery rotation. So if they have a few minutes, and they want to learn a little bit about malrotation and volvulus, they can watch a, you know, a video or listen to a podcast or read a chapter. So I think I think there’ll be a lot of good things have come out of this. In talking to some of the younger like the first- and second-year medical students where everything for them is online right now in virtual, and a lot of them actually like it because the format has changed to more of a flipped classroom. So they have to prepare, like the one second year student was telling me he had to do all his reading for the anatomy lab. And then when they were logged on, it was they were expected to have prepared. And then the, you know, the anatomist was showing them the different structures. And he said, wow, for it, compared to last year, he said, I’m getting so much more out of like lectures, because it’s much more active learning, and I have to prepare in advance. And I thought to myself, well, maybe you should have been preparing beforehand, as well. But anyway, um, so so I think there’s good things. I mean, as surgeons, we always, we don’t always like change. And we kind of get upset sometimes when there’s change, because we’re used to doing things a certain way. And it’s that works for us. And, but I think I think there’s gonna be some really good things coming out of this. Jeff, what do you think?

Geoffrey Blair  43:16

Oh, yeah, I think they’re, I think we’ve discovered things. One of the challenges that we all faced, because we still, to some degree, still do lectures, is engaging the students. I’d give a lecture and I would throw out a question and the students, bless their hearts would sit there. And I’d have to maybe embarrassingly point to one resident or one student in the front row, or in the back row, or whatever. And that always was awkward. Now with Zoom contact, I find that through the chat line, interestingly, there’s more engagement. So I’ll give a talk say, I was giving a talk the other day about the queued abdomen, try to make it as cased basis I can, and then asking the audience, which is all virtual, and I can’t see them, you know, well, what do you think? And suddenly the chat line is filled with answers about what they thought was going on, and suggestions about what could be done next. And, indeed, I have, I have to now invoke one of the students to help me moderate the session because it’s hard to keep track of what’s happening on the chat line, as well as my is when I’m giving the, the the slide presentation. So I think there’s some good things that are coming out of this. I’m still worried, though, that students, by their very nature are just looking for the answers. They’re just looking, okay, I just want to know what I can mark on the exam, as as to what the right answer is, for multiple choice, question number 17. And I just want to get through this and worried that somehow, either over Zoom or, or whatever, we’re not giving us sort of conceptual learning. So what I’m trying to emphasize to our surgical teachers, and in BC, we have a total of more than 500 surgical teachers throughout our province wide program is feedback, feedback, feedback. Thankfully, students in this COVID times are now able to get into the hospital and and have their clerkship experiences. Maybe not as much experience as in pre COVID times, but still they’re on the wards they’re in the clinics. And I think it’s probably the most important thing that learning experience they can have is to have a surgical teacher say, Well, what do you think about this? Okay, let’s talk about that thought process you went through? Why did you frame it this way? Why not frame it that way? Think about this, you know, next time the next patient, think about emphasizing this aspect of your examination as opposed to others? Why did you do it that way, that sort of interchange, still has to go on. And it’s that way, I think the students will learn how to be good doctors, good surgeons, you know, as a subset, but good doctors, because about 90% of our students or their abouts, don’t go into surgical fields. But we still have to teach them lots and lots of stuff. And most of that stuff is not memorizing Virchow’s triad, but the concept around that. The concept of what a DVT is and how dangerous it can be and what effects it can have locally and systemically with pulmonary embolus. That concept, as opposed to knowing that answer is C on the multiple choice question. It’s tough to get that stuff across over Zoom. But it shouldn’t be tough. In this sort of teacher-student interaction on the ward. Students, to a large extent are taught by residents these days. Ameer, I’m sure you’re a very good teacher. And Chad, I’m sure you are as well as, as a staff surgeon. But I think we have to place a lot of attention and gratitude on the residents. Because on a day to day, hour to hour basis, I think it’s the surgical residents who are really interfacing with our students far more than the surgical faculty. I don’t want to say to the surgical faculty that you don’t need to do that. Because I think that the teaching a surgical faculty member can give is worth its weight in gold. But residents have that sort of on the ward near peer advantage. And I don’t think we’re doing enough, at least not here, necessarily UBC, we’re doing enough to least support, train, facilitate and encourage our surgical residency teachers. I would venture to say it’s that way across Canada, as well, we can do more.

Chad Ball  48:25

You know, Jeff, I I couldn’t agree with you anymore. My observation and just the ballpark, I think that, you know, right, rightly or probably wrongly, I bet you 90% of the education directed at a medical student, at least in Calgary, and many of the places I’ve trained comes from the the resident physicians, and I don’t think we are exactly right, we do enough to recognize that and thank them for that. And, and as you say, support them for that. You’re absolutely right. One of the things I wanted to pick up on it, you know, it’s it’s funny how human nature sometimes is that we need a bit of a shock to the system to engage in maybe transformational changes too big of a term, but insignificant, you know, concept changing jumps forward and COVID at your right has provided us with an opportunity for many beneficial effects. You know, I would suggest that the reason maybe you have so much engagement in in the Zoom lectures that you give is number one, it’s because of you like you’re such an engaging lecturer. I think Zoom as a platform has really caused a lot of us that do give a lot of talks to sit down and contemplate more, more specifically and with more granularity, how we get our message across, how we engage folks. And I think this technology probably has a reasonable future in doing that and improving that. And the other thing I would say is it’s probably a lot less intimidating or concerning for a student to type into a chat box as opposed to put their hand up in front of 200 of their classmates and potentially, you know, as you sort of insinuated earlier sound silly or fear that you sound silly in asking that question.

Geoffrey Blair  50:07

Right. So but it does diminish the ability of a teacher to come across with the full force of their personality. Heck, I’m sort of known out here bc used for standing on the podium and pointing my finger at 288 students saying, beware the child who vomits green. It’s tough to do that over Zoom.

Chad Ball  50:32

I love it. I love it. If anyone can figure it out, it’s you Jeff for sure.

Geoffrey Blair  50:37

Well, I was singing the other day on one of the Zoom lectures. And let’s sing. You know, so I think you have to be you have to explore. But it does diminish the opportunities to have your personality come through. Andreana, we did.

Andreana Bütter  50:52

Yeah. Well, the the Zoom thing is interesting, because I also kind of I have always made my lectures very interactive and really case based. And I’m always more interested in the students with the wrong answers than the right answers. And we talk about why that’s the wrong answer. I think they learn much more without being, you know, belittling, or demeaning. It’s a very positive thing. But of course, I don’t know their names. Now on Zoom, all their names are displayed on the screen. So I’m able to say, George, you know, what do you think? And so now, they really can’t escape me to try to get them involved, if nobody’s sort of volunteers and answer so. But yeah, I do miss the the in person, there’s definitely something about the in person that Zoom will never be able to replace, you know, where we can we just try to do the best that we can. For now.

Chad Ball  51:42

Yeah, there’s, there’s, there’s no doubt about that. We wanted to ask you and you know, another question. In particular, if one of you would be willing to describe the origins and the goals and really the the process of C-CASE and you mentioned it earlier, I think it’s really exciting and innovative and important.

Andreana Bütter  52:03

Yeah, so. Alright. So yeah, C-CASE is, we sort of came up with this a couple years, I guess about yeah, a couple of years ago, CASC, the chair chiefs of Canada came to us, Jeff and I and said, you know, we really undergraduates is great, but, you know, can we kind of bridge undergraduate and postgraduate and, and sort of do a joint conference. So I, a bunch of us got together in London a couple years ago, and had a little retreat. And, and sort of hammered that out and came up with C-CASE. And we had our first meeting last September in Ottawa, which was great. We had lots of really good talks, and amazing, you know, presentations by medical students and residents and and educators. And it was really exciting to all be together and, and we still had that the flavor that that CUSEC had had with the with the biannual symposia. This year, we were having were decided to keep it he was supposed to be in Montreal at the end of this month. Of course, with the pandemic, we couldn’t do that. So it is virtual. But, you know, we’re hoping we can still try to keep that togetherness and, you know, discussion amongst each other as we have before. We have the CEO of the Royal College, Dr. Susan Moffat-Bruce, is giving the introductory address. We have a session on artificial intelligence and surgery. We have Dr. Dimick, from the University of Michigan giving a talk about defining surgical culture. We also have a talk from Dr. Talarico, from University of Toronto about virtual learning, teaching and learning and how U of T modified their curriculum. And we have almost 40 abstracts being presented by medical students and residents. So it really is going to be really exciting at the end of the month. And, you know, I can provide you with the link and we’re very grateful to you, Chad, for the support from the Canadian Journal of Surgery and and last year, you published all the abstracts and some of the papers, and we have a lot of support from the different surgical societies as well actually have contributed financially to this to help us. So it’s really great because we really want to have more conversations with our postgraduate surgical educators and really work together to say, because, you know, they, you know, they, they could be saying to us look at we’re noticing in our surgical residents that they are they’re lacking X Y Zed in medical school, and then you know, Jeff and I and everybody else across the country, we can start making some curriculum changes and work together on that. So that’s that sort of C-CASE in a nutshell. And, and, yeah and our plans.

Geoffrey Blair  55:08

And I think if I may interject, I think it, it really is going to be a springboard for a renewed efforts to really collaborate across Canada. You alluded to that Andreana, that, strangely enough, and I have commented on this before, strangely enough in Canada, even though we’re all under a public health system and so forth, we just don’t collaborate on educational matters as much as we, we should, or, or could. And I see the possibility that we’ll get a fairly standardized surgical undergraduate education curriculum formulated in the not too distant future and really collaborate more, we’ve seen that with COVID. Andreana, you commented on how you and I and others were online together, trying to plan out how each of us were going to teach in this COVID pandemic during the pandemic. So I think that C-CASE is going to be that springboard for better national cooperation. You know, the science, the pedagogical science of undergraduate education isn’t dry or boring, it’s exciting. There’s all sorts of vistas opening up for opportunities to experiment, to try new things. And in my decades of practice, like I think every doctor, and certainly every surgeon, right, they’re frustrated with the healthcare system, I want to see this or that changed for the better. And I’ve tried in small ways to make changes here and there and elsewhere. Sometimes been successful, sometimes not. But then I stand back and look at what we’re doing now in undergraduate education, to influence the minds and the learnings of these young doctors. What a profound, and I hope, effective way to really make change for the better in health care in Canada. If we can get these doctors to care, to think and to act in the right way. Boy, we have done more than any a paltry effort that I’ve ever been able to apply to the healthcare system in the past.

Andreana Bütter  57:29

Don’t forget, Jeff, they’ll be looking after us one day, so we want them to be well trained.

Geoffrey Blair  57:35

Yes. Once in a while remind them of that.

Andreana Bütter  57:37


Chad Ball  57:38

Yes, yes, totally. Well, you know, guys, one of the interesting, really interesting podcasts that Ameer and I’ve reflected on a lot was with Janice Pasieka, who you may or may not know, but she’s sort of an internationally famous endocrine surgeon here in Calgary. And she outlined, really in full disclosure, and it was extremely interesting how she personally tried to become a better teacher, you know, sort of searching out great surgical leaders, great surgical teachers, which are often different. And actually coaching strategies as well. So maybe in closing, Ameer and I would like to give you know, the last word to each of you, and chat about whatever you’d like. But in particular, I wonder what your view on how we can each become better teachers in the operating room and around the operating room, and in general, as surgical educators? What would you recommend to all of us?

Geoffrey Blair  58:38

Andreana, I’m gonna give you the last word. Simply enthusiasm. In this age of COVID, with the virus being so contagious, there’s one other thing that still is happily, very, very contagious, and that is enthusiasm. If you can, if you’re enthusiastic about your career as a surgeon, then it’s easy to be enthusiastic as a teacher. And if you bring that to your teaching, it doesn’t mean that your lecture, your seminar, your bedside teaching has to be perfect. The students will feel that enthusiasm, and know draw energy from it. And that’s the one piece of advice I would have.

Andreana Bütter  59:41

Yeah, I totally agree with that. And I, I’ve tried over the years to reflect on when I was a medical student and what did I really enjoy and who who I really felt was an effective teacher and why and there are things you know Ameer you mentioned about Jeff saying things that you heard and it stuck with you years later. And I have tried over the years to reflect on that to about you know, when I was taught, what did I really enjoy? Why did I enjoy it? I agree enthusiasm is certainly critical and and students really seeing that you really love what you do. You know you’re devoted to that you really want what’s best for the child and that’s why you’re doing what you’re doing. Or your patient so I, for me, that’s what I try to use and sometimes it can be challenging when you’re tired or you have a difficult case and might not be able to do all the teaching that you want to do, you might have to maybe do it afterwards or something. But for me, that’s I just tried to put myself in their shoes and remembering how when I was a medical student and first time in the OR and and wow, it’s like such a overwhelming experience. And just, you know, trying to put them at ease and and trying to teach them something along the way that you know, hopefully will stick with them and be helpful and useful for them.

Ameer Farooq  1:01:15

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.