E51 Ernest Moore On Developing Acute Care And Trauma Surgery

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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 broad 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  01:13

In this episode, we were honored once again to have another icon of trauma surgery join us: Dr. Ernest E. Moore is a trauma surgeon at the Denver General Hospital. In this episode, we explore Dr. Moore’s early insights into the development of trauma surgery and then later acute care surgery as distinct specialties. And how he defined not one but two major surgery journals, and had an almost unfathomable research productivity. Finally, we tried to glean some insights from Dr. Moore as to how he thinks surgery will continue to develop in the future, about his thoughts on gun control as a trauma surgeon and how we might rediscover our passion and joy as surgeons. Sir, we’d like to just start off by talking a little bit about your training pathway. You’re certainly not going to be unknown to any of our listeners. But many listeners may not know what your career trajectory was. Where did you grow up? And where did you do your trading?

Ernest Moore  02:14

Well, I grew up in Pittsburgh, and my father was a old time family practitioner. And interestingly, despite his hectic schedule, as you can imagine, an overall general practitioner back at that time. Interestingly, of the six children, four of us became physicians. So the hard work to us looked appealing. And despite his rigorous schedule, we all pursued medicine. So I think our interest in medicine was spurred by my father and actually all my uncles are physicians as well. One of my uncles was Blalock trained and set up the open heart program at UCLA many years ago. So I grew up in Pittsburgh, and I went to Allegheny college, a small liberal arts college, just north of there. And they have a unique program at the University of Pittsburgh School of Medicine, where college students were invited in and actually paid for summer research. And they’re trying to recruit regional individuals to go to the University of Pittsburgh, specifically to become interested in academic pursuits. So I was very lucky because I got to work with some real legends in surgery. I start off with Larry Gary, who you may not know, but he was in Vietnam, and he’s the one who really characterized the catecholamine response to shock. Then I worked with Dr. Henry Bahnson, the cardiac surgeon and he was really sort of my mentor in medical school. And I spent time with him developing the intra aortic balloon because he was one of the pioneers of that. And so I was very fortunate to be invited into these research labs at my early age and that sort of cultivated my interest in research.

Chad Ball  04:47

It’s really interesting that you have so many physicians and docs in your extended family. Dr. Moore, you know, one of the things that Ameer talks about on the podcast rather frequently is you know, his dad is a general surgeon. I’m curious as an individual who really has no medical professionals in my family really anywhere: how does that inform your sort of view of his job and of medicine in general? And what were some of the pros and some of the cons of growing up in that kind of really rich environment?

Ernest Moore  05:23

Well I think some of the pros is you got to see some of the rewards of medicine. And I think that one of the things that some of the current generation of physicians, including trauma surgeons, don’t recognize is the gratification of being a physician no matter what field you’re in, you believe you’ve really helped a human being. And I think despite my father’s chaotic schedule, I mean, as a family practitioner, literally, he had office hours six days a week. And the only reason he didn’t have office hours on Sundays was because we went to church. But I guarantee after church, we went in the station wagon with all the kids and made the rounds on a Sunday afternoon. So he basically worked six and a half days a week, and he loved it. And I think we got to see the gratification he had, despite the very demanding lifestyle. You know, as a family practitioner, he wasn’t rewarded financially that much. But I knew that the people in the town respected him and he was a living legend. He had delivered about 80% of the people in town. We lived in a small town north of Pittsburgh, and when he walked down the street, you know, it was gratifying for everybody to recognize him and say, thank you Dr. Moore. Thank you, Dr. Moore. And I think that’s really, for us what motivated all of us to go into medicine.

Chad Ball  07:11

Wow. That’s a remarkable story. And you know, I’m sure it’s not unique growing up in that environment for many surgeons and many physicians, but, you know, hopefully, we’ll come back in the podcast and talk about the passion of surgery again. One of the things I want to move to though is to obviously congratulate you but in particular mention to a lot of our listeners that you know, the Denver Health Trauma Center, which is clearly Denver’s busiest and you’ve been out for many years, was recently renamed the Ernest E Moore shock trauma center. And clearly that’s a tremendous honor. And it’s not like you weren’t in the top, you know, three or four or five iconic trauma surgeons of all time. But that seems to be just a whole other level. How was that experience? How was the ceremony? And how do you put that into words? How do you frame it?

Ernest Moore  08:04

Ah, that’s a good question. I guess embarrassment might be the first way to explain it. I almost refused to go through with it. I had a discussion with my wife. Because when it first was presented to me, I thought this would be overwhelmingly embarrassing. But on the other hand, my life’s ambition was to establish an academic trauma center. And in that sense, I sort of reveled in the celebration that I had succeeded, at least to what I had aspired to. Sure, there’s many more things I could have done. The celebration was something more than I could ever expect. And I mean, just sort of like going to your funeral before the time because you know, all these people came from out of town and said all these things that were grossly embellished, overstated. And here was a black tie thing and there was heavy alcohol and celebration. It was just a fun occasion. Looking back, it was an opportunity to sort be gratified with what we had done.

Chad Ball  09:36

Well, you deserve every single one of those accolades. And there’s no question despite your humility that, you know, people are underselling not overselling. So congratulations. That’s amazing. You certainly deserve it. You know, I’ve seen you give so many talks over the years like so many of us and honestly, every single one of them is is superb. One of the ones in particular that stands out, actually Ameer saw it as well,  both of us watched it. It was the interview session you did on the AAST platform. And you talked about in particular, there’s some seminal moments in history with regard to the first real or dedicated trauma service in the United States. And then the evolution towards defining the actual, you know, subspecialty of trauma, injury care, and eventually critical care. For our listeners, maybe who might have missed that talk, can you give us some details on what you talked about?

Ernest Moore  10:35

Well, I’m not sure I can remember exactly. But in general, I think that many appreciate or should at least appreciate the fact that trauma centers in the United States, developed in county hospitals – there was so much trauma that it had to be organized and dealt with. And city hospitals were the environment in which it could be created. And of course, buddies down in San Francisco. Last year, was a legend in Cook County. And Bob Freeark, was the other that was apparently developed about same time. And of course, now it’s Cowley Shock Trauma. And Baltimore came along a decade later. But yeah, these individuals had vision. They saw a need in the county hospital, felt it was their obligation to serve the public. So that’s how trauma centers developed, regrettably. And I think, again, a note on medicine itself. As you all know, at least I can say that in United States, we’ve gone from a profession to business. So trauma used to be done at County hospitals, because we want to serve the people but is now translated over to major economic centers, because it’s lucrative. It’s more of a business than it is a service to the community.

Chad Ball  12:19

Yeah, there really has been a significant evolution, there’s no doubt. You know, how do you reconcile the business side of it with the altruistic non-business side of it? And it’s a it’s a question probably, that seems intuitive to many Americans. But in Canada, of course, we don’t really have that system. It’s essentially public health care with very little carved off at this point to the private side of the money generating side.

Ernest Moore  12:50

Well, I think it’s very distressful to watch it evolve into this. And the ability for us to manage your life has been completely removed. And we’re now at the mercy of CEOs and boards that have maturely no knowledge of medicine, and frankly, have little interest. And I think it’s just obscene that we run around, even our so called County Hospital, we run around with CEOs making seven figures. And you know, we’re paid very well, I think, I’ve always said we’re paid well, but to see CEOs run around in their fancy cars and paid three times as we are to sit over in their office in managed insurance negotiations, to me is despicable. But it’s totally changed our priorities in healthcare. And we are driven the way we were before by trying to do the best in using research and education as an opportunity to improve patient care. They’re the last priority now as I’m sure you’re aware, and in fact, it’s frightening to see how research is just almost eliminated.

Chad Ball  14:21

And, you know, it’s almost depressing to see that even in Canada, and certainly Alberta, we’re having the same problems. Research is just so far down on the list of opportunities, you know, based on funding in the healthcare structure here as well. The reality is the provincial governments really don’t care about it at all and they have a hard time reconciling the link between quality outcomes for patients and efficiency in general research. So I think it’s a battle everywhere, no doubt. Speaking of research, you know, if any of our listeners put you into PubMed, the response in terms of volume of work you’ve produced and been involved with over your career is almost unfathomable. I’m curious, maybe threefold, what are some of the biggest contributions that you’ve made that you feel the most proud of? Because often times I think we both know that maybe those are different from the outside perception of some of the amazing work that someone’s done. I’m also curious how you’ve been so productive for such a sustained length of time. Again, it’s darn close to unique. It’s something that you know, I try to emulate selfishly, but you seem to do it over a long period of time. Yeah, those are the first two questions.

Ernest Moore  15:51

Well, I wouldn’t say that my achievements are that remarkable. But I would say that anything I’ve done academically, I would say should be credited to my mentors, and they’re the ones that really showed me the pathway. In terms of the research that we’ve done in trauma, one of my mentors was Dr. Ben Iseman, who was the first academic chief at the Denver General and hired me. And he was a remarkable individual. And when I first started, I remember I sat down with him. And he said, “well, I’m hiring you because I want you to develop a trauma like down at San Francisco General”, and I said, “well, okay, that’s a great idea”. And so he took me from raw surgical residency to become a director of trauma. And then he said, “the greatest advice, you know, if you want to be successful in research, it’s fairly simple. You go to M&Ms every week. And you write down the recurrent problems, and ones that people don’t know the answers to. And then you sit back and you go review the literature that’s available and see what’s been done and try to come up with some questions or so called knowledge gaps we call them now, to address”. And that was very shrewd advice to me. The very first thing I noticed when I started as a junior attending was, how many people died from liver injuries in the ICU after we got out of the operating room and probably won the battle. And of course, it was coagulopathy. So that really was the first area of academic interest I had. And it taught me that I couldn’t stick with one area of research. That I had to keep looking at the next uncharted arena to begin to do research. And so shortly after coagulopathy, we got into multiple organ failure, which of course, Dr. Eiseman in 1975 was credited with coining the syndrome. We took advantage of his inspiring work and developed basically a research program around that. And ultimately, that led into various evolutions. Then we developed the multiple organ failure score and begin looking at neutrophil priming and the second hit, and so on. And at one point with our NIH grants, it looked like we’d run out of gas and then stumbled on the idea of linking the gut to the lung and started looking at what was in mesenteric lymph. So every time we turned the corner we’d look for new areas that we thought needed to be explored.

Chad Ball  19:31

Dr. Moore, in addition to you know, all the achievements we’ve talked about one of the other things is certainly that you’ve been the Editor in Chief for quite a while at the Journal of Trauma and Acute Care Surgery. And then of course, you’ve certainly had your fingerprints and guidance over the World Journal of Emergency Surgery and the WSES in general. How do you frame those editorships and in particular for the Journal of Trauma Acute Care Surgery, how has that impacted your career and your practice? And what’s your sense overall of that pretty incredible experience?

Ernest Moore  20:10

Well, again, I was lucky to be at the right time in the right place. I did my surgical training at the University of Vermont. And that’s where Dr. John Davis was the Chairman of Surgery. In fact, he is the one that converted me to do trauma surgery because under the initial guidance of Dr. Bronson in Pittsburgh, I was planning to be a cardiac surgeon. So when I did training under Dr. Davis, he made it so intriguing that I couldn’t resist. But having done my training in Vermont, I was lucky to be asked by Dr. Davis to do the abstract section for the journal. So I mean, literally, as a second year resident, I was reviewing papers in the Annals and writing in the Journal of Trauma summarizing research. And that really taught me a little about journalism. And then of course, as it went on, Dr. Davis turned the reins over to Dr. Pruitt who is also a long term mentor of mine and a friend. And so that sort of led naturally into my interest in the journal and taking on some of the editor and editorial duties. The society’s an interesting story in itself. When I developed the trauma center at the Denver General, one of my major themes was that trauma surgeons need to be broad based, and needed to do vascular, thoracic, complex abdominal and promoting that by keeping a small staff and rotating all the cases and double scrubbing and so on. As time went on, the Journal of Trauma seemed to be drifting more towards critical care. And I kept saying, at the various board meetings various committees, kept saying, you know, we need to diversify a little bit, we need to get more of our trauma mission, because frankly, if someone’s sick, they don’t call the specialists they call the trauma surgeon. Well, there’s a guy in Italy, Fausto Catena, who heard me talk about this, and just out of the blue one day, I remember I stumbled out of the operating room and someone said to me, there’s a guy from Italy and he wants to talk to you on the phone. So I go on, this guy introduced himself, I didn’t have a clue who he was, and I didn’t think he had a clue who I was. And he said, “hey, I got an idea. I think we should start a new journal, focusing on emergency surgery. I’ve heard you talk and I know traumas linked to it”. And he said “how would you like to start a new journal?” I said wow, that’s interesting. He said, “I’ll pay you and your wife to come to Bologna next week, and have a date with a lawyer. We’re going to set up then develop this journal and pay your trip. And we’ll spend a week here and I’ll introduce you, and we will travel around together”. And then when I’m talking to my wife she said, “geez, who is this crazy guy? Worse than you!” And so we signed up and went and that was it!

Chad Ball  23:43

That is awesome.

Ernest Moore  23:44

It was unbelievable. So that’s how the Journal of Emergency Surgery started. And it was largely because I couldn’t get traction with a WST to get interested in that arena.

Chad Ball  23:58

That’s very interesting. You know, it’s almost independent of the journal but certainly related. You were one of the very early supporters that I remember talking with passionately about the conceptual framework of what eventually became acute care surgery as a full subspecialty. And, of course, you know, there was other folks in that conversation with you as well. But how did you see it as the future so early and in particular, where do you think it goes from here?

Ernest Moore  24:29

Well, the concept of integrating emergency surgery really came because again, of the experience that the county hospital where the trauma surgeon was the surgeon who did everything that no one else could or would do. And so my vision was to maintain credibility of the discipline that we needed to keep up our skills and present ourselves as sort of a, quote master surgeon, that when there’s a problem no one else can do, we do it. And I think on the one sense, acute care surgery has salvaged trauma surgery as a viable discipline. On the other, it has I think, lowered the reputation of trauma surgeons because many trauma surgeons in the United States don’t do much high level operative work. And so it’s been a two edged sword to say the least.

Ameer Farooq  25:43

Dr. Moore, people have these phrases, right? Like, you know, so and so literally wrote the textbook on such and such a topic. But in your case, we can literally say, you wrote the textbook on trauma. And Dr. Ball and I were looking at that, a copy of the textbook just before the call, and just admiring that fact. Can you tell us how you got involved in writing the textbook? And how do you think about the importance of such comprehensive Bible style textbooks in 2020?

Ernest Moore  26:17

Well, the story behind the book is interesting. I first entered a book with Dr. Osmond called Critical Decisions in Trauma. I’m sure you guys don’t have a clue what that was. But it was a book of algorithms. So we took every trauma problem and made it into an algorithm and then explain in the narrative of why those decisions were made. It’s really the template of what’s done by the Western Trauma Association. And it came really from that project. Well, as a result of that book, which was unexpectedly very successful on trauma, and it makes sort of some sense at this point, because if you’re confronted with a bullet to the carotid, then what do you do? What do you do if it’s three hours old, and so on? And this book would go through all that decision tree. Well, based on the fact that I had gained some reputation in editing, and I give complete credit to Dr. Osmond because he made me co enter his book, but I guarantee he did 95% of work. I came to the American College, in Atlanta, and I had a message at my hotel room that somebody from McGraw Hill wanted to talk to me about editing a book. I said, wow that’s interesting. And so I got on the phone, and this person said, I’d like to meet you while you’re at the college and talk about doing the big textbook in trauma. Because you know, the one that’s out now, which Rutherford is doing which, in Barbara, was at our institutions, the vascular surgeon then is really not selling well. And most of the authors are not trauma surgeons. And I said, sure. So she said, make me a list of the chapters and the authors you would select. So fortunately, I had a list of all WST members, and then that weekend I went to this thing. And she was rather non committal. It did sound interesting. And then I didn’t hear anything for about two weeks. And then she called me back and she said, I got a proposition for you. We’re interested in you being Editor. But you know, we interviewed another guy named Ken Maddix, from Houston. Do you know him at all? I said, yeah I know him. I knew him more by reputation than personally. They said you know, if we sat down and compared your notes, they’re almost identical. He’d picked the same topics, the same authors. He’s got the same idea you do. Do you think there’s any possible way you guys can work together? Because we think as a team, you’d be stronger than independently. And I said, sure. Of course Ken was older than me and had a much bigger reputation in trauma than I ever had. And I said, sure, why wouldn’t I want to partner with this guy? So that’s how the book evolved because they called Ken and offered to him and they said, can we get you guys together in the next week. He and I were on a conference call together, then Ken said, you know, I have a junior guy, you probably know Dave Feliciana. I said, Yeah, yeah. Actually Dave and I were pretty good friends at that point, because we were sort of growing up together in the academic arena. He says, how about if we add him on, and the three of us will do it. And I said, great. So that’s how it started. And I can tell you some amusing stories about that, which again, I probably shouldn’t. But if you talk about two personalities who are journalistically diametrically opposed you would find David Feliciano and Ken Maddix. Ken would just sit down and wrap things off. And yeah, wouldn’t give a second thought he’d  just ramble on. Dave Feliciano, when he wrote something, it would take him a month. He was so meticulous, he wanted to look up every little detail. So I was sort of the arbitrator between these two fighting each other constantly with every edition of this book. We became long term good friends. It was amusing watching the different approaches to journalism that ultimately led to this product.

Chad Ball  31:11

That’s such a great story. And I can certainly see you in the middle of both those gems for sure.

Ameer Farooq  31:17

Dr. Moore, I did want to touch on a slightly different topic. Which is, you took the unusual step of…or maybe it’s not that unusual, and maybe you can talk about whether it’s unusual or not. But you took the step of actually speaking out against assault rifles. And in fact, there’s a well publicized article about you actually disagreeing with your brother about whether assault rifles should be banned or not. What compelled you to kind of speak out about assault rifles? And how do you see surgeons participating in this very national public debate around gun control in the US?

Ernest Moore  31:59

Well, that’s a politically sensitive topic. But let me frame that a little bit. I’m an avid hunter. I grew up you know, in western Pennsylvania, and the only time the boys and I got to spend time with my father was hunting season. So we all became very avid hunters. And I remain an avid hunter. Elk hunting is one of my favorite passions, despite my wife’s disapproval. But I am a very avid hunter, but I did witness, as you may know, Columbine. And I was struck by the fact that there are so many innocent, high school kids in this devastating event. And then that was further supported by the Aurora  movie theater shooting. And it just to me, was so unconscionable that we would arm crazy people with these devices that could go out and randomly kill innocent people. Not to say that gun violence in United States in the ravages, you’re deserving. But I always say when the residents say, oh, you know, so and so got shot, and I say, you know, you play with fire, you get burned. So, to some degree, you know, some of the violence we see with guns is brought upon by individuals that you know, they made that decision. But these poor kids that sit in high school and have someone come and just mow him down at their desk to me was unacceptable. And I, despite my joy of hunting…and I don’t necessarily enjoy killing animals, I certainly enjoy hunting them. I didn’t see rationale for having an assault rifle. I just didn’t see the purpose of it, you know? It’s a military device as you know, and it’s designed to kill as many people as possible in a short time period. And so it just didn’t seem to be an instrument that should be put in the hands of people that can’t make rational decisions.

Ameer Farooq  34:26

One of the things, and we keep going back to this interview because I reread it last night and just found it moving at places. One of the things that I really enjoyed, that you spoke about in that interview with the WAST, is sort of like the fact that there’s this rhetoric around limiting work hours, has perhaps kind of dampened the conversation around loving surgery and the fact that actually having a passion for surgery is what makes your career fulfilling. And we sort of touched on it a bit already. In the interview, but how do you think that the conversation has changed? Or how do you think the work hours has sort of changed that conversation? And how does that current reality concern you? And what do you think we can do about it?

Ernest Moore  35:16

Well, I think there are two things that hurt our discipline. I’ve learned one is that we have given up complex surgery. So that we now view laparoscopic cholecystectomy as a challenging operation, which has led to, you know, our basic skills have deteriorated to a point of being embarrassing at times. The second thing, though, that hurt us, I think, as a discipline is this concept of shift work. And perhaps that’s epitomized in trauma. You can’t select when someone’s going to have a severe injury, and you simply can’t treat them by turning the light switch off and on. I took a call just two nights ago, and a guy was shot six times with large caliber bullets. I’ve been back to the operating room with him every day, for three days. And, you know, the first time was three o’clock in the morning, the next time was two o’clock in the afternoon, and I just finished him two hours ago. And that’s the way it’s got to be. You got to be committed to those patients, and you got to put everything else away, and take care of those patients. And I missed, you know, research meetings, I missed conference calls. But when this patient needed care, I took him to the operating room and lead the team through, and that’s a rarity here. I often listen to stories at M&Ms, which just drives me crazy. And complications where someone will have five different attending surgeons and no one knows who’s responsible. Of course, no one wants to take the blame. And my constant rebuttal to that is, you know, why don’t you guys take care of these patients? You put a knife on them, you own them. Why would someone else take someone back to the operating room or open the abdomen or whatever it is, when you’re the surgeon? And these people, a new generation, look deranged. Why would you do that. And they walk out here, you know, routine leave at 4 in the afternoon and think that’s a full day’s work. And to me, that has destroyed our reputation as trauma surgeons who neither can a) take care of everything, but b) are always available and take care of our patients. And most regrettably, I think the new generation and I’m speaking generically, they’re clearly exceptions. But the new generation is missing that gratification of taking care of that patient. What I started with – what we respected out of my father. You know, we all have these miraculous saves and everyone in the hospital knows you, the nurses know you the family knows you, the people that bring news around know you. It’s just the gratification of doing something beyond what’s expected is lost now, because with this shift work, no one knows who the attending is, and when someone gets in trouble in the middle of night, they call who’s on call, not the surgeon who did the original operation. So really, in my sense, you know, this has significantly robbed us of the gratification of why we do all this. So that’s my concern.

Chad Ball  39:04

I can agree Dr. Moore. Of course, as the scenario or as the case gets more and more complicated, there’s so many details that are lost in translation, when you have those sign overs, change overs, shift work, whatever the terminology you like to use is. It becomes scary on occasion. I don’t necessarily think… you might disagree with this, but I don’t necessarily think that patients and society and the public at large, understand that structure and understand that the risk to them, but also to quality and efficiency in general that comes with that structure really exists. I almost feel like as a system, if that’s your system, and it’s a shift in shift out framework, we’re not being honest or at least forthright with the patients in terms of that level of risk that you’re touching on.

Ernest Moore  40:04

Well, absolutely, you know, the class has made it such that a patient’s family would rather see clean shaven, bright eyed physician in the morning rather than someone dragging in unshaven and blood over, and then recognize the difference. And in fact, if anything, they believe that we all need 12 hours of sleep a night and we shouldn’t work more than 30 hours a week. And there isn’t anything such as stress, because that limits our decision making and I totally disagree with that framework.

Chad Ball  40:50

Yeah there’s no doubt there’s some giant problems attached.

Ernest Moore  40:54

Well, I guarantee you did your wipple today. I guarantee you wouldn’t dream if you ended up having a biliary pancreatic leak, to have one of your partners take care of that.

Chad Ball  41:05

No, you’re exactly right.

Ernest Moore  41:07

You wouldn’t sleep with it. You wouldn’t live with it.

Chad Ball  41:10

Dr. Moore, in closing, I wanted to bring us full circle. You started this amazing conversation with us talking about growing up in your family and with your dad. You touched on it very briefly, you have a couple of great sons. And I can tell the audience, having talked to one at length, and the other one a little bit, they’re really good guys. Like, you know, you and your wife have done a tremendous job. And I know they know that. I’m curious with all the stuff we’ve talked about; your clinical volumes, your administrative burden, and, of course, your research side of things in addition to all the things I don’t know about that you do on a daily basis. How did you balance and manage your family? Because I think lots of us struggle with that equation for sure.

Ernest Moore  42:06

Well, I’d give 100% of the credit to my wife for anything good that’s happened. Family, I can assure you. You probably know my wife. She’s an internist. And she’s a very quiet and reserved person, that is all my friends would say. You know, I’m fine with you, but I do not want to cross paths with your wife, and definitely afraid of her. So she’s kept me honest. And I think that, fundamentally, when you begin your career, you need to decide what your priorities are. And inculcated in me and certainly reinforced by my wife was that the family is your number one priority. And you know, you’re reminded about it every day, you go on rounds, you talk about Dr. Osmond, and medical students and residents and our eyes are glazed over. They have no clue who you’re talking about. And here, you know, in his time, he was literally a walking legend. And three years after he dies, no one knows who he is. And so I think that you have to be careful what you think you’re accomplishing and understand that really, your legacy is your family. And in that sense, the priorities as you go through life, I think become important. And so, I would certainly give my wife credit for all the academic achievements of our boys. And you know, Hunter is a transplant fellow. And Peter is a pulmonary fellow. And both of them are going to be full time academic, when they finish. So we’re proud of them. And we’re proud that they’ve, you know, pursued those careers, because I think they recognize and they see all their friends who have made much more money than they’re ever gonna make and realize they could be making money in other professions, but looked at the gratification of what medicine presents. Again, as I went through my challenging years, and certainly arising out of 40s and 50s, the academic challenges and demands were tremendous, but I set the priorities. And I’m glad that I did. And the boys remark about this when we have a few beers: that I committed myself to their activities and what I focused on because I couldn’t compete with my wife in the academic arena with their education, was their sports. And I can guarantee you that unless someone’s died in the operating room, I never missed a hockey game. I never missed a lacrosse game of my two boys throughout their life. And they acknowledged that later. They knew I’d been in the stands every game. And they knew no matter what the outcome that I was there to support. And I think that, as I always say, my favorite quote, I’m not sure I can take any credit for it is: you cannot work hard unless you play hard. And you got to remember that your family is your number one priority. And that’s the life I’ve tried to live. It’s certainly not been perfect all the time. But I still believe that’s important. And people have asked, why do I still go to work? You know, I should have been retired 15 years ago. I certainly could have afforded it frankly. But I can’t wait to wake up and come work. Whether it’s a research lab or taking a trauma call. I just can’t imagine giving that up until the point at which I think that physically or mentally I shouldn’t be doing it. And it’s just a way of life.

Ameer Farooq  46:38

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