E59 Officer Of The Order Of Canada Vivian McAlister On Why He Became A Military Surgeon at 52

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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

Our guest for this episode does not believe in comfort zones. Dr. Vivian McAlister is a transplant surgeon and a professor of surgery in London, Ontario and a former Editor in Chief of the Canadian Journal of Surgery. At the age of 52, Dr. McAlister decided to enlist with the Canadian Forces as a combat surgeon. For all of his amazing contributions as a combat surgeon and as a researcher, he was recently named an Officer of the Order of Canada. In this episode, we talk about why he chose to become a military surgeon, some of the challenges of current training paradigms, and his experience being an Editor in Chief of CJS. Please note that in this episode, we do discuss the very real but terrible things that Dr. McAllister had to witness. while on tour with the Canadian military. Please see show notes for details. Dr. McAllister, thank you once again so much for joining us on the podcast. It’s a privilege for us to have you on and to get to learn about you and your training pathway and to pick your brain. For the few people who may be listening who don’t know you, can you tell us where you grew up and what your training pathway was?

Vivian McAlister  02:25

It’s my privilege to and thank you for having me. So my introduction to Canada was after graduating medical school at Trinity College in Dublin, I did two years of Family Medicine training. And my first job after that was to go up north in northern Saskatchewan, which I thought was for a year for a bit of adventure. And to be quite honest, I’ve had a wonderful career, but that year was particularly special. And after that I did a few years as a  family doctor in Saskatchewan, and then went back to Ireland and completed surgery training. But I always wanted to come back to Canada and Bill Wall advertised for a fellow and I joined him for training in liver surgery and transplantation in 1990. So that was my training pathway. After that I got a job in Halifax as a surgeon with the team down in Halifax doing liver transplantation and general surgery.

Chad Ball  03:39

What was it like to train under Bill Wall in the heyday, Dr. McAllister?

Vivian McAlister  03:44

You know, I’ve been so lucky. I wonder if we’re all the same Chad, I don’t know. But I feel I was at the transition period between surgery that had not changed in roughly 100 years. And then during my fellowship, everything changed. So that when I got into practice, I actually remember remarking to one of the surgeons saying, “Do you know that I wasn’t trained for any of the operations that I’m currently doing?” They had all been invented after my fellowship. So working with Bill was having this connection directly with the past of terrific surgery, of very technically demanding surgery. And, you know, a situation where you’re expected to get the best results and there was no excuses. There were no excuses. So it was terrific. It was one of the best training experiences in my career.

Ameer Farooq  04:47

It’s always remarkable to me, when I hear people say that and just reminds you how important it is to always be learning and have the ability to change what you do, no matter where you are in your career. And be able to embrace new techniques for things that you may have never have done or seen as a trainee. So that’s quite inspiring. One of the things you’re so well known nationally for is sort of your turn towards the military, I’d say relatively as an experienced – or relatively late in your career.

Vivian McAlister  05:21

That’s okay, Ameer. You can say “aging career”.

Ameer Farooq  05:26

So yeah. So you became a member of the military later in your career. What prompted you to do that? And how does transplantation sort of merge with trauma surgery?

Vivian McAlister  05:36

Well, there’s a lot of questions in that one. The first thing was that my joining the military was a confluence of certain events. So as a surgeon in Halifax, I had been in direct contact with members of the Canadian Armed Forces, who were training in medicine and in surgery. So I was very familiar with what was required. In fact, one of my trainees, Jay Doucet, asked me after completing general surgery, could he do a fellowship, and I was a transplant surgeon. And I said, Jay, what interests do you think the military would have in transplant surgery? And he said, well my interest is really to stay and learn for another two years, rather than go and be working in a hospital that didn’t have a lot of acute care patients. And that was the way the military worked in those days. So we invented a fellowship called Catastrophic Surgery. I had to change it later, because we call it a Catastrophe Surgery later, because we didn’t want there to be the impression that we had created the catastrophe, catastrophic surgery. And Jay is now a trauma surgeon in San Diego and doing very well with the American College of Surgeons and contributing a lot. But I noticed that he still has in his CV that he did catastrophe surgery with me. And what we defined that as, was looking after a patient who either has catastrophic injuries, one patient with catastrophic injuries, or multiple patients, so that the catastrophe is the fact you’ve got a lot of patients at the same time. And I think we were ahead of our times during that in the early 90s. So later, what happened was with the war in Afghanistan, I was very conscious of the fact that all the jobs that I got, had been done by other Canadians over the years, and I was walking in their shoes. And I felt that surgeons owed it to the country that if we got a remarkably good living, that we do have, that if soldiers are put in harm’s way, there had to be a surgeon right behind them ready to care for injuries so that they had the best chance of survival and full recovery. So it was at the right time in my life. My children had grown up, and I offered my services. Now, I was, as you say, known for being a transplant surgeon. But they were short. So they didn’t have any choice. And they accepted me on that basis. But I think it turned out to be quite a good combination. To have the training as a liver surgeon and a transplant surgeon who was faced with patients with catastrophic injuries.

Ameer Farooq  08:46

I think Dr. Ball probably would agree with you. He’s, you know, my sense from Dr. Ball is that his liver training really helped with his trauma surgery as well. Are you able to share any highlights of what that experience was like being a surgeon with the military, and what really stands out for you as part of that experience?

Vivian McAlister  09:09

So my first deployment was as a civilian augmente of the team at Kandahar airfield. And I joined a very unified, organized team of military physicians, nurses and technicians. And they knew what they were about. And it was clear to me within 30 seconds of getting there that they knew what they were about. And I would best contribute if I conformed to what they were doing. So I learned a lot from them in the first deployment. I also learned that I enjoyed doing what I could do and I was able to help. So I offered to join and put on uniform, so that I could be an integral part of the team. And I’m very pleased that I did that. So I had many deployments afterwards, in uniform. There are lots of highlights, you know, I think you’ll have to tease them out of me one at a time, really. But what I was pleased about when I got there first, they were a little suspicious, you know, an academic surgeon is going to be pointing, you know, looking down his nose at us. He does austere, he does, you know, unusual type surgery, transplantation, what’s he going to contribute to the team? And very soon after, I was there as my first deployment as a civilian, we had a young patient who was maybe nine years old, he’d been shot in the back. And he had three operations. Prior to that they had dragged him up to survival, with fantastic critical care. And suddenly he started to bleed again. And we realized he was bleeding from his liver. And they turned to me and said, “what are you going to do now?” So we were about a month into his care, and I operated and as you know, he stuck down and a little child, very delicate. And I managed to go in, and I tied off the right hepatic artery with a very simple operation, and everything got better. So my reputation was made. And I was delighted because the patient was saved. And that was a very, you know, important highlight, I think, in my overall career, because it set me on the path. I knew that I could do what they needed.

Chad Ball  11:51

That’s an amazing story. And, you know, I feel strongly about what you and so many of our colleagues have done, and I hope, you know, in my career time, I’ll have the opportunity to engage in that type of environment and scenario as well. It’s really, really impressive. I’m curious what your view on war crimes for, you know, in general, maybe, but in particular, medically related war crimes would be. How do you think of some of that?

Vivian McAlister  12:28

Yeah, well, that’s a really a really important question to me. And I’ve, it’s not one I contributed anything like I should, to it. I never expected to be faced with worries about that. My worry was that I would perform as required to help patients. But when I saw patients with these extraordinary injuries, I mean, unbelievable and then realize that these were wrought upon that patient by another individual, another human, who tried to do this to them. I realized, after a while, the pattern, you know? Surgeons are wonderful at seeing patterns. We see patterns very quickly. We wouldn’t be good surgeons otherwise. And I saw the pattern that this was not an attempt in Afghanistan, or in Iraq, to try and immobilize an enemy. This wasn’t taking a soldier out. This was actually trying to cause the maximum injury to a human, knowing the systems we have to look after patients that they would survive. And we saw injuries over and over there that if you got the same injuries on the 401, in Ontario, you would not survive. We could not get you from the 401 back to the hospital in time and help you survive. Not not at the rate that we achieved in Afghanistan. So we were kind of playing into the hands of these very evil people who escalated the injuries over the five deployments that I had there, and I saw them get worse and worse and worse and worse. And we discovered later that they had medical intelligence to know what we could look after. And they just escalated to take us to the next level. So in the end, you know, we described the effect of the anti personnel IED in the British Journal of Medicine, and it’s almost horrific to remember, you know. It was basically one leg blown off below the knee, one leg blown off above the knee, the perineum riped apart, the pelvis shattered by the force going up, and it breaks all of the ligaments in the pelvis, and then injuries in the abdomen from below. Because our hardware above protected the box and the abdomen from injury. And then arms – gone. Eyes – gone. Unbelievable that they did this to another human. So I started to think about it and said, you know, this is more than a challenge for a surgeon, this is actually a legal challenge. To do this, has got to be wrong. So I looked up the law on the matter. And it is absolutely abhorrent to the law, to cause what’s called superfluous injury to an enemy is a war crime. And I saw systematic war crimes over in Afghanistan, perpetrated against us, and against the people of Afghanistan. And, of course, we’ve left there, and they’re still doing it to each other. So I feel we looked patient by patient, but I’ve let the side down. I know this stuff. I tried to include it in some of the papers that we wrote about it, but nobody’s paying attention, and it won’t stop. The capability of humans to harm other humans has only gotten worse. And they’re not stopping. They’re gonna keep going. Until the most. I mean, I don’t know what the next level of injury can be, because I thought I saw the worst. But Chad, I think there are war crimes, and I don’t know what to do about it.

Chad Ball  16:49

It’s a very dark place to go to mentally and you know, in the real world is as you have and it’s Yeah, it’s, it’s, it’s absolutely terrible. What What is it really interesting conversations that we had on cold steel was with Phil Dyer, who, of course, you know, well, from Vancouver, and we talked about a paper that was impressed with the Journal of trauma that really supplies or reinforces some of the nuts and bolts of your comment about differential in our ability to save severely injured patients in the military side of things versus the civilian side and this particular manuscript, really outline the special operators, Special Forces, deaths, and the m&m process that then happened starting in the desert all the way back to the US, and how they were able to turn that around since September 11, in increments, and really achieve remarkable outcomes. And as you point out, you know, in in disease patterns and injury patterns that we would never be able to salvage in the civilian world. It is absolutely remarkable. How do we as a, as a, say, a trauma collective in Canada, bring home some of those lessons and try and build our trauma systems to be better?

Vivian McAlister  18:15

Well, you know, our trauma systems are already enormously better than what they were at the beginning of the wars in Afghanistan. And the war in Afghanistan really did teach us the importance of evacuation from the point of injury, immediate actions by medics there and getting them practical so that they were they were capable of doing good care, and then getting them back to the first point of resuscitation, damage control surgery, and then on to definitive surgery. And I think that’s the model that we’re using now in our systems. And we’re getting better and better. You know, in Ontario, we have orange, which is very similar, almost modelled on the medical evac helicopter evac system that the Americans supplied for us. Within the military, we have some troubles because we don’t have the same evac system, and we rely on our allies to be able to do it. Interestingly, Phil was in Iraq. And I took over from Phil on deployment there. And one of the things we had a very quiet period, and we did a lot of exercises, and then we had a busy period. And during the exercises, we tried to stress the system and see where are we weakest and you know, actually one of the weakest places we are with severe burns. So the Americans have a wonderful system of care for severe burns in the military. So they’ll send a burn team all the way they’ll send one anywhere in the world now to pick somebody up. And it’s not just critical care evacuation, it’s burn team critical care evacuation. And that will save the life of a severely burned patient that brought them back to Texas and look after. When we try to think about what would happen to a Canadian soldier or citizen who was injured with severe burn in Iraq, the best system I could think of was to call the Americans and get them to at least to Texas. And then we can think about where they go from Texas, in Canada. And even then in Canada, we don’t have the same level of burn care that we had, maybe 20 or 30 years ago. So I think that’s our greatest weakness. I think evacuation is actually improving. And we’ve learned a lot from the military. The next challenge will be how to deal with these specialized but severely injured patients.

Chad Ball  21:05

I’d love to walk down the rabbit hole a little bit with you of sort of resident training in 2020. Our colleague Paul Engels, who you know, as many listeners know, is a trauma surgeon in Hamilton at McMaster. He’s in the midst – it’s not published yet – but is looking at, you know, exposures in terms of numbers of operative cases as well as just level one or high acuity trauma exposures in residency within general surgery across the country. And I’m, you know, not just myself, but really a lot of the trauma surgeons and acute care surgeons across the country are extremely concerned at the low volumes that are general surgery residents are currently seeing. And certainly there’s there’s no better places and worse places across the country. But I think it’s probably quite concerning whether you’re going to take a job in in Timmins, Ontario or whether you’re in Lethbridge, Alberta, or anywhere in between you’re going to have to deal with a trauma here and there. And I worry that we’re not doing these graduates justice, in terms of their trauma, training and exposure. What’s your sense of that?

Vivian McAlister  23:30

Well it’s a great point. A very serious point. The residents who graduated when I graduated were expected to go into practice – community practice, there might be one or two surgeons at the hospital, and they were expected to deal with the full gamut of general surgery, where there would be world traffic accidents where there would be massively injured patients. This has changed up to today, but it’s only a question of proportions. So there’s maybe 20 to 30% now of people who are going into community practice right away. So our residency training programs still have to be bale to give graduating residents the skills sets that are required for that type of practice. And although that type of trauma they’re going to see is rare, they’re going to see it, and they’re going to have to be able to deal with it properly. I think luckily the world has moved on since when I was a resident. With ATLS, that was just coming in after I graduated, you’re going to know how to resuscitate those patients. With damage control surgery, you’re going to know how to get the patient from your centre to the next port to call. And that’s something that actually, we learned from the military. When we were in Kandahar airfield we were only part of the chain of evacuation. We weren’t the definitive surgeons. You had to just get that patient to the next level of care. And get them there as well, and in as good health as possible. And I think Timmins, the example you picked, is very similar. They’ve got to get the patient to Sudbury, or Toronto or London. And to know how to do that has to be in the skill set of a graduating resident. But it’s not difficult. That’s not difficult. You’ve got to know how to operate quickly, how to pack things, how to stop bleeding, and how to limit contamination. Really we’re not asking you to be a definitive trauma surgeon. And we do have systems I think now, throughout the entire country, that if you are injured, it doesn’t really matter where you’re injured, you’re going to get roughly the same type of care. You’re going to get resuscitated, you’re going to get damage control surgery, you’re going to be moved to the major centre, and you’re going to get definitive care. And even within a city, it’ll be the exact same. So if you’re in a community hospital in Toronto, and that happens to be where you’re brought, you’ll get that type of care and you’ll move to the next level of care. And you know, this is a parallel development that occurred in the military for wartime surgery, what has now been more or less completely deployed across North America. So there’s minimal differences. Or at least, we’re trying to minimize the differences to the outcomes to patients. Depending on where they’re injured.

Chad Ball  25:54

That’s very well said. And you’re exactly right, that the homogeneity of our province wide trauma systems, I totally agree is remarkably good in Canada. And, you know, we don’t have to go far south of the border to compare state by state the differences in those systems, which are dramatic. You know, if we shift gears a little bit here, I was hoping you’d be willing to talk to us about the Canadian Journal of Surgery in particular. You are obviously the longtime editor of CJS and did some really amazing things. And, you know, Ameer, and I and Harvey have talked about you behind your back, you know, in a very glowing and deserved way, about how you really took this journal from sort of moderate heights, I would argue to great heights. Your impact factor during your tenure, you know, it skyrocketed. If you look at a number of indices, the Canadian Journal Surgery is now in the top 10 amongst surgical journals that are peer reviewed. And on PubMed. I am lucky enough that you showed me behind the scenes of how you did that. But for our listeners, how did you do that? What did your time as editor of CJS mean to you? And where do you think the journal should and will go from your launching pad?

Vivian McAlister  27:14

Well, now very kind of you to say, my launching pad, I’m just part of the continuum. And you’re continuing it for me, and I’m delighted about that. No, I I took over from Garth, who was, you know, a very diligent editor, a very much in the old school of things. And actually, the Impact Factor growth, you know, if you really understand your journals could be due to his tenure, not mine. I helped by continuing, maybe I changed maybe one of our goals, instead of having an impact factor growth, which was a very, which remains important to us. But I want to have a Canadian impact growth. I said to the team, to the editorial board and to the managerial team, look, we’ve got to matter to Canadian surgeons, if you don’t matter to Canadian surgeons, you don’t matter to anybody. But if you matter to Canadian surgeons, then you’ll matter to everybody. So we had to have an impact in terms of surgeons who are practicing real time surgery in Canada. And if anything, Chad, I think that was my main interest. And I included in that an interest in history and interest in topics of concern to surgeons, as well as the more traditional academic approaches. There are elements of the Canadian surgery that I miss, that I don’t think we managed to achieve in my time. One is that we’re a very clinical journal. And we think a lot about the training of surgeons, and we’re an opportunity for surgeons in training to start writing. But if you write your best paper, as a career surgeon in Canada, I want to do to publish in the Canadian journalist surgery. Okay, you know, you get a little more kudos if it’s in the annals of surgery, but it’ll live longer if it’s in the Canadian Journal of Surgery, because somebody is going to read your paper 40 years, 50 years or 100 years from now and say, that’s what they were doing in Calgary, or that’s what they were doing in Toronto. And if you’re in the Annals, they may or may not find you because you’re lost in the mass. So I really wanted to exploit the Canadian impact, and we didn’t achieve that. And one of the things we still haven’t done is looking at research that Canadian surgeons are doing, especially preclinical research, laboratory research, we have very little of that in the Canadian journal. So I have mixed feelings about the journal, I think we have achieved a lot. But we’re nowhere near the level of excellence that we should be. If we were at the level of excellence of the surgery, the academic and clinical surgery in Canada itself.

Ameer Farooq  30:37

One of the things sort of on a related note that we wanted to talk to you about is the surgical history that you are a master of, particularly within the country of Canada. Why is that something that’s so important to you? And you wrote a fascinating article about this for CJS on the Canadian history of surgery within the country. Why is it so important to you? And why do you think that that should be important to surgeons?

Vivian McAlister  31:05

When you get your job in surgery, or even if you get into a surgery residency training program, you’re assigned a locker, and somebody had that locker before you. The locker I got in Halifax still had the lock on it from Bernie steel. So I got the lock cut off, and I thought there’d be some wonderful things in it from Bernie, but he cleared it out. He just put the lock back on and it was empty. But at the same time, you’re always walking in somebody else’s shoes. You know, you only inherit your job, because somebody did that job before. And, you know, if you go down the list of people who walked in your job, who wore the shoes of your job before it goes back, you know, 150 years. So you can’t not be involved in history, I don’t know how anybody would think that they’re the first person on the planet to do this. So the same applies to specialties. You know, when you’re doing a special surgery, and you say, I’m, you know, I’m delighted that this particular operation went well, but you’re not the first. So you’re always following others. And it’s impossible in surgery, to have an appreciation for what you do without knowing about your past. Funnily enough, we are very similar as surgeons, to musicians, I don’t know, maybe it’s traditional musicians. But traditional musicians usually always started by saying, I was taught this tune by someone. So, you know, by McMaster in Nova Scotia, or something like that. They always credited their teacher, whoever taught them and their teacher was taught by somebody else. And it’s the exact same thing in surgery, because we have a skill, we have to be taught, you have to learn from somebody, and therefore, it has to come down through history. So you can’t not be involved in history, it’s just impossible. Then the other things that we do, like when we end up in war situations, or in unusual situations, and specialties with trauma, with transplantation with vascular surgery, you’re facing the exact same difficulty or challenge that your predecessors faced, and not to read how they managed, what they’re doing. You know, it’s just beggars belief. I think everybody is interested in the history of surgery when they practice surgery. So that’s where it comes from Ameer.

Ameer Farooq  34:00

You know, I couldn’t agree with you more. And I loved this vision that you have walking in and putting your stuff in another amazing legendary surgeon’s locker and there’s sort of this like, sense of an unbroken line going from you to the surgeons in the past. It’s quite a moving and beautiful thing to think about. How do you think about igniting trainees’ passion in understanding our history? I mean, it’s sometimes hard to, you know, think about how, let’s say Kocher, or some of these surgical greats, how that sort of relates to you sometimes in the sense that what we do now is very different in many ways?

Vivian McAlister  34:48

It’s not different at all. You think it’s different, the patients are exactly the same. And if you are Kocher when you’re faced with a patient with a difficult thyroid, or if you’re faced with, a patient in billary surgery, you’re the same as the other surgeons. I think of them when I’m actually operating and I’m facing a challenge. In London you say, you always wonder “what would the chief do?”, and the chief was Angus McLaughlin. And the old surgeons always said, you know, when they’re stuck, they just try and think in their mind, what would the chief do in that situation, but we all go through that, you know, you’re going to face a challenge. The minute you graduate from residency, and you’re the only one who decides how the ship is going to sail, what direction you want to take. Are you going to cut here? You’re going to cut there? You’re going to abandon or you’re going to keep going? And you have to think back into your training. And you’re gonna ask yourself, what would somebody do? So that’s, I suppose, how you ignite, as you said, the interest in history. One of the things that history, or at least historical papers have that we don’t have today, we tend to write in a very distant voice. In articles of today, we write very much from a very high level, and we don’t insert ourselves into the papers that we’re writing. In the past, they actually inserted themselves and their patients directly into the writing, they even named their patients half the time, or they will give initials, or they will give very revealing elements to their patients lives. And so to read the historical papers is actually fascinating. You almost start there, you can feel what they’re thinking, if you’re a surgeon in the same situation, and you understand, and you read their papers, it’s like reading a diary, half the time. So you just have to try and read it. I’ll give you an example. For some reason, I ended up looking at a surgeon in Halifax called Murphy who died in the 1980s. But he had a career going from the 1930s to the 1980s. And his career included writing plays, and writing screenplays for television, and everything. And he’s remembered for that, but actually, he wrote extraordinary papers, and one of the papers he wrote in 1940, was about dressings. And he talked about how hazardous it is to keep changing dressings every day – people poking their fingers in his wounds and causing all these infections. And then he went and looked at the history of closed treatment of wounds, and he was talking mainly about compound bone fractures and complex limb injuries. And at the time, Joseph trovata, then in England who had pioneered closed dressings for compound fractures in the Spanish Civil War had written a big textbook on it. And Murphy followed it all the way back to the Franco Prussian war and a French surgeon called Ollier, who actually described the exact same thing. And even earlier described, what we all, as surgeons get worried about is when people keep taking our dressings down, and changing the darn thing, every you know, twice a day or and stuff like that. You say, if you just left it alone, that would heal. I had left it the way I wanted it to heal. Anyway, that surgeon 150 or 200 years ago was facing the exact same thing that I am today. And I can read them. I can understand that by reading them.

Chad Ball  39:11

That’s so interesting. And you know, it’s just another great story. The listeners, I think now probably have a flavor for it and won’t be surprised when I say that one of my very favorite things to do over the years is sit with you at the annual CHPB dinner and listen to some of these stories and you know, you’re such a great storyteller and I don’t want to put you on the spot or paraphrase the story. But, you know, some of your stories really are truly epic. A lot of them also highlight though, some of the old school hardcore nature that you certainly endured and maybe I did to some extent as well and it seems like a long way away from the training environments that we all work in now. I’m curious, just in terms of a 30,000 foot broad stroke, what are some of the big ways that training, in our case, residents, have gone through over the length of your very long and impressive career?

Vivian McAlister  40:20

Yeah, I don’t know if you’re getting at this Chad, but, you know, I went to boarding school as a child. Before I went to university. And bullying was part of the culture in that school. And as you went up the years, you know, you could bully the years below. But I refuse to take part in any of that. I absolutely refused, I was kind of known for not conforming, at that time. And actually, I don’t think there’s any role for bullying in training in general surgery. Now, the old school felt that all we’re doing is and the only people they bullied in the old school were the the graduates. The residents that they really felt were going to be the best residents. They never bullied people who weren’t residents, or who were not going to succeed. They only bullied the tough – the top tier, and they felt they were hardening them for facing the real world. When you get out there, you’re going to have to face this. And I’m just preparing you to work under stressful situations, to learn how to slow your breath, your breathing down, to control that tremor to everything exactly the way it needs to be done. In a slow and controlled situation, even though everybody around you is going crazy. And to some extent they’re right. But you know, there are other ways for us to train that today. And in the end, for all the bullying that I endured, I don’t think I learned a thing from it. I had to face it all again, when I was out as an individual surgeon with a, you know, a critical situation, and I had to be able to provide the care that was required. So I have no doubt that the graduates of today with a different system will actually perform as well or better than I did, when faced with the exact same critical situation. Hope I’m right. But I really have no doubts about that it’s the way to go for the future.

Ameer Farooq  42:50

So there’s this really great movie that I’d recommend all our listeners check out called Whiplash. It won a bunch of awards. And it tells the story of this drummer who wants to get into this symphony orchestra in I think, in New York. And he has this sort of very sadistic kind of overbearing conductor who just you know, rides him relentlessly. And one of the things he says in the movie is: “the worst thing that you can possibly say to someone is good job.” Of course, I’m not advocating that that’s how we should be. But, you know, it’s funny that you say about picking on the best. When we were young and doing Taekwondo then our instructor always used to pick on me and my brother and it used to drive my brother (who’s now a lawyer) crazy! And he’d be like, “why are you always picking on us and not the other students?” And he said, “well, it’s because I only care about you and the people that can do well”. And this is sort of a comment and a question from me that, you know, sometimes when, as a trainee, you feel like why is someone hammering me? But maybe it’s because they really see some potential in you and want to bring that out in you. And I wonder if you found that to be true?

Vivian McAlister  44:10

Oh it’s absolutely true. You’re absolutely right Ameer. And how we train those who follow us is actually the critical question for civilization. If you think about it, that’s what it’s all about. You know, I’m known for having a quiet demeanor in the hospital in the operating room. And if I get stressed, it actually sets off these enormous alarm bells within the operating room. It’s worse than if I had behaved like some of the people who train me. Far worse. The whole place, I could hear them going quiet, and they’re all stressed and upset. And I have to stop it and I’m watching a resident doing something and I said, “look, this is a critical stitch, just stop for a second. Take a second, I want you to just breathe more slowly. Let’s get it in properly”. And then he doesn’t do it properly at all. And the stress gets worse. And then I say, okay, I’m making the situation worse, I gotta calm this entire room down myself, because I’m not, you know what I mean? It’s that we do bring out stress, no matter what the situation is because we’re dealing with critical situations. So learning how to teach your students to deal with that stress and perform the best they’ve ever performed. The worst the stress is, that’s the secret. And it’s probably the secret for everything that we do in society.

Ameer Farooq  46:01

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