E66 Vahagn Nikolian on Telehealth

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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

The COVID-19 pandemic has made us rethink the way that we provide care and there’s no place this is more evident than in the rapid adoption of telemedicine and virtual consults. Dr. Vahagn Nikolian has been thinking about the way that we can adapt for virtual care far before the COVID 19 pandemic. Dr. Nikolian is a surgeon at Oregon Health and Science University and specializes in abdominal wall reconstruction. In this episode, we talked to him about how he got interested in telehealth, how we can streamline it and improve it and where he sees telemedicine going in the future.

Chad Ball  01:46

For those listeners who may not know you north of the border, I was wondering if you could tell us where you grew up and what your training pathway looked like.

Vahagn Nikolian  01:53

So actually, I’m a first generation immigrant, proud Armenian born in Iran and then moved to the United States at a very young age. And in many ways, I think I’m lucky enough to say that I’m living the American dream. You know, my family was in Los Angeles centered there, I went to school at USC medical school there as well, and trained in a great environment for anyone that’s learning medicine at the LA County USC Medical Center, and the county system. And there’s a lot of opportunities for autonomy for residents and medical students. And then, for residency through the match process, I kept a very open mind. My mentors gave me a lot of drive to go after places that I hadn’t necessarily been exposed to. And I went to the University of Michigan for residency training. That was an unbelievable experience, wrapped it up a few years back and had the great honor of training at that institution with wonderful mentors like Dr. Hasan Alam, Dana Telem, among others. And that’s where I really discovered my love for abdominal wall reconstruction. That’s been after Michigan and ended up going to Columbia University Medical Center. And I worked in an apprenticeship fellowship with Dr. Yuri Novitsky, learning about abdominal wall reconstruction and various approaches to taking care of patients with hernias. So that’s that’s the I’ve sort of been everywhere now I’ve ended up in Portland. So if you want to think about are you progressed east, and then realize that West Coast is the best coast. So now I’m back in the West Coast, and in Portland, Oregon, practicing abdominal wall surgeries.

Ameer Farooq  03:38

Congratulations on a great career so far, and the places that you’ve trained are obviously phenomenal places. And one of the things that I’ve always enjoyed seeing from your posts on Twitter and following you from afar is getting some snippets and glimpses into what those mentors are like, or were like for you. And one of the tweets,  and I don’t have the exact phrasing the way you said it. But if I recall correctly, that, you know, there’s a tweet that you had that where you sat down  with Dr. Alam, and when you were sort of just about to go into practice, and he and you laid out your goals, your five year goals? And he said, Well, I think those are actually not ambitious enough, or I think you’re selling yourself kind of short. I think you can do more. Can you talk a little bit about the way that your mentors have kind of impacted you? And maybe when is it important for a mentor to actually, you know, you know, I often find that it’s usually the opposite that mentors kind of say, “Hey, calm down there, cowboy or cowgirl”, like, you know, you really need to have real more realistic expectations. But when is it when is it sort of the right thing to have a mentor say to you: No, I think you could do more?

Vahagn Nikolian  04:46

Thank you so much. That’s such a great question. And pretty cool that you you pick that up just through, you know, our interactions online, on Twitter and Social Media. I think it speaks to just how connected we can all be through these new mechanisms. So Dr. Alum without a doubt is one of the most influential and important mentors of my career. He served as my primary mentor for my academic development time at Michigan. So for two years, I took time away from clinical duties to focus on research and academic development and I sat down in his office. And just like you said, he asked me what were your goals? And mind you, I started residency, with a very limited research background, I had done some projects, but didn’t really know the fundamentals of how to be a successful researcher. And when I laid out my, my, what I thought at that time were, like, maybe goals that were unattainable, he actually gave me the motivation to say that I could even do more than that, I think that’s the sign of a true mentor is maybe seeing something in you that you don’t necessarily know you have, and willing to give you the resources to then accomplish those goals. And I was lucky enough to work with them. And, and fortunate enough that, in fact, his vision was very much something that I was able to accomplish. And that was through his support. So I’m very lucky to have that. And with regard to when a mentor should be able to push a resident or a mentee beyond where they feel comfortable, I think it takes a skill set to know what someone is capable of. It takes experience, to go through the process with many mentees and understand when you can ask them to do things beyond what they perceive are their limits. And then also having a healthy relationship with the mentee so that you can have honest feedback, honest dialogue and continue that process of growth. And so you know, now that I’m a faculty member, at OHSU, I’m trying to sort of use those same tenants to help my mentees, whether they’re students or residents, accomplish their goals, and, and work with them towards the ultimate goal, which is growth.

Ameer Farooq  07:18

We really wanted to delve in very deep on your research and academic focus, which is on telehealth. And, again, I know this because and we have tweets that document this and papers, that document this. You’ve been interested in this topic, long before COVID-19 changed the landscape in the way that we are now having to practice medicine. What motivated you to get interested in the topic of telemedicine when you did?

Vahagn Nikolian  07:48

Yeah, so for me, it’s been a few years now. So when I was in the midst of my academic development, I’m actually towards the latter half of it. We were seated with a visiting faculty member at the University of Michigan. And we were having dinner and I was one of the residents that was present at that dinner. And over the course of dinner, we sort of…the conversation digressed into some of the inefficiencies that exist within the medical center. And one of them was about just how inefficient some of our clinic encounters seem for us and for probably our patients. Specifically, we focused in on patients that were undergoing simple laparoscopic operations that have low complication profiles, and how bad we felt as physicians when you know, inevitably our clinics would get backed up or patients would be sitting in the waiting room. And when we would see them there was very little that we were providing from a clinical perspective, it was mostly just checking the few wounds, making sure that they were doing alright, and then encouraging them to then, you know, live their life to the fullest. But the interaction itself kind of lacked in terms of a clinical encounter. And, and given those circumstances, we asked ourselves, is there a better way or more efficient way to do it? Just around that time a paper had been released in the Journal of the American College of Surgeons looking at the potential for telephone based follow up on patients. And so after we had dinner and went home, I was kind of amped about the conversation and I sent over the publication to many of the people at that dinner, some of whom included Dr. Allum, Dr. Mohan, who was the chair at the time and asked them would they be interested in pursuing a similar program for those patients that we’ve discussed at dinner? You know, at that time telehealth was definitely a novelty and not necessarily something that was regularly practice, but they were open to the concept. And within a week, I had sat down with Dr. Allum and I had given him a proposal for a project that we would deem a quality improvement project. And that was around October of 2016. By March of 2017, this concept that came up at a dinner became a reality. And we actually saw our first patient in what we call the surgery e-clinic. It was an acute care patient who had undergone an appendectomy, and the interaction went great. And we started giving this opportunity for all of our patients who are undergoing relatively straightforward surgery that we’re not associated with any intra-operative or post-operative complications. And, and we look to see what the patient experience was like. That initial experience was really profound, we saw that most patients were very happy with the experience. They felt that the e-clinic platform was effective in, you know, making sure that they were doing well post-operatively. And that if they were given the opportunity, again, they would probably take it in that small cohort. At a time when telemedicine wasn’t a reality, about 80% of people who were given the option of a virtual visit, in the post op setting agreed to it, you know, they were given options of in person versus e-clinic and they elected to do e- clinic and were very satisfied with it. So that was kind of the the jumpstart. Up until then, if you had asked me what is going to be your eventual academic focus, what is going to be where you want to make an impact in surgery, I would probably be reaching for ideas that weren’t like genuine passions, but rather opportunities that already come my way. Once that project happened, I think I really defined virtual care telehealth and improving access to care as my academic focus: the thing that I wanted to make the biggest impact with beyond the operating room.

Ameer Farooq  12:10

Yeah, that’s fantastic. And this, the serendipity with which sometimes these great ideas happen is always really amazing to hear about in the aftermath. But obviously, you know, you had to take the initiative to really turn that into something where people would have generally just complained about it, you you took it and actually ran with it and turned it into a real productive focus for your academic career.

Vahagn Nikolian  12:35

If I may say, that without the institutional support, it would be impossible. There was a lot of moving parts to make that happen. You know, though I sat down and came up with the idea with Dr. Allum and some of my mentors, there was a lot of great coordination, whether you’re talking about or restructuring of how patients were scheduled for the clinic appointment, making sure that there was appropriate resources dedicated so that we could efficiently schedule patients, educate them on how to use the virtual visit, platform or app. And then making sure that when patients had any issues, triaging them to the appropriate settings, so that no patients had any unforeseen complications. So again, I think it was a very, very much a team effort. And it speaks to what we can accomplish together. So yeah, very pleased that the University of Michigan supported this concept.

Chad Ball  13:41

You know, I think that’s a really important point not to gloss over is, is the support of the environment and the people and the structure around you. You know, I’ve told this story a couple of times. On the podcast, there’s a partner here we have named Andy Kirkpatrick, and we do a lot of telehealth and tele-ultrasonography. With both space medicine, as well as some of the more remote regions in Western Canada in regard to trauma care. And, you know, we both feel a little bit guilty about, you know, the starts and stops over time with regard to, you know, whether it’s synchronously helping with remote resuscitations for injury in a place like Banff, and these programs have come and gone and they’re generally you know, stopped due to a lack of funding, as opposed to a lack of interest in. In a healthcare system like ours that’s publicly funded, it’s really hard sometimes to generate momentum from the bottom up. And, you know, I was wondering if you could speak maybe, or, or at least talk about, you know, how maybe to generate that kind of interest if you end up in an environment that maybe is less supportive, or maybe to be more honest, it’s just less familiar with some of the amazing things that that you and Hassan have done.

Vahagn Nikolian  15:02

So I think everyone can identify a group or a patient population that they can help. Clearly, there’s going to be people that are uncomfortable with these new concepts or new approaches to care whether you’re talking about telemedicine, telementoring, telesurgery, even, you know, there’s a lot of hesitance to give up the standard ways that we’ve done things. Because the way that we’ve done things has been good, we’ve been able to connect with patients, we’ve been able to sit at the bedside and get them through a very challenging scenario. And I think it’s this pandemic, if anything, it’s given us a new sense of what we can accomplish from afar, remotely. And definitely, in spite of the data that exists out there to support the use of telemedicine, even before the pandemic, there was a lot of rules, regulations, and things that stood as barriers against expansion. And all of those things, combined with some of the subconscious, and even conscious biases that we have, as providers, I think made it so that it was difficult to not necessarily experiment, but try it out and see if there’s a patient population that you’re seeing as a doctor that would be conducive to this form of care. The other thing is, whenever attempting to do something that’s different, rather than pushing everyone towards being forced to do it, I think having an organic growth, which happens through demonstrating good outcomes is probably the best method here. So if you’re enthusiastic about a certain approach to patient care, don’t necessarily say, I think this is a great way of doing it so you should do it too. Rather, tell them this is an approach that I’m interested in exploring. Focus on, you know, a grassroots organic method of growth, where you demonstrate that it’s safe, you identify, you know, the patient population that you’re working with, and why it worked for them. You find ways to share that information with your colleagues, whether it’s through academic ventures, whether it’s through, you know, an opportunity to present at your institutional, Grand Rounds or conferences. And then slowly, but surely, people will want to learn more. I mean, we’re  naturally, all working in very academic environments, supportive environments, and if someone’s doing something that’s effective, there will be people that want to learn. And so I found that the organic approach that we had was nice, because it started with acute care surgery. And within about a year, maybe two, even before COVID, people were starting to talk about it and starting to find their own patient cohorts that could benefit from it, whether it was a patient that was being followed for cancer and had had their surgery and now was in a surveillance program. Or if it was a patient that was being optimized for a surgery that they weren’t ready for yet, but needed, just you know, intermittent evaluations to make sure that they were still progressing towards their goal. These weren’t patients that you necessarily had to drive into the hospital. And people started using it in that way. And I think it’s been, it’s been very successful.

Ameer Farooq  19:03

You obviously did a great job of demonstrating this and in the form of your Annals of Surgery paper where you really outline all the things that you talked about in terms of how you implemented this in Michigan, and that the patients in general really liked the platform and were really satisfied. But I’m curious, you know, we’ve talked about the fact that sometimes it’s hard to implement these things. What do you think were the barriers to actually implementing a telehealth program? You know, initially, do you think it was all cultural? Or do you think there were other factors that have played a force in in making it slow to adopt, like, obviously Now COVID has catalyzed things and we’ve seen this rapid shift. So what do you think was the main barrier holding people back from adopting telehealth into their practices?

Vahagn Nikolian  19:54

Yeah, I think it was multifactorial. I think every stakeholder had established barriers, when you’re talking about the physicians, there was, you know, these constructs that we had mental constructs of what is an appropriate way to evaluate a patient? From a patient standpoint, I think if you were to ask a patient without necessarily providing context, would you prefer to see a doctor over a video or, and not having a physical exam or have them evaluate you in person and perform a physical exam? Clearly, you’re going to get a biased answer there. And then there was a lot of policy issues. I think the way that telehealth was structured pre COVID, was very much centered around the concept of rural populations. And so a lot of the policies that existed at least in the United States with regard to patient origination site where the patients actually housed at the time of their evaluation was very much focused on the patient being in a rural setting. And so there was issues there. And then finally, I hate to bring this up. But it’s, you know, we have to talk about especially in the United States, reimbursement and what you were reimbursed for, based on the type of evaluation really was limiting expansion of telehealth, many medical centers were finding it not to be a, an approach that was sustainable. And so when you put all those things together, I think it was just an overwhelming burden. And there wasn’t infrastructure in place. So as a result, the initial barriers were multifactorial. I think now that we’ve expanded some of these barriers, we’ve changed and they’ve evolved, and maybe they’ve even been broken down. So I guess we can talk about that in a little bit as well. How are these barriers changing? And what does that mean for the future?

Ameer Farooq  22:12

Well, I’m curious, you’ve obviously reviewed the literature on this. And I think you have a review paper on this as well. What does this landscape of telehealth look like today? In the United States, let’s say like, obviously, you know, this telehealth I think we’re using in a very broad stroke kind of way. But this could mean anything from you know, a phone call to, you know, augmented reality or virtual reality, you know, at its most extreme end of this spectrum, in terms of how people are followed up, what does the spectrum look like in terms of how telehealth is being used in the United States right now?

Vahagn Nikolian  22:53

I think at this point, we’re doing it all, you know, we’re changing the way that medicine is delivered. We talk about it at OHSU all the time, that we’re developing a digital or virtual hospital. And it’s multidisciplinary, whether you’re talking about and now our focus on the surgical side of things, a preoperative evaluation of pre medical clearance for a surgery, us, you know, performing the surgery, or coordinating with a surgeon at another institution to provide telementoring or tele proctoring services, having patients who have complications at other hospitals, and rather than transferring them to a tertiary quaternary center, providing tele ICU care. And then in the post operative period, providing post operative tele visits for immediate post op follow up, as well as surveillance programs that are focused in on making sure that patients do well long term. So I think the entire, your process of an experience of being a patient is evolving from one that always required you to go to the literal or figurative hospital on top of the hill, to decentralizing the care. And, you know, rather than focusing on the Medical Center, focusing on the patient, to provide care as close to home and as efficiently as possible.

Ameer Farooq  24:33

If we let’s say if we just focused our discussion a little bit to surgery because i think i think the discussion gets a little bit too hard to grasp and maybe a bit too complicated if we, you know, start talking about telementoring or, you know, tele ICU care, but if we focused, let’s say on preoperative evaluations and post operative care, in a surgical setting, what do you think are the most common kind of platforms and techniques or ways that telehealth is being delivered is? Do you think it? Is it mostly, do you get the sense that it’s mostly being done on zoom? Or is it mostly on the telephone? Or is every place kind of figuring out their own platform and doing that?

Vahagn Nikolian  25:15

I think the platform is one of the biggest barriers to expansion. And I say this because often times, it’s not really a matter of being able to, like, I don’t know how much the video like what mechanism you use to connect with a patient, whether it’s zoom, whether it’s your EMR based app, whether it’s alternative software applications, I don’t think that makes a huge difference. Really, it’s all about what information do you have? What information do you need, and for every doctor, every surgeon, this is going to be different based on the clinical entity that they’re focused on. And so, you know, for my residents, and my medical students who come to my in person clinic, and you know, we run our clinics, just like we’ve always run them, the resident or the medical student goes and sees the patient, they come out, then staff it with me and give me sort of what they think is going on, we go and see the patient together, we maybe before seeing the patient, we review the imaging, we review the data, we come up with a preliminary plan, get some feedback, I tell my students that the vast majority of the patient evaluations you do in the clinic, especially in the new era, where we have all the CT scans uploaded on the medical record system, we have all the labs we have oftentimes, the old operative reports from prior surgeries, you oftentimes can make an asynchronous assessment and plan even before seeing the patient. You come in with this preliminary concept of what you think is going on with the patient, what you think you’re going to provide in terms of services. And then when you meet with the patient, you fine tune it through your history and physical and you understand how are you going to provide the care that the patient desires and address the issues that the patient is here for, with the you know, the resources that you have at your medical center. And so the vast majority of patients, I think, asynchronously, even before seeing them, you could do that. And a lot of the information you tease out from the conversation with the patient is just that: it’s teased out from a conversation from the questions you asked. I would say that there’s a very small proportion. And this is kind of controversial. But a small proportion of patients, you absolutely have to lay your hands on and do a physical exam so that you can guide your decision making for an operation. But for many others, I think you can make that asynchronous decision, especially if you have radiographic diagnoses, biochemical diagnosis. And so it’s evolving. I think the preoperative setting, you know, who is the perfect patient for virtual, it depends on what your subspecialty is. You know, I can see in hernia care, for instance, that’s what I focus on. If it’s a patient, who has a very consistent story within an inguinal hernia has an inguinal bulge that’s obvious on video, and has an ultrasound that was performed at an outside facility that demonstrates an inguinal hernia. You know, it seems like a patient that would you know, have all the things that you need to make that decision that a surgery is warranted. I use that as one of my examples. So clearly, there’s patients that come in with a possible inguinal hernia where they don’t have a bulge, they don’t have an ultrasound. And so you’re going to be limited in your ability to do a virtual console. But at least that initial conversation that maybe is done in a patient centric way where the patient doesn’t necessarily have to drive hours to come to your clinic or take time off work. You can then coordinate say okay, well, based on what I’m hearing, it sounds like you may have this problem. Why don’t you come to my clinic, I can’t fully distinguish the diagnosis. Or you may say you know what, based on what you’re telling me I need further imaging. Regardless of, you know, whether or not I see in person, let’s get the imaging and we’ll go from there. So we can triage it and make it more efficient and make the clinical experience centered around patient like the in person clinical experience centered around the patients that truly need to be there and open up space for patients who truly need to be there to have more ease in accessing in-person care.

Ameer Farooq  30:06

Yeah, you know, it’s funny when I was a medical student, the Canadian Medical Association Journal, which is sort of like the main medical journal in Canada had this contest, which was called the “Two Essay Contest.” And they invited medical students and residents to submit either short story or an essay about their vision for what healthcare would look like in 100 years. And so I wrote this short story that’s called “Touch”. And it was it was about essentially, envision a world in which there would be no role for the physical touch of a physician or a doctor, in the care of their patients, and what that does to the relationship with patients. And, you know, obviously, I didn’t have to wait 100 years, to see that partially realized. So like, it’s so interesting. And it’s so true that there’s many aspects, particularly in surgery, and particularly in specialties that are heavily image based, you know, I think of Dr. Ball and, and liver resections, where you the CAT scan really does tell you so much about what the operation is going to be like. That, you know, you do start to wonder what exactly the in person evaluation adds. The challenge, though, is that obviously, then it actually requires you to really systematically think about what are the things that I have to actually see in clinic and what I don’t have to see in clinic. And in some ways, it requires a lot more work on the physician’s part. You know, in the old days, you could just have everyone come to clinic, you don’t have to think about it, whether they needed to be there or not, you could just have them come to clinic, that would be your trigger to review their imaging that would be your trigger to review their CEA, let’s say after a colon resection, like you wouldn’t even have to think about those things. How do you counsel people who are looking to set up a virtual telehealth program in terms of a) creating a triage and criteria for who is appropriate and b) kind of maybe mitigating set like some of the perceived extra work that you’d have to do to actually look at each patient and triage them? For whether they’re working? They’re appropriate for virtual care or not?

Vahagn Nikolian  32:15

Great question. I think this is so challenging, because every specialty and beyond the specialty, every diagnosis, has a very different set of things that we need to make an effective decision assessment and plan. And so it really is about working. And it’s slowly expanding the program. And so I tell people like, are there, I mean, COVID has almost served as a natural experiment for this. And I think because of the reliance that we’ve all had on virtual care during the last almost year, I think it’s easy to now look at actually what we’ve accomplished. And understand which patients we were effective in caring for through a virtual platform. And for every doctor, this is going to be different. Remember, although you know, the utility of a physical exam may not necessarily be true for a patient with a pancreatic cancer, right? If some people would say, if you have a CT pancreas protocol, and you know the degree of invasion around the vessels, you know whether or not you need to put an incision on some. Clearly that, from a technical standpoint may be true. But there is such an important element of connecting with that patient before they undergo such a big operation, or you tell them that they’re not eligible for the operation that they’re hoping to have. And so most importantly, we’re not saying that every patient should be seen in this setting. We’re saying that you as a physician have to decide what you’re comfortable managing in this setting. And you have to make sure that the patients that you’re seeing in this setting are comfortable with the concept of being evaluated like this. You may find that there’s never going to be a perfect situation. We’re all patients that need to be seen or can be seen like this, who are willing to be seen like this, but you may find a certain group of your patients who, you know, a larger percentage is willing to undergo this, this approach to care. And what that does, and I tell everyone like what this does is it can potentially mean that the other patients that you need to see in clinic will be able to see you in clinic more readily whether it’s having an appointment that’s sooner than they would have expected or an appointment that is, you know, more prolonged, where they can actually spend a little more time with you in the in person setting so that you can, you know, work them up and understand how to help them. So those are some of the things. I would say that the barriers right now are that when we transition from an in person setting, to a virtual setting that the resource allocation is very different as well. I can talk about my clinic, I do a normal in-person clinic on a Monday, and on Thursday, I do a virtual clinic. And this was intentional. When I started at OHSC I said I truly want my virtual clinic be a true entity, I don’t want to integrate my virtual care in the midst of my in-person clinic, they’re. They’re separate entities, when my schedulers are putting patients and I say put this patient for virtual put this person for in person. My in person clinic, I have unbelievable resources. I mean, I feel so fortunate to have a medical assistant or nurse, a receptionist, medical students or residents in with me in the clinic. So we have so many people helping coordinate care for the patients that show up. My virtual setting – it’s like a one person band. So like I check the patient into the virtual setting, I review their medical record, I then come up with the plan. And then at the end, the clinic I email a plan for all the patients that I saw to my scheduler or medical assistant or nurse. And so it’s a very different setup. So I think we’re gonna have to recalibrate and understand that if we want virtual care to be a true entity, that we have to dedicate resources and reallocate the resources that we’ve used in the traditional settings, to the virtual environment, so that we can give that same care without being overwhelmed. Right now, sometimes I feel a little overwhelmed when I do virtual care. But I think it’s getting better, we’re definitely getting better, because we’re seeing the utility.

Chad Ball  37:17

You know, you touched on so many nuanced and important things there, It’s probably worth revisiting a couple, you know, it’s interesting as a liver, pancreas surgeon, on that side of my job, if you had asked me before the COVID pandemic, you know, what we what we could do virtually, with regard to telehealth, you know, I probably would have listed about 15, or 20%, of what we actually ended up doing. And I like to think of myself as a pretty open minded, optimistic, innovative guy, and I would have been dead wrong. And it was a, it was a really powerful personal lesson for myself, as well as really all of my colleagues, to your exact point in terms of what you can actually do when when motivated by the by the right drivers and the right environment. And I love how you said that COVID is almost a natural experiment, because I think that’s exactly the way that we should look at it. It’s also interesting to reflect on on your comment, at least for me, personally, with regard to trying to assess out which patients you know, are comfortable, which are happy with a phone or a video conversation and which ones aren’t. And for example, in you know, pancreas cancer, I’ve actually found that it’s not topic or scenario, sort of related or based at all. So I find that some people that have unresectable disease, are extremely happy to have a fast phone call on the phone, and are thrilled to move on to the medical oncology palliation or maybe neoadjuvant therapy side of things immediately. Whereas yours, you’re exactly right, other folks, you get the immediate impression that you should probably meet in person and chase that. The other powerful thing that, you know, as you know, doing larger abdominal wall reconstruction, larger cases, and as we know, in HPB, is that there’s something to be said beyond resectability in terms of just looking at the physical nature of a patient. You know, it’s one thing to ask them on the call, right? If you and I went for a walk, how many blocks could you walk for we had to stop and why do you stop, but it’s another thing to be able to watch them try and get up on that examination table and can’t do it. Those sort of subtleties, you know, can really be helpful for some patients in some cases.

Vahagn Nikolian  39:45

Yes, absolutely. Absolutely. Whenever I think about which patient population would work well for telehealth, one of the questions I’ve posed on some of the presentations I’ve given on this topic: it’s always my last slide. And I always and I hope this isn’t the last question, but maybe I’m jumping the gun here. But I always ask people, when you’re in clinic, before or after you see your patient, ask yourself: what role did the physical exam play in my decision making?

Chad Ball  40:23


Vahagn Nikolian  40:24

And ask yourself, did I know what my recommendations to the patient were going to be before I even saw the patient? I think if you just think about those two questions, and on the patient level, you’ll be able to see just how frequently virtual care may be an option for you. It may not be your go to, but it could be an option.

Ameer Farooq  40:54

Just to reiterate what you’re saying: you’re not saying that everybody should be seen virtually. And it’s so important to just like, with everything that we do in surgery, to select the right patient. I did want to pick up on one other thing that you mentioned, which is the fact that you schedule your clinic separately, you have the virtual clinics on Thursday, and you know, your in person clinics on Monday. I think workflow is a big part of maybe why some people don’t want to switch to doing telehealth, obviously, COVID is for force people to do that. But, you know, maybe pre 2020 I think one of the main barriers may have been workflow, in that, you know, it’s much easier as a physician to just have people kind of lined up for you in in the office, and then you just bounce between rooms and the rooms get cleaned, if you have a nurse or someone else to help you out. Whereas with telehealth, you know, potentially there are some challenges, you got to phone them. I think if you’re using a video type platform, sometimes are more elderly patients might have trouble logging on to it. You know, it is a different kind of dynamic. I know in your Annals of Surgery paper, you actually found that telehealth visits took on average much, much, much less time then than in person consultations. But I’m curious, maybe for both you and for Dr. Ball. How has tele health impacted your workflow? And do you think it’s made it easier or, or harder to kind of be efficient in in this whole process?

Vahagn Nikolian  42:25

So I think telehealth is changing with the focus: where we center the focus in terms of efficiency. When we’re talking about in person clinic, again, the providers are the center, right? It’s your clinic, it’s your time, it’s your Monday, from eight to five, where you’re going to be seeing patients and just like you said they’re going to be in clinic, you know, when they come you’ll see them. For the virtual care, it centers more around the patient. And currently, with the resources that most places are allocating towards the telehealth experience, it can feel that like it’s much less efficient for the surgeon to see a patient in the virtual setting. Why? Because you don’t have the medical assistant or the the receptionist working to check the patient. And there’s no one else reviewing the electronic medical record or updating the medication list. There’s no one else to just run by as a “hey, would you be able to see if we can get these labs drawn today,” you’re basically on an island by yourself right now. And so clearly, we have to change that if we’re going to be an effective virtual sort of medical setting. We have to have a medical assistant just like we do in clinic, we have to read define how the resources are allocated. So, you know, one time someone was asking me about, you know, a 15 minute appointment to see someone where you were maybe walking into the room for five to 10 minutes to tell him that the incision look good, was just that. It was five to 10 minutes of your time. But now, if you have connectivity issues, and they don’t pick up the phone call or they’re unable to get to the video, it may turn into a 30 minute experience. It seems like it’s not conducive to being efficient. Remind people, I mean, for that poor patient who lived four or five hours away. You just saved them eight hours in commute to maybe lose about 10 minutes of efficiency. How could we make that better for the physician? Maybe allocating resources, having a concierge program. So we call it a concierge program, where the medical assistant will check into the video visit, just like you’re used to in clinic. You’ll know when the patients are ready to be seen when their medical record has been updated. When everything is in order and their videos up, you’ll be queued into when a patien is ready to be seen. And you can start stacking your patients in, in the clinic in the virtual clinic just like you did in, in person. So it’s an evolution, it’s an evolution. And I think we’ll get there eventually, but clearly not there yet.

Chad Ball  45:26

You know, again, so, so many great and really salient points that you make there. The first one I love is that, you know, I think you’re right, we we’ve shifted some of the, I guess you could call it burden from the patient to the physician, and the system, as a result, I think that’s appropriate. I mean, your examples, perfect. For a lot of us that work in tertiary or quaternary care facilities. You know, patients are driving for hours each way or even longer. Patients are taking a whole morning or whole afternoon off of work. And when you think about it, now from a patient point of view, but from a societal point of view, and then you experience what’s going on now. I mean, it’s amazing that our preceding dated system existed for as long as it as it did, and that certainly speaks to inertia, lack of vision that, you know, outside of rare folks like yourself that, that were doing this early, but, you know, the rest of us really are late to the party, but boy oh boy, is it a party. My other comment is, is that we you know, we recently had Karen Norris, on our, on our podcast, and she’s, you know, you probably don’t know her, but she’s really the conference planner for a lot of major medical and surgical conferences across Canada and into the US. And she talked about the future of conferences, being hybrid in nature, and more importantly, philosophically being designed, as opposed to being quickly constructed, you know, in the most recent iteration here in the past year. And in going through some of those possibilities in planning our next national meeting at the end of this year. It’s unbelievable how fast virtual experiences have come in such an incredibly short time. And you know, it’s interesting to hear your concierge comment, because some of these waiting rooms, the visuals of the waiting rooms, what patients can access while they’re waiting, you know, pre-populating forms and information. The future is absolutely incredible.

Vahagn Nikolian  47:28

Such great points. And again, I think the other thing I tell people is you can’t judge virtual care by what your experience has been in, in the midst of a pandemic. This is clearly a sub optimal scenario, we’re doing our best to just keep a flow, make sure that the patients that need to be seen are seen. But clearly, this isn’t the best way to judge whether or not the platform works. I think even in spite of all the barriers and all the things that we’ve had to overcome, it’s worked pretty well. And has it been perfect? By no means has it been perfect, but clearly, it’s demonstrated a potential. And through iterative improvement, I can’t imagine we can’t do a lot better in the future when it’s not necessarily the only approach. And it’s not something that we’re rolling out, but rather something that we’re improving upon.

Chad Ball  48:32

The future is clearly bright. I think, you know, most people, if not everyone in the surgical community, and I assume the medical community at large is now been woken up. And we’re just thankful to have leaders like you in this space that I think will take it all to the to the next level. I also wonder if our evaluation tools need to change as well, you know, at a 30,000 foot level, you probably call them traditional, but you know, this space and this technology and the patient experience in the physician experience in the system, expectations, probably all need to be evaluated and looked at in a different way than than we have been traditionally.

Vahagn Nikolian  49:09

Yes, by all means. I think if there’s anything we’ve learned from this past year it’s that there’s a lot of new and exciting ways to do the things that we’ve always thought were not possible. We can definitely get better. And then again, the nice thing is because we we were forced into a new normal for now, a year, it is a natural experiment. We have data across every subspecialty and across every domain. We can identify ways to do things better. Things that have already worked well, in spite of suboptimal conditions, things that clearly didn’t work well and we should just recalibrate and start afresh. And things that are going to need some iterative improvement. So clearly a lot of potential. When I was sitting and preparing for my first job out of fellowship, it was last February, so almost a year ago, it’s just been a year. And I remember they asked me what my academic focus will be as a faculty member. I said telehealth and virtual care – I want to improve access to care. And for many, they’re like, yeah, I think that has the potential to be something over the next few year. How? What are your short term goals and I’m like, my goal would be to demonstrate that it’s safe for my patients and hopefully generate enough, you know, data on the patients that I take care of, to encourage others to do the same, and then hopefully drive for some policy change. Literally a month after that conversation, COVID becomes the major issue. And we completely changed the way that we deliver care. And all of those data elements that I was thinking that I would have loved to have to be able to analyze –  all of the policy changes, I was hoping that I would be able to push towards change. All of the perceptions from a provider and patient standpoint, they all happen. So now we’re sitting here, and everyone, whether they are people listening to this podcast, us sitting talking amongst ourselves about, you know, what the future holds, we all have access to this unbelievable wealth of knowledge at this point. And it’s on us to try to interpret it and understand how we could use this last year to make the future even better.

Ameer Farooq  51:48

One of the interesting studies that, again, you tweeted out and I had the chance to look at that I thought was really intriguing was the study that was done, was spine surgery patients that looked at how often management changes, you know, you’re talking about the safety and efficacy of doing virtual care. And we’ve obviously been talking about this a lot about, you know, does it really matter if we had a physical exam or not. But this study actually looked at whether management changed when, let’s say the patient was seen through a virtual visit. And then when they actually came for an inpatient consultation? Do you think that, you know, obviously, again, this is going to vary a lot, depending on the specialty, but how do we avoid that kind of surprise, you know, I’m thinking of recently, one of one of my faculty surgeons in Vancouver had a patient that they talked to over the phone, and the pre-admission clinic had recorded their BMI as being 35. And they actually hadn’t seen them preoperatively, they just talked to them on the phone, they had all the imaging, all the things that you think were necessary to make a decision for the operating room. Then the vision showed up on the day of the operating room, and we’ll just say that their BMI was not 35. It was significantly more than that. And you know, it was a big shock. You know, they obviously were able to adapt, but, you know, it obviously throws everyone off kilter, and it made it a very challenging and difficult situation to deal with. So how do we get around that type of problem going forward?

Vahagn Nikolian  53:26

Yeah, similar things have happened to me. I personally saw a patient who had a similar storyline, and especially in the setting of doing abdominal wall reconstruction. And you want to be careful, because BMI really plays a role in terms of post operative outcomes. And so you got to be careful. That said, I think you build that into the new normal. You expect that the virtual platform is not perfect, just as the in person platform isn’t perfect. Some surgeons are seeing patients and then operating on them, maybe two to three months after their evaluation, just given the latency and scheduling. And things change. People evolve. People gain weight, people lose weight. I don’t think it’s a failure necessarily. It’s just a product of, you know, the times I mean, we’re not oftentimes able to operate on a patient within a week or two of their surgery and oftentimes not safe to do so. So you’re going to have that happen, and that’s okay. I wouldn’t deem it a necessary failure. I think as it happens, though, you have to ask yourself, could I have prevented this? How could I have prevented this? So maybe you as the surgeon who’s evaluating a patient who lives six hours away, and reviewing their CT scan and understanding what’s going on with him. You recognize okay, I want to save this poor patient a six hour trip to my hospital so that I could see them in person, trusting that the CT scan is reflective of who they are. And trusting that the information I gather, that’s going to make a difference for my operation, it’s appropriate. Now, for the pre medical clearance, maybe for these patients, we say, okay, well, although their age, and some of their other comorbidities don’t necessarily merit another evaluation, and technically, if I had seen them in person, I would just send them to a phone, pre-op clearance program with our anesthesiologist, in this particular case, maybe I should divert this patient to a primary care provider locally, close to their home, who can evaluate this and make sure that all the other elements that I’m expecting to be in order, are in order before I commit this patient to a scheduled operation, potentially take an operative opportunity from another patient? Things of that nature. So again, I think, not a perfect setup right now. Definitely opportunities for improvement. I think the preoperative evaluation, I tell many of my patients who I evaluate – who I feel like I’m comfortable making that decision: hey, I have all the information I need. You seem like a reliable patient, you seem like the information you’ve shared with me is is about all I would need to make a decision. I always end the conversation, ask them, are you comfortable making a decision about whether or not you have an operation with a virtual eval? Or do you want to come in and see me in person? By just opening it up like that, I think they’re thoughtful enough. I’ve had patients say, you know what, let me come to your clinic and see you in person still, and I feel comfortable doing that. We don’t necessarily have to dedicate the same amount of time because I’ve already gotten to know them, it almost becomes like an established patient evaluation. But I think it helps triage and provide that patient centered care we’ve been talking about.

Ameer Farooq  53:30

I really liked that question. And I think that’s it’s a great one, to kind of give people the opportunity to make a decision that way. And maybe it allows them the opportunity to reveal something that maybe they weren’t going to tell you before. So I think that’s such a great and insightful question. We’ve been talking a lot about, you know how this relates with surgeons, but we haven’t talked about how perhaps this impacts trainees, certainly in Vancouver, which is where I’m doingt my fellowship, no residents have been coming to any of the in person clinics. I’m curious how you have you think virtual visitors have impacted trainees? And also maybe how trainees can be incorporated better into virtual visits?

Vahagn Nikolian  57:55

I love the question. I love the question, in particular, because this is a question that we specifically asked all of the members of the American College of Surgeons, the resident cohort, and so we had about over 500 residents respond about their personal experiences with telehealth and virtual care. And what we found was, as you would expect, the majority of residents had almost no virtual care experience in the pre COVID era. In the post COVID era, their experiences didn’t improve that much, but their desire and interest in telehealth definitely increasingly and they saw that there is a utility. We’re currently analyzing the data but it appears that irrespective of region irrespective of training background, residents are enthusiastic about the concept of telehealth. They see that it’s going to be a viable entity in the care of patients in the future. And they want to be involved in these interactions. I tell my residents that we’ve always focused on bedside manner. And as we evolve, we’re going to have to focus on also the concept of website manner, and making sure that you can effectively communicate with a patient over a virtual platform and give them the confidence that you are making a decision that’s in their best interest. And so definitely, works in progress, a lot of opportunities to develop resident based curriculum around it, students, medical students and medical schools are looking at curriculum. We’re developing some curriculum around the concept of the virtual hospital and trying to improve that so that residents and medical students see just the potential of what can be accomplished, digitally, at remote sites in austere locations, in rural patient populations, a variety of places.

Ameer Farooq  1:00:06

That’s fantastic. And I think that there’s ways that we can integrate trainees in ways that we hadn’t thought about before. And perhaps even get more out of these visits, particularly maybe even for early learners, where they can, you know, really attend more clinics and really understand the decision making in a way that they couldn’t, that we haven’t even begun to think of. So I’m really excited to see where your research goes, and, and the virtual hospital will be cool.

Vahagn Nikolian  1:00:37

Think about the potential for trainees. Let’s say you have you’re in a hospital that doesn’t have some subspecialty care that you’re interested in learning about. And you know, it’s really difficult to coordinate a visiting internship at another institution, there’s a lot of things that have to fall into place for some kind of opportunity like that. But imagine, we now change it so that you can have a virtual experience where you can walk into the clinic with the doctor that you’re interested in shadowing, virtually see their patient, and most importantly, see the patients with them, and most importantly, discuss the nuances of care that only that sub specialty doctor that you’re interested in working with – the doctor that sees these really rare diagnosis is able to enlighten you with. We can really expand the potential for trainees to learn from extramural sponsors and supporters. So I love the idea that we’re no longer going to be as restricted by our geographical ties and be able to expand our knowledge, irrespective of where we live.

Ameer Farooq  1:01:54

Not to belabor this point too much, because I know that the circumstances will be different depending on what what system you’re using, and how exactly the virtual visits are set up. But what seems to work well, just logistically in terms of integrating residents and medical students into your clinic? Let’s say if we were using zoom, do you get the resident to kind of talk to them first and then put the patient into a breakout room kind of thing? And then both rejoined? How does logistically do you think, currently, and obviously, this will change, most likely, but logistically, how do you sort of see the best workflow in terms of getting residents involved?

Vahagn Nikolian  1:02:39

Yeah, I try to mirror I try to mirror the in person clinic experience, just so that we don’t have too many variables that are changing. And just like we did in the in person clinic, where the resident or student will go see the patient come out, you know, present the patient in a standard format, and then give an assessment and plan or will then review and then go back and talk with the patient, we try to emulate that in the virtual setting as well. I feel that by doing it in that way, the only variable that’s changing is the physical location of the patient and the providers. And then we’re able to more easily understand, okay, what is the benefit for the student or the trainee? What is the benefit for the patient? What is the benefit for the system by just changing this one variable, the origination site or the location of the patient?  So just doing it in that methodical approach, I find that I’m able to get a little more out of it and be able to really understand the impact of the virtual experience.

Chad Ball  1:03:51

If you were to go back and provide yourself with early advice, sort of a younger you as you maybe enter practice or maybe you entered training, what would you tell yourself given the experiences you’ve had since that time?

Vahagn Nikolian  1:04:03

One of the pieces of advice that my mentors gave me that really changed my perspective and made me a better doctor, surgeon and person, was not to get too high on the highs and not to get too low on the lows and try to stay even-keele. You know, life is a roller coaster. Surgical training is definitively a roller coaster. And and not getting too down really can help you and then not being afraid to actually celebrate the good moments and just find the the happiness that comes with you know, the good that comes with what we do. So you know, not getting too high on the highs and not definitely not getting too low on the lows.

Ameer Farooq  1:04:58

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.