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Hello, good evening. Good day. Good morning. Good afternoon, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David o'regan. I'm a retired cardiac surgeon in Yorkshire in the United Kingdom. The past director of the Faculty of Surgical Trainers of the Royal College of Surges of H and the visiting professor at Imperial College, London. We've got a technical issue at the present as my guest is stuck on the other line without a camera and he will join us as soon as we have the camera. But I'm delighted we also joined by and welcome. I think we're all on. We're, we're here. Thanks very much indeed. So I'm delighted to introduce our special guest this evening. Professor Chris Tara. I met him recently in London and he returned to Canada. Now, Chris was the president of the Canadian Sur Association of General Surgeons and a present to recently, he was on a medical panels commissioner for the government of Alberta and the Ministry of Labor. He was a general surgeon specializing in Bariatric surgery and surgical oncology, is an associate dean for the Faculty of Medicine and dentistry for the University of Alberta, and also Associate Professor of Surgery for the University of Alberta and director of the surgical residency and training programs for mcmaster. Chris has many years of surgical experience and in his retirement is written a number of books and this is the most recent the history of eminent surgeons where he looks at famous surgeons and what it means to be a surgeon. And part of this evening's conversation is to talk about that subject that many surgeons say we do not have complications. Welcome Chris and thank you for joining us from Canada. Thank you. Thank you very much indeed for your introduction. And, er, er, just if, I mean, you've got my CV, right? But I'm er, moved on from those various posts at mcmaster and I'm a retired emeritus professor these days. But, er, thank you so much for that very kind introduction and thank you for inviting me to be along with your in, in this marvelous, er, er, exploration of surgical skills and, and the softer elements of, er, er, of surgery, er, and all the issues that we're going to bring up and discuss such as complications. So, Chris, what do you think? What data do you think surgeons should keep? Yeah, and sure it, it's, it's a tough one, isn't it? Because a lot of data is kept about us at all times. The whole system is designed to collect, er, er, length of stay data and, er, um, a myriad of issues around complications or whatever. So, the issue is collecting data that is meaningful ultimately to help you improve your surgical skills and techniques. So, uh, I, I, it's nice to collect, uh, you know, how many wound infections did you have last year and, and so forth? Um, and I think that, that, that helps tremendously and there should be a sort of a baseline of things like wound infections and lengths of stay and so forth. But the more subtle ones, er, you know, unusual complications that you might have got or, you know, er, how many dvts occurred. Er, one has to separate out the various bits of data into complications, er, that, that are surgical in, in nature and maybe be in your hand and surgical complications that may, to some extent be outside your hands. DVTs are a good example. Urinary tract infection may be completely outside your surgical hands. Er, but an anastomotic leak on the other hand is, er, probably very much a part of what you've done. So, how would you define a complication then? Um, it, it, it's, it's far better defined in the literature than I have done but, um, it, it's defined by, um, er, un unexpected or un untoward, er, medical events that have occurred, er, for the patient that's extremely broad. So, how would a surgeon focus on that? Um, well, I still think it's, it's start big and then, and then shrink down to specifics. I think it's important that the surgeon focuses on their particular areas of, of complication. Er, you know, for you, it might be post coronary artery bypass infarct rate. Very specific to you and your particular, er, area and giving you the opportunity when looking back on such things to say. Yeah. Well, clearly something, something is awry. Er, you know, maybe I'm not using the right suture material or whatever it is. Um, and the one question that always determines a surgeon from another is, have you had any complications? We have asked that in the pre chat? Yeah. Well, that, er, you know, er, that's, er, one of those great truth or lies that people will say. I, I never had a complication in my life. You know. Er, I think there's another factor when considering all of this and that is that I always used to like quoting this, the less the pathology, the better the outcome. So, you know, excising a sebaceous cyst is unlikely to have too many, too many complications. But removing a retroperitoneal sarcoma is going to be fraught with the complications. And in fact, in, in, in my bariatric practice because I'd focused on, on redo surgery, people who'd already had a bariatric procedure and we're now undergoing some revision procedure. Er, I would always tell a patient that there's at least a 50% chance that you will, you will suffer some complication. You know, even even wound infection and I was assiduous in leaving the wound open to heal by either secondary, intentional, delayed primary closure. These are all effectively complications. Mhm. And, and what is this is the honest truth of these sessions and sort of taboos? What has been your worst complication? And how did you deal with it? Um I think the important thing when dealing with, with bad events is, is communication, relaying your, um your concerns to, to friends and colleagues in the first instance and then, er, going up the food chain as it were and speaking to mentors, er, to, to determine whether there's something that, that you could have done differently. I think that's a very important part of the, of the, how to manage um er, what is inevitable but this must not crush you, you know, because of the reality that complications will occur. So how do you do that? How do you build that resilience? Well, I think the resilience must come through, er, through having, er, close comrades and confidence and people and, er, even, er, going home to family and just saying I had a shitty day and this is what happened and even if they may or may not understand what you were doing, er, they can, er, sympathize and, and so forth. So, as you say, resilience is an important part of it and, and being resilient without being hard without being um you know, er, water off a duck's back. Oh, I get come. So what, you know, there has to be that, er, that finding of the balance and that, uh, uh, uh, uh, how, how would you instruct or teach the learning surgeon to find that balance? I, I think at least in the first instance through example, the, er, after all, so much of surgery is about observation and I think it's important for the, the trainee surgeon to see the train or handling these issues and these problems in an effective way, er, and demonstrating the sort of the whole communication, the communication side of things and whether this is in the surgeon's lounge, er, just discussing the cases with people afterwards, er, or at the scrub sink. Um, I think, I think it's most important to communicate. There is an element or an, a necessary element of vulnerability and humility in that. Yes, of course, don't want to do that. People don't necessarily feel comfortable in being humble or admitting, admitting error. It's not after all, it's not in the, in the surgeon's mind to, to admit, to admit mistake. It's not been taught as part of the, part of our ethos if you like. But I think this is, this is what we must do and how do we go about doing that? You're in charge of a residency program. How do we go about teaching the new generation that this is important? Well, first again, it's to articulate, you have to, you have to expressly state that this is an important part of the process. I think the, the, the, yeah, I mean, some of the reasons why we're discussing all of this is to expand everyone's remit beyond the technical and into these somewhat softer skills that are, that are equal in measure. Um And um I think all one can do is teach by example and demonstrate um good, good skills, good mentorship, good coaching skills. I would charge everybody to read Atul Gowan book on Complications. It's, it's, it's a really very thoughtful book. Um, er, and has lots of interesting quotes and, and so forth and he writes so beautifully. It's, you know, it's a, it's a page turner. You can, you can catch on to it quite nicely. What did you take from his book, Chris? I took that I was extremely jealous of such an accomplished individual and that he was a remarkable individual, capable surgeon who was also able to put pen to paper and, and um, that was, that was a great stimulus to me, to put pen to paper for my little surgical book that you kindly showed just because it's an additional skill and it's nice to be able to, to put pen to paper and to write more than, you know, I fixed this hernia dust. It is a would pen to paper and reflection help in thinking about the inevitable complications of surgery. Have you done that? Yes, I think so, I mean, have, I did, I do it enough. No, of course not. Um, but the reflective process is important. Er, er, and if pen to paper is, is your method, I think that's good. My, my, er, pen to paper was post hoc if you will, after I'd finished, um, doing surgery and was using it as a form of entertainment in, in retirement rather than the time. But I am sure that there are those who, who wish to reflect on their, on their complications, um, day to day and might, they might walk around with a log book with a, you know, with a, with a, with a, with some sort of a binder that they walk with, er, and, um, that may be their, their way of doing things. What data should a surgeon keep good data, quality data? I mean, you've come back to this and I think it's rather hard because as I say, it, it's species specific, it's specific to your area. I think it's, I can always remember keeping a log for myself of my sarcoma patients. A big binder kept all the data and I think it's a nice way of focusing your interests and potential research interests by picking something that, that is of interest, er, interest to you and can be something that, that you can publish on. And I mean, typically writing, you know, this is, I did, er, you know, 3000 of these who, who else cares about such things. But, um, it does help to focus your thinking because you might note in your list of, er, er, of procedures that something turned up that was, was unusual or, um, you know, um, was part of, of, of what you were doing and it could lead to a, a research question and this is when you can engage others in saying, well, this is this of any interest to other people. You did mention seeking out mentors. How would you recommend a training surgeon finds or seeks out mentors? Yeah, I think it's a critically important piece of the, of the whole surgical training puzzle and it always struck me that those surgeons who had mentors were the most successful in career advancement. Er, and I think having a mentor is, is, er, is very important but, you know, people aren't gonna, you know, stand up and say I'll be your mentor today. Um er, so easily, but certainly it is worth looking for somebody who, er, er, might be like minded has the same sense of humor. Er, these are, these are ways in which mentorship can be, can be very helpful. And you're looking, remember that you're looking for in a mentor, you're looking for different things to the coach, to the actual trainer. The mentor is more of an advisor, someone you're going to bounce ideas of career advice. Um you know, even nasty things like, you know, one resident may be accused by another resident of inappropriate, um, you know, advancement. Um, and, um, this is where a mentor can be, can be extremely helpful. Mhm. And how, what would you, what would you recommend to a surgeon starting a career in surgery? Because it all, this seems scary to something. Right. I mean, I, I would certainly recommend the idea of, I mean, the first, the ideas need to be introduced and it isn't something that you do on the second day that you go knocking on 1000 people's doors and asking to become a mentor, you know, allow time to develop, allow for, um, the natural order of things and for people to, er, to present themselves as, as, er, somebody who, um, who, who could be, your mentor could be good for you and of course, you don't just need one, you can have several, it's not, it's not a one shot deal. Mm. Um, I, I put together a few things to show people and what I believe is important. We work in a show me environment and if you're not prepared to show me, then I'm not prepared to have an operation by you. And then in that show me data, I'd be looking for somebody who's safe, somebody who is effective and somebody could offer a good experience so safe I would look at as mortality and that's easily measured, but effective would be all the complications but the effective and complications are often thought of as short term complications and we often think of and forget about the long term complications of what we do. In other words, was it worth going through the procedure? Did it actually relieve you of the symptoms you started with in the first place? And certainly in bariatric surgery did many people actually say that was worthwhile. Yes. I think a lot of, I think there was a lot of satisfaction and obviously the aim of the game was twofold. I mean, first of all, it was to try and get people to lose weight. I mean, that was, that was a critical component. Uh, and I think there was plenty of satisfaction in that side of things, but I felt that for these type of patients that I dealt with, they needed to be schooled in the idea that they were on a journey and that the journey was getting over the operation and being and tolerating. Um, you know, some long term consequences. Er, you know, they often, um, talked about the Dumping Syndrome, which was, which is very common in redo gastric surgery. I found the Dumping Syndrome to be less common in the bariatric population, but certainly did exist and it's an incredibly unpleasant complication to have and the strategy is necessary to, to try and limit that dry meals and so forth, er, are very important parts of the process and, and educating the, the patient that, uh, you know, you you may have this for good and you have to be, you have to be wary of that and education being uh the essence of part of that consent process. Then for a patient with complex things, remind, remind me what dumping is dumping, multiple different descriptions of the dumping syndrome. But basically, it's the problem of a high solute load high in sugar and so forth in the er, arriving rapidly in the small bowel and then this sucks liquid and fluid into the small bowel so that people will feel faint, uh, bloated and then eventually have a copious diarrhea. Um, so what's the prevalence of that after the surgery? Well, as I say, after bariatric surgery, it wasn't terribly, wasn't terribly common, um, in, in, in ulcer surgery, it was frighteningly common. You know, people used to have redo ulcer operations and they really did suffer with this a lot. So, the Dumping syndrome was quite a big deal for that population. So it's good news that, you know, an ulcer is just an infection. When, when does the complication need to be described or specified as part of a consent process? I think you, yeah, I, I think you do need to, er, I mean, the first part and, you know, we, we've got a whole section on consent and the whole, the fi first part of the consent process is that it's, you know, there's a lot of information going in one ear and coming out the other because they're overloaded with this terrifying individual, er, plowing them with information about what's going to happen and so forth. So, you know, I think there is a, there is a duty of care that demands that you do list out the more common complications. Um, this doesn't need to be like the, like the Americans where they, you know, spend two hours obtaining consent to list out every single complication and working out well. Is it a 5% complication rate something you mention? Or only if it's something that occurs, you know, 20% of the time or? And so, I mean, in a way that that's inside your practice, what you, what you would think is appropriate to mention, but certainly one does need to, to be able to, um, to educate the patient in the complications. And I mean, if you're, if you're particularly rigid in your, in your consent process, you need to get the patient to relay back to you what you said to them and you'd be amazed how, how often people just just didn't get it. And, and often I think it's useful to have in complex surgery. I think it's useful to have friends or relatives who will have heard a different part of the story used to be very important in the cancer world to have to have relatives there as well. Um So that, that's also part of that, that consent process and making sure that you, you've outlined things in ways that make sense, er, and, er, you know, don't scare the pants off people at the same time. Indeed. Um, and, and one of the questions to ask is what are you going to tell your family once after this consultation? And as you say, what patients receive and perceive is totally different sometimes to what you have communicated in that regard. I mean, it is an interesting one that we should, we should be discussing. It's become much more common. I don't know if you saw it in your practice laterally that people would come in with a, with a recorder, some sort of dictaphone and record the conversation. And I know that some of my colleagues who are terribly anti that and felt that that was a complete affront, but I certainly didn't feel any problem with, uh with having a recorder. Did you, did, did that bother you if people came in with it? Not at all? But it's interesting that you say that some of your colleagues were affronted. Why would that be? Um, I think it, I think it was about trust. I think that, you know, they didn't, they didn't, there was this idea that they didn't trust what they'd heard and that, that's why they needed a recorder to listen to it later or, you know, you said something and now I'm going to sue you because, you know, it did or didn't occur the way the way you said. So, um, it can be used as incriminating evidence later on. And that's one thing we should be avoiding, of course, is doing something with the fear of litigation because if you're doing that, it's more likely something will go wrong. So we had, there were always quite a few colleagues who were absolutely, you know, had avoidance behavior to, to avoid litigation. And if, if they are that type of person where they're terrified that they might be sued, it really is a moment for people to reflect and say, well, should I be in this particular business if you know, this is going to, er, this is, this is going to happen. Um, and I think that that's, that's a very important part of, er, er, a, a part of what people do. I mean, if you're a plastic surgeon, er, you know, you have to be aware that, er, that you may not be able to make people as beautiful as they'd like to be. Er, and they may sue you for that. Some plastic surgeons I think, take pictures before and after and keep them on file as well. So, you've got photographic evidence of it. I do recall being sued for a wound infection, post appendicectomy. And the lawsuit, this, I was a trainee at the time and the lawsuit was successful against not me, but the hospital because we had admitted to give antibiotics and the person said that they had an unsightly scar which when viewed by a plastic surgeon was four millimeters at its widest and 10 centimeters long. But this particular person, it meant that they had seven creases down one side of the body instead of six creases in view of their size. And I just thought, well, there you go. Interesting. Yeah, that's what happened. But there, but there was an omission because we didn't give antibiotics. What, what about patient experience, Chris, what should we be doing for re recording or documenting patient experience? Because we both enjoy getting thank you cards from patients. How should we be collecting that data or showing that data? I think again, this is important to realize that the world is moving on and there are now, I know in some us institutions where the intraoperative or R is, is being recorded for the patient and you know, then they can pick up on an error that's made at the time again for, for litigious purposes. So again, it's being aware that this is the future and that people will be starting to record this sort of information. You know, people will have body cams and who knows what to record all this. And I think our job is to be cognizant of such things and not try and dig one's heels in and say I'm not allowing it but to put it in its in its rightful place and say this is good. This is, this is what we expect. Hm. Indeed. So, are you an advocate then for, uh, cockpit recorders in surgery? And black box tire gran talks about, er, personally I would not have liked it very much but I'm, you know, more recognizing that this is an inevitability that's, that's coming down the line and this is all part of the, part of the future. Mm. And indeed, and I, I think the new generation needs to be aware of this and it's something that you need to work with rather than against. And, and as they say, in politics, perhaps in surgery, the microphones on all the time. Yeah. Be mindful what you're saying, what you're saying and how you're saying it uh but also document very clearly what you've said every time because unless it's written down in law, it doesn't count, does it? Yeah. No, I mean, and documenting by writing is important. But um you know, how, how much and how, how much do you have to do? How long do you have to go on? How readable does it have to be? I don't know how legible your handwriting is, but mine is appalling. Um You know, and I, because I can't read my own handwriting, let alone. So, yeah, I think it's, I think we have to be cognizant of making it legible as well. And legibility cannot be an excuse and perhaps even type it, type it out, the one element that I included as part of safe and effective was patient experience. And I asked new patients directly the question anonymously at our patients, whether they knew or follow up. Um Mr Regan listened to me with carefully and with intent and I put it on a like it scale and also Mr Regan um treated me with respect and compassion. I mean, that's a very interesting topic that you've raised there, which is the idea that you are now quizzing the patient and making them grade you then and there with a 10 point like at scale saying, you know, he was compassionate seven out of 10 or whatever it is. I didn't do it. It was done done by the staff in the clinic. But I asked the staff after they had seen so I had no influence and it was anonymous. Yeah. And I, I was doing that following my visit to the Institute of Health Improvement, the Executive Patient Safety Officer Program and thinking of experience and the Disney effect. And the difference between a five out of five experience and a four out of five experience and a five out of five experience in is the aha awesome, amazing compared to the four out of five experience, which is, oh, that was ok. But 75% of people don't come back. Yeah, I mean, and, and if, if you do that, you really need to look at your five out of five satisfactions. But what is interesting the, the experience of asking that question in the first place. And you thought, look. Yeah. And, and I've always had a little bit of difficulty with the, I'm always very loathe to put five out of five on anything, you know, top mark because there's the implication is that you can't do any better and that isn't quite true. There's always a little bit more that you can actually do. So, again, that's how do you measure yourself if you say, well, you know, I give myself a five, you know, and the nurses gave you a five and everybody was, you know, all dancing and was that right? So those are, those are tough issues to, to tease out, I think. Uh Did you ever ask patient satisfaction to yourself? Absolutely. Yes, I did. And um uh yeah, iiiii, I did eat a lo uh a fair amount. Um And, um, you know, I was uh willing to take some of the criticism and some of it you weren't because sticks and stones, of course. Um So, um I think you have to be, be prepared for, um, you know, getting responses that you're not quite happy with. You think you're a genius, but they don't think so. Um Is, is, is a, is a very real part of it. So, um, uh you know, I think it all has to be, all of these concepts have to be put into the grand continuum of activity of which assessment surveys. Uh feedback loops, et cetera are all very much, very much part of it. And, and it's that they add up to a whole, rather than being a thing in their own. Right. I think is an important part. It's all part of the learning, isn't it? Yeah. And, and you're only as good as your last operation. And if there's a complication we all walk away thinking. Well, what could I have done better? It was very interesting to actually watch the British open at the Royal Liverpool Golf course and see these people come off the first day, five under, but the next day totally tank it and leave the leaderboard and you only as good as the last stroke. And that focus and that diligence and that pre preparedness to learn is the very essence of being a surgeon. Yeah. And I mean, I think the parallels between surgery and golf are, are, are, are very tight. I mean, it's, you know, you have the coach, the swing coach, there's somebody who tells you what to do and, and, and, and the, these are very useful, um, people to have by your side and they all have them. And so, er, seeing, seeing effective coaching in action is, is very important and maybe the parallels are even further. You don't, you don't imagine a golf coach as a golf mentor, you don't see them in those to, you see them as, as teaching you how to swing and it's flat or it's not. And I think that's a good, a good example of where there are different roles, different jobs that make up the hole as you say at. To goi had a coach in theater. Yeah. And uh told and yeah, it was an amazing that, that story of him doing thyroid operation and, and that, that was amazing. But as surgeons we sort of lone wolves in some respects and we don't, we don't have that. And perhaps as a profession, we need to be thinking that having somebody observe you, having somebody as a mentor and having a coach would be good for your development. And Mark De Laval and a cardiac surgeon was finding that with the switch operations, they weren't going as well as they had been. So he went off to relearn as an expert surgeon and uh going back and thinking of Tiger Woods actually to improve his golf, totally deconstructed his golf swing as well. And that need to actually improve and be mindful of your progress or lack of progress over time. And the insight is absolutely necessary as part of the career. I would like to ask questions from the audience and perhaps we can even ask our fellow sense, Chris Cuddy to join us in this conversation and his observations. That's Mr Mr Kady, you, your thoughts seem very reflective. Well, what amazes me is that both of you see the need for a mentor and that mentorship needs to become more mainstream. I think there's very much a um a mindset that if you need a coach or a mentor, there must be something wrong with you, that your performance must be not good enough and it's up to you to make it better. And I think that most people don't understand the role of a coach or a mentor is to, it is not to tell you what to do, but to see you with a different pair of eyes and get you to reframe your, your position. And it's that different way of looking at situations that will make you think. How can I do this better? It's all about asking questions. It's all about continuous improvement. And I, and I think that is the the most important element of this discussion is that as surgeons, we should be asking ourselves all the time, how can we make this better? How can I improve and what can I learn? We need to embrace this as, as part of our thinking. And I strongly commend the surgeons in training to start thinking and behaving in this respect. I'd really like to thank my guest Chris Tara for joining us this evening and the insight from Fellow sense. Chris Caddy also like to thank Gabrielle who is behind the scenes ensuring that everything works and that we were connected this evening. Please take a moment to fill in your feedback form and attendance form. We look forward to your comments. These are areas we're going to explore in future episodes of the Black Bart Academy. Next week, we're going to close our Stitching series by talking about closing tissues and layers, use of drains sutures and look forward to you joining us then. Thank you very much. Indeed, Chris. Thank you, Chris. Thank you, Gabriel. Wish you well and do tell others about the site. This is free and I hope you've enjoyed it. Thank you. And indeed, thanks very much. Indeed. Great discussion.