E114 Tarek Razek on Global Surgery
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Chad Ball 00:12
Welcome to the Cold Steel podcast hosted by Ameer Farooq and myself, Chad Ball. We consider it an absolute privilege to bring you guests from around the world who are truly experts in their craft. Our mission is to offer you a combination of not only master classes on clinical surgery topics, but also insights into achieving personal growth, productivity, and fulfillment as a surgeon and perhaps more importantly, as a human.
Ameer Farooq 00:43
We're delighted to have Dr. Tarek Razek on the podcast with us. Dr. Razek is a trauma surgeon at McGill University and a major figure in global surgery in Canada. He pondered with us the questions of how we can best make an impact in global surgery, without repeating the neocolonialism of the past. He also reflects on his experiences working with the ICRC and the sometimes jarring experience of returning back to "civilian life." Please enjoy our conversation with Dr. Tarek Razek.
Tarek Razek 01:31
Yeah, so I grew up my whole life in Montreal. I was born in Ottawa, but really, my family moved to Montreal when I was extremely young - around one year old. And I really spent my whole life growing up in Montreal, or to the core. So that's my background. And I did almost all of my training, as a kid from Montreal, at McGill University. So I did my undergrad at McGill. I did my med school at McGill. And I did my general surgery training at McGill. So that was a lot of McGill. So it was good. After that I had decided to pursue a fellowship in trauma and critical care. And fortunately, was able to get into the program in Philadelphia at the University of Pennsylvania. So that was a really big shift for me. And I think it really had a significant impact, to round out having a different experience in my training, which was very important and very rewarding for me - that experience.
Ameer Farooq 02:31
What was that experience like being in Philadelphia? And how was that kind of different from the training that you had experienced up until that point?
Tarek Razek 02:40
Well, it's interesting. So when I trained at McGill, and I think probably one of the reasons why I was guided into going into trauma as a major component of my career was that I started my residency training in 1993. So, I'm dating myself. And that was the year actually that the trauma system was implemented in Quebec. The regional trauma system was begun just around the year before that. And so, I witnessed over the course of my training, the maturing and the growth of an organized regional trauma system in my urban environment. And at our academic health centre, one of our hospitals, the Montreal General, was designated as one of the adult sites to be a regional site for that regional trauma system in Quebec. And so, I watched that mature and grow, but as you can imagine, when that initiated, although there was some really strong leadership in our department of surgery and in our health system to get that going, obviously, we didn't have a lot of experience, and there wasn't a lot of teams that were trained at the get go to engage with that attempt to have a more sophisticated health system around trauma care. And so, despite watching all of that mature and the evolution of that over my early years of training, when I went to Philadelphia, I entered a system where they had a mature regional trauma system, probably going back more than 20 years. And so, I entered a world that was lightyears ahead of where we were, where I came from, in terms of the maturation of that system. So it was a real eye opener. I ended up very fortunately working with an amazing team there - the luck of fellowship draw, there was a powerhouse group there. Dr. Schwab ran that program and was one of the early guys setting up regional trauma systems and maturing them in academic centres in the States even at the time, from when he initiated the program with that Dr. Rotundo, Dr. Cotter, Dr. Pat Riley, these guys had a huge influence on you. But they came from a place where they had grown up in a system that was already quite mature. So I got to work with these guys who were very experienced, very skilled trauma surgeons who had dedicated their entire careers, and were now in their mid- to late-career phases, having focused exclusively on trauma, and it had a massive impact on me to see these guys, to see how they worked and how good they were, and how focused they were on trauma - not just clinically but yeah, clinically, it was very impressive. But academically, research wise, system design, their vision for how to do things, training, was just a real eye opener.
Chad Ball 05:48
I think that's such an interesting story. You're right; we talk about it, I think all of us in Canada that have gone to the US and these really special, special places. And obviously Dr. Schwab's program in Philly, that you were at is clearly one of them. It's one of these sort of iconic and legacy-type centres and programs. And it's amazing how much we all learn. It's also almost like a force of nature, no matter where you come from in Canada to walk into the centres where these folks are so dedicated - like timewise, mentality wise, drive wise, like they're sort of "all in" to try and fix injury at every level.
Tarek Razek 06:32
Yeah, you're absolutely correct. And like where you trained is the same experience, I'm sure very similar. You go into these big houses, these big training centres and the dedication to trauma as a surgical disease ... I would go in on rounds in the morning, and you'd have had a like trans pelvic gunshot wound that would have come in the night before and one of the attendings, or Riley was classic for this, would come around the fellow's desk/fellow's office area and just throw like three papers down on your desk about management of trans pelvic gunshot wounds, and I'm sitting there going, [interviewer :yes] "There's literature on trans pelvic gunshot wounds?" He goes, "You'd better read up on this before morning report." And that's in the mor ...[inaudible] it just blew my mind how sophisticated they were. Yes, these are unexpected events. The whole paradigm of trauma to me, and a lot of them are critical emergency care and including critical care is around the fact that that disease process is not something that's predictable in terms of exactly what is going to happen exactly when, but it is predictable, unfortunately, that is going to happen. And so, just because it's not something you can predict, the way you could predict a scheduled program of health care, you still should be prepared for it. It's not something that just because it's trauma, you're unprepared; that's one of the things that blew me away with those teams was how organized and prepared they were to deal with what was going on.
Chad Ball 08:01
I love the way you frame that. You know, one of the things that you and Matt Kaminski have organized, based on your current position and your history with the Trauma Association of Canada has been our sort of biweekly case-based rounds, which I would encourage all of our listeners to check out if they can because they're really quite phenomenal. And it's interesting, I sort of love when you and Matt blow across the country to some degree and really across the continent and ask about differences and approaches to care. And it's always interesting for me to see how variable in particular some of the system limitations or benefits may be of a given place actually come up. I'm curious from a Quebec point of view, for maybe our non-Quebec listeners, what some of the challenges that you guys deal with, maybe day to day in injury care that are different from the rest of the country or pockets of the country. And then what some of the really great benefits with your super-high-speed group would be as well.
Tarek Razek 09:04
Well, that's really well framed. I think that those case rounds that we host through the Trauma Association of Canada with Matt, and his experience, having transitioned to working in Cook training and working at Cook County in Chicago, you go and you get these experiences from very mature, elite teams. And I think all of us who are working back in the Canadian context, especially, but are trying to sort of continue to bring back and develop and mature that expertise and that infrastructure for dealing with that part of the health system in an increasingly more sophisticated way, and trying to implement better infrastructure and better clinical care programs for those kinds of problems. And I see it as one of our major responsibilities as professionals in this area of work - is to try to figure out ways to enhance the capacity for us to serve the community, to take care of these sort of emergency and critical scenarios and trauma being a very key component of that. And what I find to be relatively underdeveloped systems in health care design relative to scheduled-care systems, one of the aspects of this is that clinical case runs is a way for us to build a community and to exchange and share that experience in evolving the systems in different parts of the country by sharing our experiences through that medium, and I think it's been really fun. It's created a community and it's allowed us to share our experiences, which has just been a phenomenal experience and it's one way we can hopefully, learn more about each other, learn from each other, and hopefully work together to actually implement ongoing changes that increase the sophistication of the systems that people can access around the country for emergency care, specifically, trauma. What you put in place to manage trauma systems is the type of thing that impacts all of emergency care. A lot of that infrastructure has a major umbrella effect or halo effect on what you're able to manage for all emergency services. And then, specifically every region has different elements that they excel at and different elements where there's gaps in the system design. Quebec, I would have to say, is surprisingly sophisticated. I'm very impressed, I'm extremely impressed with how in Quebec, the regional trauma system is organized from a data acquisition and how it is overviewed, overseen by all of the leadership in Quebec with a really robust data-collecting system, which has been really well developed out of the Quebec City team, who have developed an amazing ability to acquire really good quality indicators, along the lines of what the US has done with TQIP - to be able to assess our performance and to gauge it against our peers and colleagues throughout the entire system in Quebec - it's 50-something-plus hospitals that are interconnected in a very inclusive trauma system, which has really performed very well, from the point of view of parts that are engaged in that system. Where we have very significant gaps in that system is the ability for the regional communities that are a bit more outside the urban centres to access that system. So we have some significant gaps in Quebec in our critical-care transport capacity, which clearly has an impact on the trauma system and clearly has an impact on a community's ability to access that system. So we fail to have a significant, adequately robust critical care transport, including not just a lack of organized regional, rotor wing or helicopter transport, but also ground critical-care transport for interfacility movement of more critically ill patients, not exclusively trauma patients. Again, there's an overlap with these systems and what impact it can have on a broad array of time-dependent critical illness, things like stroke, things like neonatal pediatric critical care services, things like general critical care service for sepsis, and obviously, for trauma, major trauma recovery. The mortality impact of having these robust health systems for trauma care and for all emergency services, I think are some of the most well-documented impacts in all of health care, all comers to any aspect of health care. We know the impact of these systems are tremendous; failing, then to give equitable access, where it is actually feasible to communities, for them to gain that advantage of that mortality impact for having an ability to access that kind of care is just something we really need to work on. And there's a lot of movement right now. So I'm actually quite hopeful, more than I have been in the past that something's actually starting to roll downhill here for that. So hopefully we'll be able to see that change.
Chad Ball 14:12
That's fascinating. Again, just to highlight the differences across the country, you're exactly right. There are regions that really struggle with one particular component of the system and others that excel at the same one. So it'd be nice if we can all continue to grow together and learn from each other. If we shift gears here a little bit, Tarek, I think most of us have a certain vintage across the country. When we think of you we think of super sage insight and advice; we think of your clinical acumen, your humour and your humility, but I think it's probably safe to say that although you may not be at 1.0 in terms of the history of global surgery in this country, you're really, I think, the most notable and certainly a very long-standing surgeon who's been interested in global surgery. I think you're the first person that comes to our minds when we think about that topic. And you really have deserved that. I'm curious if you can walk our listeners into your definition of global surgery, and then talk to us a little bit about how you got into that sort of interest, how you've matured it and some of the experiences you've had.
Tarek Razek 15:24
That's really generous Chad. I've been very privileged to work in and explore working in a more global context. In the area of work that I think we both share quite a bit of passion for, which is trauma systems, trauma, clinical care, emergency service, critical care services - it's a fascinating area of work. And again, [I've] been tremendously privileged to do that on a broader scale, having had some of these opportunities over my career, but I really feel that you're overstating my role. I've been very fortunate to work with some mentors, who really showed me that that path was an option. I think when I began my training, I didn't really understand or realize that the skillsets that you're learning in this profession are extremely universal, they're very portable, every community needs increasingly sophisticated support and development in terms of accessing health care services, especially for emergencies. It, to me, defines something that approaches a fundamental right, for communities to have access to and it's something that is really critical for any community to be spending a lot of energy and effort to develop for their own safety and security in their settings. So, I didn't really appreciate the universal nature of that when you're just sort of diving headfirst into acquiring the skillset so that you can develop and obtain that expertise. But I owe it to a lot of my mentors, both at McGill and in Philadelphia, who really sort of opened that door and showed me that reality because of some of the work that they were doing. And then that was instrumental in me then being able to continue down that path. So I really owe a great debt to some of the senior guys that came before me, the David Mulder's, the Ray Brown's, the team in Philadelphia that we've mentioned already, etc. But yeah, it's been fascinating. And I think the concept of global surgery to me is sort of fallen into it by the nature of that universality of the importance of that kind of system in any society to be present and to be good. The concept of global surgery to me is a term and what it means ... I don't know that I fully have my head wrapped around what that means to me. It's simply the work that I do. At home, I help to manage and run and clinically work in a trauma and critical care system in a surgical department and that's my responsibility both helping to organize the clinical work and - something that I enjoy tremendously - is working on the education and training side. So to grow new generations of people and help them become better than we are doing this work over time and at a university teaching centre to help with the teaching and training aspect of things. And then also on the research and academics side of things to be involved as much as I can, where I'm able to help propagate an increasing sophistication in our knowledge of what we do and how we do what we do. And that's what I do. But that's what I do with colleagues in other parts of the world. There's other colleagues in other parts of the world who work in other environments who are trying to do exactly the same thing, because again, of the universality of the need for that kind of infrastructure for any population. And I work with them; they work with us and we work together as to forging those partnerships professionally and personally, to explore that work together, learning from each other and learning how to best apply it in different contexts and gaining an understanding of the global environment of those different contexts within which these systems have to be developed and deployed so that populations have access, increasingly better access to increasingly better health systems and delivery of that health system so that they can have better outcomes for when things happen when they require emergency services. And that to me is what global surgery / global health is about. It's about creating a community - just like we were talking about earlier - and creating a Canadian community to explore and deal with the different gaps - learn where things are going well, learn where things are not going well and understand just in the Canadian context, the wide disparities of the contexts within which we have to deploy some of these health care systems, from the far north to our urban environments, some of our very remote rural environments. There's a wide array of contexts in the Canadian scene, and how do we then deploy and give the best access possible to those communities for this kind of care. It is the same thing on a global scale. So we all learn from each other. That's to me what global surgery is.
Ameer Farooq 20:30
I like the fact that you deliberately talked about the fact that global surgery isn't about this kind of far-away or foreign concept where you go somewhere else, quote, unquote, to deliver care, but it's also about improving the disparities within Canada, of which there are many. You don't have to spend very long working in any hospital to realize that despite all the principles that come under the Canada Health Act about equitable care for everybody, it's not equitable. As we've talked about a bunch already, there's lots of different motivations for why people get interested in global surgery. From what I understand, you used to visit your extended family back in Egypt, as a child growing up. I wonder how much of an impact that could have had in terms of motivating you to do this work? I know, certainly, when I was growing up, we would go to visit our family in Pakistan every year or every two years almost. And that has a profound, profound impact on you as a person. I have this memory of going to visit a friend of ours who had actually gotten shot for whatever reason that I won't go into, but he had been shot and so we went to the hospital in Pakistan and even the corridors of the hospital were recovered in this beetlejuice [inaudible], which is what people chew and the whole corridor was all stained red by people spitting. And that little detail kind of stuck in my head; I could not have ever imagined a hospital in that shape. And that certainly had a profound impact on me. So I'm curious what impact going to Egypt as a child had in terms of your motivation to do this work?
Tarek Razek 22:34
Yeah, Ameer, thanks for sharing that. I think that's a very similar experience to what I would have gone through when I was younger, and taken to visit my father's family in Egypt and going to Cairo and Alexandria and then traveling to the south of the country, where you have some family in the South as well. It just cracks open your mind. And it prevents you from having a more narrow-minded perspective on what the world really is, and what the human condition in the world is, when you go to a place and actually embed in the place within a family and live as one lives in those environments. I remember, as a child, we would go to my family's home in Alexandria and there'd be a pen in the back with chickens and turkeys and some other animals. And by the time we'd have left from having stayed there for a couple of weeks, there were far fewer of them in the pen then when we arrived. The realities of how ... and there was no refrigeration really commonly available at the time when I would be visiting there when I was young. You just see a different reality of life that people live. And like I said, it just opens your mind to that. And also, even though things can be quite different and they were. You know, I grew up in Canada as a kid. I would do these intermittent visits to Egypt, but I'm visiting family. And so you realize that these differences are not quite as one might think they are or not as significant as one might think they are at first face value when you go there and live with your family. In these very different environments, they all of a sudden don't really become so different. And yet at the same time, like you were saying the difference is that you remark on the differences as well, but you integrate them into your life. So it just shakes down a lot of these barriers. It prevents you from thinking about people as other; you integrate things and it becomes much more of a very different worldview. I think that you can't escape then; that it's just embedded in your mind. And the degree of poverty that you see is striking. And you just realize that there are these tremendous inequities in the world that exists that people have to live through and live with. And it just gives you a wildly different perspective on that, and it makes a part of who you are, as opposed to something else other elsewhere. And that just changes your whole perspective on everything. I think I've had such a tremendous privilege. One of the most rewarding things I think, through engaging with colleagues around the world, as much as I have been able to in the work that I do is because you embed within that work, so you're not there just visiting; you're there working with colleagues - very intimately, very significantly, and you begin to have this shared experience. And because you have a shared common experience in the work that you do, you immediately are able to engage on a much deeper personal level, I find as well, and it opens your mind to this reality that exists in the world, that you are able to engage extremely. I feel extremely fortunate to have been able to meet colleagues and develop relationships with colleagues around the world and explore with them their struggles, share the simply unbelievable similarities of the struggles we all have doing the work that we do, and yet become very appreciative of the differences and the inequities in the world in terms of how we have to meet those challenges and the difficulties that there are in meeting those challenges and to work together to try to find ways to improve how that all plays out and find strategies: help with education and training, help with system implementation for better health care systems, design policies, and learn from them, from their expertise, in terms of well, what are the realities? And how do we then contextualize some of the things we have learned in terms of adapting them to make them work in different contexts. And that's where I think you have that respect for colleagues who are working in very difficult circumstances, but doing amazing things. And you develop a deep amount of respect for their knowledge and expertise of doing it how they do it in their context. And, you know, you begin to rely on that very heavily when you work in this more global context. And you develop a deep respect for these individuals. And again, you break down those traditional barriers of people. And you realize that the similarities are overwhelming, and the respect is quite significant there that develops.
Ameer Farooq 27:31
Yeah, you know, we have a certain amount of arrogance, perhaps maybe arrogance isn't the right word. But we have this certain sense of like, whatever people are doing out there it must be substandard to what's going on in Canada or the US or Europe. But then when you actually go and spend some time working anywhere, whether that's Pakistan or Egypt or any of the places that, hopefully, we can get into with you on the podcast, you realize how tremendously resourceful, amazing, brilliant, so many of these people are in being able to do the things that they do with the constraints that they have. Dr. Cameron talked about this concept on the podcast of frugal innovation, where people develop innovations because of resource limitations and then actually are able to bring that back to sort of high-resource settings and innovate in that way. We wanted to ask you a little bit about your experience working with ICRC in Sudan, that must have been a tremendously powerful experience. Can you talk to us a little bit about what that was like?
Tarek Razek 28:37
Oh, yeah, definitely. I'll just go back little bit on what you were talking about. I think the term I would use for how we sometimes view ourselves and how, not exclusive to health care but definitely within in health care, is hubris. We do have quite a bit of hubris and I think we need to work to diminish that and have a bit more respect for other colleagues around the world. And I'll just give a very brief example of a woman who I worked with in Dar es Salaam in one of the earlier projects we were engaged in, and she was an orthopedic surgeon. So she's Tanzanian and she did her training in orthopedic surgery in China, in Mandarin, and she had young children at the time as well. And when I met her she was back in Tanzania working as an orthopedic surgeon. And she was helping us implement some of the basic programs we were doing with databases, etc. And we were touring a new build of part of their hostel that was being built by the Chinese. And she was showing us the new structures being done and you couldn't find your way around in the new build, [and she was] trying to show us where the new receival trauma area was going to be. And there were a couple of workers that were from the Chinese company that were there. And she went up to them to ask them, where should I go to see where this area is going to be built and she just dropped this whole request in Mandarin on them. And the looks on their faces were quite hilarious. Some of these people you work with are just unbelievably impressive. Looking at her I'm like, what was it like for her to train and learn Mandarin and train in China as an orthopedic surgeon and come back and be working in a very challenging environment in Dar es Salaam? I mean, it blows my mind what some of these people are able to do and achieve. And we don't tend to have that perspective of what's going on in the world that's as well informed as it needs to be for us to have a better, more informed perspective on what's really going on. And part of that is born out of that hubris, you know, so I think it's a major challenge, we have to educate ourselves to overcome more and to be more open minded towards what is happening in the rest of the world. I deviated there, sorry. So the ICRC thing, you know, I'd always been very interested in working and experiencing the same type of work that I was passionate about, that I had trained in, to find ways to do it more expansively beyond my own context to learn something outside of my own context that I was in Montreal. So where does one do that? Where do you go to expand your horizons as a young just grad, you know, relatively newly graduated practicing surgeon in this field? Where do I go? How do I access an environment that I can explore the limits and push myself to explore further limits, put myself in an uncomfortable place, if that's one way to frame it, to grow, to be able to grow professionally. Where do you do that if you want to do trauma? So one of the first things I actually thought of and very seriously considered joining the Canadian Military in their Medical Corps to get access to do that kind of work in different contexts, but at the time, and this is how old I am, I guess. But at the time, they weren't allowing specialists to join in the reserves; you had to join regular Military and that was just not an option for me; I wasn't that interested in the military; there were a lot of issues in that for me and joining the regular Forces just didn't make any sense at all. So, where was the next place I looked to find ways to have an organized, well-managed, system to access an environment where you could really push yourself and experience something in the realm of being a trauma surgeon. Well, I went to the ICRC and I'm happy I did, actually, it was a really interesting but very, very fascinating organization that I can't tell you I fully comprehend. I think it's the only nonnation state that has a seat at the UN; they have a really interesting role in the structure of humanitarian activity in the world and it's fascinating. But it was very, very interesting to do that. I got deployed to this place called Lokichokio, which I think is no longer actually running. But it was one of their training environments where they would send younger recruited surgeons working with the ICRC in their war surgery teams to work in a more long- standing installation on the border dealing of Kenya and Sudan dealing with the conflict in southern Sudan that had been going on for decades at the time, and still is a grumbling issue in that region. And you would go to this place and you would go with senior surgeons and they would help to get you trained, so that you could learn how to function in that context, within their scope of practice that they define in the ICRC and to understand how to work in that specific type of environment, which was quite obviously a different environment than where I had been training or working in previously. And it was a fascinating experience. What was really one of the most striking things was the integration of a global community, working together to support a regional community that was struggling with crisis and lack of access to health care infrastructure, and to help support the delivery of health care in a difficult context to communities that were in desperate need for it. And there were anesthetists from Australia and Russia and there were nurses from all over the world working there, but all on the same team, and it was really a phenomenal experience to work with these integrated international teams, all working in the same way, working in the same club, working together to provide care to communities that were in crisis. So it was a really interesting experience. I'll never forget the first day there was a British vascular surgeon who I was relieving; I was taking over his post. We had a couple of days overlap and he was taking me around the installation and showing me the operating rooms, etc. And the operating rooms, when you walked in, it was one large room with three operating tables in the same room. And it was a busy day when we walked in and all three tables were running. And I looked at it I'm like, oh my God, this is M.A.S.H. I couldn't believe that I entered this context; I was just so excited to be there. It was unbelievable, but also [I was] extraordinarily nervous, because you had to deal with obstetric emergencies, orthopedic emergencies and general surgery emergency - the three big things you deal with in surgical emergencies, and it was quite challenging.
Ameer Farooq 36:07
You know, one of the things that I've noticed, obviously, I've never done this myself, but in talking to some of my classmates for my Masters, who had been very heavily involved with MSF or ICRC, one of the things they talk about is just like the camaraderie that that gets built in going through that experience. But then almost like there's this disconnect when you come back. I don't know how many months you were there or how long you were there for, but depending on the length of stay for people when they're deployed, actually coming back to their civilian life can be quite challenging or jarring, because you spent so much time in these very intense environments where you really see people really suffering, like for real, really suffering, none of the, 'my coffee order kind of got misplaced or misunderstood,' like this was real, real suffering that people saw. And for them to come back to their civilian life was actually quite hard. I don't know if you felt the same way or what was that transition like coming back?
Tarek Razek 37:16
I think that's a very real and common experience. And it's complex, but I think that you are absolutely right. I was deployed there for three months. On returning there's a mixed reaction that you get, I find. I've done a couple of deployments with the Federation of Red Cross after the earthquake in Haiti; I was there as well. And you come back from those postings, and you're so right, those realities of what you witness and see, and again, in the human condition, that is the reality of the world. You get exposed to that reality very directly. And on returning, it's a double-edged impact; I find on one side, it allows you to have quite a different perspective on the petty problems that you perceive yourself to be having that maybe had a greater importance to you relatively before that afterwards, you put it into a much more appropriate context, I think, and it puts your own personal struggles, your struggles at work, etc., it puts them into a completely different perspective that I think is actually quite a good one because it's much more realistic for what's the real perspective of what's happening in the world. And you are able to sort of place that in a proper place, I think, and not let it overcome you in terms of the pettiness of some of the things that we allow ourselves to become occupied or overly occupied with. So I think it has that as one side effect. But the other one is, what you were saying is exactly right, people, for a variety of reasons, either are never exposed to that kind of situation or reality. And also, oftentimes, if I find myself talking about what we witnessed and what you did, and the work you had to do, and the realities of those environments, people don't want to hear that very much, not a very pleasant conversation and it's not something you want to dwell on too much. People just kind of shy away or shun that kind of reality because it's just very unpleasant to hear about it. And, I would tell people that I had been [inaudible]. "Where were you the last couple of months or what have you done lately?" I remember, I'll never forget going to a dinner party soon after returning from that deployment in the Sudan and I remember talking to someone and they're like, "Oh, you haven't been around the last few weeks." And I'm like, "Yeah, I was deployed with the ICRC in Southern Sudan." And they're like, "Oh, you know, we were in Kenya once and we went on safari and blah, blah, blah ..." And I'm like, "Oh, my God, I just can't handle this conversation right now." You have to balance who has that shared experience and just recognize that's it's just not a commonly shared experience. And you're gonna have to share that with a select group of people if you want to really discuss it. And it's not easy to discuss with people that don't have a shared knowledge of that reality. And that's just the deal. And I think it's been unfortunate because I think if we had a bit better awareness of that global context, and it doesn't have to be such extreme examples, just like what we were talking about earlier, just the reality of day-to-day life in some of these more low-resource contexts. I think if people were just a bit more aware of the realities that are going on out there, it will give us a better worldview and it'd give us a lot more ability to understand our fellow humans in the world and what they're going through. And I think we would behave probably very differently.
Chad Ball 40:44
I think that's an important thought maybe to pause on for a second, because it's something that I didn't do personally very well, whether it was Haiti, whether it was East Africa, like a lot of the places that I think we've all been, to be honest with you. I just sort of assumed when I came back from the first few of these places that everybody would want to hear about these experiences and be informed and be educated to some extent, from the perspective of the traveling group. But you're right, people generally don't want to think about suffrage and challenges globally. They do want to focus - to Ameer's example - on their coffee a little bit. I think that's a very threatening sort of context and set of knowledge and experience that you're right - you have to tread lightly and be very, very cautious about who you're talking to with regard to [inaudible].
Tarek Razek 41:48
Oh yeah, no doubt, Chad. You're right. You're so consumed in whatever the experience is that you may have just had and then to be sort of rebuffed about other people maybe not really wanting to hear about all of that is a difficult one to accept or digest when you are trying to share an experience that marks you and that you're very passionate about. But at the same time it's about reversing your perspective. And I find that a very difficult thing for all of us to do is to take a moment and pause and try to understand the point of view of the other person and see it from their perspective and try to approach it then a bit more, I don't know what the right term is, maybe gently or more thoughtfully, from that other point of view. And it is quite jarring for people that don't have that experience or aren't as passionate about that particular aspect of things, to hear something that's so shocking, maybe or distressful to hear about, so you have to approach it very carefully in a stepwise fashion and see where there's some receptivity to it. But it's just as jarring for me to see that there's a disinterest in what I'm so interested in, or what I have just been so heavily marked by, but from the other point of view, that other person is being jarred by the nature of what I'm expressing, perhaps, and it's quite overwhelming. And so having that shared point of view or having the perspective of the other point of view and trying to incorporate that in is a very challenging thing to do, but it is a very important thing to do.
Chad Ball 43:34
Another thing that I think is really impacted a lot of us was the commentary that you wrote on in the Lancet Global Health about the need to move beyond descriptives, studies and statistics. And just so you know, that's a piece that I printed out, and it's still on our wall by the photocopier in our trauma group area, because I think it is so powerful. I was wondering if you could sort of communicate that to our listeners and talk about what was the genesis of that?
Tarek Razek 44:04
Well, it's quite overwhelming that you looked at it to that degree, because it is something that I think our group, and a lot of the colleagues that we work with around the world, frankly, is what I've learned that point of view from. It's not from me; it's from the colleagues that I work with in other parts of the world who expressed the perspective of they're fatigued with sort of this, you know, it's an overused prospective term, maybe but it is a Neocolonial power approach to doing this kind of work where people would go in, would study something, do a flash study - essentially you have some funded postdoc who's going to do some very good research on something, but then nothing comes of it later. And that data is taken away. And it's brought back to wherever the postdoc came from and is maybe published in a beautiful peer-reviewed article, and then the grant money runs out, and then nothing happens and nobody goes back. And the colleagues, who are there in the environment where the study was done, don't benefit from anything that was done. And there's no support, no ongoing support; you're not really building a community that is working together to advance the entire infrastructure, and that the science, the clinical delivery systems, the training and education, so nothing is done from that work. There's nothing implemented on the ground. That is extraordinarily frustrating, as one could imagine, for all of the people and all of our colleagues who are working in these extremely difficult contexts. And that's some of the concept behind that perspective. So I think we're very focused on getting the work done and studying the work that's being done. I mean, I don't want to minimize how important it is to collect the data, to use objective information to inform what we're doing and evaluate what everybody is doing. It's what I do. Again, I often do this, and I reflect back on my home. And what I do at work is I accrue a huge amount of data of the work that we do day to day, and then intermittently regularly, we analyze that data and review our performance compared to our peers and then make decisions about how we're taking the next steps forward. It's exactly what we need to be doing with all of our colleagues in every other context where they're trying to do exactly that. You do the work, you implement what we know works by using the local expertise to adapt it to the context, working collaboratively with these teams. One of the big overarching principles of the work that we do is it's only by invitation. I don't think I'd really appreciate someone coming to my home context and telling me what to do; I kind of have a sense of what I want to do in my own context, in my own work environment, but I would sometimes appreciate help to learn more about what other people have done in other similar environments and then work together to implement advances and improvements and changes into my context and then evaluate it, review it and then proceed. And so I think it's about getting that work done on the ground and studying that work that's done on the ground. And it's sort of a five-foot view, as opposed to a 10 000-foot view, which you should do more intermittently, a five-foot view needs to happen every day; a 10 000-foot view needs to happen, but only every once in a while. And the problem is we're only kind of doing the 10 000 foot view. And we omit the five-foot view. And I think it's to the detriment of our colleagues, and it's to the detriment the health care system development. Allegedly, that's what we're supposed to be working on is providing better service to the communities.
Chad Ball 48:18
Such a beautiful and important way to frame it. I think you're right. One of the personal experiences that was the filter with which I looked through your commentary and probably made it so powerful - and not to denigrate or pat on the back any specific environment, but as you know, I think Morad Hameed and I have been deeply involved in Cape Town in South Africa for what next year, I think will be 20 years. And I think despite the challenges, the sustained relationship, as you're pointing out with Andy Nicol and the team at the Groote Schuur Hospital, the well-known hospital, has been really fruitful for both groups and really made some incredible gains that have been bidirectional without question. And I compare and contrast that experience with some of our experiences in Haiti, particularly, where I felt initially guilty for sure, but just uncomfortable with the lack of sustainment and improvements and sort of moving forward and leaving some of those - I hate the word legacy - but leaving some of those benefits that help a local community going forward. And I'm curious - I have some theories - those two examples for example in my scenario, but beyond me, me, me. I'm wondering if you have some thoughts on why that is, what some of the contributing factors to success versus quote unquote failure or certainly lack of legacy would be for us when we travel to these other locations and try to embed ourselves within them.
Tarek Razek 50:04
The work that you guys have done at Groote Schuur in Cape Town is remarkable. And I think it exemplifies exactly the type of long-term relationship building and work that benefits both parties that is really what brings together a global collegial community that helps us to advance the work that we do in our area of expertise, that hopefully provides a benefit to the communities in which we live and work, respectively. And I think that that's a great model. And I think you're right, one of the things that I think I've come to understand is that the success of a particular engagement isn't really dependent, obviously, on me. I have a certain responsibility in that relationship, but there has to be some stability, and you have to be invited in, you have to be welcomed in, there has to be an openness and willingness to engage on both sides. And it's very much a bipartisan relationship. And when there's a failure to develop that, I think it's a short-term failure, because long term, it will succeed. But the timing is just oftentimes not correct, because of the lack of ability to engage on either side of that equation, whichever side that may be in difficulty to do that at the time. And there's lots of things that impact that, whether it's resources, politics, leadership change, there's many, many things. And it really, it's a long game. And I think, in the long game view, they will all succeed, but in the short and medium term, they don't. And that's the nature of relationships. And that's the nature of this kind of work. And I don't let that bother me as much as I used to, you just keep plowing ahead. And wherever you're working will have a benefit, because it's such an integrated activity and it's so universal, what needs to be done in many communities that wherever you're working will have an impact in the other environments in some way indirectly as well. I think it's fascinating what you're touching upon with that work, and it's the same thing in all trauma systems and trauma systems, especially but emergency care systems writ larger, is if you think about what trauma systems do, as a model for emergency care systems, [inaudible] and COVID is exemplified this. These diseases implicate different segments of our communities differently. COVID or trauma can impact anyone in our community. But we know that they impact different segments of our community differently. Socioeconomic factors are so key as a public health construct that have consequences for the risks for certain diseases and certain realities in life - no doubt about it. I think that's really well documented. And trauma is definitely a disease that is linked to socioeconomic factors. What trauma systems do, which is fascinating, is you take this cohort of the population that is disproportionately affected by a disease like trauma and you turn what are often, sadly, uninvited guests into our sophisticated health care system, especially when you look at scheduled-care components, which is the majority of our health care system. You take this cohort of our community, which are often not as welcomed and not as easily welcomed. And I refrain, I call it as the uninvited guests who show up. And the trauma system flips that dynamic completely upside down, and you turn what are oftentimes uninvited guests, and you turn them by the nature of the construct of the trauma system into the VIP. So that trauma patient in the trauma centre becomes the VIP of that trauma centre, as they ought to be because they have the most critical need. And you've designed an entire high-level system to respond to the needs of that cohort of our community, which I think is a very uncommon thing. If you think of any other realm of our society where you take the community that is impacted disproportionately by trauma, and you turn that community into a VIP into a very sophisticated component of our health care sector. What other part of our community in our society does that? So I think trauma systems are a very fascinating construct from a social point of view, what they mean and how they impact. And look at the outcome impact of this in those communities and the importance of it. And by extension, though, interestingly, for all of us, is anybody can suffer from a trauma event at any time. So having these systems in place, and I think COVID has been a remarkable in-your-face-kind-of exploration of the same type of inequities of impact, and of consequence, and of how much we design the welcome for those segments of our communities, into our health care sector. And if you look at what trauma does as a system, I think it's ... so that has broader implications for the global construct of health care policy and design that I think are lessons I've learned in trauma-system design that are very important aspects of how we look at building and constructing the systems and services in our communities.
Ameer Farooq 55:54
Just a lovely way of putting that and framing this whole problem - putting that into perspective, because COVID has highlighted, as you said, all these inequities that were latent within our society, but suddenly, we had to care about it, right? Like if Peel in the GTA is having huge numbers of COVID, suddenly, that really matters to us, because all of us are getting affected by that. But you know, the reality is, we were always interconnected; we always are, in some way, affected by our fellow brothers and sisters around the world. In some ways, I think COVID was, as you said, a very amazing way to kind of put that in perspective. And unfortunately, those disparities live on. I mean, if you look at the way that the global vaccination rates have gone, those disparities are still getting propagated forward. So, in terms of global surgery, what do you think the big challenges are going to be going forward? You know, especially thinking about that whole decolonization-type of perspective, decolonizing global surgery, addressing these inequities, which don't seem to have gotten any better, necessarily, since that Lancet report in 2015. So I'm wondering, what you think are the big challenges and big opportunities going forward for global surgery, especially in a post-COVID-19 world?
Tarek Razek 57:25
I think your comments are excellent. There's a lot of challenges, but those challenges are what makes it stimulating; those challenges are what drive the energy, the enthusiasm and the passion, because those are challenges that we need to struggle to overcome. And that struggle is the fun part. It's a bit unfortunate that we have these struggles and challenges facing us, but I think that's what is set in front of us and those are the things we have to climb over. So I look forward to meeting those challenges. But they are big and I think, you know, look in terms of the COVID analogy to the realities of the trauma and surgical services that are there. And I think there are a lot of analogies to make between the two situations and how they've played out. You look at the G7 meeting that just happened and they did not come - they failed to come - to an agreement on a better distribution, a more equitable distribution of existing vaccine stocks, and for it to support the needs of the broader global community. And that's extraordinarily disappointing. But sadly, not very surprising. And I think post-COVID-19, we all have major [inaudible]. I think there's some interesting advantages that we've been forced to learn in terms of how we deploy some of our information technology, in allowing us to engage better. So I think we've learned some things coming out of this COVID reality that I think will help us in going forward actually, that we can connect a little bit more easily and a little bit more frequently, with less logistic difficulty to accomplish many, many things. And we've had, for example, an education program that we've been doing with a couple of the universities in Senegal in the last couple of months, and they've been fabulous to do and the integration between our trainee teams and our surgical teams with their teams has been just phenomenal and quite remarkably easy to do. So I think finding ways to engage in these partnerships and sharing knowledge and information and experiences I think is one of the struggles, but I think that there are solutions there that we need to learn better to deploy to meet those struggles and meet those challenges. And one of them is IT [information technology], so I think the need for better IT support. I mean for all of us who work in the Canadian health care system, the IT in our healthcare system is quite something in terms of how not sophisticated it can be at times. And I think we struggle with that in our broader health care systems globally. And I think we need to learn better to deploy better IT in supporting the needs - data acquisition, data management. There is no excuse for us to be this poor in how we accrue and analyze data for the health of our populations. From a broad perspective, there's no excuse for it; it doesn't make any sense to me; it's very disappointing that we are not able to deploy existing, very sophisticated, but quite affordable, IT infrastructure to do this better. So that's one of the things we have to figure out and get this more deployed in terms of gathering better information to inform our choices and our progress. That's a huge problem, the connectivity and finding ways to connect more, but again, that's also being gradually overcome as the IT infrastructure and even very low resource settings is improving dramatically. And I think that allows us to connect better and will improve our ability to share and engage in this global context, which is what I think global surgery is really all about - just sharing our experiences and learning from each other. So I think that that's also one of the challenges, how do we manage to learn how to connect better more frequently, more consistently, and learn from each other and expand our minds, as we said earlier, and gain that knowledge from around the world and integrate it better. And I think that changing the way people see things is one of those major challenges. And I think it comes from a greater shared experience, like when you share a pop culture experience together, like Chad talking about M.A.S.H. If you're not from the same generation, you kind of don't know what we're talking about; if you're from a generation that experienced that you instantly know what that is and there's no explanation required. And so I think we need to enlarge that shared experience so that we can have better connectivity. And I think that's one of the great challenges facing the world right now is doing that better. And I think we have the tools in front of us that we're using currently for this podcast, to do that. And we should deploy them; we need to work on that very aggressively. But one of the underpinning major limitations to getting all of that done is financing. We need to have more value added to putting financing into this area of work. And I think the lack of our ability to comprehend the value of not-for-profit structures in how we design our initiatives, so that they can be sustainable, fiscally, and responsibly managed - I think the idea of donating, the idea of charity, it always kind of gives me a bit of, I have a bit of a negative response to those words. I prefer to see things done in a structured way with partnerships, with a proper well-thought-out business model that allows the sustainability of the project itself to run. And that to me is hinged upon a sophisticated not-for-profit approach to the design of what we do. And that's key, so that you're investing in a not-for-profit structure to allow these programs to continue to flourish and develop. And I see unfortunately, very, very little of that. You hear a lot about private sector for-profit. In health that cannot be the totality of how we approach this, especially in low-resource settings, especially for emergency services, which don't run on a for-profit model almost anywhere in the world. You know, that aspect of health care is often run on a not-for-profit structure base. And we need to figure that out in the global context and deploy intelligent well-thought-out, well- invested-into not-for-profit strategies to develop health care infrastructure, so that you don't lose your money but you don't make it for a third party. You're making it to reinforce what you're building in the first place and to support the people who are doing that building. And that can be a very successful model and it needs to be worked on. It disappoints me how little investment there is. It's really shockingly devastatingly poor, how little investing there is in this work given the importance of it, and we have to figure that out. Without financing it doesn't go anywhere.
Chad Ball 1:04:34
Yeah, I mean, that's another beautiful and disappointing combined viewpoint of that problem and it's something I'm glad you bring up and I'm glad you continue to rail against it publicly, because I think voices like yours that are so experienced and so insightful are what's needed on a continuous basis. You know, it makes me reflect a little bit on this country. When we have very limited resources, what we can accomplish if the collective motivation and the leadership is there to do that, in the right places. I think of the Canadian Space Agency. In a country where we've decided that satellite radar technology, robotics, and essentially aerospace, health care, which is really dominated by remote teleultrasonography are our three areas that we're going to continue to fund and work at. It's amazing that we can't seem to gain traction and forward movement in the areas you're talking about, despite the overlap of even those two extremely opposite worlds. It's remarkable. So I hope you continue to do this. And I hope you continue to lead all of us because I think we're all supportive of it. And we all need to do it deep in our soul, for sure. We'd like to end the podcast by asking a question, I think that you've probably heard us ask a lot of guests, which is that if you were to go back and talk to yourself, potentially maybe as a surgical trainee and then secondarily as a junior staff person starting out, what sort of advice would you like to have had from experiences at this point in retrospect?
Tarek Razek 1:06:19
Yeah, that's a tough one. And I think there's a couple of things I probably would say to myself, and one of them is, make sure you get yourself very well trained. And I think everyone can reflect back upon parts of their training, when you kind of dipped in your enthusiasm. And, it's a tough slog, some aspects of getting trained in this area of work. But keep an eye on that prize of getting yourself well trained. And I think I could have helped myself develop what I needed to develop a little quicker and a little better when I was in that phase of my life, when I was focused on training or should have been - I would argue a bit - more focused on my own training. And then another thing would be to take some time while doing that. And this is a bit of a competing interesting thing that you have, but that's the point, is that you have to acknowledge the competing interests of what are priorities in your life, and balance them more thoughtfully, as I would have probably balanced my personal and professional life a little bit better in those, I would say, very challenging early days. I think some aspects of my early career, just because of the nature of what was going on around me on my early return to Montreal and the infrastructure that was in place at the time was quite, I would say very difficult. And I would definitely tell myself to take it easy a little bit and balance a little bit better, my personal and professional time and energy, because you can't recover that time later. And there's only so much you can do. But I'm thankful that my family is ridiculously supportive. And I've been very, very fortunate. And I think, luckily have been able to balance that I think better and better throughout as I get a little wiser and have survived some of my mistakes, in terms of balancing that - doing that balancing act. But doing that, well, there's different phases in life, and I see some of our young trainees and I think that there are times when you have to dive into the professional side of your life and dive into your getting yourself well trained aspect, and you have to really go headfirst into that when it's the right moment, but understand that there's different phases that need to happen over time, and you have to pull back and then get back in and you have to be able to balance that well and it's difficult to do. And then one of the other things is not to always listen to all the advice you get from your senior colleagues. So you can take everything with a grain of salt. If I had listened to everything that I got told about what I wanted to do early on both vis-a-vis trauma as a career path, which was very much something that I was told not to do by many people and the global work, which I was told by I think virtually everybody that I would have spoken to at the time except for very few exceptions, who were those mentors to sort of open the doors for that reality. But the vast majority would have told me not to do that. [Inaudible] it was very intimidating to not listen to some of that advice, but I'm very glad I didn't. So don't hesitate to follow through on your passions because you're in your own time and the other people you may be listening to - yes sometimes they give you tremendously good advice and I did get some tremendously good advice but I got some very bad advice as well. And I would say focus on your own passions and take that in with a grain of salt and incorporate it in a way that you are satisfied with and not just to please others. But it's challenging to do that.
Ameer Farooq 1:10:23
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 thoughts, comments or feedback. Send us an email at [email protected] or tweet at us @CanJSurg. Thanks again.