E120 Officer of the Order of Canada Jonathan Meakins on Art and 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 masterclasses on clinical surgery topics, but also insights into achieving personal growth, productivity, and fulfillment as both a surgeon and perhaps more importantly, as a human.
Ameer Farooq 00:43
Dr. Jonathan Meakins is a former chair of the Department of Surgery at McGill. He's also an Officer of the Order of Canada for his outstanding work in immunobiology, laparoscopic surgery and transplantation. Among his many interests is his love of art. And at the age of 73, Dr. Meakins has gone back to school to obtain his masters in fine arts. Check out the show notes to see some of the fascinating work Dr. Meekins has done to demonstrate how the critical viewing of art can perhaps make us better clinicians. Can you tell us about where you grew up and where you did your training, sir?
Jonathan Meakins 01:18
I basically grew up in Montreal, I was fortunate enough to go to largely private schools. One of them was a boarding school, which I don't recommend, I then went to do a bachelor's degree at McGill. And as you may have discovered, I have a long, strong family history of doctors here at McGill. And so I opted to go to medical school at Western. And I think for my personal growth and development, that that was a very good decision on my part. And I have no regrets at all leaving Montreal and not having a McGill degree. My surgical training was entirely at the Royal Victoria. And at that time, McGill was much like Alberta and Edmonton and Calgary; Edmonton, Calgary were competitors, and in Montreal, the Montreal General and the Royal Victoria were competitors and ran, despite being in the same institution, two completely different residency programs with no overlap. So I had the misfortune of never training or experiencing surgery at the Montreal general. They in fact, had outstanding surgeons and it's hard to imagine that that wouldn't have been beneficial; however, it was not the culture at the time. In the middle of my residency, a little bit to the annoyance of Dr. McLean, but fundamentally with his support, I went to the States to do a doctorate in Cincinnati in surgical infection and surgical immunobiology, and that thesis and those three years were basically the intellectual infrastructure, or what I like to call intellectual capital, which you require to develop a laboratory. And when I came back and finished my residency at the Royal Victoria and came on staff, again at the Royal Victoria and McGill University, my thesis was basically the foundation of my first MRC grant. In those days, you would get a grant for two years and you could then renew it; but, the renewals were usually for only a single year until you got a program grant ... So my first grant was in 1975 that we eventually got after two renewals. An annual renewal is really tiresome, but we got a program grant in 1979, or 80, which continued into the middle 90s - not run by me the entire time. Dr. [inaudible] who was a colleague in the lab and eventually took it over when I became chairman in 1989. I might add, that training doesn't actually stop the day you leave your residence. Most of us think it does or did then. But in fact, training is an ongoing process that continues and those of you who have grown up in the modern-technology era will understand very clearly that you're retraining yourself with every new set of instruments. Laparoscopy has made enormous demands on retraining, and so on. And I I've taken repeated sabbaticals within that framework of re-education.
Ameer Farooq 05:47
Sir, you've had a storied and well-known career. I'd be remiss if I didn't mention for our listeners that you've won an Order of Canada; your career has just been full of so many things. You've written a number of textbooks. But if I could ask you, sir, what have been the things that you're most proud of over your career? What are the things that you look back on and really, now look at and think that these are the things that I'm most proud of?
Jonathan Meakins 06:18
It's the first time I've actually had to think about that in concrete terms. It would be silly of me to say that I wasn't delighted to be an Officer of the Order of Canada, or to have received honorary degrees from McGill and Western. And they were, in a form, highlights but they were a function of other activities that were of significance. And I guess, I tried to put some of that into some context. But I would have to say that developing a model of surgical infection, which integrated using Venn diagrams, the bacterial component, or the infectious component, the environment that was the patient in which the infection took place, and then the host immune response into an integrated approach to the management and study of surgical infections, I thought was a very constructive way of looking at that problem and was the source of innumerable ways of thinking about the overall problems of surgical infection. So, that when one area didn't work out terribly well, you always had two other areas in which you had irons in the fire to work on. Starting with the laparoscopy, we established from the very first case at McGill, a registry and then established a randomized controlled trial, which we eventually had to terminate because of lack of equipoise. But those two studies led to papers in the Lancet and innumerable papers presented at the American Surgical, and throughout Canada, the United States on the issues associated with laparoscopic surgery. That basically was integrated with the whole concept of: How do you deal with a new procedure? How do you evaluate it? And how do you start to identify what is a good new operation versus what is simply marketing and I'm being very unfair, but there are a number of gradations in between. And that led to a number of discussions and papers on: Should the rules of evidence be altered for surgery? And when I was at Oxford, we finally actually had a series of seminars or colloquia at my college in Oxford called the Balliol Colloquium. And we eventually set up three manuscripts, which were published in The Lancet in the fall of 2009 - identifying at least a roadmap for management of and evaluation of new procedures, which have been referred to innumerable times over the last 11 years. So I thought that was an important process, but it's interesting - it took a long time to get to that point from 1989 with the beginning of laparoscopy to 2009. That's 20 years of fussing around, trying to get at the answer to what is not a simple problem, but a very important approach to new technology, as you'll understand, it applies to every single branch of surgery and interventional medicine. The other area that I thought was significant was contributions at the American College of Surgeons, which are sort of [inaudible] with the overall framework of the college, I was on the Board of Regents, was involved in a number of important changes that took place, not the least of which was the establishment of a division of education and an outcomes division, which now most of them are flourishing. I would say also that sabbaticals are invaluable in terms of personal development. And they made a huge difference to me in terms of growth and development of myself as an individual, but also in terms of what I was able to bring back to the department.
Chad Ball 11:18
There are couple of topics there I was hoping we could drill down on, if you're okay with it. The first, obviously, your Lancet papers with regard to the introduction of novel technologies, particularly in surgery, but in medicine as a whole are really the standard bearers. And your experience at Oxford certainly sounds like it was amazing, over what I believe, was about six years. I'm curious what that experience was like, firstly, and then secondarily, what drove you to pursue that particular award and preceding competition? And finally, why at that point, so why not earlier or potentially later? I was hoping you could frame that.
Jonathan Meakins 12:05
I can. I think the key word is competing for the position. In fact, I was 62 when it came along. And I spent six months at Oxford on sabbatical in Peter Morris's department, and he was at the edge of retirement, and they had not yet completed the selection process; it had fallen behind, seriously, from an administrative point of view, and they were suddenly finding themselves offering the position - as Peter Morris was leaving - to someone who eventually turned it down. Now, while I was there, I spent a lot of time observing activities, not only within the hospital, but within, curiously, the examination system. And I ended up writing two reasonably long reports, which were really [inaudible] because here you have a guy from North America coming in and criticizing the way in which things are done or not. Well, you can imagine that the receptivity index is low. So they had to be extremely carefully crafted, and then almost negotiated, to be acceptable. So both of those things took place. I won't go into the details of the examination system because it's not really important. But I wrote a report that they eventually adopted for changing the exam system in the last year. And with respect to how the hospital ran its surgical services, I also wrote a report on that, that had to do with how we had made all the changes to day surgery, same-day admission, pre- admission clinics, etc., at the Royal Victoria. So, I left in the fall of 2001 and came back to my previous position, which was chair of the department and head of surgery at the McGill University Health Centre. And rumors started to circulate that they were having trouble finding someone and eventually I was asked if I was interested in the post, so I said sure, of course I'm interested in the post. Nobody at 62, which you've picked up on rather cleverly, gets a new job of this sort. They go to 50-year-olds as a general rule, and even in Europe, they tend to even pick people in their 40s. So they were in a bind, in a way. And they needed somebody who had hospital experience as well as university administrative management experience. And there is not a huge number of people around like that, who are movable, because they usually have already arrived at a job they like. But I'd been in post at the Royal Victoria for, I don't know, 12 or 13 years, 13 years. And it was my second term as Chairman of the Department of Surgery. And you sort of run out of gas wherever you're working. The concept of five years/renewable once is a very sound one. And the University of Montreal actually uses four years/renewable once on the principle that once you've got to the end of eight or 10 years, what you can get done has been done. And all the problems you can't solve, you still can't solve tomorrow. And maybe it's time for someone else who can come in and solve the things you can't solve and bring in some fresh ideas. So I was kind of, I don't say I was floundering, because we were making some progress here and there. But fundamentally, the opportunity to go to Oxford was terrific. So they asked if I was interested, and I said, "Yes, I'm interested, but I won't compete for the position. So you either offer me the job or you don't." And the system they have there is that they have an electoral board of nine people: four from the Division of Medical Sciences, a chair, two people from the college, which you would be expected to join, and two outsiders, in this instance, one from London, and one from the North. At any rate, I got a phone call in June of that summer, saying that I had been elected. And so I knew it was going to happen. And my wife and I went to Oxford in the middle of June and again in the middle of July, to negotiate my own terms and those for my wife's job, all of which got done satisfactorily. And so we moved on very short notice. I mean, it was the opportunity of a lifetime to be quite honest. It's a wonderful place to live and work, the atmosphere, the environment, the architecture, the history. It was a tremendous opportunity. And while there were a number of lumps and bumps getting along as a North American with the English mindset, and to say that the English surgical community was pleased that a senior Canadian surgeon had got this job, I think would be an overstatement. There were some lumpy times with the rest of the surgical community, but life goes on. And it was a great experience. You have to cut all your connections with North America, so with the United States and its various societies plus Canadian structures, but we do it again. Both of us had a wonderful time, and I think there was some genuine intellectual and academic productivity, both within the department, the university and in our own lives. And that innovation study was fantastic, I think. So I think that that addresses your question. It was an opportunity that I couldn't turn down even though it came with a lot of lumps and bumps; we had to sell our house; we had to figure out what to do with the farm; we moved to a new country, didn't have any idea where we were gonna live. It was very exciting - a fantastic thing that happened at the age of 62.
Ameer Farooq 19:52
I wanted to ask you a little bit about another passion in your life and I don't know how you manage to pursue the all these different passions within a 24-hour period. But you've had a long fascination and love for art. What is it about art that you enjoy learning about and studying about and pursuing so much?
Jonathan Meakins 20:30
I think, frankly, I was introduced at a very young age; I was taken with my sisters, repeatedly, to the Montreal Museum of Fine Arts. As a child, I don't know when it started, but certainly up until my early teens, we would go, there would be family adventures on the weekend. And then I had eight weeks in a schoolboy trip in Europe, riding around in a minibus, six of us, with a teacher and his wife. And we went to, really the major cities of the UK, Ireland, Paris, Amsterdam. And while it was in-city, obviously, the museums and cultural activities were significant. And the same in London, there's so much to see and do in London. And we went to Stratford, got introduced to Shakespeare in a real sense, that is seeing it. Opera, theater, I was sort of a transformative experience, such that at 21, when I graduated with a BA, even though I didn't know which medical school I was going to, I applied late. So it was in the middle of the summer when my final acceptance came in. But anyway, I just couldn't see not going on this three-month, mini-sabbatical, I look back on it now; I didn't think of it that way then; I thought of it just as three months in Europe, on a scooter. Fantastic. So we did that. I did that. And basically went from London to Gibraltar to Florence and Rome and back to Amsterdam and London. So that was quite an adventure. It took us three months. And I did the same thing again, between third and fourth year in medical school. Most of my classmates all went to be interns or work with people they wanted to have a residency with, etc. And I went to Europe for three months, best thing I ever did. Or second best thing. I picked a very good wife - that's the best thing I did. At any rate, that concept of taking time off and exercising my brain in different ways, I think is a part of the way I grew up. But it certainly reaffirmed my interest in going to museums and seeing art. And if there was one thing that happened ... two sets of images I can still recount, one is that there's a very young boy seeing Goya's Disasters of War, a set of prints that are horrific in terms of the war they portray, but also intensely moving and fascinating. And then the landscapes that I saw in London of Constable, Turner and Gainsborough along with those in Holland, van Ruisdael, [inaudible] the two van Ruisdaels and to some extent Rembrandt's landscapes. They just seem to touch me one way or another and remain still an interest today, those particular artists. So when we took our sabbatical in 1980/81, one of the things we did a lot of was go to antique stores, art galleries, museums, to try and see whether there was something that we might want to collect, and when the dust all settled, it really turned out to be works on paper, stimulated by an extraordinary exhibit we saw of Pizarro, where half of his print output was exhibited. And suddenly, we wanted to collect, or I wanted to collect. And we eventually settled on prints, and collected or accumulated prints for a long period of time. And you asked, How do you fit it into a day? Well, you look at catalogs for 10 minutes, or 20 minutes or half an hour before you go to sleep at night; I never watched TV. I always thought that if I read the newspaper, I could turn the page, whereas when you're watching TV, it's a lot harder to turn a page because they're setting the agenda. And I never quite cared for that. The concept of the CBC or ABC or NBC setting my intellectual or informative agenda. So newspapers were my source of news. By that time, I found sports on TV boring. And so this was just a way of exercising my mind, I guess. And it hasn't stopped - the art side of things - I should say.
Ameer Farooq 26:50
That's tremendous Dr. Meakins. I particularly love this idea that in some ways, art is very different than other forms of media, because really, there is some onus on the person, the viewer to actually do some work in terms of actually interpreting what they're seeing. It's not just one-way traffic from the TV screen or the computer screen to your mind. Sort of along those lines, you wrote this really interesting piece in CMAJ [Canadian Medical Association Journal]. There was this article written about one of the pieces of art in the hospital, and you sort of wrote a rebuttal about the art collection at McGill. I was hoping that you could talk a little bit about it, because I think it gets at some of the interesting kind of thoughts like, 'What should art in the hospital or in medicine really look like?'
Jonathan Meakins 27:56
That's a very good question. So let me tell you how I got started on this. The hospitals were going to move and no one was thinking about what they were going to do with the heritage items or the art that was already in the Royal Victoria and the Montreal children's hospitals, to a lesser extent the [inaudible]. So, without going into the details, the CEO was persuaded that he needed to set up some kind of group to manage all of this work. How do they transfer? Where does it go? How does it get organized and cataloged? Well, we did that sort of well. It's very difficult to imagine emptying your own house and knowing where everything is, and then translate that into when emptying a hospital that was built 120 years before you're moving. So it was a challenging task. And I don't think we got it all right. But what we have persuaded the CEO and the hospital is that we have to rehang those pictures, that we need to create an environment that is humanistic - that has a distraction quality for patients, family, and actually, I often think more importantly, the staff. So, I'm quite persuaded that the art that we've put up at the Glen and at the Montreal General have transformed the experience of people who are looked after in the areas where the art is and there's something more positive than would have been otherwise and that the workers in those areas are simply more contented with their environment. Now, imagine that a new building that has nothing in it, from a distraction point of view, other than the things you have outside people's rooms with disinfectants, masks, gloves, gowns, etc. - it could be said to be ugly. And putting colour on the walls of quality really transforms that environment extraordinarily. And so we have worked with artists; we've worked with the collection that came out of the Royal Victoria and The Children's to rehang a lot of that work. It's taken quite a bit of discussion with the owners of the hospital; the hospital is not owned either by the government or McGill; it's owned by SNC-Lavalin. Because it's a private-public partnership, and part of the deal is that the hospital is rented by SNC for a period of 30 years, then it reverts to ownership by McGill, I assume. At any rate, SNC was for a long time disinterested in the idea of putting pictures on the wall; they saw it as nice, white, and it was annoying to have these people wanting to hang things; the nails might go into a pipe or disrupt something else or wouldn't be done appropriately, etc. So it took us a couple of years to really develop a warm relationship with SNC, which exists now. So when we make an application that we want to put up 15 or 20 pictures in a clinic or in a ward, we can provide them using computer technology with the exact location of the pictures. They review what's in the walls and then will approve either our design or make modifications, and we will then go ahead and put the pictures up. So we had a number of artists who have volunteered or said they wish to donate work, and we have an acquisition committee and an acquisition process, which is quite rigorous to ensure that - I don't paint - but anything that I might draw is not going to get hung on the walls, or no doctor's wife or husband, who thinks they're an artist is going to get their works automatically placed on the wall, which we knew had happened in the past. Same goes for photographs. We all think we're good photographers, but if you talk to a professional photographer or look at how they take pictures and what they do with their negatives, you'll see that there's a difference in the quality of the image, as well as their aesthetic component. I just use Ed Burtynsky or Jeff Wall as perfect Canadian examples - use of cars for portraits. Extraordinary. And we all think we take good pictures. But the fact is that it's the pros who really take the good pictures. So that was one thing that we did, was using the old material, plus new material artists submitted. Plus we had a series of exhibitions in the research atrium; there's room for 12 very large images, and we've had a drawing exhibit, a couple of photographic exhibits, two painting exhibits. And the issue is that if it's a single artist, the artist has the exhibit for six months and then gives us one of the pictures. One of the artists actually gave us two of his paintings. Otherwise, we get one of those and then it gets moved into a high-profile area within the hospital where lots of people get to see it. Now that's a long-term process, but we also have photographers and printmakers coming to us with an idea or a set of images, which goes through our acquisition committee. And we have rejected material, but that's just sort of life. And then we get to hang it in the clinics, in the corridors. We've done a number of wall wraps with socio- cultural issues. We have a lot of material; it would take me well over an hour, maybe two hours to walk you through all of the areas where we've hung artwork. Not only do artists donate, but owners donate and there we have to be quite a bit more careful. But in our Department of Radiology, for example, there are 60 images, lithographs and etchings by a single artists. So there's a real coherence to the artwork that's in that area. That transforms the walls, it transforms the space, it means you're not in some kind of hostile environment, that it has images that create sort of a human environment. And we think it's working. But we have heritage objectives. We have exhibition cabinets, in which we're placing antique instruments, and old cutlery and the crockery that used to be used at the Royal Victoria, you'd be amazed at the quality of that material, we'd all be very happy to be eating off today.
Chad Ball 36:51
That's an amazing story. It's clearly a program that you're obviously passionate in and I can certainly see the benefits of it. I think Ameer and I both compare and contrast your program to what we have locally here, which is really the opposite end of the spectrum. And you're right. With that kind of consideration and care, I have no doubt it invites a quality of artistic endeavor and delivery that besuits that effort and really does change the environment. To that end, I was hoping you could also talk about the Archives of Surgery paper you wrote in 1996 on surgical infections in art. There are a lot of messages in that manuscript, and I love it. We're going to link it to the podcast, so the listeners can all be sure they read it. But you did make a specific comment towards the end of it, I think, where you said, learning to see what we look at also makes us better clinicians. And I was curious what you meant by that and really how that piece of language articulates really the greater intention of the whole Archives paper.
Jonathan Meakins 38:13
I got started on that because I knew a curator whose brother was a doctor and we had a little visit from the University of Michigan History Group in Medicine. And so [inaudible] gave this little talk about images that he knew of where there was a disease evident. And, of course, artists are frequently just painting what they see, they're not clinicians, although on occasion you can find situations where the artist must have known what was going on. So the best example I'd suggest that you look up is either a painting or etching by Jusepe de Ribera called "Drunken Silenus" and what you will see there is a drunk, but you will also see the manifestations of advanced cirrhosis, with ascites, a certain amount of hairlessness, obesity, swollen legs, and gynecomastia, all of which are classic signs of ascites. Now that may be just transforming what he saw when he painted an old drunk. It may also reflect insight on his part. So anyway, in that sabbatical in 1987/88, I'd been to this lecture this fellow gave and we went to museums all the time during that year. And one of the things I looked for was evidence of medical issues in every painting that we looked at. So that you could break it down into things like trauma, injuries, skin diseases, eye diseases, deformed limbs, [inaudible], other structural things. And every once in a while, I'd see an infectious problem. And in that paper, I think I show a picture by Basil of Claude Monet with streptococcal cellulitis on his leg. But at any rate, the idea is that if you see what you're looking at, you're clearly being a good observer, and that a significant component of clinical medicine is simply looking at your patient. I remember as a medical student, a professor of medicine came in and said, "the physical exam starts as the patient walks in the room." And of course, being young and really smart. I said, "That's ridiculous." Until I actually had an office and watched people come in the room, and you - you're assessing them up. How do they look? How do they feel? What's their body stature, what body language are you getting from them? The more you think about that, the more cues you pick up concerning the patient's concern, what kind of a person they are, how they're likely to respond to your recommendations, etc. So, observation, I think, is really key. But if you're looking at not absorbing it, or not taking it in, or actually not seeing it, it's like hearing and listening. You can hear what's going on, but if you're not listening, you're not going to get what the patient's trying to tell you. And the concept is very much the same as looking at people, and actually seeing whatever subtle messages they might be trying to convey - or they're not trying to, but that's, that's actually what's going on. So that's part of what that's all about. And, I became such a strong believer in that sort of thing that I think you walk into a patient's room and you look at them, and you look at the urine bag, and you look at the iris in the patient's face, lying in bed, and what there is, pick up a huge amount of information, just by walking from the door to the bed. And so that's what I mean by the value of observation and that if you train yourself that way, you will be a better clinician, because you're integrating constantly what's happening, you're turning your interaction much more than a three hour. I've given a talk based on that lecture for infection, but also for all subject art and medicine, and challenged clinicians in the room to tell me what's wrong with this pace, this subject or that subject, and I've used it for medical students to make the point about observation as well. In other words, they all can look at something and not see that the man in the painting has severe arthritis of the knee or has a squint with a wandering eye or has cancer of the breast or a dislocated shoulder or torn biceps, etc. All of that stuff's there if you're actually integrating the whole image into [inaudible]. So I found it very useful to show to even advanced clinicians who don't always get the test, but who find that there's something to be said for enhancing their capacity as observers.
Ameer Farooq 44:57
We ask almost all of our guests to go back in time and take them back to the time when they were residents or perhaps early attendings and knowing what you know, now, what advice would you give yourself?
Jonathan Meakins 45:11
I thought that was a very interesting way to phrase the question. Whereas normally it would be "What would you give advice to other people about?" What I'm going to say actually is, I think what I, I sort of did, but certainly would articulate to residents and medical students who would come by for counselling. It's amazing how many came to ask, what should they do. And of course, you have no idea what they should do. And getting them to crystallize their thoughts about that was quite important. But as I thought about that, the question I asked - and I still think it would have been useful if someone had asked me, but I think I'd already done it - but it's "Whose job you want?" Folks seem to have difficulty deciding that they want to be a community surgeon, a big- city surgeon, a country surgeon, an academic surgeon. I did my own thinking about career structure, but I think that that's a very important question as well. What kind of a career do you want? You have to learn to make decisions that are actually not crucial. So what I mean by that is ... "I'm going to go into orthopedics." Well, do you want to be a hand surgeon or a shoulder surgeon or foot-ankle surgeon? Well, actually, it doesn't much matter. All you have to do is decide you're going to be one or the other, and then go and be the best you can be. And I don't think that those kinds of questions are asked often enough. But when I thought about this, I really [inaudible] figuring out what I would ask myself. But the most useful thing I found that I asked other people was "Whose job you want?" Because if they can do that, and I then translated back, I can now admit it, but if anyone had asked me at that time, whose job did I want, I would have to have said I would like Lloyd McLean's job, which I suppose is a self-fulfilling prophecy, because that's what happened. But they also have to know how to structure a career. And not everybody does know how to do that. And I did come to medicine with a big advantage that I had a grandfather who was head of medicine at the Vic and McGill for, I don't know, 25 years. And so a lot of the issues associated with academic careers kind of filtered down. As I was growing up, I have no real recollection of how that happened. But I seemed to understand some of the issues - even as I was in medical school - about how to structure where I wanted to go and what I wanted to be, although there were some right-angle turns along the way. There was one other thing that I mentioned earlier, you just have to decide. And the analogy I would use always is I had a farm and we used to prune our apple trees and other plants. And the fact is that when you trim an apple tree and come back a year later, you cannot tell which branches you cut off that have allowed the tree to become straight. In other words, if you come to a fork in a tree and you cut this one off, the tree will simply straighten out. You decided to do something and now you're going to do it. Yogi Berra had an expression. "When you come to a fork in the road, take it!" You can interpret that any number of differently ways. But, it's really the truth, because it doesn't actually matter which pathway you take as long as you do the best you can do and are the best you can be.
Ameer Farooq 50:25
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.