E124 Paul Engels on Trauma Training in Canada
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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
This week on the podcast, we spoke with Dr. Paul Engels, a trauma surgeon from McMaster University. We got into some pretty detailed discussions around trauma training specifically, but more broadly about how we define what residents should or should not be able to do at the end of their training. We'd love to hear your thoughts. What should general surgeons be able to do with regards to trauma? Send us your thoughts at [email protected], or Tweet us at @CanJSurg. Where did you grow up? And where did you do training?
Paul Engels 01:16
Well, first of all, thanks so much for having me on the podcast. It's a really great program that you guys have and it's a pleasure to be invited to participate in it. I actually grew up in Calgary, so I'm a Calgary boy. And I spent my high school and undergrad there. And that's when I travelled to Southwestern Ontario to do my medical degree at the University of Western Ontario. But the draw for Alberta was very strong, so I went back to Edmonton this time for some of my training. And I did my general surgery residency at the University of Alberta. And then I stayed on for another two years and completed a critical care fellowship. And then went back to Ontario, this time to Toronto, where I did a year fellowship and trauma and acute care surgery at Sunnybrook Hospital, University of Toronto, and then returned again to Alberta, to Edmonton at the Royal Alexandra Hospital, where I worked for a couple of years, there, with some really great colleagues, mentors. And then, I went back to Southwestern Ontario, to Hamilton, where I've been here since I guess about 2013. And I practise trauma surgery, acute care surgery, [inaudible] surgery and critical care.
Ameer Farooq 02:36
What drew you to trauma surgery, because that's what you've ultimately chosen as your subspecialty in your career.
Paul Engels 02:42
I think interestingly enough, I did my general surgery, and I was first drawn to critical care. And so that was what drew me into that. And then I think from there, I really kind of solidified my interest in like acute care, both medical, critical care and surgical care. And, and obviously trauma is kind of at the tip of the spear on that. So in many ways - I don't want to admit I'm a adrenaline junkie - but it probably appears that way, when you boil it down.
Chad Ball 03:13
I think a lot of us, if not all of us can relate to that, Paul, so, we certainly identify with it anyway. One of the things we really wanted to talk to you about today was your passion for in particular, I think it's safe to say resident education, but probably even beyond the resident moniker - probably really all surgical education, trauma education, emergency general surgery education - you're really carving out a footprint in this country with that passion and that viewpoint. Specifically, you wrote an article that was published in the Canadian Journal of Surgery that sort of outlined, I would say potential national concerns, was a comparison piece to some other places as well. And I would say, my sense, I don't know if you agree, but in talking to other folks is you really hit a nerve there that I think a lot of us are highly concerned about. And I was wondering if you could lead us into that topic and that piece in particular, and give us your upfront thoughts.
Paul Engels 04:14
Yeah, certainly. As you as you mentioned, Chad, there's a whole cohort across the country that have been engaged in this work. And it's great to work with colleagues that share the same passion. So it certainly is a big team effort by many of us who are engaged in this. I would say that coming back to my journeys back and forth between Ontario and Alberta, I started to really recognize that there's major differences and I'd always kind of taken for granted that surgical training is critical training; it's Royal College-certified, it happens in Canada, it's great no matter where you are. Not to dispute that component, but as I went back and forth to different places, and often used to work and train in different centres, I realized that surgical training is actually not equivalent across the country. Certainly some places have their strengths, but all places have their weaknesses. And how that plays out is actually I think it's more tangible than I initially believed. And so [I was] starting to see the volumes and experiences that some of the residents were encountering, and the usual thing when you ask them, "Okay, well, just do it, like you've done this other operation." They're like, "Well, I've never done that operation." Well, how is that possible? And certainly, some of that is the evolution of trauma care in particular, but I'd say surgical care. But there are other components that go along with it, which aren't necessarily related to anything other than concentration and exposure. It started appear that there's a gap here in terms of what we thought we were providing versus what we're actually providing, and whether that gap persists at all centres across the country is to be determined, but certainly, it was starting to appear to many of us who were looking at it. It was enough of a flag that certainly, with colleagues, as Chad mentioned, we wrote that article and from there, that's been a stepping-off point to do some further investigation.
Chad Ball 06:15
You touched on so much material there; I want to start and drill down on the nuanced narrative of, as you said beautifully, what we expect, and maybe what the public expects, and maybe equally important, what the Royal College in theory demands, with regard to trauma care and training. As you know, and I say this at my own risk, one of the things that we check off on the Royal College requirements when a resident graduates, for example, is a research requirement. And I would argue that that's done, in general, without really much evidence in most places that that resident has done really any significant research or understands any sort of research methodology, but it's sort of a checkbox, and away we go. My sense, and I think a lot of our senses is, we're doing that with trauma care, increasingly, year after year, with some of the deficits, I think that we'll get into. What's your sense of what the public expects, and what the Royal College expects, and how that intersects with our reality of the current time?
Paul Engels 07:28
Yeah, so it's all easy questions this morning, is it? I think it's interesting, Chad, to break it down even further and say, what do we expect of our colleagues in some ways? And what do we expect at the profession of general surgery? I think that the expectations placed on general surgeons to provide this care are vastly different across the country, not just for those that work in an actual designated trauma centre versus a community centre, but also, depending on the population density, depending on the conglomeration of hospitals, depending on the provincial organization of trauma care. So the expectations, I would say, I'll stand on this, that the expectations of general surgeons across the country to provide trauma care is extremely variable. And so that begets an issue of well, "What are we training our residents to be able to do?" And there's different expectations, I think that those of us who see the value of trauma care and see the value of trauma care provided by not just a subspecialist trauma surgeon, but by a general surgeon would say that these are core components of training that they need to learn, they need to be facile with, and they need to be able to provide to the public. Many others would disagree with that, I would say, and certainly they have with me and say that, "No, that is not a core competency, the functional practice of a general surgeon." I recognize it may say that on paper, the Royal College, but it's not. I think there is a component of a lack of shared expectations from the trainers to the trainees. So, partly, I think solving the trainee problem also involves solving what we expect of general surgeons and trauma systems in Canada to help them better align with, "How do we train for them to practice in this paradigm?"
Ameer Farooq 09:31
Well, I think one of the premises of your commentary that you wrote for CJS with Dr. Ball was that there was this paper by Strumwasser and colleagues where they actually reviewed operative trauma case logs for residents in the US. Can you talk a little bit about that study and what they found there?
Paul Engels 09:49
Yeah, so the paper that you're referring to, Ameer, I think it was I saw Dr. Strumwasser present that at the AAST and then I think it eventually got published in, I think, 2016. I'd have to check the exact reference, but we know that trauma care has been evolving over the last four decades, but in particular, the last two with regards to decreasing need for operative management, use of non-operative management and then hemorrhage control adjuncts like interventional radiology, [inaudible], stenting, all this type of stuff. So, in the paper, what they examine using ACGME case logs for general surgery trainees over the last 10 or more, maybe 15 years, just looking at the number of cases that they are involved in, over their training. The sum total was that basically they saw that the previous general surgery graduate would have received the same amount of trauma exposure and experience as a current graduate who had done a complete trauma fellowship. And so the highlight from that, to me is that we can't expect our current graduates to have the same amount of trauma experience that we did in the past. So, if our expectations haven't changed accordingly, then we have a gap here. And we don't know what that gap is, as it relates to Canada, because Canada, at least doesn't have publicly available case loads. I think most or many of the Royal College programs probably maintain them internally. But it's certainly not in the same degree of standardization like the ACGME. And I'm not saying that case logs are the "be all end all," but I think they are one important component of information when you're looking at how things are changing and adjusting that should be included - at the very least - as some sort of performance metric to understand what's changing in clinical practice, what's changing in terms of my residents' exposure? And are these changes for the good or do they need to be looked at more closely?
Ameer Farooq 11:46
That was one thing that I thought was so interesting about your commentary, and it's something that just had not occurred to me was this operative log. I thought all residents and residency programs had to maintain logs; I thought all of us had to submit it. But I think what you're talking about is a little different - that these are not publicly available logs where you could compare program to program, is that correct? Can you talk a little bit about that? What is the difference between American and Canadian programs in terms of training logs?
Paul Engels 12:25
I've not gone through it; but, I think as Dr. Strumwasser illustrated, you can approach the ACGME and with appropriate approvals and protocols, etc., you can actually do research on those case logs, etc. I am on some of Royal College committees, but not the general surgery committee, so I'll defer to anybody who has expertise. But it is not my understanding that you can approach the Royal College and ask for the case logs for all 17 general surgery programs across the country. That's just not going to happen. And I'm not even sure if the case logs actually get even transmitted to the Royal College Central. This begets the other comment I made earlier is that transparency has a lot of value, I think, and you see that when you look at some of the programs in the States, where they'll [inaudible] present their numbers, etc. Transparency in the Canadian context has some potential risks, and there are differences to the different training programs, and that's a good thing, because it draws applicants who have different interests, and it can cater to it. But if you're looking at core experiences, once you start to put the numbers up, people are going to draw some conclusions. So I wonder how that factors into the kind of psyche, mentality of maintaining the appearance of equitable training programs across the country.
Chad Ball 13:54
It's interesting from my perspective, at least in my head, there are some analogies and synergies here between trauma care training and HPB-related topics and clinical content training. And by that I mean the era that trained you and I would have rolled over and essentially stroked with the idea that we were uncomfortable converting a laparoscopic cholecystectomy to an open cholecystectomy and taking that open gallbladder out. Obviously, as an HPB surgeon, I do open cholecystectomies multiple times a week. It's not a big deal. But I think it's safe to say that really the whole country and - I would guess - the whole continent has moved away from that being an expectation of training. In other words, the camera can go in and things like that, pull the camera out and refer the patient to some HPB surgeon in a tertiary quaternary care place. I'm curious what your sense is on the trauma side of that equation. So clearly, when the patient shows up in Timmins in a major car crash from the highway, you're the general surgeon, they're hypotensive you have to deal with that. There is no ability to back out of that. At the same time, we have this significantly, as you pointed, out limited exposure to that scenario and the ability to deal with it on one side. On the other side, we have [inaudible] stable patients that really do get transferred out of smaller centres across this country every single day to quote/unquote, trauma centres. Because our relationships are so good, and those transfer agreements work so well, and it's fundamentally different than the US, in the pre-hospital, in the communication and in the collegial side as well. I'm curious how those two issues, how you reconcile them and what you think about them.
Paul Engels 15:43
I guess it comes back to what I was getting at with some of my earlier comments about the organization and the expectations. I definitely would say, based on the contrasting experiences that I've had working in Alberta and southwestern Ontario, that there are different expectations that the providers, [inaudible] surgeons have for themselves. Certainly, if it's a car crash in Timmins or an isolated community and that person is super sick, we would all hope that that general surgeon - or whomever it is - that the team taking care of that patient would do whatever is needed to provide the care to that patient, and then stabilize and ship out. When you have the situation where the ability to ship out is easier, then it becomes more justifiable, I think, not to provide surgical care to the patient. And certainly we probably can all tell stories, but, that was new to me to see the surgical teams to decline to provide necessary surgical care and eschewed them to other centres that were, in their mind, justifiably close enough that they could defer that care. So it does come down to that set of expectations, I think, Chad, because if you're going out into practice, and your expectation is, "I work in hospital X, and it's an hour away from a trauma centre or whatever and my hospital, quote 'unquote, doesn't do trauma, I'm just not going to do trauma. So I'm not going to bother learning these these skills or whatnot, or I'll get the checkbox, but I'm not internalizing what I need to know because I fully expect that I'll never use these again."
Chad Ball 17:40
It's a really tough conversation, right? Because we've known for decades, and it's clear not only in Canada but in the US and a lot of European countries that your risk of dying for matched injuries between large urban centres and rural centres, or rural places, is much, much higher in rural communities. And that can be 3 times higher to 10 times higher depending on the injury you're talking about. So whether knowingly or not, somebody who lives in a smaller, rural or farming place carries everyday a higher risk of dying of a theoretic injury. I don't think that's something we talk about very well. And it does play into the whole sort of platform or foundational view, as you're pointing out, of what we need, when we need it and what's reasonable.
Paul Engels 18:31
We talk about Canadian health care, but as you and I have discussed, there is really no such thing as Canadian health care; there's province-based health care. And so the maturity of each province with regards to its trauma system, actually, I think, has a big impact in terms of what those people training and practising in that province have for a set of expectations in terms of what they need to provide and to learn about trauma care. I do think that that's part of the picture. And that kind of speaks to the bigger picture is when you're trying to figure out, from a Royal College perspective, "What are we training our grads to do, what are we expecting them to do when they go out and practise in the Canadian context?" You have to have an understanding of what that Canadian context is, in my opinion.
Ameer Farooq 19:12
I have a question for both of you. I think this is pretty neat to have both of you, who are trauma surgeons, on the line. So I think this can be a really rich discussion; we can clearly talk about this. I think anyone who has worked in the Canadian health care system recognizes these problems that you're talking about - that there's variability in care. Having laid that as a framework and as a ground fact, what is it that you both think that residents should know coming out of general surgery residency, or is that not a fair question? Should we make that a context-specific question? In other words, maybe it shouldn't be an expectation that everybody knows the same things. But really, once you know where you're going to practise, that's when it becomes clear that there should be these standards that people should know. And maybe people have to come back and do more training. And of course, again, easy questions for both of you first thing in the morning. But I'm wondering, what are your both of your thoughts about what is it that residents should know coming out of general surgery training? Maybe we'll start with you, Dr. Engels?
Paul Engels 20:22
Well, I think that if you look at the Royal College paradigm, five years and you come out as arguably an omnipotent or pluripotent general surgeon. This was probably before of my time at training, but I think, close enough, I think there was a bit of an existential discussion across the country about whether or not general surgery should be migrated to a four-year core program, and then at two years, so specialization in some of the various subspecialties, in the context of what people had either selected or can identify just where they're going to be from a job market perspective. I think if we are still going with the paradigm that after five years, you should be a pluripotent general surgeon able to do anything from breast surgery to reasonable HPB to trauma surgery to colorectal APR, whatever it is, that we have to train to that. As it pertains to the trauma-specific competencies, and this is an ongoing area of research with others in the field, like Dr. Brett Mader in Edmonton, who's leading some projects in this trying to figure out what is that core group of skills that must be imparted and general surgeon must come out with, and it's probably going to come down to resuscitative and hemorrhage-control skills, most likely, because that would at least keep the patient alive and their ability to either be transferred out or have help transferred in. And maybe I'll stop there and let Chad have some airwave time.
Chad Ball 21:55
No, I don't think I have a lot more to add, Paul, I would agree entirely with you. It's going to be damage control scenarios, via laparotomies via tourniquets, maybe even intravascular shunts potentially pushing it, but balloon work, just all hemorrhage control, whether that's in the torso, or the neck or the extremities.
Paul Engels 22:17
I'll add on to that. Because what you've outlined, I completely agree with. And then I would say that, and I think you'll agree with this, those skills are actually the ones that I don't think are all that transferable from elective surgical practice. I don't think that putting in shunts is something you're going to get a lot out of your elective surgical practice. I don't think that damage control, packing the abdomen, etc., is something you can get out of doing a laparotomy for XYZ cancer, in your elective rotations or scheduled care rotations on colorectal, HPB, etc., I would say that those are the skills that you actually need to have done. And so that begets back to my concern that we need to have the residence achieving exposure in these exact cases, not just things that are comparable. I do think that they need to have actual trauma laparotomies, where they packed the abdomen and dealt with difficult hemorrhage. And then certainly, if we're not able to achieve that with clinical exposure, we need to think about adjunctive medical educational opportunities, [inaudible] tissue, hemorrhage control simulation, this type of thing; you lead a nice course and I'm involved with the American College suite of courses. There's lots of other opportunities to help augment that. My opinion is that, at its core, I think it's unreasonable to expect a general surgeon to be able to pack an abdomen and do damage control surgery if they've never done one. And some of the research that we're doing demonstrates that there are graduates across the country who are coming out who've never done that.
Ameer Farooq 24:09
One comment I'll make, and I'm curious about your thoughts, Dr. Engels, we've really pushed in Canada towards a competency-based-by-design type residency program and residency-training paradigm. One of my lingering doubts - and maybe I'm one of those holdovers and someone who just needs to get with the program - but one of my concerns about CBME [competency-based medical education] is that it's very hard to agree on what a graduating resident should be able to do. I think if I pulled trauma surgeons potentially across the country and then I pulled general surgeons, I think you might get a different set of answers as to what people would expect to be able to do from a trauma perspective. Certainly, I can see from a colorectal perspective, it's kind of interesting, right? We have this idea that people should be able to do X, Y, Z colorectal thing, but is that really fair in 2022? I'm a little bit curious about what your thoughts are in terms of "Is CBME really, is that something that we can really quantify as to what people should be able to do, especially when we're not always sure, for ourselves what people should be able to do?" And the second part of that question that's sort of related is that, "When we know that, perhaps you aren't going to find those opportunities for learning in elective surgery, should we be sending residents to centres where they will get that exposure, perhaps to high-volume centres in Canada or perhaps, more accurately, high-volume centres in the US?"
Paul Engels 25:51
I don't want to sound like a dinosaur. Seeing CBME rollout in our institution, I actually think there's a lot of positives, and there's gonna be a lot of benefits. But I don't think we've landed on the bullseye yet for what some of these targets are for some of these skills. Let's take a laparoscopic cholecystectomy ... okay, sure, no problem [inaudible] I'll sign them off as independent during the unremarkable gallbladder without inflammation, etc., but at what point am I going to sign them off and say they're independent when they're doing a hot gallbladder? I don't know, like, I have to see that. And I'm not sure if a number can be a priori ascribed to that, I guess, you can try it and see. But there is that gestalt, and that was the thing that the people who trained us relied upon, and no doubt there are problems with that approach. I think the problems really come down to when you have residents who are not performing at the level of expectation and you have performance issues, and so it's harder to quantify, it's harder to focus on how to get them to improve. I don't think it is a problem when you have a high-performing one. And then so the CBME, I think will help bring up the floor, so to speak, if I can use that term. I'm not sure if it necessarily is going to make it all that much more easier to identify the minimal competency. I think that if we are going to agree that residents need to obtain competency in certain fields, whatever that is, if they're not able to achieve it, given the clinical milieu of their home training program, then yeah, and so that comes back to my point earlier is that I think that being transparent about what the clinical milieu is of the training programs and what residents can be anticipated to be exposed to is helpful because it'll identify the weaknesses that each program has, because every program has weaknesses, and then identify the programs that have strengths and probably there could be maybe overall better training for our general surgery trainees if we adopted a more regional collaborative approach to training as opposed to a single-city or single-centre type of training approach. The other thing I just want to add to that is you mentioned the colorectal, which I think that you're in that process of, I find it a different, interesting paradigm, now, the number of surgical subspecialties by the Royal College that exist. So, vascular is on its own now, fair enough, but colorectal, surgical oncology and actually trauma general surgery - we just developed a practice eligibility route as an EFC. So it's actually a Royal College accreditation now. So as we develop all of these subspecialty accreditations, what belongs in those fellowship subspecialty accreditations and what skill sets are there and then what skill sets belong in core general surgery? To me, it eats away at that existential question: "What is general surgery in 2022 or what is general surgery going to be in 2030?"
Chad Ball 29:12
In my mind, there's sort of three domains to this. The first really surrounds the structure of training, as you guys have beautifully talked about, and you're right. If you look at the American Board of Surgery, it seems clear that they're gonna go to a three-plus-two model for general surgery in the US in the near future. So three years of core training and then you're gonna go into a quote/unquote, community practice, that's a two-year HPB, two-year [inaudible] trauma, two-year ... it's all different and there's certainly intriguing and potentially really neat things I think that could come out of that. You have to try it to really know if it works, but that's interesting that you guys have also talked beautifully about defining expectations and requirements and the importance of that and probably the gray nebulous nature of it in its current state, but it seems like people are doing that work, and it's coming. The third thing, though, I think, is less quantitative and certainly on the softer science side; I think that most of us do this job with an inherent, I hope, humility, and genuine concern for the patient. And I remember, when I was in the US doing my fellowships, there was a number of really iconic American surgeons that talked about the fear. And they said that the idea is that fear is something that most of us have - the fear of doing something bad to a patient. And so that will drive a lot of our behaviour and a lot of our search or quests for knowledge and training. And I think to specific examples that you would know, well, Ameer. So, we've had Alex Poole, who's been a surgeon in Whitehorse for 20 years and came through Calgary on the podcast talking about his hypothermia algorithms. But one of the things that's amazing about Alex is that when he needed more HPB training, he came back to Calgary and hung out for a few months and did a bunch of complex cases with us. When he felt he needed neurosurgical or gynecologic or obstetrical training, he dropped into Vancouver or he dropped into Edmonton and did a bunch of that. It's the same sort of model that Paul and I see around us all the time for our military surgeons, who, before they go say over to Afghanistan, are learning or relearning craniotomy, craniotomy, decompressions, as an example. I like to think that there's a certain percentage - and hopefully that's a large percentage - of graduates who say, "I'm gonna go work in Lethbridge, Alberta, I'm gonna go work in Fort McMurray or Timmons, or Williams Lake, and I need to buff up on my trauma skills, where can I go and do that?" And probably that internal drive is more powerful than saying, "Person X needs to go to Atlanta or Memphis to do a high-volume month, although those are incredibly valuable experiences that will be life changing. But I'm not sure how you make that a mandatory thing as opposed to appealing to the concept of internal drive and the fear in general.
Paul Engels 32:21
I would echo that, Chad. And I think that everyone wants to do well for their patients. If they know what their expectations are then they very much, almost certainly are going to rise to them, and how we could help provide those stepping stones to get there, I think there's some work to be done there. But you've outlined some very good examples. I think once people know what the expectation is, I think that the drive and the fear, so to speak, will push them towards that. And just to bring it back to some of the early stuff, I do think it's about setting that expectation, right? When people come out, what do they think they're going to be expected to do? And so relating specifically to trauma care, if it's just "You got to tick the box," and that's it and then I'll go on my way, and I'm a graduate - that's not going to generate the fear that goes along with, "Hey, there's a really bad trauma downstairs and I haven't seen that case and I need to come in and see that case." So just to close the loop on that. The fear thing is interesting, actually; it exists in law enforcement as well. They very much talk about harnessing fear as a powerful motivator and a positive force in terms of training performance and stuff.
Chad Ball 33:44
It's a fascinating area in general, psychologically, across a lot of high-intensity jobs. You're totally right. I was wondering if we could switch gears just a little bit here. I don't want to put you on the spot and I don't want you to out what's coming down the pipeline, but I will say that you're leading and doing some amazing national, coast-to-coast work on what we talked about - the expectations, but more importantly, probably the actual description of what's going on across training trauma centres in this country with regard to resident trauma, training exposure and teaching. Can you give us a little preview, a little trailer what you found and what your 30 000-foot thoughts are so far?
Paul Engels 34:31
Yeah, for sure. So I think you're alluding to the trauma recon study that we've been working with connects to perform and it's basically doing - more or less - an environmental scan of participating trauma centres across the country. We don't have every centre participating, but we have a very good representation from various provinces, looking at the both formal and informal educational exposures regarding trauma care, trauma education during the residency, as well as more objective measures, such as trauma operative case logs. We have our data and we're in the process of analyzing it; it's actually quite large, which is great. And we're hoping that we'll be able to start to share that in a public format, in the near future. And the overall thrust, like you said, Chad, is and I really believe that in order to know where we're going to go, we need to know where we are. And I think this will help shed that light and demonstrate where we are. For those of us, like yourself and myself and Ameer and others who I think have some insight into this are probably not going to be as surprised, but we're still going to be disappointed in what we see with the results. It is interesting when you start to look through some of this. There's certainly some residents that have very massive exposures and then there are people that may not have actually been exposed to trauma operations during their training. And that's not even speaking about what their involvement as a learner was with the case. Certainly, there's limitations with the study, looking at presence in the operating theatre for trauma operations. Then you can think of all the operations that you're present for as a trainee that yeah, you tick the box, because you were there, but what did you actually do? What did you learn? And so that's going to be another area of study. And we've seen that; it's interesting in other research where you look at resident-reported operative role versus staff-reported operative role of the resident. There's often significant discordance between those. How that all factors into CBME and everything else is for people with bigger brains to decide, but we really are excited about this and are really hoping that we'll be able to show everyone at least where we stand, so there's no ambiguity about where we stand, and then discuss if this is the right place for us in Canada, and if not, what do we need to do to make things better? And certainly the idea was that in the context of CBME it's right to understand where we are, because we are going to need to make adjustments with CBME and hopefully, this will help inform that.
Ameer Farooq 37:25
I love that comment, "Oh, I did that operation," and then, you know, the staff leaves the room and, "Wait a second, I don't know, did I actually do that operation? It seems a lot harder than before."
Paul Engels 37:36
I always ask the resident and they're like, "Yeah, I did the operation." And I'm like, "Well, who was holding the cautery?" They're like, "Well, I was." I'm like, "Well, you didn't do the operation then." [laughs]
Ameer Farooq 37:43
[Laughs] that's right. That's right. Well, I'm curious your thoughts on training courses. There are a variety of different ones. I know you've been involved in designing and running courses, because I've done courses with you as my instructor. I know you have a pretty good sense of what the courses are like out there for residents and, in fact, for practicing surgeons. What's your sense of how courses or simulations fit into an overall training paradigm for Canadian general surgery residents?
Paul Engels 38:22
This is just my personal opinion, obviously. I think it's going to be integral, I think it's going to be absolutely necessary to make use of courses, whether they be surgical courses or crisis resource management courses or other things. But I think that type of paradigm of simulation in education needs to expand more than it is. My vision would be that you come to work and 1 out every 10 days you just show up and they tell you you're doing simulation today. And you're gonna go and you're going to work in whatever it is, a hemorrhage control lab, or you're going to work in a CRM high-fidelity lab, or you're going to do mock trauma codes on a pregnant patient, or whatever it is - these kinds of rare events. But literally, it might be 1 out of 10 days, when you come to work, you're going to be doing simulation. And that's because we're not going to have the same clinical exposure to all these rare and high-stakes events that we could count on with just living in the hospital. And that's totally fair. I'm not saying to go back to that. But we do need to compensate for the lack of exposure that goes along with that. That's what I would envision. I would say that the nice thing is that there's actually a lot of really great courses out there. We really should move them into the core of residency education and look for ways that we can collaborate amongst institutions, to make them more cost effective as well as to share the expertise that many of the institutions have developed in some of these areas.
Ameer Farooq 39:59
Can you talk a little bit about some specific courses? Obviously, there's lots of courses out there. Just a disclaimer that if you haven't mentioned something, that doesn't mean that it's not necessarily a good course. But are there some courses that really stand out to you as being fantastic courses for residents and for that matter, attending surgeons, to take to brush up on their trauma operative skills like, ATOM or ASSET, what are some courses that stand out to you?
Paul Engels 40:28
In full disclosure, I am a member of the [inaudible] for American College of Surgeons, and I'm also an instructor for DSTC [Definitive Surgical Trauma Care], but I would endorse both the DSTC course, which is run by not the American College, but IATSIC, which has a combination of didactic as well as a hemorrhage control lab component. And ATOM, which we teach here in Hamilton, similarly, the didactic component and a live hemorrhage control lab component, and then the ASSETT course, which is a cadaveric-based dissection course. All three of those have their strengths and overall they're all complimentary. Certainly there is some overlap of content, but each course has something special that it offers. And for anybody who's going to be practising trauma care, not necessarily trauma surgery, but is going to be responsible for providing operative trauma care, I would highly endorse taking all three of those. I don't think that you would lose out by taking those. Sometimes you hear people say, "Oh, these courses are expensive." And you say, "Well, it's an investment in your education." So I think it's a worthwhile investment. And then the other one would be - Chad mentioned balloon skills and things - is the best course available, if that's something that you're going to be doing. And wherever BOA fits and lands in the Canadian trauma care paradigm is still to be determined. But certainly I think having some facility with basic endovascular idea, access wires, catheters, I think is good for a general surgeon, graduating in 2022.
Ameer Farooq 42:10
There are some really great courses. And we'll link to this [courses] in our show notes. We're also hopefully going to have some [inaudible] from Dr. Ball's hemorrhage control course. We're hopefully going to have Dr. Scott Gamora back on our show to talk about control of laparoscopic bleeding, because he does give a great talk on that as well. So just for our listeners, stay tuned. This has been a really fascinating discussion about resident education and trauma care in Canada. I wanted to also just briefly ask you about the T-SPIKE project, because I think that's another fascinating bit of work that you've done in Ontario to develop this trauma system. Can you talk to us about that a little bit?
Paul Engels 43:02
Certainly. The T-SPIKE. The background is - I don't know if this will be surprising to people or not, certainly not to those in Ontario - but there actually is no coordinated trauma system, provincial trauma system in Ontario, which is obviously paradoxical it being the probably the oldest and largest province. But be that as it may, there has been some work over the last number of years - the last five years - to create what's called regional trauma networks, and there's some ongoing work to help roll out more of an occlusive trauma system, such as those that exist in Nova Scotia, Alberta and BC. So one of the things that we were looking at, in our particular area regional trauma network is, "What is the burden of injury? What is the burden of injury and what is the care provided in our catchment area.?" We have a catchment area of about 2.5 million people and that comprises 22 separate hospitals, and we're the ministry-designated lead trauma hospital for that region. We wanted to see if we could actually figure out what that burden of injury is, because that's going to help inform system-level changes that we could in terms of rolling out a more inclusive trauma system and optimizing where patients go, where they need to go, over triage, under triage, all this type of stuff. We tried to put all those pieces together and you can think about all the different data elements that exist, prehospital, the receiving hospital, the transporting ambulance group, maybe that is rotary wing, maybe that's ground, and then lead trauma hospital. And all of these systems are not related, unlike some of the other provinces, and so you've got nine different ambulance systems, you've got 22 hospital systems, you've got Ornge, you've got CritiCall, which is like RAAPID and Alberta, then you've got the trauma registry. And so we tried to actually put these all together and see what we could map out. And that was the study methodology that we published is that it is possible, but not 100%. And it does come down to the irony of, 'we don't have any way to recognize a trauma patient from time of injury, through their health care journey, at least in Ontario.' I'm hoping that you guys have something better in BC and Alberta, and I know that The American College was discussing some really interesting proposals about how you could do that when you slap on a universal identifier when you see someone in the scene, and that universal identifier gets propagated through the system. But it is interesting because I like to have a systems look at it. You basically are identifying that, when it comes down to managing your trauma system, you're managing your trauma or health care system, we actually have a very poor idea of what we're providing, by whom, and where, and certainly, even if we have that idea, we have a very poor idea of what we need to change to improve it. And so that's my overall interest - is trying to improve the system to make it function better for our patients, as well as the providers.
Chad Ball 46:13
The last question, as you know, that we try and ask a lot of our guests is sort of a fun one. It's a bit of a closer and it very simply is, "If you were going to go back and talk to your younger self at some point along in your training, what advice would you give yourself in retrospect?
Paul Engels 46:31
Life kind of comes in various phases. And once you leave one, one can't go back. So no matter what phase you're in, recognize that you're never going to have this phase again. So try to enjoy it. And if it's not something that's enjoyable, try to get as much out of it, because it will change it, will pass. And once you go forward, it's like those parking garages with the spikes - you can't go back in and so just enjoy each part of that life as it as it goes forward. Because it's a one-way journey.
Ameer Farooq 47:10
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.