E127 Rob Leeper on Competitive Motivation in Trauma Simulation and Starting out in Practice
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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 00:42
Dr. Rob Leeper is a trauma surgeon at Western University in London, Ontario. We spoke with Dr. Leeper about his work on trauma simulation, and particularly on his work on data-driven, competitive motivation strategies. Finally, Dr. Leeper shared with us the tips that he wished he had had when he started out in practice. Can you tell our audience where you grew up and where you do your training?
Dr. Rob Leeper 01:06
Yeah, absolutely. I'm about as sort of a suburban, London, Ontario of a guy as you get. I'm born or raised here, I moved back to my same area and raise my kids here now. I escaped briefly to Kingston to play football and to do undergrad and did my residency and both general surgery and critical care here, and then had a wonderful couple of years away doing trauma surgery and acute care surgery in Baltimore at Johns Hopkins Hospital, which was a really cool four-and-a-couple years for me before, like I said, I got back on staff here at Western.
Ameer Farooq 01:40
Remind me again: What position did you play in football? And you played at the college level so you must have been fantastic.
01:48
Fantastic is a stretch. I was a running back and linebacker all through my younger years, and I played linebacker at Queen's. I was exceptionally average. My brother won the Vanier Cup for Queen's; that was kind of a — that had been my most fun day in the sport, was watching him win the Vanier Cup with my old team at Queen's. So, it's been a great sport to me and I coach all my kids, and my oldest son plays now, and it's been a wonderful, wonderful sort of piece of my life. But fantastic is a stretch. I'd say average to slightly above.
Ameer Farooq 02:20
Wow, what an experience for yourself and then watching your brother; that must have been amazing. Tell us about what your — well, first of all, what got you interested in trauma surgery? And then what was the experience like training at such a hallowed institution like Johns Hopkins?
Dr. Rob Leeper 02:37
Yeah, I mean, the answer to the first part is really easy, and this'll date me in a major way, but there was a television program called ER when I was a kid on NBC, and the character Peter Benton was kind of my hero. And I think we're all like that, as kids you grew up watching, I don't know, LeBron James or James Bond, or you know, somebody else who seems to you to be a superhero. And to me, I looked at this guy and said, Oh, my gosh, this guy, whenever these other doctors are in trouble, they call him. He shows up and does something daring and the person survives, and it looks incredible. I want to be like that guy. And so really, from about, you know, eighth grade on, that was what I wanted to be and to do was to be like this guy I saw on TV. So that's what got me interested in it, honestly. And then the second part of your question was about life and training in Baltimore. And I think, you know, I really remember very clearly my Chief of Surgery, when I was a med student, Ward Davies, telling me that his fellowship years were the best years of his life. I thought, that's a weird — that surprised me. "What do you mean?" And I totally get what he meant after being in Baltimore. It's a couple of years where you're at the peak of your kind of training, you've just finished the hardest part of your training, you're Royal College certified, and then you go to this place where all you do is the best cases, all you see is the hardest stuff — the biggest gunshot wounds — and you're tackling it in some ways for the first time as an independent staff person. And it's an incredible way to sort of learn the trade and have great wins and great losses and learn how to bounce back from the bad days and not get too high off the good days. The people I met there, I mean, I could name a ton who, you know, people in the trauma world would know data fraud was our chief; you know, Elliot Haut was my fellowship director, so just incredible people there, and even the cross-town, cross-pollination, getting to do a lot of training and, and time or shock trauma, getting to just be around, you know, Scalea and those people was a really cool city to train in, to work in. It was awesome. So I really, I always tell my trainees fellowship is something — it's the cherry on top of the cake of training and we should all look forward to that opportunity.
Ameer Farooq 05:01
And some of those names that you mentioned are just legends in the Toronto world, and I still enjoy your banter with Elliott Haut on Twitter. That certainly gets me laughing every time I see that, so I can only imagine what it must have been like to actually go and train with them. I think, you know, looking at your your research and all the work that you've done, it seems like your interests in simulation and trauma started fairly early on, and you did some work, I think as a fellow while you were in Baltimore, particularly around the Multidisciplinary Difficult Airway Course — correct me if I'm wrong — but tell us a little bit about that work that you did on the MDAC.
Dr. Rob Leeper 05:47
Yeah, totally. So yeah, you're absolutely right: simulation and using high-fidelity simulation to train has been something I've been really interested in forever, it feels like. And again, broken record-like, it actually takes me back to football. You know, a lot of what we would do in football, and as you guys know in sport, is go out as a team and simulate something bad happening. "Oh, wow, here's a really good play that he runs. Let's do it." We'll record it, and then sit there in the locker room and break down the tape. And I remember my coach Pat Tracy saying like, "Leave her. Why are you on numbers? I need you outside? I need you here, not there." And then okay, well, the next time we run that play, we're gonna do a better job of it, right? And so simulation has that chance to simulate problems. And in my situation, I always record by [simulations], and break them down. And that's what we have been doing, whether it's trauma, difficult airways, crisis in the operating room; it's kind of the way I skin an onion. This particular project that we did in Baltimore, I was lucky as a fellow to be able to plug in and be part of a really cool program that was already kind of in existence. And it was, as I mentioned, the Multidisciplinary Difficult Airway team. It's actually called the DART team — the Difficult Airway Response Team, and it's great because it arose naturally out of a need. They had 1 sentinel case that opened everyone's eyes to how bad it could be if airway experts aren't around, and the hospital set out to sort of fund this program that allowed the trauma surgeon, an ENT surgeon, anesthesia, emergency medicine, to all be available and on call to respond immediately, like to a trauma, anywhere in the hospital if there's an emergency. So that program was started before I got there, but what I got to add, which was great, was kind of an analysis of what our educational piece had done to add to that program. What we ran there was this big, four-times-a-year educational simulation course — a full day, where all those different providers from, like I mentioned, anesthesia, emergency medicine, surgery, ENT and even some of our CRNAs (our nurse anesthetists) and other folks would get together and train together. It was just like what the military does with, you know, getting away for training a couple times a year, just to see what sports teams do to get together and practice once a day or once a week, whatever. And we drilled and drilled and drilled and did these simulations that really seem to improve team functioning when it counted and when people work together for these events, so it was a big deal; it was really cool.
Ameer Farooq 08:28
Just want to pause for a second, because I think people don't always appreciate what an institution like Johns Hopkins does from a research perspective and what kind of infrastructure they have in place to actually make it possible for people to do high-quality, high-volume research. Can you just tell us for a second what kind of — when you plugged into a research program like Johns Hopkins, what did that sort of look like? What kind of support or resources did you have to do work at Johns Hopkins?
Dr. Rob Leeper 08:58
Yeah, there's a lot that's amazing about these big American centres. And, you know, Johns Hopkins in particular — I think the thing that blew me away, on a research side, were the amount of people, funding, time and energy that was available for that kind of work, from the affiliation with the School of Public Health, C-STAR program, the number of grad students who were just keen to jump in and help you with things, and even at the level of the hospital, to say things like, "Hey, we think this makes care safer". And, you know, we did an analysis of them — some of the group that I got to work with — did an analysis looking at medical legal settlements. And so, we can save potentially a million bucks per bad event if we have a Difficult Airway team. "What do you think about funding this?", and they went, "Oh, yeah, that'd be great". So just the idea that because it's an institution that is in some ways, you know, research-focused and has an outcome focus, they're willing to invest and do things, then unfortunately, when you look at the other model that we work with in a publicly funded system where it says, "Hey, the government gives you x dollars; try not to spend it all". There's no — they don't have that same desire — that drive — to innovate and to proliferate their research sort of infrastructure. So it really is, like, in some ways in Canada, you feel like you're working against the stream; whereas, in Johns Hopkins, you hop on and the river is just flowing in the right direction. You just go for the ride. It was really, it was a really impressive place to work — absolutely — and I think a lot of the American surgery schools are like that.
Chad Ball 10:40
Yeah, that's a really interesting comment, Rob. I think you're exactly right. Each of the places I was in in the US was very similar. The Americans have a really, I think, important way of linking funding and cost — so, money in and money out — to the patient as the patient moves along their health care voyage, and you don't get these Canadian silos where the OR budget has to give and the floor budget has to take, and there's cons. But, it really is security linked to that, then. In your early career, you've been very, very enthusiastic and prolific on the research side, as Ameer said, simulationist, as well as other entities as well, that certainly will link to the podcast, too. But what are some of those those sentiments and those structural elements that you've been able to bring back from Hopkins into London and try and sort of nudge maybe London in a little bit left, a little bit right, despite London, obviously, being a very proud and impressive, historically productive research-type centre?
Dr. Rob Leeper 11:55
Yeah, I mean, I think in terms of things that I brought back from my training in the US to London, the little changes we tried to make. I mean, it's interesting, I have a couple — my brain is going in a bunch of directions — the one thing that I really appreciated was a funny silver lining from our life with the virus, which was that during the the worst of our COVID years, we actually were able to institute a Difficult Airway team in London. They actually — the hospital took some COVID funding from the government and was able to step up and pay for staff physicians to be in-house 24 hours a day, and did some training, got us a special room, bought us equipment. All of a sudden I went, "Wow, this is sort of like what they would do in the US". They really are investing and putting a lot more into patient care. I was pretty impressed by that, actually. And so that was the first thing in my head, was the fact that we actually developed and built a routine now. I mean, not to bad mouth or complain, but with, you know, with COVID thankfully waning now, that funding has gone away, and the team has gone off. So I kind of — I'm a little downtrodden with that in the moment, but I understand why we're having a lot fewer responses. But I thought that was actually a positive change, that it showed the hospital kind of adapting and recognizing the patient can be really stepping up and supporting the way that we would in the US. So, when I was there, a couple of my really favourite trainees down there, the [inaudible] brothers, were publishing on the first year of data that Elliot had gotten, where he realized that the residents sucked at prescribing DVT prophylaxis. And so what he did was he went to the the EMR and said, "Can you please give me an anonymized list of all the residents and the number of times they appropriately prescribe, you know, Lovenox or whatever the drug was, for patients?", because, you know, it was a computer order entry. And so suddenly he has this anonymized list of every person, and he published it, emails it out. All you can see is your name Rob Leeper, but the other 50 residents are on there too as blanks, and it shows you where you are on the list, how — whether you're at the top of a list or the bottom or the middle somewhere. And you can imagine that surgical training program, in particular one like the one we had in Baltimore. These are Type A people, these are competitive people. And suddenly after about the first month or two of that data being available, they clustered super tight near the very top. They're all 90+ percent at prescribing the drug because nobody wanted to be last. You know, it's like the Lake Wobegon phenomenon: everyone's above average, nobody wants to be last. And so we borrowed that same strategy for our trauma simulations and my Master's sort of thesis when I was down there was I was doing interdisciplinary insight to trauma centres in the trauma bay, and I would record them and score people. And I brought that home with me, so that when I do our trauma [simulations] at home, you know, we have 25 residents in our program, I assign them to 1 of 5 trauma teams named after famous surgeons from our past. And they stay in that team all 5 years, when one graduates and a new one joins. And so I score each of the teams for each of the sims that you do, you know, between 1 and 5, who won that [simulation]. And it's anonymous; you don't know where the other teams rank, but boy, the teams really compete, they really push one another. And I look at now over the last 5 years, as we're doing some of our analysis of the data, and the clustering of scores near the very top are the kind of, the — if you look at sort of — imagine a, I don't know, a target shooter shooting bullets at a data target. We're clustering very, very tight now around the bullseye because people hate to be last. And so that idea of just, you know, no one's being publicly shamed, it's all anonymous. Nobody knows as well as the score, but you know where you ranked, and that really drives trainees and people to try to get that gold star — try to get number 1. So that's been a really neat, sort of, not a trick, but a good motivational strategy I borrowed from Elliot and from the folks in Baltimore.
Ameer Farooq 16:05
Yeah, it's kind of neat, right? Because clearly your background as a competitive athlete sort of plays into this as well, too, right? Like, you know, there's multiple things happening here at that lineup to make you the — kind of the perfect person to institute something like this. Tell me a little bit about like, what is this — how does this get operationalized? So you're doing — so, tell me about what the these simulations look like, and like, how do you sort of score people? Tell me a little bit about — actually, paint me a picture of what this actually looks like.
Dr. Rob Leeper 16:40
Sure. Luck is a good thing to start with. So, the 5 trauma teams. They're sort of — and this is a bit nerdy; plug your ears if you're afraid of nerd culture, but they're a bit like the houses of Hogwarts, right? I assign them all based on the names of our founders. And each house has its own vibe and its own team colours, actually. I buy them all, like, sets of FIGS scrubs at the start of the year, and then I replaced them. So I buy new ones for each new person. So there's like a red team, and blue team, a green team and a whatever team. So when they show up, the trauma team looks good. They're all matching scrubs. And me and our fellow that year, and often my brother who I mentioned, played at Queen's and is now 1 of our anesthetists here. So he works. I mean, we do a lot, we collaborate a lot on simulation research, which is fun. We designed up a sim scenario or two, usually. We might run through 2 per day in a 24-hour session, and each scenario will have, you know, it's again, based on on the kind of the scripting that we did in Baltimore. It has, you know, predefined and timed events when they're going to arrest, when they're going to have sudden arterial bleeding. And then we have expected outcomes. So, how long would it take the students to recognize the positive FAST? How long until they request an MHP? So we have about 8 or 10, usually rubric-based outcomes. We're looking for the score, we record them and then, in addition to doing a real-time, just hot debrief afterwards, we then go back and score the tapes. I often get med students come and watch these videos with me over our online archiving system, and they'll score those key features in the rubric. And then I can give, actually, a report card, and I can send you a copy if you want to look at one, but I have a very formularized report card that the residents get back that say, here are your scores. Here are the 10 things you're looking for. Here's what your times were, and it was the first place, second place, third place, fourth or fifth place time compared to the other internal controls, the other 4 teams. And here's the overall rank, and here are, you know, 1 or 2 articles I might link to that sort of support your learning around this sim or this particular aspect of how to manage pancreatic injury, or how to think your way through a difficult trauma airway. So it's a really relatively robust and almost formulaic and repetitive, iterative process that I use to train our people up so that when they leave, even though London isn't the busiest trauma mecca of a city, but by the time they leave, they can think and talk and work their way through a trauma sim, a trauma [resuscitation], I think about as well as anybody, and they compare very favourably to the folks that I trained and worked with down in the US.
Ameer Farooq 19:19
Can you give me an example of — what's something that you've seen, not to give away your sims or to pull the lid off the box, so to speak, but can you give us an example of — what's something that you saw a team do that you said, "Okay, you could have improved on this", for example?
Dr. Rob Leeper 19:40
Oh, gosh. The big question. What could they have improved on? A good example? Yeah, sure.
Ameer Farooq 19:47
Just so that people can get a tangible idea. Like, when you're saying—when you're doing these sims and you — what are some of the things — what scenarios would you have and what are, sort of, the things that you're looking for that you want the teams to do?
Dr. Rob Leeper 20:02
So I'll pick — and again, it's a little bit of a law-and-order style, and I always take from the headlines, I always try to find the case that's hot or spicy in the real world of our trauma system, and then bring it to sim. And I'll often capture images or especially the point of care ultrasound images from cases. So, many years ago, when I was first back, we had a really difficult case where an unrecognized positive intra-abdominal FAST and pericardial FAST led to a big delay in patient care and actually patient death. Whether or not they were to survive anyways is the question, but the patient did pass away. And so we captured those images on our system I said "Okay, wow". And they were tricky. They were — there was so much clot that it almost looked like the liver had in those views. And so it fooled the people involved, and so I captured the images, I brought them to the sim world. And our confederate in a sim plays the role of a really confident rider who says yeah, you know, and — during the sim, beeps are going off, the mannequin is gasping and the confederate puts the ultrasound probe on the mannequin and shows the participants the screen of our ultrasound. And it's exact, it's the loop from the actual case and says, "Hey, look, so FAST is negative, so I better move. Must be bleeding from the pelvis or the leg. Let's keep going". And 5 years ago, when they showed that clip, 100% of our trainees said "Yes, sir, I agree. Let's move on". They all took the word of this new clinician, you know, for granted. And when I asked them in debrief, "Did anybody have any worries?", half of them were like, "Yeah, you know," I'd raise your hand and say, "I thought it was positive, but I was afraid to speak up". So 5 years on, after doing all these sims, and now after, you know, having been through it for their entire training program, I ran the exact same sim again with a whole new group that all graduated. It's 5 years later. And in this case, about three-quarters of them spoke up right away, said, "Sorry, sir, no, that's positive". And whether that means they're just getting better at reading ultrasound? Maybe, but I think they're learning better how to communicate and how to speak up to authority in crisis, how to actually — give voice to concerns, and rather than going into silence, find that appropriate pool of shared meaning, or to align to what I would call a shared mental model of the patient. And I'm seeing that so much more with our trainees, both in simulation, and in the trauma bay, which is, I think, a huge win. I think this particular patient might survive if they've rolled in today, whereas they didn't 7 years [ago].
Ameer Farooq 22:49
Congratulations on such a fantastic effort. How often do you run the sims?
Dr. Rob Leeper 22:54
So each team gets 4 sims per year. Like I said, we run them — they do 2 per sessions. So each team comes for 2 separate sim days, usually in the winter and the fall. So, 4 times per year, 20 cents total per academic year. So by the end of your 5 years, you've seen 20 high-fidelity trauma sims to complement all the ones — all the real traumas you've seen in the trauma bay.
Ameer Farooq 23:20
And this is happening at the C-STAR right that you're in, you're in the simulations, facilities that you have to watch. That's
Dr. Rob Leeper 23:28
Right. We run — C-STAR is an amazing group for us. I hope every centre has their own big simulation enterprise; ours is C-STAR. We run all of our trauma that we run there and in-centre. Although we also do a lot of in situ work bringing — C-STAR brings the mannequin and brings people out to our trauma bays or ICUs or operating rooms. And we've done a lot of work that way, too. But yeah, that one is run actually in the centre.
Ameer Farooq 23:53
Again, congratulations on such a phenomenal amount of work. And we're hoping, Dr. Paul and I, for sure — and I'm sure people listening to this across the country — would love to bring similar type things to our training programs around the country. So again, congratulations on such amazing work. I wanted to slightly shift gears a little bit to talk about 1 other thing that you've done, because I found this just provocative and interesting. And you actually looked at the impact of specialty training on trauma resuscitation. Curious what you found there and what the influence was to do that work.
Dr. Rob Leeper 24:31
Yeah, this was — I love this paper. And it's actually my favourite kind of paper because, sure, it's a provocative question to ask. But what was interesting was, we really wondered because in our centre, which I think is somewhat mirrored across Canada, but totally unique to the trauma world, especially compared — the Americans would look at us like we have three heads — we have shared duty. The trauma team leader for a given day is about equally as likely to be a non-surgeon as they are to be a surgeon, somebody from emergency medicine or in critical care vs. somebody from trauma surgery, and it creates a bunch of cool opportunities for natural, observational studies. And so I was, I think, a senior resident. We looked at and said, "Let's just pull 10 years of data, and let's try to figure out if there are differences in the ways that people are managed", be it from surgeon vs. non-surgeon, trauma team leaders. And I mean, like you'd expect in trauma, with big numbers and 10 years of data, you're not going to see a change in mortality, in resource utilization, blood product utilization, all those big-ticket items that are very patient-driven are pretty similar across the board. The places we started to see changes were — certainly, we had trends towards, you know, faster access to the operating room, shorter [resusciation] times, but the place that was really significant for us was in the rate of missed injuries. And I don't know if this is something that every trauma centre looks at as hard as they maybe could or should, but we demonstrated that if, taking into account even the tertiary server the following day, about 14% of all patients have at least 1 missed injury, which means that it gets discovered later in clinic, later on in admission — a broken foot, you know, a sneaky ligamentous injury that was missed. And interestingly, the folks who are [resuscitated] managed by surgeons were significantly less likely to have missed injuries than those that were managed by nonsurgeons, and why would that be? "Why would that be?" I mean, we had a bunch of — it generated a bunch of good hypotheses. So the 1 thing I would say is that the higher fraction of our emergency medicine providers, who are the nonsurgery TTLs, don't practice inpatient medicine, so they don't see the other side of patient care. And I think — when I really think back, in my heart, about some of the conflicts that we've all had over our life with our colleagues in emergency medicine, there's that fundamental misunderstanding of, "Well, you don't get what happens after they leave your department. You don't understand the longitudinal nature of their care and how this really plays out in the long term", and I do wonder if that is part of it. Like, in their minds, is that that big of a deal that we missed the pinky toe fracture? It's not; it probably isn't. But when you actually go to count them all, the surgeon-led [resuscitations] were a lot more likely to be, I guess, detail-oriented and not prone to getting lampooned in M&M rounds 2 weeks later, because they missed an injury. So that was an interesting finding, and it just spoke to, I think, the different approaches and the different sort of paradigms within which surgeons and nonsurgeons approach trauma and [resuscitation].
Ameer Farooq 28:06
That's such an interesting thing that you just said about M&Ms, right? Like, you know that Richard Thaler, the behavioural economist, talks about accountability bias, right? So when you put yourself in your shoes standing on Friday morning, or whenever it is that you have M&M rounds, then you maybe act a little differently sometimes in the moment, because it really forces you to be that maybe 1% extra diligent. Again, maybe again, it speaks to our nature as surgeons. I don't know.
Dr. Rob Leeper 28:37
I'm not sure if it's the right way to do it, Ameer, but you're absolutely right. Data from 1 of my mentors at Baltimore always said start with Tuesday morning and work backwards. That was — the M&M mornings in Baltimore, because he knew that John Cameron would be weighing in on yes or no, at the end of the M&M, whether you were justifiable or not. And he just did not want to have Cameron say, you know, "That was a terrible job!". You don't want to hear that, right? So that may not be the best way to practice, but it's a reality, and I think that particular study you talked about reflects that reality among surgeons and surgeon trainees.
Ameer Farooq 29:11
Do you incorporate, in your trauma teams simulations, given this sort of findings, and obviously the reality in Canada is that a lot of our traumas are going to be managed across the country by nonsurgeons, non–trauma surgeons for sure and nonsurgeons for sure. Do you incorporate other nonsurgical disciplines like emergency medicine into your simulations as well?
Dr. Rob Leeper 29:38
Yeah, I mean, to be sure, a lot of our trauma fellows are nonsurgeons. We've trained a bunch of really good [emergency medicine doctors] who now work with us on the trauma side in London. So they come as fellows and work on [simulations]. Now, our confederates are usually playing the role of an [emergency medicine] position. And then we, depending on the scenario, we all — we like to bring in special people to the [simulation]. So I had a pre-hospital focus in 1 of our [simulations] a few years, and I brought in 2 of our really, I think talented paramedics who can join us for the 7 days, and they actually did the handover, and they were part of the [simulation] with the attorneys. I've brought in [emergency room] charge nurses when we did a—we practised a multi-casualty [simulations], where they had to manage more than 1 room at a time and had an [emergency room] charge nurse to help them divide resources and get that sorted out. So we try to bring in people who enrich and add to the experience, because really, at the end of the day, what I'm really passionate about, if I had the perfect world, all of these [simulations] would be in situ. They all happen in the trauma bay, where all that richness of multi-professional and professional education would happen. But because we are still doing those up in the centre, I try to bring people in selectively, who would be the most important extra element for that particular [simulation].
Chad Ball 31:17
We wanted to switch gears a little bit here and talk about your insight into starting practice, and obviously you know where I'm going with this. For our listeners, we asked Dr. Leeper to give us a talk when you had just sort of started, I think it was in your first couple of years back in London, at the Canadian Surgery Forum. Hamid and I had asked you to do it, and the title of the talk was something to the effect of "Things I wish I had known when I started" or "Things I'm glad I knew when I started as a junior or a young staff surgeon". You hit on a number of topics, and I still talk about that lecture and that talk and, you know, it really is one of our favourites of all time. I was wondering if you could start us off by sort of framing how you thought about our question to you and that talk, and how you put that together?
Dr. Rob Leeper 32:13
Yeah, so that was, I mean — first of all, big picture. I really am and blessed or cursed with loving the sound of my own voice. So when given a mic and an opportunity to speak into one, I'm always happy to do it. And when I got that email from you and saying, "Hey, Rob, can you talk a bit about just being a young trauma surgeon and tips on starting practice?". I went, "Oh, this is great. This is awesome". I mean, I have a wealth of things to talk about and tips to share, because all I have to do is think about all the things I've done wrong; all the screw-ups that I've had and stuff that I wished I'd done better, or you know, or started off on a better foot. And that makes the list of things I can talk about really easy. So that's kind of where I went from. I said, "Okay, what are the things that I've struggled with, the things that I've worried about? Or the things that I've seen done badly, and what's the corollary of that? How do I spin that in the other direction?". And yeah, so it was a ton of fun to just think about — to just go through that list and think about all the things that I could share. And yeah, you're right, it was things like, man, I had the hardest time, when I first came on, finding a really good secretary, you know? And I was so lucky to at least for a while be able to hire one who had been really experienced and knew the system in and out and and actually Neil Perry and Daryl Gray's secretary for many years. So that was huge; it gave me the time I needed to then find another great one, who is looking after my office now. I was so, kind of — like silly small things, like being destroyed on-call, and I'm going, "Man, I wish there was a couch in my office to sleep on. Oh, right. That's why Dave had one in his office. I better get one", you know, to some of the really — the broad strokes stuff. Even early in my practice — and this happens to everyone — the first year of practice is notorious for this: you're going to have some bad outcomes, like a bad patient death or 2. And I got to reflect on a few that I've had, and the difference between ones where it hit me and pinned me down, or ones where it happened, but I knew we did all the right things, and it was way easier to kind of file away and learn from it and move on. And what made those 2 deaths different; that was — so again, it's probably one of the best lines. And again, if you're fearful of nerd culture, plug your ears again, but it's probably one of the best lines that you ever get from Yoda. When he says to Luke, "The greatest teacher failure is...", which is a line from The Last Jedi. And he's right, you know. If you're not focusing on your failures and finding ways to learn in the midst of all that suffering and sorrow and shame and anger, you're missing out. And so I just — that was an easy talk to give. I just went back into it and made a big list of all the things that I've done wrong. And the talk could have gone on for hours, Chad. I had to really cut back on it. Well, you did a beautiful job. And for our listeners, which is to be the majority of them, who weren't at that talk, I hope you'll humour us here and take us through a few examples. And I'd love your thoughts on it because they, again, they were so insightful at the time. You talked about, for example, hiring a fantastic secretary or assistant. And that's true. It's incredibly true. And it may be the single most important thing when you start. Now, I think usually you don't have that insight or maybe even that ability to kind of select out in some Canadian healthcare systems, who you want. But it's so critical. You know, you also talked a lot about the importance of the nontechnical skill side of surgery, and you talked about it in a couple of different ways, whether that was critical care, sort of clinical content, hardcore knowledge, as well as it was sort of the social patient focused, patient–family centred side of things. I'm wondering what your thoughts are on that today? Yeah, I mean, I remember that slide exactly. I actually put up Lawrence Gilman's book on nontechnical skills in trauma, a book about which I'm late on a chapter for, by the way. Sorry, Lawrence. And to me, I think that's true. A lot of our trainees, at the end of their fifth year, they tell me things like, "Well, Doc, I just got to be able to pull the trigger. I've got to be a really good — I've got to put that stitch in. I've got to have downtown hands if I'm going to be a good surgeon". And you do! And there's no question. Like, you know, you have to have really good technical skills. But if I ask myself the question: What holds people back in their practice? Or what makes them struggle or be less than excellent in practice? It's not going to be the technical stuff. Everyone can sort of put a stitch in or put a clip on, or whatever. It's the nontechnical things. It's having a 3- or 4-dimensional view of the trauma bay. It's managing your affect, your emotion around an urgent case or a difficult person in the operating room. You know, how do you sort of manage that? That to me — if you're going to focus on something — if you're going to be — if you want to have 1 thing, like if you're making a character in a video game, and you want to maximize 1 particular sort of attribute, take nontechnical skills all day, but make that 100. Max that category out, because that's what really, I think, at the end of the day differentiates really high performers from the more average group crew. So yeah, I think that, and that's true I think broadly, in the sense of just being a high-performing person, but if you shrink it down and bring it back to just the trauma bay, you know, again, I'd have residents who think that to be a great trauma provider in the acute phase, they have to just be able to bang in a subclavian line in 1 second. They have to be able to do a cric[othyroidotomy] with their eyes closed. And sure, those are important things, too. But it's actually more about being able to think and talk your way through a tough trauma. Because there's lots of people that — there's this great line in Whe Were Soldiers, where this senior NCO, who is played by — I forget who plays it; some really gritty actor. They say, you know, the whole movie, the whole time, "You never carry a rifle. You're always just carrying a pistol". And he says, "Well, turns out if I ever need a rifle, there are a lot of them laying around", you know, from dead soldiers, right? And it's true; in the real like heat of the moment there's always a lot of people around who can put in a line or put in a cric[othyrodotomy]. What they need — what you need to be, is their leader. You need to be a person who can stand back and actually manage them and get those 10 cats to pull the dog's lead in the right direction. So I think people focus too much on technical skills, because it seems like that's what Top Gun would do, that's what Maverick would do. But really, at the end of the day, it's more about being able to think and talk your way through problems and having that situational awareness more than just the ability to tie a great knot.
Chad Ball 39:57
That's a great analogy. It's Sam Elliott. That's one of the —
Dr. Rob Leeper 40:01
You're right. You're right.
Chad Ball 40:03
Yeah, he's a sergeant major. And that's one of the best movies of all time, if you ask me. Everyone should watch it. And another thing that you talked about, which I thought was interesting and incredibly insightful, again, was the idea of saving every Thank You card from a patient. What did you mean by that?
Dr. Rob Leeper 40:20
So funny. I took, literally — I'm meeting a friend tonight who's just having a bit of a tough spot; he's a colleague and a friend. And we're gonna get some drinks tonight, I just took a picture of a Thank You card that I have posted on my wall and sent him and said, "Hey, here's a picture of a common patient of ours who was saying thank you to you and Dr. so-and-so for all the hard work we did together". And it happens, you know; his father's passed away. And he's having a hard time and like, what other specialty — like, my brother is an anesthetist. He gets no Thank You cards. None, right? What a unique and lucky and so special place we occupy in our patients' lives that they think to, after going through a cancer diagnosis or a grievous injury, to take the time to write a Thank You card and bring you a bottle of wine or a gift card or something. That's really special. And to do anything other than cherish those little mementos is crazy. You're foolish to get rid of them, because they meant a lot to that patient. And boy, they can mean a lot to you, as you sit in your office looking at them. Mine is posted on a bulletin board behind my desk, and as I sit there and look at an email about another, I don't know, grant I didn't get or another, you know, order I didn't put in properly for day surgery. Those Thank You cards are a real reminder of what we do it for. And that particular bulletin board that I have — that I look at, I have a little — I pull the cards off every few years and replace them. But the heading across the top of the board is something from Band of Brothers, and it's called Why We Fight. That's the name of their — like the sixth episode of that miniseries, when they're liberating camps in Eastern Europe. And this is the whole reason why you do it, is to have good outcomes and have patients who are grateful because you were there for them. And so that's — I think that's — I couldn't advise it. There's a lot of good advice in here; that one might be my strongest advice, is to keep those Thank You cards and remember why we fight.
Chad Ball 42:35
Yeah, I like that very much. That certainly helps on on tough days, too. You talked about not ducking the hard clinical cases when you start. Tell us about that.
Dr. Rob Leeper 42:44
Yeah, that was important. It was my very, like, sort of last week in Baltimore, I was going home and I was talking to my mentor Dave Efron and saying, "Hey, Dave. Do you have advice for me, and like, you know, things to do in my first year back?" And I said, "I think it might be smart for me to try to, you know, maybe not take on the worst case in my first year back, try to refer Neil Perry for the first year". And he said, "Stop. Just stop, because I didn't train you to go back and not do hard cases". He says, "If you're the person who's on call, and who decides to manage the case non-awkwardly because it's difficult, everyone will know — especially you", you know? He says, "We are transparent. Our motivations, our decisions and our, kind of, I guess bravery is obvious to those around us, and mostly to yourself. So, if you start off ducking tough cases, if you start off narrowing your practice's scope to only things that you're quite certain will be successful, then you'll never get off that track; you'll become an 'I'm-not-comfortable' surgeon. And Dave never ever wanted to hear the phrase "I'm not comfortable", because he said, "No, Rob. You're going to — I'm sorry to say you're going to have to be tackling the toughest cases from the minute you put your boots on the ground. That's the burden of our profession". That's — "Geez, Dave. You're right. Thanks for that". And he's right. He's totally right, you know? You just — it might be nice to think there's a way to have a slow, safe start, but there's not. So just accept that and acknowledge that, and when the tough cases show up, do them. And call for help, for sure, but don't — but yeah, definitely, definitely, everyone will know, especially you. So take a month.
Chad Ball 44:51
Well, I like that sentiment and your little qualifier there, which is not so little in reality, is asking for help. And I think that speaks to another 1 of your points, which is the importance of great partners and great mentors. You know, you obviously have the benefit of some tremendous, experienced surgical talent around you when you started. And in general, you have Kim Wesley and Darryl Gray and Neil Perry and some of the other names you've mentioned, for sure. You know, we can't necessarily pick all of our partners, but we can certainly pick, I think, in the right times, when we're being hired, the institutions that have that support system and have those wonderfully experienced, insightful and helpful faculty groups — what is your sense of that slide, thinking back to it in your particular scenario in London, for example?
Dr. Rob Leeper 45:44
Well, I mean, I have the slide open in front of me now. I'm looking at it right now, and it's funny how much younger everyone looks just 5, 6 years ago. But yeah, I think it's so important, Chad. People will choose how they rank in CaRMS. They'll choose, where they choose for fellowship. They'll choose where they end up getting hired for a lot of reasons; location and remuneration, and opportunity and OR time and whatever. But boy, pretty high on that list has to be the people you work with. They're going to make a huge difference; who you work with, and how you work together, right? What is your — what's your call structure like? What's your — how do you bill? How do you, you know, how do you share work? How do you share referrals? Those kinds of considerations, it matters so much. And it's not as much to me about the bottom line, like how much time — how much money do I make? That's not what's important at all. What matters is when you're having one of those difficult cases, when you need suddenly to have a partner pop in and do OR list because you got called away for an emergency, you know, are they going to respond? Are they going to be there? Will you enjoy spending time with them at Royal College exam day, at meetings and so forth? It matters so, so much. And it was a huge part of me wanting to come back and work in London. I just knew that I loved these girls and guys that I worked with so much. And it makes a huge difference, you know, that notion of a positive culture and of a can-do attitude among your partners? Boy, it's way easier said than done, but if you find it, hang on to that culture and those people, because it really, really makes all the difference.
Chad Ball 47:37
I'd like to — maybe our second last question here, split it into 2 parts. The first is that you did talk about, you know, a number of clinical trauma-related, resuscitation-related topics in that talk, but I'm curious if there's anything that we missed that really strikes a chord with you beyond that from your lecture. And then the second part is, you know, it's been a few years since you gave that lecture now, and is there any insights that you would offer our junior faculty listeners, or maybe even fellows and senior trainees, in terms of things you've learned since that wonderful talk?
Dr. Rob Leeper 48:15
Yeah, nice. I'll interpret that as, what's the favourite slide we haven't talked about, and what's the slide you would add now? For sure. So, I think my favourite slide that we haven't addressed is — it was a revolutionary war era banner that says, 'Give me liberty or give me death'. And I changed the word liberty to the word Cordis, which is a — that's a brand name, but it's the introducer sheath, the 9 French industry sheath that we use in London, for our MTP, our massive transfusion protocol. It's a big, big, big central line. And I think that's probably one of the more important things I can say to people. And there's a lot of folks who want to dredge up administrative data that shows that patients who receive [inaudible] access in the trauma bay are less likely to survive. And of course, that's a selection bias because they're sicker, but I would say to people, you know, it's important to be able to pop into an IO when they first get there, and getting peripheral IVs is important, but I think 1 of the things I see too much of is, like 5 different IVs hanging 1 bag of blood each, none of it's actually going in, and getting a single access point in resuscitation; a single large-bore, you know, industry sheath attached to a rapid interchanging device. That sounds simple enough, but actually, you need to make that the centrepiece of your hesitation. That is — it's meant to be a crew-served weapon, where more than 1 person is responsible for checking and hanging blood. And if you can create that single access point with a crew serving your level 1, your transmission device, you will actually successfully get blood into the patient at an incredibly faster rate than this kind of diffusion of responsibility of multiple sites. So I would say that that slide is one of the things I come back to quite a lot when I'm teaching both senior and very junior trainees about how to do trauma [resuscitation]. And then, if I could speak on 1 more thing, you know, I have to say, I'm going to be derivative, and I'm going to do what I've done my whole career, which is to borrow from story mentors. I would just reference back to what I heard Dr. Wall, say on your podcast just a few weeks ago, which was when you asked him what he would look back at and maybe modify about his career, his practice, I was a little bit — I don't know, I almost pulled the car over, and he says that he would stop and smell the roses more, you know? And having been his trainee, that really struck me, because boy, Dr. Wall never stopped for anything when I was his trainee. And I think that's probably true. I have a slide about taking good vacations, and especially in the post-COVID era, I've taken a ton of good vacations, and I probably should take more of them. I think spending — finding more time to stop and smell the roses with your family, with your kids, to coach your football teams. If I was making this talk again, I guarantee there'd be a slide of me coaching my kids' sports on it, for sure, for sure, for sure. Because that really matters a lot to me. And I know — I expect it will resonate with a lot of our listeners and for those that don't yet, you know, are yet in practice or have kids or whatever else, you know? Earmark that for down the road. That's a really important concept.
Ameer Farooq 51:35
You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you like what you've heard, please leave us a review on iTunes. We'd love to hear your thoughts, comments and feedback. So send us an email: [email protected] or tweet us: @CanJSurg. Thanks again.