E128 Helen Pham on Australian surgical training programs and advice for starting residency

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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

A big welcome to all the new residents starting this week on their journeys to become physicians and surgeons. To help you on your journey, we caught up with Dr. Helen Pham. Dr. Pham is a Clinical Associate Lecturer at the University of Sydney and is as a current HPB fellow at the University of Calgary. Dr. Pham shared with us some of the differences in training paradigms for surgical programs between Canada and Australia, and also gave us her invaluable advice for new trainees. We would love to hear your tips. What do you wish you knew when you were starting out as a PGY1? Email us at [email protected] or tweet at us @CanJSurg. Be sure to check out Dr. Pham's amazing notes and list of textbooks and resources that are included in the show notes.

Chad Ball  01:30

Can you tell us where you're from and how you ended up in Canada at this point, and sort of what your training route or voyage has looked like?

Dr. Helen Pham  01:38

Yeah. Thank you so much for having me on. It's been really great here. Well, as you can see, from how I speak, I'm not from Canada; I'm from Australia. I did my training in Australia. So I graduated from an undergraduate medical school, which goes for 5 years, and then I started as a doctor in 2013. And the way — I guess it is different, because I did 2 — in Australia, I did 2 years of internship, which is a hospital doctor, before applying for a surgical program, and then I did 1 year of what we call an SRMO, which is an off-program training, and then I did 4 years of training for surgery. And this was all really in Sydney, and I've been sent to different hospitals within Sydney and probably at the borders of New South Wales and Queensland. And then, on my — I sat my exam — my fellowship exam — around May, 2019, and then the year after that, 2020, I was very fortunate to be given opportunity to be a staff Specialist General Surgeon in the hospital where I trained at, in Westmead Hospital, as well as a position of what we wish they don't have here, which is called the Clinical Superintendent of Surgery, which I can talk more about later, but that gave me the ability to be more independent. And then I was very fortunate to actually know a surgeon who came here who was a very close mentor of mine, Dr. Steven Craig, and he was at Foothills for an endocrine fellowship, and I've always wanted to do HPB and he knew that, and he saw the volume here, and he saw the staff support and the types of cases that we get here. And I was very keen to be here, so I applied for this job, and I was very fortunate to have the opportunity to come here for a year.

Ameer Farooq  03:45

You obviously do a lot more generalist-type training and practice before you actually enter your subsequent subspecialty or specialty pathway. How do you think that that has affected the way that you practise perhaps now as a surgeon, and as an HPB surgeon? Do you think that those years were valuable? How do you feel about those years where you were more of a generalist before you entered your subspecialty?

Dr. Helen Pham  04:16

Yeah. I agree; it's very different. And I am biased because that's the only training program that I went through and I knew about, and it's similar to what the UK training program is like, and actually some of our — other countries, as well. I actually think — I, myself, think that was probably the best way to be, and there are pros and cons for it. The way in Australia, and I guess the UK, works is that the hospital — when you graduate as a medical student to a doctor, you don't just, you know, subspecialize into any program; you do cardiology, geriatrics, which I did. I did emergency, geriatrics, cardiology, I did [rehabilitation] terms. And for 2 years, you do get an idea of the overall holistic management of the patient, but also you get to work with a lot of people that you probably wouldn't work with if you go straight into a surgical program. I have good relationships with geriatric doctors, as well as the [rehabilitation] doctors and the cardiology doctors, the respiratory doctors as well. And I think it also gives you a bit more clinical maturity. You're not going from a medical school to another, kind of, structured learning program into a specialized — you're going to be a helpful and — helpful doctor to the — and a helpful member of society. You're employed by the hospital. You're not employed by a college. You're not employed by an overriding board. You're employed by the hospital. So the hospital sees you as a staff member, as someone that actually should contribute something. So, I think that extra maturity, that extra step in, I think, really helped. And it helps because most of our trainees have to do usually another year on top of those 2 years, because of how difficult it is to get into surgery in Australia. Every year, hundreds of people apply for the surgical program, and they probably only take about 60 a year. And there's a lot of people who are very qualified and are very far down their postgraduate years and still find it difficult to get in because of how competitive it is. And I think that does give a lot of clinical maturity, and most of the residents that come on to surgical programs now already know how to do appendixes. They already know how to do gall bladders. They know how to work up very simple — or, they know how to work up basic surgical pathology before they get on to surgical program. So I think that is helpful. I think it is long, and it can be extremely frustrating. But that is part and parcel with how the structure in Australia, how that's different from Canada and actually North America, as well.

Chad Ball  07:12

That's really, really interesting, Helen. So, you know, one of the things, I think, that all of us struggle with in Canada, and in the US to some degree as well, and I think it's not specific to any individual, but I certainly had to stop and think about it, and I bet you a mirror would probably tell you the same thing, is that the flipping of your switch in your brain from "I'm a learner. I'm in school", which as you know, goes on for all of us around the world for so many years, to "This is a job. I show up every morning —", you know, like one of our recent guests says, "Wake up, get up, suit up, show up and do it with a smile". There's a professionalism job component to looking after patients, as well as receiving all this amazing environmental education, of course. But it sounds like you guys really have that trigger, that switch relative beyond compared to us, where really I think — and Ameer, feel free to disagree — but I think for us, that trigger really happens at the end of residency, when you start a fellowship and you say to yourself, "Oh, boy. This is a whole different level of responsibility and accountability". And it just feels fundamentally different. What is your sense of that kind of really important trigger — a time point?

Dr. Helen Pham  08:37

Yeah. That time point has to happen early. I mean, the way that we have to think about it, like you said, is you are now getting a salary; you're getting paid. You're not going to work — and the difference is, you know, from a medical student to a doctor, you reach a point in your training where your skills, your knowledge, everything you do reflects the effort that you put in, not what's handed to you — the opportunities that you try and seek throughout your training, per se. But the education really is up to you, and you have to be your own advocate, and you have to shape your own ability to be a doctor. You have to shape the way that you want to be; make the most out of it. And I think it is no longer a structured curriculum when you get into surgery, and I think that trigger has to happen very early, as early as you can be, to be honest, because at the end of the day — that's why in Australia, when you become an intern, PGY1, PGY2, you are very well looked after. You're supervised, in a way. You're supervised, but you already — you have to make decisions. You have to prescribe. You have to work up these patients, and you're basically completely accountable to every action that you make. And that culture in Australia, I think, is very different from other places. I mean, I've only been in Foothills, but from what I've spoken to with other doctors around Canada, and as well as North America, there is a different culture. And I mean, I don't want to go into it too much, but I mean, the hidden curriculum is what I — is what in Australia — it's a bigger deal. And a lot of papers are out there about the hidden curriculum and how badly it can affect juniors, and how much it can affect the overall culture. I think I agree; we have to bring surgery into the 21st century; it's not in the olden days anymore, but I would caution that we shouldn't — all this stuff that we used to — that we would risk pushing the pendulum to the other way. The values such as resilience, hard work, flexibility and to know that you're not just here as a career, but you're here as a service to the community; that is no less important than what it was 150 years ago, and that should not be ignored, either. I don't know if you guys agree with that, but I mean, in Australia, that's more of the overall culture. And I think that's what I was taught during my training early on.

Ameer Farooq  11:26

Yeah, I was going to echo a lot of things that you and Dr. Ball had said. We actually have a really wonderful medical student on our service here at St. Paul's right now, who was a pharmacist before starting medical school. And there just is a different, sort of, maturity, right? Part of what is funny about residency here — and again, I can only really comment on residency here — is you go out of undergrad, you go into medical school and you're in residency. And many of us have never actually held any other kind of full-time, professional job, or — professional or otherwise, right? So, there are some aspects of what we do that really is a job, as both of you had said, and is a service. And of course, that's not to say that being a doctor is quite like having another job, but there are some aspects of it that you just — you have to understand that no matter how you're feeling or how tired you are or whatever the case might be, you have to show up with a certain level of excellence. And Helen, you're in some ways really well-qualified to think about these differences in training, and perhaps even how you might instill that into residents, and we're going to get into that a little later in the show. But I understand you were a Program Director for General Surgery in Australia. What was that experience like? And what were some of the principles that you had for residents coming into the program?

Dr. Helen Pham  13:02

Yeah. Actually, it was really interesting, because in Australia, it really reflects the difference in organizational structure. And my job was actually called the Superintendent of Surgery for my network, and it really is different from — you don't have anything like that here in Canada or in North America, I think. And what that is is I was really the organizational manager, or the manager role of junior surgical residents from a training perspective, but also from an administrative duties perspective, such as accreditation, teaching, research and leave requests. It is not the same as the college [inaudible] equivalent, and there is a separate supervisor of training, which I worked very closely with, and the additional role that I had, which I actually enjoyed, surprisingly, but was — I was the surgical representation in meetings with board members, directors of nursing, and I sat in multiple committees with procedural surgical governance, workforce meetings. And basically I was employed by the hospital, not by the college, and the difficulty of navigating the politics of that — it was interesting. About 30% to 40% of my job was actually training-related, and my favourite part of the job was actually about residents — training residents, not just the ones that — because what we have is what we call unaccredited residents, residents off the program, but ones on the program as well. And I love that part of my job because I knew them very well. I knew what their CVs looked like. I knew what terms they were doing. I knew what research they've done, how they were studying for their fellowship exam, what [their] future applications for fellowships are. So, I had a very, very close role with him, and I had to report back to the district Director of Surgery, and because of that, I actually continued on to be involved with the overall interviews and resume interviews for the training program, which is actually very interesting because it's nationwide. To get on surgery in Australia, you apply to a central, kind of, board, which is the RACS (the Royal Australian College of Surgeons) and the General Surgeons Australia, and they then will tell you which hospitals you go to. So it's completely centralized and standardized, and the same people — and I found that that does make it a lot more transparent. You know, you're not getting employed based on what you're like, how well you talk, who you know. You're being employed onto the program based on your merits. And that really is the only kind of — that seems to be the only way that I know how it works, and there are pros and cons for that. I then have gone on to finish a Master's of Public Health and I'm finishing my Master's of Health Leadership, because I think my favourite part of that job of looking after is seeing the really good residents that try really hard; they're doing surgery for the right reasons. They understand and they know expectations early. They don't expect, you know — I think residents that go into surgery thinking that it will be hard to get in, and then it will be easier as the years go on; I think that's extremely naive. I think [that] by having such a difficult system to get into surgery really, unfortunately, to weed out a lot of the ones that probably aren't doing surgery for the right reasons, but also may not have a completely naive view of what surgery is, and it's better to know early that surgery's not for you; it's better to go into another specialty. I think that's the thing that Australia, and being part of the recruitment process, that we afford. We're able to give that opportunity for junior doctors to be able to make that decision early. I don't know what it's like here, but I see there's quite a lot of unhappy — I mean, there's a lot of residents that find out halfway through training that it's difficult, that it's long and that there's a lot you sacrifice. And there's no — and I think, like you said, this is not a 9-to-5 job. This is not just a job that you turn up at 9, you go home at 5 and that's it. And I think the reality of that needs to be put in the recruitment process, and it needs to be emphasized very early, because that is probably the reason why most people leave surgery — the burnout, all that stuff about not having the real expectations of what surgery really is and that you're really sacrificing a lot of yourself to be able to provide a surgical service, to provide a job and provide something for patients.

Chad Ball  18:05

It's an interesting thing to drill down on right now in terms of the timing of your exposure to reality. And I know that sounds like a harsh statement, and I don't really mean it to be; it's my word-finding difficulties. But if you look at Canadian medical school programs, for example, there's less and less exposure to surgery. There's also less and less responsibility during those [rotations], medical student rotations on surgical services. And I think you can probably, maybe comment on that; whether you think I'm right or wrong compared to Australia, for example, and your experience this year, but that's the second part of it. And the third part of it is even when we look at other residency programs, so let's pick emergency medicine, for example, at most places. Many places, they're not doing any surgical rotations through the residency. Family practice: no surgical rotations through the residency, which begs the question, how do you know how we work? How do you know how to refer patients, which is a primary job in that domain? It just seems like we're increasingly siloed and increasingly delayed in terms of exposure to reality across this country. What is your sense of that? And how does that work in Australia?

Dr. Helen Pham  19:23

Yeah, I do agree. I think you are siloed. And in Australia, like I said, people who want to do, for instance, cardiology or infectious disease or neurology, they actually have to do surgical programs in their first 2 years. You have to do a surgical program. For 3 months, you have to do an acute care rotation, such as ICU anesthetics or ED, for 3 months. And that is for every single person that goes through internship in Australia, and it's non-negotiable. And that's the way that the regulation is. Once you finish your first year, you then stop becoming a provisional doctor, and then you become a real doctor. You still get paid, but it's regulated very well and you won't pass. And that's the difference; there is a stricter amount of requirements that need to be met. And even in the surgical program, it's very structured, very heavily regulated. You are to do 6 months of this, you have to pass this, you have to get the adequate amount of numbers for this to be able to move on to your next term. And I think that goes — and I have friends in physician training, and I have colleagues that have an interest in training, and they have to undergo the same overall scrutiny by an overall [inaudible]. But I think it just reflects that you do have to be held accountable for what your training is, and how you're — and the colleges should be held accountable for who they train, and what doctors that they, I guess, push out to look after people in the community. And I think that's probably really helped. And I know that the residents here do do a small term in MTU, they do a small term in geriatrics, they do a small term in anesthetics. I don't know if that — I think 5 years is a very short period of time to do surgery. And to do that during your surgical term, I think it really has to — well, it works for some people, but I think it really depends on the person how much you get out of it. And you really have to work really hard to be able to have the same amount of surgical knowledge and ability to be able to meet the requirements that's expected from other places.

Ameer Farooq  21:45

Yeah. The only flip side that I'm sure you could comment [on] is that I have a number of Australian friends, particularly from my time doing my Master's in Boston, and they — it becomes quite demoralizing or depressing sometimes for them when they, for example, try to get into a surgical training specialty, and they can't, or keep getting moved around to different places. But there's no perfect system, of course, and I couldn't agree with you more with respect to 5 years is such a short period of time. I mean, I'm coming to the end here of my own fellowship, and I just — it is a very short amount of time to become a surgeon. So, it really does, it does go by so fast, and you really have to make the time count. So, you know, that part of it is absolutely true. In your role as Clinical Superintendent, you must have had a number of residents come through with a variety of different backgrounds and motivations and struggles and challenges. What were some of the things that you would tell people who are starting out in their training program? And what would you do if there [were] people that you found that were having trouble after beginning their surgical training?

Dr. Helen Pham  23:14

I, myself, found it was in a transition from being, I guess a junior doctor entering surgical training; it is not an easy one. And I think, with these — and I have had juniors come to me about — various amounts and different levels of residents come to me about what they've had problems with, whether it's technical, whether it's clinical, whether it's a communication problem or whether it's a research problem. And I think what I would tell them, as their senior, I would tell them about the realities, and also, how I would go through with dealing with it. I guess if you're doing — I mean, I love surgery. For me, I think about it all the time. I want to always do surgery. And for people who — and I think it's the same with you Ameer and Dr. Ball, but, you know, going through this, there's a lot of self-doubt, there's a lot of kind of bad days, good days, long days. And I would tell them to have at least — so colleagues. It's the people that matters. Colleagues that they trust, that they can debrief with, they can have — come to have like a mentor, not someone who is like a surgeon. Not someone that they can have coffee with all the time and hang out, but someone who they look up to from a surgical point of view. And I say that to all my junior residents find a surgeon in the hospital that look up to, that you want to be when you grow up. What do they do well? Are they technically good? Are they good with patients? Are their research good? Why would you look up to them? And work towards that as a goal. And I think having the same people — the people that go through the same thing to talk to about this stuff is helpful. Writing things down, having a goal for things to accomplish by the end of the year, I find always helps. And like I said before, I think we have, we're very different; we do 6-month terms at a time. So for instance, here, [for] residency training I did — for 4 years, I did 8 terms only. So you have a good professional relationship with the team that you're with, you know in those 6 months what you want to have, what you want to finish by. So if I did, you know, head and neck or endocrine as my term, I would know that by the end of the term, I would want to be able to do this operation independently. I will be able to present these patients. I will finish this project. So I think having a goal is helpful to be able to remove yourself from the overall feeling that you're kind of lost, or you're struggling with a whole career program. I think having short-term goals, having long-term goals, and then having people to talk to and writing things down in a logbook; I think those are the things that I found help the most. And then I would follow up with these juniors, as well. And most of the times when they come to me, I follow up with them about 3 months later to see how they're going, what have they improved on, if any of their culture has changed, or any of their environment has changed. I mean, the reality is, there is a small percentage of people that do leave surgery, and I think that shouldn't be discouraged. I think if they're doing it for the right reasons, if it's because of a variety of things, such as the workload or the technical, I think that should be also encouraged and to be supported into another training program, if that's the case, and unfortunately, we have had people like that, but I think the earlier the better.

Chad Ball  26:57

Now, those are all great comments, Helen. And that's a really good sort of 10- or 30-thousand foot view of this topic. I think we want to drill down here, if it's okay with you, and the preface for this is that I was lucky enough to be part of an authorship group about 5 or 6 years ago that wrote a piece in the Canadian Journal of Surgery about important things they don't teach you in medical school. And a lot of that was transitioning into residency, training, [inaudible], like those sorts of, you would think, bread and butter, common-sense things, but it was interesting to actually put it down on paper. So for a lot of our trainee listeners, in particular, I was hoping that you could give us insight into, with your "retrospectiscope", what these folks have in their toolbox, like the actual nuts and bolts of their new, exciting job as an intern or PGY1 resident from not only a prospective point of view, as you've outlined nicely, but in terms of the actual nuts and bolts and mechanics of it, what will their day look like? What should their day look like? How do they become technically proficient? What's critical? What's not? What's some of your advice?

Dr. Helen Pham  28:17

Yeah, and I think the main thing — I mean, yes; attitude is everything. I would recommend most of the people going through — and even as a senior or seniors going into fellowship — coming early, being prepared, reading up, and I think that also reflects the attitude that you're not turning up to work just to — you're not going to university to just get people to throw information at you. I think there is so much to be said for actually reading up on the patient, reading up on the operation. For every operation and every patient you see, you need to read about it. So if you come across a patient with a weird pathology, if you saw someone with a femoral hernia, read about what it is, what's the incidence of it, how they present, how would you fix it? And I think, do it before, do it after, and then before the operation, read up on the steps, write down the steps, because I think the biggest thing I wish I knew was that what you see, you may only see once in training. And I wish I knew that early. And if you see a [inaudible], a primer cavity approach for femoral hernia once, you may not see that again until you're on call as the staff surgeon. So, I would say the most important thing is, every single case you see, you need to write down. You need to write steps that you could have improved on, and write down the steps so you can compare with other operations that you see other surgeons that do it, because the more techniques, the better you get. The other thing I would want to say is, it's all about practice. I've had a good amount of colleagues that have, what we say — they have the talent. They can operate; it just comes naturally. I, myself, it was not natural to me. I don't think I — I think it wasn't — I didn't have the talent, I didn't have the hands. And I had to make it up, and I had to do it by practising; practising at home, going to the SIM lab. And I think that putting the time in to do that, you really to be honest, is only — if you don't do it, you only do a disservice to yourself and you do a disservice to the patients that you look after. So, I think practising is the most important thing, as well. And then keeping an open mind and don't fall into the "surgery only" mentality. As a junior, I think for medical students going into — as a resident; you know, skipping steps and then going straight to a CT scan is probably — it will not make you a good doctor. You will miss things. And when you're tired, when you're overworked as a senior, the other things that should be second nature, you should be reviewing the patient A-B-C-D-Es, you should be doing from the basics; bloodwork, giving fluids, doing bloods, if they're septic. You know, it should be A-B-C-D-Es, doing blood cultures, urine cultures, chest x-ray; that should be so second nature to you, that when you move on as a senior resident and have more responsibilities and have more complexities in your learning and in your thinking, those simple stuff should be simple. You shouldn't have to think about it. And I think that is a problem I think I've seen when people struggle. And that is the thing that you need to do as a junior going in, as a medical student going into it as a junior resident, is you have to not skip steps. You have to do everything. Do it thorough, do it once. And don't fall into just, "I don't want to see this patient because it's not a surgical patient. I'm just going to scan them and I'll see them later". And then the other thing is be flexible. Like I added, this all goes down to attitude and expectations, but being flexible, being prepared to move, being prepared to stay back. There are regulations, I believe, in North America about doing that, but I think that can only help, as well. And then I guess more of a technical aspect or more of a specific recommendation would be, I wish I did more research as a junior, but I would try and work on it early. If you get through the early things in research, and I guess you have more experience about this, Dr. Ball, but with research, the more you get involved in, the easier it will be as you're a senior to juggle different things and do research at the same time. So doing it early, being able to do the early things like simple statistics, data collecting, doing [literature] reviews, because your training will only get busier. Doing that early and getting your foot in the door with that early is helpful for yourself, but also for the patients, as well.

Ameer Farooq  33:23

Helen, as you know, our residents start July 1, right? That's the day when people start their PGY1 year. What are some pro tips that you give people for their first month, their first year as a junior surgical resident?

Dr. Helen Pham  33:39

I mean, starting is pretty overwhelming, but I think the main thing is, you are in a very supportive environment, whether or not you think it or not. It is difficult, but you are looked after by a range of — in Australia, it's more of a hierarchy system, but you are looked after by a range of seniors. So be prepared, come early, ask questions, be proactive, and really just respect the hierarchy, in a way, but respect how your seniors are going to teach you, what they do. Watch. Write things down. And I think, you know, having someone early that they can talk to, both from a professional point of view in terms of critical feedback, but also if there's a colleague and I think the collegiality amongst residents is so important and having someone that you can debrief with, talk about your experience with, is also helpful early on. You know, the main thing I would say is this is not a social gathering. This is a job. So, when you come to work, you just do your job You treat it like a job. You come in, you're professional, you speak to patients professionally. And I think these people coming out of med school, these are the first time you've spoken to angry patients, the first time you've spoken to patients at all. You are a health care professional. And I think being able to keep that line and being able to be that, and overall, to be able to keep that in mind; that you're looking after people, the community, early, I think is helpful. And it is extremely important when you go to work. And I guess the biggest thing I would like to tell them is, this is a long interview. [You] don't know it, but you're about to enter the interview for your job for the 5 years. So you're doing a 5-year interview. And every single day, and every single thing you do, how you respond to your failures, how you respond to things that you get wrong, how you receive critical feedback, how you deal with patients — you're being assessed for 5 years, and that will determine where you will be as a doctor, and also where you are as doctor in your own insight.

Ameer Farooq  36:19

I loved your comment about keep writing things down and really trying to keep track of these things. Because it's funny how you'll suddenly be faced with the same scenario; you're like, "Oh. How did so and so do this and this and this?" I'm curious how — practically, what did this look like? Like, do you have a notebook where you have all these things written down? Is this all handwritten? Do you use anything online? Any of those kinds of tools? Are there any "productivity tools" or anything that you particularly found helpful? I can tell you for myself, I have all my notes saved on Evernote. And so the nice thing about Evernote is that I can actually hand-write stuff on the back of my list; for example, someone gives an impromptu session, I can write hand notes on any piece of paper, and then take a picture of it. And those notes are scannable on Evernote. So I have all my notes on operations, I can drop pictures; those are all scannable. Are there any particular really little tips and tricks that you found to be helpful? Particularly for keeping track of educational things or notes yourself? Or waste your operation? What are some things that like you found super helpful?

Dr. Helen Pham  37:40

Well, you sound like you're much more technically better than I am, because I wish I had Evernote; that sounds great. I didn't have that. I have OneNote, which have different tabs. I used to use Word, and I had a combination of Word and handwritten stuff. I think it depends on what I'm doing. So for all my operative stuff, all the steps, I would have handwritten books, because we have to keep a very, very strict logbook. So we had to collect all the patients' stickers and write things down. But in that logbook I would have a page next to it where I would write the operation, and then at the corner there would always be 3 things that I could improve on, and I still do that now. I did a gall bladder a few weeks ago, and I would write down that my port was in the wrong space or, you know, I probably shouldn't have burned that area. I would have it together with my logbook for overall training. I think wherever works for you — something that's easy to be able to relook at. And wherever I go, you know, as much as I didn't want to do breast surgery, I had to write down all of the steps. So the breast operations, all 3 surgeons had a different way of doing them. And I would have it handwritten and I'd draw little pictures, and what sutures they used and why they would use that suture. Was it a tapered point? Was it a round point? So there's different — I would do that written down. I think right now I'm using OneNote for overall knowledge, and I use, usually, Excel to keep track of all my research. But I mean, I wish there was a — I wish I could have time to somehow put together an integrated all-in-one, and I think it sounds like, Ameer, you've got a much better system than I do. But I would, just to be able to — something that is easily accessible, that you can reread, that you understand. I mean, this isn't for you. This is not to show people. This is for you to learn, and if it's something that works for you is probably the only thing that I would say, and I would say that you have to do it in all facets. You have to do it for research, you have to do it for, you know, you can do it for knowledge. So, you know, writing down notes on what you've learned, and writing notes on acute pancreatitis. Having a folder of guidelines or landmark papers in a folder somewhere; either you can print it out and kill some trees or you can add a folder onto your laptop or your desktop. So having those different facets in your training, not just operating, and I think that all needs to be looked after by yourself, but also needs to be written down. And like I said, yes, I have all 3 that are kind of separate, but they all work for me. And I think you need to think of it like that — clinical, technical research and nontechnical as well.

Ameer Farooq  40:35

The 1 thing I also wanted to pick your brain on was, you know, it's kind of overwhelming as a junior resident to come in and to have someone say, "Well, you should read around cases". And then you're faced with the challenge of actually figuring out, "Where do I go to find this information? Where did I go to actually do this reading?" What was your approach for reading around cases? Did you have a main textbook that you used to go to? Are you an up to date — What were the things that you used to use as resources for actually reading? For example, did you read a textbook cover to cover? What was your approach to actually doing the reading and learning?

Dr. Helen Pham  41:16

Yeah, so I agree, I think I got better as I became more senior, for sure. I kind of knew how to hone in on which resources to use. But no, I wouldn't read it cover to cover. I mean, I think in my memory, I don't know, my brain is very small; I kind of cannot keep all that information in. I'd need to have a clinical background and a focus to what I'm reading. So I would have a combination of things, and I would have textbooks, and I use the Textbook of Surgery or [inaudible] as well for that, but I use UpToDate. I love UpToDate. And for operative stuff, there's a lot of stuff out there for operative. I found Zollinger is hard to read, but operative stuff really is, to be honest, it's reading ... I know the operative dictations are helpful, but looking at videos, like, you know, YouTube, a whole bunch of videos, you know, to see. And interestingly, even as — like when I was a staff, I had my own waitlist, and I had to do my own waitlist. I had to do a hemorrhoid, and the hemorrhoid — this probably shouldn't be up on a podcast — but I do a hemorrhoid [inaudible] with it, and I've done about 20 as a trainee independently and hadn't done one for about 3 years. And I would just look up the videos, look up what the overall —  there would be, I forget the name of it, which I will send a link. There is a surgical textbook that's written by Jamieson in Australia. He wrote about the anatomical relevance of every surgery, which I found very easy to read, very clinically relevant. And he wrote it like a story, and I would use that as well. And I think in terms of knowledge base, like I said, I would use UpToDate, and as I became more senior, I found that guidelines and papers were much more important, like much more easier to read, much more evidence-based and much more kind of up to date. And I used to use Cameron's as well, and that's written in 2016. And a lot of the stuff, especially with the thyroid stuff that I was learning and the neuroendocrine stuff, the most useful guide, really, was papers and guidelines. And I would send a link to — there's an app that I would use, which most people I've spoken to, residents, who uses, called the Read [by] QxMD, and that is through the university, and I got it through my college, but it is an extremely valuable app that basically has customized or personalized saving of all of your interests and what the new guidelines, what the landmark series — and for me, it was all pancreas, billary and stuff, and you know, that is just on your phone, and you could easily get papers and guidelines that get notified that's come out. And I can send a link for that as well.

Chad Ball  44:35

That's all really interesting stuff. It certainly dates me massively, but just for our younger listeners to put this into perspective, and I'm sure you intuitively know this, the reality is all this stuff didn't exist except for textbooks when a lot of us were coming through, and the truth is you did sit down, to your point, Ameer, and you memorized Dr. Cameron's textbook, Dr. Sabot's textbook from start to finish, and Dr. Schwartz's textbook, and there was about 5. And then you had review articles, for sure, that were peer-reviewed publications. But the amount of material and the depth of the material and the visual aid videos and narration that's available now — it really has equalized the playing field. And for those of us that — and you guys included — that go around the world and are lucky enough to be involved in low-resource countries, through the internet they obviously have the same access to all of these materials, and their knowledge is oftentimes incredible and supersedes our developed countries by far. So, we live in a pretty amazing time. And having to go back to some of the things you said, it makes you a little bit sad, you know, when someone does come to an operating room unprepared or doesn't know the basic anatomy attached to the operation you're doing, because those resources are so available to everyone globally now. You know, just to transition a little bit, one of the things that I got told as a junior resident, that I was reminiscing about when you were talking about that, Helen, was that I got told by somebody who was a couple years ahead of me who said, "The day I started, never ever miss an operation". So whatever rotation you're on, as a junior resident, as an intern, whatever it is, you get to the operating room. And if that means you have to get up really early — super-duper early — just to scrape that availability and that space to be able to get in there and watch, then that's what you should do. And that was probably the best piece of advice that I got, sort of out of the gate. Obviously that reality, the volume, technical proficiency link becomes more and more important as we all get more senior in that education process. I'm curious, and particularly in North America, where we have quite rigid work hour restrictions or call frequency restrictions, depending if you're in the US or Canada, respectively; How do you generate more cases, do you think, in that environment? And also, how does that compare to Australia? So if I'm a junior resident or senior resident, whatever, who wants to do more cases, wants to do more call, wants to pop into other rooms, is that possible in Australia? Is that something that's frowned upon? Or looked well upon? What's your sense of that landscape and its importance?

Dr. Helen Pham  47:32

Yeah, I mean, that's actually interesting, because I found recently here that yeah, there is regulations, there is restrictions, you know, you are only allowed to do a finite amount of call; you're only allowed to do a finite amount of hours in a week. And I, to be honest, have not been trained like that. That's just not how we are. None of the surgeons or surgical trainees in Australia have that mentality at all. And it really hones out on: you get what you put in. You get what you put in, really. What you learn, it really reflects on the effort you put in and staying back for operations, going on the weekends to see transplants and retrieval, that was the norm for us. We had a WhatsApp group, and when I was doing transplant, and I think for those few months, our transplant fellow was away, or she was pregnant or something, and we needed extra hands on retrieval. And we had a WhatsApp group of residents, [inaudible] residents, interns, senior residents, who put their hand up to be available short notice on weekends to go on retrieval, because we would fight over it. So if there was like — we had to take a plane or fly to Melbourne or fly to Canberra to get an organ, there would be a WhatsApp to say, "Is anyone free at 4 am?" And there would be 3 people that would put their hand up, and then they would then negotiate who would go first. There was never, it never — in fact, in the hospital, it's the norm to be the fourth assistant, the third assistant, because everyone wants to scrub in; everyone wants to see. And if you don't, then to be honest, the culture back home would be that it's your loss. "Tough," you know? It means that you may not get the numbers and you may not get the — because it's competency based training; you need to be able to do this amount before you actually pass. You need to be able to do an appendix independently by the time you're finished as an R2, need to do a gallbladder by the time you're an R4, independently. And I think that fear of failing, the fear of not moving on in the program, which is very strict in Australia, drives a lot of the people to actually learn, have the residents to actually work harder, but to be able to kind of really seek out these opportunities. And, you know, inherently there is a big difference in Australia and North America, really because of the — and I can't really compare it severely, because of the fact that we are pretty overstaffed there as well. We have a lot of support. If I have 3 juniors that had COVID, I would be able to find 3 people that would replace them. If there were people who was away for a month, you know, the unit would not suffer, because we wouldn't be able to find a resident to be able to fit in. So, you know, the health care system inherently is very different. And it does support juniors in Australia to be able to seek out opportunities outside of their time, you know, to be able to help. And I guess the other thing is that we have private hospitals in Australia, and you get paid for going there on the weekends outside of your work hours. And we would be able to go on the weekend if we wanted to see a list of sleeve gastrectomy, you just speak to the surgeon and he would comment that you'd help him with a list of them or a list of [inaudible] one on the weekend; we would do that as well. And I think the structure, the overall support, the overall health and the amount of support that the government puts into health care is completely different from here and over there. And I think as much as I want to tell the juniors and the residents in North America to just work harder, see more, be more; it may be very different.

Chad Ball  51:45

You're right; it's easy to say all these things, but if you're limited by structure, in some ways it really can create conflict amongst your colleagues if you're the person trying to do these additional cases, even if it has no relevance to the other person's training, but it can create conflict, and it can just be structurally limiting. You know, you use the word, culture of surgery, or the term culture of surgery, there. And I think that's a really interesting thing to maybe get close to closing with. The culture of surgery, as you trained in, as I trained in, as a mirror, for the most part trained in I think is certainly under fire. And it's, in this country anyway, it's under fire from our universities, and from, in many ways, the changing narrative in society as a whole. I think a lot of the concern, of course, is that you have about 100 years of the way things have been done and has produced, really, decades and generations of well-trained surgeons, and a lot of people feel that that's at risk with this evidence or this desire to change the culture. As you guys have both pointed out, we can certainly update it and improve it, and I think that's what we need to do and all get together on the same page. But what's your sense of the culture of surgery now as compared to historically? And then, where do you see the culture of surgery going, both in Australia as well as in North America? And that may be an unfair question, but I'm curious on your thoughts about it, because you're so insightful about so much of it.

Dr. Helen Pham  53:24

Yeah, I think it's really complex. And I guess there's a lot of things in the surgical culture — I mean, you hear the horror stories of, I guess, a lot of surgeons I've seen. So back in my day, I used to carve my own scalpel and work for 10 days straight. I mean, that stuff I think doesn't have — it's changing for the better. So there is a lot more supportive doctors. There's a lot more mindfulness well-being. There's a lot more inclusiveness. And I think that should be encouraged. What shouldn't I think, like I said before, the caution of pushing it the other way, and the evolution of surgical training, the evolution of surgeons, is not just that of making it, like — it really is not a 9-to-5 job, and the risk of pushing it into the culture the other way, away from what the other extreme is, a lot of the things that I still hold very important and I think is very important in a surgeon, such as accountability, the ability to continue to look at your own outcomes, resilience, hard work, flexibility, adaptability; I fear that that would be less important and more protected by universities, more protected by, to be honest, that administrative kind of work, which, to be honest, in their own agenda, is to promote a safe working, to promote a safe working culture. But I think the hidden curriculum, the overall underlying culture of what makes surgery — what makes medicine — different from any other specialty in the world — what makes surgery different from medicine? I think that shouldn't be — that is no less important. That shouldn't be ignored, either. And I think the way forward would be, you know, there should be more transparency and accountability of training. I think while there is a lot of support for residents, there should also be support for the institution to be able to — and support for patients, and the accountability of who you're training, what caliber of doctor you're training, what caliber of surgeon you're training, and to not discourage people to take an extra year, to not discourage people to stay back an extra year. Those types of things used to be seen as bad, or you're a bad resident, or you're a bad doctor. But I think especially with what the restrictions that we spoke about now about the timing and how much you're working, and now with the whole work–life balance, which I actually believe it's actually a work–life integration rather than balance. I think the way that it needs to be fought is to be able to continue the old — to continue the values that would ultimately make it patient-centred rather than trainee-centred. It's not about the trainee; it's about the patient. And the training, education, is about their future patients and their present patients and their previous patients and what they learned from them. And I think if we move towards surgical training to look at patients, patient-centred, community-centred rather than just the training, I think the overall picture — I think that's where we should be going but I can't comment, I don't know what it's going like. And in Australia, especially, there is a lot of push towards — there's a lot of stuff. For instance, we've got this new operating respect module, we have all these different things that are pushing us into an area, which I fear would lose the values that I think would make surgeons surgeons.

Ameer Farooq  57:20

Yeah, and I just want to echo what you're saying. I think to be clear, there's lots of things in surgical culture that need to change. Like, you and I would not have been in surgical training programs 100 years ago, right? We just wouldn't — we would not have been the people who were accepted into surgical residencies 100 years ago. So there's no question in my mind that there's lots of things that need to change, just like we don't treat [myocardial infarctions] anymore with morphine. Just the same way, there's ways that we can make training programs in 2022 better. There's a lot of things that we just even haven't begun to scratch the surface in terms of getting the most out of every case. Anyways, I could go on about this, but I think there's a lot of things that we could do better. But I couldn't agree with you more that there are some things, the values of which should not change in terms of our commitment to the patient, our commitment to treating ourselves not, you know, automatons that show up and just are passive observers and get what someone else teaches us. No, we're people who want to be the best that we can be — high performers, just like any athlete or musician or whatever analogy you want to use. But those things should never change in terms of our pursuit of excellence. I couldn't agree with you more. Helen, it's been just a fascinating and wonderful discussion with you this morning. Thank you for taking the time to speak with us. If there was 1 piece of advice, if you could give yourself as a junior resident or a junior doctor just starting out, having gone through what you've gone through, what would that piece of advice be?

Dr. Helen Pham  59:03

Yeah. I mean, I think I'd give myself a lot of different advices, but I guess the main thing I would say is see; move around more. I think there is a lot to be said about the fear of moving around. And I know there's pressures of family and your personal life, but the ability to be able to see different surgeons, move around — I was in the same hospital, like the same cities, but I was really kind of trained in the main hospital for 9 years. And when I went to another hospital for 6 months, I learned so much. I loved it. And now going across the road to a world to North America from Australia. I think I would say don't be afraid to move; see more. And I wish I did. I wish I had put my hand up to go to different places. I wish I saw more in Queensland, in New Zealand, and I would say to not be afraid of that and not be comfortable. You want to be challenged and I wish I wasn't scared of being challenged.

Ameer Farooq  1:00:18

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. Send us an email at [email protected] or tweet at us: @CanJSurg. Thanks.