E92 Wayne Rosen on EBM and Intercessory Prayer, Objectivity in Science, and COVID19 Ethical Dilemmas
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Wayne Rosen 00:00
This notion that you could presume that prayer is just another intervention such as a medication or radiation treatment, and that you could measure its impact raises really interesting problems and challenges. You know, suddenly you start to say, well, what about the dose of prayer? What about...can you over pray or miss pray? What if the person receiving the prayer has a different belief or religion than the person praying? And it leads to all sorts of bizarre and strange questions. And so, you know, I thought it was really an interesting sort of little foray into really how we sort of believe and arrive at decisions in medicine.
Chad Ball 00:47
Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad Ball. We've had the absolute privilege of chatting with some amazing Canadian as well as international guests over the past year. While the topics have been broad in range, rather clinical, social or political. Our aims for the podcast continue to remain the same. We hope to inspire discussion, creativity, scholarly research, and career development in all Canadian surgeons. We hope you enjoy our second season as we continue to highlight some incredible guests, deliver detailed masterclass sessions on a myriad of clinical topics and introduce some fresh new features such as debate and companion formats. We hope you relish the podcast as much as we do.
Ameer Farooq 01:47
Dr. Rosen is a colorectal surgeon at the Peter Lougheed Centre in Calgary, Alberta. Dr. Rosen has long delighted the Calgary surgical community with his entertaining and thoughtful critiques of a whole host of philosophical and bioethical concepts and how they pertain to surgery, ranging from evidence-based medicine to how we might ration surgical resources in a pandemic like COVID. We recorded our conversation with Dr. Rosen back in May of 2021. But many of Dr. Rosen's insights, particularly about COVID-19 vaccine hesitancy are still very cogent and continue to hold relevance today. We would love to hear your thoughts on any of the topics we discussed this week, or any other prior episodes on Twitter @CanJSurg, or via email at [email protected] Dr. Rosen, welcome to the podcast. Where did you grow up? And where did you do your training?
Wayne Rosen 02:44
Thanks, Chad. And Ameer. It's great to be on this podcast. And I've really enjoyed listening to other speakers. So, to answer your question, I grew up in Toronto, and then went to Queens for undergraduate in Kingston, Ontario. And there I studied a very practical and financially secure area, namely philosophy, and did that for my undergrad, and then subsequently pursued it for a few more years overseas. And that was when I decided to go into medicine and ultimately came back and studied, did a year of prerequisites and then got into med school at Queen's again and then went there. And then after I finished medical school, or as I was trying to decide what to do, I was somewhat torn. And although I don't think I had really a surgical personality or whatever we mean by that, it wasn't sort of something that I normally have thought would apply to me, I ended up planning to go into urology, and started off my training at Queen's with the expectation that I would move on to a urology program a few years later. But fate had something different planned. I was very influenced by a couple of general surgeons in Kingston and ultimately decided to go into general surgery and got a position out in Calgary and then sort of the rest is history. It's been a great ride so far.
Chad Ball 04:16
The background in my mind leading up to this this week was I recently listened on the weekend to a podcast - Dax Shepard’s podcast, which as you know, is top 10 in the world right now, and he interviewed Prince Harry. And you can imagine the stuff that they talked about, and it was a riveting interview quite honestly, and I certainly wouldn't call you Prince Harry. That's in no way what I mean. But you are, you know, a member of the Rosen family; of Rosen suits, so to speak. Which is really an iconic brand across the country. And I'm curious, you know how you, maybe I'm using the wrong terminology, but how you broke free from that because my understanding is certainly that you are one of the few family members who's was off, not only in medicine, but doing something potentially different. And I could only imagine growing up in Toronto with that environment, how difficult maybe it is to break free and create your own path. I'm just curious if you're willing to talk about that with us.
Wayne Rosen 05:19
You know, it's not as exciting or dramatic as one would expect. Because my parents were both very humble people, and really didn't have expectations for us, as we were growing up as to what we would do with our lives. My father worked very hard. And ultimately, as you know, became very successful. But neither of them pushed me in any way to go into business or into the family business, especially. My brother did end up going into the business and he runs the Harry Rosen's now. But, you know, that's just happened to be, you know, his personal choice. Neither of my parents went really past grade nine or 10 in high school. So, I think they were just delighted that we went on to university and, you know, as a parent now with a son who's going into university, you know, I think how I will feel if he chooses something not terribly practical with great job prospects, but I have to remember my parents were open minded about that sort of thing. I do have an interesting anecdote or two though about being Harry Rosen's son. When I went to school in Kingston, Ontario, there was a local fuel magnate there named Harry Rosen, and no relation to me. And he actually had a son named Wayne Rosen, who went through the medical school there. And was well liked. So often, people would ask me whether I was the Wayne Rosen and they were inevitably referring to Harry Rosen, the fuel magnet son, and they had a little, they had a little, you know, their trucks would drive around town, and they had this little sign on them that said, "don't wait till you're half frozen, buy your fuel from Harry Rosen". And so, it was kind of this funny thing. So, I was quite anonymous in Kingston, and no one there really knew. They figured if I wasn't related to the Harry Rosen's of Kingston, it really didn't matter.
Ameer Farooq 07:17
Well, you're certainly not unknown in the Calgary surgical community, not least because of the delightful and fantastic ways that you break down complex problems. And I'm sure that this is in no small way because of the fact that you took unexpected forays into things like philosophy. But you've given so many of these iconic talks. And one of my favorites was this one that you gave on intercessory prayer. And our listeners might be thinking, What in the world is Ameer asking about? So maybe I'll just ask you to briefly kind of summarize what you talked about in that talk on intercessory prayer.
Wayne Rosen 07:55
I often get interested in these funny little rabbit hole topics and then go down them. And the intercessory prayer topic caught my attention, because intercessory prayer is this belief that you can use prayer to intercede in people's health. And the intercessory prayer studies are a series of studies. And there's quite a few of them, in which people attempt to measure the impact of prayer on people's wellness. And you could imagine, well, they follow all of the usual structures of randomized controlled trials. So, a bunch of people in, say, Denver, pray for people in the ICU in New York, the people in the ICU are blinded, they don't know they're being prayed for or such. And you try to see whether there's a difference in outcome. And I think most people in medicine find that sign kind of strange and weird. But I think it tells us a lot about sometimes the way we are in medicine, the way we construe problems. But this notion that you could presume that prayer is just another intervention, such as a medication or radiation treatment, and that you could measure its impact raises really interesting problems and challenges, you know, suddenly you start to say, well, what about the dose of prayer? Can you over pray or miss pray? What if the person receiving the prayer has a different belief or religion than the person praying? And it leads to all sorts of bizarre and strange questions. And so, you know, I thought it was really an interesting sort of little foray into what, you know, really how we sort of believe and arrive at decisions in medicine. There's even a as you probably know, there's a Cochrane Review. In fact, there's two Cochrane Reviews. And I guess it sort of also speaks to the tendency sometimes within scientific groups to be very literal in your understanding that, you know, while we treat, you know, chemotherapy, we have to treat the intervention of the Prayer the same way we treat an intervention such as chemotherapy, and so we need to measure it in the same way. And I guess I find that kind of interesting and puzzling at times.
Ameer Farooq 10:12
Yeah, well, the thing I enjoyed most about that talk is I think, certainly a big part of the audience when we first heard that talk, I think walked away thinking, we're laughing about how ridiculous is it that someone would study intercessory prayer, and its effect on whatever outcome. And you had a couple of just memorable lines in there like, is intercessory prayer more or less effective than lasix? But what I loved about the talk was that in many ways, I found it to be a sort of veiled and entertaining way of looking at the problems with evidence-based medicine. And you've written extensively on this topic. In fact, you have a whole website that called limits of ebm.org, where you go into some of your critiques, I think, on a philosophical level with EBM, and you know, like this whole idea about intercessory prayer and evidence based medicine kind of illustrates the problem, I think that you highlight that, you know, if you just study every intervention as if it's, you know, another medication without really thinking about what it does, or, you know, maybe historically how we would think about biological plausibility or the mechanistic way that, that that thing works, then you kind of run into these problems, where you're just chasing these endpoints, and not really understanding you know, what the issues are, or whether what you're doing is actually worthwhile or not. And obviously, you can talk about this in a much more eloquent way than me, but can you talk a little bit more about what are what are the other issues that you see broad philosophically, or philosophically with EBM?
Wayne Rosen 11:57
Yeah, thank you for that question Ameer. It is a topic that's near and dear to my heart. And you're right, the work on intercessory prayer has a number of other areas I've done some work in on wine, objectivity of wine tasting, and things like that are in many ways, all sort of outgrowths from a deep skepticism I have about our approach to a lot of medical science. And I guess the primary, you know, when I boil it all down to the real key questions that come to my mind or that challenge me are really twofold. The first is that, you know, it's an assumption within the entire paradigm of evidence-based medicine that we can measure and quantify various aspects of medical treatment and medical results. And that sounds really good, you know, we need to measure, we can measure the intervention, and then we can measure the outcome. But when you actually look at the specifics of those interventions, and those outcomes, they're very complicated. You know, the example I often use is something such as fecal incontinence, you know, if I want to find out if my intervention is better than yours, then I want to, first of all, be able to measure the degree of someone's incontinence, and then also measure my intervention, and then be able to measure it after my intervention or the outcome afterward and see whether I made an improvement or not. And the problem is that, while you can create nice tools and instruments for measuring incontinence, they don't capture the essence of the incontinence phenomena entirely. And it's really, you know, each person experiences it somewhat differently. For some, it’s the fact that they can't go out and socialize, for some it's other factors about it, it's the soiling of the underwear, it's whether it happens at night, and no instrument can adequately capture the nuances of it. And so, I think we often forget that, you know, what we're doing is really very crudely measuring phenomena. And then because numbers come out at the end, we somehow think that we've, you know, we've got a hard number, you know, my intervention, improved it by 15%. Therefore, it must be better. But the truth of the matter is that it's much more complicated. You know, the intercessory prayer studies are interesting, because they're all over the place. And I think this leads to the second challenge I have with evidence-based medicine: is that I don't know that we're always impressed or change our views based on evidence. I think that even if a bunch of studies came out, showing that intercessory prayer work, most people wouldn't believe them. And the reason is that it doesn't really fit our overall view of the way medicine works or the way our interventions work. And in general, I really don't know that we're often convinced by evidence. I think that usually we use evidence to support our belief systems and create a narrative that we find compelling. And if the evidence doesn't really support that or fit into our narrative, then we tend to dismiss it, and disregard it. And I think that plays out in a lot of journal clubs as well, where I can't say I've ever been to a journal club where, you know, the vast majority, let alone everyone, but even the vast majority of people say, yeah, this is a great study, I'm going to change the way I do things, or I'm going to do it this way. I think the way we change our views is sort of incremental. We get lots of evidence, we have conversations, we sleep on it, we ponder, and then ultimately, we maybe try something, it seems to work. And we go on. So, I guess really, you know, to go back to your original question, I think there's sort of an assumption in evidence-based medicine that we can be directed by the evidence, and that it will tell us how we should proceed. But I think it's often a case of the tail wagging the dog - that mostly it's our belief systems up front, that determine how we interpret evidence, or what evidence we even consider.
Ameer Farooq 16:11
I think that's a very cogent critique. The counter argument to that where they talk about this idea that there are a lot of interventions in medicine that made sense mechanistically, biologically that have biological plausibility, you know, the classic example being stenting renal artery stenosis, and hypertension. But when you looked at the big, randomized control trials, it didn't seem to make a difference in in any of the outcomes that you'd care about, like mortality or morbidity, even though it made biological sense that if you stent the renal artery when you have renal artery stenosis, that you would improve outcomes. So how do you, you know, if you think that there are issues with evidence-based medicine as you brought up, and certainly this is a probably a bigger problem in surgery than perhaps even in medicine, but how would you respond to that critique that, you know, there's a lot of things that we don't really know how they work. And so, there's no really better way to figure out what we should be doing other than to run randomized control trials.
Wayne Rosen 17:11
Yeah, so it's a good point. And I, I guess, I would respond, you know, I know that one of the original impetus or ideas behind evidence-based medicine had to do with the fact that people would often treat people with an acute MI with a beta blocker. And it was sort of assumed that you wanted to avoid packy arrhythmias. And it turned out that when they studied it, people who got a beta blocker ended up having a worse outcome. And that sort of said, see: physiologic rationale is not sufficient. Indeed, you know, we need to have evidence to support it. And I would say that maybe we've gone a little bit the other way. There are times when physiologic rationale makes sense. And, obviously, it's what informs a lot of our studies in the first place. But I guess I think the way we make decisions, and the way patient care is much more complicated than just carrying out a study. And the fact is, it's very, very difficult. Much of the phenomena we're trying to measure is inherently qualitative. And just because we give it a number doesn't mean it's real. It's, you know, it's often a facade of objectivity. But, you know, that doesn't really exist. I have more to say about that. But I think that's sort of one of the important factors, I think the way a lot of our treatments evolve. It's not that I don't think studies are important, and that I don't think we should do research. That's, on the contrary, I think it's really important. But I do think that we have to be very thoughtful that the way research informs treatment is not a simple, you know, from A to B type of experience. I think the medical community functions very much like a marketplace. We've all experienced lots of treatments that come in, they have a 90% success rate or efficacy rate initially, and then it gets out into the marketplace of individual practitioners. And then we find out that actually, it wasn't so good. I mean, the fistula plug is a wonderful example of that. For fistula. But countless examples of that. So, I think ultimately, you know, we do research. The marketplace of medical treatment sort of goes on. And then often, I find then once we've shown that it doesn't seem to work in the marketplace, then we sort of do research that corroborates ultimately what the marketplace is showing. The research ends up supporting it. So, I think there's just this very complex back and forth between the way we do research and the way we make our decisions. And that it's not a simple decision.
Ameer Farooq 19:57
Well, I think it's been no more evident now with COVID, right? Because, you know, there's so much information. And the real challenge now in some ways is that everyone can find the data to support their particular opinion or their particular, you know, leaning or bias, you know, whether you're an anti-vaxer, or whether you're a huge proponent of the vaccines, whether or not they have side effects or not, you know what I mean? So, it's never been more apparent now that science is not just this sterile, abstract thing that scientists do in an ivory tower, but really that it is an interplay with society and societal values and culture. Can you talk a little bit more about the fistula plug straight? You write about it beautifully on your website. And I think it illustrates these concepts.
Wayne Rosen 20:52
Yeah. And before I do, though, I will say one thing. People often ask me, you know, if you're criticizing EBM, you know, what's the alternative? And I guess the response I have to that is that when people, initially, you know, for many era, for many centuries, people thought that all of the planets of the earth went around the Earth, the so called geocentric model of the universe, and then the heliocentric model came in, and the earth revolved around the sun. And, you know, if you ask people, why did people think for so long that the earth went around, or that the all the planets went around the Earth, people would say, because it looks that way. But the truth is, it would look exactly the same way if the earth revolved around the sun. It's really how we interpret it. And so, I think just by being wary and skeptical of some of the aspects about evidence, that helps us interpret the evidence in a different way. And maybe we don't have the same assuredness that certain things mean certain things. The case of the fistula plug I think, is really fascinating, because the people who developed it, I won't go into the details of the treatment. But the people who developed it, and who ultimately had a patent on it, published initially, research showing a 80 to 90% success rate. And then a couple of other studies corroborated that. And I personally thought this was great. It made some physiologic sense as well, you were closing the internal opening of the fistula, you were providing a matrix for the fistula tract to close over. And providing drainage externally, it seemed to be a very, it seemed to have a lot of good physiologic rationale. And sure enough, it seemed to work in practice. But then I started doing it. And of course, like many things, it didn't seem to be as simple as the teaching videos, or the people presenting at meetings made it come about. And then, you know, after doing half a dozen with zero success, I revisited my approach to it then. And I probably did 10 or 12 overall, but never really found that it worked. And then I started, you know, a couple years past, I reviewed the literature, and of course, the numbers went way down, it went from 80 to 90% to, you know, as low as five or 10%, or such. And I loved the, you know, in one of the abstracts, I think it was Steve Wexner's abstract on the topic, you know, there was this very pregnant line towards the end of their conclusion was that further studies will have to be done to explain the variation in outcomes between different studies, you know. And we're talking about, you know, 15, or 20%, success rate up to 85, or 90%. And that's a pretty extraordinary variation. You know, if your money manager told you, we could go from this or that, you'd probably be taking your money out pretty quickly. But I think that doesn't so much tell us that the fistula plug is a bad thing, or any such thing. It just tells us that the type of science, medical science is extraordinarily complicated. I mean, that's why we see such diverse variation in outcomes, because the fact that the things we're measuring are not simple quantitative measures in many instances. Trying to measure whether a fistula is healed. It's kind of interesting, you think it'd be very easy or. But it's actually much more complicated than just that.
Chad Ball 24:32
One of the talks that you alluded to that we were all lucky enough to be at and you had us drinking wine was exactly that. Was sort of the world of wine tasting. I was wondering if you could walk our listeners through your view on that particular topic as well because it's fantastic.
Wayne Rosen 24:49
Thanks, Chad. Yeah, so the wine, my interest in wine tasting really derives also from my interest and skepticism or wariness about evidence-based medicine. And it's the notion that, you know, there is objective value or quality in a wine. And when you evaluate wines, you find out that, you know, the cost to produce a bottle of wine is essentially the same wherever you do it, you know, between two to $10, a bottle. It just doesn't cost more. Even a $10,000 bottle of wine only costs that much to produce. And when you go to the wine store, of course, there's a whole bunch of different prices. And so, you have to ask yourself, you know, there's the transportation and all that, but you have to ask yourself, well, what is it that distinguishes the value or the cost of a bottle of wine? And it's because we have this notion that there's somehow objective taste or objectivity to what makes for a good wine. And, you know, on first view, of course, wine tasting seems very subjective. But then there are these various experts out there who tell us that, you know, certain vintages and certain productions are extremely good, and they're ones we should like. But you know, I think there's actually a bunch of literature out there that shows that most experts, even true experts, even Robert Parker, can't really distinguish or can't even tell if they've tasted the same wine before. Although Robert Parker maintains he can. He has an extraordinary gustatory memory, and he can actually recall every wine he's tasted over the last 30 or 40 years. The truth is that most of us can't. And I think it's sort of highlighted by the fact that you know, it's such a subjective experience. That how do I know you're tasting the same thing as I'm tasting? A few years ago, I sent off on a lark, I did my 23andme and did my genetic background. And one of the things that comes back when you do that is you get some information about whether you have certain genes that allow you to say, smell asparagusic acid in your urine after you've eaten asparagus, or whether cilantro tastes bitter to you. And, as you probably know, about 30% of people don't have this gene. And so they don't smell a strong odor if they eat asparagus, but about 70% of people or so do have this gene. And if you ask people who don't have it, you know whether they can smell anything, they often just look at you quizzically and say, what are you talking about? But those of us who can smell it really notice, you know. Some people find cilantro very bitter. Other people say what are you talking about? It tastes terrific. I love cilantro. But the point behind this is that if cilantro and asparagus can be so different, how do I know I'm tasting the same wine as you? How do I know that tannins or other components of wine, I don't have different genetics that makes me appreciate them in a different way. So, it's really all about a critique about the objectivity of wine tasting, and why I think that you should never spend more than $20 on a bottle of wine. And it's not that wine isn't good and yummy, and that people don't really enjoy it. It's just that my $10 bottle of wine may be your $300 bottle. But just because someone says that it's worth $300, that doesn't mean it should be.
Chad Ball 28:33
I love that. I love it so much. You've solved all my questions when it comes to wine. The first talk I ever saw you give was actually about the economics and the potential long-term reality of cigarette smoking. So, we've gone from wine, maybe you could highlight, you know, your view and what some of the evidence is surrounding that as well.
Wayne Rosen 28:57
Sure. The lecture about smoking really derives back from an interest I had in, you know, my bioethics background, and whether we should hold people accountable for their lifestyle choices. And originally, I did it, I originally got interested in this when I was a resident and I did a paper on whether people who have alcoholic cirrhosis should have the option of having a liver transplant versus people whose disease was extensively not self-induced. And then I pursued it further in other forms of you know, lifestyle. But smoking is the most interesting one, just because the outcome is so clear. And I think most of us have, and this I'm certainly speaking on my own behalf. I have a primordial instinct that we want to you know, we want the system to be fair and we want to hold people accountable. And people who smoke are somehow breaching the public trust because they cost the healthcare system more. And we should hold them accountable for, you know, their extra health care costs. And so, when you do a deep dive into the topic, it turns out that yeah, smokers do cost a lot of money. They get certain diseases related to their smoking, you know, cardiovascular and respiratory diseases, as well as they start more fires in bed, and they get into more and more vehicle accidents, and they miss work more often. And there's a whole bunch of factors that you can quantify and say, you know, this is approximately how much they cost the economy. But if you're gonna hold them accountable for something like that, then you have to also say, well, what about other things, you know? They pay a lot of excise taxes. And it turns out about 70 to 80% of any pack of cigarettes is taxed, either from the federal or provincial government, everyone wants a hand in it. And when you really crunch the numbers, you sort of can see actually, the excise taxes come pretty close to offsetting, you know, any extra costs associated with smoking. But then it doesn't really stop there. It turns out the tobacco industry makes a significant economic contribution to society. You know, there's the growers, the producers, the manufacturers, the retailers, the transportation, people, all of whom contribute to the, you know, economics of society. And then it also turns out that smokers die on average about 14 years earlier than nonsmokers. And when you crunch the numbers of, you know, money they would get from Social Security, it worked out to be about 80 or $90,000, that are not dispensed, on average per smoker, because they died prior to accessing or just shortly after accessing the pension system. And when you start to really crunch these numbers, you sort of go wow, actually smokers seem to more than offset, they seem to make a financial contribution, because they've been paying taxes their whole lives. And then the argument goes even further. And it turns out that smoking tends to be a reasonably efficient way of dying from a medical point of view. And that there are, if you don't smoke, people who die from smoking tend not to get very resource expensive diseases of old age. And there's a whole bunch of modeling studies out there that show that if you got everyone to stop smoking today, you'd initially see a dip in the cost of health care for the next 15 to 20 years, but then it would start to rise because these people would be getting, you know, hip replacements and dementia, and lots of other diseases. And it turns out, you know, you don't really, when you prevent smoking, you don't really save costs, you just defer them. And so, all of this really is the fact that anyone I think, who has looked at this, in a serious fashion will tell you that smokers make a huge net financial contribution to our society. And that, frankly, we should be holding nonsmokers accountable. And so, what would we be holding smokers accountable for? Less costs and subsidizing those who don't smoke? And such. So that's the gist of the argument. But you know, like any of these, the point is really just to get you to say, ah, you know what, that makes me reconsider my original principle, which was, you know, holding people accountable. And maybe I wasn't right to sort of jump on that train and think that just because you have a bad habit, because if we're really going to do that, then maybe we should be thinking that people who live more riskier lifestyles, such as skiers or rock climbers or others, should be paying higher premiums or should not have access to the same health care resources.
Ameer Farooq 33:53
Yeah, I mean, clearly, so much of what you do, and I hope we've highlighted some of the work that you've done to help all of us kind of open our minds and see the world with a bit more complexity. You were part of the COVID pandemic response committee in Calgary, I think, if I'm correct. And we actually talked about this a bit before I finished residency. But I'm curious what that was like, in terms of thinking about that, you know, terrible situation that we, I think thankfully in Canada largely escaped, which was what they had to experience in Italy, where, you know, there was a real sense of having to ration resources. How do you think from an ethical standpoint about the idea of having to ration resources in a setting like COVID, where there really would be huge demands on the healthcare system. How do you even go about approaching a topic like that?
Wayne Rosen 34:53
I was a little, you know, I didn't have a huge role in it. And I was really involved in mostly from the Department of Surgery side about what would happen to acute care surgery should, you know, there be a huge influx of, you know, COVID cases and a lot of ICU beds, etc, were taken over? I think, you know, this is ultimately a question of resource allocation injustice. And one of the things I think that is clear is that there are different types of resources. There are resources that are fixed and finite, and you can't get more of them. And a classic example of that are livers, you know, liver transplantation, how do you allocate livers, because if someone gets one, some other person doesn't, and they die. And then there are a lot of other resources, which are more elastic. And in the case of, say, surgical care, acute care surgery, the resources are relatively elastic, you know, our ability to still even in the midst of an incredible surge of a pandemic, we'd still have enough elasticity in the system to be able to take care of patients with perforated, discusses and other illnesses. And then there's this sort of middle ground where ICU and ICU ventilators and beds and such, are somewhat fixed, but also a little bit elastic. We have extra ventilators in the case of the OR, they may not be the same types of ventilators. But we have you know, room or space where we could expand out. And so it was really a question of trying to say, Well, what are what are the absolute limits to our resources? And how would we sort of incrementally add on to what we have if we need to? I wasn't as involved as much with the work in the ICU. John Kortbeek as you probably know, did a lot of work in that area. From the surgical resources point of view, I don't think it was as big an issue. I think we had enough elasticity and accommodation in the system. But then the question is, how do you arrange or make a just decision in that regard. And that is a challenge. And you know, the sort of general principle that I think most people abide by, in some form or another is measuring the outcome in some form. You don't want to spend a lot of resources on people who have, you know, a very small chance of succeeding, but are going to use up a lot of resources. You'd like to optimize, you know, the number of people who survive. But it's not just that. We also all recognize, even though we don't want to necessarily put it in absolute writing, but we recognize that younger people who have more innings to play in life, so to speak, are people you might want to, you know, give preferential treatment to. Older folks will often say we paid their taxes we want, you know, what's our due. But many people are open to being flexible within the system. I think, I'm glad we never did really have to up to this point, and we haven't had to in the course of the pandemic, make true life and death decisions. But I think those are some of the principles that would probably, or that should play a role. And then it's not just having the principles, though, then it's really the execution and creating a mechanism where such decisions can be made in a fashion that's transparent, at relatively fair and people have an opportunity to appeal it if they wish to. The final comment I'll say in this is that I often make the distinction in these situations between outcomes, which are unfair, and outcomes, which are unfortunate. Our goal is to try to be fair and treat people fairly and justly. But we have to recognize that some of the outcomes may be unfortunate. And that's inevitable in a system where we have finite resources.
Ameer Farooq 39:11
Yeah, thankfully, we really didn't have to get to that point in Alberta and BC, because that would have been really, really hard. And you could see that from reading descriptions of healthcare workers in other places having to go through that. I think the next big challenge, though, as a society is, you know, as we sort of get to this point where we're really rolling out the vaccines, and thankfully, the vast majority of Canadians are getting the vaccine. I think the next question we're really going to have to tackle from an ethical standpoint is, well, how do we deal with or how do we treat those who choose not to get the vaccine? You know? We've already alluded to the fact that there's so much misinformation that's out there and, you know, you do have to feel for people who kind of is wary or suspicious of getting a vaccine. But in terms of reopening our society, in terms of travel, you know, there's a lot of ethical questions, even, you know, in terms of our healthcare system, with those who choose not to get vaccinated and then suffer from COVID. And then COVID related complications. How do you sort of frame that in your head, Dr. Rosen in terms of thinking about how we deal with that portion of our population that will choose not to get the vaccine? And I know, this is a big question, and not an easy one. Maybe that can be encapsulated in a in an hour's podcast.
Wayne Rosen 40:42
But it's a great question and a really important question. So, I hear you loud and clear, Ameer. You know, we have lots of restrictions on our freedoms in society, you know. We have to wear seatbelts. In most places, even in the United States, you have to wear a helmet if you're riding a motorbike. And most of us recognize that there are some limits on our freedom, and we abide by them. And usually, we accept that the state has a certain paternalistic role. And, you know, even if it's in our best interest, you know, we accept that. And the same, I guess, goes with masks. You know, it's kind of interesting, I think the mask is very similar to the sort of motorcycle helmet. People who are really resentful, but they accept that they have to wear a motorcycle helmet or a seatbelt or get a driver's license. It's kind of interesting. But when you get to, and then usually, of course, not always, but usually the impact of not abiding by those rules is that it's going to affect you personally. And you alone. The interesting question about vaccination or people who are hesitant about getting vaccinated is, you know, it has an implication or impact on people who aren't vaccinated? In some ways, it's a little bit like secondhand smoke, and how do you accept the fact that we want to make sure that those people who, you know, want absolute safety are protected, but people who don't want to get vaccinated, you know, have a right? I think the actual process of... I mean, I think the difference between the helmet and the vaccination is that one is a very, you know, personal, intimate experience getting a vaccination. In that we can't sort of just presume that it's like wearing a helmet. It is, you know, not a violation, but a trespass on a person's body. And so, you know, I don't think there's a simple answer to ensuring everyone gets vaccinated. You know, for years, it's been debated within the healthcare system, whether we should compel all healthcare workers to have the flu vaccine because they, even if they don't get very sick, they can transmit it to people who are extremely vulnerable in the hospital. And there's been a bit of, you know, split on this. Some provinces and some ethicists feel that you should force you know, it's part of a requirement, just as we expect healthcare workers to have hepatitis vaccination as well. They should be compelled to get the flu vaccine. And then there are others who say that, you know, we have to draw a line at some point and that there's lots of questions about the value of the flu vaccine, etc, etc. So, I don't think there's a simple answer, I think, what will happen, and I've already seen it happening is that many people who have vaccine hesitancy are gradually coming along, and sort of recognizing lots of other people are getting it and recognizing the benefits of it, not just that they won't get sick, but the fact that the economy can open, that they can travel again, and that they're not putting other loved ones or vulnerable loved ones at risk. I think there will always be a certain number of people who will resist it for a whole myriad of reasons. And I don't think we can compel them. I don't think we should, I think it'd be like forcing someone to have an operation that they don't want to have. I think the potential for regretting it is huge. But, you know, I wouldn't compel it. I think the good news is, I think that from a practical point of view, the majority of people will probably get the vaccine and that we'll reach some form of herd immunity. And that we might even find that people will jump on when the incentives are clear: that they can travel, or they can do various other things.
Chad Ball 44:48
You're well known in the medical school for teaching the med students on both ethics and professionalism and certainly we recognize those two concepts are different, but there is a Venn diagram to it. They are related. We're curious how, I guess firstly, your perception of the topic of professionalism has changed over the years. And then secondarily, perhaps directly how social media has sort of informed that more recently.
Wayne Rosen 45:19
So, I do distinguish, and the med school distinguishes between ethics and professionalism. And my real domain there is bioethics. But as you mentioned, there's a fair amount of overlap. One thing I would say, though, and this is a little bit more on the ethics side is that I've always been very careful about ethics. I'm not even terribly comfortable saying teaching ethics, because you know, ethics is very different, or, you know, ethical reflection is very different than a lot of the medical knowledge or a lot of the knowledge that students acquire in med school. When people come to med school, very few of them or for that matter, in residency, very few of them have strong views about Starling's law of the heart. But they do come with strong views about physician assisted dying, or abortion or other issues that typically arise in the course of medical school. And so, I think that as a person who instructs that area, my approach is much more similar to say, you know, an art historian, in that, you know, people come to art with their preconceived views and ideas. And my job is somewhat to guide them and help them flesh out some of the details of their understanding about it. But I'm not really teaching about the art, per se. And I guess I think ethics is very similar. And I suppose on reflection, I would think professionalism is a little bit the same way. I do think that what it means to be a professional in medicine still is very real, it's very important. And I think we all sort of know what it is. And although it's very, very difficult to clearly define. There was a famous case, you may remember about what distinguished pornography from erotica and the judge ultimately said, I knows it when I sees it. And I think that we all know professionalism when we see it. Or we see violations in professionalism, or at least obvious violations in professionalism. But there is a gray zone in the middle. And I do think it changes with time. Our views about what makes a professional or ethical views change with time. And I think as a physician age, he or she needs to acknowledge that, you know, the way we thought a professional that should behave, may change a little bit with time. As a really good example of that - about 30 years ago, when the Supreme Court of Canada considered physician assisted dying, it turned it down and rejected it, and it was a close decision. Five to four. But ultimately, they felt it was unconstitutional. And then, you know, 25 years later, they reconsidered it and it was unanimously approved. And that's really an indication of how our personal views or values and beliefs and society in general changes. And so, I think, you know, when I think about professionalism, I think it's changed and evolved since I started out as a physician and that it will continue to change. In the area of social media, I think we're starting to appreciate the fact that there are certain things and because it's still relatively new, we're starting to appreciate that, you know, certain behaviors online are not appropriate or have questionable professionalism. Whereas other ones that we thought a few years ago weren't, are probably quite acceptable. I'm still struggling with it. And the only other comment, I would say in this is that I think in many instances, it's not so much a reflection of one's professional view, but it's also a reflection of one's personal approach to privacy and not being out there. Some people feel very strongly that they need to stand up and make their views public on social media. Others, even though they hold very, very strong views just don't want to. Don't feel compelled to put their views out there because they feel very passionate about their privacy and don't want to attract that sort of attention. So, it's a huge topic and I know Sean Langenfeld gave a great podcast or was involved in a great podcast a few months ago on the topic and I think I really found a lot of his comments very illuminating and yeah, inspiring.
Ameer Farooq 49:55
If you could go back in time and give yourself advice as a senior resident or as a chief resident, knowing what you know now, what would that advice be?
Wayne Rosen 50:05
You know, I thought about this question, because I've heard you ask it to several of your previous participants. And, you know, I would tell myself to do exactly what I wanted to do. To be passionate about the topics. Although I did at one point think I could do research, I realized that it really wasn't my bailiwick, and that, you know, my area of expertise, any contributions I was going to make, were going to be in the area of bioethics or some of my, you know, other talks that you guys have alluded to today. And so, I would say, I would probably pursue even more. Be true to yourself or myself and pursue those areas. But on the whole, I wouldn't change much because I'm really, really blessed that I've had a great career. Great leaders, great mentors. And so, I guess that's a bit of a way out of saying I wouldn't change too much right now. And I would just say, I'm glad I was relatively true to myself. And I would still say, be even truer to myself.
Ameer Farooq 51:25
You’ve been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So, feel free to email us at [email protected], or connect with us on Twitter @CanJSurg. Thanks again.