E93 Husein Moloo on quality improvement shared practice models and philosophy
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Husein Moloo 00:00
Don Berwick has great lines. One of his great lines is this: a system produces the results it is designed to produce. If you want to create a system, let's say at a departmental level, where you have employee ownership, you have peer-to-peer kind of pressure on performing quality stuff, then, to me that means you need some way to engage that frontline.
Chad Ball 00:37
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 brought in range, whether clinical, social or political, our aims for the podcasts continue to remain the same. We hope to inspire discussion, creativity, scholarly research, and career development in all key insertions. 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 01:37
If you were to wander into one of the operating rooms at the Ottawa Civic hospital and hear a discussion about colorectal surgery, Plato and Drake happening simultaneously, you could be pretty sure that you were in the OR of Dr. Husein Moloo. Dr. Moloo is a duly trained minimally invasive and colorectal surgeon in Ottawa. We had the pleasure of speaking with the Renaissance man about the impressive quality improvement initiatives he has led in Ottawa, as well as his thoughts on the unique shared practice model in the Ottawa colorectal group. True to the advice he shares at the end of the podcast, Dr. Moloo continuously remains fresh, and was actually recently named the maiden Director of Planetary Health at the University of Ottawa. This was such an enjoyable conversation. So, without further ado, Dr. Moloo.
Chad Ball 02:21
Can you tell us about where you grew up and what your training pathway look like?
Husein Moloo 02:24
Yeah. So, I grew up in Toronto, I guess, you know, a lot of people don't talk about their, I guess, educational experiences prior to their training. But let me tell you that mine was kind of, I think, life shaping because I went to this... and take this in the best way possible. It's kind of like this gifted High School, okay? It was called the UTS, University of Toronto School. And back then it was semi-private. So you know, you wrote this exam, you got in. Somehow, I got in, I assure you, I was at the bottom of my class. And the thing though, and the reason why I bring it up is to say that I was humbled, basically when I went there. And my friend group that I continued to interact with, they kind of you know, it's great, you get introduced this incredible milieu of people who inspire you and have continued to kind of do that for me. So, I'll tell you, for example, and I'll get to my training in a second. But, you know, like one of my buddies, he was like, you know, you must have seen in the media, like those million species going extinct. That whole study from the UN on biodiversity. He was like the Canadian leader on that. You know? And so, you know, just doing these incredible things. Another guy is a New York Times bestselling author, you know? He actually wrote an article for Roscoe. Another buddy of mine is like, taking the year off just because, you know, he's been COO of this and this and that, and he's done incredible things. And he just kind of follows what is kind of fulfilling to him. And I could name more people, but it's just to be surrounded by that, from that age was good. And it really humbled me and made me realize, you know, I'm not very smart. And so then, I end up going doing my undergrad at Western. I did my Gen surge and medical school at Western as well. And, you know, I wasn't one of these people who had any clear path in front of me. I had done zero research as a medical student or in my first years of residency, and then I sat down with a program director and said, hey, I want to do laparoscopic surgery. Kind of seems like maybe that's where things will go with certain things, and I want a big community job maybe and I think that would be a good fit. So, they said, well, you know, we're gonna hook you up with some research with what we think and I don't want to offend anyone here but they thought, at that time, they thought it was a great program. And it was Dr. Poulin, Dr. Madsen, Dr. Schlachta at St. Mike's in Toronto. And they were kind enough to let me do research with them in third year, which kind of then set up my trajectory to do MIS, which I ended up doing in Ottawa because I moved to Ottawa. And then after that, colorectal fellowship, and yeah. And then kind of from there, just tried to continue to learn after that.
Chad Ball 05:37
Yeah, that was an interesting group at the time, eh? Like some real pioneers in terms of Canadian MIS surgery and a heavyweight collective for sure.
Husein Moloo 05:45
Absolutely. Absolutely.
Ameer Farooq 05:47
I wanted to shift gears here for a second and talk to you about quality improvement, because that's clearly a huge passion of yours. And something you're well known across the country for, particularly in the colorectal circle. You know, the first question I want to ask you is maybe a bit of a basic one, but I feel like quality improvement is this, again, a nebulous sort of term, that might mean a lot of different things to a lot of different people. So, what exactly does quality improvement mean to you?
Husein Moloo 06:14
At its very general level, you know, what I really like when I think about quality improvement is throwing the C in front of it. You know, the CQI - that continuous quality improvement. And that, I think, is anything at the end of the day at its most basic level, and whatever you can do to reduce harm to patients. And so then, you know, when you take that, and you go to something more, I guess, definitive, like, you know, I think the IHI quadruple aim, for example, touches on some very, kind of big piece of that. So when you think about that, there's, you know, patient experience, for example, like that, if they have a terrible patient, if there's a terrible experience, that's patient harm. You know, when we talk about doing these things, and reducing costs, I think that within our current context, and the context we are going to be, our health system is going to be in within our lifetimes, I think, for sure, like reducing costs, is a really big thing. The public health part of it, I think, is really big that I've continued to hopefully understand more. And, you know, I went back to school and just did a Master's in Public Health, which I just graduated from in November. And then like the whole thing with you know, the healthcare team as well, like, I think we see, you know, especially with COVID now and things like that. There's a significant kind of mental health hit that people take with going through all these tough times. And so, I think all those things kind of play into it really well. But at the end of the day, to me, it's a lot of you know, it's patient and team centered, and reducing harm to both those parties.
Ameer Farooq 08:00
So what kind of motivated you to get interested in QI? Was that something that you were working on as a resident, as you mentioned? Or how did that kind of evolution come into play?
Husein Moloo 08:08
Yeah, so it's like most things with me, right? I don't really have forethought. You know, I think, all of us kind of want to offer the best care to our patients. And so, we were in NSQIP which I think everyone knows about. So NSQIP had shown that our hospitals, specifically like colorectal had, like, really high morbidity driven by a high SSI rate. And actually, we saw that across our whole department. And, you know, I was kind of tapped to do QI stuff for our division. And so, that's really how it happened. It wasn't because I was like, oh, I have a real interest in this. It was more the division head going, like, yeah, here's a guy kind of in is, you know, kind of junior guy in the division, I'm going to tell him to do QI. But it was interesting, like Dr. Poulin at that time, he told me...and Dr. Poulin has told me a lot of really smart things. But he said, you know, QI is gonna sustain you into the future, mark my words. And lo and behold, I mean, it really is one of the things I enjoy most and makes my career fulfilling. So he was right. Thank you, Dr. Poulin.
Ameer Farooq 09:26
I want to get back to the work that you've done and dig a little deeper into the work that you did subsequently. But I just want to pause and note something that, you know, you talk about the fact that you sort of took these suggestions from your mentors and kind of ran with it and went with it. And we've had guests on the show that you know that we always ask questions about what people might have done differently or what advice they would give to themselves as a resident. A lot of people have said, you know, I would have been more deliberate in what choices I made. But I think there's some role, as you've clearly shown for kind of being open to the possibilities, particularly early on. And it's curious, is that sort of how you approach your career a little bit? As you kind of have this sense of openness to possibilities? Or do you think, sort of now as you advance, maybe towards sort of a mid-career point, that you're much more deliberate about picking what kind of career choices you want to make?
Husein Moloo 10:29
You know, there's some people I think, because virtue of their intellect, drive interest. I'll give you an example in Ottawa. Rebecca Auer, like, what a great researcher, right? She's like an inspiration to so many people, including me, and I go like, wow, like, you know, be awesome if I could, you know, delve down to a level where I can start figuring out how to cure cancer, but you know, what, like, I'm not that smart. So, I'm gonna go with my strengths. And I'm gonna take like, the, you know, I don't know, if you've come across this book by David Epstein. It's called "Range". And, you know, he talks about the fact that, you know, it's okay for some people to have like, a lot of different areas that they find interesting. For me, QI is like an outlet to a whole bunch of different things. And so that's what I've been enjoying, you know? Just trying a lot of different things. And I enjoy them. And as long as I'm enjoying them, I don't know. I have still not become deliberate, is the answer to your question.
Ameer Farooq 11:44
Well, it gives a person like me hope, because I have eclectic interests, as you know. And so, I quite take that advice to heart. But let's go back to the QI stuff. So, you got tapped by Dr. Poulin to be like the QI person in your department. And then you went ahead, and you just ran with that. And across the country, I think it's safe to say that you're well known for developing some very innovative programs in Ottawa, particularly the Comprehensive Unit Based Safety Program, or CUSP. Can you tell us about CUSP and what was involved in generating that?
Husein Moloo 12:20
Sure. So, you know, again, I started off for our division, actually. So, it's just general surgery. And you know, I knew nothing, right. So, for six months, I'll be honest, like I did nothing. Like there was an SSI rate, and I had no idea how to move that forward. So, by that point in time, you know, we talked about the fact like, you know, a three year undergrad, four years med school, five years Gen surge, two years of fellowships, or I guess, three years through the fellowship plus a master's in epi, right? So, I had all this education, I really couldn't move. I didn't know how to. And so, we end up, the hospitals getting kind of worried at this point in time, because they've been in NSQIP for two years prior to this, and the needle hasn't moved either on that. And they're worried maybe this is gonna get out somewhere. And you know, everyone's going to look pretty bad because we had this data and nothing happened. They'd really try a kind of top-down approach which hadn't really resonated, or been effective. And so, they end up paying, they give each of the division leads, they're like, here's like $1,000 to go to this NSQIP conference. So I go, I sign up really late. I was like, I'm going down. It's Salt Lake City, maybe it's not super exciting to a lot of people. But I mean, no one told me it was super exciting. So, I was like, I'll sign up for like, you know, a workshop. And the last workshop available is the only one that was available. Something called comprehensive unit-based safety program. It's CUSP, and it's run by Johns Hopkins. And so I go to that. It's like a half day thing. And so I'm listening and I'm like, wow, this sounds pretty simple. Like it makes sense. Like, basically, you take a multidisciplinary team, you get an executive sponsor for that team. You do it unit based, which kind of made intuitive sense to me, like, you know, for example, you do it on an inpatient floor, you do it for like, let's say, colorectal surgery in the OR. You do HPB surgery in the OR for example, and you meet on a regular basis and you generate ideas. And it just so happened that the department chair of surgery, like the interim department chair, who is just switching that time. Dr. Sodereesen happened to be sitting there with me in that thing, and we're sitting there, we're like, this kind of makes sense to us. So, we come back. And, you know, I got this small grant to kind of start off three teams in colorectal surgery on the general surgery inpatient floor at the two main in-patient hospital sites. And we basically start this process by asking two simple questions. It's like, you know, how's the next patient going to be harmed, and what can we do to prevent it? And we also threw in, we kind of cheated. We made like four questions like, how do you think the next SSI is gonna happen? And what can we do to prevent it? And we gave it to everyone. Like housekeeping, because these are people are on your team. Housekeeping, OT, PT, frontline nurses, residents, surgeons, you know. There are probably some names I'm forgetting here. But like, yeah, we distributed widely, we got a bunch of ideas, those ideas started our teams rolling, we picked some quick wind things. And all of a sudden, you know, again, it's the first time like, people were a bit skeptical, but it was the first time if you think about it, I don't know how often this happened to you. But at that point in time, it was the first time for a lot of people that a frontline nurse sat down with a surgeon in a meeting for like an hour that was dedicated to patient care, and for there to be OT and PT there, and a resident and everyone's discussing, what can we do to make things better, that really resonated with people. And like, became a powerful thing. And then it spread. So went up to like, you know, 17 teams, and we developed some infrastructure around that, and, you know, tried to share those lessons that we learned with other places. And then the Santero collaborative came along and we kind of shared there, and there was a BC collaborative that already existed. So, you know, it kind of shared what we had done there. And so it's just, you know, it's one of those things again, like most things, man. Like, I didn't come up with that idea myself, I just kind of took it and tried to adapt it for our context. And you know, it happened to work. I knew we had kind of made it when on the surgical safety checklist now, we have something in Ottawa where it says like, are there any custom measures for this case? And so you know that was kind of nice to see. But again, that's a team effort. And, again, I think that's where that humility, from going to UTS came in handy. I realized, I'm not that smart. To come come up with ideas and solutions. That sitting down with people, and it's not supported by evidence too. Multidisciplinary teams are better than kind of uni specialty teams in terms of coming up with solutions and having mixed demographics, etc, etc. But yeah, all that to say, it's led to a lot of different things. And if I can still drill it on a little bit more, it's gone on to like stuff like, beyond SSI and stuff like that. Opioid reduction. Our big thing last year is looking at reducing our carbon footprint. You know, we did a thing on measuring surgeon empathy. So, like, that's where like, then again, I'm using kind of QI to explore things, which I think really matter. Like the climate crisis. So yeah.
Ameer Farooq 17:51
Can you give us an example of something that came out of the discussion from over these different groups that you wouldn't have necessarily thought of? If you hadn't kind of changed the approach. Because I think fundamentally, and again, just like all great ideas, they sound simple when someone presented it. But like, obviously, you had to clearly recognize that this was the approach to take. But you know, fundamentally, I think what you did differently is you made it much more granular and much more about what everyone's frontline experience was. And you could leverage what people's real expertise was in all these different facets to come up with a plan that perhaps people hadn't seen before. So can you give us give us an example about something that came up from those discussions and turned into an initiative that you wouldn't have seen otherwise?
Husein Moloo 18:36
Sure. So, um, you know, sitting down at those meetings, for example, one thing that came up is, it seemed absurd in a way that, you know, you have, like nurses who are looking after surgical patients for whatever amount of time you want to call it, 23 hours and 55 minutes out of the day. 57 minutes out of the day. 59 minutes, if the surgical teams running really quick, with really never any clear communication between, like the nursing staff and the surgical team. And back then, you know, there was nothing like...so that was the underlying problem. So, then we had some meetings with frontline nurses, residents, surgeons to be like, what can we do? This doesn't make sense, like, what can we do? So, you know, there were multiple things that came out of that. One of those things was before it became kind of fashionable for a hospital - we started these kind of, we call them like, I can't remember what kind of rounds we call them. But we had these rounds where basically, a surgical team would be there and you know, every nurse would come and talk about patients we're looking after and run through with the entire team. So OT, PT, dietitian, everyone will be there and kind of talk about the plan and what the discharge plan was. Now this morphed into discharge rounds. And these floor huddles became a thing which again, got piloted on our floors, which were already doing it, so it was a quick win for the hospital and then spread across the whole hospital, and I think that again was recognized probably at multiple centers at that time, and it's probably become a thing that's in most hospitals now. But back then, that was something like, you know, without sitting down, like that whole communication piece, you know, you talk about patient care, that's one thing. But also, like we did a, you know, we actually checked what the culture of the floor was, and how nurses and residents founded before and after, and it made a huge difference, actually, to the way nurses felt. And even three years later, our results dropped off a bit, which spoke to the fact that we need to keep on concentrating on stuff, but it was still significantly better than at that baseline in terms of nurses feeling like their ideas were heard and stuff like that. And then that's where you kind of build culture, etc.
Chad Ball 21:02
You've given us so many pearls, and you very eloquently talked about so much stuff, I want to maybe hit or unpack that term "culture". Because I think that's at least in my mind, really the key to continuous and progressive and long-term change. One of your many administrative titles is the Vice Chair in Quality. So obviously, a high-end leadership position. And you've outlined how you used CUSP and sort of a bottom up and out approach to engage the folks that are stakeholders, and maybe historically haven't been stakeholders and should be stakeholders going forward. We also talk a lot in this top podcast about you know, leadership and teamwork and what those definitions really mean. And who does it well. So, I'm curious from your sort of Vice Chair, leadership view of things. How is it that you really inspire change in culture in your environment? And I know that's a very broad 30,000-foot question. But what are the nuances if Ameer wants to sit down with Morad Hameed in Vancouver and really pursue the same directive? Or we want to do it here in Calgary in the same way that you've done it? What are the nuts and bolts of that?
Husein Moloo 22:17
I would track this back. And I wish I had this article in front of you, but you know, one really fun magazine to read or journal to read every once in a while, is the Harvard Business Review. And in 2014, they had this really nice article on what companies do to improve culture that drives quality. And the number one thing you just spoke about is, for example, you know, you speak to someone like Morad. So, you get leadership emphasis on this. Then the second piece of that, is you get kind of credible messaging around it. So, for example, you know, let's say, you know, decide, Ameer is gonna start running, you know, improving communication with surgical staff. Well, you know, if Ameer is the guy who's constantly berating the entire team. And I can say this, because I know Ameer is like a super nice guy, you know? You need credible messengers for sure. So, you need that leadership emphasis, you need credible messengers. And then, you know, the big piece in that article came down to...and they looked across health care organizations. And it was like, it was basically employee ownership and kind of keeping peers accountable. And I think that's where, you know, you talk about, like, the thing I always keep in mind with QI, whether it's culture, whether it's an SSI thing or communication is...Don Berwick has great lines. One of his great lines is this: a system produces the results it is designed to produce. So if you want to create a system, let's say at a departmental level, where you have employee ownership, you have peer-to-peer kind of pressure on performing quality stuff, then, to me, that means you need some way to engage that frontline, to have their ideas heard in a credible way. You need people leading those teams who are credible, and then you need the leadership people to buy into it. And that's what kind of, you know, that's why I think CUSP kind of worked because, yeah, that frontline, you had an executive sponsor, and in teams that work. And not all their teams work, right? I mean, we've failed lots of times. You know, sometimes that credible messenger was not there. But, you know, and part of that messaging as well just in terms of QI, building culture etc. is not being afraid to fail. Like, you know, one thing I always throw up in my presentations is, and I stole this from Cliff Ko, I told him I'd steal it from him. You know, he runs like bass, this NSQIP program. He gave this great analogy of like, you know, a great Canadian analogy. Which is, if you want to score a goal in hockey, you got to get shots on goal. To get shots on goal, I think you need a team. And then, you know, as part of that team, you need to realize not all your shots are gonna go in. So, to me, CUSP is that team and stuff. And yeah, so I think those would be the critical pieces to kinda moving things forward.
Chad Ball 25:46
Yeah, it's well said. I mean, I think Cliff Ko has delivered more practice changing advice in his, you know, moderate career than most of us together will do in a lifetime. He's an amazingly smart guy who's changed the world. Very cool guy. You know, maybe the last question that we would like to ask on the QI side of things, or the continuous QI side of things, which I absolutely love, and will start to use. Is if you're a resident, or a trainee or even a faculty, what are some of the training access points that you can improve your knowledge and your understanding, besides going to a NSQIP conference. You know, and obviously, the background is, you know, you're MPH and we have a number of surgeons of our vintage across the country now that have done formal masters in QI. But beyond that, where can we access that kind of information training?
Husein Moloo 26:42
So, I mean, for example, IHI has a great online, and a lot of it is free, modules to kind of learn like, oh, you know, this is what a PDSA cycle is, for example. You know, there's all sorts of different fellowships which people don't need to kind of leave for a long period of time. Like, back in the day, when I started get serious about stuff, I did one with the American Hospitalization Association, National Patient Safety Foundation, that's possible for residents as well. You know, there are opportunities like through IHI and stuff, so there's so much stuff and the online stuff just continues to explode, especially with COVID right? And with all the virtual stuff that's available now. So, I think, where people are interested, as long as you've got, you know, and I guess like, its time, right, which is, I have to throw this slide in just because I've been doing peloton recently. Jess Sims always says time is a non-renewable resource. So, I mean, it's pressing stuff, right? But, if you have the time to put towards something you really care about and are passionate about like this, then yeah, doing some of that stuff online, I think would be a great way to start. And then, I think a lot of it is like, practical stuff, like, you know, learning about change management as well. So, there's the QI stuff, but if you don't know about Kotter's steps of change, I think, and you're trying to create change, that I think you need to educate yourself just a little bit more, you know? And again, like, those HBR articles, like, I mean, his is the first article and their little change book. But yeah, there's so much. There's just so much knowledge out there, right. And I mean, you just talk to someone in the field, I think is the best way to start. Because then they can point you to stuff which they think is relevant and will hopefully make your learning a little bit more efficient.
Chad Ball 28:39
You know, one of the really interesting things I think in the last... you can correct me if I'm off a bit... but five to eight years is your Ottawa groups have really started to look at preoperative anemia. And obviously, I'm hooked in with the HPB colleagues that you have. But I'm wondering if you could sort of talk about that a little bit and where you guys have been and where you're going with that topic in general.
Husein Moloo 28:59
Yeah. Well, thanks for asking about that. So, again, along this theme of QI right, we started to look at, you know, what can we use? So, we did a lot of stuff in OR, like closing trays and wound protectors, which we actually got that idea from HPB. And then we started looking at preoperative kind of optimization. So, you know, a great researcher, Dan McIsaac, who I've been lucky enough to work with on frailty. And then we started looking at other modifiable factors. So, you know, what are things that you can like fix and have an impact that are based on evidence? Well, smoking is one of those things, so we worked on that. And your journal, Dr. Ball has been kind enough to accept that. So hopefully, that stuff on smoking will be out soon. Another area was, you know, kind of a little bit more controversial, but one of our teams and actually guinee oncology worked on it with glycemic control. So, we got some stuff instituted on that, kind of department wide. And then, you know, when we start looking at stuff, I went to this talk. And I wish I could remember her name. It was a hematologist in Toronto, which is awesome. There's all sorts of stuff. And I realized, like she gave this talk about anemia and all the impact that it has. And it just blew me away. Because, you know, I used to see like a hemoglobin of 105, and I'm like, yeah, it's fine. Or like if they have 90, I'd sent it to internal medicine and be like, yeah, you know what, give a transfusion. So, they weren't doing anything about it either. And because this anemia area was kind of an orphan area, because no one really was owning it. So that's kind of what struck the kind of interest in that. So initially, is QI, looking at our SSIs, working on stuff, and then kind of moving to like some preventative, I guess, medicine type stuff. And that was kind of part of the bundle that we looked at.
Ameer Farooq 30:49
Alright, to continue our Peloton metanarrative, we'll switch gears again, and talk about something that I think is really unique to the Ottawa colorectal group, which is your shared practice. And, you know, to paraphrase top knife, your group actually has a shared practice, which is one of those things that's often drawn or talked about, but rarely photographed. And so, can you describe for our listeners, what exactly does your practice look like? And how exactly does a shared practice work?
Husein Moloo 31:20
So I started solo practice, and then the HPB group got to get full credit, I have to shout out one of my best friends forever, Fady Balaa. He was doing that in HPB. And so, I looked at that, and I was like, you know, and we were chatting, we chat all the time. We've got to do this in colorectal. And so, one piece, and I'm sure you guys know this already, but if you're ever recruiting people, and you have the privilege to do that, it's very simple. For me anyway. Every colorectal surgeon that I've recruited into our group, I clearly believe, and it is very out to be true that they are better than me and will like to exceed me in every way. So that was my real only hiring criteria. So, it's a bar separado there but like these guys are awesome. So, I got to do a special shout out to Isabelle Raiche, Rob Williams. That's like my work family and actually family even outside of work. But I started solo practice. And Isabelle Raiche is the first person in and then Laura was added pretty soon after that, and after that, Riley. And I'll tell you from going from me to Hameed to Isabelle, we got almost another full surgeons worth of resources. It wasn't quite two FDEs, let's put it that way. And what we did was, we basically have one central line, either of us will see that person in clinic, either of us would operate on it. And then that quickly evolved to the same model with Laura, except when Laura came, we got maybe another half surgeons worth of resources. Now we’re sitting at about two and a half surgeons worth of resources for three people. Not bad. And that gives you some flexibility to do stuff that you want to do like QI or, and these guys have all done amazing stuff outside of just clinical stuff. And then when we when we had Riley, we basically we didn't get anything. But we made a decision. We really liked Riley, we wanted to hire him on. We had enough nonclinical things we were doing that we were happy. And number one, to get a pay cut, because we got you know, if there's resources at the end or what generate money. There is money for other things like being programmed, the director of general surgery like Laura is, but at the end of the day, it was a pay cut for all of us, but you know, an intentional one. And the way we work now is essentially let's say Ameer, you come in tomorrow into cancer clinic, you may see any of the four of us. Now usually maximum, there's usually two of us in clinic, sometimes three of us in clinic. So, you may see any of the four of us in clinic and then your surgery may be done by surgeon number two, and then you may be rounded on by surgeon number three. And then when you come back to have your pathology reviewed, that may be surgeon number four. And we kind of take a week at a time rounding on the floor. So, we're rounding one weekend out of every four. And you know we take our turn on going through the paperwork that comes in, like in terms of triage or referrals that come to our office and stuff like that and you know, blood work that comes in on patients and stuff. And yeah, that would be the main piece. And we have a shared administrative unit. So, we have two admin assistants for the four of us. And again, everything was just central cue for scopes, for ORs. Just next surgeon available goes in.
Chad Ball 34:58
I think probably that's more and more common, at least elements of that. And if you look across the country, you know, acute care surgery, trauma surgery are probably the forefathers and foremothers of that model to some extent, and you guys are really taking it on the scheduled or elective side to the next level for sure. I'm curious, though, how do you articulate those transitions and that overall care model to the patients? Is it something that you verbalize when you meet them in clinic? Or is it an information package that they take home with them? Or is it stated when they come in? What is that sort of back-and-forth interaction happen, firstly? And then secondly, how do you handle it when there is a problem, maybe that requires, you know, more detailed or more long-term continuity, and maybe it's not even a problem, maybe it's just complexity, whatever the driver would be.
Husein Moloo 35:56
From the messaging standpoint, our office messages that. As soon as patients enter the system, they know, they're told it's going to be any one of the four surgeons that will see them, and they're looked after by a team. And that's what we message to them, as well as that. Basically, instead of receiving care from one surgeon, they're receiving care from a team of surgeons. And I'll tell you, the vast majority of patients, they buy into that, first of all, and then some of them actually articulate the fact that they've had surgeries before, but they really love the fact that they've got this team that's there. Because I mean, no matter how awesome that one individual is, it's really tough for that person to be available 365 days a year. And I mean, that's really what we have. And, you know, we have a backup colorectal call for when, you know, when general surgeons on call, if you need a surgeon on call. If there's an issue that requires nuanced care, they know, like, there's a call schedule that's put out for subspecialty with our names on it. So, there's care for that, too. That's much easier to service as a group versus an individual. And then, you know, the second part of your question in terms of complexity, you know, I think complexity, first of all arises, I guess, very quickly, in my mind, as I'm answering. It's like two scenarios. Like one is, yeah, initial elective, complex cases, in which case, having input, an instant second opinion, in clinic, etc., is invaluable. And I think when you look at literature around, even in the business world around, people who become more senior, the decision making is actually sometimes worse. Because, you know, people may have thoughts up to that point, but then it's that single person that's kind of making that final decision. And so, they found that by having more of this group, decision making, you actually make better decisions. That's more of an elective type setting. But even when you get complications, you can always go back to that group. Like we have teaching sessions every Friday morning, where we discuss complicated cases, if there are any that we need to discuss. But also on the floor, I'll tell you as a solo surgeon, and Chad, you probably don't have this problem. But man, I've had some complications. And some of those complications stayed for a really long time and rounding on those people. It's tough. And, you know, part of the toughness of it is one, I mean, it's just, I mean, it's tough. But the second part is like, you know, you almost sometimes lose that perspective. And, by us kind of changing every week. It doesn't stop you from coming back around if you want to, but there's someone in charge that week, and they bring that fresh perspective, right. So, it's kind of like this renewed thing. Like I used to do public exonerations, by myself, well, guess what, now, we always make sure there's two of us booked. Guess what, like, when I'm hungry for lunch, probably, I don't know if I was doing as good surgery for that patient, but I can now step out for half an hour, an hour if I want. And my partner is gunna be there. They might even do a better job than I am. So, I can step out and then I can come back in, and they're gonna be there till the end of that case. So even when we're closing fascia, hopefully, you know, between two staff and of course, our awesome fellows and residents, like we're going to do the best job possible.
Ameer Farooq 39:39
We've had David Urbach come in and talk about this on the podcast as well. And I think there's a lot of value in thinking about having a model like this, particularly as we now think about trying to catch up with this COVID backlog. So, you know, I think it's really super important, I think for groups to think about how they can optimize their flow. But I think it does require a big mental change. You've demonstrated this throughout our conversation, but it requires huge humility to say, you know what, I'm certainly not necessarily better than my colleagues. And secondly, that they can do just as good or a better job than I. My dad used to say that one of his mentors used to say, these hands are for this operation, but that mentality kind of has to go. So, I am curious, though, like, I was lucky enough to spend some time with you. And as a group, you're such a great collaborative group, you talk to each other. So while you clearly like each other, what happens if you have a dispute or sort of a difference of opinion about how to manage a certain patient or manage a complication? Or just generally have a difference in approach on a specific situation? How do you kind of resolve that difference?
Husein Moloo 40:53
Yeah, you know, like, that happens, right? I mean, it'd be impossible for that not to happen. But I think, you know, it's that. We just, we have one of our fellows, we just did this kind of scoping review on group practice. And, you know, one of our findings was, obviously, look, personality is a big thing. You get the wrong personality, and that can actually take away from your quality of life within a group. So, I say that, because picking those people is super important. And the reason why I think is exactly these types of scenarios, where you can have a very clear, open, honest discussion about what you think in a safe space. And arrive at a consensus. And that's usually what happens, right? Because, again, I think we're all there. Just like, you know, the vast majority of people in medicine and surgery, we're there to help people. And so, we're trying to arrive at a conclusion that we think is going to help the most, and usually through consensus, especially, you know, with the relationship that we have built over these years, and the trust is, you know, we can arrive at that. And we can pivot and change, and I think that, for me, makes me a better person and surgeon for sure.
Ameer Farooq 42:14
Do you think that it shifts your relationship with your patients? Like, you know, you've done both solo practice, and obviously, now the shared model. And there is a sense of, of having ownership over the patient? This is this is my patient, I'm going to look after them, you know, whatever happens, I'm going to take care of it. Do you lose that at all? Or is there a sense of like, these are all my patients, and I have to kind of take care of them? As if they're all my patients, kind of thing? Like, can you talk about that relationship?
Husein Moloo 42:42
Yeah, no, I think that's exactly what you said, you know, the latter pieces. They're all our patients. And, you know, what, like, it feels a lot better that we're a team. And we're looking after all these patients, and those patients know that. They've got a team that is looking after them. And so, I think, you know, it's a great thing. Like I said, I think it's great for patient care, I think it's great for surgeon lifestyle. There was that survey, you know, that came out, I'm sure you guys are aware of it. The biggest regrets that retired surgeons have, right? And number one was not spending enough time with family, and number two was they want a less stressful practice environment. And I would say, you know, group practice hits number one and number two perfectly. And so, you know, I think when I look back at my career, one of the best things that will come out of this is this group practice and being so thankful that you know, I was able to have partners to do that with.
Ameer Farooq 43:59
So here's comes a real serious question. When things are going down in the OR and things are tough, what is the music you're going to put in the on in the OR? I know the answer.
Husein Moloo 44:10
You know the answer man. It's Drake all the way. All the way man. But the great thing about Drake is Drake knows when I'm in trouble, man, and he comes on the playlist. My playlists are at random. The residents and fellows don't believe it, man until they experience it. You have to experience it to understand that the six God also has jurisdiction in my OR.
Ameer Farooq 44:29
Okay, why Drake? I mean, I know you're from Toronto, and you're brown like I am. And so, it's ticking all those boxes. But why? Like, why not Kendrick Lamar?
Husein Moloo 44:42
Is Kendrick Lamar Canadian?
Ameer Farooq 44:44
No.
Husein Moloo 44:45
There's your answer. No, so like, Drake's Canadian. He's awesome. I like his music. And he's proud man. He's proud to be Canadian. He's like, proud of Toronto. He's like, he has a lot of Canadian pride man. A medical student asked me, did I ever think about working in the States? I was like, you know what? No! Because I'm Canadian man. Like, I want to give back to like my country, man. Like, this is where I want to be. And this is where Drake wants to be too, man. So, I'll tell you, Justin Bieber, also Canadian, also awesome. I know people like to hate on him. He's awesome, too. That guy's the demigod of my OR. So, you know, when there's like kind of minor problems, Justin will come out and he'll help. So yeah.
Ameer Farooq 45:37
That's fantastic. I love it. I also have to just ask you, and maybe this is an even more difficult question than the last one. But, you know, we've had long conversations about philosophy when I was there on elective. So, I'm curious, who's your favorite philosopher? And why?
Husein Moloo 45:55
You know, man, that's a really tough question, right? Like, there's so much good stuff. I'll tell you the stuff that really got me hooked. I love the dialogues between Plato and Socrates. The cave analogy is something that I think really resonates with my worldview. You know, I think everyone should read the cave analogy. I made my daughter's read the cave analogy. I love stoicism, too. I love the meditations by Marcus Aurelius. You know, so much smart stuff there. Right. I guess if I had to pick one thing, it would be that cave analogy that Plato wrote up, and I think that'd be my favorite piece of philosophy. But I mean, so much other good stuff out there, right? Fulfilling life, Aristotle talks about all that stuff. It's all good. But if there's one, just like, there can only be one. There's just that one God in my OR, Drake.
Chad Ball 47:11
I love that. I love it. I couldn't agree more. Marcus Aurelius never leaves my nightstand. So, I hear you there. If you were to go back in time, and give the younger self some sage advice, what would you tell yourself?
Husein Moloo 47:24
You know, I'm going to say, I'd give myself the advice that I think I've taken to heart. And that Eric Poulin gave me. As I remember, I was in a cafeteria in Toronto, my third year of residency when I was doing my research there to try and nail that MIS fellowship. And it's very simple. And he said, you know, make sure, every year you do one new thing. And he's like, it doesn't have to be surgical. You know, it doesn't need to be like picking up a new surgical technique. But he's like, do one new thing every year. And that will, again, sustain you and keep you from getting bored. And man, I've really conscientiously tried to do that. And I would say that out of almost anything has really kept things interesting for me. And so, one new thing every year. I think that would be the advice I would encourage everyone to. And you know, I'll just give you an example. Like, you know, it could be like, one year it was like doing QI leadership fellowship thing. One year it was doing Leadership Academy. One year, it was like starting up TEM at my institution. You know, for a couple years I was doing my MPH. So, you know, this year, it’s really working on global health, and really pushing that part of stuff, which I haven't really done before, but that's going to be my thing in 2021. And so, yeah, that would be it.
Ameer Farooq 49:27
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.