E99 Neel Datta on Surgical Workforce Planning
Listen to this podcast on SoundCloud
Chad Ball 00:12
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, whether 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 00:55
We were so lucky to have Dr. Neel Datta on the podcast this week. Dr. Datta is a colorectal surgeon in Calgary and the former program director of the residency program. He has previously done a Master of Health Economics at the London School of Economics. And he's used that expertise to really interrogate some of the key issues around surgical workforce planning, particularly with regards to unemployment and underemployment of surgeons in Canada. We also wanted to say that we're so excited to be releasing our 100th episode very soon. It's been such a journey and such an honour to interview so many amazing people on the podcast. And we're so grateful to all of our listeners for tuning in every week. We have a very special episode coming out for our 100th episode. So, we hope you stay tuned for that we hope to continue to grow and evolve the podcast and continue to make it entertaining, educational, and hopefully most of all thought provoking. So now without further ado, Dr. Neel Datta. Can you tell us a little bit about where you grew up and what your training pathway was?
Neel Datta 02:11
Well, Chad and Ameer, I think it's more a pleasure and privilege for me than the two of you. You know, Chad, you were my senior resident through tough rotations. And Ameer, you're one of our rockstar residents that we train. So, this is a wonderful experience for me. So, I am a Calgary boy, in my opinion, but I was actually born in New Brunswick and lived in Saskatchewan. My father was an expat in Nigeria. So, we lived there for a long time. But many of my formative years were in Calgary, and particularly I did medical school and surgical residency in Calgary. And I was lucky enough to do a master's in London after that - in Health Economics and Policy, and really privileged to be a colorectal surgery fellow in Toronto. And once I finished my fellowship there, I was lucky to come back to Calgary and I've been here for about 10 years now.
Ameer Farooq 03:15
Most of our listeners will know that you are the program director for many years, and certainly during my stay as a resident in Calgary. And we recently had Dr. Karimuddin on the podcast as the program director of UBC. And he talks a lot about his thoughts around the quote unquote, "struggling training", although he didn't really like the term struggling. And he kind of talked about his approach to the trainee who is having trouble during residency and how he kind of gets them out of that. How do you help that resident along and get them to where they need to be?
Neel Datta 03:48
Well, I guess the real question is, why is someone having trouble? And I suspect that there's many reasons, you know. Chad and I have spoken about this quite a bit. But there's systemic factors that affect our ability to train residents and there's probably personal factors as well. When I look at our training now, I do see some major systemic factors. So, there's often a question about volume of training and our ability to deliver the volume within the confines of how we train people. And there's been changes in the type of procedures that we do. So, we're doubling the number of minimally invasive procedures that we do. At the same time, you know, vascular surgery has got more and more separate from us, they're doing more endovascular cases. So, for example, a general surgery resident may not get the same type of experience when they're on their vascular rotation as they did historically. And then, you know, things like trauma surgery have become more non-operative. So, I think general surgery has an evolved quite a bit. And all of us are getting more sub specialized. But at the same time, we've kind of stuck to those five years where we train everyone to do everything. And I think the worry I have with residency right now, is, are we training over a five-year period? Are we training people to do 500 procedures twice? Or are we identifying the key procedures that general surgery residents need to do and making sure that they become exceptional at those. And so, I think that there's a lot of system factors that affect our ability to train people. And then there's personal factors, you know, I may seem a little old fashioned to say this, but I do feel that we're in an era where we tell people that they can do anything and everything they want. But, you know, the longer you go down the path of being a surgeon, I think we realize that it is hard to make all of those balances in your career and in your life. You know, I've really focused my practice, because I want to be good at a few specific things. And I think that that'll bring more rewarding success, too. And so, I do think that we're going to encounter a lot of challenges in our ability to train people because of those confines. And I would say that in an ideal world, if we had infinite ability to expose people to procedures, an infinite amount of time, probably everyone could become a surgeon. But I suspect that our ability to truly train competent surgeons, I don't think we can do that with everyone. Not sure that answers your question.
Chad Ball 06:56
Yeah, that's a really interesting point, Neel, and you're right. You know, I've listened to you talk about that a few times, I think you're dead on. There's a whole bunch of issues that seem to be shifting more rapidly in the say, the last five to 10 years than probably in the preceding 50 years. And I think most of our listeners, and certainly some on the call, know what a lot of those are. You know, I think maybe it's worth focusing, for example, on exposure to trauma care as a good example, since you brought it up, you know, we'll soon have a peer reviewed publication of really the national resident exposure to trauma training, that's both operative and non-operative cases. Hands on and didactic from across the entire country by Paul Engels from McMaster. It's a beautiful project. And it really shows that significant disconnect between you know, I think what you formerly as a program director had to sign off, from the Royal College in terms of, you know, training achievements. A person can do this procedure and that procedure and this other procedure and understand these levels of knowledge. But really, we know, it's not even close to occurring. And I think to your point, trauma care being slowly sort of moved out of a lot of residencies to any high-volume effect. It's concerning. You know, I guess my question to you after that ramble on is, are we trying to do too much in 2021, and trying to ram too much into current trainees with the work hour restrictions and with the current framework and modeling that we use? I guess that's question one. Question two is, do you think, given your experience and doing this for a while, that competency-based training will help or hurt that? How do you see that coming along?
Neel Datta 08:57
Well, I think that you're absolutely right, Chad. We need to look at the cases that a general surgeon does most often in Canada and work back from there to make sure that we make them experts in those fields. And you know, I think we have an excellent residency training program here. We get exposure to the whole gamut of subspecialty general surgery. But the majority of general surgeons in Canada, and there's practice variations, but the majority of them, their number one procedure is colonoscopy and endoscopy. Then hernias, gall bladders, appendectomies, breast resections, and colon resections. That's about seven or eight procedures. So, from my perspective, if we're really focusing on training general surgeons, we should make them exceptionally competent at those things first. And then build the subspecialty training depending on their interests, or their future job, things like that. So, I do think that we need to work backwards from, you know, what do general surgeons do. And they're not spending all their time doing Whipple's. They're spending their time doing colonoscopy and hernia repairs, for example. And then build subspecialty training after that. In terms of competency by design, I actually think that there's gonna be a lot of advantages to that. And that's because right now, there's really a push to train people in five years, and kind of get them out going forward. And there's a couple reasons for that. I do think we have an element of failure to fail. But also, there's huge financial pressures in the five-year residency versus the subsequent competency by design residency program. And I think that the CBD is going to allow us to really tailor our training to the strengths and weaknesses of our residents. And that may mean that some residents take more time to become a successful, competent general surgeon. But I think that from a patient care perspective, that'll be way better. And I think it'll be easier for us, as surgeons, to say to someone, you know, you do need a little bit more time in this area, for example.
Chad Ball 11:28
I mean, I think you're dead on. It's so interesting to think about, you know, you bring up a Whipple procedure, and sometimes you're doing, you know, to be honest, a really hard resection, and you're like, I don't necessarily think the resident is getting anything out of this, because it's such a challenging case where, you know, at the faculty level, they are 100% focused and intense. And other times, it's not like that. And you say, well, I have a Whipple procedure. What is it that a resident could potentially learned? Doing an open cholecystectomy, and some really hard gallbladders, quite honestly, that are usually all inflamed and gross and can be one thing. Or the technical nuance of hand setup and placing fine sutures is another thing, but you're right, like, they don't really need to know how to do a Whipple in any sense of that word. If we are honest, I think it's been very clear to a lot of us that you were a great program director, and the residents really loved you. And before we move off this topic, I just wanted to ask you, what sort of benefit that you got from that experience was, and what some of the things - one or two or three of the things that you enjoyed the most - that you'll really take with you going forward. Because I think, you know, clearly anybody in Canada and probably the world that engages in that role - it really does change them. And it really is a bi-directional relationship. The trainees are certainly better off almost always, for all the effort you guys put in.
Neel Datta 12:51
if you're a really successful program director, you'll have a host of residents who really appreciate that. And some who probably don't like the decisions you make. And at the same time, you're going to have a group of staff surgeons who appreciate the work you're doing and a few of them who strongly disagree with you. So, I think if, at any given time, if there's a little bit of conflict, you're probably doing a half decent job. When I thought about being program director, it wasn't really right at the top of my goal, as top of my mind for an ambition or goal or a leadership job that I was aiming for. And that's really because I didn't have formal surgical education training. My master's was more in management. But to me, being program director is the best surgical leadership role. And you know, it was Morad Hameed, who's been on your podcast, and is a huge mentor to me. He's the reason I went into surgery. And I think you know, both of you, I'm sure he's influenced your careers quite a bit. But Morad, when I was considering being program director, I asked him what his thoughts were. And he said, you absolutely have to do it because you're training future surgeons for Canada. That's the best job. And he's absolutely right about that. I think that it is the best surgical leadership role because of that, and you can really make changes. You can adjust the programs how you feel fit, you can motivate, mentor. You can help pick those people who are coming to program, all of those things. So, it's an exceptional job, and I encourage anyone who's considering leadership to take it. The things that when I reflect back, you know, we have so many great residents and I think my relationship with the residents I trained and I was a program director for, those are just such strong relationships. When our former residents are off getting jobs and doing big cases, they often call me. And we see each other at conferences, and there is a connection that you have with your program director. So, I would say that connection that I have with my former residents - Ameer, you're definitely one of those people - that to me was the best part of being a program director. Seeing those people, our residents go from, as you know, Chad, and R1, not done anything at all to being very competent and being able to upgrade independently as chiefs. That to me is by far the biggest reward. And I think that's the thing that I'll take away from my career the most. And I probably say, you know, I'm a mid-career guy right now. But I suspect at the end of my career, when I look back, the thing I’ll be most proud of is being program director, because it is a huge undertaking. It comes at a cost. But there's that reward of seeing surgeons develop and graduate that is fantastic.
Ameer Farooq 16:14
Well, at the risk of sounding super sappy, I'll just say on behalf of all your former trainees, we really appreciate all the hard work that you put into it. And I'm sure it wasn't easy, both when we complain and maybe sometimes when you push the staff a little bit too much as well, too. So, on behalf of all of your former trainees, I really appreciate it. You know, talking about trainees and thinking about, you know, your former trainees that are now working, we really wanted to get into an area of expertise for you, which is surgical workforce planning. You and Matt Strickland recently published a paper in CJS that outlines kind of the problem of surgical workforce planning. And I think anyone in Canada who's listening to this podcast, who is a surgeon, or a surgical resident knows that this is a really big issue and a timely issue. So, can you start by just telling us like, what is the scope of the problem? We all kind of I think intuitively know that it is an issue, trying to find a job for new graduates. But how big of an issue really, is it?
Neel Datta 17:20
Well, I think the first thing to say is this is a predominantly Canadian problem, because we're working within the confines of a public system where there's a limited number of resources. So, to frame the Canadian contracts, frame x number of surgeons, and we don't have the resources necessarily to support all of the people that we're training. That doesn't mean there isn't a demand for the work of the surgeons. It just means that within the confines of our public healthcare system, we don't have enough positions for those people. If you look all the way back to our initial study on this, a royal college report on unemployment, resource intensive specialties, the problem works up to about a 20 to 30% rate of unemployment. Or more likely, underemployment. So, I do think it's a big issue. I think it's more recognizable in orthopedics and general surgery where we have higher volume of trainees. I think that in other specialties, such as cardiac surgery, where there's a much smaller labor market, it's harder to predict whether that's a true problem, or purely based on resources. But I definitely think we have a problem. And I said that it's a truly Canadian problem, because it's not just a public health care system, but it's also a very small population spread over a vast geographic area, which results in an inherent challenge in delivering healthcare. So, all of those things that result in a perfect storm for us to not necessarily perfectly match our healthcare needs, to the supply that we're producing.
Ameer Farooq 19:27
But can you just explain for our listeners who may not know what those terms mean: underemployment and unemployment. What's the difference between those two terms?
Neel Datta 19:34
So unemployment is where you have no work. Period. You cannot find gainful employment to sustain your life, or your practice. Period. That's, for example, a surgeon living in an area who has no access to clinics, operating rooms, endoscopy, what have you. Underemployment is more in the Canadian context, and that's where someone is working, but they're working on a part time basis or a locum basis, and not from their own choice. And that's probably what is most common in the Canadian context right now.
Ameer Farooq 20:16
I think if I remember correctly from your paper, something like 20% of graduates felt that they were under employed. Like, it was not a small number.
Neel Datta 20:26
No, and I actually think that it's higher, depending on which area you look at. So, orthopedics, for example, I think their rates were quite a bit higher than our general surgery population. But our general surgery jobs are also you know, starting to get harder and harder to find. And so, I think that we're going to see that quite a bit. There's also pushes for people for a variety of reasons to live in certain areas. So, Toronto, for example, is place where, you know, your spouse may have a job, and you're trying to find one, and it can be quite challenging to find work. And I think that's one thing that needs to be addressed, from our perspective. We need a national approach to the workforce problem. And that is exceptionally hard in Canada, where health care is really, you know, delivered on a provincial or state basis. Right? So, having a national mandate is quite challenging for us.
Ameer Farooq 21:28
I want to come back to that in a second. Because I think that's a really important point, particularly, you know, in Canada, where we have this big geographic spread. But I want to talk and ask you a little bit and Dr. Ball as well, because you both collaborated on a number of papers that actually tried to estimate what the workforce would be. And I'm particularly I'm thinking of two papers where you look at this: for HPV and thoracic surgery. When you think about it, it's quite a complex thing to actually try to estimate how many surgeons you will need for a given specialty dealing with a certain number of patients and a certain number of problems. You know, granting that you know, technologies change and and approaches to diseases also change. But can you maybe both of you talk a little bit about how you actually go about estimating workforce planning and workforce needs.
Neel Datta 22:24
Chad and I worked on a few papers together looking at our workforce. And very generally, when you're looking at the workforce, you want to look at the demand needs. So, the healthcare demands, the prevalence of the disease. And you want to look at our supply. Now, in general surgery, that's extremely challenging, because we have a huge broad range of patient populations, we work in with a broad range of diseases. And general surgeons have a huge scope of practice, right? And quite a bit of variability. And so, Chad and I started working in thoracic surgery on this. And we have to also credit our former department head, Sean Grondin, who was really keen on answering this question, and we work very closely with our thoracic colleagues to do this. But the other reason we picked thoracic surgery to really assess the workforce is: it's a perfect specialty to build that model. And the reason is in Canada, the predominant disease they treat is lung cancer. And it's a fairly small supply group. So, when we looked at how to predict their workforce needs, we looked at those two entities. And we were quite lucky because the Canadian Thoracic Society has worked hard at trying to assess their workforce. So they had a lot of data on this. And they brought that data to us and said, "how do we figure this out to see how many fellows we should train", for example. And so, they knew how many thoracic surgeons are working in Canada, the case mix of those thoracic surgeons, the estimated age of retirement of those surgeons, and they also have a confined labor market with very minimal entry and a very high bar to entry. And they also know exactly how many cells they're hiring and exactly how many thoracic surgeons they're hiring. So, they had a closed labor market that we can use. And that really was the basis of the supply aspect of our model. And then we needed to tackle how to figure out the demand. And when we looked at the case mix, it was very clear that the overwhelming percentage of cases that our thoracic surgeons do is lung resections for lung cancer. And so, we used lung cancers that demand model. And we worked with an exceptional group of engineers to build a micro simulation model where we took the whole Canadian population, roughly 30 million people, and we built a model that had the characteristics that really resemble Canada: immigration, emigration, age, case mix, disease, case mix. And we use data from the old Canadian long form census to populate things like smoking history, and cardiac disease, for example. And we were able to build a demand model that grew over time, and predicted our Canadian population to go, you know, from 30 million people to about 45 million people. And really give us a sense of where we thought the disease prevalence of lung cancer would go. And then we could adjust our fellow inputs. So, we could say, hey, if you're training, double the number of fellows in thoracic surgery in Canada, how does that change the supply of thoracic surgeons and consequently, the operative volume of thoracic surgeons across country. So that was the first time that we really built a comprehensive supply and demand model to predict workforce issues. And then after that, as Chad knows, we started having fun with it, you know. We started putting in more policy levers to get really, you know, more nuanced understanding of how simple policy shifts can have dramatic effects on the needs of surgeons, or how many surgeons that we need to do all these cases. And the next study that we did, we looked at how an implementation of a CT screening program in high-risk individuals, so people with long smoking histories can affect the early recognition of lung cancer and consequently, the operative volume. And those types of policy changes can have a remarkable effect on, you know, the number of surgeons you need. You may need a third more thoracic surgeons, if you all of a sudden implement a screening program. So, I think that it was a really interesting opportunity for us to work on a very clear problem in the Canadian context.
Chad Ball 27:36
It seems to me that this kind of work is so deadly important, quite frankly, to prognosticating, the health of our specialty, not only at the training side, but at the financial side, which you're also an expert on the other prism. And the other filter. And I'm curious why we haven't seen more of this, either before or since your work, and where you see it going. And in particular, you know, I realized, as you sort of highlighted very superficially, quite honestly, the thoracic and HPV side of things is steady, double or even or easier to study, because it is quite narrow in terms of a lot of the factors you mentioned. But how do we apply some of these principles to greater general surgery across Canada, given the diversity and practice, the diversity and training pathways? And for sure, the diversity and geography and how folks are paid and all those elements? How do we really propagate this great work you've started?
Neel Datta 28:41
Well, it's obviously much more challenging in general surgery. But you know, how we're paid is probably one of the things that affects that, you know, fee. The majority of general surgeons are fee for service, paid across the country. And none of us, or the majority of us are not employees. We're independent practitioners. In the UK, where it's a salaried NHS system, they're way better and have much more robust data on exactly what their supply needs are for the NHS. And so, I think we're in a very challenging situation, but most people would first start out by saying, well, it's impossible to model general surgery because it's so complex. So, I don't know how to solve this, but in reality, we should just start with very robust national information databases. So, we should have readily available on a website for every general surgery resident and every staff person to look and say, "where do every general surgeon in the country work?" How many surgeons are in each of these centers? What is their breakdown of colorectal, hepatobiliary, breast, those kinds of things? And ideally, we would all give an opinion of roughly when we expect people to retire. And just having a rich, open network of data like that, I think would allow our residents to have a way better understanding of where future jobs would lie. And I think that would be an easy starting point for us to start matching our needs, to the actual national needs based on resources. So, I think that's the first thing. You know, general surgeons, we're always very...we don't want to talk about income, and how factors like that affect our ability to decide how long we're going to work and our retirement goals. But if you're an economist like me, that's a very appropriate thing for people to speak about, you know? I don't think that we should hide the fact that we all need to run businesses, we all need to have an income and pay off our student loans and support our families and have a little bit of money saved for retirement. And if that means you need to work to 65. Then I think that that's very reasonable. And we don't do a good job of, I think, being honest about those things. And that's going to take a lot of time to change. Because I think that that's a cultural thing. Do you disagree Chad?
Chad Ball 31:44
No, I think that's well said. I mean, I think we don't talk about any of this stuff very well at all. And, you know, one of my favorite podcasts was with Shane DiNapoli, who, as you know, is an accountant for many, many surgeons and set up some of the initial prof corps in the country for physicians and it's refreshing to always talk to him and listen to him, because his view is so pragmatic when it comes to money and income and planning and retirement and all the issues that you talk about that we don't talk about culturally, as you point out, in our specialty, for sure. And I think it's probably to our detriment as well. It is interesting to reflect on the other side of that, and, you know, I won't get into it. I don't think our listeners probably really care too much. But, you know, with all that's going on in Alberta right now, with regard to the government and the cutbacks and the shift in power and the legalese side of it. It's interesting, in particular, to think about, or ask the question, how many people do you think...what proportion go into their specialty, their residency, with the thoughts of income in mind? Because my initial gut reaction would have been very few. People become a cardiologist, a general surgeon, gynecologist, because they love that content more often than not. I think that percentage probably varies a little bit from specialty to specialty at the end of the day, if we're honest. But what is your sense of that? Because my belief is that it really doesn't have a significant impact up front at all.
Neel Datta 33:21
I would agree with you. In general, I don't think that income, a) should matter in our choices as physician or a surgeon. And I think that if that is a main indicator of what you want to do, then you'll probably be unhappy. You know, if you look at the behavioral economics literature, there's good literature to show us that, you know, over 70, 80, 90,000 dollars - dramatic changes in your income don't necessarily correlate with huge increases in happiness. We focus a lot on income, but the reality is, it's not how much money we make. It's what makes us happy in our lives. And so, I would say that I hope that's not the case. There are probably some specialties where people are more motivated on the business side than we have been traditionally in general surgery. But I think most people would say that general surgery is a calling. It's not a job. And when it's a calling, you worry less about the income that you have. That being said, I do worry about the mix of individuals entering our medical schools. Because if you look at you know, fairly recent data, and there's some universities such as University of Manitoba, for example, it's doing a great job at changing this but there's been a shift where the majority of our medical students entering medical schools come from fairly affluent backgrounds. And I think that is very much to do with how expensive medical school has become. And as a result, it seems quite daunting to people. And I think that over time, the student loans have gone up, the comparative income has gone down. And that puts increased stress on graduating medical students, residents, and subsequently surgeons, which I think is quite bad for our surgery group. And as a country.
Chad Ball 35:50
Yea, there's a lot of points to that we can unpack in there. You're totally right. There are some major concerns in sort of the trends and the shifts that have gone over the past decade, for sure. I want to hold your feet to the fire, maybe this is unfair, you'll hopefully tell me. I want to ask you some real short snappers here regarding this topic. The first is: in 2021, is your impression that we are training too many residents within the specialty of general surgery or not?
Neel Datta 36:18
Yes, too many.
Chad Ball 36:21
Why do you say that?
Neel Datta 36:23
The reason I say that is we have general surgeons who don't have jobs or full employment to the effect that they would want. And I also think that you know, historically would, you know, 30 years ago, when we trained five general surgeons in Calgary, a portion of those went off the cardiac, a portion of those went off to thoracics, a portion of those went off to vascular. Now, thoracic is still a delayed entry residency program. It's after you do general surgery. But cardiac surgery, for example, is not vascular surgery. It's not. And I do think that that those types of things have a huge effect. And if you look at just very rudimentary data, if you look at the Chi height data, we now have more physicians per capita than we have ever had in the history of our country. And, yes, the hours worked. And things like that may have an effect, but so does non-operative management of diseases. So, when I look at it, I do think that we are training more people than we have jobs for. And, you know, in general surgery, the majority of people who need surgery in Canada get their procedures within a reasonable amount of time. Orthopedics for example, they can probably train double the number that they have now and still have waitlists for joint replacements. That's not the case in general surgery. So, I do very much worry that we're overtraining for the number of jobs that we have. And keep in mind, Chad, that the other thing is, the whole population of surgeons and physicians is working on average, five to seven years later in life than they used to. Why? It's a great job. We're getting smarter about things like access surgery, right? And daytime ORs for access - meaning a reduction in nighttime work. And people are living longer and are healthier. So, it's very, very reasonable for someone in their mid to late 60s to continue to work as a general surgeon and not necessarily retire right at 65. So, I do worry that we're overtraining for our current resource abilities.
Chad Ball 38:54
My second question is very simply, how much are we overtraining? Like, is this a 10% problem or a 50% problem? Or something else?
Neel Datta 39:03
I don't know if we can... I don't know if we can say that easily. And I think that there's geographic differences, you know? Between Edmonton and Calgary, we train anywhere from 10 to 15 surgeons a year. And the question is, are we hiring 10 to 15 surgeons a year? No, we're not. So, I think we need to look at it a provincial basis. I think Toronto currently is training 12 residents a year. And the question is in that Greater Toronto Area and surrounding communities, are they hiring 12 residents a year? If the answer is no, then we probably should reassess that. If they're hiring 11 of 12, we're probably pretty good at, you know, producing our labor market according to needs. But if they're hiring one out of 12 people, or if we encounter your hiring, you know, one out of the five that we train traditionally, then maybe we're training too much. And I think that that's a decision that really has to be done on a provincial basis.
Chad Ball 40:14
Yeah, it's really interesting. Yeah, as you know, it's particularly, I would say, even more interesting for those of us that train fellows, you know, in these narrow subspecialties, like HPB. It's a really big deal if somebody sort of has no prospect of a job to enter a fellowship training program in North America. It makes everyone quite nervous about it. And you sort of come back to that fundamental discussion. Right? Amongst your group. Do we train people because this is what they love? And they're going to be good at it? And we want to do that? Or are we training people, you know, to a manpower resource, supply demand environment that we have to be careful of? And I think some programs clearly do that much better than others. What's the sense of that for you guys in colorectal fellowships?
Neel Datta 41:02
Well, just to make a point on what you said, I think that there's another factor that we're missing in that whole discussion about training fellows. And the thing that we're missing is, in our 2013 Royal College report on unemployment, a very high percentage of people who are going into fellowships said that they were going into fellowships because they did not have adequate job prospects. And that I think, brings another level of complexity to the issue of fellowships, because my worry there is, why is someone pursuing a colorectal surgery fellowship? Is t just a placeholder until they find the right job? Or is that something that they're passionate about? So, I think that's another factor that we need to consider and be cognizant of, you know? When it comes to colorectal surgery, we've been fairly cautious in terms of the number of people we're training, but we also have added more and more fellows. So right now, and Ameer, correct me if I'm wrong, but we train somewhere around four to seven fellows a year. And we may have 16 members of our Canadian Society of colorectal surgeons. So, within a 10-year period, we're completely, you know, doubling our population if no one retires. And obviously, there's some retirees, but I do worry that we're going to be running out of jobs for those colorectal surgeons.
Ameer Farooq 42:39
You know, we've been talking about general surgery a lot. But I am kind of curious why other specialties also don't seem to be able to plan this well. Like you look at neurosurgery, you look at cardiac surgery, where they're, you know, they're taking only one resident a year. And you know, the number of places they can work are pretty defined. It doesn't seem like they have gotten around this problem, either. It seems like neurosurgery residents also struggle a lot with finding a job. Now, this is anecdotal. I don't have any base data to back me up on this. But you know, from looking at my co residents, that seems to be an issue. Why do you think that is, even in specialties that have pretty defined numbers of residents and predefined places where they could potentially go?
Neel Datta 43:27
Well, the elephant in the room that nobody as a staff person wants to talk about is call coverage. And I unfortunately, suspect a portion of that is really that main issue. And it is very hard to adjust the number of trainees you produce or have in your program as a program director, because of that stress. And that's multifactorial, but our cases are more complex, or patients are sicker now than they ever were before. And there are huge demands for, you know, call coverage workforce. And there's no doubt that our residents provide excellent call coverage that, in many ways make the life of staff people easier. And unfortunately, I think that to a certain degree, affects our decision making in terms of the number of people we're training. And I think that that's probably hard for many of us to admit, but if I was being purely blunt with you Ameer, I think that is a big issue. Chad, do you disagree?
Chad Ball 44:42
No, I think I think there's certainly an element to that. And again, it sort of circles back to the culture of medicine and the culture of surgery, and stronger in some sub-specialties and specialties than others for sure. But as you and I know, when you can compare it to the business world and the economics world, it couldn't be starker in terms of how these issues are addressed and how they're disclosed and how they're sort of framed in general. I think you're right; our specialty has a long way to go to achieve, you know, openness and honesty about a lot of these topics you bring up.
Ameer Farooq 45:20
Well, you know, you brought up this issue about the "on-call ologists", right? You know, a lot of residents and fellows are accepting positions where they're perhaps, you know, sharing a practice. But really, the underlying unwritten kind of agreement is that they're going to be the on-call person. They're going to do all the nights for perhaps the older surgeon who retains their elective practice, and doesn't do much call and then, you know, that actually, in some ways perpetuates the problem further, where they can keep going for longer and longer. And, you know, the younger surgeon continues to not have a firm elected practice and just keeps doing on call. How do you get around that type of problem? And I'll say up front as part of ostensibly the millennial generation, perhaps we don't work as hard? Or we have a better... how should I put this. You know, we have a healthier appreciation for the work/life harmony or work/life balance. And so maybe we don't want to do as much call or don't want to, you know, do as much operating on clinic? I don't know that there's actually data for that. But certainly, there's an impression about that. So how do you kind of reconcile those two issues when we're thinking about matching workforce to job requirements?
Neel Datta 46:44
Oh, I find that issue of having our recent grads doing locums a real challenging thing. Or being an oncologist quote, unquote, on call. And I think that it's bad for the profession. And I think it's bad for patient care. And I think that it results in multiple factors that affect our decision making, which isn't good. So, to give you an example, Chad, when you finished your hepatobiliary fellowship, say you had family or for whatever reason you move to Toronto, couldn't find work. So, you started picking up a call. And for about a two-year period, you worked doing general surgery call, appendixes and gallbladders. And you know, emergency hernia surgery, and two years later, you get a job in Calgary as a hepatobiliary surgeon. You come, and there's all of a sudden, all these referrals for Whipple’s and major liver resections coming your way. Question is, after two years of doing locum work, has that eroded your skills that you gained from a phenomenal HPB fellowship? It probably has. And so, I think that from a pure patient care perspective, that definitely affects you know, how we are as surgeons, and we have to be very cognizant of that. And, you know, I know for me if I had finished my colorectal surgery fellowship, and then not done a laparoscopic poach or a low anterior resection for two years, and then all sudden went back to it, that would have probably eroded my technical skills to a certain degree. And I think that that's bad for patient care. And it's something that we as a national group have kind of ignored. So, I think that that's one problem. The other problem is, you know, with underemployment, with huge student debt, with people having young families, there's huge financial pressures on those individuals that are locuming or just doing weekend call coverage. And I think that many of us are very altruistic and always have patient care in mind. But I think that when you have huge amount of pressures like that, you may be more likely to operate on a patient with appendicitis or diverticulitis or you know, maybe something that could be managed, potentially non-operatively. And so, I worry about other factors that affect our patient decision making. Because we are all human and we have many stresses that affect ourselves, our practices and our lives. And so, I personally have an issue with how we're dealing with the locum thing. And, you know, I would like us to again have a much better national approach or even on a provincial level, you know, here in Alberta, we have a provincial rural locum program. But if we could build that to be a more structured program with salary support versus fee for service care, you may be able to have kind of better decision making, we may be able to incorporate having some of these recent grads do more assisting and continue to develop their skills until we can find the perfect job for them. So, the issue with the on call surgeons is one that I think that we're ignoring as a Canadian society, and one that we really, really need to address. I think it's one of the most pressing issues that we have right now.
Chad Ball 50:44
Yeah, those are some great comments, Neel. You know, to your point, I think the more technically demanding a subspecialty becomes, the absolutely more true that is.. I mean, there's no way you could do a liver transplantation, HPB, a lot of the high-end MIS colorectal work you're talking about in the pelvis without doing it consistently. And you worry that people don't ever get that critical number of cases to be efficient and fast and coherent and together in the operating room. It's a huge concern. Having said that, there is certainly a signal, a cohort of graduates who want nothing to do with any of these traditional practice models, and really do want to be oncologists or whatever the term is that you would like. They go into large pools that cover emergency general surgery, call it multiple hospitals and essentially become surgical hospitalists for lack of a better term. And, you know, that could be a great practice if it's done with enough frequency and enough variability as well. But you're right, when it comes to, you know, high end fellowships, it's, you know, I personally think it's a shame to train folks that we can't place. It's a real disservice to them. Not out any particular specialty, but I would argue that nationally, ophthalmology has probably the largest challenge with that, in that regard. I mean, there's a third of Ophthalmology trained, fellowship exam completed folks in a number of cities in this country that do not have operating room privileges. And when one of those jobs pops up, three and five and seven years into a non-operative practice in that city and all those people apply. Even doing something like a cataract quite honestly, the technology has changed so much in the last five years as an example. It's really hard to get going again, so I don't know. I feel bad for a lot of this poor planning and the impact it's had on folks who have probably start altruistically doing a thing that they love.
Neel Datta 52:53
Yeah, absolutely. Chad, I think that, you know, you hit the nail on the head with ophthalmology. And, you know, I think EMT is another example. Many of their recent grads have essentially non-operative clinic practices. And the question is, is that what they... In a perfect world, is that what they desired to do? And were we, as people who educated these individuals, you know, did we give them the right education in terms of where they'll have jobs? To make that decision? When they were medical students, did we say to them, hey, these are, you know, three, four or five years from now, where jobs are going to be coming up. And the type of case mix that those jobs would have. And you should kind of plan accordingly if you're interested. That would be the ideal situation. We're definitely not doing this.
Chad Ball 53:47
Yeah, exactly. I'm curious, do you get a sense, or have a sense of the rural versus urban divide? I mean, you talked a little bit about, you know, preference or family pressure to be in city X or city y. But is there a problem in what's I guess commonly referred to as community general surgery practices versus urban? Like there is in say, gastroenterology? Or is that really not the case within General Surgery across the country?
Neel Datta 54:17
Well, I actually think that's a problem across the board in specialties, in general, and the real question you have to ask, it goes back to that question of socio-economic status of people coming into medical schools, and also the case mix, or where people come from when they're going into medical schools. And they'll be the number one predictor of a physician who will work in a rural setting is if they grew up in a rural setting. And the majority of our medical students don't grow up in rural settings. They're, in fact growing up in urban settings. And so, if you grew up in Calgary or downtown Vancouver, it's unlikely that as a staff surgeon, you're going to want to move back to a rural setting, even if it would be a very fulfilling job. Right? So, I think that if we want to address the problem of there being a paucity of physicians in certain rural areas, and an oversupply in major urban centers, it's already at a lot. We're already behind the eight ball when they're coming into general surgery training. Rather, we need to fix that mix of people coming into medical school. And so, we really need to push more rural incentivization into medical school, if we want to meet those patient needs for the rural population.
Ameer Farooq 55:47
I mean, that's a whole podcast in and of itself, you know? The whole medical school, kind of selection piece of things. But certainly, there needs to be something where we can better match and get underserviced populations better care as well. And whether that's at the medical school level, or figuring out ways to make it more, you know, attractive or easier for people to go to rural locations. I'm not sure. But certainly, there's a lot of work still to be done. You know, as if there weren't enough challenging things about this whole situation. Now we have COVID to throw in the mix. How do you think COVID is going to affect all this workforce planning and job planning? And how do you think that's gonna impact jobs going forward? Do you think this is gonna, you know, force people to stay on longer as the fact that they've had this interruption, potentially, in their elected practice? And they kind of have to catch up? Or do you think this is gonna incentivize some people to get out?
Neel Datta 56:46
That's a great question, Ameer. So, I think in the short term, COVID, has dramatically affected the ability of our most recent graduates to get jobs, because, you know, across North America, there's less hiring going on. And I'm hoping that that'll be a short-term phenomenon. And you know, the longer that COVID persists, there'll be more people who will be looking for jobs. And I think that'll change how COVID has affected, you know, surgeons and their opinions of what's important in their life and how much they need to work. I think that that's two things. I guess there's the financial question. And there's the, you know, wellness aspect of it. When, a few years back, we hosted an employment seminar at our Canadian Surgical Forum, and one of the panelists that we had, and I think, Chad, I think you were there for this, but one of the panelists that we had was Tony Gomes, right? One of our great Lethbridge surgeons, very well known, very involved in our provincial and national committees. And he gave a great perspective, because one of our audience members posed the question, well, you know, in 2008, we had a huge drop in stock market. So obviously, a lot of senior surgeons will have to work for years more to make up for that loss in expected retirement income. And Tony Gomes, I remember, said, you know, everybody remembers the loss in the stock market in 2008. And everybody talks about that. But everybody ignores the multiple subsequent years of record highs in the stock market. And so, yeah, there may have been some changes in income over this COVID period of time, but will that really affect the ability for surgeons to retire and for jobs to open up? It really shouldn't. The other question to that is the whole wellness aspect of it. And, you know, for my wife and I, we have two young kids, we have a very busy life, our life slowed down a little bit in terms of all the extra curricular things that we used to do. But it gave us some pause to realize, you know, what's important, and our nuclear family is spending more time now together than we ever have. We're exercising more together than we did before. We're having a lot of fun together doing simple things at home that we, you know, for years didn't do. We were playing board games, playing card games, where, you know, you're really recognizing that there was some aspects to our life that were too busy. So, I think that there'll be a portion of surgeons who recognize how much they want to work or evaluate it. Some may decide they want to work more. But I think there'll be some people who will decide that they want to have, you know, more time to pursue other interests in their lives that are just as rewarding. So, I think that only time will tell how this will affect the job situation across Canada. But that thought that this'll make jobs even harder for the next three, four or five years. I don't think that'll be the case. I think that it's really the supply and demand issues that will be more affecting the number of jobs that pop up across Canada.
Chad Ball 1:00:45
I want to conclude in sort of two quick areas if that's okay. The first is that we will be doing everyone a disservice if we didn't talk about how well rounded a guy you are, and particularly focus on your interaction and your involvement with a restaurant you co-own. I want you - and try not to be humble - to tell our listeners about that venture, why you became interested in it, the story of it, which I think is fascinating, and maybe how it's going and how you how you managed to be involved in that.
Neel Datta 1:01:21
Thanks, Chad. So I think what I'd love to say to your listeners is, you know, surgery can be all consuming and overwhelming. And we love it, right. That's why it's so addictive. We always love to operate. And it can take up 24 hours of a day, easily. But spending some of your time to expand on other pursuits. And putting some money behind it. And enjoying the ride is something that I would encourage more and more people to do. I love entrepreneurial pursuits and you know, fiddled around with little things for years. But we were very lucky to be able to partner and start a small restaurant, which is called Calcutta Cricket Club. For anyone who's in Calgary, we'd love to have you after COVID to come and you know, enjoy a night at our restaurant. And I really have to thank my cousin Shovick. This was his brainchild. And ever since we were little kids, he's wanted to have a restaurant. That's really an homage to our parents who were immigrants from the Calcutta area. And you know, our parents immigrated to Canada at a very interesting time. They moved in the 70s, when India was going through a lot of shifts. So, they moved to Canada, to smaller areas in Canada. So cold, not as many people and a little barren. And they left a dramatically changing subcontinent in India; one where there was way more women entering the workforce, there was more people going out and experiencing this great culture. And Calcutta is a very unique place because it was of course, the capital of India during the colonial period. So, there's all this colonial infrastructure there. And when the Brits left at partition, a lot of that colonial infrastructure came into the hands of Indians, and it was kind of changed and the Indian culture groomed these previous British establishments. So, for example, my grandfather was a member of the Calcutta Lake Club, which is a very historic Asian Rowing Club. And when we used to go and visit in India on our summer vacations, you know, our evenings would be a dinner at the lake club. And our parents would be walking around having gin and tonics. It was really a social club. So, our restaurant in Calgary was really a thank you and an homage to our parents. And our goal was to create a social club that is welcoming. You come you have some drinks, and it really brings that unique Calcutta, Indian cuisine to you. And I think that we've done a great job with it. And I'll say it's one of the most beneficial experiences I've had outside of medicine. And there's a few reasons for that. Number one: it's extremely creative. So, you know, when we were designing the logos, and I got to witness that and see our menu come to life, and our drink menu. It's a great creative endeavor. So just being part of that opens your mind. The fact that we employ, you know, many Calgarians, that teaches you a lot about business, it teaches you about communication. And it's a great thing to put back into a community that I love. I'm a very proud Calgarian as you know, and to be part of the community that way is very... it's fantastic for our family. And you know, what people don't know is, with the absence of HIPAA and other compliance issues and things like that, you can get data in restaurants that you know, that you may not get in surgery. So, we know what dishes are popular, what's not, we know what's reordered, we know how many people are coming through our restaurant on a given night. And when I look at that, and this is all app based, like I don't have that kind of data in my clinic, to be able to measure the workflow in our clinic to optimize, you know, how many patients I see, for example. So, it's been an extremely rewarding experience, I think, for my parents who were immigrants to this country to be able to come and have a great meal at our restaurant. And you know, we have a back wall at a restaurant that has all of our, you know, family photos. My grandfather's med school graduation photos on the wall, for example. That's definitely a source of pride for our family to be here and to be able to do that here in Calgary. And I have to thank all of our main partners: Cody and Shovick. They're the ones who really run everything and my wife, Sheila and I, we really feel very appreciative to have just been able to be there for the ride and experience it and I would encourage all the surgeons out there listening and residents to find another passion along with surgery. And explore that passion and build on that. And I think that you'll find it very rewarding.
Chad Ball 1:07:17
I think that's well said. That's such a great story. It's such a great restaurant, I echo everybody should go check it out. You know, it's interesting that you highlight that you can get more data from your restaurant sort of process than you can in your healthcare working process. And it just, it reminds me I've been I've been telling other residents now for about a year here in Calgary to watch the Formula One series on Netflix called "Drive to Survive". And when they're watching it, in addition to how beautifully it's filmed, ask yourself the question: "And when you look at what I think is the ultimate team environment, how does that sort of parlay or how is it compared to what we do in surgery from a teamwork, from a leadership, from a data point of view?" And I think, you know, as you've insinuated, there's a lot of fields like these that crush us in healthcare that we can learn from. The last thing we want to ask you, you know, Ameer and I try to hit everybody up on the way out is, it's very simple, but I think it shows us a lot about our guests. If you could go back and give yourself advice as a trainee, what advice would that be, and I'm particularly interested, maybe as a second part, would any of that advice have to do with your economics background, unemployment issues, feeding into that thought process? Or maybe not so much?
Neel Datta 1:08:46
I don't know if you felt this way, Chad, but in my fifth year, there was a couple things I noted. So, when I was studying for my exams in fifth year, I would have these revelations. I'd sit there in fifth year, and learn something, and I'd think to myself, how could I have not known this for five years? And wow, that would have made so many other things so much more understandable. And I'd say to myself, I can't believe someone didn't teach me this. But in reality, probably that was my issue. And I should have been reading more as a junior. And so, I think that is a simple thing. I could say that. But the other thing that I noticed as a chief resident was definitely in those last six months of my residency, I became very nostalgic about operating with many of my mentors because I realized that would probably be the last time, I was operating with some of these people who really trained and built me into a surgeon and have helped me so much. Now I became quite nostalgic. And I think that, you know at that time I realized, you know, if I was to do it again, I'd probably take a little bit more time to enjoy those first four years. You know, you're often bogged down with the hours and the effort and things like that. But you really need to enjoy the moments of residency because I know our cohort of residents who train together, we really look at those five years in a very nostalgic fashion. And I think I would have taken more moments to enjoy myself and those periods of time while I was operating with some of my mentors. So, I think that would be definitely something that I'd say to a younger Neel Datta. From an economics perspective, you know, I really got a better understanding over time of behavioral economics: those things that make you happy. And, you know, there's personal and there's professional things that make you happy. And Chad, you and I have spoken a lot about this. But, you know, I think that part of intrinsic happiness and motivation...I think Dan Pink is very correct, that purpose, autonomy and mastery are very important in that. And I think that we have so much purpose as surgeons, and we have some autonomy but sometimes we lose that. And we need to focus on mastery. So those are the things I think that make you really happy in your practice. You know, when you have just a laparoscopic anterior resection that goes just perfectly. You know, they end, and you aim and strive for that mastery. And so, I'd tell my younger Neel Datta not to worry as much about student loans or getting enough cases in or things like that, but really focus on mastering those things very early on. And I think that will make all surgeons happier.
Ameer Farooq 1:12:13
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.