E64 Ahmer Karimuddin On The "Struggling" Trainee, CaRMS, & Resident Selection

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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  01:12

One of the most challenging scenarios for mentors and mentees alike is the struggling trainee. A trainee doesn't know what to do. A lot of faculty also find it a challenge to know what to do or say to help a trainee get back on track. So for this episode, we enlisted the help of Dr. Ahmer Karimuddin, to talk about the topic of the struggling trainee. Dr. Karimuddin is a colorectal surgeon at St. Paul's Hospital in Vancouver, British Columbia. Along with Dr. Tracy Scott, Dr. Karimuddin is the co-program director for the UBC General Surgery Program. We talked to him about how to approach a struggling trainee, as well as some of the innovative strategies the UBC program is utilizing to more objectively select residents. As always, we would love to hear your feedback at [email protected], or on Twitter @CanJSurg. It's truly an honor, particularly for me as your fellow, to have you on the show. Can you tell us a little bit about where you grew up and where you did your training?

Ahmer Karimuddin  02:08

I think I can't start without actually acknowledging that your radio voice or podcast voice is pretty on the ball, compared to your regular voice. That's pretty impressive, Dr. Farooq. So I grew up in Mississauga in Toronto, just outside Toronto, and did my medical school at Western, where you know, it's the home of general surgeons, something like 10 to 15% of the class actually applies to general surgery programs. So I think my fate was sealed when I actually got into medical school at Western to be honest. Brian Taylor, who was the Chief of Surgery at Western University Hospital in London at that time, was one of my very first mentors. He's a colorectal surgeon. And, in fact, he's the one who, when I decided I wanted to do general surgery, he's the one who helped me find my electives across the country because electives had been filled out by that time. So I really owe a lot of what unfolded after that to Dr. Brian Taylor. I ended up in Saskatchewan for my general surgery training where you know, I was trained by a prior editor of the Canadian Journal of surgery, Dr. Roger Keith, who was also the president of CAGs, as well. And then I did my colorectal surgery in Toronto, where, you know, you interviewed Helen McRae recently and Marcus Bernstein as well, who were both my mentors, along with that Nancy Baxter, Robin McLeod, Zane Cohen, all spectacular people who've helped shape me to the surgeon that I am today.

Chad Ball  03:39

It's funny how many people talk about having a mentor, that really just saw something in them and took an interest in their life what they were doing. And you certainly seem to have found that in Brian Taylor. Do you have a sense of why he sort of, I mean, this is always an interesting question to question to ask a trainee. But do you get a sense of what it was that he saw in you? Or why he took such an interest in you and arrange your electives and all those kinds of things?

Ahmer Karimuddin  04:11

To be honest, I don't really think it had anything to do with me. I think it had to do with the fact that he was the type of person who, when someone went to them, saw that person as a true human being and did whatever he could to help them in that moment. And I think that's what I would...the people who have been my mentors. I saw this in action too, that it wasn't just me, it wasn't me who showed up or someone else went and spoke to them, they would actually still go ahead and do their best to help them in every context. And that's what I, to be honest, I've taken away from those interactions, whether it's Brian Taylor or Zane Cohen or Roger Keith, if you went to them as a student or as a colleague or as a resident and asked them for help, they would do whatever wherever it was in their power to be able to help you. Because they saw you as the human being sitting across from them who was coming and asking for something that was theirs to give, and that's something that they could do. And so I don't think Dr. Taylor saw anything special or unique in me. If he did, that's pretty awesome. Because I don't think I saw it in myself back then. But what he did see was someone who came to him for help, and he did not turn me away.

Chad Ball  05:24

As usual, you're probably being too humble and too kind, as always. You did your masters while you were a resident, and then after fellowship, you went on to be a community general surgeon in Victoria. You and I have talked about this a fair amount in terms of how important that experience was to you and your formation. Can you talk a little bit about why, you know, those few years that you spent as a surgeon in Victoria, were so important to you, and how that perhaps shaped your career going forward?

Ahmer Karimuddin  05:54

So you know, one of the funny things about Victoria, was that prior to me actually going to work in Victoria, I had only been to Victoria, for a CSF. Like, I'd never actually gone to Victoria on its own. And there, I showed up to work because when I finished my fellowship, that was really the only place that was looking for a colorectal surgeon for work around the country, which is, you know, very similar to what the market is like these days. And what was unique about Victoria at the time, was that it's a large tertiary services location, where everything gets done locally and nothing gets sent away, except for transplantation. All the surgeons there had subspecialty training, but a doctor, Allen Hayashi, was one of the Edmonton style master surgeons, he was a pediatric surgeon, but was also Chair of the provincial breast surgery program and that's probably one of the most high volume endocrine practices in the country between adrenals and thyroids and parathyroids. Like a true master surgeon. And he had a rule in Victoria when he was a division head, it was that even though you may be a colorectal surgeon or an HPB surgeon or whatever, but on call, you have to tackle everything, and you couldn't hand stuff off. And so that really, in my four years that I was in Victoria taught me to be able to, how to handle difficult situations, how to stay out of trouble. And if you get into trouble, how to get out? You know, asking for help was really important, because you needed to know when you needed help, and your colleagues are all busy, and you have to, you know, you got to make sure you really needed them. And along with that most of your work was a GP Assist, sometimes are exceptional. You know, this is a shout out to Dr. Ted Pereira, who was my GP Assist for many years, who in Victoria, who was spectacular, but some who weren't that good. And you have to be able to direct them and interact with those. And so by the time I started having residents join me my clinical work, which is about two years into practice, I really felt that, you know, that I could help them solve their way through cases and direct them in a way that may actually prepare them better for independent practice. And I think that's been helpful. For me specifically.

Ameer Farooq  08:07

It certainly is a different pace than perhaps what is sometimes found in more academic centers that have a lot of residents.

Ahmer Karimuddin  08:16

Oh yeah. I mean, talking about the pace. William Orrom, who is the senior colorectal surgeon there in Victoria at the time. In his list, I would start at 7:50 and finish at 3:30. He would do like a low anterior resection, an APR and a right hemicolectomy and still be done by around 2:30 or 2:45.

Chad Ball  08:34

It's almost unbelievable, how fast some of these very experienced surgeons, with the right conditions, of course, they could just be unbelievably fast. What was it then that sort of ultimately made you come from that very high paced, highly clinical role in Victoria? And over to St. Paul's in a more academic setting?

Ahmer Karimuddin  08:56

This was one of the most, I think, difficult decisions I ever had to make, about three and a half years into my time in Victoria. My future colleagues, Carl Brown and Manoj Raval offered me the chance to come and join them here in Vancouver. For me, the draw from the non clinical side was the area around postgraduate medical education. Victoria has a thriving distributed medical education site where we have medical students who would work their way through and I spent a lot of time with them. However, my first love was always postgraduate medical education and I always wanted to have more meaningful and direct interactions with residents and that wasn't going to be possible in the long run in Victoria for me. So having the opportunity to come to Vancouver to build a fellowship program to engage in, coronary colorectal surgery was something that would only be possible in Vancouver and you know, when you see the caliber of my partners like Carl Brown, Manoj Raval, Terry Phang, it becomes obvious why I would want to move because they're just all such exceptional and welcoming people. You know, I left a, you know, a practice in Victoria that was quite busy and moved to a new practice in Vancouver. And to be honest, I didn't miss a beat because they supported me so well in that early phase. And since then, you know, I have to be honest, I miss the people in Victoria but from a clinical practice perspective, I haven't looked back because things have been so good for me with this group specifically.

Chad Ball  10:22

One of the things we wanted to ask you a little bit about, was your role as the co-program director at UBC? Was that something that you always saw yourself doing?  Or how did you sort of come into that role? How did you end up there?

Ahmer Karimuddin  10:35

I'll be honest, I can't explain why from the day in residency that I realized I wanted to do more than just clinical surgery. I knew I wanted to be a program director. And when people ask me about that, because you know, it's always one of the things I think about. The big reason for me is that it kind of feels like a safe and almost an altruistic position to come from. I mean, you know, for your faculty, you're the person who's trying to make the residency or training experience better, it doesn't benefit you in any meaningful way, specifically, because as a program director, right, it's not like, you know, you're getting paid anymore, or you're going to get any plaudits or awards, or the program or the training experiences better. But it's, so you're coming from a fairly wholesome and safe space. And for the individual residents, what you're trying to do is help them be better to do better and to succeed. And from that perspective, it's I feel that it's a very safe space for me to be in because I'm always advocating for something that's easy to advocate for. And for me, specifically, the idea of being a co-director was really important because I think surgical residency is amazingly complicated. It's becoming more and more diverse, both in training sites, both in the type of training and the type of training residency, and also the type of trainees and faculty members we have. So having someone like Dr. Tracey Scott, who's my partner in this, to work on this, in tandem, I think has been a real value, because we see the world in slightly different ways. And that's slightly different always seems to bring the whole world in to focus a little bit better.

Chad Ball  11:58

And I think that's beautifully stated. It makes complete sense to me, you know, you've sort of described I think, piece by piece, how you view the role of program director, but I'm curious, you know, broadly, maybe two questions. Has it been the sort of experience that you that you thought it would be? And I'm curious what sort of particular changes you and Dr. Scott have implemented recently at the in the UBC program? Because certainly the residents and the particularly applicants across the country, really see it as a leadership type program.

Ahmer Karimuddin  12:36

Thanks for that, Chad. You know, in this upcoming CaRMS year where we haven't been able to have electives and stuff, we're all very nervous about how people perceive us because we haven't had a chance to show them what our culture and what our day to day lives are like. I think for both Tracy and I, it was really important to build a program that felt home in the 2020s. You know, many people when they think about medical education or surgical practice, or surgery, they like to think back to the good old days, you know, which were neither as good or as old as we'd like to think that they are. But you always reflect back to some kind of glorious past where things were better, and residents are better and certain experiences are better. But the trouble is that you know, in 2020, our world, both in surgery and around us has been rapidly changing. And modern surgery, I was chatting to someone like in your practice you reflect everyday is so frighteningly chaotic and complex. This is not in a bad way. But when specifically in a way where it's just really hard to do things in a predictable way. You know, and quality improvement. People like to talk about these PDSA cycles, right? Like plan, do, study, act. But in surgery, and in our worlds, as you know, surgical leaders and administrators, we're often dealing with things that are unstable. And so you have to do something and then respond to that and almost be reactive, as opposed to being truly proactive. And what Tracy and I kind of in our conversations really have realized is that for us, the only thing that we can actually be proactive about is about our principles. And we spent a lot of time going over these and sharing them with our residents and our faculty, which was that we really had to treat everyone, which included residents and faculty, as human beings. Because at the end of the day, that's what we all really are. We're all human beings, who are trying to figure out how to get through this complex, chaotic world, who have now committed to being excellent surgeons as faculty and training excellent surgeons as residents. And so that in itself is kind of the principles where we come from that let us do a number of innovative things around the province, which I think has been quite helpful. You know, we're a distributed program of something like I think 35 different sites across BC. So you know, for example, I'll give you a simple example, we took our academic half days, which were always a challenge because residents wouldn't show up. They will always find something more important to do and we would go just from taking attendance to doing all kinds of things to make sure that they would arrive. And finally, like, why aren't they coming? And the issue was that they felt that we were pulling them away from more fun surgery. And you know, Chad, you can reflect on this as a resident from your account as well. I mean, half day was never as fun as being in the ER, especially as a senior resident. And so what we decided to do was that we said, okay, well, if that's the case, we're going to deliver a lot of educational content online through the American College of Surgeons score curriculum, which is phenomenal. And we actually got that idea from Tony McLean in Calgary, who had bought that for the residents in Calgary. But then what we did was, we actually decided that every three months, we were going to have a full day symposium that was not going to be just for our senior residents, but it was also going to for all of our provincial faculty. So our senior residents would come and learn with the provincial surgeons, because if it was relevant to you, Chad Ball, as a practicing surgeon, how could it not be relevant to me as a resident? And you were actually there for the very first one that we did, which was the acute care surgery module. We were lucky enough to have you come and join us as a visiting professor. And as you saw, we had 30 residents. But we also had 35 faculty members who were there. And what each of the residents said was, I didn't think I could leave the room because there was Dr. Sampath, who's the Chief of Surgery in Richmond, who was there the entire time. And there was, you know, Dr. Ball was out there and heard it the entire time. And since that time, over the last three years, we've had, I think, now 12 of those symposiums. Attendance has been 100%. You had over 30 faculty in each of those sites, which is preserved and recorded, and through Zoom. And that really has been quite novel. So that really came from an idea that we're going to treat our residents as humans. That, you know, well, let's find out what's valuable to them, why aren't they coming? And instead of trying to tell them what to do, let's work with them to make a better structure for them.

Chad Ball  16:51

I love that concept of adhering to principles as opposed to just you know, like, a certain rigid structure for the program or a certain particular format for the program. And one thing I wanted to pick up on, you know, you made it seem like, oh, this is so easy, you know, this is something I love, I just advocate on behalf of the residents. And this is great. And you know, you made it sound so easy. But one of the chief residents, and I had this conversation when we were in fifth year, and I said to him, you know, if anyone offered me the chance to be the program director, I don't know if I would take it. Not that I think someone would offer me that, just to be clear, but it's such a difficult role, because you get it from both the residents, you know, if the residents don't like what's happening, they give it to you. And then the faculty, if there's changes that you make that force them to make a different change to the way they practice, they don't like it either. So how do you kind of reconcile those competing forces or those competing kind of interests?

Ahmer Karimuddin  17:53

So a lot of conversations, and I think it's also really important for people to realize where you're coming from, and what your perspective, because I think what people react to, which I think applies in many different ways in our lives is when we, when you tell people what to do, and they can really understand the principle behind what you're coming from there, they'll react and push back. But if you talk about the principle and why you're doing what you're doing, and what's driving this change, they may be unhappy about your decision. But they can't argue with the principle because principle is something that I think we all agree on. So whether it's the competency by a competency based medical education model that are all colleges laid out, or whether it says whether it's that you know what, talking to a resident this way, or changing the rotation schedule, the last minute, isn't the approach isn't the human or the nice thing to do. That helps, I think contextualize many of those conversations. So you know, for example, when Tracy and I took on this role, we actually, you know, I told you earlier, we have almost 40 distributed sites Well, before we actually physically went to each of these sites, we went to Cranbrook went to Prince George went to camp river went to every location around the province our residents go, there was a big time commitment. But we went everywhere and told them what our principles were, that we were going to treat the residents and faculty as human beings, we were going to be committed training excellent surgeons, we wanted residents have ownership of their learning experiences. And we made sure that we spoke to this repeatedly to the residents. And then these are principles that we held ourselves accountable to in the first six months to a year or so as we went forward. And and now I think now that we're kind almost like three years into the process and gone through a Royal College accreditation process. Everybody knows what these principles are. And so when we have debates and conversations and disagreements about something, we always pull back to these kinds of founding principles and say, Okay, well, this is the response, I'll align with these principles. And if it does, then we're going to try it and if it doesn't work, you can tell me that I'm wrong. But then then we'll try and find other solution. But it's the principles that you have to align yourself with and I think you then I think it's harder for people to come at you from all sides, you know?

Chad Ball  20:01

That's an amazing story. I did, of course, realize the that you two had had done that, you know, that kind of effort that all branch to these sites, I can only imagine how much that that meant. That's, that's absolutely marvelous. I also know the whole country is talking about, you know, your quarterly structure in terms of a full day educational event for the residents that has been taught from all around the province as well. And so Congrats, congrats on that. You know, one of the interesting things and I know more, I would be okay with me telling you this is that before he gave it a go as, as a program director, you UBC he was very unsure, sort of because of what Amir had said, just, you know, as we all know, more does a lot of different things and was worried about it the time commitment. But you know, what, one of the things that I when he and I talked about it before I took that role that I thought was potentially really, really good for him because he is so good at it is to is to interact with and and try and help the struggling trainee. So clearly that reputation follows you as well. And I'm curious how how you determine who's struggling, and how you frame that that scenario, and in particular, that initial interaction with that individual.

Ahmer Karimuddin  21:17

So I think it's a fair and I think it's important for me to say this, that we have to make sure as we talk about this, we don't make struggling or having difficulty, or any of the synonyms that people might want to use as some kind of a negative word. I think, you know, Chad, you and I have a residence together, you know, at the same time in different programs. But as you have when you think back to that time, we you know, we struggle, you know, we struggled a lot as we went and worked our way through residency, and the only way in time, you know, when Pete when you look back at your success and achievement, if you sometimes you gloss over the struggle, but the only way you become the person that you are the senior leader, like you are Chad is through struggling and pushing yourself. And part of the human experience of training is there always has to be struggle, we spent a lot of time talking to our residents about this idea that in surgical residency, you have to spend time in what's called a zone of proximal development. This is an educational and psychological term that people use a lot. But the idea simply is is that you will only learn when you're outside your comfort zone. And the tasks you have to do are just outside just outside your intellectual, clinical and technical abilities as a surgeon. So that idea of residency being a struggle is critically important. And one of the things that I say to my trainees, and I and I learned this from Tracy is that, you know is that if you spent a day where you didn't enter the zone of proximal development for a resident, that's a wasted day. And most of our residents are pretty good at this because you know, they're resilient, they're strong and passionate about their work and they want to be pushed. But but the residents are truly struggling and having trouble usually gets brought to our attention our programming kind of three ways. The first and to be honest, the least often taken path is that a resident comes to us directly and says, you know, I'm struggling with something, it could be, you know, managing juniors on call, it could be rounding on the ward, it could be laparoscopic surgery. It could be anything. But what it does happen in a resident comes to us directly and raises this issue. That actually is probably one of the most amazingly productive and critically important encounter as a program director, that that happens to you as a mentor. And as a faculty lead, I really want to encourage you to own that moment. Because the resident in that moment is making themselves vulnerable and trusting you and hoping that you have a solution that they can find for their problem. So that I think is really important. The other part though, the track that occurs is when a faculty member reaches out to us as a program director and says, You know what, Chad, I'm having trouble with Ahmer because he's not doing this well, or he's not he's having difficulty with this. And, again, I would say as a program director or as even as a division head or any leadership position is an important moment, because a faculty member is now displaying concern for a resident, but it's also reaching out for help and figure out how to guide the training helps them find their path through. So as a program director and as a leader, it's really important that you make time for these kinds of conversations. Because as a program director, you can provide perspective of the faculty member and of the resident and to help figure out why someone is struggling. The final pathway, which tends to be the most challenging one, to be honest when something randomly shows up on an evaluation. So in our program, Tracy and I review all the resident evaluations kind of on an ongoing basis. Then we have a competency promotions and remediation committee that's composed of nine surgeons and a senior resident who go over these evaluations on a six monthly basis as well. And so sometimes we'll pick up something Wait a second, they here they said that Chad's been having a really tough time generating differential diagnoses with acute care surgery. cases, how come this didn't get picked up or no one brought this to our attention. And then that is a vendor playing catch up because you've fallen behind. So in our program, we rely on that competency promotion mediation committee to actually be our last level filter. And along with that, we ask the residents to keep a dashboard and a tracker form that helps us kind of keep track of these things, and helps us contextualize evaluations. But those are kind of the three ways that we find out or determine that a resident is struggling.

Chad Ball  25:31

I find it so interesting, first of all, that you picked apart the term struggling because I think you're right that we don't meet him, you know, we don't always think about it like that. But actually, the process of you having trouble, or the process of you trying to grow is not an easy one, and is often quite painful. And the other thing is that, you know, one of the things that I've observed is that it actually takes a lot of courage, both from a faculty perspective, and a trainee perspective to acknowledge that there's something going wrong, like, you know, it would be much easier for faculty members to actually just kind of almost sweep it under the rug, or just sort of allow that person to pass a rotation because in some ways, it's very difficult to actually it's very difficult to feel someone you know, to be to be blunt. And so I'm curious how you make it possible for trainees and faculty alike, like how do you create a culture where you don't have that sort of negative stereotype around identifying issues and identifying problems? And and bringing that to attention?

Ahmer Karimuddin  26:42

So I think first we need to just acknowledge the fact that we're surgeons, and Chad will agree with this, I would challenge you to find me a surgeon who didn't think badly of themselves when they had a negative encounter happen, or they had a negative complication. So as surgeons, we always have a hard time with difficult views. And so we shouldn't expect our trainees to be any different than that, right? There's a lot of I think, stress and blame, even to ourselves, when something bad happens. But one of the things that helps us is that, you know, when I have an anastomotic leak, and I'm feeling really crappy, one of the first things one of my colleagues or someone would say is, well, you know, for these low rectal cancers, there's a 10% anastomotic leak rate, and our rate on this is like five ish. So you're okay. Right? So that's kind of, you know, you try to contextualize it. Well, you know, if you look at any of the HR literature for people in law, or accounting, or senior management in large corporations, there's about a 10 to 15% attrition rate and about a 15 to 20%, or even higher, sometimes, bad kind of quarterly evaluations, which I think, is kind of surprising when we think about that. But it's probably reflective of the real world. Because if you think about it, there's that Murphy's Law, or some kind of law that people talk about, right? Where they say that you get promoted until the level of your incompetence. So there's a funny way of looking at it. But there's also actually a real way, in that you actually keep progressing until you struggle. And until you reach a spot where your skill set isn't going to be sufficient. And so we shouldn't expect our residents to be any different than that. And I think that's really important for a program and for faculty, and for residents to understand. That even though all of our faculty, even though all our residents are amazingly bright and talented individuals, they're going to reach a point where they are going to struggle. And that's an important thing for all of us to keep talking about and acknowledging. And along with that, it may be the fact that for some of these people who are in the world of general surgery, it may not be their long term home, you know? We've got a system with CaRMS and everything else makes it really hard for people to get a real experience of what it's like. So, you know, in the US, there's like an 8 to 10% attrition rate. And I think the Canadian rate is the same for all residency programs. And surgery is no higher than that. So you know, there is going to be that space where there's going to be a group of people who are going to struggle, and we have to accept that and acknowledge that's normal.

Chad Ball  29:09

Well, it's so hard because, you know, most people, by the time they get to the residency point have actually never, I shouldn't say never had to struggle, but you know, they've consistently been the top performers in their class and university. And then they clearly had a competitive application in medical school to get a spot at the residency level. So often it's sort of humbling to have these moments where you realize, wow, there's so much that I have to learn and there's so much that I have to get have to get better at.

Ahmer Karimuddin  29:39

Yeah, and I think we're when you look at that specific comment, right? Like we're going through Congress process right now and we're looking through files and for shortlisting, and things like that, and the overarching response in most of our faculty and many residents, when they look at those files is how did I ever get in all those years ago compared to CVs of these medical students? And when we meet with these medical student and these residents, you know, we all say they're talented and intelligent and well intentioned people. And yet, here they are, right? They're kind of struggling. And so what I think is really important for us as a training program is just to emphasize again, that having people on remediation tracks shouldn't be considered a bad thing. Identifying residents who may need extra adaptation, it's not a bad thing. In fact, it's kind of a human thing to do - to give people an opportunity to respond, and show you and themselves that they can succeed.

Chad Ball  30:32

You know, having said all that, do you wonder, having seen firsthand a few residents that have that have really had trouble during residency and you know, a few of them who ultimately had to transfer out or quit the program, I wonder if there are any sort of consistent characteristics or, you know, issues that you notice, that residents seem to have? And I know, that's a very general, broad, sweeping kind of question. But I wonder if there's there any qualities that you notice that residents who are really, really having a tough time tend to share?

Ahmer Karimuddin  31:13

So I'll work my way through this in parts? Because you've asked a broad question. So I think the first thing to remember is that for many trainees, when we tell them or they're first informed, that they're struggling, to be honest, it's a real honest shock, followed by some level of disbelief, right? Like, these are people who are successful and talented, who've had success in most things in their life. They're working endless hours in residency running around doing all kinds of work. And in the midst of all this, where they feel like they're at their wit's end, we're now telling them they're struggling. And usually behind this, is the fact that no one's really told them this before. They may have had a vague comment, a preceptor been made during rounds, or at a coffee break, or someone couches in a feedback sandwich, you know, where like, you're a really nice person, we love working with you. And you know, you did a great job on call last night, but you really had trouble with this thing. But we really like you, and you work really hard. So that feedback sandwich actually makes the whole problem just kind of  disappear. The message disappears. You know, in our program, when you look at our narrative comments on forums, they were like, less than 10 words most of the time. So residents don't really have a lot of insight on this issue, because we don't often talk to them about it that way. Then when they ask most faculty members, what they can do to get better, they get told, and we've all heard this, read more, work harder and pay more attention. And you know, those aren't really actionable things, right? So if they don't know what the problem is, and we can't tell them how to fix it, they're going to react to that kind of struggle in a negative way. So what I often say is that the most important part of dealing with a resident who's struggling and what probably unites all the residents that are struggling is an issue around insight. And the insight issue is related to the difficulties, it's feedback. And it's related to the difficulties with faculty members, giving that feedback. We can't kind of reveal, mostly caught up in the human reaction of the moment that we can't say the hard thing that's that's important to say. And that I think makes things really difficult. You know, in our program, this was I think, about a year and a half ago now, we had all of our faculty and our residents go through this thing. And this is a plug I'll make for the crucial conversations force that this company called Vital Smarts puts on. It's basically a one day course, which I think, has been amazingly helpful for our faculty that helps you learn to focus on the issue, without sugarcoating, but remembering that you're talking to a human being who has feelings. But also prioritizing that it's important for the resident to hear this feedback. So the idea that you need to tell them what the problem is, that you want them to improve on, is at the core of that kind of interaction to help them get insight on. So yeah, that's what I kind of would say. The issue is almost always insight, as being the common issue. And then it falls on us, as faculty members and program directors to help them get that insight.

Chad Ball  34:23

Like, I couldn't agree more with everything you just said, so, so deeply. It sounds like this a course I should take, because I think we all struggle with that from time to time for sure. I'm curious, when you're evaluating CaRMS applications, what are some of the, maybe the absolute red flags that you would counsel potential medical students against? And what are some of the big bright shining lights that really stand out to you in these applications? Things you love? So both sides of that equation?

Ahmer Karimuddin  34:55

So, you know, I will say that if anywhere in a CaRMS application, which includes the Dean's letter where all of the evaluation narrative comments are, or in the reference letters, if there's any comment about how the resident was difficult to work with or had challenging encounters with other healthcare providers at UBC, that becomes a really big red flag. Because for us, the idea that people have to learn to work together and and to be honest partners and looking after patients is really important. And so that, for us, to be honest, is our only significant real red flag. It's this idea of having had conflict in those encounters. I think, you know, for most medical students and residents, it's really important to remember that every day on clerkship, and every day of residency, and fellowship is actually a job interview. And every encounter you have while you're at work, is a job interview. And as long as you're able to remember that, and then be able to kind of keep your behavior focused, and that align, you end up getting really good evaluations, really good reference letters. And, you know, one of the most wonderful reference letters that I recently read was someone made a comment that if this person became a surgeon, they would want that medical student to be their partner. And I think that's always a resounding kind of reference to get. So I think those kinds of comments, where people within the field of general surgery feel that this person can be a colleague and an ally, are always comments that I take very much to heart.

Ameer Farooq  36:33

Sorry, there's the customary ambulance going by St. Paul right now.

Chad Ball  36:38

Ameer, have you been shot?!

Ahmer Karimuddin  36:40

Well, he's sitting in a room that's half the size of your closet at home right now Chad, so there's no way he got shot there.

Ameer Farooq  36:50

I'm very well protected, and I'm very few feet away from the operating room which is good. So going back to the whole, concept of a trainee who's really having a tough time, I won't say "struggling" anymore, because, you know, we've talked about how maybe that's not such a bad thing to struggle. But say that the trainee who's really having a tough time, and they don't seem to have much insight into what's going on with their behavior or with their performance, how do you actually, you know, get that trainee to have some insight? Like, you talked about sitting down with them and saying, look, there's some concerns, and you talked about doing the whole Crucial Conversations kind of method. But what if that person just doesn't seem to get it? How do you approach that?

Ahmer Karimuddin  37:41

Right. I'll walk you through our process that we actually recently went through with one of our residents and I'll be honest, this is this is something that takes a lot of time, a lot of effort. And I think for Tracy and I, it's something we take very seriously, because one of the things you have to remember is that as part of the CaRMS process, these people have entrusted their program that they're at with their future, and we're training them really well. So I think this is something we have to take quite seriously. And most program directors across the country do take this quite seriously. And I think this is the one thing that drives people to become program directors - is to do the job around remediation, and helping struggling residents do better is kind of what drives most of us who do this work. So the first thing that we do, and then that first meeting with the resident, when we've been told something, we're trying to get as much information as we can. So if it's a bad evaluation, we call up the faculty site leader at that rotation, ask them what they thought, confirm that the larger group felt this way as well. So it wasn't just one person who thought that say, Chad wasn't doing well, and it was the group that came to this. So we then send the resident down, we actually have a designated meeting, we make sure that they weren't going through some kind of illness or personal stress, because you know, humans can struggle when their role is off kilter. So you want to make sure that all of that is in place. You know, we also in that conversation, really focus on reminding the resident that we're committed to their long term success, and that many residents will struggle. And we then talk to them about the area where the faculty identified where the struggle was. If you can reach common ground by talking about the faculty members who saw this and your own instructions with it, that is awesome, right? Because then you've reached a moment where you can talk about how to mitigate and modify for the future. And to be honest, it's usually a conversation that takes about an hour, but by talking about the evaluation from a site and everything else, we are able to find insight in many of our residents in this encounter. But you know, in this specific encounter, we couldn't find insight with the resident after the first meeting. So Tracy and I asked them to step away and we set up another appointment with them in a week. And then we actually speak to our CPR Committee, which again, as I said, is a group of nine surgeons and a senior resident who go over all the prior evaluations to see if there are any pieces of information or nuggets that were missed before and then the conversation becomes even more crucial in a way. We go over the initial concern, talk to you about the fact that the CPR committee has now looked over it and what their perspective was. And we then ask the residents what they've thought about over the last week or so. And we also kind of point out in this encounter, this is the part that I think is different. But we learned this from our post grad faculty leads. And actually in a way for Morad as well, (Morad Hameed), is that we tell the resident we're not there asking them to leave, or kicking them out. But this is a concern, and one that has to be dealt with. And so if we frame it in that context, and make sure that they know that we're there for them, the second meeting tends to be quite powerful, because by then they've actually had time to think and process their past shock and denial kind of aspect of it. So I think that really helps. I think what you were trying to get in your question Ameer is that, what if this is someone who's been having trouble over and over and over again, you know? We're now on evaluation number five or six, where the same issues come up, or it's something that sorted out shortly. And then, you know, presented itself again. These are difficult things. Um, you know, one of the things that helps with all residents and remediation or how we're having difficulty to make sure that they don't regress back as identified by a faculty mentor for them, who was there for support and guidance, not for judgment. And in our program, we often, with these remediation things, we don't make it a secret, to be honest. We want the resident to raises this with the faculty around them. To say, you know, I'm struggling with developing treatment plans for unwell patients, or I'm struggling with laparoscopic procedures or directing my assistants. Can I work with you today? And I think we tried to normalize that process, there's less chance of regression or falling back again. But it can happen, you know. We've got residents who have trouble identifying an R1, they get better in the moment. And then when they transition to enroll as a senior resident, they regress a little bit. And the theory on this from a psychological perspective is actually quite interesting. It's that if you struggle at something once, it requires a lot of your focus. And sometimes if you have to put a lot of your focus on learning something new, like acquiring laparoscopic skills, or running a trauma team, you'd suddenly begin to have difficulty with things you didn't hadn't have difficulty within a year or two, like dealing with an acutely unwell patient. And so this idea of progression or regression becomes something that requires focus. And so this is the lens, which is you talk to our residents who are having trouble and are in difficulty. But if it happens again, and again, that's when it becomes hard to be honest. Because we need to ensure that the residents accept, and this is important for us to keep this lens as well, is that we've got their best interests at heart. And we are committed to training them and helping them grow. And we want to see them happy and succeed. And so what we talk to them about in this context is that, you know, you're working really hard, you've been struggling for six months, a year, year and a half. And you're to achieve a barely competent level two training, which is going to continue maybe even in practice in the future. And so we know that there's a group of skills in surgery that are really hard and challenging for you. And so do you want to spend the rest of your life having this much focus and attention paid on this part of your practice? To the detriment of your other goals and the detriment of your personal life and other things that come along the way? Is surgery that important to you that you're willing to spend all this time and energy to maintain a competent but not excellent or exceptional level of performance? You know, are you sure general surgery is what you want to do? And if they come back and say, the answer's yes, I've always wanted to be like Chad Ball, and I want to be Chad Ball, and I wanna figure out how I get there, then, you know, then it becomes really hard because as surgical educators, you gotta have a commitment to train them and to help them grow. As long as the challenges aren't related to patient safety and professionalism issues. But if they are actually able to come to a realization on their own, that the answer is no, then we have to help them find a way through that and figure it out. And to be honest, in the last kind of, you know, three years now as Program Director, we've been able to find a space for most of our residents, because they see us coming at it from a human perspective, and that's been quite helpful. What I will say is that this mostly applies to clinical training, right? Like, if it's a professionalism issue, those need to be called out right away and there has to be less gray area for those. So if you've got an issue with colleagues and other healthcare providers, you've got to call them out right away and stop it right now. Because if you let those kinds of behaviors slide once or you walk past it once, by just walking past it, if you justified it, then it becomes really hard to correct years down the road.

Ameer Farooq  45:09

I'm curious if you've actually seen a lot of trainees sort of turn things around? Like, you know, you have that really struggling trainee, who maybe was really having a tough time. And then, you know, you had these conversations with them. In my experience, again, which is very limited, just having seen some of my peers go through things, it seems like, you know, it is very difficult, once a resident has sort of been identified as struggling, it often becomes very difficult for them to kind of pull things around or turn things around, because they sort of have this weight of expectation upon their head. And they kind of feel these eyes, looking at them and watching the back of their head all the time. And so it becomes kind of this like self-fulfilling cycle where they can never sort of seem to get out of it, and they themselves start to feel victimized. You know, I could specifically think of one person who I saw kind of fall into the cycle, and I can think of really only one resident, that I know, who turned things around as a senior resident and became a stellar surgeon by the end of training. How often do you find that trainees really can take, you know, challenges that are happening to them, like, let's say, outside of, you know, personal things that might be happening? How often do you find that residents are able to turn things around and really become excellent surgeons once they've been identified as "struggling"?

Ahmer Karimuddin  46:31

So I think that's a really important point, because there's a whole psychological impact of having difficulty and struggling and being called out over and over again, and that can take a psychological toll. And I think as programmers, and one of the things that's really important is that when a resident is having difficulty in achieving or maintaining competencies, it's really important to get them in touch with things like the resident wellness office, and all the physicians or programs that are actually in place to help with that. Because that's really the only way to successfully remediate and create a strategy that works, that has to be tied to an overall wellness strategy. So I think that part is really important, because if they are well, and they're intellectually, and emotionally in a good space, they'll figure out a way of getting through those struggles and committing to it, you know? But we need to be able to provide that as a profession, and as a training program, unify that scaffold that actually supports and provides for that. I'll be honest, I think  in my years now, and you know, with Morad Haneed and Adam Meneghetti, and now myself and Tracy Scott, as Program Director, we've been able to successfully remediate almost all of our residents who've gone through this. Which I think has been quite powerful for us to see, but also for people within our program - to see that there's a pathway back. You know, most of those people who had struggles and who we remediated through are now practicing surgeons in our local BC community and doing quite well and thriving. So there is a path, it's just a path that requires a lot of work and support around it. And a lot of commitment from the trainees part as well. Like they have to be committed to the journey, because as you just outlined, for some people, it just gets too much to bear.

Chad Ball  48:23

Well,  that's a testament to each of you, and to be honest with the names, including yourself that you just described, I'm not surprised. And, you know, I would imagine that taking a trainee and successfully shepherding them through that process and helping them, you'd probably get more satisfaction out of that than even the sort of rock star training that flies through our program and doesn't have any issues whatsoever.

Ahmer Karimuddin  48:46

I mean the rockstar community is an interesting one, right Chad? Like we're probably, as training programs, getting in their way, you know? Like they are going to figure out a way of kind of thriving and excelling no matter what kind of training program they're in. And so, for them you're right, it's a different kind of situation. But each of the people that I've named, whether it's Morad or Tracy or myself, we get a lot of joy out of that work we're able to do in shepherding his residents through. And then when we you know, see them out in practice and read positive comments about them from people who didn't know they ever struggled, it's really heartwarming and puts us in a nice happy smiley place.

Chad Ball  49:23

You know, it's interesting, one of my very, very good friends was the Program Director for quite a while in General Surgery at the University of Southern California in Los Angeles. And he had a number of interesting experiences during his time in that role, one of which was the frequency with which residents would sue the program in the university. So one of the first things he did was create a professionalism committee, constructed of broad representation from trainees and faculty and non Department of surgery member. And when a resident broke what they then constructed as a code of conduct, a code of professional behavior, they went before that committee for an evaluation. Essentially, they had two free passes at it. And by the third time they were generally ejected from the program. When he constructed that platform and process, the lawsuits went to zero almost immediately. And it's interesting for me to think about in the context of Canadian centres for sure, which are, there's no doubt, different. But I'm curious, you know, the issue of professionalism intersects sometimes with lack of insight, or certainly can. So how many of these issues do you think you have in your program and in Canada, in general, surround the concept of professionalism? before you answer that, the other interesting thing within this code of conduct of professional behavior was some very intriguing line items. One of them, for example, is that you should be responding to a professional related work email within 24 hours if you're not on vacation. I think to some people, that probably sounds a little bit excessive, but to others, it sounds sort of dead on. So again, I'm curious, how does professionalism or lack thereof intersect with trainees in your experience?

Ahmer Karimuddin  51:19

I think that is a really important issue to raise Chad, because I think professionalism is one of those things that it's hard to describe, but we all know what it means in a surgical context. And, you know, we want to train residents to our reflect kind of the values of our profession and are able to reflect the best or recommended professional behavior in that context. And so what your colleague and friend seems to have done in USC is really, I think, important, like as a program, you really have to work hard to define what is acceptable, and what is unacceptable behavior. And once you've defined that, you have to hold to it. Because if you, you know, for example, if a resident is having multiple encounters, the medical students are putting it in their evaluations that this resident is, you know, not supportive, or is being bullying or is creating an unsafe work environment. Well, as a program, it's actually really critically important that you call out that problem as soon as you hear about it. And I think that's what really helps you to create this space where, you know, where professionalism actually gets headed off almost at the past, where the remediation issues you're dealing with aren't about, you know, a inability to work with teams or being rude with nurses or other kinds of really challenging things. Because those are calling right at the top. Those are things which, you know, if they happened once, you're going to be put on watch, if they happen twice, then the next time it happens, think that "three strikes, and you're out" rule, and you have to hold yourself to that. That applies to faculty members, as well to be frank with you Chad, because one of the bigger things of this is that we'll hold residents to standards we don't hold faculty members to. And so we need to make sure we do all of those things to be able to create an environment where professionalism gets called out. We've been lucky at UBC in my time here that while we've had occasional professions and complaints about residents, but we haven't had anyone who we had to take seriously because of that, but I think it's mostly because of our culture where we call people out right away. So if I get a message or a phone call today, I'll be on the phone with the resident, along with Tracy, and sometimes even more at his division head within like the hour, and say hey, we heard this, what's your side of it? What happened?

Chad Ball  53:53

You know, one of the things (if we shift gears a little bit here) that a group of us is trying to do in Alberta, led by Sean Gregg and, and a number of others is to integrate artificial intelligence into some of the not only clinical algorithms, but just overall patient care that we provide. And it's a little bit tangential initially, I think. You know, we're trying to use AI to screen for mental illness in the context of pancreatic cancer. But I do wonder when you look at how fast AI has has come, what its intersection or role will be in some of the interviewing processes that we have potentially down the road for general surgery residency. You know, it's really interesting, this single company that we've been involved with, did 19 million interviews, I believe, in the US alone in 2019. And there was a lot of big companies involved: McDonald's, Price Waterhouse, Kraft, Heinz and so on. And essentially, as a candidate or as an applicant to these jobs, you would sit down in front of an AI algorithm with a video on and answer a number of questions over 20 to 25 minutes. And it would essentially pre-screen you before you got to a second cycle or a second round, maybe a second tier, that may or may not be then a real person interviewing you in real time. It's interesting to look at those algorithms. To ask a question, for example, about teamwork. And the applicant answered the question using the word "I" instead of we, that would be one of these filters that would be considered a negative scenario. I'm curious then, in terms of application and selection concepts in general, my sense is that we don't really do a superb job of selecting residents to our programs upfront. I think we'd like to think we do. But at the end of the day, I think there's probably still a very arbitrary nature to a lot of it. Maybe that's the wrong word. But there is certainly risk to it. So I'm curious, do you think we're good at selecting folks into our programs and with things like AI and comparing it to the current structure and process? Where do you think we go forward from here to improve things?

Ahmer Karimuddin  56:17

That was exactly mine and Tracey's big concern around: How are we going to select residents better when we haven't actually got any face to face time, through this weird CaRMS year that we had. And so we reached out to this company called Talent Click. They're a large multinational company based out of Vancouver that does exactly this kind of work that you talked about, for multiple fortune 500 companies. And we reached out to them and said, "Hey, listen, what do you guys do for this?" So they came up with this idea of utilizing an online questionnaire that each of the trainees fills out, which takes about 20 minutes for them to do. So how did they base it? Well, they first told us to get 10 faculty members who were considered leaders in our program to fill it out, to define what the criteria and what the best resident would be or the best surgeon would be. And then they made us run it through our resident group. So we ran it through about half of them. And they use that to create this profile, kind of like the machine learning thing you spoke about, of what the perfect resident would look like for our program. And we then we actually got all of the CaRMS candidates to fill this questionnaire out. And it assigns them a score that kind of ranges from, you know, kind of like a zero to 100. But we trialed this at first with our international interviews with our Saudi and our Armenian candidates, because we were super stressed, because they couldn't come for electives. We didn't know who they were. And I'll be honest with you, the questionnaires that they filled out, were frightfully accurate. Well there was one candidate who scored poorly on "team". And so they tell you what question to ask about team. So you ask this generic question, which you think is going to be too easy. And all this candidate did for 12 minutes after that was talk about, 'I, I, I". And we asked other candidates that question who would score higher on this on the score? They were didn't do that, and was such a stark contrast for us. So we learned a lot from that. And we're actually using that this year. We'll find out how that works out or not. But you're right, we need to use some of these technologies a lot more. You can't get hired into senior leadership position at a large Keegan bank without filling out something like that.

Ameer Farooq  58:41

You and I have talked about this a lot. And, you know, we've talked about how Malcolm Gladwell his a whole concept around this. He talks about revisionist history, and about sort of being a hiring nihilist. And this idea that we just perhaps aren't as good as we think we are at selecting people with the "right stuff". And so I certainly do think that there's going to be some component that's going to be objective. And you know, I don't think you can completely eliminate the the subjective component of, you know, do we think this person will have a good fit. But, you know, it makes sense that there's going to be some objective measures or some objective process for getting residents. One of the other things that I'm very excited about that you and Dr. Scott have put in place this year, is blinding for applications. For the reviewers. Can you talk a little bit about why you are blinding and what exactly that entails?

Ahmer Karimuddin  59:42

So you brought up Gladwell, so I'll put in a plug. Talking about "hiring nihilism", Talking to Strangers is an excellent book that actually talks about just that - about how poor we are as people in judging others and determining if they're going to be good fits or not. So I think that's been an important thing for us to remember especially in this era, where we're becoming more and more aware of issues around diversity and inclusivity, that our conversations around "fit" have to be based on more factual things, then the more highly visible or more explicit things that we are able to see about people. And that's where I think questionnaires and machine intelligence, things in the long run are going to be helpful for us to define what we mean by someone being a better fit or a good fit. And how that can extend to candidates of color or candidates of different gender or candidates from different background experiences. So there is a clear role for this. And I think we have to figure out what that is, because the human equation, as Malcolm Gladwell convincingly talks about in Talking with Strangers, isn't very good. We're not good at this stuff. And so I think that's important for us to reflect on. What we're doing this year for blinding, is something that I think has taken us a lot of work and time to come to, but, you know, CaRMS applicants put a lot of effort into their files, and they put in a lot of detail and they have struggled to find referees who write great reference letters about them. But it always bugged me. And something we've learned from, again in the Human Resources literature, is that knowing a candidate's name and gender can influence the way in which you rank or you assess them. And so what we decided to do this year is, we were going to look through all of our CaRMS files, (110 applicants this year), and we were going to remove all references to their name and their gender from the document itself. And we were going to use that, and then do our shortlisting, kind of from an anonymized or blinded file. So we'll see how that works. Our shortlisting meeting is next week. But we were quite supported in this by our universities, hiring people, and by Morad as well in trialing this out. And so we'll see how it goes. We're hoping that this will help us select an evermore kind of diverse and representative group of candidates. And we'll keep you posted.

Chad Ball  1:02:18

We try to ask all our guests a common question at the end, which is, you know, if you were to time travel backwards and talk to your younger self, what sort of advice would you give yourself?

Ahmer Karimuddin  1:02:29

I think, what I would say to anyone who asked me this question, and medical students bring this up as well. So always remember that residency is a non stop job interview. every hour, every encounter is a high stakes encounter for you because you're working with people who can train you to become excellent, and whose advice and counsel you'll rely on for the rest of your lives. So make those encounters of a high quality and trust in the people who train you. You know, when I was in Saskatoon, as scary as it was, when you went to Roger Keith or Andy McFadden and asked them for help, they were always there to help ensure and guide you. And I think as for trainees, that's something they need to remember. That there are people around them who care and who are there to help. So even though it's going to be high stakes, and it's going to be a space in which you have to work really hard, you need to ask for help when you do. So I don't know if that's a good answer or not. But that's kind of my thing: just be at your best and ask for help when you need it.

Ameer Farooq  1:03:40

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 at @CanJSurg. Thanks again.