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Sustainable Surgical Practice: Defining Workplace Standards for the Modern Era · Behind The Knife: The Surgery Podcast

• ACS Workplace Standards Audio_Clean === Speaker: [00:00:00] Hey, welcome back to Behind the Knife. I'm Steven Thornton, one of the Behind the Knife Surgical Education Fellows, and today I'm joined by my co-host, Dr. Emma Burke. Speaker 2: It's really great to be here today, Steven. This is one of those episodes that I think will hit really close to home for pretty much everyone listening, whether you're a resident grinding through training or an attending a decade in practice, wondering how you got here. Speaker: That's exactly right. Today we're talking about surgeon wellbeing and workplace sustainability. Specifically two brand new papers out of the Journal of the American College of Surgeons that I think represent a great example of the advocacy coming out of the college these days. Speaker 2: And we have two incredible guests to walk us through this work. First, we have Dr. Douglas Wood. He's the chair of surgery at the University of Washington in Seattle. The past president of the Society of Thoracic Surgeons, vice Chair of the American College of Surgeons Board of Regents, and the lead author of the Framework Paper will be discussing Dr. Wood, welcome to Behind the Knife. Speaker 3: Dr. Burke, thank [00:01:00] you very much. Uh, it's a privilege to be here. Behind The Knife is a great podcast. I'm thrilled to be able to be part of it. Speaker: We're also joined by Dr. Thomas Varges. He's a cardiothoracic surgeon, current editor and chief of the Journal of the American College of Surgeons, and author of the editorial accompanying Dr. Woods' Framework. Dr. Varese, welcome to the show. Speaker 4: Thank you, Dr. Thornton. I echo Dr. Woods' remarks behind the knife as said. An absolutely high standard for podcasts, and we're absolutely honored to be joining you today on this topic. Speaker 2: So let's take a moment and just talk about what prompted the development of these workplace standards. Speaker 3: Well, Dr. Burke, thanks for that question. You know, the Board of Regions of the American College of Surgeons really represents the whole. Specialties of surgery across all the domains and represents, I think, recognition of. The [00:02:00] increased employment and increased burden on surgeons, that has led to discussions about how can we try to balance those burdens and problems that have led to attrition, to burnout, and to frustration of autonomy, uh, or lack of autonomy in our practices and. This has led to discussions about unionization. The board had a labor lawyer talk to us about what are the issues of unionization, and ultimately a year ago, to help develop some discussions about what options we might have. We developed a unionization task force, and as that discussion developed, we recognized that while. Unions do have a role of kind of setting workplace standards for people in employment in [00:03:00] other ways. It sort of was against many of the principles of professionalism and autonomy that we. Respect and appreciate as surgeons and therefore myself and others, really proposed this idea of developing voluntary workplace standards that we would, that could be specialty specific and would define parameters of what is a reasonable call burden and what is a reasonable patient census, or what are, what types of administrative. Tasks, what limits, uh, there should be on those as a way of strengthening how our surgeons can work in the workplace. And so, uh, I'll probably stop there 'cause I know you have other questions, but that's how it evolved. It started really with the discussion of unionization and really morph from that into this development of a [00:04:00] concept of voluntary workplace standards. Speaker: Dr. Varese said, be curious, your reflections on, on those topics, what are your observations about surgeon wellbeing? Stated the workforce and this trend toward immunization. Speaker 4: Yeah, I, I think that what I'd like to do, Dr. Thornton, is to take a step back. I mean, I, and I think Dr. Wood alluded to this correctly, you know, as a journal editor and as somebody, as all of us are in this age of information overload, the thing is there's these critical issues that we have to tackle, and everybody talks about the use of data and data science. To increase transparency, accountability, and outcomes. Like that's, that's the framework that ev everybody's thinking about. But then that word framework really comes to mind because it's like, how do you organize this information or how do you act on that information? And so for us as a journal, you know, we're always looking for opportunities to help our membership, our readership, [00:05:00] and critical stakeholders to make a difference. And what we loved about this particular project was. The Board of Regents really started tackling this issue. But then they realized that you actually needed some mechanism to organize the information. And that's where I, I really love that, the framework. I mean, we, we absolutely loved it. Uh, don't get me wrong, we always love most of the products coming outta the Board of Regents, but it, it's just one of those things that, that it, it really, what we're hoping to see is people will not only read this article, but appreciate that this becomes an opportunity. For organizations and groups to, to is start organizing their own information so that we can do something about it. Speaker 2: So then Dr. Wood, thinking about how the Board of Regents came together to put together these standards, can you describe for our listeners what that process was like? Speaker 3: Yes, Dr. Burke, as I said, it started with this task force that included many of the members of the Board of Regents as well as a lawyer [00:06:00] consultant. And in that process we actually developed. A rich set of resources on unionization that is now on the website of the American College of Surgeons that has frequently asked questions and a lot of information for any groups that are interested in the concepts of unionization. But as we developed this. Separate but related concept of workplace standards, really it developed in creating a draft that will try to address what are the I important domains that we need to address. Things like call and call is more complicated than call frequency because there's also call intensity and. When we put call intensity and frequency together, then the question is when certain limits are exceeded, [00:07:00] how is that compensated or how is that restricted? And we made recommendations of certain call frequency and intensity and that exceeding that requires additional compensation so that there is some benchmark of. A reasonable amount of call intensity and frequency is in a given workplace, and that when that's exceeded, either more people need to be hired or more compensation needs to be provided. And the other, you know, there's several areas, but another important domain is access to resources, and I'll talk about maybe the most important resource. OR block, because we've realized that there's often a disconnect between what. Productivity expectations are that is how many work RVs are you expected to [00:08:00] produce and access to or block. So there's a recommendation of providing calculations on an individual surgeon level of average work RVs per OR block, so that one can calculate at the health system level how many or blocks Dr. Varghese needs. To meet his productivity expectations in at his health system. And these are really meant to be helpful to both individual surgeons so that they have the resources to do the work that is expected of them, but also the health systems where they're employed, so that they are actually aligning resources appropriately with what the goals are for their surgical workforce. Speaker 2: Yeah, and I think as a trainee, I really just assumed these things happened. Like I assumed that health systems accounted for how many ORs they needed to pay for the surgeons and you know, how intense your call was. And I think that, you know, in residency everything's so [00:09:00] structured. We have set limit hours on work and things like that. And so realizing that when you're an attending that doesn't end was very fascinating when I read your framework. Speaker 3: Yeah, you're right. I mean that is, that is. A benefit of residency it, there is good structure around it didn't used to be, and there is now, and yet still. Our resident structure allows 80 hours of work per week, which is double the normal expected work hours, but that, uh, that restriction goes away. When you're attending, you actually think that you have more control as an attending, and in some aspects you do, but in other aspects you don't. In that there can be expectations of. Uh, I guess unlimited endurance of surgeons to stay up overnight and do elective cases the next day. And. All of that is are things that we [00:10:00] train for and at times that we need to do. But in the interest of patient safety as well as sustainability of surgical careers, there needs to be some structure around that that helps us define what is reasonable for surgeons to do, and also. Helps us regain some agency and autonomy that has been lost as we've gone from being self-employed to being predominantly health system employed as surgeons. Speaker: Dr. Varghese hearing Dr. Woods' reflections on this expectation of unlimited endurance from surgeons, and particularly at the faculty level, where some of those A-C-G-M-E protections go away. I was really struck by one phrase in particular from your Jack's editorial, and it was that surgery has long equated excellence with endurance, and I'm curious your [00:11:00] reflections on that line. Speaker 4: Yeah, I, I think that you know, there's that cliche that says that the system is designed exactly the way it's meant to be. So when you see outcomes like Dr. Wood said about burnout, fatigue, patient safety issues, things like that, the system is designed the way it's supposed to be. But we have to also point the fingers at ourselves. You know, it was kind of a pride like thing, uh, you know, show no weakness, don't complain. You know, the, the only, uh, thing about, bad thing about Q2 call is you miss half the time. Uh, uh, you know, we hear these kind of. Things that have been passed from generation to generation. Uh, but at its core, it's that we're missing the point. Uh, you know, the, the point of all of this is every single one of us are motivated to make sure that we can deliver the absolute best care for our patients at all times. That's the reason why we all do this. And so, as Dr. Wood alluded to, why wouldn't we want to [00:12:00] be prepared to do that? Wouldn't you want your surgeons. Rested. Wouldn't you want your surgeons performing at the highest level of their capabilities and the professional standards? You know, that that's what we need to do. Because the cynical view of all of this is, uh, let's just keep doing what we're doing. And that's why like in the editorial, I mean there's a lot of great stats out there, but the one I thought would resonate the most, at least with the C-Suite, is the average cost of replacing a surgeon is, uh, it costs about a half a million to a million dollars. And in certain specialties there's more of that. And I haven't even put in there about the time it takes to recruit somebody, uh, you know, to move somebody to, to new place to get them up and running, all those different things. And so the goal should not only be recruiting the best and the brightest, it should be also about retaining. And so I think the core issue at all of this is culture building. You know, we have to, you know, point the finger at ourselves about allowing the culture that has existed. But now we have the opportunity to do [00:13:00] something about it. Let's all work together to build that better culture going forward. Speaker 3: Dr. Varghese, I was glad that you, you brought up the problem of every second night call is missing half of the good cases, you know, that was. The, the joke that was said when I was a resident and I'd call every second night, and I think you stated it very well. Our culture is one of, you know, toughness and that's good, you know, it's okay to be tough, um, and, and have grit. But unfortunately, I think particularly in situations where we're now employed. That toughness, and I guess I'll also connect it to our commitment to patients can be exploited, an exploited unintentionally, probably, mostly unintentionally, [00:14:00] maybe sometimes intentionally of well. The surgical service is the one that can have an unlimited census, uh, on the trauma service because medicine and orthopedics and neurosurgery all are full. The surgery service just keeps growing and, uh, it's, it's unsustainable. Uh, and there need to be some limits around that as well. Speaker: Yeah. One of the things I really like about this framework and, and the editorial. That it points towards the importance of systems solutions. In listening to your reflections and thinking about my own aspiration to be a surgeon, I'm so inspired by and compelled by the surgeon ethos. Speaker 4: Mm-hmm. Speaker: The extreme culture of accountability, the hard work ethic, being willing to go the extra mile to do what's right for the patient. When we face big [00:15:00] challenges in American healthcare and there are tensions on what it looks like to deliver excellent care in different circumstances, the solutions don't lie at the individual level. It, it sounds like you guys are making a really clear case for a framework that allows us to understand the infrastructure we need to do right by our patients. Speaker 3: Dr. Thornton. That's well said. You are right. And a a point that I'll make about that is the framework that we have published, uh, is exactly that. It is a template to, uh, provide guidance of how this can be applied at the specialty level. And Dr. Bargh emphasized this in his editorial that, that. This would be applied differently in different specialties. It's gonna be different for cardiothoracic surgeons than it is for trauma surgeons or orthopedic surgeons or ophthalmologist, or [00:16:00] OB GYN. So you know, we have very different types of practices and types of call and. The intent of this is to create a framework that then allows specialties to develop that for their specialties so that we have expectations that ophthalmologist will create their own paper, uh, that outlines how this would be applied for ophthalmology and in fact. There may be more than one ophthalmology paper because it may be different for retina specialists than for a, a general ophthalmologist. And as I've met with other surgical specialties, and think about orthopedics, you know, there's orthopedic trauma surgeons and then there's joint replacement surgeons. They have actually quite specific [00:17:00] practices, and the frameworks may be different for them. And you can picture the number of general surgery specialties and recognize that surgical oncologists are likely gonna look different than trauma surgeons, uh, or endocrine surgeons. Speaker 4: And, and probably what I would add is I love the way, uh, uh, Dr. Wood, uh, you know, stated that the framework is indeed a template. And, and I think that that means that we still have work to do. You know, uh, and, uh, what, you know, one thing that we're imagining going forward is all these different specialists creating their. You know, specific guidelines based on the framework. And then the guidelines then become those guidance documents for individual hospitals and local environments to, to, to establish what their local standards are going to be. And so those three terms, uh, it's good to differentiate that out. The framework is the templates that'll lead to the development of [00:18:00] guidelines. And then individual hospitals and local environments will look at those guidelines and then decide. What are they gonna use for their local credentialing and, and establish the standards at their local environment. That's what we hope to see forward, but that does mean that we still have work to do. Um, and hopefully we can, uh, all recognize there's work to do and, and work on this together. Speaker 2: So as you both have thought ahead to how this is actually going to be implemented, both at a specialty level and then a local level. What are some of those barriers that you foresee to implementation of this framework? Speaker 4: Yeah, I'll say that there's gonna be pushback. Mm-hmm. Because anytime you ask a system to change, and anytime you ask a group of people to do some more work, inevitably there's gonna be some people that's gonna push back against that change and there's gonna be work. Uh, you need to collect that data at the. Institution, organizational region, uh, national levels to be able to do that. But I, I think that, uh, I'd love to hear Dr. Wood, uh, [00:19:00] tackle this. 'cause I, I suspect that this is what they realized. You know, they, they went in diving in about the, you know, the unionization effort, but then realize there's a ton of work still left to do. Is that correct, Dr. Wood? Speaker 3: Yeah, you're absolutely right. I think that, as I mentioned a minute ago. What we've published is a framework and, and the publication that you're referring to actually reflects a document that was developed within the Board of Regents and was approved by the Board of Regents in its October meeting and the publication that we're referencing in the Journal of the American College of Surgeons that was published last month really. Came from that framework document. I have now met with 13 surgical specialties. Uh, the leadership from 13 surgical specialties to describe the framework to them. The majority of them are working at some level [00:20:00] of developing specialty specific framework that like I just discussed. So, uh, one barrier, Dr. Burke is. At the specialty level, you know, it takes some volunteers that are willing to spend the time to take the framework and then think how does this fit for our specialty? And to turn that into a a publication, we would like these to be peer reviewed publications in that specialty's journal that is connected. To the work of the American College of Surgeons, and that is really co-branded with the surgical specialty and the American College of Surgeons as the house of surgery. Then that's just the aspect of having it published, and Dr. Gh talked about the potential pushback and many have. Whether I think there'll be acceptance at the health system level, if there will be resistance or pushback, uh, as [00:21:00] Dr. Varghese said, I, I'm sure. Yes, because anytime you propose something, people are gonna be concerned about the consequences and costs. I actually think the way we've developed this, that this is a win-win. It's a win for surgeons and a win for the health systems where they work. Because I think the intent is that this not only supports surgeons to have. Better control over their workplace, but also helps health systems be more systematic about how they deploy surgeons and the resources that surgeons need to do their work effectively and safely. And I'm emphasizing the aspect of. The effectiveness of patient care, but let's get down to what we don't like to talk about, but finances, because I, I actually think that deployed [00:22:00] appropriately, this helps both surgeons and health systems have transparency about the financial implications. To better achieve, uh, financial success in the work that they're doing to provide efficient patient care and have the resources to, for surgical care in a health system. Speaker: Building on the idea that guidelines are the next step from framework and that those guidelines can be used to advocate at the institutional level. I'm curious if we can talk about some more of the practicalities of that. Maybe for our trainee listeners in particular, who are the relevant stakeholders at an institution that need to be in the room around these discussions and who should be leading the charge in those conversations? Speaker 4: Kind of a, uh, a useful way of thinking about this is. There's like four different areas that you need to make sure, uh, when you're talking [00:23:00] about change at, at any institutional or organizational level. There's, you know, the actual data or you know, the framework that leads to the guidelines. There's that you need champions. Uh, the, the third area is resources, but then the fourth area is also critically important. You need some mechanism. To do a surveillance and feedback platform. Uh, you know, it's, it's not, uh, this is not the 10 Commandments that come down from Mount Arafat and then everybody follows that. Exactly. There's gotta be some mechanisms to understand that there may be some nuances that, uh, at the University of Washington in Seattle. That different from the University of Utah and Salt Lake City based on, you know, trauma populations and, and things like that. You know, the local environmental factors as well. But all those four areas are important. Um, and so I think as Dr. Wood alluded to, this is like the first step is organizing the data. The data is already there. The framework is used as a template [00:24:00] to organize that, that gets guidelines, but then you, at the, at the local level, you still need those champions as well. And so I, I would start there first because, you know, the natural way to think about it is the, uh, you know, the surgeons, uh, the surgeon is part of a group. You know, they have partners, uh, you know what that looks like. Uh, are you organized in a school of medicine with rigid departments, or are you a differently a, a workforce where there may be a private group that's affiliated or there may be other things that are, uh, uh, hospital employees? That's the way I would probably start with first, but I'm curious to see what Dr. Wood thinks because Dr. Wood and the, the Board of Regents have already started these conversations. So probably a great question, uh, Doug to ask is. Describing all the different organizations you guys are meeting with right now. Correct. Speaker 3: Yeah. So that's one aspect, uh, that I, I mentioned and, and it's leadership in multiple specialty [00:25:00] organizations. But to your, to your point, Dr. Thornton, and, and adding to what Dr. Baris said, what we would expect these workplace standards would be able to be adaptable to. Essentially all workplaces meaning. Academic medical centers in a major metropolitan area and a rural critical access hospital. We've actually thought about that in the, in the development. And so the stakeholders are going to be a little bit different depending on what the organization is of your workplace. And in a place like mine, which is a major academic medical center with departments, you know, the. Appliers of these workplace standards would be somebody like me, a department chair, in coordination with the hospital and health system in terms of how to assure that. We are meeting this for the [00:26:00] variety of specialties that are within the Department of surgery. If you are a solitary general surgeon in a rural critical access hospital, this may really be between that surgeon and the CEO of that hospital in a rural community. But we have tried to specifically. Create standards that would be able to be adaptable across a wide spectrum of types of both specialties and practice environments, and are really not meant to, I, I guess, constrain the flexibility and. Goals of an individual surgeon. These are not meant to constrain surgeons. These are really meant to empower them to have the resources and and structure that they need to do their work well, Speaker 2: and that's interesting too 'cause when I first read this framework, I was thinking about, you know, when I finally [00:27:00] finished residency and fellowship and I'm looking for my first job. How will these standards impact the way that I run my job search? So is this something that you all foresee having a stamp similar to other programs by the American College of Surgeons, such as trauma, a CS verification or bariatric certification? Is this something that you all foresee being something that hospitals advertise that they comply with for surgeons when they're recruiting? Speaker 3: Yeah. Dr. Burke, I, that's a great question and I don't know yet. Uh, I think that what you, what you propose. May be the case and maybe evolve that way. Right now, how I envision this is an iterative process that requires initially getting some of this in the literature and creating some culture movement. That, uh, is empowered by having something that's published in the peer reviewed literature that [00:28:00] you, when you're looking for a job, can point to and say, this is really what I expect in a, a job where I'm going to work and me wanting to hire you is going to want to, uh, actually be effective in recruiting. You and other great surgeons to my department, to our health system. And the intent here is to really create it so that it's voluntary, uh, it's doesn't have teeth in it except peer pressure. A movement across the all of the specialties of surgery to create some standards that help us have better control of our lives. Have a healthier intersection with the health systems where we work. Speaker: One thing I want to talk about with the framework itself is how many different levers of influence were identified as it relates to surge [00:29:00] and wellbeing and sustainability? And I'm curious both of your reflections around the relative accessibility of these different levers among things like call and compensation. Access to the OR clinic and other resources, inpatient, census, fatigue, mitigation, and administrative burden. Is it salient to either of you that some of these might be. Easier to achieve in the short term, and that some of them might reflect more aspirational long-term goals. Speaker 4: That's a, that's a complicated and complex question, but I'll, I'll probably hit at it from the 30,000 foot view first before letting Dr. Wood probably talk about the specifics. But the challenge in all of this is, you know, anytime you put out a framework, a template, a standard guideline. There's always gonna be somebody who says that, well, what about this? Or, you didn't do this, [00:30:00] or, how come you didn't think about this? Like, it's hard to be perfect for every single audience out there. Part of it is, you know, you could only act on data that can be measured. You know, for example, there's a lot of different debate about what is the definition of quality. You know, quality. The definition truly is, is are you doing a good job in a way that can be measured? You know, there's no quality if you can't measure. What you're trying to improve or what you're trying to, you know, establish as, as a standard. And I think that, you know, I, I, that's why I applaud Dr. Wood and the Board of Regents for tackling this. This is not an easy issue. I mean, people have been talking about a lot of these issues for decades. I love this work because it's like the group said. Okay, let's start doing something about it. Let's stop talking around the workplace issues and burnout and, uh, let, let's start approaching this as saying, let's tackle this about how do you create the better workplace culture [00:31:00] that, you know, how do you make sure that, uh, we're creating that environment that surgeons can thrive? I mean, that, that's the take home I took from this, but Dr. Wood, I, I didn't know what your additional thoughts were. Speaker 3: Well, uh, Dr. Thornton, you know, I think to your point of what's deliverable and what's aspirational I, I, I guess I'm gonna be blunt to say I think these are intentionally, easily deliverable. I don't actually, the stuff that's in the framework, I don't consider to be a big reach that is, except in the aspect that Dr. Burke asked about is how does it get implemented? And obviously it takes time to, to kind of get specialties involved and get the movement to move things. But, uh, I'm gonna give a pick out. A [00:32:00] couple of things and give you examples. I think all surgeons right now are frustrated by compliance modules that we are asked to do every year, and that they seem to be. Growing that, you know, one year it's five hours and the next year it's eight hours, and the next year it's 12 hours of sitting in front of a computer learning, redoing fire safety in the operating room or bloodborne pathogens. So that is work that that takes time away from patient care and is. Mind numbing and, and in many cases not that useful in terms of it, what it provides for us in terms of effectiveness in doing our jobs. It's [00:33:00] obviously, it comes for a reason. It's well intended, but. It's grown out of proportion and is work that, uh, act actually adds to burnout and dissatisfaction among surgeons. Just saying, this is how many hours is reasonable. If you're gonna do more hours than that, pay us for it. Uh, is that's, that's very actionable. That's not, that's not aspirational. And the other one that I mentioned earlier about. The productivity per or block. That's not a hard calculation and it's not a hard thing to implement to say if we spec this much productivity from Dr. Varghese in a given year, he needs this much or block to accomplish it. You know, those, I think it is not really aspirational. I think that is. Really deliverable once you have the data to make [00:34:00] action, to provide the resources to surgeons to do their job well. Speaker 2: Dr. Wood, it felt good to hear somebody in your position even complain about the modules. Um, I just did my one on phishing emails like two days ago. Speaker 4: I, I suspect we're gonna get in trouble for that. That's all good. Speaker 3: Yeah, I, I know I, I apologize Probably I, I said things that I shouldn't, but yeah. I'll admit. These are, are often responses mm-hmm. Uh, to something that occurred in a hospital and a health system or at a national level that are then efforts to try to keep us educated. That's what I mean is well intended, but they seem to be ballooning out of control. And I have a department of, you know, 200 faculty. And wow when that hits, uh, there is a lot of disgruntlement and reasonably so Speaker 2: going back to culture because I think that really is the take home message of the whole framework is improving our culture as surgeons and how [00:35:00] we work and how we live. Dr. Wood and Dr. Varghese, when you guys think 20, 30 years into the future this has been implemented, workplaces are better for surgeons, how do you see this impacting the way we recruit medical students into surgery? You know, I hear so often when I teach the medical students, or even in the literature, so much of why medical students don't choose to go into surgery relates to lifestyle. Perceptions that you can't have a family perceptions that you're always on call. Do you guys think this will have a meaningful impact on the pipeline into surgery in the coming decades? Speaker 3: Yeah, I, I'm excited to respond to that question because, you know, at, and particularly in, I guess my demographic, my age group, I come from old school, which is we just work all the time and. I'm now in charge of a department where I want to recruit great students and residents to become part of my faculty, people [00:36:00] like you and Dr. Thornton. So I have felt very motivated that we need to evolve the culture of surgery to continue to have a work ethic and commitment to patients that we're proud of, but that. That doesn't have a stigma of being insensitive to the rest of life. And recently a resident told me that somebody advised her that maybe she should, she would've a better life being a pediatrician than a surgeon. And I was dumbfounded because I thought we stopped saying stuff like that in the 1980s. So, but that was last week. And I, I want us to change that. I want the best students to want to be surgeons because we have a great specialty. We get to do [00:37:00] things with people that help them live better and live longer. What could be better than that? And we want to continue to recruit the best people and. The way to do that is to maintain the positive parts of our culture of accountability and commitment to patients, but to soften this aspect of unlimited endurance and that we're willing to sacrifice our personal lives and our families for work, uh, we shouldn't need to do that. And so my goal, Dr. Berg, in all of this is that. Not 20 years from now, but next year, no one's saying you would have a better lifestyle as a pediatrician than as a surgeon. I want, uh, surgeons to have a positive, sustainable life and a thriving and [00:38:00] satisfying career. Speaker 4: Well, well, Dr. Burke, the only thing I would add to this is now the listeners know why Dr. Wood is one of my favorite human beings in the, in this world, because as a leader, uh, he has been consistently challenging these myths out there. Let's take a step back. For the first time in the history of the world, there are five generations of people in the, in the workplace right now. If you just think about your MAs to the nurses, to the people in the operating room, to the surgeons, to the trainees, uh, there's, it's multi-generational right now. That's number one. Number two. Everybody works hard. There's no medical student in this planet that doesn't work hard or hasn't worked hard to get to their level. So one of the myths that has always been out there is when people are saying about lifestyle choices. They're not saying they want to work less, they just wanna work smarter. And I think for surgery, this is a critical [00:39:00] time period because as Dr. Wood alluded to, you know, unfortunately this burnout culture we've created, we kind of did to ourselves because we didn't question anything. We didn't push back, we didn't ask. Well, why should there be like 20 people standing around in the middle of the night in a hospital? Uh, that doesn't make any sense. Isn't there some way of doing this better? Or, as Dr. Wood alluded to, you want Dr. Varghese to be highly productive, but you don't give him or block, I mean, it just. We're just directly addressing that. And so my hope is is that a, as Dr. Wood alluded to, that these conversations lead to meaningful change, not performance, art, meaningful change that is gonna create the better workplace. And surgeons are always gonna work hard. Of course, we work hard, we're gonna work longer hours. If our patient's sick, we're gonna be there. But I, I hope that this leads us to work smarter, work much more efficiently, work in such a way that every single one of us have [00:40:00] long, healthy careers that are gonna be robust. And that last about 35 to 40 years. That's the hope. Speaker: You both mentioned this experience of training in the era of, the problem with Q2 call is that you miss half of the good cases. And now at a national level within the house of surgery, you're both leading the charge on building a culture of excellent patient care in the context of having a sustainable profession. I think some folks find it challenging to be visionary leaders in that way to make things better for the people who come behind them. I see that at every level. I, I see it in my peers. I see residents who struggle to imagine the ways that we can make undergraduate medical education better for our medical students. And instead they fixate on the idea of, [00:41:00] well, I endured this and so can you. So I guess my, my question, if not a little philosophical is. How do you become the type of leader who's able to facilitate conversations and drive change to make things better for the generations that come behind you? Speaker 3: Well, you know, thank you for giving that attribution to us. Uh, I. Dr. Varghese deserves. I sometimes wonder whether I deserve, but I'm trying. And I would say if I reflect on that, I think it comes from curiosity, humility to listen and to pay attention to, I guess, changing norms, generational norms, cultural norms. That actually are very different than existed when I was a [00:42:00] resident, where I literally decided that I would not have a family and would kind of put my life on hold for the nine years of my residency and didn't do anything until after that. That's wrong, and I mean, I don't regret what I've done, but I would like it to be better. And, and I think that I benefit from the variety of people around me that educate me, and it's my residents. It's the students that I work with, and I have amazing women allies who I, I think make me better as a leader by. Recognizing kind of their perspective on careers as surgeons. And I'm specifically talking about this gender [00:43:00] issue because I think a, a view that I've had is making surgery equally attractive to women as it is to men. Is better for both genders, meaning it raises all boats that it's good for us as men to have the adjustments, lifestyle, cultural, that. Women pay attention to, and we've tended not to because it makes us, makes it better for both of us. And so I've benefited from those allies as well in changing what was a norm for me that I, my mantra has been how I was trained is not how I want my current residents to be trained. Not I did it and so therefore they need to. Speaker 4: Yeah. I, uh, beautiful words. Uh, Doug, uh, and, uh, Dr. Thornton, the only thing I would add to that is, uh, uh, Doug's heard me say this before, is [00:44:00] to remember the definition of allyship. Uh, the definition of allyship has two parts. Uh, the first part is excellence in all we do, but that second part is critically important also, is lift others as we rise. And Dr. Wood is absolutely correct. We want. Surgery to be the absolute best profession of all time. This is an amazing, incredibly meaningful, rewarding profession. There's so much you have a patient in need, you're able to identify the problem and then you're able to do something about that and transform their lives for the better. We have the best jobs in the world, of course, we want. The best cultures. We want people to thrive. We want the best and the brightest from all around the world to come into our profession. That excites us. For me personally, it, it started with, I'm very blessed to have had phenomenal mentors such as Dr. Wood and other. My first job at the University of Washington [00:45:00] was the dream job for me. I could walk down the hallway and. Run into all these, you know, exceptional leaders and people who led their lives with the highest of integrity and the highest of standards. And I was able to literally berry pick and say that I want to do this. Like Dr. Wood, and I want to do this like Dr. Ron Mayer and I wanna do this like Dr. Eileen Bulger. And it, it was just like I, I lost count of the number of role models I had. But it does start, I think that, as Dr. Wood started, uh, with is it does start with curiosity, asking those tough questions. Why is it that surgeons have such a high burnout rate? Why is it that surgeons aren't doing something about this? They're all good intention people. Is it because that the system that's in place is hard to change? Is it because of ignorance? They don't know what the best standards are out there and they, they only know the standards that's in their local environment. Do they not realize that? There are organizations like the American College of Surgeons out there that can help, but [00:46:00] you start with that curiosity and you start asking those questions. But it's really about how can we make things better. Um, I'm, I'm excited. I think this is, I know there's a lot of challenges in the world and there's a lot of naysayers out there, and, but I think that, you know, this is a great time in the history of the world, and I believe the best is yet to come. And the work that the Board of Regents and Dr. Wood did with this framework, I, I personally think is transformative. Of course I'm biased. It, it got published in Jack, but I do think we're on the cusp of seeing all these organizations and specialties start putting forward, um, their, you know, workplace standards and guidelines. And, and it's gonna be amazing to see surgeons thrive as a result of this movement. Speaker 2: I wanna say thank you both, especially Dr. Wood and the Board of Regents. You know, I'm a female trainee. I have a daughter that I had in training, and seeing these workplace standards makes me think she actually [00:47:00] might wanna be a surgeon and I might not discourage her from being a surgeon. So thank you. I think this is incredible work. Speaker 4: Yeah, just, just let us know, Dr. Burke, when, when Dr. Wood and I can start our recruitment efforts. You know, kindergarten? No problem. We'll, we'll be there. It's Speaker 2: she's two. She's at daycare now, so Speaker 4: she's in daycare now. Speaker 3: Well, I I'm excited to hear you say that, Dr. Burke, because I, I want surgery to be an attractive specialty for your daughter. And, you know, this is an important, I think, commitment of the American College of Surgeons. So I'm gonna call that out as. You know, the American College of Surgeons is the house of surgery, and this is a initiative, an effort that really is meant to support. The whole house of surgery, all specialties of surgery, and all of our fellows and members, uh, in the American College of Surgeons and, and surgeons that are not, uh, members of the American College of Surgeons. This is an effort by the college [00:48:00] to lift, con, continue to lift up our profession, uh, to do what our commitment is, which is to. Serve all with skill and trust. And so I, I think the Board of Regents has been really thoughtful in their leadership, in developing these workplace standards, getting them published and hopefully. Helping then lead to the part that we've been talking about is the implementation and a, a change in our workplace and culture that make that continue to make surgery the best specialty. Speaker: Dr. Wood and Dr. Vargis, thank you both for your visionary leadership and allyship in this space. We really appreciate you coming on the show. Speaker 4: Well, thank you. Thank you all. Uh, I mean, as Dr. Wood alluded to, uh, we're all huge fans of the Behind The Knife podcast, so it, it's, it's an honor to be here today. Speaker 3: Yes. Thank you, Dr. Thornton and Dr. Burke. [00:49:00] I.