Michelle Moyal, DVM (Host): Welcome everyone, to the Cornell Veterinary Podcast, where we deep dive into the discovery, care and learning that happens at Cornell University's College of Veterinary Medicine. I'm Dr. Michelle Moyal, a Primary Care Practitioner and Chief of the Primary Care Surgery Service here at the college and Schitt's Creek fanatic, just so everyone knows. But I am also a lover of all things Cornell Vet. And in this episode, I'm extremely excited, because we are talking to Dr. Nicole Buote. Dr. Buote is an Associate Professor of Small Animal Surgery. I have to take multiple breaths because there's a lot of stuff in here and I love it. At Cornell Small Animal Hospital. She got her Doctor of Veterinary Medicine degree at Tufts Cummings School of Veterinary Medicine and is a Diplomat of the American College of Veterinary Surgeons. She is also, so freaking cool, a Founding Fellow in minimally invasive surgery. Now, Dr. Buote came to Cornell after a decade of working at a large private practice specialty hospital and brings with her, a deep knowledge of minimally invasive surgery and other cutting edge techniques, which is really exciting, I mean there's all sorts of things, scopes, robots, oh my, right, to assist in surgical procedures, so I'm beyond excited to have you here.

Welcome to the CVM podcast, Dr. Buote!

Nicole Buole, DVM (Guest): Thank you so much for having me. I'm super excited to chat with you.

Host: Yay! Oh, I love this. Okay, so I want to jump right in because I think this is a really cool topic, and we haven't, like, touched on anything like this so far, so I'm very excited because it's an opportunity for me to learn. And before we kind of start talking about cool things like robots, which I'm, I'm very pro robot um, could you tell me how did you get to where you are now? Like, what first, I mean, let's go way back. Like, what drew you to veterinary medicine?

Nicole Buole, DVM (Guest): Yeah, I mean, I think typical to most vets that you're going to ever talk to, right? It all starts with a love of animals. And I was not unique, right? I loved, the animals that I came in contact with in my house, my friend's houses just out, everyday life. But what really sort of changed that from just a more typical love to a passion or a career, was a love of science and then people as I got older and I had more veterinary experience and I really learned that Vet Med is sort of one of those fields where we learn to be creative and how we communicate with our patients and we really get to be a part of the love between an animal and their family members. So yeah.

Host: I love that. love that. And it's true. And for everybody's who's listening, if you're like, veterinary medicine, yes, because people are gross. I've seen on mugs.

Nicole Buole, DVM (Guest): Oh yeah.

Host: I've seen that on mugs. We're just joking. People are not gross, but there is a lot of interaction with people and families. And in order to do anything we need to do with animals, we, we communicate with people.

so, yeah. And so how did that bring you our way? How did that bring you to Cornell?

Nicole Buole, DVM (Guest): I feel so blessed to have had sort of dual careers so far in my career. I basically, I came to Cornell because there were a lot of reasons, I won't lie. There were some personal and some work life balance reasons. But from a professional standard, I just really wanted to do more.

I wanted to investigate new surgeries for, pets. I wanted to be in a better work environment for that kind of support which is probably another conversation for another time. But I really wanted to be able to examine some new cutting edge procedures that I knew I just couldn't do in a private practice setting.

Host: Absolutely, right? So I'm sure you got to expand upon your surgical knowledge in practice, but kind of the academic world just brings like whole new galaxy to what you get do and the opportunities you have. That's so neat. And you heard it here. She said work life balance. I love this. Everybody listening. And so let's talk about that because you were at a specialty practice and I'm sure it was busy. I was in a specialty practice for many years. So what was that experience like? Like, what did it, teach you? We kind of mentioned how it was different from Cornell, but like, how really?

Nicole Buole, DVM (Guest): I mean we've talked about this before, like that I feel like is its own whole hour long podcast, right? Like the differences between academia and private practice, there are, almost too many to enumerate sometimes, but I do feel very lucky that I had that experience. So I'm not in any way, kind of bashing on our private practice colleagues, you know what I mean?

Because it's such an important, part of veterinary medicine. And I was able to get really good at doing surgery. It was really empowering for me to be able to see a lot of different cases, help a lot of different animals. And I am the type of person that is constantly going. So I was still able to do some clinical research on my own time, but eventually, management change...

Host: Because you had so much time.

Nicole Buole, DVM (Guest): Exactly, exactly, exactly. And I had two small kids.

Host: Oh my goodness.

Nicole Buole, DVM (Guest): Yeah, but you know, that's the thing. So management changed and the focus of the work sort of changed and it became just a sort of an environment that I didn't enjoy. As you know, right, when you're unhappy at work, especially for work that we do, where we're so passionate about it, when we become unhappy, we bring that unhappiness home, you know what I mean?

And I wasn't feeling fulfilled and I wasn't feeling like I was able to be a good role model for my two kids, you know? Showing them that you can be super passionate about your job and the hard work and the hours are really, you know, meaningful. And I wasn't really feeling that.

And so I realized I, wasn't able to explore the work I wanted. I wasn't in a good work environment. It wasn't healthy sort of environment. So coming to Cornell has been just basically a game changer for me cause I feel so supported and happy to come to work. I mean, we all have bad days. Don't get me wrong, it's

Host: Oh, sure. Absolutely.

Nicole Buole, DVM (Guest): But it is night and day. But without that experience, A, I wouldn't know how good I have it now, and B, I wouldn't be the surgeon I am, because, again, I had all of those years of just a lot of technical experience.

Mm

Host: I think you bring up a lot of good points, right? So you got to work with a ton of different people from different backgrounds, which is really important in veterinary medicine. Like what lovely perspectives, right? Cause we have to think about that. But even more important, we understand that veterinary medicine and any medicine for human professionals listening out there also, this is hard. This draining. This is mentally taxing. It's physically taxing and, just because that environment wasn't for you, it doesn't mean it's not for everybody. Like people can thrive at a specialty practice and maybe at that point in time, it wasn't good for you. And so that's really important for us to know because you got so much knowledge and you had so many opportunities from there and then you were able to pivot. And I always talk to our students about just because you're at one place,

Nicole Buole, DVM (Guest): Yes. Yeah.

Host: If you're not happy or that passion isn't there anymore, it doesn't mean you don't pivot to another place or different career.

Nicole Buole, DVM (Guest): Right. Yeah. I mean, I think that's one of the things about Vet Med that I love so much is there's so many different options and we have, so many different venues and kind of paths that you can take. And I tell my residents, your first job doesn't have to be your last job. You know what I mean? Like if it is, that's wonderful. And there's no, no problem with that whatsoever. And I really enjoyed probably, eight or nine of my 12 years in practice. So it, you know, if, certain things hadn't changed, I'd probably still be there. But again, I'm glad, everything happens for a reason.

And so, like, I'm so happy to be here right now at this point. So.

Host: I love that. And we, and audience, I know I did such a fabulous intro that you wouldn't think Dr. Buote and I know each other, but Dr. Buote and I have spoken and we chat and we do have a lot of similarities in this discussion, right? So I was the same, and so I love that you're talking about it because also was in practice and then transitioned to academia.

So, is there one thing at Cornell, like, in this environment that stands out to you, like, for when you go to work? Besides the singing and the pollyanna and, because, you know, birds carry my lab coat

Nicole Buole, DVM (Guest): I know.

Host: when go to work.

Nicole Buole, DVM (Guest): I mean, it's kind of embarrassing because I remember interviewing here and thinking, these people can't be real. Like, they can't really be sort of this nice and like, genuinely supportive people. And I've been here for three years and I, honestly feel like it's true, and that is a huge thing. I mean, I ask people to help and they bend over backwards.

Host: You're like, they actually help.

Nicole Buole, DVM (Guest): I know, and, and I talk to a lot of my colleagues and friends at other universities and, they're all different in good and different ways. But I usually come away when I talk to them, feeling how lucky we are for the amount of support that we have.

And, that does sort of play into why I came because I knew I was interested in robotics and they said they would help me start that investigation. And they have. So, that's part of why I'm here is because they have been and seemingly continue to be supportive, which is a really great environment to work in.

Host: Yeah. Surrounding yourself with the people that have a similar passion or similar motivation, maybe different passions, different that I love that. And so, okay, well, let's jump in because you were mentioning it. You specialize in minimally invasive surgeries. So for all of us in the audience who might not know what the heck that means, I mean, I think we could kind of like think through it a little bit, right?

But can you explain what that means? Like, first of all, what is it? And then why would our audience, why do we want them to consider it? Why should they be thinking about it or talking to their vets who are like me about it?

Nicole Buole, DVM (Guest): Yeah. In brief, just like low level what, any type of minimally invasive

Host: I need low level. That's audience. That's, that's for me, guys. Just so everybody knows, kids.

Nicole Buole, DVM (Guest): It's really any procedure that can be done through small incisions, or sometimes no incisions whatsoever. So, the procedures that I like to do are things where we can use different types of imaging modalities. That's kind of called like interventional radiology where we can take ultrasound or x-ray images and pass wires and stents and all sorts of things just through a vessel, right?

And so you end up with no incision and you've had a major surgical procedure, which is pretty nice. The laparoscopic which is like abdominal procedure and chest procedures. We use small incisions, like the size of a eraser, on a pencil.

Host: For those of you who don't know that, kids, are these pencils we had use when people our age went to school,

Nicole Buole, DVM (Guest): Don't even say that! Oh my god, a pencil? They don't know what a pencil is?

Host: Half, it's like a half of a Skittle.

Nicole Buole, DVM (Guest): Oh my god, I'm really depressed now. Now you've depressed me. I was like, yeah, they'll know what pencil is.

Host: Sorry.

Nicole Buole, DVM (Guest): Oh man, I'm gonna

Host: Just maybe case, just in case.

Nicole Buole, DVM (Guest): I'm gonna, I'm gonna have to go sit in a closet now. Um, Yes, well, okay, look up what a pencil looks like.

And so the, some of the incisions that we can make are as small as that. So, it's about 5 millimeters sometimes twice that big. But there's still tiny little incisions that we can put a camera and a telescope in inside these body cavities and we can do these major procedures. And why they should ask their vet about it and why they should care is because just like in people, these procedures are associated with decreases in pain and infections.

And so, there are so many different options nowadays. But if you were going to have a lot of these procedures done as a person, you would want them to be done in this technique so that you would feel better quicker and not have to be in the hospital. And many owners would like that for their pets. So.

Host: That's just incredible. And absolutely makes sense. So my mom just had a heart valve replaced and they replaced it through a small incision in her leg and put a valve in her heart.

Nicole Buole, DVM (Guest): It's crazy.

Host: And so, yeah. And when we think about, so the same in pets, you're telling us instead of breaking into the chest, which it does, it is that dramatic. It is. Now you get to enter and do everything you need to do, but through small incisions. And then not only do the owners of pets that they love, love, love, and adore who they're putting, they're like placing them in your hands for these very serious procedures. Now you can decrease the risk of infection.

And again, do this with very small instruments, and then the pet is more mobile, we hope, right? And then they can hopefully heal because they don't have a huge incision, and so that's so neat! Ah, that's amazing! And so what, can you give us, I know you mentioned some, but can you give us some examples of procedures you do minimally invasive manner?

Nicole Buole, DVM (Guest): Yeah, there's so many which is great, you know, that keeps me very excited to come to work, but, I mean, we do things that I hate to say simple because, as you know very well, right, nothing is simple, everything, nothing is routine,

Host: We never use routine. Exactly. Exactly.

Nicole Buole, DVM (Guest): But we do things such as spaying, especially like big dogs where we can also use the spay procedure to also do the gastropexy procedure where we're tacking their stomach to the side so they don't get that terrible disease GDB, where their stomach flips on themselves, which could be fatal. So we do procedures. Yeah, exactly, exactly. We do that procedure pretty commonly, but then we do things like removing kidneys and removing lungs.

Host: I know you mentioned something called gastropexy, which by the way, for people listening at home, there's a life threatening condition, right, she said called GDB. It's essentially where the stomach gets really big and twists and it can be life threatening. But you're telling me you can help prevent that through minimally invasive surgery.

Nicole Buole, DVM (Guest): Yeah, so we, can, at the same time as a spay or at a neuter procedure, we go in with this little camera and these little tiny laparoscopic needle drivers and we can actually attach the stomach to the right side of the body wall so it can't flip on itself. So those are some of the very common procedures that we do, but then we also do more advanced procedures like removing kidneys and lung lobes and, adrenal glands and taking out stones from the bladder and lots of other types of cholecystectomy, which is really common in people that they do minimally invasively. That's the standard of care where you take out the gallbladder. We can do that in your dog as well. So lots of different options.

Host: That's incredible. And I'm going to just backtrack for one second. You said with needle drivers, which is an instrument that holds like the little needle and the suture that you use. Does the instrument, like break it down for me, does the like laparoscopic instrument hold a little needle driver?

Nicole Buole, DVM (Guest): Yeah, well, the laparoscopic instrument holds the needle and it's a straight instrument, very long that we put through these little tiny, ports, you know, which are also what kind of go through the, yep, exactly, go through the skin of the abdomen or the chest. So all of our instruments are really long and straight and they go through these tiny little incisions and we're standing on the outside, you know, at the end of that long straight instrument, sort of manipulating it in order to suture or dissect, you know, any, you know, yeah, yeah, exactly.

Any of those structures.

Host: You, are like the puppeteer of the organs.

Nicole Buole, DVM (Guest): It organs. does look like that a little bit.

Host: That will be new title I'm going call you that in the hallway.

Nicole Buole, DVM (Guest): And that is actually the difference, that's one of the big differences between laparoscopic procedures and robotic procedures.

Host: So I want to bring this up because this is an important topic. So for veterinarians out there I kind of do my reading and I'm looking into some things and there have been some instances where a veterinarian like me, a generalist, maybe spoke about a procedure in a large dog like that and spoke about spaying, because a lot of us really believe it's important, and we spoke about that procedure, that gastropathy, that summit, essentially the body wall to the stomach. And we don't bring up laparoscopic surgery or referral to someone like you. And that it could be an issue. Now I want everybody to know, because this is important. We want all of our clients to be really educated so they can make the best decision for their pet. So what should someone like me be saying to an owner to talk about this before they get to you or to help them think about it?

Nicole Buole, DVM (Guest): Yeah. I think that's such a great point. And, when I was in California in private practice, those kinds of discussions when they didn't happen and then the owner found me somehow on their own, they, were really sometimes frustrated and disappointed, that they were not told ahead of time.

So I, 100 percent agree with you that I think educating and giving owners options is so, so important, because it just really increases the trust between the general practitioner who is like a part of their family many times, people really connect with their general practitioner.

And so it just increases that trust for them to be able to say, look, there are these other options. Minimally invasive procedures aren't going to always be an option. You know, It does depend on the disease process, lots of other things that we do that take into account. So sometimes we do have to do an open approach, but giving owners the option and understanding that the opportunities that exist out there, again, only makes owners happier, you know what I mean, to, know it, and then they can kind of make that decision of something they want to pursue.

With regard to, like, what I would have GPs tell owners, I would always say if they have an owner who's interested in discussing a minimally invasive approach, I think the number one thing is I want them to know which procedures can be done that way. I'm always open to phone calls. Like, I love referring veterinarians on the phone because then they're more prepared.

They can prepare their owner better. And I think the other thing that I always tell them is, you know, because we haven't seen Fluffy yet, we can't promise that this can be done. Sometimes, tumors are too big to be taken out with tiny little incisions, or sometimes, there's something else that makes it not, not possible but if there's a way, I definitely have the will.

So, you know what I mean? It's like really a matter of making sure owners are aware. Because, we want to help if we can.

Host: So I love that you mentioned that and I think I, I would forget that sometimes in practice. So much like tell the students, hey, if you have a question, you can approach pretty much almost any faculty member in the building and ask for help.

Nicole Buole, DVM (Guest): It's so true.

Host: When I was a practitioner, I don't think I thought, I wonder if I can just pick up the phone and call my local specialist, but you can. And it's not about, keeping them on the phone for like an hour and a half, because everybody's time is very valuable and we need it. We need our rest, but you certainly can call and say, Hey, what do you think about this? Okay. Can I send them over? And then that helps both the specialist who is there because they want to help the patient, right.

And their family. And it also helps the family because the family could get there and be like, wait a second. I had a different point of view. I thought I was told something different. And we love really good communication. And again, for everyone, medicine we know is not an exact science. So one of the beautiful benefits of consulting with a specialist is literally they look at everything and they look at the patient and they say, Yes, this is something we could do.

Or, no, this not ideal. So I love that.

Nicole Buole, DVM (Guest): A hundred percent.

Michelle Moyal, DVM (Host): Thanks for sharing that. And so, okay, we're still on laparoscopic. I'm just wondering, is there, cause usually, there's like one case in your mind where like, it really, you're like, I will never forget that. Right? Like, and is there like a case or, even more than one where you were like this, this made a big difference for this patient? Like, I will never forget that.

Nicole Buole, DVM (Guest): Yeah. I mean, I have one that comes right to mind when you asked that question. It was Kaija. She was a husky that I saw here at Cornell maybe about a little less than a year ago now. She had a thymoma, which is a mass inside the chest. And it's a type of tumor and it sits in, like, kind of near the neck inside the chest.

Kind of way far up. So it's not associated with the lungs, but it's this mass that forms there and it can cause secondary problems by having, not only just the fact that your pet has cancer, but it can also cause other symptoms by kind of sitting there in the chest.

And so Kaija had gone to her local practitioner for a cough, and they had taken some chest x-rays, and they found this mass, and he or she referred Kaija's owner to a specialist, who talked about doing a pretty, it's a standard procedure for this per for this diagnosis, but it's a pretty invasive procedure. It's called a median sternotomy, and that basically means cutting through the bones in the front of the chest.

Host: And when you say standard, that means essentially every doctor right now, or like the majority of doctors, if they saw this, they would say, okay, the plan would be to go through the chest and do a median sternotomy.

Nicole Buole, DVM (Guest): Exactly. So like that is a perfectly acceptable surgical approach. But this mass can also be taken out thoracoscopically, so that means with tiny little incisions, again, we go in, we kind of cut the tissue that's attaching that mass to the chest, we put it into a sterile bag inside the chest, and then we pull it out of a very small hole so that the dog doesn't have to have the sternum broken, and then wired, back shut.

And so he found me on his own through doing research and came, and he, it was from Massachusetts, so it came from many, states away, a state away. And had the surgery here. Kaija went home, you know, in two days. She's still

Michelle Moyal, DVM (Host): doing well.

Two days? That's incredible.

Host: And if she had had a sternotomy, she probably would've been in the hospital much longer.

Nicole Buole, DVM (Guest): Yeah, four or five probably, just because it's so painful. Again, we are very good at managing pain, so I don't want to make it sound like if your dog has to have one of these done, it's the end of the world, because it's definitely not. But when they're on more pain medication, that affects them, right? It decreases their appetite. It decreases the movement of their intestines.

So then they feel a little bit nauseous. And so there are all these other effects to having to give them more pain medication and having this really large incision that goes all the way down their chest. So again, having said that, some of these masses are too big or have too much blood supply and it's dangerous and we can't do it with the scope.

But this was an owner who was interested in at least seeing if that was possible. And it was possible based on our imaging and she did really well. And I really felt like I did good. That was one of those procedures where I made a difference with with that dog and the owner really knew that. And that made it even better.

Host: Oh, I love that. And I love stories like that. And I want everybody to know, and I'm sure Dr. Buote's thinking the same thing, we love our professionals who do the standard thymoma surgery too. We need those professionals. Just in some cases, right? So for certain patients, if we have the opportunity and the family can pursue that option, then great for them to have more options to choose from. Not that one is better than the other. So I want everybody to think like, I'm just like oohing and aahing, cause I think this is cool, but there is no judgment here. This is a judgment free zone, right? But that's so neat. Oh my gosh. That, that, that is amazing. And so, okay. I'm like, I want a drum roll, but I don't have one, but it's okay.

I've been waiting to talk about robotic surgery. And so I'll admit, I have like an old school, students won't know, Battlestar Galactica, like droids, Star Wars, like I jump right to that. But you've introduced robotic surgery, like to our hospital, which is again, incredible. And we're the only veterinary college to be doing this right now, which is like, wow.

Let's just hear more about this technology. Like, how do we use it? Who does it benefit? Like, I'm here for the robots.

Nicole Buole, DVM (Guest): Let's dive into it.

dive

Host: into the robots.

Nicole Buole, DVM (Guest): Yeah. So, again, I could talk about this for a long time, but the main differences between Normal, sort of traditional laparoscopic surgery, which is also amazing, and the robotic surgery is the instrumentation. So, the instrumentation with robotic surgical options

are hyper articulated. And what that basically means is that instead of having an instrument like a needle driver that holds suture for you to suture tissue to, and it being really straight with no, no ability to bend, the robotic instrumentation has multiple bends to that instrument. So it actually acts just like a human wrist.

And so because of that, it's much more comfortable to control. There's a lot more flexibility. It's very intuitive when you're suturing with it. So it, allows you to do a lot more than you can do with straight instrumentation, which is very difficult.

If you ask any of my residents, a gastropexy, which is, again, one of our more common procedures is one of the most challenging because it requires laparoscopic suturing inside the abdomen with a very long straight needle driver, which is, counterintuitive to how the human wrist works. So we are, constantly working and, on the human side, one of the reasons robotics has really taken off is the ergonomics for the surgeon are so improved that hospitals are seeing less surgeon injury, you know, less days out, more efficiency in the OR, quicker procedures, less complication because the instrumentation allows us to use these tiny little instruments just like we would if it was an open procedure. So that's the big benefit to it.

Host: And I would think also, right, so obviously if the surgeon's not injured, then they're there to do more procedures, which is awesome. But I mean, the instrument is straight, but the patient is not. So if you're working in a space that is not a box, right, and it is rounded and other things are in the way, then using a robot helps you navigate the stuff in your way. So it, supports the patient, right? Cause you get kind of move and bend with the patient's anatomy.

That's

Nicole Buole, DVM (Guest): Totally. And the big procedure that everyone will know of associated with robotic surgery in people is prostatectomy, which is removing the prostate when there's cancer in it. And the reason that robotics made such a dent in that procedure and really allowed it to help human, help human men with that disease was that it allowed for really fine very delicate suturing in a very tight space, which was the pelvic canal.

And so allowing for that type of accuracy, is something that we really could benefit from with our animal patients because our animal patients are usually smaller and have really small, tight spaces. So, the thing that excites me about this is being able to not only push the envelope for our veterinary patients, but also the potential for translatable work over to human, you know, especially human pediatrics, but we only are leasing this robot.

So we need to make sure that we can get some support to be able to buy it. Otherwise, we won't be, yeah, yeah we won't be the only surgery.

Yeah.

Host: So still small incisions?

Nicole Buole, DVM (Guest): Yeah. Still. Yep.

Host: So like the benefit of laparoscopic but because of this like hyper flexibility, like me walking down the street versus like a ballet dancer or a gymnast deciding, me doing a cartwheel is not the same as Simone Biles doing something. And so this robot brings Simone Biles, if you will, into the OR because it can kind of navigate so well and so finely.

Nicole Buole, DVM (Guest): Yeah. It's really incredible. Like we did the very first live robotic gastropexy, like on client owned dog. First one in the country. We did it a couple months ago in November and the procedure took 26 minutes because of how you know, how intuitive the suturing is. So, again, just we're at the very infancy of this in veterinary medicine. But I'm so excited to see where this goes. Cause I, feel like this, could be a game changer.

Host: That's so neat. And again, but compared to laparoscopic pexy, is there like a big, the time that it takes for

Nicole Buole, DVM (Guest): The time to sense about a half, as long. You know what I mean? And granted it is, that was like the very first one. So our times will get even less. And I did allow my resident to hop onto the surgical console to get, to do a little bit of the suturing too. So, you have to keep in mind like with all of these brand new kind of procedures, they only get better over time as people get more trained.

And people get more familiar with it. I mean, right now, again, we're the only vet school who has a robot. So we're really, we're the ones figuring out how to set them up in an OR, in a veterinary OR, who to work with, with the draping, getting our technicians all set up on how to clean, you know, all of it is brand new to us. So we're really making strides and figuring all of that stuff out.

Host: I love that. So the learning process is not in the equipment alone. It's having the equipment, it's maintaining the equipment. It's people navigating around the equipment. This is a big, this is a big thing. And I love that. And, you know, I always talk about Cornell and do the greatest good, but like, this such a neat moment in doing the greatest good, right? Because this can translate to the human side. And I love to talk about that. Like

Nicole Buole, DVM (Guest): Yeah,

Host: It's medicine. This is not like veterinary, just veterinary medicine, just human medicine. And I love that. And so, I mean, I have other questions, but I want to ask something really cool. Cause I, wrote it in your intro.

So, you are a founding fellow in minimally invasive surgery. So, we know you're a veterinarian. We know you're a board certified surgeon. So what does that mean? Founding fellow? Like, what did you do? What did you bring to our profession? Tell me, tell me the goods. Do you have different initials?

Nicole Buole, DVM (Guest): Yes,

Host: Love me some extra initials.

Nicole Buole, DVM (Guest): I know, it's not really extra initials, we just usually put that whole kind of clunky sentence at the end. At the end. Um, but yeah, so, so the board of the ACVS, which is our College of Veterinary Surgery, they have a couple different sub specializations that are out there. And so minimally invasive surgery became a sub specialization probably, I can't remember if it was like five to 10 years ago, maybe, less than 10, but it became a sub specialty a little while ago.

And in order to be a Founding Fellow, basically what that meant was I had so much experience and I had published on minimally invasive procedures. I had spoken at national and international conferences about minimally invasive surgery that I didn't have to go through a specific fellowship myself because I already had all of those qualifications.

Yeah. So so now Cornell can, because I'm here, we actually, and we actually are, starting a MIS fellowship where we have our first fellow starting in small animal in April.

Host: What's MIS, if you don't mind me asking?

Nicole Buole, DVM (Guest): Yeah, minimally invasive surgery.

Michelle Moyal, DVM (Host): Oh, you did say that. Yes. Thank you for everyone. That's okay. But awake.

Nicole Buole, DVM (Guest): No worrys, but we have had a large animal MIS fellow for a year now. So I mean Cornell is definitely not only performing these procedures, for training the next set of surgeons to go out and be amazing.

Host: Right. And it's not just small animal. That's right. There's large animals or larger animals, right? So like horses and things like that. So so cool. I guess my question, to you is right now, where do you think this will go in a few years? So as a general practitioner, I deal with people that may not have the finances to do things like that. So you, do you see this in a realm where it will be more mainstream in the future? Do you think maybe we'll do more laparoscopic, like the cost maybe of that will come down as we explore robotics?

Nicole Buole, DVM (Guest): Yeah. I'm so glad you asked that because I, so I teach two courses to the students. I teach a minimally invasive elective course where they get to go through a bunch of different training and then they do a live procedure at the end of that course and they just absolutely love it. And then I teach an interventional radiology course where they get to a bunch of training there.

I feel really strongly about teaching the students both of those courses, because in the 20 years, I've been a vet for almost 20 years. In May, it'll be 20 years. So in the 20 years I've been a vet, I remember vividly when I was a resident hearing that laparoscopic surgery was like a flash in the pan. No one was going to do it.

No one was going to pay for it. It was stupid. And now, fast forward 15 years, like it is a standard of care for a lot of, no, I don't want to say standard of care, but it is very much a part of our surgical our surgical caseload. And, and the, so much so that the ACVS, you know, our college of surgery requires our residents to get training in it, right?

Because it is so much a part of it. So if you had been back there at that time, you know what I mean? No one believed it. So I think robotics is it gonna be in every general practice? Of course not, but just like laparoscopy wasn't thought of, as something that was gonna stick around, and has proven those naysayers wrong, I think robotics absolutely will become at every university, and I think for sure at some specialty practices, they could absolutely have a robot. And what I see is that general practitioners have a lot of laparoscopy already. And there are only more and more that are getting it. And one of our students that did my MIS course, who's graduating this year, she is her, the practice she's going to I spoke on the phone with her practice owner and they're going to set up, they're going to buy a tower for her.

Oh,

And I was like, this is amazing.

Host: cool. That's

amazing. is amazing. Oh my gosh.

Nicole Buole, DVM (Guest): So it's happening.

Wow. I'm excited.

Yeah. And I mean, the robotics stuff is expensive. There's no question about it, but just like laparoscopy, the more people who do it, the big problem with robots was da Vinci was the only game in town for many years. And now there are seven new robotics companies coming to market.

So costs are going to go down. And again, I think that will every surgery need to be done with a robot? No, but, we'll be able to, if we research it, if we do the work, we'll be able to tell which procedures really benefit patients with the robot and which ones don't.

Host: That's so exciting. I can't believe that about that too. That's incredible. But I remember thinking, so I've been around a while too um, I remember thinking, oh, endoscopy, like the tube that we put down the throat, the gastrointestinal tract in animals, thinking that, that had to be an only specialty thing. And now so many general practices have them. It's incredible. So progress it's inevitable. And so that's really cool to hear. So, it's clear that you enjoy, they're making me say this, it's clear that you enjoy the cutting edge of surgical techniques. I do applaud the pun. Um, Why do you think you're drawn to this so much?

Like, I mean, you like surgery, that's awesome. But why do you think you love like this? Why the new, why the?

Nicole Buole, DVM (Guest): Yeah. Well, I think, I mean, I'm sure you have found this in your career as well, right? When you've changed, when you've like gone from private practice to academia, I'm sure people asked the same thing, kind of like what made you do that and what made you excited about this kind of different, aspect of your career. When it comes to MIS and the robotics and all of that, what really encourages me and inspires me is, again, that ability to potentially take a procedure that can't be done with less pain. It's just a more open, massive, maximally invasive procedure and take that procedure and change it into a way where these animals can walk out the next day or two days later feeling like nothing happened,

Host: Or feel better, like feel even better than they did when they came in.

Nicole Buole, DVM (Guest): Exactly. So that's what keeps me going is, I feel like we kind of stagnated a little bit some at some point with the laparoscopy. We just kept kind of doing the same thing with minor variations. And I really, really want to discover some new things that aren't being done now that we can do that are better, better.

Host: Right. No reinventing the wheel, so to speak. You would like to be making new things. Oh, that's so, that's just so incredible. And so, like, what do you think is the favorite part of your job right now? Is that it? Like, kind of being on the cusp of this exciting new thing?

Nicole Buole, DVM (Guest): Yeah. I mean, I, a hundred percent, if I had like 48 hours in every day instead of 24, I would sit and read as much as I could about all the different, stuff that's out there on the human side that we don't, kind of even consider and try and translate things to our veterinary patients.

So I, I love being able to learn new things about the job that I do, where I'm like, I never even considered this or, let's think about it from this perspective. But I'll tell you, probably what's right up there with that is, is the training of students and house officers, or like our interns and our residents because again, like, we had this brand new robotic procedure, never been done in the country, and I let my resident, get on the robot and do some of it.

And I can't even imagine not letting him do that, you know what I mean? Like, it, just so exciting for me to drag my residents along with me during these, you know what I mean, during these procedures. So I just. I love that. That's what makes me so excited about coming to work is being able to train them and get them excited, hopefully, about some of the stuff that we can do.

Host: I love that. And it's the same, you know, and I teach obviously general practice surgery and general practice cases, but like when it clicks for them or they try a technique or they get something, it's just joyful. Oh my gosh. I wish I could explain to others and I'm sure other people have had joyful moments, but watching a young soon to be doctor like, have those things that they've been training so hard to do, like be manifested in front of you and you're part of that is really incredible.

Nicole Buole, DVM (Guest): Yeah, exactly. I mean, the journey that I see residents take over their three years when they like first start doing the really hard stuff with the scope where they're suturing and then at the end or hopefully before then, but they're like, just whipping through a gastropexy and just feel really good about it.

And I feel like I had a part of that and that makes a difference to me a lot. And, that is one of the best benefits of being here at Cornell.

Host: I love that. I love that. My goal is to be like, someone's telling a story and they're like, that Dr. Moyal, told and I never forgot that. And even though I won't know, I'm thinking it. So, do you have a favorite procedure?

Nicole Buole, DVM (Guest): No, that's too hard. I, it's like, I like so many of them.

Host: question about

Nicole Buole, DVM (Guest): I'm sorry. Yeah, it's like I have, I love, you know, laparoscopy. I know, I do. I mean, that's the joy of, my job, though. I definitely think that, I love some of the more advanced, minimally invasive things that we do. Like, I love taking out kidney tumors and adrenal glands, and I love taking out things in the chest, like the mass I talked about, and lungs.

Host: My heart rate is increasing right now as you are saying that stuff. Thank goodness for people like, you.

Nicole Buole, DVM (Guest): Those are the things that get me, like, super duper excited, but there's nothing wrong with, again, our more common laparoscopic spay gastropexy. That really gives me the opportunity to, like, teach the student while the resident's doing some, you know, I mean, they all have a great purpose.

And yes, I'm hoping that we're going to be doing more and more robotics, so those will probably become my favorite once, once we get more of those cases.

Host: Because robots. Um,

Nicole Buole, DVM (Guest): Yeah because robots.

Host: So music in the OR.

Yes or no?

Nicole Buole, DVM (Guest): 100 percent yes. Yeah. No, I kind of feel like you're a sociopath if you have to have quiet, but, but I say that with love because I know people, I know people in my section who don't have music who I love very much, but I just like can't handle it.

Host: It's just, I am the same way. I need music and our the students on I teach, the students are allowed to pick the music that they want to do surgery to in our OR. I love hearing what they're into. So what Dr. Buole, is your music of choice when you are performing surgery? I must know.

Nicole Buole, DVM (Guest): Yeah. You know what? It's funny, because I let the resident pick.

Host: Oh.

Nicole Buole, DVM (Guest): I do have rules. They're always, They're like, I do, I, because, again, I'm so, I'm such a nice mentor, you know what I mean? That I'm like, and I don't really want to be judged. Number, number, like, so that's really probably the number. Yeah. Um, but I, yeah. But I do have rules. So I, and I am not sure that I, I don't know if this is a safe enough space to share those rules because I'm sure some of your listeners will take issue.

Um, but yeah, but I'm not a huge like country music fan, which, my, to my husband's chagrin, he likes country and I always turn it off when I get in the car. So I, I don't. I don't allow country. It's too distracting, too whiny for me. And then I'm not like into like heavy metal screaming. So like that, I'm like, no thank you. But other than that, I'm like, pretty much like you pick it. We've got one technician who loves show tunes. So that's an interesting time when that goes on. Cause she starts singing. So I'm pretty good. I just need there to be some music.

Host: Gotcha.

Nicole Buole, DVM (Guest): Cause I love to have that in the background.

Host: I'm married to someone from Texas, so I, had to to embrace, country but I agree. I can't even work out to something with a more metal edge just because it makes my heart kind of race, are some people that love it. It just drowns out and it becomes like the perfect noise for them.

Nicole Buole, DVM (Guest): God, I, can't do it.

Host: To each their own.

Nicole Buole, DVM (Guest): Yeah. I think I have like PTSD from when I was a surgery tech at Tufts. Like as a student, there was a one particular resident who just would destroy us at two o'clock in the morning with like heavy death metal. So I was like, no, thank you. No, thank you, so.

Host: You, but you remember that doctor.

Nicole Buole, DVM (Guest): Oh, yes, I do.

Host: And much like we want people to remember us, here we are. You are talking about this person. That's incredible.

Nicole Buole, DVM (Guest): Yeah.

Host: And so, you know, I try to ask a few, um, do you eat candy? Candy or chocolate?

Nicole Buole, DVM (Guest): Candy or chocolate? I am not a huge sweets person, but if I had to choose between the two, I would say chocolate, but it would have to be dark chocolate.

Host: Oh, hmmm.

Nicole Buole, DVM (Guest): Yeah.

Host: Healthier version. Okay. So you a salty person?

Nicole Buole, DVM (Guest): Yes, definitely a salty person.

Host: What is your snack of choice? I'm sure our audience would be like, what is she snacking on right after she uses a robot? Cause I need to know. Cause

Nicole Buole, DVM (Guest): my,

Oh, that's, well, and I don't know how you are, I don't know how you are on a surgery day, but people make fun of me because I do not, like, eat or drink, which is terrible by the way, this is like a PSA, do not follow this, but I do not eat or drink on, like, surgery days. Like, I get down to the OR and I'm there all day. So, I don't tend to eat on those days. But, on the days that I do have time to snack, I'm definitely like a potato chip person. Definitely love potato chips.

Host: I do love chips.

Nicole Buole, DVM (Guest): They're like a weakness of mine, for sure.

Host: I have declared my love for smart food, that cheesy popcorn, in previous episodes, but I am also pro chip, for sure, for sure. And so, oh, I love it. I just, hearing those like, those little things. By the way, yes, everybody needs to drink water during the course of the already use restroom. I tell this all the time, because in practice. I would realize that I didn't have anything to drink and I'm sure you found yourself in that position because you're just like, no, let me, I need to get to my patient. And so that's the dedication a lot of veterinarians have, but we don't want it to be at the cost of our physical health.

Nicole Buole, DVM (Guest): No, definitely not. I always make sure that my, students and residents are good, but like, I'm a terrible person with myself, because there's always something to do.

Host: Yes, I totally understand that. I'm like, you go get lunch. And then I'm like, eaten yet. Don't worry. I can wait. It's fine. It's fine. I love that, but that just shows, the passion you have for teaching and taking care of our students and taking care of our future colleagues, and I'm so excited.

Is there one thing you just want the audience to know before we kind of sign off about what you do, or minimally invasive surgery, like, you're like, if there's one thing I would like you to know, it is this. Robots.

Nicole Buole, DVM (Guest): Yeah, I mean, definitely robots, definitely robots. I mean, I guess just like you said at the very beginning of this, I think the one thing that I would want people to know is that there are so many options available now for surgery and to involve your general practitioner, but also, you know, do a little research yourself, find out if there are other options because sometimes, as you know, it's it's really hard to keep up with everything that's going on.

And so take the initiative and understand that yeah, sometimes it's not going to be possible for your pet, but there's, it never hurts to question and see if there is a less invasive way because when it comes to animal care, we can't communicate with them the same way we can with a person, you know, it's very similar to pediatrics, and so the more we can do to lessen their pain and their discomfort and their fear of being in the hospital, the better, I think. So.

Host: I love that. And the more families, become educated on what to do for their own pets. So a general practitioner like myself, we try to do as much like continuing education to all of these things to be better doctors. But sometimes there's a procedure, you know, that maybe we aren't familiar with. And it's, it's not intentional to not offer something. So so if a family does research and then they come to you with it, then, we learn and we look up more and we get to talk to specialists like you. And then they get. So, everything is better for everyone. So I love that. Dr. Buole, thank you so much for joining me.

This has been amazing. I've learned so much, and this is so cool, and I'm gonna, I would like to come, I will walk across the building, will, I would

Nicole Buole, DVM (Guest): Walk across and come see a robot. Yeah, we're doing one next Friday, actually.

Host: I will put that on my calendar. All thank you so much for joining me and for everyone listening. Thanks for joining us today on the Cornell CVM podcast. Tell your friends, rate it on your favorite platform, because we're fabulous, and we will talk to you soon. Bye.