Matt Sherrer, MD (Host 1): Welcome to another edition of the Fresh Flow Podcast. Mitchell, I have some concern for you this week. I know this is a call week for you. I know you're doing some nights. Are you hanging in there, bro?

Mitchell Tsai, MD (Host 2): I am hanging in there. Even though the audience can't see, my nose is completely red and I look like Rudolph the Reindeer.

Host 1: It is. It is. Mitch is not only dealing with lack of sleep, but also it looks like a cold. But because of his dedication to the cause, he is here and is functioning probably double what my brain functions at, even though he's limited. So, glad to have you here, bro.

Host 2: Oh, thanks, man. That just means I'm firing on two neurons, right, versus your one.

Host 1: Well, this is going to be a good one. We say that we like to talk about interesting topics in the perioperative space. And so if we're going to do that, then we can't just invite anesthesiologists to join us, right? We actually have to bring the people who operate. And so today, we are going to go across the ether screen, or as Mitch calls it, the blood-brain barrier, and go across and talk to a surgical colleague. So, this should be a good one. Mitchell, you want to do an introduction here?

Host 2: I'm really excited today to welcome our guest, Dr. Elise Ames, orthopedic surgeon here at the University of Vermont, Larner College of Medicine. I've had the opportunity to grow up here in this department as an anesthesiologist and institution, but I've also had the wonderful opportunity to just work with amazing surgical colleagues. And so, Elise, welcome.

Elise Ames: Thank you. Happy to be here.

Host 2: We're going to go cover sort of a lot of topics, right? But, you know, we're anesthesiologists, you're surgeons, but hidden in your CV, I think you look across what you've accomplished in the department, the institution, you know, and even across the country and your efforts to innovate graduate medical education. And if you look at us, me and Matt, you know, anesthesiologists, we're the champions of patient safety and that's what we're supposed to do. It's relatively easy to build the case that Anesthesiology has done well or better than any other specialty. But with that in mind, what do you see are the opportunities for orthopedics and then for the perioperative space?

Elise Ames: That's a great question. So, we're really talking about collaboration, right? We're talking about collaboration on both sides of the drape and even by inviting me here, you've done that. I'll have to rat Mitch out a little bit by saying that every once in a while, we might get a little bit testy with each other on both sides of the drape, particularly when I might happen to be assist a hand surgeon instead of a resident, which then he managed to leave the room and I got to operate with the hand surgeon for the next 11 hours in my complex spine case, who is still pissed off at Mitch's side, but you know, come here or there.

So, thinking about collaboration, I think there's huge opportunities that we don't pay enough attention to. And I think sometimes it's because we're very focused on the clinical world. And as my current roles, I've retired clinically now just recently, and doing a lot with national education, and particularly residents, and in fact, all different specialties, not just ours. So, I was thinking about that, and I think that I would like to use an example and spend our time today a little bit talking about collaborative work on a learning model. So, you're going to have to spare me for some education geek speak every once in a while here, because that's what I do.

So, here's an example that goes to, I think, your question, Mitch, right out of the model of learning from excellence. I just had the opportunity with my national hats on to sit with an anesthesiologist who's very involved with this. He's the founding director of the National Center for Patient Safety in the VA system. And that has an emphasis on culture and his emphasis is on culture. So, you might say we found some common ground there because that very much aligns with my interest. And what struck me in a very long conversation was that his comment was we tend towards reactive approaches and we like to react, we like to concentrate on specific paths, whether you guys are at the head of the table, I'm at the other end. And that makes sense, given what we do for a living, but I think there are a lot of other opportunities. So if both of us are coming from cultures that are reactive and task-oriented, that may not be so consistent with where education is going. So, I have some ideas about future opportunities for that with respect to that question, Mitch, if that's a direction you'd like to go.

Host 2: Absolutely. Matt and I need guidance.

Elise Ames: And there you have the perfect answer for most anesthesiologists during surgery.

Host 2: More Matt than me. But you know, go ahead.

Elise Ames: All right. So, here's what I would suggest to everyone listening to this, let's talk about collaboration. So, collaboration's a culture phenomenon, right? We either collaborate or we don't. There are some cultures that do it very well, there's some cultures that don't. And that's not about the specialty name or even the MD degree. That's kind of about the person that's standing there. And so, you know, I think we have to think about the culture on both sides of the drapes, really. And that's a local phenomenon. So, the questions you might ask is the questions I ask myself all the time. How does a group assess that? How does your department think about it, and figure out where you are, and how does my department think about it, and where we are, and how do we bring that all together?

And then more important, and I think Matt may have some comments about this too, is think about the O.R. as a theater. I like to use that analogy a lot. Somewhere in that theater, there's a very impressionable learner. And whether it's a medical student, a resident, it doesn't matter, but somewhere in that theater, there's somebody watching us work through this, and how does that affect them? How are they watching the banter between Mitch and I, and deciding is that fun? Is that okay? Is it not professional? There's a whole lot of stuff going on at that cultural level. And then at the accreditation level, which is what I'm really mostly involved in now, what's the role of standards? I'm not a fan of a lot of direct mandates. I'm just not. Although it amazes me how often we in medical education or medicine as a whole search for them and then the associated tool. This is the rule here. Where's the tool that's going to get me that "answer"? And my concern is I think anything that has to do with culture maybe doesn't fare very well.

Host 2: I like to add that we spoke with Jim Rathmell down at the Brigham and he talked about for anesthesiologists, right? One of the things that we need to do is we need to be at the board. We need to be present in the system. And when I'm onboarding our new charge anesthesiologists, the first thing I tell them is you got to walk the walk and talk the talk and you got to walk around and meet everybody, right? You got to introduce yourself to the surgeons and you got to understand them, right? Because it's a quid pro quo and to that comment of the medical student, yes, it's a one encounter that the medical student might see, right? But for you, as a physician, it's the other encounters afterwards, right? And what you want to build is social reciprocity. And that's what builds that culture.

One of my favorite stories is I'm going to pick on Patrick Schottel because I love him. But you know, trauma surgeon came here, thought he had a trauma room, right? And one day, he came up to the board and he said, you know, "How come my room can't get going?" and I explained to him and I was like, "Well, if you help all these other orthopedic surgeons get finished, I can get your room going." And he looked at me and he's looking at all his senior colleagues and he said, "Go get dinner." And I was like, "That's a great idea. We'll call you when we're ready," right? But a couple of weeks down later, I walked up into his room and I said, "Hey, look, we can't get your case going. I need an hour. Can you give me an hour?" And he looked at me and he said, "Can you give me two hours?" And I was like, "Yeah, sure. You got journal club, interview, faculty, dinner or something?" He goes, "Yeah, I need to go home and put the kids to bed, right? Then, I'll be right back." And I said, "Absolutely. You tell me what time," right? And that's where I think the culture part, right? Everybody putting their best foot forward and everybody knowing that you're going to put your best foot forward first.

Elise Ames: So I agree, but we also have to recognize that sometimes the best patient care outcomes come out of putting our best foot forward. So, we have a tendency to try to understand sharks by looking at shark attacks, right? We want to look at failure. We want to look at the disaster. That's what M&Ms plays into, and I'd love to talk about that a little bit if we get a chance to do so. Because with M&Ms, specifically, there's a lack of appreciation for the complexity of what created the problem. And therefore, the coin of phrase stuff rolls downhill and the physician ends up at the center of that "blame and shame" culture. I didn't make that up. That's a standard description. And I think we should move away from that, and I think we should move towards some sort of proactive systems-based methods to identify hazards, whether you call them close calls, whether you call them whatever. I think there's a lot to do here and this requires perhaps some shift in who comes into medicine in the first place. You guys probably have enough gray hair as I do to be wondering kind of what's going on with people coming into medicine these days. We could have a very long conversation about that, I'm sure, but we should probably avoid that pitfall.

So, I'm going to flip it on the other end and say, really, more importantly, what this means is that senior clinicians, us, the gray hairs, the Pat Schottels, we need to understand the system we live in. We need to demonstrate the skills required. And to your point, Mitch, we need to live well. And in the current setting of wellness issues, that may be a big ask, but we need to live well and get home to take care of our kids just exactly in the example you gave, because that's how we're going to end up coming out of this relatively intact and hopefully with a better system.

Host 1: Wow. There's so much we could talk about. At least one of the things I kind of struggle with is that we talk about culture and we talk about teamwork and collaboration, and we've got to teach these things to our trainees, right? We have to instill that in them. At the same time, we don't have much time with them, right? We only have them for a short period of time. And at the same we also need them to be excellent, right? We need them to be outstanding surgeons. We need our residents to be outstanding in Anesthesia. And I've made it a point to try to instill some of the things that you've talked about, but what I found is that, gosh, they're busy. They are so busy becoming excellent clinicians that we don't necessarily have time. And I personally have not figured out the magic formula of how to instill this. So, is there a way that we can start to instill some of this stuff at the resident level? Is it going to have to be a fellowship thing after they've trained? Give me some secret sauce here because I'm struggling with it.

Elise Ames: Well, as I said, I started this call by talking about culture and to some degree we can't control that, right? And there's a huge debate in education as to when are these really important things that you just talked about, Matt, that you can't control, when are they instilled? When you get a drive for self-responsibility, self-learning, all that. I think it's long before us, frankly. But how do you then also not punish the learner who's trying their best just to stay alive, to your point, right? They're just trying to float, keep their heads above water. And, you know, the work to do things at the national level, like not make as many rules, try to leave it to programs to innovate and develop, to adjust to their own cultures. The problem is that is, to your point, yet another burden. And it also, frankly, is an expertise that not many of us have, and we're still wrestling with it, and it's something that we have to think about.

I think we have to decide this, whether we like it or not, and no matter how hard it is, because otherwise it's going to get decided for us. And whether that's in education, whether that's in systems, whether that's in patient safety, we've certainly seen a heck of a lot of rules in our time developing as providers and that's got to stop at some point. It's got to start being a team sport. It's going to be hard. It's going to be an incredibly hard to transition.

Host 2: There's a book called Subtract and how the human tendency is just to keep adding things to systems and nobody ever actually thinks about removing things and to make things simpler. But I think graduate medical education has become sort of unwieldy in the sense. But I think one of the things that David Adams and I have talked about, and he was my program director, he's now the chair at Indiana for Anesthesiology. But over time, we sort of pushed the responsibility and the autonomy further, further back in training, right? Well, it used to be medical students were autonomous. And then in residents, you were autonomous. Now, you're not really autonomous until you get out on your own. And so, how do we bring that back safely?

Elise Ames: This is a huge, huge question. And trust an anesthesiologist to bring that kind of thing up, because I'm happy if I can make it through the Sunday Times, you know, forget thinking at this level, Mitch. But let me think about it, because I do know a little bit about this sort of thing, you know, whether you call it a burning platform, whether you call it experiencing a little pain or unease, that sense that opens a sense of urgency. And all of my roles have really informed my personal concerns, exactly what you're talking about there. Can I give you an example of something that's on the national front right now that I think we all have to think about that's really relevant in Vermont in a funny way, as Vermont is always a funny place, and Alabama. Matt, you may have other thoughts here because I think you're--

Host 1: We're plenty funny down here. Plenty of funny down here.

Elise Ames: Yeah, I know you're funny, but I mean, I wanted to start and see if you guys want to go here, because I think this is interesting. The world as a whole, and whether you know this or not, let's not assume everybody knows this, but there's a massive amount of legislation happening at the state level to approach the care of how we're going to care for patients in rural areas, right? So, let me just define one thing before I go back to that. I don't know what rural means, and if you really want to dig into this data, is Vermont a rural state, or is Alabama a rural state? You have to go in a zillion directions to even start to understand that. Actually in Chittenden County, we are not classified as rural, Mitch. We are not a rural center, which is the weirdest thing I've ever heard of, because in the part of Vermont I grew up in 30 minutes from here is. So, go figure. So, for the purposes of this conversation, I'm going to use the terminology of a DIO friend who is living with this in a different state, she calls it frontier medicine. So, I don't know if that resonates with you, Matt. I don't think there's a lot of frontier in Alabama. But you know what I mean, right? It's providing care to the patients who are not 30 minutes from the ______ OR, these are the patients that are really struggling.

So, when I'm talking about the question of care and providing care for patients in rural areas, this is 100% my personal opinion, but the states have basically said to medicine, "Hey, you guys haven't helped us. And despite the fact you have so many trainees spots, and by the way, we do have enough training spots statistically in this country to train our workforce by the numbers. The problem is the distribution." Both of our specialties have developed into ridiculously specialized worlds and there are financial drivers to that for both of us. Orthopedics and anesthesia have got to be at the top of that heap.

So if the motion for legislation here, it's funny you mentioned David Adams, I'll bet you he's involved in this at some level. The movement is towards providing care for individuals who can't get to us, Mitch, can't get to the tried and true warts and all U.S. education system, whether you like it or not, whether you think it's quality or not. And I understand that the state move to sort of stabilize this in whatever way is because medicine has not solved the problem. And in fact, we've probably aggravated it. And I understand that we're going to have to have major changes to get to a place where we can even start thinking about it. And that's why this topic comes up for me in that context of this conversation. But education standards, all those things that you guys talked about as hard to deal with are there for a reason, and that's to make sure that we can provide at least a basic level of competent care. So, I used the C word, sorry about that.

But I believe, I really do believe that that's what patients want. They want a competent person providing their medical care. And I also believe that's what they deserve. So then, you get into a little bit of trouble because there's no standardization outside of the standard MD, GME world in the U.S. for process or education. So, for example, If an international medical grad wants to come in, and states are going to ask the licensing boards to try to figure out if that person meets their standards, that opens some fairly scary doors, I think. I'm skeptical about a state government's process ability to do that, and it's not the government, it's not the senators and the policymakers that are going to be doing that, it's the state medical boards. Is anybody asking them? What on earth this kind of thing does? You're going to see this becoming a bigger and bigger topic, I think, for all of us.

Host 2: You know, Matt and I, last year, beginning of last year, we published a paper on the Icarus Paradox and about how snow melts at the edges, and when you think about rural healthcare systems and how healthcare systems are struggling across the country, right? So yes, there's standards, but then how do you enforce standards when you can't even keep the institution afloat? And then, the second part of that is we have 50 state medical boards, right? I don't know if Puerto Rico has one. But then, this goes back to the Founding Fathers, right? The battle between the states and the central government, the federalist papers from Hamilton. We should be able to figure this out, but instead we're going to come up with 50 different solutions, and maybe none of them are going to be optimal.

Elise Ames: And that's at an education level, that's a fear. Because the other thing is we probably have some responsibility to be trying to solve this problem within our own folks, too. And that's going to be a big challenge. In our specialties, like how do you define what every orthopedic surgeon resident should graduate with when that's only a small piece of what we end up doing in an entire residency to your point about pushing things farther and farther back.

Host 1: Wow, tough problems, almost overwhelming to think of. So, I'm going to think even simpler here and go back to this idea of M&M conference, right? I think maybe you and I've talked about this and maybe we've touched on it here that that is the best way to learn. But then, you've mentioned collaboration a lot and we still seem to be in the hospitals pretty siloed, right? I can't sit here and say that we have some sort of a big standard regularly occurring education session with our surgical colleagues. And good grief, what we're doing is a pretty high risk thing, right? Pretty high stakes. How in the world can we look at healthcare and say it's a team sport and then not actually train together as teams? Do you guys have something with your Anesthesia Department and your Surgery Department that we should be looking into? We have little things here and there. But man, I wish it was something that we could do regularly. Is that a possibility for the future?

Elise Ames: What do you think, Mitch?

Host 2: I can answer this. This is like, you know, Matt teeing up the golf ball and saying, "Go ahead and whack at it". But, you know, during my tenure, when we were working with the O.R. Tactical Utilization Committee, probably a decade ago, we instituted the multidisciplinary grand rounds here. One session we hired a jazz band and used the jazz band to teach leadership, and it's still one of the most fun things I ever get to do. But I think the most powerful one was when we had an M&Ms, a cardiac M&M, and the nurses, the perfusion, anesthesia, and surgery was up there presenting the case together, right? And to watch Bruce Leavitt, who was the surgeon, present the case, that was powerful because that's a surgeon standing up and leading, saying, "This is what happened." And that discussion should engender how are we going to do better/ and I think we missed them. I think we should bring them back if we can. But yeah, I think, M&Ms in silos, especially in the perioperative space in this day and age, it doesn't make any sense. I mean, the San Francisco 49ers, I don't think the offense and defense are going to practice separately the entire time they're preparing for the Super Bowl. The Kansas City Chiefs are just going to hang out with Taylor Swift. So, you know, it is what it is.

Elise Ames: I agree, Mitch. I think there are huge challenges. But I wonder if there aren't some common foundations under there. You mentioned jazz. I don't do jazz as you know. There's a lots of things that Mitch and I can easily go out and learn. I can learn in his world, he can learn in mine that have absolutely nothing to do with medicine as a whole. So, I wonder what you guys think about those efforts that, to Matt's point, bring communities together. I think that's what you're really asking, Matt, right? Is there a place that we can agree that two communities might be able to find common ground?

So, again, this is a little warm and fuzzy perhaps, coming from a surgeon, you may be like, "What?" Mitch, you may have taught me about this a long time ago, but this idea of servant leadership. And when I talk about that, I'm not talking about the now popular servant leader check. I'm talking about our servant leaders, the groups that are going to work on these questions about growth and well-being of a community. Does that make sense? Am I going in the right direction, Mitch, with your thought? Because I think what we're really talking about when we're talking about both advancement and being the best you can be and also being healthy, which I go back to your send the surgeon home to be with his his kids, that is absolutely being the best you can be. To me that defines both the rewards and the challenges of life as a program director and that's really where I come from, at heart, that early experience, which is now still there, 20 whatever years later, has defined me. So, I've read that. I've defined that a little bit as I've gotten more gray hairs. I don't know if you read Chris Argyris, Mitch?

Host 2: Rings a bell.

Elise Ames: He wrote a little teeny book that's called Teaching Smart People How to Learn. Have you read that one?

Host 2: I have not.

Host 1: I saw smart people on title and I thought that I wasn't included, so I haven't read it.

Elise Ames: Thank you. And then learning teaching smart people how to learn. That's what we're doing every day, right? Some smarter than me at this point. My residents are smarter than me in lots of ways. But anyway, Chris talks about the evolution of leadership towards managing people at very high levels of skill, but all levels of organization, right? And that describes our systems pretty nicely. At heart, you're trying to combine mastery with the ability to work in teams. And he goes on to talk about the fact that we make assumptions that the people we are, very good at learning. In fact, that may be true. We are very good learners. We wouldn't be who we are if we weren't very good at learning something. But I'd be curious to think, to hear, do you guys think of your learning in medicine, your progress to where you are now, as narrow or wide? Because I think we're in a very narrow window of expertise. And then, I would put out an argument that we could easily discuss for a long time about whether expertise equals mastery. So, I'd be curious for your thoughts about that.

Host 2: Matt, you want to tackle this or you want to just let me go?

Host 1: Yeah. So, that makes me think of T-shaped people, right? People that have a deep expertise in something, but then also can span boundaries. And was I good at that when I first started? No, gosh, I was terrible. I had my expertise in anesthesia, but did I know how to go out and handle negotiating with administrators? No. Handle the relationships in the operating room? No, not so much. Handle being a team leader now instead of the person sitting and turning the dials? No, I was terrible at it. It's taken a long time to even begin to get good at it. And it's come through a lot of trial and error, a lot of mistakes, a lot of watching mentors and seeing how they do it. And I don't have a perfect answer for it. But was I good at it? No. Terrible.

Elise Ames: So, that's an interesting conversation because that really leads this idea that expertise does not equal mastery, right? Again, forgive me a little bit of educational edgy geekness here.

Host 1: Bring it.

Elise Ames: I am a huge fan of this idea of mastery, because I understand it as generational, I understand it as a lifelong journey. And I said somewhere along in here, I'm sure, that I think physicians need to be self-driven educators throughout their entire life. And we tend to focus on residency, and now maybe medical school too as the place where we get those skills. And I'll buy that. I mean, UME starts it, and GME feeds an interest in it. I mean, we can certainly kill that interest in our residents if we're not mindful about what we do. But the skill set to get it, we tend to spend our entire productive lives trying to develop those skills you're talking about, Matt. And I would say that you probably still feel like you're still developing them, that it's not over in any way, shape, or form.

I'm a huge fan of Anders Ericsson for that. I know Mitch is familiar with this because he's seen me talk to residents about it. But you know, there's the Malcolm Gladwell 10,000 hours concept. Remember that? So, Anders Ericsson was the guy that actually developed this concept of deliberate practice, but Malcolm Gladwell was the one that said, "Yeah, all you got to do is put 10,000 hours into something and you're great." And we all know that intellectually that's not true, but the concept is worth exploring and how you're using your time and time in the saddle, particularly with respect to GME because it's so narrow. I would just put this up for anybody who's totally a geek about this stuff and interested that Ericsson then changed over to defining it as purposeful practice. That resonates with me, for sure. We're still putting in the time every day to get better and better, but we have to have some purpose behind what we're doing in order to make it productive.

Host 2: I think this is where William Butler Yeats got it right, right? Education is not about filling a bucket. It's about lighting a fire. And then when you think about purposeful practice, that goes back to Csikszentmihalyi with the concept of flow, right? The task at hand has got to meet your skill and you got to be challenged and you got to be continually challenged to get better.

I just want to add to the discussion here that, Matt, when you talk about transition to practice, that can be done with teams. Elise Ames made a really bad decision probably 10 years ago where I get to lecture their orthopedic interns. Sometime at the end of summer or the beginning of fall, I get to meet--

Elise Ames: I gave you the interns rubric.

Host 2: Yeah. The orthopedic interns and I got to meet them. And for me, part of the joy of being in an academic hospital is that I have my anesthesia residents that I need to train, but I also get to watch the orthopedic residents grow up, right? And when they become a chief resident, it's fun just to watch them lead the team and be able to do what they have to do. And what I teach to orthopedic residents is that, you know, I understand that you work for two masters. You have your attending surgeons and your patients that you need to take care of. But then, there's also the OR master, right? But you shouldn't have any problems with the OR master because that's our purview and we're here to help you and the patients, right? And so, it was a horrible decision, Elise.

Elise Ames: Yeah, not one of many in my professional development report.

Host 2: Elise, there's this myth in academic medicine that you have to be a clinician, a researcher, an educator, you're three-pronged, you got to be able to do everything, right? And then, you know, along with this, Brooks, from Strength to Strength, right? You're on the other side of the Frank-Starling curve in terms of your career, and I'm not saying that in a bad way. But what do you want to share with Anesthesiology residents of the future? And then, you know, what do you want to share with the physicians of the future, right? Because I think we're heading into unheralded times for healthcare systems.

Elise Ames: I would note that for those of you that don't know Mitch, this is a very typical Mitch Tsai question. So, preparing for the future, there's nothing small about that question, right? And I think my answers to your other questions probably suggests I don't have a lot of answers yet, nor the gray hair to be able to do this. But I'm going to go back to something that Matt commented on because it rang a bell with me. There's lots of talk about things like being in the zone or going with the flow. I think, Matt, I heard you use the word flow, correct?

Host 1: It may have been Mitch, but I'm going to take credit for it, even if it was. So, the answer is yes, it 100% me.

Elise Ames: Either way, I'm going to use going with the flow for a little analogy because this is me and this is what I like. This is where my brain goes. If you're going to use going with the flow, to me, in my older days, it should be a relaxing thought, right? If you're able to just go with the flow, the OR is running smooth, everybody's happy, this, that, and the other. That should be a relaxing thought, but I don't find being in the operating room at any level much like that these days. So, if we think about the anesthesia and surgical specialties, flows can be too high or too low, right? You think urology, maybe? Think about flows, maybe intermittent or restricted. ENT, our ENT colleagues would talk about that when they're talking about airways. So, the orthopod in me reminds me or makes me think about the fact that flows respond to biomechanical stress. And that's because they're subject to human factors. And I believe that's what surgeons and anesthesiologists are facing the most.

And so, the ability to deal with that and stay healthy, the adaptability to the world that's around us, which I don't know how you guys feel, but it's nothing today like it was when I trained, and it's nothing today like it was five years ago here in Vermont. I think Mitch would probably agree with that. So, our ability to do that hinges on responding to stress in such a way that we can be adaptive and we can use our adaptive skills without causing harm to ourselves or, more importantly, to our patients. So, this gets kind of back to where I started with and why I'm interested in M&M educationally with this idea of reactivity. "Okay. Smack, you were bad. What are we going to do to fix it?" "Yeah. Well, maybe we'll talk about that, but we won't do anything," that's not proactive. And I think it gets away from some of the things that we should do to prepare for the future. Not only with respect to our own development, but just in terms of thinking about the next generation. I understand that's a huge, huge ask. It makes a massive amount of difference. And perhaps, as I said, all due credit, this is not something I sat on an airplane thinking about yesterday because it just came to me. It's something that was triggered by a conversation with an expert in another field and we need to be doing that to get there, I think, personally.

Host 2: You know, I want to add, Annie Duke wrote in a book Quit, there's a chapter six, it's about monkeys and pedestals, right? And we know how to build pedestals, we really don't know how to train the monkeys. How do you do the hard part first? Because if you do the hard part first, the easy parts are easy, right? I think that's probably the challenge for us in academic medicine. And I think it's a good challenge to have because medicine's future isn't going to exist in our current undergraduate graduate medical education, right? And like you said, it's the network, it's the chance encounters, it's the conversations we have with colleagues in different disciplines, right? But medicine's future is going to exist at the intersection between two different thought processes, right? And we need that. We need people to know how to find that.

Elise Ames: And we need to be able to get happy enough within the system. Sometimes I'm afraid that's going to require just a blow-up. Resonant unionization just is happening all over. Is that a blow-up reaction? Do we have to get that bad to get the system to help us make it everything better? I don't know. I worry.

Host 2: I worry in the next five years when all the residents are going to join our group and they're going to wonder what we've been doing for the last 15 years.

Elise Ames: There you go. Well, they're already wondering what we've been doing for the last 15 years. And not only that, they're wondering why the heck we haven't been attentive to our families and wellness and why... you know, I don't know. There's just so much to that. And there's so much coming. And the thing is, you just really have to care. We as educators have to care about the next generation. Me on my side of the drape has to care about the person on the other side of the drape, and the person under the drape has got to be the unifier. And I think we've got to get back to that.

Host 1: Well said. So, you mentioned that you've now moved on and retired from the clinical aspect of your career. What's the thing you miss the most? Because, you know, we've had on other podcasts talking about just what fun environment it can be. When it works well, when it's going well, it can be so incredibly fun. What do you miss the most about the clinical side of things?

Elise Ames: Apparently being delayed out of Chicago for three hours and then sitting on a plane for two makes you think a lot. So as I said, I was delayed in Chicago last night. And Vermont's a small place. It usually happens whenever I sit at a gate in an airport on a flight that's going direct to Vermont. You meet someone you know. We're flying to Burlington. We're just that type of a small community up here, and this time it was a patient, and this patient hadn't realized that I'd retired, so we had to go through that whole discussion. In\ my role as program director, I advise future surgeons on a lot of things, and clinical life development is one of those, one of which being you're going to meet patients in the grocery store, you know, who you are sticks with them. And I have to admit, it was a little tough to be sitting there listening to this patient say how wonderful I'd been and how much of a difference I'd made and thinking, "Oh my God, I can't do that anymore."

So, I do miss taking care of patients, I really do, but I also know myself well enough to know that, in our conversation about surgeons and personality in the system, I would have been pretty miserably unhappy having to compromise my own idea of what being a surgeon meant. So if I'd have gone into evaluating spine patients for my younger partners or something like that, I don't know that that would have been very good for me. And therefore, probably not very good for the patients.

So, I guess the bottom of that ramble, which is the answer to your question, is that it takes courage to divine a new concept of what it means to be a happy expert in something or anything or your tendency as a human to rest on your laurels being, "Okay, I was prepared for two days and I'm totally bored. So, what am I going to do now?" Either way, I personally believe, and my mentors have taught me, that the learning journey never ends. So, that's why it's been well worth doing for me, although I've got to admit here in the first couple years of it, it's tough and has only been recently that I've started to feel like I could make as much of a difference somewhere else as I could for that T10 to the ilium pelvis from Tuesday.

Host 1: Mitch, how many podcasts we've done now? And all of them, we've heard continuous learning, lifelong learning. It comes up every time over and over and over again. It's interesting to me.

Host 2: I think it's not necessarily walking away, I think it's walking towards something else, right? And so, thank you, Elise.

Elise Ames: Finding a different way to help.

Host 1: Elise, this has been cool. I have to say that I am very happy that you came on the Fresh Flow Podcast and went into an elaborate discussion of flow, thus showing that you understand the brilliance of the name Fresh Flow for an Anesthesia podcast.

Elise Ames: No. Typical orthopod. I don't even know the name until you just mentioned it. So now, I'm like, "Oh, great. You're listening to me." This has totally paid me off. I seriously swear to God, I had no idea that that's the name of this podcast. Although maybe I must've processed it at some level because flow came to mind, and that's what I was thinking about. So, that's pretty funny.

Host 1: Elise, this has been really cool. This has been a pleasure having you and thank you for the leadership at the national level for the ACGME. We appreciate all that you do and the fact that you're taking a new and fresh approach to it. So, thank you for that and thank you for being here with us.

Elise Ames: Hey, my pleasure.

Host 1: Thanks guys. We'll see you next time on the Fresh Flow Podcast.