Dr. Matt Sherrer (Host 1): Welcome to the Fresh Flow Podcast. Mitchell, good to see you, brother. How are things?

Dr. Mitchell Tsai (Host 2): Pretty good. How are you doing?

Host 1: Man, fantastic. All right. So, I always have a question for you at the beginning. You got to see pictures of my kind of slightly celebrity sighting in Birmingham this past weekend. What is your biggest celebrity interaction in your life? Do you see a lot of celebrities up in Burlington, Vermont?

Host 2: No, we actually have to travel down to Boston for that. So, I would say, let me count the number of years, six, seven years ago, my youngest son and I stopped at some hotel just outside Patriot's place after we went to Thomas the Tank Engine Land. And I got to take a selfie with Florence Henderson, Ms. Brady.

Dr. Peter Nichol: Wow.

Host 2: And as a kid growing up in Southern California, I sent it to all my cousins because I was like "I'm with Mrs. Brady." But no, no, it was tremendous. But like I said, you have to travel down to Boston to see celebrities up here in New England.

Host 1: That's fantastic. The context for this, as we were just discussing before the show, I was just driving around in Birmingham and happened to see Guy Fieri's son, Hunter, from Food Network, who's on a bunch of the shows with him these days and stopped and talked for a second, took a selfie, sent it to Mitch. One of the few people who would know who that is. So, our colleagues in bigger cities are like, "You guys really need to come to our cities more often, because your places sound pretty boring." But we are excited to have a good friend from the Association of Anesthesia Clinical Directors meeting here with us today. Mitchell, do you want to introduce, Dr. Nichol?

Host 2: Yeah. So, Dr. Peter Nichols, a pediatric surgeon at the University of Wisconsin. just between you and me, Matt, he is a Rhodes Scholar candidate, so I think we're going to get really outpaced on this one. But I first met Peter when he attended the meeting, and it was eye-opening for me just to have a surgeon in the crowd, a surgeon presenting to us because, you know, we're all trying to solve the same problems across the country. And so, bringing in that different perspective is definitely helpful for the organization. So, thank you, Dr. Nichols, for joining us.

Dr. Peter Nichol: Thank you for having me. It's a pleasure to be here.

Host 2: One of the things we've talked about at the AACD is that there's a difference between healthcare and the global North and the global South, Host 1:right? And are there lessons to be learned in constrained environments, resource environments? And I don't know how it's going at your organization. But a lot of the times things like, you know, supply chain disruptions. It's not dissimilar to what is experienced in the global south.

So, one, what motivates you and what you do? And then, what are the lessons we can glean from different countries to help us deliver care here in the United States?

Dr. Peter Nichol: Well, you're right. I mean, the problems are the same. It's just a matter of what your technology is and what your scale is. But, boy, I would say one of your biggest problems in the global south is that you do not have the level of training for ancillary staff-- it has been my experience- that you have in the United States.

So, nursing in Guatemala, for example, which is where I go every year for a week, they essentially need a high school degree and it's on-the-job training. There's no formal education pathway. And so, you have to bring your own staff with you, which becomes a pretty big logistical lift. But the flip side is you have to learn to do more with less. And so, the people who can survive down there and actually thrive usually are very agile thinkers. They're creatives.

And honestly, you know, it's all a matter of scale and proportion, but I do a ton of outreach in the state of Wisconsin and, you know, I go from being at a big academic university where we have everything to much smaller rural areas that are under-resourced and lack of providers and lack of infrastructure. And, you know, I've learned a ton by going to those places in terms of what you can do without, and the things that you take for granted. And one of the best lessons I've learned is there's a ton of waste in the global north, unnecessary waste that we've had the luxury of wallowing in that is going to probably go away now pretty quickly in the next five or six years based on what's happening demographically in this country, and now what's happening policy-wise in Washington DC.

Host 1: So Peter, Mitch has talked on this show before about what we call T-shaped people, right? People with deep expertise, but a broad range of interests. And to that end, you're a pediatric surgeon. You got a deep expertise in that, but you also have a broad range of interest. And one of the ones that you have an interest in is the work that you've done with sterile processing. Now, how in the world did that come about? When I think of surgery and the glamor, the glitz and glamor that you guys get,, that we as lowly anesthesiologists don't get, the topic that I would think you would pursue is not necessarily sterile processing. How in the world did that come about? How did that interest come about? How did you get involved with that? Just tell us about that journey.

Dr. Peter Nichol: Well, let me preface this by saying, and this may not be the best metaphor, but I really feel like in terms of the delivery of surgical care, the surgeon's really just the matador. And when you look at bull fighting, 90% of the killing the bull occurs before the matador even gets in the ring, right? No, I really mean this. Like, there's this entire team of people that take their shot at the bull to weaken the bull, and then the matador comes in, delivers the faena complete, and then somebody else drags the bull off the pitch after the bull's dead, right?

And so, you're asking me how I came to this? There were several things that happened. One was I became very disillusioned. I had an NIH-funded lab, and I became very disillusioned with the National Institutes of Health. And I became disillusioned with them primarily because I had a grant that it was in a scoreable distance and needed a resubmission. And when resubmitted it, I don't know if how many of your listeners have submitted NIH grants, but you know, you should be essentially going back to the same group of reviewers, or at least several of the same reviewers to re-review the grant when you resubmit. And I got all new reviewers, so I went from getting score to being triaged, and I had it out with Jill Carrington, who was at the NIDDK. She's the head of NIDDK. At that time, and curiously, she and I had had the same scientific mentor, and I said, "What is it you guys do there? Like I know you have all these patents, but what have you actually fixed? Because I just feel like you fund people because they write papers, not because they solve problems."

And I started becoming disillusioned with the NIH in about 2015, 2016, and I ran out of money. And right about the time I was running out of money, there was some overlap with being in the position of being named the Director of Surgical services at my children's hospital. And on spring break in 2017, I was CC'd on the third of three emails from my orthopedic spine surgeon about Bioburden being on his instruments. And it was a third email in two weeks and he was furious and he was a really good guy. And, you know, a lot of the spine cases that you do in Peds, these are like Medicare Medicaid families, right? The reimbursement's not great. And beautiful heart, great guy, but he was frustrated. And he finally CC's me and there's this whole series of emails from all the the leaders. And there was a lot of hand waving and really not a lot of direction on what to do about this. And I sent off a pretty choose email saying, "Look, if we're manufacturing airplanes, we would stop the line right now, because this is a major safety issue." And I'm one of those guys that you got to walk the walk.

So as soon as I get back from vacation, I went down and took a tour of sterile processing, and I was kind of overwhelmed with how chaotic and how poorly organized it was and the conditions that we were making people work under. And then, I went to do a lit search on this, and I really couldn't find a whole lot on it. And that was that. That was sort of like as one career was ending, one door was closing, another was opening. And that was, I would say my frustration and my anger led me into this. That's kind of how it happened, and a sense of righteous indignation, which I think was appropriate.

Host 2: You know, I just wanted to add, I'm making my way through Power and Progress by Acemoglu and Johnson. And they talk about the difference between Europe at the time in the 1700, 1800s with the industrial revolutions of Britain and America, kind of back to back in a way. But they talked about the difference between American sort of engineers and how American engineers weren't necessarily trying to build a better mouse trap, but they were actually trying to build a better mouse trap, and because they didn't have the labor market, trying to figure out how to make devices that actually scaled the abilities of people to do what they need to do.

Over the years, what I've heard from you, Peter, is that sterile processing is probably one of the most important things of the perioperative services. And if you think about systems and picking constraints, you know, in the OR management science, we focused on the operating room, right? And we know that a lot of these operating room metrics don't make a difference. But when you think about what you just said about sterile processing, how it's the foundation of what we do every day. And we've definitely known a change in our sort of SPD services when the guy who'd been doing it for 30 plus years stepped down. So, kudos to you.

Dr. Peter Nichol: Two things. One, you're talking about human-based informatics in terms of the guy who stepped down, and I've got a whole talk on this, but this is an area that we don't really think about, which is you have this person with all this expertise and all this knowledge, there's no way to download or transfer that information to somebody else. When that person retires and, you know, there's 6,200 hospitals in the country? And you figure you got probably two or three of these people. So, every team has a care team leader, every surgical team has a care team leader, every place has an an anesthesia director, a nursing director, a sterile processing director. Many those people are very valuable and there's no way to download that information in a meaningful way to pass that information on so you don't have disruptions in the system. And this is one of the things we're really struggling with now is people, like the person in your SPD department, which you by the way emailed me about two months ago as they check out, is we don't really have a plan for of succession around this. The time it took that person to accumulate all that knowledge, right, 30 years, and no meaningful way to transfer that. And now, we're in a more complex environment than we were 30 years ago. It's a huge problem we're facing.

So yeah, the infrastructure is incredibly important. And I hate to use metaphors that relate to like the Soviet Union or the Russians, but their hockey for about 20 years, 30 years was the best in the world, because the idea was that you are each serving each other, right? The goal was not to have a superstar. The goal was to have a great team and all members of the team. Maybe a better example is the Argentinian football team. Right now, you have a guy like Lionel Messi on there who's a world leader in terms of soccer, but everybody on that team plays for each other, right? And so, you have to step back if you really want to be the World Cup champion of this stuff. And look at it through that prism, through that lens, if you want to optimize your performance of all your teammates.

Host 1: Peter, I was in San Antonio for the Final Four recently and got to hear Coach K talk. And he talked about exactly that with the US Redeem team, basketball team, has all these huge egos under this umbrella of USA basketball. And he, got them to really come up with their own standards. "Okay, how are we going to behave with one another? How are we going to set those egos aside under this overarching umbrella of USA basketball?" And it was a lot of, "Hey, we're going to be on time. We're going to be humble." LeBron spoke up and said, "We got all the best players in the world. No blank excuses," right? But they came up with these standards. And Coach K then said, "Okay, this is how we're going to interact with one another. But my job is to make you guys realize that you don't play for USA Basketball, you are USA Basketball. So once again, we go back to sports because we're dudes and that's what we do. But there's so many lessons to be gleaned for those teams like the ones you mentioned.

Another question for you. I happen to know the Secretary of the Association of Anesthesia Clinical Directors, who's planning the meeting for next year, and the topic of human-based informatics sounds incredible. So, if you have any interest, we might be able to put you on the stage next year in Austin.

Dr. Peter Nichol: I'd love to. And I can send you my slide deck, but there's about four or five aspects of this. And so human-based informatics, if informatics is the extraction, storage, retrieval, analysis of information and human-based informatics, every step of that touches a human. And a really good example of this is an EMR, right? So, all the documentation in EMR is done by humans. And then, the storage goes in the EMR, and then the extraction and the analysis is done by humans in most cases. Now, we're getting into GenTech technologies that are going to help us with this kind of stuff.

So, this is an example from my third-world developing country experience, doing global surgery is we had this wonderful guy who was a jack-of-all-trades who ran our ORs down in Patzún, Guatemala. He lived in Guatemala City and he would go on these missions, not just ours, but all over the world, year round. This is how he made a living as an expat from Canada. And he was in Sudan and he got hemorrhagic dengue fever. And he's probably a couple years older than me, came back to Guatemala City and died of a heart attack. And it was devastating. Not replaceable. Like he's not a replaceable teammate. He knew how to fix all the equipment we had. He knew where everything was. And we actually had to pick up and move to a different hospital, because we no longer had him. And I refer to that as the Joe problem. And like I said, 6,200 hospitals and probably every single one of them has got at least 10 Joes in it. That if you lose that person, like you lost your SPD person, Mitch, in Vermont, the whole system starts grinding to a halt. It's awful. So, I mean, that's where it really gets exposed in terms of human-based informatics.

Host 1: Yeah. Looking forward to that in 2026.

Host 2: I just want to add, from the clinical director's perspective, it goes back to the idea of T-shaped individuals, right? If you have team members that have a deep level of expertise and a broad range of interests, and this is just speaking purely from the anesthesia perspective, I can move people around a lot easier when people can do multiple things.

If you look at the workforce shortage, the locums market, and now with Peds and Cardiac, anesthesiologists, it's hard to find them. It's getting harder and harder, and the system becomes more and more constrained and up to a point where, it's not resilient. It's rigid in the sense that if that the next piece goes, you know, the, whole tower of cards is going to come falling down.

So, you've talked about teams. We've talked about constrained environments, and we've talked about your work in sterile processing. I mean, what do you see? And, you know, this is, a nod to Dr. Matt Sherrer here, but looking around corners, seeing the future, what are the innovations out there that're going to help perioperative services sort of move forward so we don't end up like your medical missions where there's only one person? I mean, what are the innovations out there? What do we need to do?

Dr. Peter Nichol: I think there are two things actually. And one of them is a human resource issue, but I'll start with the second one first. And that is, I think, GenTech technologies are going to become incredibly important in the next five to 10 years, simply because the Boomers are aging out, and this hits us on multiple levels.

Number one, if there is going to be Medicare left, they're switching over to Medicare Plus. Reimbursements go down. There's more of them than there is of any other generation, and they're very demanding. And they're going to require their cataract surgery, their heart surgery, their orthopedic surgery, their cancer surgeries, all that stuff. And you have fewer people coming into the funnel to do the work. And so, we're going to have to, with a very critical eye, look at what are the tasks that we're putting on human beings that really are not a value add and are probably going to make dive people from going into healthcare. We have to eliminate those tasks.

And I've got a paper right now in to review. You guys, you saw this presented a year ago on charting in the ORs in the EMR. And the error rates with that is astonishingly high. and that's just if you do it on time, something as simple as timestamping. If we don't move to innovate to get rid of those tasks or unburden the human being of those tasks, the amount of work is going to continue to explode and nobody's going to be going into healthcare.

I think the other innovation that's going to happen is going to be more gradual, but you're talking about the lack of resilience in the system. And the lack of resilience in the system has to do with how we train people and how we set the funnel for who we select. And I think this current administration, particularly the way they're cutting funding, NIH funding, they've already announced potentially 50% cut to Medicaid. it's going to force a reckoning around all these super specialized specialties And I think we're going to have to both shift the funnel in terms of who we're going to get into healthcare and also how we train them to be more generalists. So, in my own institution, because there's such a shortage of pediatric anesthesiologists, we're trying to figure out where we can do cases on healthy kids over the age of three with general anesthesiologist, because it is not really a good use of our resource to be doing an inguinal hernia in a five-year-old with a peds anesthesiologist when that's a limited resource.

So, I think, there's going to be a lot of changes coming to the way that we both get people into the funnel around healthcare education. We're going to start asking fundamental questions like what is the predictive value of an organic chemistry score? And I looked at this five years ago, what is the value of an MCAT score? So, an MCAT score tells you how well you'll do generally in the first year of medical school, and I think the three of us know that probably 98% of what they taught us the first year medical school we don't use. And there's two problems there. One is you're using a test for a throwaway year, honestly, in education of stuff you're never going to use. And two, why are we having that year of education at all? So, I think there's going to be some significant innovations around education, and a reckoning around that, because that's going to be driven by market forces. And we're already seeing it. I mean, Matt's had to deal with this around an AA school and a CRNA school fighting down in Alabama when there's enough food at the table for everybody, probably enough for them to all gorge themselves on and die of rupture stomachs, right? That's how much work there is down there. And yet, people are still fighting so there's going to be innovation around education and a reframing of how we think about this stuff.

Host 2: I've made the comment, and I think the scale's on multiple levels, but we fully agree with you. I think there's some programs now in across the country that are looking at three-year programs and what are we going to cut out? I think the other piece of this is the Flexner report came out in 1937 or 1939, right? The basis of American medical education is almost a hundred years old. There've been a lot of innovations technology-wise in the last 90 plus years, right? So, where's the data science? Where does AI fit? Where are all the other disciplines that have sort of come about during the communication age of the knowledge economy? Why aren't we capitalizing on that?

And then, the other piece is that it scales up to the healthcare system, right? Not just at your hospital deciding who should be doing pediatric coverage, right? But ultimately, it's a bigger question of how does Wisconsin deliver pediatric care? Where are we going to do the pediatric care? So we have the skillset that nobody's being stretched at some rural hospital to cover that five-year-old inguinal hernia, right? How do you regionalize healthcare delivery?

Dr. Peter Nichol: Right. I think part of it though is we go up to Gundersen, which is up in La Crosse, and they have a superb General Surgery training program that takes essentially rural kids. And for the better part of their time there, they're training rurally. And 80% of those kids go back into rural practice even though they do fellowships.

So, you have to think both as a system and in terms of healthcare delivery. And also, since we're a university, health education, we have the rural track, although there's a shortage everywhere of rural physicians, I mean, 18% of the population of this country lives in rural counties and 2% of the medical students come from those rural counties. So, we have a huge mismatch in terms of who's coming into the funnesl. But my goal would be to train the general surgeons up in the rural areas to do five-year-old inguinal hernia repairs, because I can train Guatemalan surgeons how to do that. And we don't do it the way that I was trained. We do it laparoscopically and it takes 15 minutes a side. it's a much easier operation than it used to be.

So, I think we have to think more broadly about this. How do you take care of an entire population? You know, 33% or 34% of the entire Wisconsin population is rural. And the two major metropolitan centers are in the south, central, and southeast regions are hard to get to. So, we have a fairly vigorous outreach program. I just submitted a paper on this to the American Pediatric Surgical Association that every time a physician travels in our system to see a patient or go to a clinic, it's usually about seven patient visits per every time a physician travels to a clinic, you are cutting the cost to those families. You're cutting the carbon footprint by about threefold. And when I say the cost, I'm just talking about the gasoline. I'm not talking about feeding the kids, pulling them out of the school, possibly staying overnight. So, we have to think in a very flexible way around these things. We can't wait for the work to come to us. We have to go out and do the work.

Host 2: I think Peabody wrote care of the patient, 1927, '28. But the basis of what we do in medicine is that physician-patient relationship. And on a completely different note, you're going to speak at the AACD, and if you could come and teach my general surgeons how to do 15-minute laparoscopic hernia repairs, I would greatly appreciate it, Dr. Nichol.

Dr. Peter Nichol: be happy to. Bring them to Guatemala. It's not that hard. But I need about a week and I need about 10 cases per surgeon.

Host 1: You can stay at Mitch's house. He's a great cook.

Host 2: Done. I'll cook.

Host 1: So, Peter, when I hear you talk about all this work to be done, the way we kind of approach it from a siloed view, I see in your CV where as I'm reviewing this, the word collaboration a lot, I see reciprocity. And then, I see you talking about triads. We kind of train in silos. We sometimes even work in silos, but there's a need to collaborate. And you have some experience in talking about these triads in the operating room. What lessons are there to be learned there?

Dr. Peter Nichol: So even though we have been a historically very siloed institution like I think all major academic institutions, the triads was one of these HR innovations that I really welcome. Probably the. Two things that helps with the most, number one, is the flow of information. because you got three of us, we're all talking, we're all in our various spheres and we're all overlapping. And when information gets around, it gets between us very quickly, it gives us more time to plan and react. And not just react, but move decisively.

I think the other thing is we're all sort of faced the same challenges. And when it's you, there is an emotional response. When it's your partner, you're the teacher, right? And so, you have this experience. And I just had this today with my nursing triage leader, who's a wonderful guy. He's just superb guy and he's amazing what he does with our ORs in terms of efficiencies. And he has worked up about something and I'm like, "Well," I said, "Dennis, this is what I would do, because I went through this with so and so like three weeks ago." He's like, "Oh, yep, you're totally right." So, we have this ability to sort of coach each other, which really, really helps. So, I think maximizing flow of information in all directions is really helpful. And then, really having a peer to bounce things off of that's your partner helps as well. That's probably the two biggest pluses for us.

Host 1: I love the quote from Ivan Pupulidy from right here at UAB. The currency of safety is information.

Dr. Peter Nichol: Yep.

Host 1: So, who really is in charge then? Is it the surgeon? Is it the anesthesiologist or the Nursing?

Dr. Peter Nichol: No, it's pretty shared. And then, there's the surgeon-in-chief. And so, we feed the information up to the surgeon-in-chief. We sit with him once a week. we make our recommendations. He's like, "Okay." And then, he has to make the decision to say, "Okay, well, we're going to do this." So, he is not making those decisions in a bubble. And he usually has some thoughtful opinions. He's very deaf politically and knows how to sort of manage things. There's always some management that has to go on. So, that's the way it feeds to him. And then, he kind of sets the policy, makes the decisions

Host 2: I just want to add that this framework scales down to what you do every day in the operating room, right? I mean, we have Dr. Shuttle, who's one of our ortho trauma surgeons, who at the beginning of the day, he runs the list with the team, the nurses and the Anesthesia, and everybody knows what needs to get done. Spine surgeon, Dr. Mazur is our division chief, I mean, he gives one of the best briefs for every case. And he'll even say, "242 mLs of blood loss." And then, I will ask him, are you sure it's not 242.7? Because I can record it on this EHR," right? I mean, it's that kind of specificity and just the knowledge and setting the expectation, right, so that you understand what everybody needs to do.

Host 1: There's a level of humility there too. And Peter, your buddy, Dr. Kole, told us last time that, he has an expectation that surgeons, "Hey, you're going to help turn over the room," because it shows that we're all in this together and the work is not bigger than any of us.

Host 2: As long as they're credentialed to mop, right? We got to get through all the steps. So, Peter, this is like the first time that we've noticed on somebody's CV that not only do you have research grants in your background, but you're a philanthropist. You sponsor a lot of charities. So, can you tell us, about Cars Curing Kids because I just put Dr. Sherrer's white Volvo on the donation list.

Host 1: Black. Black Volvo.

Host 2: Sorry.

Dr. Peter Nichol: Yeah. So, this was another one of these endeavors that came out of my frustration, kind of like my interest in sterile processing. But the real story is that I took care of a patient who was born prematurely, had a bad pediatric surgeon at another institution, had necrotizing enterocolitis totalis. And so, for the uninitiated, that means you get this invasive infection of the intestine that happens in premature infants. And you really have two choices. You can either take all that out and commit to short guts, you know, the kids have short gut or you just let the kid go. You know, just say we're going to do comfort care. And neither of those things happened.

So, the problem was that all that stinky dead gut sat around in the abdomen of an 800-gram baby. And in a baby that size, that much inflammation causes a huge amount of, collateral damage to the nervous system and everything else. So, her biological mother had some pretty serious addiction problems. And the family sort of -- well, the mother, because I don't know if there ever was a father, at least other than biologically-- the mother kind of just abandoned the kid. And the bedside nurse in the NICU became very attached to this child. And then, she got sent over to my institution because she was in intestinal failure and her liver was failing. And we didn't really have a way of saying, "We're going to stop," because we didn't really have involved biological parents. And this nurse started calling every day to check on her. And then, all of a sudden I found out she's fostered the kid. And then seven months later, she adopts the kid. So now, her name was McKenna, the child. And McKenna never sat up. I kept her out of liver failure for a while. This is before we had this intralipid infusion called Omegaven. And I knew she was going to go into liver failure. She did. And I actually sent her down to Nebraska to have Dave Mercer look her over. Dave Mercer's wonderful, wonderful guy, great surgeon. And he almost convinced them to do the transplant. And the mom, because she's looking at her, she's like, "Look, she can't even sit up. She can't even talk. She's three years old." Like, we're not going to do this. She doesn't understand. And so, they came back and she died.

And the mom, Chris and her then boyfriend, who became her husband, came to my office one day with like $800 in checks and said, "We want to start a foundation in her name." And I'm like, "Oh, am I going to start a foundation with $800?" Like, "What the hell? How am I going to do this?" So, we had a wonderful development guy who worked with the University of Wisconsin Foundation named Russ Austin. And Russ is one of these guys. He played college basketball. I hope I can swear. He's a great artist. I mean, this is like one of his great gifts. And he could just fake it until he makes it, but wonderful human being.

And he is like, "Look, I know you're passionate about surgery. I know you're passionate about short gut. What else are you passionate about?" I'm like, "Cars." He's like, "Well, how passionate about cars?" I'm like, "Russ, have you seen my ride?" He goes, "No." I said, "Well, I got a GT500. It's tricked up for the track, and I tracked that thing like three times a year." He is like, "Great! Let's do something about cars." I'm like, "Really?" He's like, "Yeah." I'm like, "Okay, what do we do next?" He's like, "Well, do you know anybody else who likes cars?" I said, "Well, do I know of a guy whose wife's a peds cardiac nurse practitioner. And as I understand it, he redoes really expensive race cars." He's like, "Call him." I'm like, "Really?" He's like, "Yeah." So, I end up calling the guy's wife, Anne. I get Anne on the phone.

She's like, "Oh, Jeff would love to talk to you about this." Got Jeff on the phone. And Jeff says, "You need to talk to this guy named George Stauffer." I'm like, "Well, who's George Stauffer?" He says, "Well, George Stauffer has a car that I redid for him that won Le Mans in 1966. It's a Ford GT. And he just sold it. But he's got a stable full of cars. He's retired. He's sitting around on his hands. He'd love to do something like this." And George Stauffer got us going with Cars Curing Kids. So, I got a whole bunch of people together that are really excited about this. "Well, I'm going to help children." And then, I'm going, you know, "I got to figure out what I'm going to do with the money." And if you've done any kind of basic science research, you realize that the horizon and stuff is 30 years away. Anything in terms of discovery is going to take 30 years and it's a herculean effort. So, we kind of did a pivot and said, you know, we're going to fund stuff that can help kids in and around the region. We're going to fund small projects. They'll help kids in and around the region within one to three years and have a measurable horizon. All we're going to ask is people come to us with a good proposal and tell us how they're going to track what they're going to do. I think, Cars Curing Kids at this point has raised over $450,000, and they've given away last I checked, which is over a year ago, like over 32 grants. And so, that was one of the foundations.

Then, of course, I started another one because there was a guy who owns a resort and, he was north of Madison and he found out about all these. He wanted to jump in, and I said, "Mike. I am not going to raise money up in the Wisconsin Dells to spend in Madison, Wisconsin. I have too much respect for the rural parts of this state. If you want to start a foundation, I'll help you do it." He's like, "Great." So, we started a second foundation and we outfitted a bunch of the rural ambulance rigs with pediatric-specific equipment that they didn't have. And now, they're pivoting towards funding a rural nursing program. It's pretty cool.

Host 1: I did not expect that story to go that way. That's pretty incredible. Mitch, I would say to our residents who you came and spoke to and said, "Build a network." This is a shining example. Build a network. Talk

Dr. Peter Nichol: And keep it alive because the second foundation kind of got mothballed because we were doing big events, then COVID hits, but keep it alive because then opportunities come along and you can reactivate it. And it's totally fine to pivot and find something else as long as it's a worthwhile pursuit.

Host 2: The story makes me think of Pronovost, right? With the central line checklist and what happened in his ICU at the time. And, again, one of my mentors is Dr. Frank Edelmann. He is the Father of Cardiothoracic Surgery here, former graduate student in English, probably one of the smartest people I know. He's a humanist, right? And he reminds all his medical students. He's in his late 70s, but he still teaches the medical students that medicine is a privilege. and what you do with that privilege is how you define your career.

Host 1: Right. Great segue, Mitch. One of the questions we wanted to ask, what do we need to be teaching future physicians? What are we leaving out? What are we missing in medical education these days that we need to be teaching our future generations?

Dr. Peter Nichol: Well, I'm glad you asked that. The timing could not be better. I've been spending a lot of time the last three or four months thinking about this, particularly with how healthcare is going to get restructured now. And a couple things, it's not just teaching them, it's how we recruit them and who gets in.

So, the average medical student takes on about $231,000 to $235,000 of debt to go to medical school. And to get into medical school for the most part, you need to go to either an elite private college or an elite state school. And I'm talking about medical school, not necessarily DO schools, but there's probably some truth around this to DO schools as well.

But we set up this funnel and it's expensive to get into. It's probably more expensive even for DO schools, because they have higher tuitions actually than most state medical schools, I think. And I'm not trying to throw shade at them because what they do is really important. But the way we stop this funnel, it reminds me of how the British used to run their militaries up until 1871. You go by a commission as an officer. So, there's a lack of inclusion around this. And this isn't just true for medical school, this is probably true for dental school, right?

And then on top of this, we have people spend-- we're reducing the amount of time. But when I went through, we had to spend two years in the dark classroom listening to people go on and on a lecture about stuff that we were never going to use. And I went to WashU, right? It was painful. Then, you get out on the wards. And the people are pragmatic and practical and can innovate and are facile do well in the latter environment, not in the former environment. But we select for people who dwell in the former environments. So, the selection process is a problem. And I actually do think the DO schools do a little bit better job than the medical schools around this, but having discernible skill sets when you leave medical school, that's been sort of lacking, I think. And we've had all this concern about work hours, which I understand, but then you take away educational opportunity. And a number of times, I was able to do something at 1:00 or 2:00 in the morning because I stuck around, and gained an experience and sort of leapfrogged up the educational ladder.

 That goes away because we're concerned about quality of life and we limit work hours, right? So, we need to start crafting medical school. Actually, all this is true also, and we're seeing now in nursing, like nurses coming out of nursing school and are afraid to put in IVs. We've got to reconfigure it around practical knowledge. And we really actually need to open the funnel up to people who already have some of this practical knowledge. I think about like EMTs who do innovations and throw in lines and give meds in the field or deal with crisis situations all the time. Why are we making it so hard for people like that to make a career progression and go into a professional level school, like medical school? Why?

So, I think we have to change shift how we do the funnel. And I think we have to really start focusing, like Mitchell said, on the humanism around this. And a lot of that is developing the basic skill sets to take care of a patient, and do a physical exam and put in an IV. And I had a wonderful internship. We had to draw all the labs and put in all the IVs after 6:00 p.m. That was at UVA. And when you're on transplant, you are up all night drawing blood, popping in IVs, drawing labs when a set of organs came in. But by the end of that year, I wasn't afraid to take care of a sick patient. And I really hadn't spent any time in an ICU. So, I think that's what needs to be reconfigured, the practical knowledge part of it.

Host 1: I don't know how your institutions do it, but when we try to claim that we teach medical students at the University of Vermont that we're in the operating room teaching all the time, it's not a structured lecture like between 1:00 and 2:00 where they congregate around a table. But like you said, it is practical knowledge, right? What are you going to do in a code instead of writing an order Place IV? How are you going to place the IV yourself? How are you going to bag mask? And it's one of the things that I enjoy about our specialty. I think Dr. Kole said the same thing about how we need to restructure residencies to make sure that we are graduating competent physicians for the future.

And then, the last piece is, I think all the solutions that have come about for work hours and wellness and DEI have all been top-down, right? But what I think you're talking about, and this is sort of biased for me because I took my son this past weekend to the science museum in Raleigh and there was this space exhibit it was awesome. But when you go back to what Kennedy did in the '60s, the Space Race, the AmeriCorps, the Peace Corps, how do we do that for healthcare so that we ensure like that 18% of the people that apply for medical school from rural places get the training, and then go back to where they're going to come from, right?

Dr. Peter Nichol: Yeah. Yeah. Well, and I think the other thing is we need to lower the barriers for people who already have a lot of the qualifications. Like one of our burn surgeons, she's NIH-funded. She's brilliant. She was a burn nurse, right? And she went and did an MD-PhD. I don't know why she really had to go back and do two years of basic science in medical school. And I was in that burn unit, you know, I remember being there with like 70% third-degree burns with her. I don't understand why someone like that has to go and sit in a classroom for two years when they have already have all this practical knowledge. We've got to change how we do education and we've got to make sure that we have a ladder that there are going to have to be criteria around this, obviously, right? And there's going to be informatics. And we have to really start figuring out, rather than test scores. How do we discern who's got the empathy and the drive and the concern to get their butt out of bed at 3:00 in the morning to go help somebody? And if they don't know what to do, how to ask for help. Like, those are two very, very important attributes that everybody has to have if you're going to have a successful practice or hospital or whatever. And if you have a handful of people who can't do that, you're going to clean up disasters left and right. And we've all seen this. I've seen this across multiple institutions throughout my entire journey from being a medical student to being here now.

So, we need different criteria and we have to able to detect and measure those criteria. And it isn't just a test score or a grade in Organic Chemistry. But then on top of that, we have got to find a way to make it easier for people who are qualified to really kind of move up the professional ladder to do that with fewer obstructions and fewer obstacles.

Host 1: I hope my son hears this one. I got a son who's entering college has, he wants to be a surgeon. It's hard to get him to listen to the Fresh Flow podcast, but this seems like a must-listen podcast to me.

Dr. Peter Nichol: This is the one that you're ready to have go to college, right, Matt?

Host 1: It's Tom, man. Everybody knows it's Tom. We love him, but it's Tom.

Host 2: So Peter, we're going to give you a question so you can hit this one out of the park, PhD in neuroscience. And so, I think Jonah Lehrer wrote the book if Proust Was a Neuroscientist. And he pointed out how the artists in human civilization have always presaged or predicted what the scientists were going to figure out. And so, one of them was how our visual information works, right? So, Chaison was a painter, and as he painted, he just kept deleting stuff so that you had the bare minimum on the screen, but you could still recognize the mountains and the oceans and the trees. And we know that the visual cortex fills in a lot of information. So, in that framework, what would the Dr. Nichol of today tell the Dr. Nichol 30 years ago? knowing everything that you know, what you got right, what you didn't get right.

Dr. Peter Nichol: I think this is a message largely for all my brethren in surgery. I think Medicine in general, the majority of people that go into this are people who want to serve other people and almost to the degree where they don't take care of themselves. Like two weeks ago, one of my favorite people in Pediatric Surgery, Brad Warner died and Brad was probably 64 years old. And Brad was everybody's buddy. He'd been the program director at Cincinnati Children's for years. He went to WashU. He was the head of the SUS and I remember talking to him about when he became the head of the SUS. He says, "Oh my God. He says, "When I took over, it was like a firing squad. I had to get everybody to just like settle down and be nice to each other. You know, it was just so vicious."

He was a great example of somebody who serves other people, right? The majority of us aren't like that in healthcare, but what we forget about is taking care of ourselves. and we all get exhausted and we all get burned out. And I think what I would tell myself now is what I was telling myself eight, 10 years ago is you don't need to work harder, you need to work smarter. And what I've learned in the last two or three years, because I'm 57 now, is you need to really focus on your recovery. You need to have a strategy for sleep. You have to have a strategy for diet. And you know, this residency thing, it's fine for a short period of time, but you're going to come out of this, and you can't continue to practice like a resident. And I think most people come out of residency sort of going Mach 5 with their hair on fire and I'm not sure we can actually go Mach 5, but going very fast with their hair on fire and they don't slow down. And I was that person. I was definitely that person. And it took a huge toll on me. It took a huge toll on people around me. It probably took a toll on my practice in the first three or four years and on my patients, because we are sort of attuned by the system or trained by the system to sort of sacrifice everything about ourselves in the service of the patients.

And so, there has to be a balance. And that balance is not something that's going to be established by a set of work hour rules. It's not going to be set by an institution or a central governing body. It is an issue of an individual giving themselves internal boundaries. And just like you have boundaries for dealing with other people, right? and you have to say, I can't do everything. I had to focus on what I can do best and I need to continue to work to be the best at those things. But I can't beat everything to everyone.

And probably the worst advice I got was from another one of my favorite people in Peds Surgery, Tom Krummel. And he said, "I just never said no." That's terrible advice. You have to learn how to say no. It's a lot easier to walk back a no than is to walk back a yes, right? You can always say, "No, I'm not going to do that" and say, "You know what? I've really thought about this and I am going to do it." But once you say yes, you're committed, whether you're going to do that in a half ass way or not, you don't want to look like a quitter, right? So, I love Tom, but that was the worst advice anybody ever gave.

Host 1: So much good stuff here.

Host 2: Seven, eight years ago, I had a decision to make whether I should recertify for my TEE boards to maintain my cardiac anesthesia practice. And I was talking to Alex Macario, who is the president of the ABA and he was actually our first podcast guest here. And I talked about it with Alex, and Alex looked at me and he said, "Mitch, if you're not dropping something every five years, you're doing something wrong." And I was like, "Thank you, sir. And I don't regret the decision that I made."

Host 1: Practical wisdom. Mitch, we have our title. There's a lot of practical wisdom in this one. So, Peter, this has been a blast, man. The cool thing about this podcast, we talk about building a network. We just get to hang out with cool people and talk about cool stuff. So, this has been a blast. I am so glad to have met you through the AACD, and you will be hearing from me about this human-based informatics talk in the future.

Dr. Peter Nichol: Listen, props to the AACD. Like, I found my people finally in medicine.

Host 2: And they're mostly anesthesiologists.

Dr. Peter Nichol: But it's all part of one team, right? And what you're really looking for, what I love about the AACD is it's all the people who are the Cassandras who are thinking outside the box who are already 10 years ahead on all this stuff. We've all kind of found each other as a wonderful welcoming environment.

It's the one meeting I go to, I always have to leave for about 45 minutes in the middle of it, because I need to take a break because it's so intense. You know, sitting for eight hours, nine hours, listen to those lectures. But it's the only meeting I go to from morning until evening. I love that meeting. Great

Host 1: people.

Yeah. That's awesome. Peter. It's been a blast, man. We'll catch up with you soon. Thank you guys for tuning in to this episode of the Fresh Flow Podcast. We'll catch you next time.