Episode Transcript
[00:00:03] Speaker A: Welcome to the Ortho Joe Podcast, a joint production of the Journal of Bone and Joint Surgery and Ortho Evidence.
Join hosts Mohit Bhandari and Mark Swankowski as they discuss current topics and publications in the world of orthopedics and beyond.
[00:00:19] Speaker B: Well, good morning, Mo.
[00:00:20] Speaker C: Good morning. Good morning. How are you? I have my. Have my cup. Good old, good old.
[00:00:25] Speaker B: Yeah. And here I come back at you with my Duncan.
So was. Was Tim's busy this morning?
[00:00:32] Speaker C: You know what? It's always busy because it has regulars and we're faithful. We're faithful to our Tims, you know, and there's. There's three things, Mark, I gotta tell you. There's three things I think that are really important that represent Canada.
[00:00:43] Speaker B: Yeah.
[00:00:44] Speaker C: Tim Hortons, the Maple Leaf.
[00:00:47] Speaker B: Yeah.
[00:00:48] Speaker C: And the band Rush and Yes, sir, I was there. In fact, I have to believe that we may have converted. We may have converted someone else to full Canadian here. I don't know, Alan, if you happen to be available to come on camera, but you can show us something truly Canadian here.
[00:01:08] Speaker D: I am, you know, I'm speaking from Massachusetts, the belly of the beach. So I don't want to instigate an international, but this is fantastic.
Yeah, this is, this is transported all the way back from Toronto, as they call it.
[00:01:22] Speaker C: So a fellow Rush aficionado and Tim Hortons lover. So there you go. There you go.
[00:01:29] Speaker D: Toronto was fantastic, so I'll bow out now. But highly recommended.
[00:01:34] Speaker C: There you go.
[00:01:35] Speaker B: There you go. I have a feeling, Alan, that there are groups of inflamed Duncan people with torches on fire out in front of your house right now.
[00:01:47] Speaker D: I know I gotta tread carefully, so I'll be incognito for a while, so
[00:01:52] Speaker B: make sure you keep. Keep it secret where you're traveling these days. There might be people following you with silencers and such.
[00:02:00] Speaker D: Okay, thank you.
[00:02:02] Speaker B: Yeah. Well, Mo, it's a great pleasure to have a wonderful guest today on our Ortho Joe show. And that would be you.
[00:02:10] Speaker C: Oh, my goodness. All right, let's go.
[00:02:12] Speaker B: So this is completely not planned ahead of time. I'll alert our audience, but I want to go over with you how the heck you got so committed to a career in research and developing high quality evidence. So let's go. Let's start from the beginning.
[00:02:32] Speaker C: Sure.
[00:02:34] Speaker B: Early education.
Were you already science focused when you were 12, 13, 14 years of age?
[00:02:40] Speaker C: Well, you know, so high school, you kind of, you know, you plug away, you try to do lots of things. I gotta tell you, very early on in my career, I think We've chatted about this.
I was. Loved art, and I just wanted to be.
It was really interested in art and. But, you know, kind of made sure I did a lot of the humanities in high school, plus sciences, got into University at McMaster and then did biology at that time. So there wasn't really. There weren't really arts and science programs and bachelor of health sciences programs that are very focused at that time, the late 1980s.
So went through McMaster. There was a two year. You could get into medical school after two years back then. So two years.
[00:03:23] Speaker B: I don't mean to interrupt you, but I want our listening audience to understand. So you obviously have artistic talent. Most people who read the journal have seen your watercolor work. You have real talent. But usually people that are interested in the arts like that don't make a sudden switch and go into biology. So what happened there?
[00:03:44] Speaker C: Honestly, it was the truth. The truth was I went to my immigrant parents who had traveled across India, had sacrificed a lot, and I said, mom, Pop, I think I know what I want to be.
I know my dream. I want to be an artist. And they looked at me very carefully and said, son, you need another dream.
So I said, okay, so what do you mean? He goes, well, you know, you've got to find a way to have, like, in their mind. And again, you know, that was back then. It was back then there was a few things that were guaranteed, you know, jobs you'd have. You'd have a job stability.
And so I said, well, you know, the idea of science is great. I liked it. And so I kind of moved. But I always kept art as a hobby.
And actually, in many ways, I think I gave it up in pursuit of other stuff and only later in my life realized how much I gave up and how much, you know, being creative and being curious is all part of doing all the other things you like to do.
[00:04:41] Speaker B: Yeah, and we, We've. We've interviewed people like Tom Einhorn, who was our editor for JB Jess Reviews for more than a decade, and his interest in music and others like you that have had.
You've been able to bring. Bring it back around, if you will, if you're a little farther along in your career and use it to balance out your life. But, okay, so we're at biology, and then, yeah, then how do we get to medicine?
[00:05:05] Speaker C: You know, like, I mean, as probably. Lots of folks who can probably relate, you know, I, I really, in my mind, I said, you know, I liked organic chemistry. I liked chemistry. I loved, you know, I Liked physics. I liked all that stuff. So I thought, you know, this is great. I could, you know, science would be great. But then, you know, you're in this groundswell of people around you are all applying to med school. You know, it was no joking. It was like, wow. Like, it seems like everyone here around me is trying to apply to medical school. So then you start thinking about it. But I didn't have, like, I didn't have a moment, you know, where it's just like, you know, there was, you know, a family member, someone that inspired me to say I should go into medical school. My parents had basically said, just. Just have a job. Like, have a job where, you know, you have stable, stable income. So they never pushed me one way or the other, and it was just made of me exploring it. So, as you can imagine, at that point I said, oh, I'll apply.
And at Toronto. And I was able to do a. Be successful in getting into Toronto's program. So I started in Toronto in 1990. So it was a class of 94. I started there. The University of Toronto was a Fairly big class. 250 back then. 250 students or so.
[00:06:10] Speaker B: Yeah.
And.
Go on. How did. How did you get from medical school into surgery?
[00:06:17] Speaker C: Yeah, so.
And I've said this multiple times. I had my first elective and probably would have been first year. We had to pick electives and people were frantic. People were going, like, frantic to get electives and stuff. But I had my first elective with the nut other than. And I think you've heard the story, Robin Richards.
[00:06:33] Speaker B: Yeah.
[00:06:34] Speaker C: And it was. He probably, like, I've told him this multiple times, but I don't think he appreciated back then the impact that he had had.
So I was.
I just saw him, I said, this is exactly. I think I found this. I found there was a culture that I just loved about orthopedics. There was the variety that I loved about orthopedics. I knew nothing at that time.
You just get. You get. You really start appreciating the resonance and you really appreciate, you know, the individuals. I looked at him, I thought, wow, this is amazing. This. This is what I would like to do. And he was very dry, very smart, very, you know, he. He'd. Any question you gave him, he'd give you a question back. And he was a McMaster med student. So, like, he. He had a little bit of, you know, like, we had a little bit of that to chat about, but I'll remember it like I was a medical student in his or Fellows Galore around him. Lots of you around the back and you're just standing there. Just don't want to screw up anything because everyone's telling you, you make one mistake and you're done.
And all I heard was my name. And he pronounced my name. It was, you know, he said, mohit, Mohit. I go, me like that can't be. Is he calling my name? And I said, yeah. And he said, come over here. And all the fellows parted like this parting of fellows and there's a light right into a wound. He said, come over here. Gave me a screwdriver and says, take out that screw. That was it then I'm in. It was like, it was just the most. And I, and it wasn't the, the, the I'm, you know, I like working with my hands and I'm, I like carpentry, none of that. It was just a human being acknowledging me, bringing me in and giving me an opportunity just to be seen. I, and it was like, wow, I owe you. I owe you a lot for that. And I never, I don't think I told him that part of it.
But anyways, that was it. And then I went all in, Mark.
All in. I went all in. And then, you know, elective after elective. And then I really didn't give my chance, truthfully. I didn't give myself a chance to look at anything else. I had just only done orthopedics and anything related to orthopedics at that time.
And I, and I remember now, I was at St. Michael's Hospital in the night around 94, when I was a clerk. Mike McKee had just been hired. Mike McKee had just shown up.
And I remember, I just, I just remember hearing, Mark, you love this one, that I remember hearing everyone saying there's some seven hour calcaneus going on in there.
And people were like really getting anxious around how much longer. And it was Emil working on something. And it was about perfection, right? It was about getting things perfect. And I remember that and I didn't understand why that was like such a big deal. But at that time it was because, you know, he had brought back some knowledge, right, from other places and stuff. And so there was a lot of that happening.
Jim Waddell was the big boss there as well. So I, you know, I got to see him.
But imagine a, a place where, you know, you know, Jim Waddell, Neil Shemmich, Mike McKee just starting out and then you've got obviously Robin Richards. And they were morning grounds and residents would go to that. And though that was a show. That was a show.
[00:09:25] Speaker B: So anyways, yeah, I'm sure that that environment had something to do with shaping your sense of humor, which is robust, I can tell.
[00:09:33] Speaker C: You have no choice. You have no choice.
You have no choice. Yeah.
And you gain a little. Yeah.
[00:09:39] Speaker B: The skill and snarkiness is.
[00:09:42] Speaker C: It's incredible.
Goodness. It was. It was actually like you were worried for some of those trainees going up, not that they were going to get harassed. It was more that, like, they would get questioned to the point of failure. Like, to the point where they can't say, I don't know. And it was just this really fascinating learning experience. Right. You'd be part of it. So you'd see it. It was really cool.
[00:10:01] Speaker B: All right. But what I really want to focus is how do you get from there with a laser, like, focus on research?
[00:10:07] Speaker C: So I applied to, like, I was very keen to go back to McMaster University.
And, you know, so you fast forward, you know, 2,000. You fast forward to, like, 90. I got into 94, so I got into orthopedic, finished medical school, and then, you know, 94 onwards, I was accepted to orthopedic training at McMaster University. I won't go into the specifics, but I got in there. It's a very small program, very small community program, actually. Really, you know, the whole plan was we. We produce great surgeons who go into the community. And actually, at that time, our seniors weren't doing fellowships. There's no fellowships. They were finishing orthopedic training and going. Working in the communities. And it was like, wow, amazing.
So two years into that, I was in an OR room with an exceptionally gifted consultant. And I remember asking, why do we pulverize the bone with these high pressure irrigation things? That can't be good. And he looked at me and he said, mo.
Why would a company, company X, Y or Z, create something that doesn't work? There's no question here. And I thought to myself, that's interesting. How could there not be a question here? And at that same time, I started looking for how do I learn about doing research?
At that time, this is my. I'm probably 95, 96, looking into this stuff. 1990, Gordon Guy, David Sackett, you know, Brian Haynes, Peter Tugwell, all this group of people in medicine were unveiling this new language, this new phenomenal, phenomenal experience that they were going to call it McMaster evidence based medicine.
And I applied back then, just randomly, to this program that was called Design, Measurement and Evaluation. That is now what is the renowned health research methodology Training program of McMaster University. Back then, it was that, and there was no one who had done it. Like, I was just, you know, it just maybe launched three, four years before that. So that's what had happened. And I got in. I just got in and I, you know, had this awkward conversation with our division head in Morsm. I said, listen, I'm taking some time away. And they'd never had that happen. That was the other thing. It never happened. Said, we have no funding for you. I don't even know if we can let you go. I don't know if we can let you back in. It was all this, what, what if? But I said, I will figure it out. I will find my thing. And I went basically knocking on lab doors and saying, can someone just give me a job?
You know, And I was paid probably a master's level payment or like maybe $25,000 a year for three years. That's roughly what I was paid. I remember being. That didn't matter. I'm just going to do it.
And then I started the course and that changed everything because that's when I really got and I started to understand stuff. And I thought, oh, my gosh, like, how do people not know in our. Again, McMaster, this stuff? Like, this is incredible. It's happening in our backyard.
And then that led to the meeting, my first meeting with Gordon Guyett and then with you and then Paul Trinetta and meal again. And all these things happened, as you remember.
Yeah, that just took things away. And that early network and that early win, you know, I talk about it now all the time, Mark, if you are early in your career and you get an early win, you'll continue to have those like you really does give you that confidence. And you need people around you that really look out for you to help you get those early wins.
[00:13:26] Speaker B: Yeah, well, yeah. And most of our listeners are aware of your incredible accomplishments.
For those of you who don't know, Dr. Bhandari has well over a thousand peer review publications in journals like New England Journal, etc. Lancet, and you've had a huge impact. But now I want to just turn the conversation if I could. In the last few minutes, we know from material we've published in the Journal that despite this very high level, level one evidence that our community of surgeons doesn't follow it.
And how.
How do you. How do you reconcile that? How do you deal with that frustration?
[00:14:10] Speaker C: Yeah, I mean, you know that. I think so the challenge is there's two approaches. Well, you, you can take, you can take an approach saying this is the best evidence, you should follow it and get upset and try to go after the people who aren't and try to convince them. But you know, Mark, after many, many years of, you know, promoting evidence that, you know, often starting with sort of the champions is a good way to start because you've got to get the people who believe in it to become sort of the ambassador, so to speak, of moving, moving the area forward. But the other thing I've become actually quite humbled by is, you know, just because we've, let's say, some of our own trials, I'd say, why aren't you doing this? And then you talk to someone who isn't doing it. And it wasn't that they really disregarded the evidence. They just had a really good rationale for why that didn't apply, or why this doesn't quite make sense, or why they were hoping to get a little bit more information, the things we didn't collect. So it's almost like you get humbled a little bit when you talk to folks and really learn from them as to why is this. And I don't know, I don't know if you've had this experience, but I don't know if it's malicious. I just think, I mean, I don't think anyone is out there doing stuff that they think is going to harm patients. I don't think that's not the motive. The motive is I really believe I'm doing good, I want to continue doing well. And here's my rationale for it. And my rationale may agree with what's being done or may disagree, but when it disagrees, that's where really I'd say the magic in some ways is to figure out why. And to your point, I think we have to do more of that, you know, and in fact, your idea, which I know has just been Niam's supported, which is, you know, how do we get evidence into action? How do we get it into practice, Mark? And I guess maybe I'll, maybe I'll throw the question back to you, you know, should we be spending more time with, you know, opponents of some of the big guidelines to say, why, why are you not doing this?
Than the other way around, which is these are the best guidelines and, you know, you should be following them. And I think that's sort of this, this evolution, right? Just trying to figure out, you know, why is this chasm happening? And I don't think it's maliciousness. I don't think people are doing it. I think they're doing it because they genuinely believe if they aren't following a guideline, they're still doing the best for their patients.
[00:16:30] Speaker B: Yeah, I, I agree with that. I, I, I do agree that, that surgeons and their rationale, they're not just, they're not just doing what they're doing because they, they, they want to harm people.
[00:16:45] Speaker D: Right.
[00:16:46] Speaker B: But we often hear, I, I know you, you certainly have had your share.
Well, that's not my experience.
And I think my response often is to get frustrated and want to start arguing. But that, that, that is totally counterproductive.
But what I've tried to do when that is brought back to me is say, well, do you, have you actually collected the outcomes on the last 10 patients with that condition? Do you really know what their outcome is?
And often their response is, well, no, but I, I'm pretty sure they're doing okay. And that, that's the, the step that I think it leads to a lot of conversation. And do you have any tips? Tips and tricks?
[00:17:42] Speaker C: It's exactly that. That's exactly it. So when someone says, you know, I don't agree with that, that's up in my experience, I say, well, great. What would change, what would change your mind? What would you need? Well, you know, I would change my mind if, if, if I found in my own practice that I wasn't getting great results. Okay, have you looked at, you nailed it. If you looked at stuff and, or, or what? If we find a whole bunch of, you know, studies on this topic, then the next step is, well, yeah, but those studies don't represent how I practice. Okay, well, how do you practice? What would you need in the, you know, and it's just that discussion because most people, I think, in many ways are willing to change. But, you know, in anything, change is a major, that the idea of change has friction. And so we have to reduce friction for people because, you know, there's no issue with the individual say, oh, yeah, the guideline supports what I do. Perfect, done. I'm great. But what if the guideline says, oh, I think I should be doing something, another procedure that I'm not doing, you know, the friction. Right. And so I think some of that is trying to figure out is the cost of relearning, you know, completely. But the learning curve, the time, the energy, the risk of that going to be better or worse than doing what they're already doing, depending if, you know, if the differences aren't Big. No, it's one thing if it's a medication where mortality is the outcome, but you know how subjective some of our outcomes are and most of our trials in orthopedics is, the ones we've done together aren't always definitive. Right. What they're saying is, well, you know, there are, you know, if you do certain things a certain way, you can probably have pretty good outcomes.
And that's always been our challenge. Right. There hasn't been a clear winner unless it's like, you know, base of neck fracture or something, you know, where you've got a fixed angle device or screws, but, you know, that kind of stuff where it's very obvious but not always the case.
[00:19:26] Speaker B: Right, yeah, yeah. Well, I think we, we really need to continue this discussion and to work on this bit and maybe this workshop that we recently have received word that we're going to have funded for this workshop for later in this year.
Maybe we can move the needle forward into how we get people to really want to look more carefully at the guidelines and where their practice interfaces. I hope it'll be a good start. But I think your emphasis on the basic understanding that surgeons aren't trying to harm people, it's just that they really feel they have a different rationale and we need to dig deeper at, at what's behind that and try to help in a collegial manner rather than a confrontational manner. I think that's the key.
[00:20:17] Speaker C: I think you're right. And again, just as a little plug for the work that you will be doing, you know, if those listening in or watching are interested in this topic of how do we actually get evidence into practice, please let us know. Maybe send us a note, you know, particularly with you, Mark, because I think you'll be looking.
I know we have some ideas of who might be on a panel, but some of you might be really keen on this and I think hearing from you would be great to help us inform this particular panel that has been, again, NIAMS funded. So I think it's an important thing. It's going to lead to some important, we hope, outcomes for our field.
[00:20:52] Speaker B: Well, I think that's a great place to end and I hope that our audience appreciates getting to know you a little bit better.
There's lots and lots of people listening to this that really haven't had a chance to understand where you're coming from. Mo and it's been great and let the competition between Duncan Duncan and, and Tim Hortons continuum.
[00:21:16] Speaker C: The goal is to convert people to Tim Hortons coffee and Rush. One fan at a time. That's all it is. That's. Alan Harper and I are committed to that. Committed to that. Long, long journey. All right. That's all we want to do, Mark.
One at a time.
[00:21:32] Speaker B: Well, may the battle. May the battle continue with. With all your energy imparted.
[00:21:38] Speaker C: Oh, awesome. Thank you so much.
[00:21:39] Speaker B: Have a great day.
[00:21:40] Speaker C: You, too. Take care. Bye.
