George Tolis: TAVR, Broken Training, and What's Really Wrong With Cardiac Surgery.

Episode Summary

Dr. George Tolis, section chief of coronary and general cardiac surgery at Brigham and Women's Hospital, joins Drs. Koka and DiGiorgio for a wide-ranging conversation on the state of cardiac surgery. He makes the case that TAVR — while genuinely transformative for the right patient — is being systematically applied too broadly, driven by industry incentive and the erosion of meaningful surgical consent. He discusses his collaboration with John Ioannidis that found no statistically significant mortality benefit for any new cardiac surgery technique introduced over the past 35 years, the paper's rejection by every major surgical journal, and what he paid out of pocket to make it open access. The conversation moves to the collapse of surgical training — fragmented pathways, work hour restrictions that leave residents unprepared for attending life, an academic promotion system that ignores teaching, and a culture that routes incompetent trainees around rather than out — and closes with a brief on Vasily Kolesov, the Soviet surgeon from Leningrad who performed the world's first documented coronary bypass years before Favaloro, and whose work was buried by the Cold War.

Chapter Markers

00:00 Introduction

01:02 Air-cooled VWs, concert piano, and how Dr. Tolis got here

02:40 TAVR: genuine breakthrough or being abused?

08:02 Finding the TAVR threshold — and why informed consent is the real problem

11:46 Collaborating with John Ioannidis: no mortality benefit for 35 years of new techniques

20:02 Why the major surgical journals wouldn't touch the paper

21:52 Minimally invasive surgery: minimal access vs. minimally invasive

26:24 When do CABG survival curves diverge — and what does it mean?

30:05 Surgeons signing off on TAVRs in young patients

33:51 Health system economics and the heart team dynamic

37:50 How to actually pick a good surgeon (ask the scrub nurses)

40:36 Cardiac surgery training: the three pathways problem

44:04 Work hour restrictions and the residency simulation gap

51:16 General surgery is like MTV — they don't operate anymore

53:21 A resident who finished training without ever applying a cross-clamp

56:34 How to evaluate if a program actually trains

59:27 Academic promotion has nothing to do with teaching

01:01:33 Dr. Tolis's resident outcomes database and three papers nobody cared about

01:05:32 The training timeline: finishing at 49, no runway left

01:07:08 One-size-fits-all RRC rules for cardiac surgery and psychiatry

01:09:16 Cardiac surgery as a disposition, not a therapy

01:12:24 When ECMO becomes the final common path

01:13:38 How you become nationally recognized without being a good surgeon

01:17:16 Vasily Kolesov: the Soviet surgeon who did the first bypass

Co-Host Handles

@anish_koka and @drdigiorgio

Show Handle

@drsloungepod

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Transcript

Anish Koka: Welcome to the latest episode of the Doctors' Lounge. are very excited to have Dr. Tolis today. Dr. Tolis is, we always have exceptional guests on here, and many, many heavyweights, I mean, among the heavyweights, Dr. Tolis is quite a heavyweight. Dr. Tolis is a Yale undergrad, Harvard Medical School, MGH, Mass General. general surgery, Yale CT surgery, Mount Sinai aortic fellowship under Randall Greep. He worked at Lennox Hill where he was the chief of aortic surgery. He then went to St. Elizabeth's where he was also the chief of CT surgery. Tufts faculty then spent some time as an attending at MGH again. And now he's at Brigham and Women's since 2021 as section chief of coronary and general cardiac surgery. He's also... a concert pianist, is that right? Wow, a woodworker. And what an air-cooled VW guy. What does that mean?

George Tolis: That is correct. Well, the first car that I ever remember my parents having is ⁓ a Bug, a Volkswagen Beetle. And I up buying one myself about 20 years ago, a 1959 air-cooled Bug. And ⁓ I tried not send it anywhere for work. I tried to do all the work myself, sometimes successfully, sometimes not very successfully. But it's just an interest of mine that

Anish Koka: That's great. you work on a auras, work on hearts, you work on VW bugs. were born ⁓ Chicago. And ⁓ like said, just a clinical, absolute clinical heavyweight in coronary surgery. Bypass, reduced or not surgery for endocarditis, fail tavers, you name it.

George Tolis: you know, it's not hard to do it in your free time.

Anish Koka: and Dr. Tolis is doing it. He also ⁓ one the, I think, of the best ⁓ Twitter accounts. is ⁓ incredibly incisive and isn't just kind of recycling some hype machine that typically see. So that's how I found him. he's a fantastic follow. I'll this again ⁓ at the end, but his X handle is at George. told us to LIS jr. So ⁓ Toll is welcome. Thanks so much for coming on.

George Tolis: Thank you very much for having me.

Anish Koka: I wanted to warm, you up with something that, we talk about a lot, in cardiology. we talk about TAVR. TAVR is a transcatheter aortic valve replacement. ⁓ really a remarkable, advance ⁓ in terms of treating aortic valve disease. has converted in many, many, many ⁓ symptomatic high risk patients into, and into something we can actually. beyond simply trying to palliate symptoms when you have severe aortic valve disease in somebody that's high risk. And normally the only thing that we had to offer was surgery, but many times we couldn't do surgery because of the morbidity associated with surgery, especially in somebody that's high risk. so that's where TAVR really, there's some great data that came out showing that one, it can be done. and two, it can be done safely and three, it's effective. of course, since that time, ⁓ the early ⁓ 2000s, right ⁓ then, indications use has been expanding. And Dr. Tolis has had a number of comments on this. So Dr. Tolis, what are your thoughts on the ⁓ ever expanding for TAVR?

George Tolis: Well TAVR is a big deal. TAVR is probably the biggest, if not the biggest, one of the biggest modes of progress that our field has seen in the last close to 20 years, not 15 years. And the reason why I'm saying that is I'll just give you a perfect example of someone that I saw in clinic last Friday, yesterday. A gentleman from Connecticut that I did six bypasses in 2021 who had a poor EF. was 75 years old or 76 or something. And he had a bypass and his injection fraction improved to about 40, 45 % from 25, 30%. So he did very well with his bypass. At the time his, and he got two mammary arteries and four veins. At the time, his aorta, his gradient in his aorta, mean gradient, was in the low teens, so about 13 or something like that. So we not add an aortic valve replacement to the aorta, once again to the the CABG, once again following guidelines. And he up now five or six years later with moderate to severe aortic stenosis and symptoms. and his coronaries are open by CT. 15 years ago, this patient would have needed a redo sternotomy with two patent mammary arteries and an aortic valve replacement, a doable operation, but a very technically challenging operation on someone who's older and sicker. And today, patient can have a TAVR and go home the next day. That is something we could not offer to patients 20 years ago, and I think that is huge, because there's a lot of people that need that kind of technology and clearly benefit from having their start-up opened up again. At the same time, where do the problems show up? There's industry behind Tabor. Edwards and Medtronic and all the companies that make these valves. with the technology being as effective and as good as it is, this technology is only applied to people like the patient that I saw yesterday that I just mentioned, then there's not going to be any profit for industry with technology. So in order for this to be profitable for companies, it has to be expanded to patients that are better off having a standard operation. And I know that's a big statement because there's no studies that show that, but by and large cardiac surgeons know and cardiologists know what works and what doesn't work. I'll give you an extreme example. If someone is 40 years old, you're not going to tell them to get a TAVR. You're going to tell them to get an aortic valve operation. Okay. And if someone is 90, you're going to tell them to get a TAVR. So where is the transition? Obviously, there's no clear answer depending on who the patient is and what the risk factors are. But there does come a point that there is a transition. And the transition point for industry needs to be lower than it should be in order for this to be profitable. And the transition point for humanity needs to be closer to the 80, 90 point. So clearly, you get into a conflict for a very valid piece of technology that can be abused and hurt people. While in other ways, it can actually help people tremendously avoid having risky operations. So I know I gave a very long-winded answer, not a very diplomatic answer, but I do think that it's phenomenal technology, I do think that it's currently being abused.

Anish Koka: How do we find that threshold? What would be the best way to find that? Because as you've very nicely outlined, the 40 year old, there's no debate, should get one procedure, an open valve replacement. A 90 year old should get a TAVR. How do we find that threshold?

George Tolis: That's a very complex answer because there's two parties involved here. There's the patients and there are the physicians. a patient will always, ⁓ no patient that will say, know what, let me not do what's the best thing for me. Let me just kind of like try to do something fancy here. No, patients want what's best for them. At the same time, we as physicians, we have to provide what we call informed consent. our hospitals feel that informed consent has to do with what time you signed the form and whether you did it electronically or in paper or whether the form is not in the folder and you you got in trouble. But for us, consent is much more important. Informed consent is telling the patient exactly what time it is. So, If you walk up to a patient and say, you want someone to open up your chest and put you on bypass or do you want something to just go through the groin and you go home in two days and be okay? No one's going to answer that question. I want someone to open up my chest. But if you tell the patient that do you want something that is more durable that will lead to less issues downstream and so on and so forth, I think then you can have a very valid conversation with a patient. Why am I saying that's not only true for TAVR, that's true for minimally invasive mitral valve, robotic, endoscopic, and so on and so forth. So the issues of consent, I think stem from physicians who, I'm not saying that they're bad people, but they're trying to do something to promote themselves. They're trying to do something different than the guy next door. And whether that is selling ⁓ minimally quote unquote minimally invasive operation or a Ross instead of an aortic valve replacement. Again, I am not trashing any of these technologies, but the why it's so difficult to answer your question is because of lack of informed consent and the source of the lack of informed consent I hate to say most of the times is the physician.

Anish Koka: Hmm. everyone has their biases. Of course, the device industry has their bias. Cardiac surgeons have a bias. Interventional cardiologists have a bias. So, mean, I guess this is the perfect place when you have ⁓ a of strong biases for, you know, solid, strong evidence-based medicine to kind of give you that, you know, at least move towards some of a threshold, right? Meaning, you know, biology is ⁓ not quite threshold friendly. mean, it's crazy. For instance, there's this idea that once you hit 45, suddenly your risk of having a coronary thrombus, a coronary artery disease, MI goes up, right? Or, you know, that's a risk factor. That's how we, when we plug it into the calculator, if you're a 45 year old, if male, you know, your risk goes up. Now, of course the 44 and a half year old, not no risk and the 45 year old is risky. So thresholds are always going to be ⁓ arbitrary. But that said, this would seem to be a place where evidence-based medicine would ⁓ be that could be used to at that threshold. ⁓ Why has ⁓ not been And what is, ⁓ I guess we start there.

George Tolis: think that's a very good question. don't think anyone knows the answer. What we know very well is that it has not been done. as I was getting older, I'm 56 now. I've been doing this for 23, 24 years as an attending. And what you have to do when the years go by is you have to rely on people that are honest with you to tell you if you can still do it or if you suck or if you, you know, they're not telling you because they want to be nice to you and if you're shaking and if you're, you know, you're taking longer and so on and so forth. So it's extremely important to have people that'll tell you that and people that will say, listen, you know, I think it's time to kind of start thinking of doing something different and not doing coronaries and all that. At the same time, there are internal checks that you have to do with yourself. And one of the internal checks that I've always done with myself is should I start doing mitral valves through a right thoratotomy? Should I ⁓ do a Ross? Should I, you know, do a mini sternotomy for the aortic valve instead of doing a full sternotomy. Since these are things that I've done them in the past and I stopped doing them or off-pump bypass, for example. I was trained with off-pump. I mean, my first, I think 500 or 600 cabbages were over 90 % off-pump because that was un-boked back in the early 2000s. So, I think you always need to have those checks and balances to make sure that you're being honest with yourself and you are not just offering a product because you can't offer the other product as well, or that you've convinced yourself that the other product is not very good. So have to do that in order to be honest with ourselves and to provide the best care to our patients. So was always bothering me that I was not getting into this sort of, a fib surgery, for example, ablation. And we went from doing two sets of lesions, the three sets, the five sets. Well, they were telling us the two sets very well. Why, why are we doing five now? What are we doing here? Or the maze procedure? Why are some people getting 95 % success and I'm not getting 95 % success. Am I not pressing the, the, the, the pedal enough when I'm doing the lesions? It's, ⁓ So you ask yourself all these questions and you wonder, why am I getting worse outcomes than what people are reporting? And in some cases, why am I getting better outcomes? For example, people say you should not skeletonize your mammary arteries because the patency goes down. And I always skeletonize my mammary arteries. And to my knowledge, people are not coming down with mammaries that are going down. Sometimes they do, but they do with everyone. I don't think that I have a sort of... an epidemic of mammaries coming down and 99.9 % of the mammaries are skeletonized. So you always ask yourself these questions and say, why am I doing things different than what they're saying in a meeting? And I know this is a long-winded answer, but I'm gonna get somewhere with this. Is this one hour or does it go longer? Okay, we can keep talking here. All right. So I was talking to my wife.

Anish Koka: No, I mean we could go longer.

George Tolis: about that and I was saying that listen I go to these meetings and these folks just say the same stuff all the time and I just get frustrated and you know I went to a woodworking meeting in Covington Kentucky and I was looking at the schedule and I was getting really upset because there's like two lectures at the same time that I want to go to both of them. That never happens in a cardiac surgery meeting. cardiac surgery meeting you wake up in the morning you're like, am I gonna go this morning? Am I gonna go at noon or you know so I was like, why am I so anxious in the woodworking meeting not to miss lectures unless it's not happening in the cardiac surgery meeting? So my wife said, well, why don't you just, you know, see if you can write a paper about it. I if I write a paper about this, I'm going to be some disgruntled guy that, you know, has not gotten promoted and, you know, they're complaining about life. So, but I thought about it. I always listen when my wife says something. So I called John Iannidis from Stanford. the meta-analysis guy, the H-index through the roof guy. I him exactly what I told you. And I said, I'm not sure what question I'm asking you, but I think our literature ⁓ is non-existent, ⁓ I'm things reported as gospel that make absolutely no sense to me. And I don't know what to do about it. And then I thought, all right, this guy's just, he's not. He's got better things to do. And he called me back about two weeks later and he said, well, let me ask you some questions. What are the main journals in your field? And I told him, Annals and JTCVS and so on and so on. I said, there's some bigger papers published in New England Journal and JAMA and so on. So we know we got like six, seven journals, European ⁓ all that stuff. So. He says, I don't know what we're going to do with this, but you have to find meta-analyses in these papers. And those meta-analyses should have 1,000 original articles so that we can get somewhere statistically. And then we'll have to look at what's there. And ⁓ don't know what we're going to look at, but that's going to give us a framework for stats. So he find a couple of residents to do that. It's going to be pretty labor intensive. So what I did. I was like, who do I ask to do this now? So when everyone went to bed my thought I was sleeping, I'd get up and go to the computer and I'd stay up until about two or three in the morning pulling articles and meta-analyses and all that stuff. I did that for about a year and a half until I got to 1,000 original articles. So I sent it to him and then he sent it back to me and he said, what we're gonna do here is we're gonna see which ones of these papers have mortality as an endpoint. And we're going to try to find statistics to see if techniques or things that have been introduced over the past 30 or 35 years have actually provided a statistical improvement in mortality. And he said, we may not find anything. You may do this for nothing. I said, that's all right. It's a question that I want to answer. So I went back and pulled more meta-analyses because some of the meta-analyses that I looked at did not have mortality as an endpoint. To make a long story short, about two and a half years later, we came up with a paper, and there three authors in the paper. He's a senior author. The guy that did the stats and all that stuff is the first author, who's an ER doc who worked with INE at Stanford. And I'm the middle author. That's it, three And we came up with a paper that shows that essentially there are no statistics to prove that introduction of new techniques in cardiac surgery has afforded patients with a mortality benefit over the past 35 years. Now that doesn't mean that things that we do have not helped patients, but we don't have any statistics to prove that anything that we do helps. Now the extreme of this is you don't need statistics to prove that, you know, when you jump out on an airplane you need a parachute, but you do need statistics to prove that a minimally invasive operation is better than a well-established open operation. The only thing that is statistically significant in the cardiac surgery literature is that an AVR helps for aortic stenosis and that an intra aortic bloom pump helps coronary bypass surgery when someone is in shock. These are the only two things that are, that were the statistics. So it's statistically significant improvement with the intervention versus no intervention or everything else. There's nothing. So all these guidelines that we have.

Anish Koka: Yeah.

George Tolis: All these things have absolutely no statistics to back them up. And I think that's telling. Now the analysts wanted nothing to do with this paper. The JTCBS wanted nothing to do with this paper. Jack, JAMA, they wanted nothing to do with this paper. So we published it in the ⁓ statistical literature, the Journal of Clinical Epidemiology. And as aside, then I went to my division and I said, can I use my CME money that I don't use because I rarely

Anish Koka: I see. So it's... Wow.

George Tolis: go to meetings to make this open access because you your average heart surgeon does not subscribe to the Journal of Clinical Epidemiology. They said no. I went to HMS. They said no. So you know I just pulled up my American Express and I paid $4,200 and it's open access for anyone to read.

Anish Koka: haha boy. you're that, by the way, that's an amazing job. You're clearly a very motivated, intense to see something through, which is not surprising given what you do. So ⁓ the issue is there's a lot of stuff that's done in cardiac surgery, over the last 30 years, that is primarily based on ⁓ what some expert

George Tolis: correct, or what they perceive as useful for their career.

Anish Koka: I So why that? Why is it that there isn't ⁓ a amount of good, strong that's being done? So for instance, take minimally invasive surgery. Why is it for minimally invasive surgery, there isn't data that's coming out that's RCT based that says, okay, we're gonna take people to do minimally invasive versus open and then see what the benefits are.

George Tolis: concept of minimally surgery is actually not a novel concept. We in 1990 lap coli take over when open colis were the only way to take out the gold bladder. if you didn't lap colis in the 90s, there's great story from Hopkins where the big Johns Hopkins. thought that it's nonsense to do laparoscopic colon cystectomy. And the University of Baltimore was eating the lunch for years until Hopkins decided to start doing lap coli. Because it worked. And because it was very good. There's a learning curve, but it became standard of care. The minimally invasive techniques are not new in cardiac surgery. The Ross is not a new procedure. Sir Donald Ross did the first Ross in the late 60s. Open heart surgery was initially done through a right thoracotomy and it was, it became a median sternotomy essentially with CABG and AVR, but mitral operations, right? know, the commissarotomies were left thoracotomy and the open ⁓ was a right So ⁓ these are not new but The reason why there's such a push for them is because, wrongfully so in my opinion, surgeons think that if I don't do a full sternotomy and I do a mini sternotomy or I do a right for a codomy, I will compete with a cardiologist who does a TAVR or who does a mitral clip. Well, you won't. It's not minimally invasive. It's minimal access. But if you think that you can compete convenience wise with a cardiologist who does stents when you do a CABG and your incision is small, you're not fooling anyone. A mini AVR, it actually hurts more than a standard AVR because you open the sternum and then you break it into the rib cage too, even though the incision is smaller. And everyone knows that a right thoracotomy hurts more than a sternotomy. I mean, it does. it's a... Now, if you're a 25-year-old sort of model, a bikini model, and you don't want a sternotomy because it's going to affect your job, and you just want a sub-mammary incision, absolutely. No question. That's the way to go. But... Mostly, mostly people don't.

Anish Koka: That's why Dr. DiGiorgio would be picking the right thoracotomy. He does,

Anthony DiGiorgio: I can't, my calendar career needs to stay on track.

George Tolis: Exactly. think that surgeons are trying to, are entering a quote unquote competition and it's not really a competition. If you want to play that game, you're going to lose it. If the game that we should be playing is durability what we do, longevity of the patients and lack of re-intervention. And whether your incision goes all the way down a little bit more, that has nothing to do with that.

Anish Koka: Go ahead, entry.

Anthony DiGiorgio: But so I think the niche now know what you feel like when we have neurosurgeons on because most these words are going way over my head Thoracotomy and aorta things like that But yeah, is ⁓ these concepts actually very applicable to things like spine surgery and neurosurgery and we have minimally invasive spine We have minimally invasive treatment for aneurysms endoscopy and to vascular versus open clipping But I think this you touched on an point there talking about

Anish Koka: ⁓ please.

Anthony DiGiorgio: Longevity and the reason we don't have randomized trials and for me and when I'm thinking about this You know to assess the longevity, right? We need 10 to 20 years of follow-up at least for a lot of things we do in spine surgery If we do surgery on someone in their 40s We really do want to know what it's like in their 50s 60s and 70s But the technology is progressing too fast by the time you have that data You're gonna have a whole new wave of technology that comes out and so is that even really possible to have? The longevity data that you really want and to also be on the cutting edge I think we all have our about which techniques and devices we use, but you're right, a lot of those are always going to be sort of uninformed opinions. again, since this is going way over my head, have to think of, when I go to my car mechanic or I have a contractor work at my house, I'm not asking for 20 year data on what transmission parts they're using. A lot of it really is influenced by cost ⁓ the recommendation of the expert who's helping me. So how do we square that and actually have the data we want? but also be able to the latest technology and give patients kind of what they're demanding in terms of access and invasiveness.

George Tolis: You can do it perfectly. Even though we don't have, like we said, randomized studies, we have some evidence. So for example, with young diabetics with three vessel disease, we do see the curves, the survival curves that diverge even at four five years. So there's no reason to think that they'll start converging again. We also have to think ⁓ of is a CABG today as a operation, as a first line treatment for three vessel disease, the same as CABG in 10 years when someone's real estate has been taken over by stents And even the op note still says Lima to the LAD, instead of grafting a three millimeter proximal vessel, with a short Lima, you're grafting an apical LED that's barely one millimeter. The op note reads the same, but is that the same operation where you're trying to go past, you know, a series of stents that have been placed on the LED in the past? I don't think it is. Do I have proof that it isn't? No, I don't. But we do have very good data that those curves diverge. ⁓ I do think that it, you know, I do think that it does make a difference.

Anish Koka: Yeah, unfortunately, oh, No, no, go ahead. ahead. Finish. Finish that.

George Tolis: Part of Yeah, part of the problem is, you said, industry will say that, that's with the old stents and the new stents now we're, you know, we're using a eluting agent and that's going to make a bigger difference, but we need another 80 years to see it. Or with a TAVR, you know, yes, we realize that some of these cases do have early failure, but now we're using the Inspirist technology for the pericardium. So that's going to be better because in ⁓ vitro lab, it appears to be better. So I don't think there's a good way to answer the question, but you do need to think of, like I said in a CABG, what is the fallback if that doesn't work? And in a TAVR, I mean data for open surgery on TAVR removal is mortality close to 10%, which is worse than a redo AVR. So putting a TAVR on a young patient, because I think that's how the discussion started, We don't know what it's going to do long term, but we know very well that if you got to take out the taver, that is a much riskier operation than anything else that we do.

Anish Koka: Yeah, so turns out epistemology cannot be reduced to RCTs for all the things that you're talking about, technology changing, we need a certain length of time. What do we do during the length of time? So I think it's going to take like some high level content expertise like you plus an ability to critically think. And then, and then on top of ⁓ have a good understanding of what the history of some of these diseases are. And so really takes, yeah, I think it's going to be a challenge. feels like, the thoracic, the cardiothoracic surgeons have been there's a paper by and Chickway, right, in the Isles of Surgery that you talked about, surgical versus trans catheter aortic valve replacement in adults less than 60 years, right? ⁓ And I think this was, kind of the CT surgery response to what you're describing happening, which is a lot of younger patients getting tavers. And what they found was that there was a significantly higher risk of death in younger patient population, correct? You, ⁓ yeah.

George Tolis: Correct, but I have a question for the authors though. ⁓ To my knowledge, for a taver to take place, a surgeon needs to sign off. Why do the surgeons sign off on that?

Anish Koka: I was going to ask you that question. So is on? why is it, that was my lead up the question of, there's a lot of what you what you believed. Yeah, me, why do do this?

George Tolis: I don't know. I'll tell you what they say. I'll probably get in trouble, well, because in order, I am not in the valve, in the heart team for valve surgery. Why? Because I use my judgment and I say, I'm not going to sit off on the tavern on this. I'm not just going to be the signature that allows someone to do something. So what that means is that I do, I do less valves. than a much younger surgeon who's part of the valve team and part of the clinic and, you know, who, the patient one doesn't want an incision, you know, I'm going to sign off on them to get a TAVR. I don't do that. I the right as a surgeon to tell that person what I would do if that was my mom, if that was my brother, if that was me. And that not conducive with a heart team, unfortunately. Because like I said, how did you find these 50 year olds that got TAVRs?

Anish Koka: I see. So this.

George Tolis: What surgeon said, yeah, you sure you can go ahead and get a taver. Who said that?

Anish Koka: So is it your contention that most of the surgeons on heart teams, so just for people who ⁓ aware, TAVRS requires a team. The heart team requires there to be an interventional cardiologist ⁓ and a surgeon. And the whole point of this was to kind of have a check and balance so that ⁓ don't have cardiologists taking everyone to the operating room. and kind of bypassing the surgeon because again, most diseases is seen by cardiologists. Cardiologists could then have a referral network to an interventional cardiologist and boom, they have a TAVR. And specifically the powers that be, Medicare, et cetera said, no, in order for us to pay for a TAVR to happen, we have to have a heart team approach to doing this.

George Tolis: A surgical opinion. Absolutely. Yes.

Anthony DiGiorgio: That's fascinating. We lack that on the neurosurgeon side. analogy is aneurysms. If comes in and ⁓ the team sniffs it first, it may go straight to interventional and they coil it without running it by a neurosurgeon who might, ⁓ clipping be better. Just an interesting analogy. I was totally unaware that Medicare had kind of set that precedent.

Anish Koka: Yeah. And so, ⁓ guess I wasn't aware of ⁓ my opinion. thought that a lot of the patients who were getting off who were young, maybe they were high risk for other reasons. So perhaps they all had heart failure or I when you look the actual If you look at the registry data in patients that are less than 65 getting TAVR, they do have a pretty significant comorbidity burden, like about 70 % of heart failure, 30 % of lung disease, 40 % of diabetes, 12 % are on dialysis. it could be that these are a higher risk younger population, and that's why the surgeons are perhaps signing off.

George Tolis: I don't have the paper in front of me, but I think that from what I recall, there are quite a few low risk patients in the group that had TAVR because it's heavily approved for low risk. It's not like illegal. They didn't do something that is negligent, but I'm sure there were some high risk patients, but I thought there was a were low risk patients.

Anish Koka: Right. No, Right. Yeah. And this goes back to Anthony, bet all cardiac almost all, sorry, not all, almost cardiac surgeons are employed by health systems, right? And, and you know, you have the service line set up now where, somebody that's coming in, you're ushering through their procedure, ⁓ know, and it's not this heart ⁓ cardiologist, surgeon, et cetera, ⁓ right? There's service line where come in and you what you need. And I think Tolos, you're right. think if you have a health system that is looking to be efficient in terms of ⁓ what is a relatively high reimbursement area, just tavers, savers, all of it together, then ⁓ you're to want people that are not going be the wrench that in the And so it's interesting. didn't realize, I thought all cardiac surgeons who did valves would spend some part of time being part of the heart team. But saying, there's a bunch of folks that are like, nope, I'm not gonna be on the hard team. Or are they told that no, you can't be on the hard team?

George Tolis: not aware of anyone who is told that you're banned from being on the heart team, at least in our institution that doesn't happen. people let you know if they're happy or not happy that you did not sign off on someone to get a TAVR Let me just leave it at that. ⁓ At the same time, if you're young surgeon, you need to get cases and you don't have referrals, you need to be in the heart team.

Anish Koka: Okay

George Tolis: in the heart team, need to be in a aortic call so you can get acute dissections, you need to do all that stuff. it is easier for me, I mean, the majority of my patients come from my cell phone. There's someone that calls me and I say, can I transfer this guy? Can you this guy in the office? Because I've been around for 20 odd years and people know me and they call me. the question you always have to ask yourself is if I were a crook, what would I do? And I'm not saying that you're a crook if you do a TAVR on a young patient, but if I were desperate, if I were, you know, I probably would have done the same thing. You've got to put food on the table. You're not doing anything illegal. When you have options, you can play the game a little bit more the way you want to play it. But when you don't have options, you got to do what you got to do. And remember, in cardiac surgery right now, if academic promotion is important for you, The only way you can develop a national and international reputation to advance in your system ⁓ through structural or through MCS transplant. There is no other field in cardiac surgery right now that can produce enough papers, enough literature. The aortic stuff is done.

Anish Koka: Hmm.

George Tolis: I mean everything, can talk about stents again. Yeah, I went to the ATS and they're talking about the same stuff over and over again. That stuff is done. So the bulk of literature now is coming through MCS transplant and through a structural. And structural is not really a surgical field. mean, we're among friends. ⁓

Anish Koka: Well, that brings us to another topic in terms of academic promotion. But Dr. Anthony, go ahead.

Anthony DiGiorgio: Well, I just wanted to touch on a point you made there about, you know, some people are crooks. And I we have to acknowledge that fact as physicians if we want to be honest about how we select or how we promote certain procedures and certain doctors. I again, I come from the world of spine surgery and Lord knows there's plenty of unindicated spine surgery to go around. You've about metrics and been appropriate, I think, skeptical about metrics as I have. But I mean, how do you tell somebody who's looking to get the best surgeon, how they evaluate that surgeon. Should they look at Yelp? Should they look up their CMS metrics? Should they look up their MIPS scores? do ⁓ counsel patients or a loved one that comes to you and say, is this guy any good?

George Tolis: people ask if, I'm sure they ask the same thing to you when you go to a party, say how has AI affected your field and how do you think it'll affect it? Are you worried about it and all that. So there are some surgeons that I know, obviously we're not going to mention names, but I wouldn't send the neighbor's dog that wakes me up at night. I wouldn't send them, I wouldn't send the dog to them, okay? And you can ask AI if that is a competent surgeon, they'll tell you that he's the best thing since sliced bread. So AI has ways to go before it can predict someone is a good surgeon or not. How do I think that you should pick your surgeon? You should find a way to ask anesthesiologists, scrub nurses, and circulating nurses. That's it.

Anish Koka: What? ⁓

George Tolis: Because you need to make sure that you're not entering a popularity contest. You need to make sure that someone is not sucking up on someone because they're a chief and they want to be on their good side and tell them, listen, I brought you this. And by the way, there's been some people that have been operated by quote unquote senior people that shouldn't be doing that very much. ⁓

Anish Koka: Dr. Tullis, I gotta interject. had an amazing, actually the ⁓ was urologist who wrote this nice piece on Dubeiki, Dr. Dubeiki operating on the Shah of Iran. I don't know if you know this, do you know this? ⁓

George Tolis: I didn't know about the Shah, I knew Yeltsin was the last one that he quote unquote up.

Anish Koka: Yes, so no, get this. It's a crazy story. The Shah of Iran had, I think a stage four, like a really advanced lymphoma. And he needed someone that he needed a splenectomy. Right. This is in the 1970s. And so Dr. Dubeyki flew to Egypt to do a splenectomy. Even though, obviously, he spends his career doing aortic surgery and. as the story is told, he of course, it doesn't go well. he ⁓ there's complication. He probably has splenic abscess and Debakey says, no, everything's fine. And ultimately, you know, month later after the was steadily declining, they open them up, they find, this pus and infection everywhere. So it's quite a, quite a, quite a story that touches cardiothorax surgery. It's like, well, maybe Dr. Debakey should not as amazing as he must've been doing aerobic work. Maybe he shouldn't have been. doing this with X3.

George Tolis: Well, like I said, I think that the anesthesiologists, the scrub techs, slash nurses, the circulating nurses know what's going on in the OR. So if you have access to them, that's who you should ask.

Anish Koka: Yeah. What, so, but wait, but ⁓ a little bit. ⁓ mean, cardiothoracic surgery, it's incredibly hard to become a cardiothoracic surgeon. mean, next neurosurgeon, it may actually be than neurosurgery. Sorry, Anthony. ⁓ One of the few ⁓ Let's not get crazy. so ⁓ how, how does somebody make through, our current system to be, not competent to operate on the neighbor's dog?

Anthony DiGiorgio: Hold on, hold on. Let's not get crazy.

George Tolis: So I don't think the system is fair to the residents today. If go back, ⁓ you the first 40 years of this, in order become a cardiac surgeon, you had to train in general surgery, you had to pass your surgical boards in order to set up the cardiac boards, and then you had to pass your cardiac boards to sort of finish your, you know, to become certified. And... What ended up happening the last 25, 30 years is then all of a sudden you didn't need to pass your general surgery boards, but you could sit for your cardiac boards. then it out that you don't need to finish your general surgery and you can just do four years of general surgery and have four three program, or you can do an I six program where you get guaranteed that you'll be a heart surgeon straight out of medical school. And many places offer all three programs. So when you are a medical student and you think you want to become a cardiac surgeon, you have no idea what the program is going to look like seven years later when you're done or eight or nine years later when you're done and what the, you know, the staff will be with the rotations. We, you have no idea. It used to be that you needed stability for three years after your decision, which means by you know, two years of training in your last year of general surgery when you knew where you're going for cardiac. Now you need to make the decision, you know, for what's going to happen eight or nine years down the road. you need to apply to different programs that have different systems. Some only have a 5-2, some other ones only have a 4-3, and some don't have a 4-3 this year because someone came back from the lab and the is very program heavy and very bad for the residents, I think. I think it's a very unfair system for the residents, like many other things are unfair for residents that I'm happy to discuss later. But the training pattern is one of them. There's no other field that I know of. Like, if you want to become a pilot, will anyone say, well, you know, this school might take you after two years of this, and the other one you need to get instrument rated first, and the other one? No. There is a path, I'm not a pilot, but my son is, so there is a path as to how you become a pilot. With cardiac surgery, there's three different paths and programs change their paths, some programs change the paths and the availability of the paths depending on the year. So that's a very unfair system. biggest problem though, ⁓ are not providing a, should a simulation of what the rest of your life will be.

Anish Koka: But if you, ⁓ sorry, go ahead.

George Tolis: And I don't think we are providing a good simulation to residents right now.

Anish Koka: Why not?

George Tolis: Because the residency the that are supposed to protect the residents that we would like to have when we train 30 years ago have gone too far. And at the end of the day, I think they hurt the residents. I'm convinced they hurt the residents, not that I think that they do. But my views are very unpopular when it comes to the RRC and all that stuff. the work hour restrictions, the fact that basically you cannot sit down with someone and tell them, listen, I don't think this is for you. And it doesn't mean you're a bad person. ⁓ doesn't can you imagine if someone applied to Verizon for a job at Verizon and Verizon jobs that you drive the van, Verizon has jobs that you install cable. And Verizon has jobs that you climb up on these towers, the cell towers, and you go all the way up and you change the antenna or you put the lights on the antenna. And some guy says, you know what, I really want to be the guy that goes up the antenna because I think it's really cool. And someone tells them, you can do it. No one can stop you. You know, you're, you, we can train you to do anything. I can teach a monkey how to go up the tower. It's not a big deal. You can, that's what we are telling people when they're medical students. then what we do is we bring them to the OR and watch the distals or the, in your case, Dr. DeGeorge, I'm sure they see a craniotomy and taking out the bone and putting it in a bucket and then, you know, clipping an aneurysm or with us looking at the coronaries and touching the heart. And they think it's the coolest thing on the planet. And they think their impression is that our life that we wake up in the morning, We go straight to the ore and we do that cool stuff and then we go home. And that could not be farther from the truth. So the, we are not doing them a favor by quote unquote protecting them to that degree and not seeing what it truly takes to do it and what it takes to do it for a living.

Anthony DiGiorgio: I think it, well, just to that point, I you know, some of the med students see me do a cranny and say, well, if that guy can do it clearly, I can do it too. Anyone can. But I mean, we both train, we both train trainees and I'm not speaking about any of my current residents. I love you all. If any of you are listening, you're all fantastic, but it is incredibly difficult to divert somebody from their training path. As you said, if you can't It's very difficult to get hold somebody back in med school. And then once they're in residency, it's incredibly difficult to fire someone. I find it's a lot easier, and I've seen this in a lot of programs, it's a lot easier for them to just kind of shuttle the person along to the next step, because then they to the next rotation, it's somebody else's problem, rather than to actually bring up the issues and either divert their training or halt their training in some way. Do you agree?

George Tolis: Yeah, I mean we live in a culture where the path of least resistance is to make someone someone else's problem. at the end of the day, the person with the biggest problem is the training. Because it's not fair to them.

Anthony DiGiorgio: Yeah, it's really, it's not fair to them to say, yes, yes, you're comp- and then release them into the wild and they become Dr. Death or something.

George Tolis: But it's also not fair to us, to the ones of us who want to tell them that and tell them that to go to HR. Because we intimidated them or because we didn't say it nicely or because we, I mean, going back to the Verizon example again, if you told me to go up the tower, I'd fall down in a second, I can't do it. Even though I'm sure it's really cool and I watch the YouTube videos of the guy that do it, I see the...

Anish Koka: Hahaha

George Tolis: curvature of the earth and all. I can do it. I don't think it makes me a bad person, but I can do it. can tell looking at someone if surgery is a good path for them or not a good path for them. And the not the Brigham or MGH, but the current system that we live in does not give me the tools to be open with a trainee and tell them I think that you're going to be really good at this or I think you're going to be, you're going to find something else. I don't hate you. I don't have something personal against you, but you'll struggle and patients will struggle too.

Anish Koka: What the sort of default is not at the institution level. It's something larger. the ecosystem. Is that, that correct?

George Tolis: Yes, I think that the institutional responsibility falls into the same path of fleece resistance. It is very difficult for an institution to a resident, almost impossible. So they answer to the same gods that we do as well, because we are the institution too. I mean, we're part of the institution. you know, so I'm a pianist. And if you someone who's very talented, and someone who's okay and they can still, they can both, you know, become good concert pianists. But you tell the talented guy that I'm going to limit your practice to two hours a day. And the other guy tell him you can just go at it. You can spend 10 hours in front of the piano if you want. No one's going to stop you. The guy that practices for 10 hours is going to be a better pianist. It's just the way it is. So when you are telling the resident that You know, if you've been up until two in the morning or three in the morning and you have, don't have, I don't even know what the rules are, but you don't have the right amount of sleep and stuff, then you can't come to the OR the next day. First of all, you're going to do less cases. of all, when it's time to become an attending, you are going to be up all night doing a dissection. In the next case, you're going to do your cases, you're going to do your clinic, you're going to go to your meetings, you're going to do all that stuff. So you are, when I said that your residency is not a simulation of what life is gonna be like, that's exactly what I meant. You are given a very rosy environment you think that, ⁓ yeah, I operate on this guy, but then I'm not the on person, so they're bleeding and I'm not gonna bring him back. Someone else will bring him up because they're on call and all this. That's not how it works. That's not how it works when you do this for a living. So. you are getting a very rosy picture about what life is going to be like. And I think that's the reason why we have so much burnout and we have all that stuff today. Because don't have burnouts because people are working harder. People used to work hard before as well. And there's other reasons too. I all the corporate stuff and all that. But the biggest thing is that people jump into this attending thing and they have no idea what they're getting into. No idea. And it used to ⁓ easier when you just...

Anthony DiGiorgio: I agree, but I do want to push back on one point in the analogy would be as if your 10 hours of pianist training was one hour on the piano and nine hours documenting what you did on the piano on a computer to justify being on the piano. that's really what unfortunately a lot of our residents, the training is not operating anymore. The training is being on the computer. We pulled the epic audit logs. I published this data so I can talk about it, but we pulled the epic audit logs from our trainees.

Anish Koka: You

Anthony DiGiorgio: when they're in a 24 hour overnight shift covering neurosurgery call, they spend 20 of those 24 hours logged into Epic. And so, I totally agree, we should make sure they're getting the adequate training, but simply rolling, I'm in favor of probably loosening some of the work hour restrictions, but we need to make sure that they're not just training to navigate Epic, that they're actually training to do the things that we want them to do, which is neurosurgery or cardiothoracic surgery.

George Tolis: I that's the end of it. do not agree with you more. I mean, I gave you the wrong, the opposite impression, I just didn't express myself right. ⁓ and you know, I've it before, you can get in trouble discussing it too. You see general surgery residents, they're not in the OR, they're in front of the computer. And I made a joke once, and I got in trouble. I said that, you know, general surgery is becoming like MTV. They don't play music anymore, you know? They don't operate. They're just in front of the computer doing stuff.

Anthony DiGiorgio: No, no, no, I just, had to be snarky about the piano comment.

Anish Koka: Yeah.

Anthony DiGiorgio: I'm gonna use that one, that's good.

George Tolis: And that's not good. That is not right. That is, I really feel very sorry for residents today and what they go through. Absolutely.

Anish Koka: So. So the response of course you're going to get from folks is going to be, this is an old cranky guy who walked ⁓ school in the snow barefoot. OK, got it. ⁓ But we're doing fine. How would you So saying that it's pretty to you the younger attendings in cardiac surgery are not as well prepared. they were before. Is there any way to quantify that? there, I mean...

George Tolis: Well, I mean, there's indirect evidence and it's nothing new. Like it's sort of like the European system. In the European system, you finish, you get a piece of paper and you don't operate basically. You just become someone's assistant you do that for five years, for 10 years. Then you wait for the person to, you know, go somewhere else or die or, ⁓ and then you kind of take over because you've helped them so much. That's not how it used to be here, but there's more and more people doing quote unquote extra training. and that extra training is so that they can gain some basic skills of what they did not get in the regular training. of my involvement with trainees, I've spoken to a lot of people over the years. I'll never forget, there's one trainee from, not gonna, there's no reason to mention the program. It's a very, very reputable program. That resident told me that they never applied a cross clamp on the orda because that's what the attending does from the other side of the table So they finished their whole training and they never applied a clamp to the orda and give cardioplegians up the heart. I mean, that's not training that is complete insanity and that person I can guarantee you that they're They're gonna go and practice on their own the first day with help from the attending they're gonna need to get trained more before they and they're gonna need to find an environment that is supportive enough to help them train and mature.

Anish Koka: Wow, I mean, this is really troubling because you can certainly see folks who have insight into their who up in situations where they don't have help, right? And where they don't some senior person and they're just, they're just out there on their own. ⁓

Anthony DiGiorgio: That's it. Yeah.

George Tolis: Well, and then they do locums and then they, you know, they go to a job where they open and close for someone for a year. And the problem there is that once your job is not a busy job, that problem is not going to get any better. It's going to get worse. And I know lots of people that are 10 years out that just have treaded water over time and then they just quit or go to industry or do something else and they don't become cardiac surgeons. the reason why that happened is because their program either made them someone else's problem. and did not have those difficult conversations. Like I said, at the end of the day, they're the ones that struggle. And that's why I think it's so unfair residents today. I don't think we had it better before. I mean, I don't think we had it worse. We worked harder, but we had it much better. Because you'd finish your program, if you couldn't operate, someone would tell you, you're not going to do this for a living, do something else. That doesn't happen today. ⁓ This career ending ⁓

Anish Koka: But that, and just to ask about that, why is it that end up in HR because of that? Like, that not an institutional, like is that so institutionally pervasive when it comes to things like neurosurgery and cardiac surgery? It seems like that would be.

Anthony DiGiorgio: Yeah.

Anish Koka: I mean, there's a whole evaluation system that's set up for residents. If the whole evaluation system is just a rubber stamp, especially for things like cardiac surgery and neurosurgery, that's a real problem.

George Tolis: I don't know. Again, I'm discussing things that I've collected over the years, talking to a lot of people in many different programs. I'm not talking about our specific program. I'm not talking about previous programs. I'm talking about what goes on with the country. the best proof as to whether a program trains is what the trainees do after they're done. Did they get real jobs after they finished or? Did they go to locums and did they do extra training that is endless and all that stuff? Just look at these numbers. So my advice to residents is if you want to know if a program is a good program, just ask them to give you a list of where their graduates have gone. I'm not saying every program is that way, but there's a lot of programs that don't train and they get away with it.

Anthony DiGiorgio: Well, and I think some of it is, is see the interns coming in. I that really the fourth year of medical school is not preparing them to be doctors as much because now it's the fourth year of med school as you're doing your away rotations. We don't really have those acting internships as that are as thorough anymore where you are holding the pager as a fourth year med student. And you see, you know, we've almost pushed training back further and further. Right. So now They're almost finishing med school as an intern, and then they're not getting the thorough training that they're getting during residency. So as you mentioned, they have to do fellowships. And in terms of firing residents, it's getting harder and harder. There's even a proposed law here in California. I don't know if it's ever going to pass, but because most of our residents are unionized, you would actually need union approval to terminate a resident, as well as ⁓ the academic institution to forward with it. So it may make it that... You know, it's just like once you get your foot in the door, you're clear sailing all the way through no matter what you do. And I think it would be a little scary. I agree.

George Tolis: I think that strip has failed. mean, it's union or non-union, it is impossible fire residents. I mean, unless there's something egregious, but if it is your judgment that that person, again, not a bad person, someone who cannot do that for a living if you do something else, that's not gonna fly. That's not enough.

Anthony DiGiorgio: And I think we should clarify, not, we're not advocating for the days that there's stories of, old neurosurgery chairman, the resident is his wife's giving birth and he says to the resident, you know, you can always have another baby, but you can't have another neurosurgery spot. We're not advocating for going back to those days. Um, but, but there is a comfortable medium and I think we swung too far the other way.

Anish Koka: All right.

George Tolis: Of course not. Of course not.

Anish Koka: other interesting that you touched on that I want to get to is the fact teaching ⁓ and residents not a path to promotion in

George Tolis: It has nothing to do with promotion. Like if you're in high school, the high school teacher, the person that becomes the headmaster and all that stuff is the teacher that has the best sort of rapport with the students and the teacher that gets the teaching awards and all that stuff. In academia in the United States, Teaching residence has nothing to do with academic promotion. Academic promotion has to do with how many papers you write and how many visiting professors you have and how many, you know, these are obviously set up by someone else who's pushing you to get promoted and, you know, how many meetings you attend and how many committees and the societies you belong to and all that stuff. It has nothing to do with teaching residence. I'll give you, you know, my personal example. I'm 22 years out. I'm an assistant professor of surgery. I'm not associate professor, I'm not co-professor. I have written three papers on not quite as busy as the I &E paper that we mentioned before. So my experience with teaching resonance, every case that I've done, I have an access database where for every graft, I've written whether I did the graft or whether the resident did the graft. For every aortic valve, whether I put the sutures or they did, tied them, everything. So you could show me a patient of mine from 20 years ago and I could tell you who cannulated the patient, who opened the sternum, who harvested the mammaries, who closed. So after I finished every case, takes you about 20 minutes to enter the data into my own access database. And out of the database, I've written three papers. The first one is that the 30-day outcomes for skin-to-skin cases by residents and by attendings by me had no mortality different. Obviously, selected cases, you know, you're not going to let a resident. So with adequate selection, training can take place without patient suffering. The second paper is we took the same patients and we looked at them long term, mean midterm, 32 months follow up to see people have gotten recathed, if you know, they, and we also did not see any difference. And the third paper is every case that I did in a five year span, we checked and saw who had been recathed, who had a coronary bypass, we saw who had been recathed. and I looked at my notes and I saw out of the graphs that were down whether these were done by the residents or by myself. So that's a long-term study for CABG that I've done who had been recathed within our system. So do these studies, it took a lot of effort, a lot of time. And I these and I presented these to STS, ATS, and I forget where the other one was. And so I have done academic research for my interest for resident education, but it's only three papers. And I'm not white papers with H-index and guidelines and this and that, because I've refused to be on them. I didn't do anything for these. And I'm assistant professor. you know, I won the National Teaching Award.

Anish Koka: Ha.

George Tolis: And I won the MGH teaching award and I'm assistant professor, which is fine because I don't have academic aspirations. But being ⁓ recognized does not lead to academic promotion. And I think that's a little bit silly.

Anish Koka: It ⁓ it again speaks, it seems we have a perfect storm of things that are really make it challenging to do a great job training residents. I you outlined a bunch of things in terms of how culture and the ecosystem has fewer volume and stuff. And then on of that, you're going to take folks that are extremely good teachers.

Anthony DiGiorgio: up your H index now.

George Tolis: 15, 17.

Anish Koka: kind not allow to kind of be promoted on the on the the ladder.

George Tolis: Well, they're rewarded from the residents themselves. I talked to people that I trained 10 years ago, 12 years ago, and you just develop great relationships, just like I talked to people that trained me 30 years ago. that I wouldn't replace for anything. But if you are the kind of guy that it's important for you or for your parents to be a full or to be this and that, Teaching is not going to do it for you. You got to find something else. You got to be in committees. You got to be in, I don't even know, I can't even fake the grant names because I don't know what the grants are like R1, R3, I don't even know what that is. But there you go. So you need that kind of stuff if you want to get promoted. at the end of the day, you have to decide what is good for you. You got to put food on the table. And what makes me happy is that in

Anthony DiGiorgio: RO1 is the currency that you're judged by.

Anish Koka: haha

George Tolis: The institutions that I've been, doctors and nurses have me to do theirs or their relatives bypass or valve or aneurysm. And for me, that is most important thing than anything else. I mean, it depends on what your priorities are. And for me, are to be a clinical guy that people go to when they have a problem.

Anish Koka: The, that's, that's, it's really, shines yeah, I like I have a much, much better understanding now than before. does raise some really troubling questions about what we're doing and how to kind of ⁓ write the ship. I don't It seems like you're saying the ship has sailed. There's no, there's no great way of kind reversing course, but ⁓ in terms of training, in terms what you're talking about, in terms of how to kind of, you know, right. ⁓ Yeah.

George Tolis: in terms of what? I don't see how that can change. I think that we're going very fast core in a model where you finish your training and you're not done. And you finish, again, I've said all through this discussion that I really feel for the residents. I started kindergarten in 1974 and I finished my cardiac training in 2002 and I never took a year off in between. You can't do that today. Today you have to do this research and that research. And I had zero papers going into medical school. Today I see these applications. People have like 30 papers, you know? I really, really feel sorry for these kids today. It's not fair what academia is doing to them. I mean, to me, if they're not promoting me, I could care less. But to them, you're entering the whole process at such a late stage. You're finishing, I mean, I finished everything when I was 32 years old.

Anish Koka: Alright.

George Tolis: and I thought I was old. People finish when they're 49 their training is questionable. It's so unfair to them.

Anthony DiGiorgio: And that. And that goes to this broader topic that we keep coming back to about the loss of independent physician, right? So if you're 40 years old, 45 years old, when you finish your training, you're not gonna wanna go hang a shingle, start a practice in a small town or an independent practitioner. You're gonna go take the corporate job that's gonna promise to forgive your loans and maybe fast track you to a retirement plan, right? The safe job. Because you don't have a 30 year runway to build and establish a practice and all that. So I agree, it's really tough.

George Tolis: Well, and I think you said we were discussing whether the ship has sailed or not. There are things that we can do. one thing we can do is I certainly not saying that the RRC people are bad people and they're doing it. Absolutely not. But this thing not ⁓ one size all. You cannot have the same rules. for residents that do field A versus field B and then people will say, he thinks that he's so important because he's a heart surgeon. I'm not saying that. I don't think that cardiac surgery or neurosurgery is more important than internal medicine or psychiatry. And you'll think that I'm just faking it, but I'm not. I mean, there is a mental health crisis and psychiatrists are extremely important right now, good psychiatrists, as there are good heart surgeons because everyone is obese and has metabolic syndrome. The difference between it's, but I think at the same time it's insane to have the same training rules for psychiatry and for surgery. Why am I saying that? Not because one is more important than another and needs special attention, but for the very simple reason that we've established that we have respect for both fields. If you played a game one day or one week and you said that I have a heart surgeon and a psychiatrist, and we're gonna play like an extended April Fool's Day thing today and for the rest of the week the heart surgeon will pretend he's a psychiatrist and go do psychiatry clinic and the psychiatrist is gonna pretend he's a heart surgeon and go do a CABG. So if the heart surgeon goes to psychiatry clinic people will say well this guy is not very good at what he does you know he's kind of rough he's like not a good psychiatrist but you can you can pass for a psychiatrist a psychiatrist cannot pass for a heart surgeon. So The training that leads to these two paths that are both very important cannot be one size fits all. That's all I'm saying.

Anthony DiGiorgio: who's ever talked to me will tell you I could never ever pass for a psychiatrist. But I do agree with your broader point.

Anish Koka: Ha ha ha.

George Tolis: Yeah.

Anish Koka: All right, well, on to things that are impacting specifically cardiac as a field, you've talked about how cardiac surgery is being marginalized by non-surgical colleagues folks viewed as a disposition, a therapy. it's a disposition for sicker, terminal ill patients rather than a therapeutic, viable option. We see it not where somebody comes in And you know, it's like, okay, consults ED surgery so they can say no something like that, right? What, you know, ⁓ is, is really a big problem that you see for cardiothoracic surgery?

George Tolis: I think it is. I think it's a problem that we see in big academic medical centers and I've talked to friends of mine who see exactly the same problem in their centers. just like you said, know, an elderly woman who has DNR, DNI, know, comes with endocarditis or comes with an acute type A dissection. And of a sudden the family wants everything done. ⁓ know, the patient said, you know, that they don't want an operation for the endocarditis and the medical service admits the patient. Next thing you know, the patient has been there for ⁓ week and then they throw an embolus and the toe turns blue. And they're kind of like not clearing the infection. And then the patient is sick of it and the team is getting sick of it. And they say, well, if you don't have an operation, you're going to die. And then the patient says, okay, now I want an operation. So you've been in the hospital for 10 days and you were DNR DNI and now you're gonna have a double valve with a reconstruction of the aurimicroctal curtain. Wait a second. Wait a second. Wait a second.

Anish Koka: They want, I I think they want, I think the team wants to say that, wonder if it's a liability shield bit that ⁓ they to say that, well, we did everything. We call it cardiothoracic surgery. So, cardiothoracic surgery is the one that said no.

George Tolis: What's that? ⁓ They really feel it. They really think they're advocating for a very, very ill sort of kind of human being to undergo the torture of going on pump and having a sternotomy at that condition. really think that it's not, there's no malice.

Anthony DiGiorgio: There's so many parallels with neurosurgery here too, by the way.

George Tolis: they really think that they're advocating for the patient. And then the question is, well, the mortality without this is 100%, okay, but no one has to die with a scar on their sternum. There's no rule that says that that is prerequisite for you to on to the next slide.

Anish Koka: You've, but, but is not something that you find discussed a lot in national meetings. ⁓ I your, you had a quip about, this is, this is what I would like to see discussed in ⁓ national meetings, rather ⁓ we talk extra lesions with RF for cryo for AFIV or through pinpoint incisions or what type of biceps emoji is utilized at the surgical

George Tolis: No. Well, exactly. When you know that someone is dying, why do you put them on ECMO? Why put someone on ECMO when you know they have no path to anywhere? Oh, because they're dying, they need to go on ECMO. Why does ECMO have to be the final common path? Now, there's work being done on that. There's rules being written about who should be on it and who shouldn't be on it. these are things that... No matter how callous you are, if you, you know, after the fourth or fifth octogenarian that gets a multivalve and gets traped and pegged and eventually there's a family meeting and they pull the plug, that gets a little bit old. you know, don't go home in good shape that week when all these discussions are taking place. So I think it's something that we as a field have to address, that cardiac surgery, that's not my expression, that's my friend Ron Reddy's expression by the way, cardiac surgery is not a disposition. Cardiac surgery should be part of a treatment plan. It shouldn't be a way to see if someone's gonna live or not and go to rehab and quote unquote, you know, move the burden somewhere else.

Anish Koka: So, you've talked about national figures in cardiac surgery and how there chiefs that hired for fame ⁓ rather than skill. think quote that I'd seen is it quite funny how you can become extremely successful and nationally recognized surgeon without being a good surgeon.

George Tolis: I think that's what's That's not my opinion. think that it's fact.

Anish Koka: Well, but how, I thought from earlier conversation, these are folks who aren't good surgeons would be relegated to, you know, doing locums or whatever. But here you're saying that, or you're suggesting that there are some folks that are able to navigate that and rocket to become chiefs and stuff. How, what's behind that? Why is happening?

George Tolis: There's people who have tremendous skills that you have to recognize when you're young that See, a mistake I used to make is I would look at people around me that I didn't think they were that good and they had good positions. had, and I was like, can this guy do that when I know for a fact that I've listened to them, they don't understand the field well. Well, people have different skills that you don't have. There's people that have tremendous communication skills. There's people that have skills where they walk into a room and make everyone feel great and feel very important. I certainly lack on that one. And people just love them. And people love with them and writing papers and getting the podium and talking about things that they don't do. it's a skill and it gets you places. mean, God forbid if you operate on someone, but it certainly can move you along very quickly up the ladder, very, very quickly.

Anish Koka: I see. But is that a new thing? this idea that you're selected for, like what is the fame from? you're saying they're just good communicators, they network well and that's, ⁓ that's not how it used to be, but it is now.

George Tolis: Academic productivity and industry. ⁓ There's people that have been, I mean, the number of people that have shut down programs because of failed sort of robotic practices and all that stuff. There's a lot of stories around the country like that. And that's pushed by industry. I mean, that's basically someone who sells a product and then the product doesn't work very well.

Anish Koka: Hmm.

George Tolis: they talk in the meetings about all the stuff that they do and it's very easy to present a something that should be a case study and present it as a series or something that you we need to remember that reproducibility is very important in cardiac surgery it's not just a feasibility study it's not a feasibility field yeah you can do something through a tiny keyhole and someone you may get away with it

Anish Koka: I see.

George Tolis: you know and that's going to be okay but that's not what makes an operation safe and reproducible there's people have tremendous skills and know who to talk to they know how to collaborate with outside forces and they do very very well for themselves

Anish Koka: All right. Lastly, sir, we love medical history on this show and you had me in the direction of a super interesting tidbit of medical history that I had no idea about. Tell me about Vasily Kolesov from Leningrad.

George Tolis: So Vathili Kolesov is a Soviet surgeon from Leningrad, like you said, who actually did the first bypass, documented bypass in the world. We like to think that it was done here by Favalor or by Dubecky. The first one to do a bypass, which was a Lima to the LAD, was Kolesov. if you read his biography, he's a very, very remarkable person. During the siege of Leningrad by the Nazis, he basically ran the hospital in Leningrad for, I forget how many days in a row, and provided care to injured people and food. There was a famine in Leningrad. during that time and he was a very very remarkable person. He unfortunately he died in relative obscurity because sort of the West know wanted this to be a Western thing and not a not a definitely not a Soviet thing but he is the first one to do a CABG and I wish I'd met him. I read a little about him but I wish I'd met him.

Anish Koka: The, yeah, so, this was, on pump off pump. How did he do it? ⁓ Wow. because given, given is who came up with, you know, putting people on pump, correct. Wow. ⁓ And and was after he was, so he's, he was doing off pump. The only place in world you get off pump.

George Tolis: Awesome.

Anish Koka: or any bypass surgery, you know, forget off-pop, any bypass surgery from 1964-1967 was with Kolesov.

George Tolis: Well, DeBakey claims, I think DeBakey claims that he also did it like later, but like a year later or something, and Kolesov had not reported it. And then Favaloro did the first documented bang bypass, not out of an emergency, but because the patient at Angina, and he did a bypass in 1969 or 70 or something. But Kolesov proceeded him by at least seven years.

Anish Koka: And so, was the issue with that not and the thing to do? Why did we such a different trajectory? that, ⁓ has everything to with the Cold War, I imagine? Okay.

George Tolis: Absolutely. Yeah, yeah. There are a lot of that former Soviet... So one my patients, she has since passed, Sakharov's widow. Sakharov was the nuclear... physicist of the Soviet Union who designed the know who basically the atomic program the nuclear program after the war in the Soviet Union and he became a dissident because he recognized that the race between the United States and the Soviet Union could not be good for the world and Khrushchev then Brezhnev they could not really kill him because he was pretty famous. But he was exiled. went up to Siberia and his wife, Helena Bonheur, would basically go up visit him and she would smuggle his writings and she published his memoirs. I operated on Helena Bonheur 20 years ago or so and she was in her 80s, she has since passed. and I had lots of discussions with her and with her daughter about Sakharov and the whole story. And it's fascinating. There was so much, ⁓ obviously a lot of bad things that were happening, but there's so much good work being done in the Soviet Union that was suppressed because it was the East and we were the West.

Anish Koka: Wow, wow, totally, totally fascinating. It's a, you know, seems much more complicated than it seems and everything seems much more, much interesting and deep you kind of dig a little bit. So ⁓ anyway, thanks so for doing this, Dr. Tolis. spent a ton of your time today. I'm happy you're on call.

George Tolis: Well, it's my pleasure.

Anish Koka: You're on call, I understand, and the that you have not been called in. I hope you have a quiet rest of the evening. ⁓

George Tolis: Yeah, I mean the beeper is right here and nothing else. So we're in good shape.

Anthony DiGiorgio: Hehehe.

Anish Koka: Excellent, excellent. Anthony, any other last thoughts?

Anthony DiGiorgio: has just been great. We got to have you back on. course, recommend and everyone follow you. George Tolis is your handle.

Anish Koka: Yep. JR. So George at George told us JR a follow. Dr. told us we're, ⁓ know, definitely, definitely going to have you back to chat. ⁓ All Thanks again. All right. Stay, stay put. Don't go anywhere. I'm going to stop it. ⁓ It

George Tolis: I'd love to come back. Thank you very much. Really appreciate it.

Anthony DiGiorgio: Thank you.

George Tolis: Yeah.