Exploring Academic Robotic Esophageal & Bariatric Surgery

Session 168

Our guest today is a robotic esophageal and bariatric surgeon, Dr. Christopher DuCoin. He talks about the traits that lead to becoming a great surgeon, the training path, competitiveness, calls, and more! Get more information about this specialty at the American College of Surgeons.

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Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:23] Interest in Bariatric Surgery

In high school, Christopher picked to shadow a surgeon. He wasn’t initially interested in gastrointestinal surgery. When general surgery piqued his interest was when he started to rotate through everything and found that general surgery is one of those with exponential paths.

In your second year and third year of your residency, you really want to dial down and look at every day like a job fair. In your fourth year, start thinking about which fellowships you want to go to. Maybe you need to even take a year off for research to tune up your application. And then usually, you’ll know where you’re going to go to in your fifth year.

Interestingly, about 80% of U.S. general surgery residents will now go into some sort of subspecialty fellowship training. Just figure out as you go through the program what your interests are, the pros and cons, the different lifestyles, and different pathologies. It’s different for everybody.

[04:18] The Biggest Myths or Misconceptions Around Bariatric Surgery

That bariatric surgery was dangerous wasn’t really a myth. In the late 90s, there was a decent level of morbidity associated with bariatric surgery such including sickness and various complications in patients who are really large.

Today, Christopher’s average weight loss patient stays in the hospital for about 23 hours, just short of a full day. They can be 600-700-pound patients undergoing GI surgery and they go home within 24 hours.

“Sleeve gastrectomy is a pretty simple operation as a gastric reduction surgery. It's probably one of the safest elective surgeries we do in the United States.” Click To Tweet

[05:57] Traits That Lead to Becoming a Good Bariatric Surgeon

Bariatric surgeons do everything from weight loss procedures to esophagectomy for cancer through a couple of little incisions. At the end of the day, you have to be really smart. You definitely don’t have to be the smartest person, but you’ve got to be able to pass your standardized tests and jump through all the hoops that are going to get you in the position to get into residency.

'What's going to separate the people who rise to the top is doing a little bit more than the average person or your peers.' Click To Tweet

When you’re tired, your body tells you to go home and you just need to take a nap. But if your heart’s telling you that you’ve got one more patient to check on the hospital, are you going to be the person who’s going to go home? Are you going to go back to the patient and make sure everything’s safe?

This cannot ever become a job. It can’t be something your career has got to be. It’s got to be something you love so much. It’s got to be just a part of who you are.

[07:52] Types of Cases

There’s a couple of really neat procedures both robotic laparoscopic and even endoscopic. Christopher went to Germany to learn how to do this like trans-oral surgery. Bariatric cases and esophageal cancer have become the bulk of his practice.

But when he started was seven years ago, he took acute care surgery for everybody else. The bread and butter cases to him included appendectomy in the middle of the night or a bad gallbladder, hernia, or stuck intestines. Christopher admits he does the cases now because he found them extremely interesting.

For bariatric surgery, you see your patient population and you know that morbid obesity is the cause of so many other issues. One of the fun things that most students, residents, and trainees don’t get to see is the long, six-month preoperative workup to the operation that they do.

The best part after surgery is when they come back in and their diabetes is resolved or hypertension is good, and their sleep apnea is different. If you do little pictures in the electric, medical, electronic medical record of what they look like, almost always a year after, you won’t even recognize them.

[12:06] How Much Psychology is Involved in Bariatric Surgery

There is some sort of underlying psychosis implied on 90% of the patients they operate on. Patients have to be evaluated by a psychologist, they’ll follow up with the psychologist, and they’ll work with them.

'There's a there's a psychological aspect to this disease process.' Click To Tweet

[13:04] Looking at the Adverse Childhood Events Study (ACES)

Christopher’s partner does the adolescent patient population. And they feel very comfortable operating down to about 16 to 18-year-olds. They go younger to 15-year-olds, Type II diabetics that are insulin-dependent already.

“The trauma behind what gets a 14-year-old to have morbid obesity is a real thing.”Click To Tweet

[14:11] Typical Day

If you’re just around attendance all the time, you come in at 7:30-8. You operate and you get home at 5 pm. while the residents come in at 4:30 am and come home at 8 pm. That’s the tough part of the training.

[16:09] The Training Path

Before third-year medical school, you get to make your decision. You get to apply in your third year and you match in your fourth year. Then you start residency and do five years in most places, and some, seven years.

If you’re going to go to a very academic heavy institute, they make you do two years of research. After residency, most people do a fellowship. And after fellowship, you start your position.

Christopher did something a little different. He did a year of fellowship in California. And then he went and did additional training in South America and Argentina where he learned the Omega Loop technique in bariatric surgery. Then he did another training in Frankfurt, Germany where he learned transoral robotic surgery essentially for a disease called achalasia.

'If an opportunity ever presents itself or might seem like a little more work but it lives with you forever on your resume, then go for it.'Click To Tweet

[20:06] Taking Calls

Christopher doesn’t take as much call as he did when he first started. There comes a point in your career where you want to take calls and you want to be busy. But you reach a point where you’ve got a large enough volume of patients and you think you don’t need to take all too much.

They have call schedules established, but for the most part, the in-house care surgeon or trauma surgeon can usually handle anything.

They all get trained and worked on the realm of “if it’s your patients, they’re your patients.” If your patients aren’t doing well on a Saturday or Sunday, you’re going to be there to take care of them. This is how their whole group is set up.

That being said, they look out for each other. If someone’s going out of town or going to a meeting or a wedding or whatever, and the patients are doing well, they will cover. But there’s usually a very cordial exchange. Most patients are very responsive. But that’s not the norm.

“The norm is if you've got a complication, you're going to come in and take care of it.”Click To Tweet

[22:42] Competitiveness in Matching

Christopher describes having a great lifestyle and that he’s well-compensated. He fits in an academic model. He is always working with residents, students, and he has projects going on. But for the most part, it has become extremely competitive.

'Robotic surgery is really fascinating. But your lifestyle has become a much bigger part of a student's decision.'Click To Tweet

[24:00] Message to Osteopathic Students

No matter if you’re allopathic or osteopathic, just research and network. And try to get a couple of extra lines on your CV doing some research projects.

You’re actually building your mentorship network because whoever’s doing a research project with you would also most likely be your mentor. That’s the person who can make a phone call for you and that phone call is probably the most important thing. And that’s someone who could call that program director on your behalf.

If you’re out in a rural community and you don’t have a ton of exposure to general surgeons, or you’re not really working with anyone, or there’s no research to join or anything like that, when you start identifying that you want to do this, Christopher recommends joining the American College of Surgeons.

They actually do everything from running small mentorship programs, which they called speed dating, where you meet various people and see if there’s anyone to click with for mentorship. The college is a great resource as they’re constantly looking for the next generation of surgeons.

[28:18] Message to Future Primary Care Physicians

Do your research and learn about the outcomes. You can get really scared that the patients are going to die. And if you saw a morbidly obese patient, it should just run a bell in your head. They’ve got a complete medical weight loss program.

So if you’ve got a morbidly obese patient with Type 2 diabetes on insulin, and you think it’s not your job as a physician to educate them on their weight, Christopher suggests you take your head out of the sand.

Your job is to educate them that their diabetes leads to obesity and they can help them get better. This doesn’t necessarily mean they need surgery, but at the same time, patients need help.

“Talk to your patients. Don't just sit there and talk about diabetes and hypertension. Don't be scared to say it's because they’re overweight. Talk about their obesity.”Click To Tweet

[32:59] Need for Dexterity

If Christopher could go back and tell his younger self something, it could be to not get discouraged and to keep pushing through.

“Get that mental picture in your brain of the end result and you can get yourself there. But never be satisfied with where you're at either. Just keep trying to push yourself forward.”Click To Tweet

In terms of operating robots, it’s a learn-as-you-go kind of thing because it’s a technology that is going to keep on moving ahead. For instance, the technology you’ve probably seen as a third-year medical student is already going to be different by the time you get to your residency.

You do have to have a decent amount of dexterity and understand spatial-visual kind of setup. But usually, most people are pretty self-aware if they have any physical limitation and they can’t do it. Those are probably the most painful conversations. But at the end of the day, they know that it was a non-practical dream.

[36:59] Future Changes in the Field

Christopher is putting his money on the AI because he thinks it’s coming forth, maybe not in his lifetime. But it would be a part of medicine in the future. Surgery will go the way of AI.