What Does Academic Colorectal Surgery Look Like?

Session 36

Dr. Scott Steele is an academic Colorectal Surgeon and Chairman of the Colorectal Surgery Department at Cleveland Clinic. We discuss his love of the specialty. He has now been practicing outside of his fellowship for twelve years now. Dr. Steele also hosts his own podcast called Behind the Knife. Check it out as well as a host of all our other podcasts on the MedEd Media Network.

[01:17] His Interest in Colorectal Surgery

Scott knew he wanted to do surgery from the first time he got his clinical years and did some primary care. He also considered orthopedics since he likes sports. But colorectal surgery dawned on him when he met some mentors. Not being a sexy topic, he didn’t really give it much time. But he found a mentor when he was in residency. Towards the end of his second year, going into his third year and on his fourth year, he began thinking about colorectal surgery. He hung around them and went to the meeting which he found an incredible experience. He thought they did both great in surgery and academics. They take care of patients that have diseases that he likes. They do some outpatient and inpatient surgeries, colonoscopies, and major oncological reconstructions. So it was something he was interested in.

He initially thought about doing heart surgery but he thought he wanted a little bit more of variety. He knew he didn’t want to do orthopedics in medical school after he did one rotation at the University of Wisconsin. Although he likes orthopedics and how it’s related with sports, it just didn’t trigger him.

So Scott did this process of ruling things out. Surgical oncology is okay but colorectal did great cancer operations as well. Surgical oncology tend to not do the wide breadth of people. They tend to serve old people, a lot of them are dying in a lot of cases. It was something he didn’t want to do. Minimally invasive surgery was a burgeoning fellowship at that time and it was its own fellowship. But he thought colorectal also does minimally invasive surgery. In fact, now minimally invasive surgery is a standard component of any particular field. So it’s not in and of itself. So he made the jump from heart surgery to colorectal surgery.

Scott was a general surgeon. He was in the military and he spent a year after his residency at Fort Hood, Texas where he practiced general surgery. So he basically did the vast bread and butter of general surgery. But growing up in a small town in northern Wisconsin that had amazing surgeons. And as a general surgeon, he didn’t want to get pigeon-holed in being the hernia guy or the bowel obstruction guy or the lap chole person. He knew he wanted to do academics. He knew he wanted to do a subspecialty. So the more and more he went into colorectal surgery, the more he realized it fit his personality. It fit all the things he was looking for in a career.

[06:03] Traits that Lead to Becoming a Good Colorectal Surgeon

Scott says that it’s more on how we are as people. But what he found with colorectal surgeons is that they don’t take themselves so seriously in broad, sweeping strokes. They have a ton of fun. They are generally good people. But they also have a side where they’re really busy clinical surgeons in the community and academic centers. And for those that did academics, it was great medicine. There was basic science research and others did hard core epidemiological research.

He adds that when you walk into a clinic and pick up a chart or log on the EMR and see what they’re doing, patients have a special part of their body. They may not even tell their spouses of many years about what’s going on with them. It tends to be something that’s very intimate and very personal. It bleeds or itches. They feel something and that patient in many cases think they have cancer or they think something’s wrong. If your arm itched or bled or you felt something, you’d look at it. But that part of the body is so hard to look at. So patients have an extreme amount of trust in you. Within five minutes of talking to them, you’re asking them to pull down their pants and look at their back side. A lot of things can be in that person’s mind. And in all of those aspects, you have to be able to go in and establish patient rapport right off the bat. Make them understand that despite their misconceptions, it’s okay. It’s very routine. And many people experience the same type of symptoms they’re experiencing. So you need to keep it a little bit light. Let them know you take their symptoms seriously and that you’re going to walk them through the process.

Keep in mind that in the United States alone, colorectal cancer is the second or third leading cause of cancer-related deaths every year. It’s something we don’t talk that much about. Scott says it’s something they can intervene and interact with that given how serious the topic is, you don’t yourself too seriously.

[09:51] Types of Patients

As a colorectal surgeon, you see all age ranges and a mix of benign and malignant diseases. Scott is the lead editor of The ASCRS Textbook of Colon and Rectal Surgery and in the book, they talk about how they organize colorectal diseases. The organize it into six folds.

First, is endoscopy. It’s a large percentage of what they do. They use scopes and they’re able to do a lot of advanced procedures through it. Second, they see the plethora of anorectal disease such as hemorrhoids, fissures, fistulas, etc. It’s the routine but stuff they do and a big part of the practice. Third subset is they see the malignancy – anal cancer, rectal cancer, colon cancer. Those are the major operations you can do minimally invasive procedures. You can use laparoscopy and open surgery. You can do robotics and all the different neat tools and tricks you do. Fourth, is they get to see a lot of the benign disease which includes a lot of the inflammatory diseases such as IBD, the Crohn’s disease, ulcerative colitis, and diverticulitis. Fifth is you also get to see pelvic floor disorders. Those are the patients with obstructive defecations and those with rectal prolapse or fecal incontinence. And last is your miscellaneous type. But the first five types mentioned by Scott are the ones where when you talk about colorectal disease, you can break each of those down. You can see how you have all the plethora and combine that with scopes where you can do things endoscopically. They have one person in their department who is a very gifted and technical surgeon. He was able to take off early cancers through the colonoscopy and save people from having to go major surgery.

It’s that wide breadth of patient variety, ages, outpatient, inpatient, scopes, major operations that is the unique part of colorectal surgery. Contrast that with things like surgical oncology or cardiac surgery and that’s what drew Scott into the field.

[13:20] A Typical Week

For Scott, he spends his Mondays in the operating room. He has all-day clinic on Tuesdays. Wednesday is his admin day as the Chairman of the Department. He typically has a lot of meetings. Thursday is an operating day and Friday, he does scopes and some afternoon meetings. This is a pretty standard week for people where you have a mixture of clinics and other things.

The person who started Relay for Life, Gordy Klatt, was a colorectal surgeon. He died a couple of years ago. He was a community colorectal surgeon and one of the last independent providers. Scott covered for him for seven years. Scott was in the military and would take some vacation and cover for him. He had a much different practice. He saw clinic a half a day everyday. He would operate on most days as well. The admin days are part of many private practices but it wasn’t part of his. He ran his own business with his wife being his business manager. He would have major operating days maybe three days a week. And he would do colonoscopy on a certain day of the week. He would also always come back to his clinic.

So there is a wide variety depending on where you’re at and what is the practice you’re in. If you have a big group practice or a multispecialty clinic such as the polyclinic in Seattle or if you’re working at an academic medical center like the Cleveland Clinic. It has a very busy high volume center.

Somebody in his department that does pelvic floor may see a little bit more clinic than somebody who’s an IBD specialist who may have a mixture of clinic and operating days. So this varies according to the individual unique practice that you want to set up.

[16:00] Operations and Calls

Scott says they treat colorectal disease. And as a part of that, the referral pattern you’re in would determine a lot of how much medical management has already been done. Many pelvic floor disorders, for example, need medical therapy or workup. Fecal incontinence in many cases can be treated with bulking agents and some Imodium and some pelvic floor retraining. So they won’t need an operation anymore. There’s also a study that 50% of hemorrhoid consults are not hemorrhoids alone. Or there’s something that never needs an operation. Diverticulitis can be treated with antibiotics. So you can see that a lot of these disease processes are treated with multispecialty type approach that medical management is a major part of it. So on a typical clinic, not accounting your post-ops or your follow-ups, anywhere between 20% or 30% depending on your individual practice may require surgery. But all of them have some semblance of needs for the colorectal surgeon to treat either surgically or medically.

With regard to calls, Scott says they vary more than anything else. It depends on who takes the call and how many people are there in the practice. It also depends if you’re asked to do general surgery and colorectal or just colorectal surgery alone. It also depends if you have acute care surgery or you have fellows and residents. Scott thinks that they’re one of the largest colorectal departments, if not, the largest in the United States and maybe in the world.  They have well over 20 colorectal surgeons. So for them, call is busy. But they can be extremely busy when you’re on call because it’s a major referral center. At their clinic, they get patients all over from the northeast Ohio to Kentucky, West Virginia, and all over the world. So a lot of the diseases that can happen that affect the colon in such a busy hospital. They have fellows and residents. It’s a very busy fellowship and a very busy residency. Scott says they are up all night long. It’s a busy call but they’re not crushed with calls. He has been on call a lot more in other places that he has worked.

Additionally, you have to determine that as a subspecialist, especially a subspecialist branching out from general surgery. This could include bariatrics or minimally invasive surgeon, surgical oncologists, colorectal surgery. In each of these, you’re oftentimes asked to take general surgery call. When he was in the military, his call was colorectal surgery and also general surgery call. That mixes in your bowel obstructions, cholecystitis, appendectomies, hernias, etc. That can drastically change your call in terms of the number and the types of patients you see. Some people want to do that. Scott did general surgery call for seventeen years. But he doesn’t do it anymore and he doesn’t do trauma anymore. He’s fine with that. But other people are looking for jobs as a part of their colorectal practice that they can still do a little bit of general surgery.

Unless you’re going to a major medical center where it’s a colorectal call only, you may be asked to do some general surgery calls. And that has its pluses and minuses. Some of their east side hospitals take a bit of general surgery call. That’s part of the institution you’re working at. People primarily at the outer institutions away from the main campus take general surgery calls. But that’s part of the hospital they’re a part of. They also have other jobs in the hospital. You’re working with people and you get to know the fellow doctors you’re working with. You help out. You cover for them and vice versa. So that’s a unique aspect of that. Scott took general surgery call because he liked it. At times it’s rough. But he can say that especially earlier in your career and especially if you’re going to a community based setting, don’t be surprised that you’re going to be taking some general surgery call.

[22:45] Work-Life Balance

Scott explains that time is the most precious commodity that you have. That’s why you need to prioritize. Really determine what do you want to do in life and what do you want to be. What are your goals? Regardless of your specialty, you have to prioritize and figure out what type of practice you have. What type of priorities do you have and where do you go?

Earlier in his career, he knew he wanted to do academics. So he had a very hard time saying no. Anybody would ask him to write a chapter and he would do it. Or they’d ask him to review an article or travel or teach a course or cover a call, he’d do it. Being in the military, he started being deployed. And then he got deployed for a number of times. The next thing he knew, he has one daughter, grew up and realized he’s missing a lot of her life. You’re going to be busy. If you want to do academics, there’s never enough time for academics. There’s no such thing as protected time. And even for those who have “protected” time, everything else impinges on it. So you have to really set aside time to decide what you’re going to do. Scott has had friends who started on academic career and did a bunch of stuff. Then they felt they didn’t have the passion for it. So they stepped back from it or did it selectively. And that’s great because it works for them.

Scott likes academics a lot and says that unfortunately, you have to find time. He reviews for a number of journals and serves as an editor for several textbooks. He has traveled the world and has met wonderful people. He has operated in places he never thought he would operate on. He would have never thought he’d see some of those places and had the unique experiences.

But Scott knew he wanted to be the guy who wants to be involved in the journal and the textbooks. He wanted to be involved in teaching fellows and residents. So when he sits down with fellows, he asks them who they want to be. Training is funny especially in medical school and residency. You constantly have people come up to you and say how you could chose this profession and that. You feel this angst that you can’t talk bad about. Or you can’t say what you really want to do. Especially when you’re training in academic institutions, you feel this push to say that you don’t want to be a community based surgeon but that’s what you want to do. Scott believes over half of their specialty is made up of community colorectal surgeons. That’s the socio-economics we have. That’s the demographics and the geopolitical aspect we have. It’s a big land mass. Many general surgeons cover a lot of things. Colorectal people may find themselves clustered or be in an independent town working on their own.

When Scott went into his first week of surgical residency, he knew he wanted to be a program director. As he progressed along his residency, he knew he wanted to do academics. And he knew he wanted to be the chairman one day. He feels like he’s the luckiest person in the world to be the chairman of colorectal surgery at the clinic. He finds it a really great job at a wonderful institution with extremely talented people in and our of his department. He has many other friends at other institutions that are lifelong friends outside of medicine. But he knew those are all he wanted to do. He knew he wanted to do the complex cases. And one of his best friends don’t want to do it. He wants to be the guy that just does the bread and butter thing and take care of patients. He just wants to be a very busy person and get home at five so he can teach his kids softball.

Now, Scott has the opportunity to do much more of this. But it’s a matter of how you want to prioritize. His advice to people is to be true to yourself. There’s going to be people telling you do this and that. They’re going to fade in and out of your life as time goes on depending on those relationships. But you have to be happy.

[27:42] Mentorship and the Path to Residency and Fellowship

As a colorectal, you start out in the communities. This is the reason you see a lot of the major colorectal training programs are community-based clinics (Asher Clinic, Mayo Clinic, Lahey Clinic. University of Minnesota, where Scott trained, was one of the few universities that had a major training program. A lot of the university centers felt general surgeons could do it all and they didn’t have the need for a colorectal surgeon. As medicine has changed as well as life in general, they have found there is a call for subspecialists. The call for having subspecialists, not always in every place, is a need. So the subspecialization in many cases has got a positive and negative effect on it.

For example, you have people that think they’re going to learn everything they want to learn in their fellowship. So they can just coast through their residency. But Scott disagrees with this. Their goal in fellowship is to refine and retrain people, not to teach them from the basics. The subspecialization has become a bit more prominent, And as colorectal surgery has really taken off and now found a niche, not only in the community but also in major academic centers, now they can go everywhere. Scott is proud to say that for the last several years, they’ve been one of the most highly competitive and sought after matches. That’s when you consider the programs, slots available to the number of applicants that apply.

Scott says when you look at some of these kids that come through and you see their CV’s, you’d be surprised to see what they’ve done. You will hear many colorectal surgeons that if they had to apply now, they won’t know if they’d get a spot. The point is that the field is now becoming more competitive. Scott’s advice to those who want to get any fellowship, including colorectal surgery, it’s important to plan ahead. It’s important that you now have some research and have good board scores. It’s important to have good mentors in life. Moreover, Scott says the best part about medicine is we never stop learning. Technology continues to evolve. Disease processes and what we know about them continue to evolve.

Depending on the general surgery you have, it usually involves five years of clinical time plus or minus research. Most programs are one clinical year. A few would be research year of colorectal and then a clinical year after that. Then post-training is one or two years. In many cases, they have a clinical associate year. It’s like a super-fellow where after finishing your fellowship year, you spend another dedicated one-year training or six months doing reoperative surgery for example. But only a few selected institutions have that.

[32:53] Bias Against DOs

Scott notices that any bias has changed over time. He doesn’t know if the MD versus DO is as prominent as it used to be. He recalls during training that there were programs that won’t accept a DO student even no matter how great they were. He was in the military for a long time and they had both MD and DO residents. Some of the best kids he has trained were osteopathic students. He also had a roommate in Iraq. He is a DO ER doctor and toxicologist and he describes him as the one of the brightest physicians he has ever met. Ultimately, you have them in both sides of the fence.

Scott went to Madigan Army Medical Center and he’s proud to be in the military and trained in the military. But comparing it to training at Cleveland Clinic, he knew he had to distinguish himself. He had to be much better. So what he tells DO residents is that they have to be real. There still may be a stigma associated with going to an osteopathic school for medical training. And because of that, you may not get the interview or they may look at you as someone who should blow their socks off. So your scores have to be that much better. Your publication should be that much better. That doesn’t mean you’re not better than the person next to you. But take that stigmatism out of it will blow their socks off. Scott adds that if in a program somebody comes to you and has an automatic bias against you, then maybe that’s not the program you want to train in anyway. Surgical residency is a fun time and it’s a lot of growth.

[37:45] Subspecialty Opportunities and Working with Primary Care and Other Specialities

At Cleveland Clinic, they have teams. It’s not all they do but they have a focus of things. They have a cancer team, an IBD team, and a pelvic floor team. They have a team of hard core basic science researchers who also still maintain a clinical practice. They run labs. Scott says you can make yourself and find your niche and do that. You can both that in an academic medicine as well as in the community. That’s the unique aspect about medicine and about surgery, specifically, colorectal surgery. Another unique aspect of being a colorectal surgeon is you can transition into teaching or mentoring type program. You can also transition into primarily endoscopy only. Or you can do just outpatient surgery and focus on anorectal type of disease. You can also do mentoring and teaching medical students. Scott says that’s the cool thing about colorectal surgery because there’s such a wide range of patients and such a wide range of disease processes that you can take care of. It really fits at all stages of your surgical career.

Scott explains that you become a doctor when you know more about walking in other people’s shoes. You see what they do and get a feel for their care path or how they treat patients. It just allows them to be better care providers. This is especially true for primary care providers being the frontline care providers. The more they know about subspecialists, it saves the patient a lot of grief when they come and see them with rectal bleeding but they’ve never been treated with fiber. Or they have hemorrhoids but they’ve never been truly treated with a medical therapy. Patients come to him and they automatically think they need surgery. So Scott’s advice to primary care providers is to take a look if their institutions have those and learn about them via algorithmic textbook. You’re never too old to take a look at just a textbook and look at rectal bleeding. You could have been trying something else all along that could either help the symptom or conversely rule it out. So you can then move on to the next step of therapy. You mostly see this in the anorectal type of processes and disease states in colorectal surgery. Hemorrhoids are the classic ones. the anatomy can be confusing to people. Nobody is expecting you to be a subspecialist or to treat complex disease. But you need to understand the very basics about certain health problems.

Other specialties Scott works the closest with include medical oncology and radiation oncology. They also work with pathology and radiology as part of the multidisciplinary team report. They also work with urogynecologists on pelvic floor disorders. They also work with general surgeons specializing in abdominal wall reconstruction. Other specialties they work with are urology, plastic surgery, neurosurgery, gynecology, and gastrologist.

Scott’s advice to students is for them to understand and appreciate what doctors do and the disease processes they treat and the tremendous amount of hard work they do. As you get older, these are the patients that refer patients to you. So have that good referral relationship because patients are your lifeline. So you realize they’re not your enemies but your colleagues who have gone through a lot of training as well.

[47:25] What He Wished He Knew About Colorectal Surgery

Scott explains that at the end of the day, it comes down to patients. It’s about understanding the degree of what a patient is going through. The medical journey is extremely fulfilling. You can do anything you want to from being a busy clinical colorectal surgeon to being a hard core academician. And colorectal surgery, like a lot of other things, provides you that.

What’s neat too is you get to mature as a physician. But if you’ve ever been sick or you’ve known somebody close to you as sick, sometimes you lose that perspective where you’re in a job on a day-to-day basis. You forget that the person sitting next to you has so many things going on.

Scott says it’s easy to lose sight of this but keep all under perspective and it makes your job even much more fulfilling. What he likes most about being a colorectal surgeon is being able to operate. He loves the ability to do something. He tells his students there’s no more intimate relationship you’ll ever have than having the trust of somebody allowing you to cut into their bodies and operate on them. Somebody’s entrusting to you that they’re going to sleep. You’re cutting into them. You’re taking out the cancer. You can’t get more intimate than that. You’ll be inside somebody else’s body. So it’s an incredible amount of trust they have that you will hopefully take care of them. Understand that you’re human and you’re fallible. There are complications that can come up.

On the flip side, what Scott likes the least about being a colorectal surgeon is the amount of time you have in medicine in charting. He likes seeing patients but the amount of time physicians have to do this is becoming less and less. Combine that with charting and EMR. Then you lose sight of the fact that you had a great interaction with the patient. This can somehow get diminished or lost in the shuffle. Scott finally says that time is probably the most precious commodity that we have in all things. It’s something everybody needs to take a better look at. Realize what you want to do. How do you want to spend it in the most effective and efficient manner that you can?

[52:45] Major Changes in Colorectal Surgery

Scott explains that technology always changes and always drives. People have a curious mind and they will continue to drive. They see a problem. They think about a problem and try to find something to fix it. Some of those things revolutionize medicine and others fall by the wayside. Right now, the hottest thing is pushing the limits of endoscopic therapies for different types of diseases and minimally invasive surgery. As we go more towards natural orifice surgery, they try to decrease that.

Finally, when asked whether he still would have have chosen colorectal surgery if he had to do it again, his answer was an absolute yes. All he can say is that it’s a wonderful career. It’s extremely rewarding. And he looks forward to doing it for a long time to come. His advice to premeds or medical students getting started on this journey is to find a mentor. Find somebody that can sit down and tell you the ropes and guide you a bit. You can read a textbook or listen to a podcast such as this or his podcast Behind the Knife. The information is out there and you have to have fundamental basic knowledge. But there’s nothing that beats relationships and has that ability to have somebody guide you through that process. Have great board scores. Do research in the field you want to go into. And you have to be competitive. You have to have the baseline minimum.

But the more fulfilling part of life is having and building those relationships and finding out what makes people tick and what makes the specialty so great. That’s where the mentor-mentee relationship comes into play. Meet other people and truly get to know them.

[58:15] Final Thoughts

If you’re interested in colorectal surgery, follow Dr. Steele’s advice. Find a mentor. Find a colorectal surgeon out there that’s doing what you want to do. And start connecting with those people. Don’t forget to check out Dr. Steele’s podcast, Behind the Knife.

Links:

MedEd Media

The ASCRS Textbook of Colon and Rectal Surgery

Relay for Life

Cleveland Clinic

Madigan Army Medical Center

Dr. Scott Steele’s podcast Behind the Knife

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