Botox and Burpees
Botox and Burpees
S04E81 - From Columbia General Surgery to Robotics: A Journey to Cardiothoracic Surgery with Dr. Joseph DeRose
Revisit the demanding yet rewarding world of surgical training with us as host Dr. Sam Rhee @botoxandburpeepodcast sits down with Dr. Joseph DeRose, Professor and Chief of the Division of Cardiothoracic Surgery at Montefiore Einstein Medical Center. We share memories from our surgical residency days at Columbia University Medical Center, reflecting on the camaraderie, jokes, and resilience that shaped our careers. Dr. DeRose's journey from those formative years to his current leadership role underscores the importance of teamwork, hard work, and precision in the OR.
Explore the evolution of surgical training and practice, where high expectations and competitive environments meet innovative advancements like minimally invasive procedures and robotic surgeries. Dr. DeRose offers insights into his pioneering work in robotic cardiac surgery, shedding light on how these technologies are transforming the field. The episode also touches on his mentoring relationships, particularly with Dr. George Todd, and explores the balance between clinical practice and leadership roles.
Balancing the high stakes of surgery with personal passions takes center stage as we discuss the parallels between the precision required in both heart surgery and sports. Join us for this nostalgic and motivational episode, perfect for current and aspiring surgeons, as we journey from residency to becoming leaders in cardiothoracic surgery.
#CardiacSurgery #SurgicalResidency #MedicalPodcast #SurgeryLife #SurgeonTalk #MedicalMentorship #SurgicalTraining #DoctorLife #HeartSurgery #MinimallyInvasiveSurgery #RoboticSurgery #MedicalCareer #SurgicalStories #MedicalProfession #SurgicalEducation #CardiothoracicSurgery #MedicalLeadership #Mentorship #SurgicalInnovation
so I just finished the podcast recording with dr joseph de rose, who you are about to hear, and it was so great to talk to him as, uh you'll hear, we haven't talked since we were in residency and, uh, that was 20, like six, seven years ago. Uh, after the podcast, we just sat for like another 15, 20 minutes talking about all the people that we knew in residency and there were so many characters, so many personalities, so many great people and from my perspective as a plastic surgery resident, I only did three years of general surgery there. So I I was on the outskirts. I wasn't a regular general surgery resident, I didn't stay but the people that I trained with were some of the most impactful people in terms of their work ethic, how they approached life, their dedication to their craft, how they approached life, their dedication to their craft and also just like how to have fun when things were really terrible and horrible and you had like a crushing amount of responsibility, and they took it all very seriously, but they also enjoyed life, and so we just ran through a bunch of names and also a couple stories that we can't discuss on the podcast because it wouldn't be appropriate, but they were just so reminiscent of some of the great things that were so special about surgical residency training. And I know if you've ever watched a show like Grey's Anatomy or ER or some of these shows watched like a surge, like a show like Grey's Anatomy or ER or some of these shows like. They try to capture a little bit of what that camaraderie is. You know how people interact in the hospital under stressful situations and maybe it's just like the fog of time, but when I look back at it, it was horrible, it was difficult. I definitely was an average resident at best at that time, but that team and those people around me tried, you know, they really tried to lift me up and make me the best person that I could be most of them and I would say I really respect that. And Joe was one of those people and and as I mentioned in the podcast, he enjoyed life to the fullest then and he continues to enjoy everything that he does now, regardless of how accomplished, how many accomplishments he's had, how big he's become in terms of leadership, in terms of you know what an expert cardiac surgeon he is. So I hope you listen to this and realize that. You know, for me it was very special talking to Joe and, I think, very inspirational to see what he's done over his life. So I hope you enjoy the episode. It really meant a lot to me. Thank you All right.
Speaker 1:Welcome to another episode of Botox and Burpees, the surgical series. I have with me a very, very special guest. This is Dr Joseph DeRose, and Dr Joseph DeRose is the professor and chief of the Division of Cardiothoracic Surgery at Montefiore Einstein Medical Center. He's also the co-director of the Transatheter aortic valve replacement program at Monofere. I know Joe and this is actually literally the first time we've talked in almost 26 years because he was my senior resident in general surgery when I was doing the general surgery portion of my training at Columbia University Medical Center. At Columbia University Medical Center, and everyone that were my senior residents, including Joe and many other people we could name, were really people I looked up to. They were amazing, amazing people.
Speaker 1:But a little bit about Joe's background. He graduated with a BS in biology from Georgetown University and you won the Summa Cum Laude Chapman Medal for the most outstanding student, which is a nice honor. And then you also went to Columbia University Vagelos College of Physicians and Surgeons and you won the Whipple Award for the most outstanding student in surgery, which is a real award. That's pretty prestigious. And then you finished your full general surgery residency at New York Presbyterian Columbia University Medical Center where I met you, and then you stayed on to do your cardiothoracic surgery fellowship at Columbia and also did a postgraduate fellowship in robotic and minimally invasive surgery there, and your specialty or your interests include robotic cardiac surgery, arrhythmia surgery, atrial fibrillation surgery, thoracic aortic surgery I mentioned the transcatheter aortic valve replacement, the minimally invasive stuff. This is a far cry from the stuff you used to do as a fellow. Probably, like you've gone into the next gen of cardiac surgery at this point, isn't it?
Speaker 2:Yeah, I mean it was super exciting though, because all those things including and most closest to me being mentally-based cardiac surgery and robotic surgery were in their infancies. They didn't even exist when I was a fellow, and then, when I was a super fellow, stuff was just starting to be developed. So I was involved at the front end of this, developing these operations, trying to figure out how to do it. It was super exciting. I was lucky that I had those experiences to be able to get in at the ground floor at the early part of my career because of Columbia, honestly. So that's all been great. It's one of my passions. It's funny. My practice is weird. I'll do the smallest operations, which are like robotic surgery, and then I'm also the director of the aortic surgery program, which are massive operations arch replacements and aortic operations. So it runs the gamut and it's really a great practice that I have.
Speaker 1:Yeah, I remember when I was training with you guys like we did a lot of laparoscopic gallbladder surgeries and I remember you guys as seniors taking the juniors us through it and everyone was super facile at it and it's so amazing to see where all of that minimally invasive stuff has gone and and the fact that you guys have developed so much of that. So, when you think back on your training, what do you remember as particularly memorable or something that was very impactful for you during your training that sort of led you to become where you are right now?
Speaker 2:I think you know you sort of alluded to it when we were getting started, to it when we were getting started and looking back now and having the relationships I have had over the last 30 years. Columbia General Surgery Training was a brotherhood and sisterhood and a family and there were very specific expectations and requirements, but there was such a camaraderie and that was something that was brought down from generation to generation. I mean, I was, you know. I'm really honored that you said you looked up to me and some of my other co-fellows but you got to realize that I had those same aspirations of the residents that came ahead of me and they were the people that I wanted to model myself after from the time I was a medical student or intern and there was a certain way that we decided that we were going to conduct ourselves as a general surgery team and it stayed with me forever. You know, and you may or may not realize this, but there was always this dynamic, not just on the general surgery end but also on the cardiac surgery end, this sort of competition between Columbia, cornell, nyu and Cornell and NYU had a certain way of doing things and at Columbia we were going to do it differently. We were going to be sort of the team, a kinder gentler group of surgeons, but we were expecting 150% from everybody at every level and a lot of these people that I looked up to, who I trained with, who trained under me, I'm still very close with and I still stay in contact with and I also am the head of the residency program here for the I-6 program and the fellowship, and I've tried to inculcate that into our trainees. You know the trainees train each other but everyone does that with respect. There are expectations and we do expect you to work hard, but that respect in the OR, I think it was always translated to me and the memories that I have are with some of the guys that you already mentioned and girls, of spending, you know, countless nights in the ER or on the floor doing what we do every third night or every other night and loving it and having so much fun.
Speaker 2:Now, some of the experiences I can't recount on this podcast, but Argenziano and Laboudi and I and Chen do recount them frequently offline and it was a lot of fun. It really was the jokes we play on each other, the jokes we play on the attendings, the stories we have so legendary that, for example, I would tell one of the stories to one of my fellows who would then do like a super fellowship or have a. We have an exchange program at Columbia with Pete and they'd run into our Genziano and he would tell them exactly the same story. So you know, I have other co-fellows, like Evan Lipsitz. He's the chief of vascular here, yeah, and when my IPH residents rotate through vascular they believe that the stories I told them were true because he's telling them the same story. So it was a lot of fun.
Speaker 1:There was such shared experiences, for sure, and I think of you guys and I think that the reason why I admired you guys and you know, being a plastics guy, I was sort of off to the side and you guys treated me with kindness and and a lot of tolerance and patience, I. But obviously at Columbia there was a huge general surgery tradition, as you mentioned, but also, uh, cardiothoracic surgery. All of the bright, best and brightest in general surgery seem to want to do cardiothoracic and many of you guys stayed there and, yeah, to see Argenziano, to see Raj, to see you, to see Nader Mozami and all these guys like just you know, who handled a tremendous workload Like who handled a tremendous workload Like. There's no doubt at that time the workload was insane.
Speaker 1:The, the tasks that were expected of of everyone, especially the seniors, was insane, but you guys had a sense of humor, you had a sense of being able to accomplish these things with grace. There was no, you know, there was no hate or malice sent downhill. If it was, it felt like a team. Everyone contributed. You know, I remember just very vividly, like Bobby Dable was my two, I was the intern, like you know, you were like my four and Moza, you know it was. It was a hierarchical hierarchical but in such a good way, and it was. That team aspect of it is something that I have taken away in terms of a lesson, a life lesson and also how to treat your juniors and the people that you work with with respect and expect a lot, but you're also giving a lot at the same time.
Speaker 2:That's so true, and we love, we loved being there, though that was the thing that I'm looking back at, like I mean we were there a lot. I mean I guess by the time you were two I think we had eliminated some of it, but most of us went through was every other night or every third. We went to that every third where it was like Monday, friday, sunday, and that was hard and it wasn't that like the juniors and the seniors, they wouldn't leave if they were not on call and you stay there and take care of whatever you had to take care of. I mean, there's a loads of stories. One story I remember, right, I forget that some of the things that I've told the juniors right, like they took to heart, they remember it. So, like Dave D'Alessandro was, I think, was he in your class? Was he a two?
Speaker 1:He was one year down. Yeah, so he was a two Before I was a chief.
Speaker 2:Yeah, and he ended up going into cardiac surgery and actually ended up joining us here at Montefiore Einstein. And he comes to me the first day that he's here and he's like, hey, I just want to let you know it's one piece of advice you gave me when I was an intern that I've kept with me forever and I'm like, oh God, what's this? Because he said to me once I came to you and said, oh, I think there's a consult over in area A, and he swim upstream and if you get called about a consult, don't ask anything but the medical record number and go take care of it. I'm glad I was able to affect you so much. The other thing that was fascinating was that like we had this hierarchy we did. And I remember Labootie saying to me when I was a two Joey, listen, you are a two, you don't speak to me directly as the five. The one speaks to the two, who speaks to the three, who passes up to the four and then maybe the five gets involved. And that was true, but it was as a joke.
Speaker 2:But eventually you'd go up and slaughter and when we were chiefs we didn't't have the attending didn't come in, right, I mean, we did the cases at night and they were on the phone.
Speaker 2:That changed thereafter and so you were like an attendant, you had your own service, absolutely one month right to cardiac surgery, fellowship, and it's a complete reset and I knew that, I mean. But you start day one and you're like oh my God, I know nothing. I was just, I thought I was attending and now I know nothing. And I think that understanding of that, knowing that you have to reinvent yourself and relearn something again, is really important and maybe sometimes I'll see that in my fellows who just get started is that it takes them a little while to realize whoa, we got to stop, reset and learn again. So, but all those things were ingrained in me. I still love it and I got to tell you every time I speak to Labuti or Jan Ziad, we're going to tell the same ridiculous stories about whether it was Ben Vinisti or ford or imitating other attendings. I mean probably inappropriate but but very funny they were they.
Speaker 1:It was so memorable. I mean I remember so much of it, like it was yesterday and uh, I was just thinking the fives were like attendings. I remember there was a ruptured, uh triple a up at allen pavilion and I was the two on and I think it was goldstein who came up and handled it until the attending eventually came up. But we were like halfway up in, you know, in surgery, like a solid hour and a half or two, and I remember holding the distal part like squeezing that like a mo, like like just don't move, like in the middle of the OR, and like it was just it. And and that type of leadership responsibility. I mean I've talked to other surgeons about, like you know, patient care versus teaching and all sorts of other debates about like what kind of responsibility residents should have. But at that time there's no doubt the amount of responsibility that we had was tremendous, especially as seniors. And that leadership experience, I don't know it, just it gets kicked down so much farther, I think in residency it was.
Speaker 2:You know what I mean. That's the one thing. So in cardiac surgery there's this whole dichotomy between I-6 residency just like plastics, i-5, matching right out of medical school and then the traditional pathway of general surgery and doing a fellowship. And you know there are pros and cons of both. But the big argument for doing the conventional pathway and then the fellowship is exactly what you said Slowly, getting just the knowledge, but the ability to lead and have independence and then learn how to teach those below you.
Speaker 2:I think it happens in the I-6. My I-6 residents are phenomenal but it happens in a different way. But that maturation is so critical and also, I think the other part of it is that and I'm hoping that residents today still have this I try to have my I-6 residents do this. I think they do, but it's to enjoy it, to share it as a team. Make sure that you have responsibilities as a three for the two for the one and the four for the three, et cetera. But enjoy it, want to be there, right, it's not about getting out as quickly as possible, it's about trying to be there as long as possible. And uh, and that was true. I mean, even though I was exhausted, I never wanted to be anywhere else.
Speaker 1:I will tell one more story. And Dave D'Alessandro you mentioned him and he's a great guy and I remember cause I I rotated over at overlook and it was actually not him, but back in the day, I don't know if you remember at overlook you took power weekends. So you're on call from Friday through Monday and you took everything that came in and and the laundry was not open on Monday morning by the time you got to to the OR at 730. So you usually like, took your scrubs, had them in the call room, took your power weekend, had them in the call room, uh, took your power weekend, uh, you know, and then you change or whatever, and um, I remember coming in on monday and jim burks had been on uh for the weekend and he took.
Speaker 1:Yeah, yeah, I know right. So he took my scrubs that I had and he had left the ones he had worn all weekend and I had to go to the OR in his four day and, for knowing Jim, it might have been like a week old scrubs that he had worn and that was a very, very, very memorable experience for me at that time.
Speaker 2:All right, here's a story which some people might think is a little bit depressing, but sort of mirrors how hard we did work. So in general surgery I thought we worked really hard. And then when I got to cardiac surgery and at Columbia, it was hard. We were on call same kind of rotation schedule but we were there all the time and then my co-fellow ended up leaving, which left me with a little call. I remember being called into the office and Sam Weinstein brings me into the office with Craig Smith. Sammy goes, joey, I got some really good news for you. I said what's that, sammy? What is it for Craig? He goes. I think you're going to be able to do a lot more cases early on in your career. I said why is that? He said well, so-and-so is going to be leaving, which means you're the only intern, so you're going to be able to take double the amount of call and I think that's going to be really good for you. And now I didn't say, like you know, oh my God, that's horrible, it's great, sammy. Thanks so much.
Speaker 2:I don't know if you ever read this. There was this book called Life and Death, and Life and Death was written right before I started as an intern. It was a book written about Columbia Presbyterian, the old Columbia Presbyterian and all the different characters at Columbia. Each chapter was one. Al Cann, who was the ward clerk in the ER, was one. He used to call me number one and my wife, who was a resident, number two. Everyone had a name, eyeball on the phone. You know, you know, whatever that was optimal and it would go down the ladder. I remember there was one chapter I read this book before I started residency and it was about the cardiac fellow. So the cardiac fellow is in the call room and and he's exhausted and we did those power weekends also, but we were up constantly and frequently your wife would bring you know if you had a kid or whatever in just to have a lunch or something, so they could see you. So the guy the wife, knocks on the call room door with her little son and says, hey, go say hello to daddy. They open the door. The girl runs right to the phone even though dad's sleeping in the bed, says hello, daddy.
Speaker 2:My wife was also a medical resident at Columbia and is an internist in Englewood. I tell her, at the top of the list, that's never going to happen to us. I said I'm going to be there for everything. It's never going to happen. So my wife used to bring my son in. Even when I was at the Allen Pavilion as the ghost and then as a fellow and he was like one or two he would come in, we'd have lunch, we'd play a little bit.
Speaker 2:So it just so happened that one day I must have gotten home after a call night on a Saturday or something, and I was home early and I was passed out in bed and for cardiac surgery. On 7 Garden gardens south there was a blue door and behind that was the cardiac surgery fellows office. We were in there constantly. So my wife goes, my son's running around screaming and all she goes, be quiet, you're gonna wake up, daddy. And he's like what are you talking about? She's like daddy's sleeping in bed. He's like well, daddy doesn't live here, he lives behind that door. I said I definitely did not do it.
Speaker 1:Yeah, I remember Sam Weinstein crashed on a Monday, I think coming back post-call, like going home, like that was serious, big deal.
Speaker 2:Those things are big deal. Here's a good story. Uh, this is a cardiac surgery story. So every night before, uh, we used to have grand. We used to have rounds on Thursdays, okay. So every night, like Wednesday night, every fellow would be in the office trying to get their presentations together to like midnight. So I come into the office and our Genziano is out, is on the couch lying flat With an EKG machine on, and I said what the hell are you doing? Because I think I'm an SVT. So I look at the EKG and I go yeah, you're an AFib. I said you gotta go home. He said no, no, no, hurry up, go out to the nursing station and get some low pressure I have to get tomorrow. So I go out to the nursing station, I try to give him a chronic massage. This will work. I go out to the nursing station, I give him a bolus of low presser, he converts, he gets back up, gets the presentation ready and goes home at midnight. I mean, you don't like getting that from the resident fellows of today.
Speaker 1:No, he, he would flip into SVT in the OR and he would Sorry, he would flip into SVT in the OR, yeah, and he would like sit there and Valsalva in the case, to try to flip himself back, yeah, into sinus, like he would. He would do that. Like he'd see him. He's like getting all red and sweaty like what the what?
Speaker 2:what are you?
Speaker 1:doing and and uh, it was nuts.
Speaker 2:Uh, I mean, and trying to get that guy up in the morning to round was effing impossible, like as a, when we were, when we were, when he was a, when he was an intern, when he was a two, when I was an intern, he used to tape his beeper to the top of his head, just like a band, like a headband. That way it went off and vibrated and you'd wake up, you'd sleep out.
Speaker 1:So so I know you had so many mentors that sort of helped form you to be who you are. But if you had to name just someone off the top of your head and you to be who you are, but if you had to name just someone off the top of your head, and who would that be? And what was it that they did for you to sort of get you to where you are?
Speaker 2:I mean, for me that was an easy one. I mean, a lot of people knew who my mentor was when I was going through residency on. That was George Todd. I mean George Todd was in vascular surgery when I was a medical student there. He'd been there forever. He was a resident there and been the chief there early on and I got close with him when I was a medical student and even at that time, you know, I wasn't one of these people that was all in to do heart surgery. I love the heart and everything and I did do some research. I just wasn't sure because you know, the rap on heart surgery was always oh, there's only two cases I could do, a valve and a cabbage. Oh, you don't take care of patients, you just operate and that's it. And you know, in hindsight I found out that none of that was true. But my early experiences with Dr Todd were that he was like a master surgeon. He set up every case like the heart surgeons did. It was very specific, he did every case the same way. But he also was a really good doctor. I mean, he took care of every part of his patient and his patients loved him. And it was this combination of being a good doctor and being a good surgeon. And then also we just had a great relationship from we just we hit it off early on and understood each other well and he understood what made me tick and uh and we used to laugh a lot together.
Speaker 2:So, um, he was the reason that I stayed at columbia. I mean, I was looking at going to brigham. I remember exactly what he said. Like I never asked him for too much advice but I'd be like, yeah, you know, these are the places I'm looking at. And he's like brigham, whatam, where do you Brigham? I said you need to stay here. I said, brigham, they all wear bow ties. You don't want to be up there while we're wearing curtains. You got to be here at Columbia. I said, oh, ok, that makes sense, call her.
Speaker 2:And then, as I moved on, um, he was always kind of there for me, you know, and he was there for a lot of the residents and he always gave really like good, smart advice and I came very close to going into vascular surgery. Um, but at the end of the day, I did love the heart and cardiac surgery. I tried to be the kind of surgeon and leader that he was uh, arc surgeon, uh, he, uh, I still speak to him. He's retired now but I still speak to him and he's exactly the same and it's great. And there was, you know, loads of other surgeons, but the heart surgeons were obviously mentors to me too, but in a different way. You know, I tried to take little things from each one of them, but, george, I tried to be, I tried to be the doctor that he was, and you know, I've told him that. And now it's later on in life and I think I've done some of that. I mean, I don't know if I'm good as he was, but I think I've done some of that.
Speaker 1:I remember him well. I never really operated with him because he you know obviously the cases. As you said, he's very meticulous and he was really particular about who he operated with and you could, he's very meticulous and he was really particular about who he operated with and you could tell he only you know he operated with the seniors. He did very meticulous carotid endarterectomies. That's the surgery that I think of him the most with. He was so particular about how the case went and he was a man of few words. When I saw him, the case went and he was a man of few words. When I saw him like he was a pretty like I wouldn't say grumpy, but he just was not very like. If you're a junior and you know he just wasn't going to really talk to you, he was focused on what he was doing.
Speaker 1:And the one thing I do remember is he didn't play a lot of albums but the one he really liked in the OR was Dire Straits. But the one he really liked in the OR was Dire Straits and I must've sat there like hearing that CD about. You know, cause it wasn't like the days of the iPod, you just had like a CD player and sometimes you'd ask the nurse to like change the CD or whatever. And that one, just you know he liked that one. He just kept playing that one over and over and over and over and over again.
Speaker 2:It's funny, I think you know he he took me under his wing when I was a medical student and he brought me in sort of to the inner circle with some of the other great residents that were ahead of me, like Galanowitz, autary, and these were guys that I looked up to, that thought were the greatest. But it wasn't until Labuti, argenziano and myself, I think, started getting to be more senior, that we broke him down I think started getting to be more senior, that we broke him down. Then we broke him down and then he realized what he would call us, you know, the morons, right, I mean incredible comp, and I think it was really good for all of us and for him. And then he started loosening up and then my first job that I ever took out of fellowship was with him. He left and became the chairman at St Luke's Roosevelt and he brought me there and hired me for my first job as a cardiac surgeon at St Luke's and probably the mentoring that I got there from him was even more important than I got moving on early in my career. He brought me in very early in leadership positions. He brought me into the whole process of recruiting, the whole department of surgery, and all of it from the residency program to research. He really gave me a lot of responsibility early on and I think a lot of the leadership skills I have are from him.
Speaker 2:He only gave me one other piece of advice when I started. I remember first day I started my first day as attending he said listen, I'm going to give you a lot of advice. One thing so, what he said and he usually would joke around with me all the time, but this was serious he said when you're first starting, every case looks like a good case. He said don't. He said do not get sucked into that. He said you will be a good surgeon when you decide who the patients are that should not have surgery, and there's going to be a lot of them. And he was totally right. You're running around, you want to get cases, every case looks like a good case and a lot of times you have to operate right. So I'm sure he doesn't remember any of this, but I did. I can take some of these things to heart. Very true.
Speaker 1:Very true word of advice. So, over the years, what do you do to become a better surgeon? You're a better surgeon now than you were last year, the year before that, 10 years ago. What are you doing to constantly better yourself as a surgeon?
Speaker 2:at this point, yeah, you know what, isn't it? True though I mean, you probably do this too Every year is learning, right, and you're trying to decide what is the next thing that I'm going to do. And I think that learning, especially when you're first starting early on as a resident, you don't understand. You think that the learning is the technical parts of it. Right, there's this classic maturation that my fellows go through. They're all panicked the first month that they're not going to be able to take the mammary down. I tell them you got to trust the process. Not a single person I've graduated can't take the mammary down.
Speaker 2:Okay, I said, but to learn an operation you have to learn the entire operation from both sides of the table. So what I used to do, no matter where I was, I would focus so much on the left side of the table, what was happening on the right side of the table, focusing on my moves, but looking at what's going on the right side of the table and saying let me put myself in that situation and I learned a lot of this with Dr Quaggivere, who was the congenital cardiac surgeon at Columbia, who was very difficult but one of the best surgeons I've ever scrubbed with. I mean he would exhaust you, but trying to watch every little move and step he made. And then when I got out I said to myself there's a lot of things in heart surgery that we do that make no sense to me. Why is everyone, why do we have to stop the heart and make a sternotomy and go on bypass? We're just sewing some blood vessels together. I mean, the plastic surgeons do this all the time with 10-0 and on our micro. Why are we making it such a big deal and constantly putting myself to learn more? And I did that mostly by reading and watching and going and watching other people. So I did not get a lot of training in aortic surgery when I was at Columbia. They hated it, they really didn't do a lot of it. But when I came to St Louis I was in charge of numbing days of surgery. But there was a guy there named Dr Agnestopoulos who had a huge aortic practice and I had just absorbed it and I said, okay, I got to get really good at this. So I found all the best aortic surgeons in the area and that time there weren't that many and I went and visited all of them. I watched all of them operate and I just took little pieces of each of it and made it my own, and I continue to do that.
Speaker 2:You have to always see what other people do, but you also can't be afraid to push the envelope. What other people do, but you also can't be afraid to push the envelope, which is hard, because when you're pushing the envelope, there's a target on your back right. People don't want you necessarily to succeed at something that's a little bit different than what they do. So today, what I try to do is always look for what the next thing is that I'm not doing as well or could be doing, and absorb it either into my practice or into the group's practice, because there's constantly new things. But you got involved in that early, so, and that's been what I've done my whole career and I and that's what I love about it I mean, otherwise you come into work doing the same thing a thousand times over.
Speaker 1:Yeah, especially in your field, there's so much change over the past 10 years. It's insane, like you said, with robotics and, and I I can only imagine what's going to be coming next, especially.
Speaker 1:I've talked to some surgeons about AI and and sort of starting to integrate that, and I've seen, uh, the ortho guys with their um, you know, sort of assisted guided type surgery, and I'm sure you guys are developing even better and improve you know safety techniques and other things to make it more foolproof for people. Do you think that these things are going to hurt surgeons skill Because, like, for example, the, the Mako system for ortho, like it almost prevents you from making a bad cut for your knee replacement, like it's like, oh, you can't do that, that's not good. Like it sort of stops you and helps guide you to make the right one and and and. Is that, are those kinds of training wheels good overall or is that something that a surgeon shouldn't necessarily rely on?
Speaker 2:rely on Great questions. I mean, look, look at general surgery and colon anastomosis, right From hand-sewn to mechanical right. I mean they're going to be done better, probably at some point with new tools, and those new tools have to be learned. I think, for cardiac surgery what's happening is that a lot of things are moving away from these big types of operations because we have less invasive ways to do it, whether it be transcatheter valve or other structural heart interventions, and same with aortic surgery, with stent grafting. But there are scenarios that will occur and will continue to occur where you have to do a third time redo aortic arch, where you have to do the third time redo operation.
Speaker 2:And part of the problem in heart surgery is that people are just not having, they don't have that experience because those aren't common operations, and so you're developing this cadre of older surgeons that are the only ones that are trained to do these big operations. I think something similar has happened in vascular, where 90% of it has gone to endo, and so when you have to do a complicated open aortic aneurysm or a complicated open bypass, it sometimes isn't as easy for the more junior people. So there are trade-offs. There's no question that we've pushed the field so far on the minimally invasive end, and that's all good. But you are giving a trade-off there, because people do need big open operations sometimes and at some point there's not going to be anyone available to do them.
Speaker 1:What is your favorite operation now? What do you really like doing at this point?
Speaker 2:So my favorite operation is a robotic cabbage. So robotic cabbage is an awesome operation. The DaVinci system. Most people don't know this, but the DaVinci system was originally owned. The copyrights and all of the hardware was owned by DARPA, the Department of Defense. That, as well as the trademarks for using the robot for surgery, were bought by Intuitive Surgical in the mid to late 90s with the sole purpose of doing totally endoscopic bypass.
Speaker 2:That was the reason for it. Oh, it wasn't urology surgery, it wasn't to do prostatectomy, it wasn't to do gynecology None of it. Gynecologists, none of them. And you know what their ideas were, for it haven't really come to fruition. But what has come to fruition is doing the robotic cabbage the way we describe it today, and that's using the robot to take down the lemma or the rima, opening the pericardium, identifying your targets and then doing a hand-sewn anastomosis with an endoscopic stabilizer through a tiny incision to put LEMAD or LAD or LEMAD or diagonal or LAD People with multivessel disease. They're treated with that plus stents, and the reason being is that LEMAD or LAD improves your survival. The stents are a way to treat the other vessels with quick recovery.
Speaker 2:Now, the reason the other stuff took off is because I don't think people had the understanding that robotics is for two reasons. You apply robotics to minimally evasive surgery for two reasons. One, it'll allow you to do a minimally evasive operation better than you could do if you just did it laparoscopically or thoroscopically. Two robotics should be applied If you can't do that operation minimally evasively, then the robot's the only way you can do it. So let's step back now in time to the late 80s and 90s, where general surgeons were amazing at doing laparoscopic everything. Yeah, so they didn't need a robot, right? But the urologists they're only a handful of people and some of our guys we trained with who were doing laparoscopic prostatectomy. Very few other people were, because neurology wasn't a field where you were getting such in-depth laparoscopic training. Put a robot in a urologist's hands. Now they're a melanodyser surgeon. Same with gynecology. The same idea occurred, and so that's how those things took off.
Speaker 2:In heart surgery it's very difficult I mean I have done what's very difficult to do a robotic cabbage without the robot. Do it thoracoscopically. But people do use the robot to do like minimally invasive mitral valve surgery. I typically do that thoracoscopically because I'm good at it, but other people that don't do a lot of that. You put a robot on their hand, then they can do it minimally invasively. So I love the robotic cabbage because it's quick, it's simple, the patients get discharged in three days and it's reproducible. And I think I also love it because it's an operation that I was involved in from the, you know, inception of the first case, a lot of these cases that are being done today. I was involved at Columbia with the first cases done ever. So you know it's exciting for me to see it and evolve and see that it's like routine.
Speaker 1:What does that do? Just stabilize the surgical site so you don't have to move.
Speaker 2:Well, the robot used to take down the mammary, which is not easy to do that laparoscopically or thoracoscopically, because there's no space there.
Speaker 2:So you have to insufflate, the chin drops the heart out of the way, take the mammary down. Then you open the pericardium and identify where you're going to go. Now what you do is you say, all right, there's the LAD, and you find a spot right on a chest wall where you make a tiny incision right on that and you can use what's called a soft tissue retractor or a regular retractor, and then you sew it by hand. You have to snare the vessel, but now it's simple. There are parts of it that do require additional training, for sure, because most heart surgeons are just, you know, used to opening the incision and going on bypass and stopping the heart and taking some veins out. But I love it, I love the operation. That's very cool Plus operation.
Speaker 2:That's my favorite one the operation.
Speaker 1:That's very operation. I like that's my favorite one. That's very cool. Um, so, when you set up for these cases, now that you've been in practice for so long and you've been operating, uh, I remember, like you said, dr todd being so meticulous about every step of his case, of his cases. What is it that you do now? That is the same for every case, or is there anything that? Or do you just kind of do everything freestyle, different?
Speaker 2:You know it's fascinating. You have to have the structure and the orientation of the operation and the operating table the same. You need to repeat that over and over, from where the towels go to where the stitches go. But every operation is completely different, and something I think Dr Todd told me about this, but something I did from my first day in practice. You know, every operation is a conglomeration of thousands of steps, literally. Now you're not verbalizing those steps to the person you're operating with, but you're going through them in your mind, whether it's from putting ports in or making the incision, all of it down to the most nitty gritty right. And so what I do every night or on my way into work is I think about the operation that I'm doing today, the very specific operation, and every steps of that operation I go through in my mind. I go through exactly how each part of it's going to be done, contingency plans on whether you know this vessel is not graftable or this looks like this, all the way through to the ends. And then what I also do, and always have done, is I also think in my mind what is going to be the roles of everyone in the room, because I'm in an academic medical center with a training program and to me that's really important, and you know the way you train residents well is to manage expectations. So, upfront, you need to know in your mind what's going to happen. You have to discuss with the team who's doing what today. All right, today we're doing this cabbage. I also have a case to follow. It might be a long day. Today you're going to open the chest, you're going to get everything set up. Then maybe I'm going to take both mammaries down and cannulate, because that might take me, you know, five minutes and it might take the fellow three hours. And then you know I'm going to cannulate and then we're going to switch sides and then you're going to do the cabbage from the right side of the table and I'm going to help you from the left. Oh, okay, that's the plan, right, or whatever it is.
Speaker 2:I realized that that takes a lot of energy. It takes a lot of energy on the attending side right To think about not only teaching somebody, but then to think about what everyone's going to do. Imagine if you just walked in and said I'm doing this case today is the way it's going to go. It's going to go fast, but the amount of the amount of value that comes from that is tremendous, both in both directions from the fellow to the attending and the attending to the fellow. And that's the way you build trust and that's the way you build dedication for your fellows and that's the way everyone feels like they're working on a team to save this patient's life. So those are the things that I go through every morning or every night for an operation. I cannot like a Like a. What night for an operation? I cannot like a like a. What you're simulating the operation Like. This was a big deal with simulating hours. They need right. I've been doing simulation, you know, since 1989 when I'm thinking about everything, but it is true.
Speaker 1:I have to say, every surgeon I've talked to so far does some sort of pre-visualization prior to surgery. I think it's universal. There's no one who never doesn't think about every step of the surgery before they do it. And I think probably if you are a resident fellow, even a medical student, like going through your own pre-vis before you do something or even watch, will help you get into that role, and someone told me that a long time ago, even as a medical student like you, should imagine yourself as the attending. What would you be doing? What should this case go as?
Speaker 2:Yeah, I think you know the one thing about that that I really tried to work on a little bit and we even was involved with one of the plastic surgeons here, evan Garfine, and I tried to work on this a little bit in an application directed towards learning and the issue is that you're going through all these things and little things are happening in your mind, but you're not verbalizing them, so no one is learning them. This isn't an original thought. This comes from a book called Peak by Anders Ericsson. That's the original source, for I'm sure most of the listeners know about Malcolm Gladwell's book about 10,000 hours. It's a little bit more involved than that. It's not 10,000 hours of doing something, it's 10,000 hours of focused practice.
Speaker 2:And then also the 10,000 hours of learning need to be important, and there's all these opportunities for learning that just go by us every day, especially in technical things, whether it be surgery or music or how to swing a golf club right. There may be things going through my mind that are happening, but I'm not telling someone about it because I think it's routine and mundane, but it's not. So what we did was we made a bunch of videos of simple things, whether it be I don't know making an incision, doing an exposure, cannulating and different fields in plastics, in cardiac, and on top of the video the surgeon is describing every single thought that's going through his mind from this is how I find the midline and this is where I buzz here. You know silly things that you think everyone knows, but by articulating them, you're articulating to the learner what are the steps, what should you should be thinking about, and that was that that's highlighted in this book. So that's huge.
Speaker 1:So I know what Dr Todd liked listening to in the OR. What do you like listening to?
Speaker 2:You know I love listening to music, especially when I'm doing work.
Speaker 2:I really do.
Speaker 2:But in the operating room for cardiac surgery I guess I didn't do this in general surgery I realized that I cannot have music, not because it distracts me, but for me, cardiac surgery it's a flow and there's a lot of communication that's going on between me and the perfusionist and me and the anesthesiologist and the nurses and back and forth.
Speaker 2:And that flow and that tempo has to occur at a certain pace. And if someone can't hear me or is listening to something else or it's not focused on that tempo and that cadence, things can go slower, things can go in a direction that I don't want them to go. And I want to establish in the operating room that this is kind of like a. This is a, you know, a holy place that we're in. We are going to do the same thing and all of us are going to be on the page about what that is and everyone's going to know exactly what everyone else's moves are and if anything is happening, that communication is going to be instantaneous. So I don't play any music in the OR, even though I used to play music all the time when I was a resident Cardiac surgery. I don't, and I'm probably in the minority with that.
Speaker 1:Most of my partners do, I would say probably so far. A third don't listen to anything, and for the same reasons that you mentioned, and then another two thirds play lots of different things. So it is interesting to sort of hear what people's uh thoughts are about that. Um, so at this point you're head of cardiothoracic surgery, you are running your residency program, you're wearing a lot of hats. What goals do you have as a surgeon at this point for the future? You've already probably achieved many of the goals you aspired to when you were a resident or a young attending. At this point for the future, you've already probably achieved many of the goals you aspired to when you were a resident or a young attending at this point.
Speaker 2:Yeah, it's funny, I guess. I mean, I don't think of myself as old I'm 56 but goldstein who also danny goldstein mentioned, who also works with me uh, referred to both he and I during a conference recently in public, as on the at the twilight of our career, and I was like, well, speak for yourself. But but it's funny how I think that your goals change over time. Right, when you're first starting, your goals are geez, I just want to do a lot of surgery and I want to be really expert at this. I want to be a great doctor and I want to be a professor, I want to publish this many papers, and those are all good goals and there's pathways to get to that.
Speaker 2:But now my goals are, like, less concrete. You know they're more about I want to be the best leader that I can be, I want to be the best mentor that I can be, and you know that doesn't always happen every day. There are days where you know you're doing things that you do and you say I could have done that better, I could have spoken to that person better, I could have trained that person better, right, and so those are the kinds of things that I think about getting better leadership skills. I've had a lot of experience and luck to be able to have a lot of exposure to the finances of medicine and of hospital systems, and I do like that a lot, and I've really tried to learn about that by putting myself in positions next to people who are expert at it. So I think, if anything in my career, that's sort of an area that I would like to continue to get involved in, maybe even at a much higher level. It's just that I'm not quite ready to give up clinical medicine.
Speaker 2:I do love it. I think it's such a privilege to be able to do what we do. I mean, I get it. It's hard, it is, but the privilege to be able to operate on someone's heart is crazy. And I really think my dad passed away about a year ago. He was like a big time internist, loved medicine, lived for medicine, and he told me when I was a kid and I used to laugh at him, but he's right, you know, medicine is the noblest of all professions. There's nothing more noble that you can do than to try to cure somebody. And these kinds of things come back to me as I get older and I'm like you know what. Those are the kind of things that you have to aspire to and you have to try to give that to those that are behind you or coming up. So I don't have concrete goals. I don't want to be president of the world. I don't want to you know, I don't necessarily want to, you know be chairman at a particular place. I just want to be a better leader.
Speaker 1:Why did you enter more leadership roles? Because I know a lot of the surgeons that we trained with at Columbia and they were only happy or they seemed like they were the happiest in the OR. You look at the vascular guys Ben Venisti, I think, todd Noe, grad like they were only happy or the happiest if they were in the OR doing something. And then when you start taking on other administrative roles or leadership roles, it's like you said, it's pulling you away from what we as surgeons ostensibly love the most.
Speaker 2:I think it's because early in my career so when George let Columbia, went to St Luke's Roosevelt now, you're right, he didn't level up and he used to make fun of everybody who was involved in that went to St Luke's Roosevelt Now, you're right, he did level up some he really did, and he used to make fun of everybody who was involved in that. Now, all of a sudden, he's the chairman of surgery on a three-campus system and he really learned how to be good at it. But while he was learning to do it, he allowed me a glimpse and some responsibility into some of his responsibilities. No matter what he was doing, I was like his secondhand man. We got to get this guy for that. I mean, I was a heart surgeon trying to make my way and, just you know, learn things at that point. But whether it was the residency, recruiting people or how to get people together, he always had me as part of it. It was almost like I was learning at his side. It was almost like I was learning at a side. So when I went to Montefiore to work with Dr Mitchler, I got a lot of leadership roles right from the get-go too, and I felt like so equipped for it, based on what I had learned. Now I learned a lot more from the way we organized things at Montefiore and the way we really put together a team, because there really wasn't one here. We built a big team.
Speaker 2:I don't want to do that as my only thing, but I understand the impacts that it has when your leaders are part of the battle. Right, you got to be in the battle and then people will respect and follow and they'll understand that the things that you're doing, hopefully, are for everyone's benefit, and that's unbelievable. There's two things to me that are unbelievably satisfying One, having a resident call me back and talk to me to tell me about you know how well they're doing and the fact that their training has made them a good surgeon. And two, to see that I've built something that's helped other people grow. There's nothing more fulfilling than that. Those are all things that reflect back on you. You don't need to say hey, I'm the person that did this, but the gratification that is amazing. So, trying to marry those two things of being like super busy heart surgeon I mean, I'm still the busiest heart surgeon at Montefiore despite all these hats, but I do like that. I do.
Speaker 1:Otherwise I think life would be boring. So if someone was to say and I'm sure you get this one of your integrated residents in cardiothoracic, or even just a younger resident or a medical student, they're like, I want to become Dr Joe DeRose someday. What do I need to do to accomplish that? What do you tell them?
Speaker 2:Well, they can only hope, Sam, no, no, I mean I don't want anyone to say that. I always tell people it's good to have role models, but take things from everybody and make them your own. I think you know it is important to have a bit of a path ahead of you, to sort of think about what are the things that you're aspiring to, and they don't necessarily have to be super concrete, like I need to have 30 papers by the time I'm 30, you know what I mean. It can be like, hey, I want to be the best clinical heart surgeon that I can be right. So then, what's the pathway for that, you know? Or I want to be a truly academic surgeon. What's the pathway for that? Because there are pathways for all of it.
Speaker 2:The end of the day, though, you can forget about all that. You have to absolutely love what you're doing, and you know, I think a heart surgery heart surgery has changed over the years. It's definitely not necessarily the most reimbursed field. There are plenty of other fields you can be in. It has remained a big commitment of time, effort and mental energy, because it is taxing when people live and die.
Speaker 2:So people that want to do this, they have to say, hey, listen, there is not a single thing in surgery or medicine that I could do except heart surgery, because if there is, you got to do that. I mean there's too much sacrifice. Once people get to that and they love it and they want to be here and do it all the time, it's an easy pathway and it's awesome. It really is awesome. I mean I still love it today. I love every day that I work. I really do, I can tell. I mean, do I can tell? There's only one thing that I love more, sam, and I think you had a question there about what would you do if you're not a surgeon and.
Speaker 2:I'm working towards that right now and that would be on the senior tour, the golf senior tour. You get off in about five. As you get up it's hard to I could play, but it's hard to play a lot because you're busy. As you get older then you can start playing. So I've started playing much more competitively and I am qualifying for some of these events. So I just don't know if my job is going to get in the way, but we'll see.
Speaker 1:I mean that makes sense. I think there's a lot of like a golf swing course management. All of that is probably amenable to sort of the approach that a cardiac surgeon would take in terms of perfecting their procedure. I would say, um, there is an obsessiveness about it. Um, I would say I see a lot of pro athletes and that's sort of their. You know, you look at a Steph Curry, you look at a Michael Jordan, like it. It also scratches a competitive itch there. I think most cardiac guys I know are. They are. They're sort of competitive in a lot of ways, like they didn't get to where they were by just rolling over and letting someone else sort of take their lunch.
Speaker 1:So I feel like that that makes sense. How you know? Do you like your golf swing? Do you feel like, uh, you know? How you know? Do you like your golf swing?
Speaker 2:do you feel like, uh, you know you know I haven't taken loads of lessons over my life because I've been playing for so long. A handful of lessons here and there. Just like I told you, peak, you have to practice, but practicing something is important. So you have to have a coach or somebody give you something to practice. But at the same time you don't especially you know I'm like a two handicap you don't especially, you know I'm like a two handicap you don't want someone reinventing your swing, you want them to change it and help it, right, right. So that is important.
Speaker 2:But but the thing about golf that I've always loved is I played other sports growing up. Competitively. Golf I only played for fun and as I moved up in my life, golf has always been my escape, right, being on the golf course like going out at 530 at night after a horrible day and just walking and focusing on your surroundings, and then, like you said, the strategy of where to hit a ball is absolutely liberating to me. I am in another place where I and you know when you're really playing. Well, you'll hear, it's a little different when you're goofing around and playing golf.
Speaker 2:When you're playing competitive golf, it's a totally different story, because every single shot has to take your utmost concentration. You're actually exhausted when you're done. But you know, giving that focus to every single shot is an unbelievable challenge. And it's also a great challenge because you'll never do it perfectly every time. I don't care what you shoot. You could shoot well and every shot wasn't perfect and that's why it's this continuous challenge. So I like it. I've always liked it. For the relaxation portion of it I do love it and I like goofing around with my buddies too. That's fun. But I like the focus part of it, the, you know, really trying to be perfect on every shot, on every putt, you know like, uh, some I've been playing more lately.
Speaker 1:Uh, I have joined a fantasy camp, that, uh, where it is competitive, for four or five days, and I've done that for the days, and I've done that for the past couple of years and I hate being the the weak link, let's say, on my team, and so I've been working on it, even though it is time consuming. Let's just put it that way. When you really play a lot of golf, it is time consuming. But I will say this I, uh, I was just thinking about you 26 years ago and you now and a lot hasn't changed you enjoy life to the so much back then and you still enjoy life like to the max now.
Speaker 1:It's really crazy to see, uh, how much you take pleasure in everything that you do. I think, uh, that would be like your piece of advice about enjoying what you do, like you enjoy everything that you do. It's so obvious how much you love that, and I think when I was a junior, I could see that in terms of what you did, no matter how onerous or challenging the task is, and I could see that now, you know, in the upper echelons of management or the most complicated case, you do like you just love it. Like you you. You uh take so much out of it, and uh I hope everyone else around you uh continues to see that as well, cause that's pretty cool.
Speaker 2:Well, I appreciate that. Yeah, no, I mean I do. I do have a lot of enthusiasm for things I do, and that's the way you know. Life is fun for sure. So it was one other.
Speaker 2:One other story I'll tell you about sort of sports and surgery. So you know, I remember, I remember this happening once, like I'm in some tournament or something and someone is like a five foot putt or someone's like, hey, this is a lot of pressure. And I say to myself you have no idea what pressure is, this is a lot of pressure. And I say to myself you have no idea what pressure is right.
Speaker 2:But there is something to it, because when Tiger Woods used to step up to a 10 foot putt, he'd seen it go in a thousand times, right, when you and I go to the operating room and we've done it a zillion times there's no pressure. We know what we're going to do, right. And if something happens, we know what we're going to do next. And so that's where the top athletes are like surgeons, in that they understand what the outcome is going to be, and so there is no pressure, right. But for us, you don't necessarily know what the outcome may be in athletics. Nonetheless, you always put it in perspective. That is not heart surgery, that's golf, right.
Speaker 1:The problem is, for me to make a long putt or a critical shot at a certain time is like me trying to do heart surgery every two weeks. I don't think that's really gonna work. Anyway, thank you so much, joe. It's been awesome and I wish you continued success. I really appreciate everything you shared today. It was so cool.
Speaker 2:Hey, thanks so much and good luck with the podcast. This is all great stuff. I'm going to listen to all of them and listen to the kind of things you're doing. It's great, thank you so much Joe.