Dr. Chang is currently the Vice-Chair of Research, Co-Director of Minimally Invasive and Deformity Spine Surgery within the Department of Neurosurgery within Henry Ford Hospital and is a Clinical Associate Professor with the Wayne State University School of Medicine. His practice is primarily out of Henry Ford West Bloomfield Hospital currently. He received a B.A.S. at Stanford University and his MD from the University of Michigan. He completed both his surgical internship and neurosurgical residency at Henry Ford Hospital in Detroit. From there, Dr. Chang also completed a Spine Fellowship at the University of California Los Angeles and rejoined the faculty at Henry Ford in 2014. He is an active member of the AANS/CNS Joint Section on Disorder of Spine and Peripheral Nerve as well as the Society of Minimally Invasive Spine Surgery.
Kari Jarabek has been a Registered Nurse for over 30 years and has been with the Michigan Spine Surgery Improvement Collaborative (MSSIC) since 2015. Most of her career has encompassed patient safety, Quality Improvement (QI), program development, management, and regulatory agency compliance. She has worked with various BCBSM Pay-for-Performance Programs with special attention to the Collaborative Quality Initiatives (CQIs). As the Senior QI Lead, she works with the MSSIC Directors and Executive Committee to coordinate the design and implementation of state-wide, quality initiatives at all MSSIC sites (30+). This directly impacts process improvement, standardization, the improvement of patient outcomes, and the reduction of adverse events. She acts as a consultant on QI issues and coaches in the utilization of change management tools to support effective decision making and assure successful and sustainable implementation of QI initiatives. Kari is Lean Healthcare certified through the University of Michigan and prides herself in taking difficult concepts and transforming them into practical methods that can be implemented on the front lines of patient care. She graduated from Saginaw Valley State University where she earned her Bachelor of Science in Nursing.
How did the Michigan Spine Surgery Improvement Collaborative (MSSIC) and the incorporation of ERAS Protocols get started?
In the state of Michigan, one of our biggest payers, Blue Cross Blue Shield of Michigan (BCBSM), funds what is called the Collaborative Quality Initiatives (CQIs) through their Value Partnerships program. They identify high-dollar areas where there's a lot of variation in care. MSSIC is a CQI in their portfolio. Each year, participating hospitals receive a performance scorecard and pay for performance funds when they demonstrate successful implementation of QI initiatives. MSSIC proposed our ERAS pay-for-performance measures to BCBSM and with their full support, ERAS initiatives comprised 50 out of 100 points possible for 2021.
After we learned what was being done in other states like Pennsylvania and from our own literature review, we identified six, Phase 1 ERAS elements that would be required for MSSIC sites. We also encouraged sites to consider other elements supported in the literature. We built an ERAS toolkit on our website with all kinds of resource documents, patient education, publications, example protocols and risk assessment tools and partnered with the American College of Surgeons to extensively educate and provide templates for our sites to work off so that they could take them to their multidisciplinary team meetings. We created the “MSSIC ERAS Patient Video” for our sites to incorporate into their pre-surgical patient education and our MSSIC QI Leads provided coaching and site-specific support as we launched this state-wide initiative.
What has your early experience been so far?
What challenges have you run into implementing some of the ERAS-related changes with MSSIC?
Another obstacle was hesitancy or imagined hesitancy with the anesthesia department regarding limited fasting, allowing clear liquids up to three hours before surgery and the carb-rich drink. To address this, we invited the Director of Neuro-Anesthesia at the University of Michigan to speak at one of our collaborative-wide meetings. He is a huge proponent of ERAS and gave a fabulous presentation and provided us with some additional resources that we were able to share with MSSIC sites. He spoke of the positive benefits of ERAS and the way it improves patient outcomes and reduces adverse events. Overall, we’ve created a noncompetitive, collaborative environment where sites can learn from each other and figure out what the best thing is to do at their site.
Have you seen any type of financial benefit or cost effectiveness?
How are you able to incorporate ERAS strategies into your existing workflow on a regular basis?
It's good to have someone who is a bit removed from the day-to-day of getting clinic done and surgeries boarded. They have a chance to kind of step back and look the whole ERAS care pathway from the time the patient is seen in the clinic, boarded for surgery, has their surgery, is discharged, then followed post-op.
Another example is our process for high-risk patients on high doses of opiates or patients over 80 years old. Our nurse will send an email every week that identifies high-risk patients and allows the anesthesiologists to do a hard stop either to refer them for opioid tapering prior to surgery. They can also discuss with the surgeons the exact indications for sicker, older patients or if elective surgeries, without impending neurologic deficits, can be postponed until they are better optimized, etc.
Overall, it is extremely useful to have a RN Spine Coordinator type position to help quarterback all these things. Hands down, our most successful sites and those that were able to implement ERAS with the fewest bumps in the road, have been the ones that have a Spine Coordinator type role.
Is ERAS being applied to all spine patients/surgeries in MSSIC?
We intentionally made the ERAS program a general template that could be implemented for all spine surgeries. The whole idea is to make this the standard of perioperative care so that even patients that aren't considered within the core MSSIC demographic, which is elective degenerative cases, can benefit from the ERAS protocols.
What are you doing differently after the patient is discharged from the facility?
Another prescribed element of our ERAS protocol is the discharge instructions given to patients at the time they leave the hospital. When our sites submitted discharge instructions for review, we looked for detailed instructions that were step-by-step in nature, objective and measurable. We asked our sites to frame their discharge instructions with mindset of the elderly patient who's overwhelmed, at home, and it is now 8 p.m. on a Friday night - are they granular enough? Do they provide step-by-step instructions, assuming the patient knows nothing? How does the patient bathe in a way that prevents an SSI? Do they need to change a dressing? If they do, what materials do they use and how do they do it? Are you instructing them to wash their hands before touching the wound or to perform dressing changes? Can their two dogs still sleep with them? Should they show their friends and family their new incision? This is back to the basics and you can’t assume patients practice good hygiene habits or know SSI prevention principles, even if they attended the pre-surgical class and received verbal information in the hospital before discharge. That was the element of ERAS that was sent back most often to our sites for revision and more detail. One of our most effective MSSIC-developed patient education tools has been the “MSSIC Personal & Home Hygiene” flyer, providing this level of helpful, granular information.
What feedback have you gotten from patients so far?
We had a specific patient from Henry Ford West Bloomfield - an elderly gentleman and his wife that went through the ERAS education and took careful notes. He was expecting to ambulate within hours after his surgery, and when that didn't happen, he questioned his care team and reached out to his wife. It turns out that there was a float person caring for him who wasn’t aware of the early ambulation protocol. The patient and his wife educated the nurse on what they learned in the class, and sure enough he was walked and did great. The big point is that he felt knowledgeable and empowered enough to speak up when things didn’t go according to what he was told. He knew why early ambulation was important and he wanted to make sure he was provided the standard of care.
Where can physicians, nurses, and administrators get more information regarding the MSSIC initiative and structure?
Ajit Krishnaney, MD, is the Associate Chief, Clinical Risk, Quality and Patient Safety Institute , and the Vice Chairman for the Department of Neurosurgery at Cleveland Clinic. He is a Staff Physician in the Center for Spine Health and in the Cerebrovascular Center at Cleveland Clinic.
He was appointed in 2005. Dr. Krishnaney's specialty interests include cervical spondylosis, degenerative spine disease, complex spine instrumentation, spine tumors, spinal cord tumors, syringomyelia, spinal vascular malformations, cerebrovascular disease including AVMs and intracranial aneurysms, general neurosurgery.
Dr. Krishnaney attended medical school at the University of Wisconsin Medical School in Madison, Wisconsin, and he completed his internship, residency and fellowship at Cleveland Clinic.
How did you get interested in ERAS?
That started through our anesthesia department. ERAS has a long history in Europe, and the chairwoman of anesthesia here was from Austria, and had made a name for herself doing ERAS at her institution before she came to the US. Here, she was looking for spots to start ERAS through the department with different groups. They approached me to see if we’d be interested in applying this to spine surgeries.
Most of what had been done in spine surgery with ERAS up to that point was very specific, meaning for MIS surgery only or for outpatient surgery only, or for a very specific subset of patients. When I partnered with one of the neuroanesthesiologists here and we thought that there had to be a way to make this applicable to most, if not all, of our patients, so we decided to try make a comprehensive ERAS protocol that could be used for all elective spine patients.
What was your experience partnering with the Anesthesiologists on implementing ERAS?
This was a partnership with anesthesia right from the start, so we wanted to make sure that we were addressing their concerns. We needed to know from the anesthesia end, especially for sicker inpatients, what were the critical things they needed optimized to make it safe and what things they did need to know ahead of time to streamline their process and workflow.
One of the first things I learned in this whole process is that different specialties think about a surgery a very different way and the language we had to build needed to bridge that gap. As surgeons, we think of surgery as the type of surgery, for example a complex deformity, one level ACDF, a microdiscectomy - all very different operations
But in the anesthesiologist’s mind the difference between an ACDF and a microdiscectomy is minimal - they're both outpatient surgeries, minimal blood loss, can be less than in an hour in many cases and most people go home the same day and so from their standpoint, it's the same case apart from little nuances like patient positioning. They aren’t as concerned if we're doing a three-level surgery or one level fusion, they want to know what's the blood loss is going to be, is it greater than 1L, do I need to setup a transfusion pump, do I need cell saver?
So we ultimately stratified our patients into three categories: minor, major, and complex surgeries. Working with them underscored that we shouldn’t look at this from one perspective, and we need to broaden our scope to work together and say “hey, we can do this better”.
You work with a large group of neurosurgeons, orthopedic surgeons, anesthesiologists - how do you get the whole group on board with these changes?
You have to go slow. It took a year and a half for us to get the protocol up and running once we had convinced everybody. You have to build trust with your partners and you need data - that's the key. You can show them the data and literature and tell them this is what we're basing it off of.
You also have to be willing to negotiate a little bit when the data is not there, but on other issues you draw a line and say look there's really good data to show this. One of those things was the multimodal pain therapy; things like gabapentin perioperatively, anesthetic infiltration in the wound, use of PCA is well established.
You have to pick and choose where you're going to draw the line and I think that you kind of have your wish list and you throw it out there and then you let people pick it apart a little bit and you try to come to a consensus.
We actually used the same strategy with the anesthesiologists. We made a hard stop for example on transfusion triggers so there was a hard rule for transfusion if you get below a hemoblgobin of 8 now in our protocol for intraoperative blood loss, but if you're above that you don't unless there's expected ongoing blood loss. On the other hand, the choice to use ketamine vs a lidocaine drip intraoperatively they can make on a case by case decision.
We went in with that mindset that most things are open for negotiation and if we can come to a consensus that everybody was happy with then that's going to be the protocol to start with and then we can refine it as we go along and collected data.
What are the economic impacts of ERAS at the Cleveland Clinic?
Economics of implementing ERAS is a calculation that every center is going to have to make on their own how much are they willing to lose potential business and make upfront investments.
Take nicotine use as an example. Apart from patients with myelopathy, tumors, infections, or progressive neurologic deficits, we made a hard stop on not performing fusions, especially deformities or procedures for pain, when nicotine tests were positive.
Our anesthesia colleagues have told us that they it’s not ideal to operate on someone within three weeks of quitting because there's still a lot of inflammation, so you want to wait out that period after they quit. This was a natural thing for us since we're mostly booking six-eight weeks out anyway for these deformity surgeries so if they've got a negative nicotine test in clinic, only then will we give them a date for surgery and they should be passed that inflammatory phase by the day of surgery, when they get tested again.
There has been a lot of discussion from payers about bundling surgery and sharing risk. That is why we were so adamant about it – if you did operate on a patient that was smoking and they did develop a pseudarthrosis, then you'd be on the hook for fixing that and assuming all the other complications that may come with it in that payment model.
We want to be ahead of the curve and minimize that kind of risk that we're taking on, and that goes for diabetes and infections also. We did a calculation on how much money we're saving on a year-to-year basis and just based on infection reduction strategies were saving almost $1.5 million a year to the to the system. We are paying a little bit up front in terms doing nasal swabs and chlorhexidine wipes before surgery, but it was far outweighed by the reduction in infections that we’ve had in not having to treat on back end
You may lose a few patients here and there, since the guy up the street may do their surgery anyway. Whether you think that's going to make a significant dent in your business or not is a decision you and your institution have to make.
Your protocol involves getting geriatricians and other medical specialists on board with management. Can you expand how this has been helpful?
You know it's amazing thing how much most medical specialists wanted to work with us when we started asking. There were tired of seeing all these patients’ post-op with delirium and different medications when they were a mess. With geriatrics, they really wanted more time with patient before surgery to optimize them rather than just a quick pre-op clearance when they see them a week or two before. They wanted to stop the polypharmacy, assess their mental status, cognitive function, frailty and nutritional status and try to build up their reserves. That had potential to be a big dilemma, but we had the advantage of booking out six to eight weeks in advance so if we could get these patients to the geriatricians as soon as possible it would work.
We came up with a special consult line for just for the spine surgery group so when we have a surgical patient, we put in an order in Epic and call the number and relay the information and within a week they’re plugged in. They dedicated a nurse practitioner just to do this preoperative stuff - they do a full 90-minute assessment and take care of the whole clearance process. It's a one stop shop for the elderly patients on top of that they also do living wills and will review nursing home options for post-op if they are likely to need it. Also if the geriatricians are concerned about a patient postop, they will already have an order in to consult them immediately after the surgery so they can co-manage with us.
One interesting topic has been pre-habilitation. For some patients we thought this could help increase their strength and make recovery easier. However, a lot of patients resisted this – they had already done weeks of PT before coming to us. They needed to just to get an MRI or to have their surgery approved. They were in so much pain by that point and really didn’t like it. So geriatrics ultimately dropped this from their pre-op optimization. But this was an interesting example of learning something from patient feedback that we had not expected when implementing the protocol.
Apart from geriatrics, we’ve had the same great reception from other services like endocrinologists and bariatric specialists. They were more than happy to help. They have fast-tracked patients with diabetes, who need weight loss before we can operate, and smoking cessation.
I wasn't expecting that much buy in from the medical folks, but I they have bought in quicker and faster than the surgeons. They all believe in this stuff right from the start that's and it’s their specialty so they all know the data, so there they've been bending over backwards to help us and get our patients scheduled.
What feedback have you gotten from patients who have gone through the ERAS pathway?
Overall it’s been very positive. There’s always some negative feedback – those have mainly been from pushback from patients who we told they had to quit smoking. They’ll tell me that nobody else told them to quit and you just have to be up front with them and let them know that this is the data and I’m not sure why they didn't tell you to quit but if you want surgery here, this is the way it has to be.
On the positive side of things, the pain management part of it has been fantastic. Patients that have had surgery before will tell you “I don't know what you did doc but you must be a great surgeon because I had so much more pain after my last surgery”/ And I think your other surgeon was just fine, it was the pain management that was the problem. They'll also tell you “you guys did so much more for my surgery than anybody else did, and made me feel safe and made me feel like you really cared about me as a patient”. They felt like they weren't just a number being pushed through the system because you spent the time to really look into all their medical problems make sure everything is optimized with all these other specialists and staff.
In the end, we’re looking at them as a person and we really want them to be safe going through the surgery and aim for as good of an outcome as possible. That makes them, and us, feel a little bit better about what we're doing here.
John O'Toole, MD, MS, is Professor of Neurosurgery at Rush University Medical Center in Chicago, IL. He received his medical degree from Harvard Medical School and completed a residency in Neurological Surgery at the Neurological Institute of New York at Columbia-Presbyterian Medical Center in New York City followed by a fellowship in Spine Surgery at the University of Chicago. He received his Master of Science degree in Clinical Research from Rush University Graduate Medical College and serves as a lecturer for both the medical and graduate student programs. He serves as Co-Director of the Comprehensive Spine Tumor Clinic at Rush University Medical Center in conjunction with Radiation, Medical, and Neuro-Oncology staff and also serves as Surgical Director of the Neurosciences Service Line at Rush University Medical Center.
Dr O'Toole's clinical specialties include minimally invasive spine surgery, spinal oncology (including spinal column and spinal cord tumors), spinal radiosurgery, complex spinal reconstruction, and spinal arthroplasty. His research interests are clinical outcomes for spinal surgery, evidence-based clinical practice guideline development, image-guided spinal surgery, and development of new spinal surgical techniques and devices. He is an investigator on a number of investigator-initiated as well as multicenter and industry-sponsored research protocols.
Dr O'Toole has presented and published on a wide variety of topics in spinal surgery and has served as an advisor and peer reviewer for several interdisciplinary education and research organizations and journals. He is an active member of multiple neurosurgical and spinal surgical societies and has served on numerous national committees and workgroups including the AANS/CNS Guidelines Committee; the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves Guidelines, Outcomes and Executive Committees; the North American Spine Society Evidence-Based Medicine Committee and Clinical Practice Guideline Development Committee; the Orthopaedic Research and Education Foundation Spine Prospective Clinical Research Grant Committee; and the Neurosurgical Research and Education Foundation Development Committee.
An Interview by:
How did you get interested in ERAS?
Minimally invasive spine surgery started to take over and my practice, since the beginning with regards to degenerative spine pathology, has been largely MIS in nature. The promise of MIS was always been improved perioperative outcomes, namely, less blood loss, lower infection rates, shorter length of stay, and faster recovery. But I was finding that it wasn't quite fast enough, and length of stay was longer than I thought it should be for some of these patients. ERAS seemed like an opportunity for us to do better and really fulfill the full promise of MIS by working collaboratively with other services in the hospital to improve patient’s postoperative experience.
In talking with our anesthesia and pain medicine colleagues here, it became clear that we needed to institute a more programmatic ERAS protocol and we used MIS as the poster child for this program. As we got into it, we started to realize this really made a huge difference, from preop to the intraop to the postop setting, and we've continued to modify it along the way. We keep adding new pieces to the puzzle and it continues to evolve to a point now where the hospital is implementing hospital-wide ERAS protocols for every patient undergoing any kind of spine surgery because this has been such a game changer.
You work with a large group of neurosurgeons, orthopedic surgeons, anesthesiologists – what challenges did you face in getting this large group on board with ERAS-related changes?
Some of the pushback also initially came from anesthesia - some anesthesiologists didn't want to be told what to do with their intraoperative anesthetic regimen. This is perhaps the cornerstone of a real spinal ERAS program, other than preoperative education for the patients. The “wide open fentanyl drip” in the OR was sort of the historical standard, so it was important to get our anesthesia colleagues on board with a different approach. Part of that may be a generational stance and the anesthesia teams we work with now are fully committed to ERAS protocols. But interdepartmental education, not just in anesthesia, but within neurosurgery and orthopedic surgery has been key.
In the end, this is the ultimate example of collaborative work in a clinical setting. We now have orthopedics, anesthesia, pain medicine, physical therapy, occupational therapy, nursing, radiology and nursing from pre-op, PACU, floor, outpatient etc. - we have all these stake holders involved because we know that every step along the way requires buy in from these services, otherwise the chain falls apart and patients get stuck. We have ‘champions’ in each arena, which if you don’t, you're going to be quixotic in your attempts at getting ERAS done efficiently. Patients are excited to hear that they are part of this kind of program to make their post-operative experience better.
What specific changes within your outpatient practice or department have been made to implement ERAS protocols? Do you have dedicated staff focusing on this?
Our surgeons and nurses know we have to counsel patients even in the first consultation – we’ll say these are the things you need to do or we need to do with you if we're going to have optimal outcomes from surgery. This means sending them to smoking cessation clinics, bariatric surgery clinic, getting them in with nutrition services, and referral to our pain service here who works closely with us to work on opioid reduction prior to surgery.
The patient education piece is the most important and the hardest to do, particularly in a big urban center like Chicago. You're talking about trying to educate a wide array of people from different backgrounds, education, and social situations about what they should do before and after surgery. We're still working on ways to navigate this educational piece, since it’s vital for success.
Many ERAS protocols have “hard stops” which limit certain populations eligible for surgery. This, among other aspects of ERAS, clearly have economic impact on the greater hospital organization. Have you run into issues in this regard?
Another example is obesity - most of us have a BMI of 40 cut off for elective cases with some exceptions such as severe cervical myelopathy or acute foot drop, but otherwise these patients are referred to the bariatric clinic. We emphasize the need for weight management preop because the data is fairly compelling on lower quality long-term and short-term outcomes with obesity.
To some extent there are hard stops and it is surgeon dependent, but you have to design these protocols and procedures in the context of your environment, nobody is operating in a vacuum. If the local environment is that 60% of the population are smokers, the economic analysis isn’t about outcomes in spine surgery with smokers, but more of the institution stepping in and implementing smoking cessation clinics. But if only 5% of the population are smokers, you know where the value is so I think understanding your patient population and getting your administration to understand that is important. Institutions aren’t just looking at your total RVUs for the year alone anymore, they are also looking at quality, reoperations and readmissions. These have become some of the most important metrics for hospital administrators, which ERAS works to address.
A significant portion of your practice is dedicated to spine oncology. Have you had success applying ERAS protocols to this, often times difficult to manage, population?
What's the feedback you've gotten from your patients?
The part we've added in the last year or two where we've seen patients have a different subjective experience is the addition of regional anesthesia. We perform erector spinae plane blocks for all minimally invasive surgeries and patients clearly note the difference, particularly in the first 24 to 48 hours. They are shocked because they very often are pain free for the first day or so, which if they've had prior surgery, was usually not the case.
What do you see as the future of ERAS in spine surgery?
I also think a lot of the advancements in ERAS are going to have to come from pharma. We’re going to need better drug options, longer acting regional anesthetics, and medications that treat pain that aren't opioid based. The pharmaceutical industry is a big part of this; the advent of gabapentinoids changed so much of what we do, so we need to find the next class of drugs that will come along to help us more optimally manage patients’ postoperative pain. Our surgeries can keep getting smaller, like endoscopic TLIF for example, that's a procedural change that can really help influence the patient’s experience. But at some point we're going to reach a limit in being able to do effective fusions and instrumentation through smaller and smaller approaches, and then we’ll have to rely on these other modalities to help us get there.
J. Christopher Zacko, MD
Please tell us a bit about your background.
How did you get involved in the field of neurocritical care?
How did you find your way to Penn State?
How is your practice divided up right now?
What got you interested in ERAS?
I started using ERAS strategies and it worked very well in my practice. I’m fortunate enough that at my hospital we already had options like IV Tylenol and Exparel,. I started using the tools of multimodal analgesia and it seemed to work like magic. In fact, my first patient utilizing these strategies underwent an ALIF. He left the left the hospital the morning after surgery feeling great. Unfortunately, he did bounce back to the ER a week later ---- with opioid withdrawal. He felt so good he stopped his chronic opioid regiment abruptly and went into withdrawal. Now it doesn’t work that well in every case I know. But the beauty of ERAS is that it doesn’t leave any stone unturned. You have to consider smoking cessation programs, nutritionists to help them with their diet, and eventually that is something that we will all insist on.
What are some ERAS applications in neurocritical care?
From another perspective, let’s take head injury as we don’t have a ton of data on how to help people with TBI. With neurocritical care you have to look at the whole patient. What we are feeding them, optimal blood pressure, oxygenation, heart rate, type of IV fluid use etc. We need to keep them as healthy as possible until they can have an opportunity to heal. We have to work all these levers to keep these patients healing and that is similar to what ERAS does. Is any one of these small details going to have a huge difference in their overall recovery? We may never know. But if you can find the best possible option for every one of these small things for each of our patients, it will surely lead to better outcomes.
What are the some of the future aspects of ERAS in spine surgery that you foresee?
Another very interesting and promising idea is being pursued by a clinical pathologist colleague of mine. We are working on a test that may get FDA approved soon. It’s a pharmacogenetic-based test that tells a patient whether if they are genetically predisposed to the development of opioid addiction. It’s powerful for the surgeon - it can be a red flag or help you know how to manage that patient ultimately. But Imagine the power of that for the patient? Here is a test that tells you that if you use these certain medications, there’s a good chance you’re going to become dependent on them. There will even be a way, in time, that these tests will look at your pharmacokinetics and know which exact opioid will work best for you. For example, a patient may be a better responder and thus need less medications if they are an oxycodone vs. Ultram. Unfortunately, this test’s approval process has gotten derailed by COVID, but is certainly the future of better understanding the role of opioid minimization in ERAS.
What advice do you have for novice or new surgeons interested in getting involved with ERAS?
In addition, think about this question: what would make you, as a knowledgeable surgeon who’s trained at various hospital, take notice of a practice should you ever need surgery? What would sound attractive and exceptional to you if you were a patient? You would know immediately when someone is going above and beyond. These are the things to focus on – and these are the things ERAS brings to your practice.
The comprehensive approach provided by ERAS are often outside the spine surgeon’s normal strike zone. But once you think about it, make a checklist, build a team around it, you’ll find you that all these little things will greatly improve the experience for your patient. Don’t be afraid to challenge the model at your institution. I heard a phrase as a med student that has stuck with me all these years, “for most surgeons you have a choice between now and later – the answer is almost always now”.