#006: Music & Surgery – Dr. Claudius Conrad
Connecting two unrelated fields can lead to world-changing discoveries. Dr. Claudius Conrad has led both the medical and music industry in combining music and surgery, revolutionizing laparoscopic robotic surgery and the approach surgeons take to building their teams and healing their patients.
Joining Fran Racioppi as the first in-person guest of the podcast, Dr. Conrad explains how the use of music can not only facilitate the healing process in patients but also improve the performance of surgeons and other healthcare professionals in the operating room itself. Listen in to learn how being a Steinway & Sons music composer and a German Special Forces Sniper have propelled him to lead the world in minimally invasive pancreatic surgery; and vice-versa!
Listen to the podcast here:
About Dr. Claudius Conrad
Dr. Claudius Conrad is the Chief of General Surgery and Surgical Oncology, and director of Hepato-Pancreato-Biliary Surgery at St. Elizabeth’s Medical Center in Boston.
Dr. Conrad has revolutionized the field of minimally invasive hepato-pancreato-biliary surgery and surgical oncology leading a robust research program to facilitate clinical innovations. As a classically trained and accomplished concert pianist, he has co-founded the field of music in medicine driving clinical and scientific research to systematically study the effect of music on healing and healthcare dynamics.
Dr. Conrad combines cancer biology and music to complement the holistic healing of patients while improving the collaboration and efficiency of his surgical teams.
Pioneering innovation in pancreatic and liver cancer surgery is complicated and difficult. Being a concert pianist is equally as challenging. Dr. Claudius Conrad is both a world-renowned surgeon and a concert pianist. Dr. Conrad spent some time with me, teaching me how surgery and music are intertwined. He spoke about his medical industry-leading work in minimally invasive cancer surgery as well as his use of advanced robotics in the operating room. Dr. Conrad also shared how he uses music to build a culture in his teams and the challenges he faces leading groups of elite performers. He is the Chief of General Surgery in Surgical Oncology and the Director of Hepato-Pancreato-Biliary Surgery at St. Elizabeth’s Medical Center in Boston. Dr. Conrad has revolutionized the field of minimally invasive surgical oncology where he leads a robust research program to facilitate clinical innovation.
As a classically trained and accomplished concert pianist, he’s founded the field of Music and Medicine where he studies the efficiency of surgical teams and the musical effect of healing on patients. He has released an album under the Steinway and Sons’ recording label called Healing Hands, a composition of classical piano pieces played by him personally. Dr. Conrad has earned two PhDs, one in Stem Cell Biology and another in Music Philosophy. He studied at the University of Munich and Harvard Medical Schools. He also completed a residency in General Surgery at Massachusetts General Hospital, followed by fellowships at Dana-Farber Cancer Center, the Institut Mutualiste Montsouris in Paris and the University of Tokyo. Prior to joining St. Elizabeth’s medical staff, Dr. Conrad worked at MD Anderson Cancer Center in Houston, Texas.
Dr. Conrad, welcome. Thank you for joining the show.
Fran, I appreciate you reaching out and having me here.
We met for the first time but I have to tell you that I feel like I’ve known you for years. It’s because I have been listening to your piano above my head for so long. For the readers, my mother lived under him for a number of years. Every time I would come home, I would listen to this concert pianist above me and I would always ask her, “That sounds amazing. Who is that?” She would tell me your story. She talked about how you were involved with various liver and pancreatic surgery procedures, and the innovations that you were making. You were also this trained concert pianist. At the same time, you were in the German Special Forces and you operated in this Alpine Unit. When I was putting together this show, I immediately said that I have to talk to you.
Thank you so much for having me. I certainly have had various neighbors over the course of my life. It has been a treat living close to your family. You’ve been supportive of my necessity to practice the piano in the evening. As you know, my schedule can be pretty hectic. Even other neighbors would consider it a challenging time, I was always allowed to practice and I appreciate that.
You had to deal with screaming kids so it was a trade-off. I want to start this story with decisions that you made long ago. I call them decisions but it’s almost a little bit of indecision because you grew up in a family where your father was a nephrologist and a veterinarian. Your mother was a biomechanical engineer. There was this system or process that you grew up and that you understood from a technical standpoint and with an affinity towards medicine but there was also a piano in your house. Neither one of your parents played the piano but you grew an affinity for the piano. When it was time to go to school, you were faced with this decision between music and medicine. Unlike 99% of students who have to make a decision between what they want to do in life, you chose both.
I was seventeen, turning eighteen when I had to make a decision that would impact the rest of my life. At the time, I was reading a book by Nobel Prize winners who were discussing how they each came to make the Nobel Prize-winning discovery. I learned from that book that it is often making a connection between two fields that are seemingly unrelated that led to big discoveries. Everybody discouraged me from exploring both fields on such a level and encouraged me to focus on one area. I’ve come to learn over the years that if everybody thinks it’s a bad idea yet your heart says, “Pursue it,” it’s a clear sign that this is a perfect idea and you should go for it.
That’s the true visionary. We talked so much about transformative leaders and becoming a transformative leader is about taking the risk and standing up in front of all the people who tell you, “No, you can’t do it.” When you first embarked on this, did you see a correlation between music and medicine?
Not to the degree that I see it now where I see those two fields complementing each other on many levels. I knew that there’s a role for music in healing. I knew throughout the history of mankind that music has always been a part of healing. It was through the course of time and deeply involving myself with music, piano-playing and medicine that it opened my eyes. I saw those close overlaps between those two fields.
From the outset, it hasn’t just been an ability to jump right into music and medicine. First, you had to get through some time in the German military. You spent some time in the Special Forces High Alpine Unit where you trained as a sniper. I find this particularly interesting because there are these extremely technical fields of surgery and piano, then you go into the military and you become a sniper. It’s also an extremely technical organization. Did you choose that? Did you see that as a stepping stone? Can you talk a bit about that experience?
The German military had a draft at that time. My dream was to be in the High Alpine Special Force Unit but I wasn’t drafted there. What’s even worse was, I was drafted into the Air Force. I thought, “I will spend the year sitting at some airport. This is not what I wanted to do.” I started basic training and my basic training camp was attached to an Army Helicopter Attack Unit. At one point, my drill sergeant came to me and said, “Conrad, we know you play the piano. You’re requested to go over to the Army Attack Helicopter camp. The commander needs somebody to accompany him on the piano.”
I was drafted to the airport where the helicopters were and I joined the commander of that camp. I would meet him on a regular basis because for our swearing-in ceremony, we were supposed to play together and the brass was thinking, “It’s a cute thing. An Army commander and an enlisted Air Force private playing together for the swearing-in ceremony.” He was an accomplished flutist. While I was working with him, I was telling him, “This is not working for me here. I was expecting more and I want to make good use of my time in the draft. Is there anything you can do for me?” He was, “It’s going to be challenging. You just drafted. You’re not signed up for more time. There’s a limited investment that the military wants to make into you so probably not.”
I finished basic training and started at an Air Force Base that was supporting the mission in former Yugoslavia and I was working in the command center in a legal capacity, looking at draft dodgers and working for the legal department. Shortly after I started, it was the day before Christmas, I got a call from my commanding officer. It’s unusual to get a call as a private from your commanding officer at home.
It’s not a good thing, at least.
He told me, “The Ministry of Defense has approved your request for evaluation by the German High Alpine Warfare Unit. Tomorrow, you’re supposed to report to the Alps for your tryouts. We like you here. If you don’t want to go, I’ll make this go away.” I was thinking for a second. I had grown comfortable at that point but I said, “It sounds challenging but I’m sorry to say I should go.” He said to me, “I’m proud of you. I’m glad you’re saying that.” I boarded the train and rode for six hours to that camp in the Alps, close to the Austrian border.
I was picked up at the train station. I get out of the car in the camp. I was there five seconds and there was already a drill sergeant yelling at me because I wasn’t wearing my hat. In the Air Force, when you’re within a camp, you’re not supposed to wear your hat because it can fly up into the rotors. I felt I was on the right side here but I was already making push-ups. I didn’t know what was happening to me. I thought, “Was this the right decision?” The next day, I was asked to gather all my things, skis and prepare for the tryouts.
The way this work was there was a glacier and the test was the first few people who made it up, carrying the skis up onto the glacier would get a grade on their ability. They then would test your skiing ability because it was said, “You can get someone to be fitter but you won’t be able to teach them how to ski to that level in that short period of time.” I did okay, especially in the endurance part and skiing part. After the tryouts, I was so worn out that I couldn’t even make it off the truck. They had to lift me off the truck. I was thinking to myself, “I’m not sure if I can do this. I can’t even walk.” The next day, I have another tour just like that on the program. I thought I’d go with the flow and see what I can persist. It was one of the best decisions in my life.
It’s that one day at a time mentality. When you look at the totality of the whole evolution, you say, “This can be overwhelming but if I focus on one day, one exercise or one task at a time, now I’m preparing myself to conquer many small victories which will get me to that big one.”
Maybe not even a day, maybe just the next step. You focus on the next step and then the next. The next thing you know, you’re going to be on the top of that mountain with all the equipment you have to carry up there.
Your commanders supported you as a musician.
They’ve never seen anything like that, that somebody is coming and wants to be in the Special Forces, and integrates pretty well but on the other hand, wants to become a pianist. When we went for close-quarter combat training in a remote village designed to train that, I was also preparing for my entrance exam at the conservatory. My commander gave me his driver who would drive me every single day for one hour to a small village where I would practice in the evening at an elementary school for a couple of hours and the driver would pick me back up. I thought it’s amazing that he’s open-minded, supportive and realizes that I need to be ready for the next steps after the military and believed in me in this way. To provide me with those resources and for somebody in uniform to go into a village and request the piano is an unusual request. He trusted me and I appreciated that.
I would bet that they didn’t have anybody with those types of requests before you and probably haven’t had anyone after. Let’s get more into the music side of things because I fundamentally believe you love medicine and this is your profession but you have this passion for music and you achieved these dual degrees and a PhD in Musical Science. You’re one of the leading doctors in the research and theory behind the intersection of medicine and music. You’ve said in the past that, “Being a surgeon helps me become a better pianist and being a pianist helps me become a better surgeon. Science and art, precision and creativity, discipline and transcendence. In the end, both are about connection.” What is the connection between music and surgery?
Over the years, the two fields have become intertwined that they’re closely connected, that they’re almost the same field in my mind. The mental attitude and your ability to produce the most beautiful music possible on stage is similar to being receptive at the moment while you’re in the operating theatre. We say operating theatre because there’s performance required. All the things that go into being a good pianist which to a degree have something to do with your hands, but it has mainly something to do with your mind, ability to perform, be creative and interpret something in a way that nobody else has been able to before. Surgery has those elements. It has something to do with your hands which is the basis but once you overcome that level where you think about your hands, you reach a level where it’s about mastery, the beauty of anatomy and ultimately, saving lives on a daily basis.
There’s an incredible amount of preparation and training that’s required to both be a musician and a surgeon at an elite level. Can you speak about your preparation in both of these worlds and the things that you have done over the long term but also in the short term, the things you do every day that train you to be skillful with a level of precision in both of these fields.
Thomas Jefferson said, “There’s no substitution for hard work.” Ultimately, that’s what it comes down to. There has to be an element of daily deliberate practice. The emphasis is on both words, deliberate and practice. You have to mindfully practice the piano. It’s easy to come home after work, you’re tired and want to entertain yourself by playing Chopin or another composer but it will not move you forward. It will not prepare you to become a better pianist. Similarly, if you go and do the same procedure time after time, it is unlikely you will contribute to advancing the field and learn how to help patients better. If you ask me, “How do you train your mind to become a pianist and a surgeon?” You have to learn how to learn and make it a habit to be uncomfortable. You always strive to put yourself in situations where you explore your boundaries with the difficulty of pieces, playing composers that don’t come naturally to you or you explore areas in surgery such as minimally invasive and robotic surgery that you may not have had much exposure to in training but you realize it may be the future.
How do you not burn out? There’s an incredible amount of practice that has to go into these things. I appreciate your comments about learning how to learn. That’s critical. It’s something we’ve spoken about in a lot of the episodes in the show, and to be comfortable being uncomfortable because if you’re constantly focused on the things that come naturally and easy, your so-called strengths, you never try to push the envelope to the next thing to expand your horizons, and then be comfortable doing that, then you can’t advance. You can’t grow. You can’t transform yourself or your organizations. If you’re constantly pressing on these things, how do you not burn out especially in something like this where the bar is high?
We take showers for our body every day. We have to take a shower for our mind every day. That shower of the mind can be different for different people. For me, it is music. When I sit and play, I have learned that you cannot make beautiful music while being tense. The learned reflex sets in to actively relax myself, which sets this process in motion of also letting my mind relax, focus on positive things and regenerate in other aspects. Running, in some ways, is about sport and physical fitness but in other ways, it is about allowing your mind to wander, recap your day and think about the future. We underestimate the importance of that in our daily life. I teach my trainees and my fellows to not forget the shower of the mind on a daily basis.
Being in Boston, you have one of the best backdrops to run that doesn’t exist anywhere in the world. Growing up here, going to school, coming back as an adult, being able to run on the Charles is one of the most mind-cleansing things that I’ve done in my whole career. I remember coming back from deployment overseas and coming back here. The first thing I do when I get off the airplane, regardless of the time, I’d go out and go for a run along the river because there’s so much to take in. It almost separates you from everything that you were doing up to that point.
I have the same experience in the Boston area. I do a lot of kite-surfing, running and the ability to go to the mountains is a real blessing. I’m happy here in Boston.
During your surgical residency in Germany, you conducted a study where you determined that ICU patients could be spared sedated medication when listening to classical music. Can you talk about that research study and why you embarked on that?
It goes into the book chapter, exploring the novel. I wanted to be a surgeon but in Germany, it’s a hierarchical system. You have not that much influence, at least at that time on your training so I was asked to be an intensivist for one year and do an ICU fellowship. I wanted to be in the operating room but I found myself in the intensive care unit. I found somebody who believed in me. We had a wonderful and intensive care director. A tough person who reminded me of my time in the military.
Something that I have always been thinking about is, what is the underlying mechanism in our body that we are relaxed by music? Usually, when you think you have a good idea in medicine, you will find out that many others have had the same good idea before you and explored it in a much more sophisticated way than you are thinking about. That’s not the case for music and medicine. I learned that there’s not a lot of information available and very few well-done scientific studies have been performed. I wanted to do this study to mainly learn what it is about music and how relaxation through music is mediated in our body. It led us to discover the first pathway of music-mediated relaxation.
What were the defining characteristics that you saw in the patients that led to that conclusion?
We analyzed Mozart’s music for compositional elements of relaxation and came up with a collection of Mozart’s slow movements from his piano sonatas. We would play it to intensive care patients as we were stopping sedation and they were waking up. We would then check on novel parameters and agents of the human stress response. We found what we thought at the beginning was an error in our testing, that growth hormone which is secreted from your brain is up-regulated. Interleukin 6 which is a chemical that cells use to communicate to each other in the state of stress was downregulated.
At the same time, another group found that cells of inflammation do have a growth hormone receptor on the surface which was that pathway we found. For the first time, we were able to connect the brain, the humoral system, meaning the serologic parameters we can measure in the blood and also stress hormones which we measured at the same time, and the down-regulation in response to music. That started the field of trying to understand how music impacts patients and later physicians in a scientific way.
Why Mozart? What was different about the music composed by him versus that of Beethoven or Chopin?
What pointed me towards Mozart was the fact that when I started to look at some prior work, it was always done about Mozart. I stumbled upon the Mozart Effect where people thought that listening to Mozart music has an effect beyond relaxation such as improving your intelligence. There has been a famous study where college students were listening to Mozart music and they scored better on specific intelligence tests that tested for spatial-temporal reasoning. I thought, “What is it about Mozart?”
I was working on my Music Philosophy PhD. I took a deep dive into Mozart’s life as somebody who had to battle disease and sickness throughout his life. His life was better documented than most composers because he would travel through Europe and send letters back to his sister and mother who stayed back in Salzburg. From those letters, we know that disease and sickness played a tremendous role and compositions are always an expression of our experience. I thought it would be conceivable that Mozart is trying to heal himself with his own compositions.
Compared to other composers, Mozart is pro-life, light and says yes to being in life and in the now. That’s how we started to look deep at Mozart’s composition. We compared it to what the marketing industry had used to improve consumer behavior. If you go to a supermarket and the marketing department designs music to be played to induce relaxation which improves your consumer behavior. It will not be Lady Gaga or Billy Elliot. It will be something that sounds almost like it but it’s not quite it. The reason for that is if we recognize something that we know like a Madonna song, then there’s a recognizing effect that takes away relaxation. If you listen to something that almost sounds like it, it creates this recognizing effect that is more soothing, something that is familiar that is soothing to you.
When we took a deep dive into Mozart’s composition, you will find that Mozart has all those variations throughout his piece. When I lecture and played on the piano, this theme comes the 1st and 2nd time, I ask my audience, “Do you think this is the same?” The audience will say, “It sounds the same.” It’s not the same. It’s almost the same. This subtle variation is Mozart’s mastery, being able to repeat a theme without inducing stress through boredom because boredom is an important stressor. Mozart is a master in avoiding that, yet giving you the feeling of listening to something you’re familiar with.
There are billions of dollars that are spent in research a year in the development of consumer behavior from a marketing department. Tying that into the music that can then have an effect on medicine is something I’ve never heard before. You took this research and the conclusions that you made on the effect on patients. You turned it towards physicians. You conducted a study where you analyzed four groups of surgeons for surgical accuracy and speed while listening to different auditory options. Can you talk about that study and the concept of mental loading, how the mental loading influences their performance, and how it affected also their accuracy, speed and their ability to recall surgical information?
This question ties into what you asked me earlier as to how being a performer tie into being a surgeon. I was always interested in how external stimuli impact surgical performance and why we’re not recognizing them as such. I designed the study where we wanted to test surgical performance under four conditions, silence, mental stress, auditory stress and relaxing music. We were not only interested in how does each surgeon work under those conditions, but what is the ability to improve under those conditions?
We simulated mental stress by giving the surgeon mental subtraction tasks. We simulated auditory stress by composing stressful music where we play one type of music. German death metal in one ear and German traditional folk music in the other ear with inverse melodic lines designed to be stressful. I’m still in shock that it passed the ethical review board because it has this euphemistic term, dichotic music. What could possibly be wrong with music? The last condition was relaxing music. It brought us to the next challenge, how do you measure surgical performance?
We determined that the two most important components are speed and accuracy. That’s when we ventured for the first time into the space of new technology. We partnered with a virtual reality company that would put an antenna on the tip of an instrument. When a surgeon is skillful, the distance between where the instrument is addressed to where he or she wants to target the tissue, that distance will be a straight line. The less apt you are and the more of a novice surgeon you are, the longer this distance will be. We were able to measure accuracy through the distance that the tip of the instrument would travel through space, and we were also able to measure time.
The findings of the study were revolutionary and were published in our highest surgical journal, which a seemingly esoteric study in music and surgical performance was good for my team and me. We found that under mental stress, everybody is bad and nobody improves. That reminds us when we think about the corporate world or other environments. We have to find a way to deal with our mental stress because no matter how you think you can suppress it, you cannot. Your performance will suffer.
Under dichotic stress, auditory stress, we found something interesting. There were some surgeons who performed as good in silence and others were 500% worse. We were able to correlate their worst performance to the role that music plays in the surgeons’ life. What they found with relaxing, specially-designed, classical music was that the surgeons were as good as in silence, but they were able to improve the most if they were performing the task a second time under the same relaxing classical music. It suggests to us that there’s a conditioning effect for motor performance that is underestimated in medicine.
That’s a cool study, for lack of a better term. I found it to be very interesting to read, especially with the German folk music in one ear and death metal in the other. I don’t know if I could function if I had each of those playing in both ears. You’ve also recorded an album. It’s called Healing Hands. You can get it on Amazon, Spotify and Apple. This was produced by a music label, Steinway and Sons, which is one of the premier piano manufacturers and music labels in that industry. You perform pieces that you believe are optimal for both patient recovery and surgeon performance in the operating room. What motivated you to do this? This is a tall task. The pieces that you specifically selected, what is it about them that set them apart?
Recording an album is a challenging task. Nobody listens to you as accurately, precisely and as deeply as a recording studio. When you show up, you have to find a way to vent your mind to the best musical performance possible. There have been pieces from my Music Philosophy PhD and from our deep understanding of what composition elements in music across time led to relaxation. I always thought that we should provide patients and the public in general with music that will be relaxing, independent of what your primary musical tastes would be.
We found music from the beginning of piano music until the 19th and 20th centuries, which shows that some of those elements are similar. Things we find in the early piano music of Bach is maybe similar to what we find now. Having this experience of recording and preparing for it was an important event in my life and in general, it comes back to how you achieve your goals. One important aspect is to have a goal and to actively set yourself a goal. By setting a concert date or a recording date, I know I will have to be at the top of my game. I will have to practice, independent of how tired I am when I come home in the evening. That helps me to stay honest, stay on my schedule and achieve the goals I want to achieve.
Music has been a common theme in a few of the show episodes. In episode four, we interviewed psychotherapist Drew Newkirk. He spoke about a partnership that he has with Darryl McDaniels who was in a ‘90s rap band, Run-DMC. They’re producing a docuseries called Songs that Saved Your Life. It is their stories of people who found solace through music in times of struggle or challenge, and even up to the contemplation of suicide and suicidal thoughts until they heard one song or one piece of music that changed their entire perspective. There’s an impactful quote that you have that I want to read, and then I like to get your thoughts on this project. This thought comes out of this quote, “Music has such an important role. It touches us deeply without physically doing anything to us. Music can restore our energy and help maintain a positive perspective of life.”
It’s always fascinating to me that philosophers from ancient times share my thinking that among all the art forms, we are rarely as touched as we are through music. People will go to a museum or read a novel. Will they have this feeling of ecstasy like a lot of people are going to a concert? Among the art forms, there’s something special about music that touches us. While we are often on shows talking about our successes, we forget to think about all our failures. I’m certainly a master of failure but I’m also a master of getting back up again. What helps me up and lends me a hand is music. If you are a cancer surgeon who tries to save the life of patients with liver and pancreas cancer, you will need a hand more often than maybe other professionals. Music lends me that hand and helps me get back up.
I want to transition into the medical cancer side of things. Before we started, we were speaking about the different disciplines that you’re involved in. I have to say at least one time, even though you gave me the modified version, but you have been a pioneer in Hepato-Pancreato-Biliary surgery which we can call liver-pancreas surgery or HPB but specifically a minimally-invasive HPB. You’ve written textbooks. You’ve written Laparoscopic Liver, Pancreas, and Biliary Surgery with Dr. Brice Gayet. You’ve also written Minimally Invasive Oncologic Surgery with Dr. James Fleshman. I read almost everything written by and about all of my guests, although I have to tell you that I only skimmed the textbooks. Don’t hold that against me because I figured I need to leave the details to the experts. It was a little too rich. I did read and skim the majority of that. These are among the most challenging and complex surgical procedures in general surgery and they require an extremely high degree of expertise and skill.
In the foreword of a textbook, you say that “Surgeons aim to minimize the trauma of surgery with the hopes of lowering morbidity, lessening time spent in the hospital and potentially returning patients earlier to chemotherapy. Because of the complexity of advanced surgery, it was not previously believed to lend itself to minimally invasive surgery. Through creativity and innovative work, the time for considering less invasive surgery has come.” Can you briefly describe what is minimally invasive Hepato-Pancreato-Biliary surgery and how has the creativity and innovative work brought minimally invasive surgery to this field?
The field of liver surgery and advanced pancreas surgery is relatively young. We have been doing surgery only for about 100 years. The way we know liver anatomy nowadays is something we know only for 30, 40 years. The field in itself, even open surgery is relatively young. There were pioneers such as my mentor in France with whom I spent a year who believe that there’s an important role for less trauma for minimally invasive surgery. Minimally invasive surgery combines the field of laparoscopic and robotic surgery. Laparoscopic, in other words, would be endoscopic surgery.
It is possible now to perform procedures not previously thought to be possible with the robot or laparoscopically, thereby preserving the immune system of the patient. We know now that the immune system of the patient is important in fighting cancer. When we do those minimally invasive surgeries, we hope to support and preserve their immune system to help the patient fight their own cancer. Also returning them to not only chemotherapy faster but also to their family and allowing them to spend time in their home environment rather than in the hospital.
You brought up robotics and you’ve been one of the leaders in the industry in the research on the use of robotics, especially robotics with laparoscopic surgery. You’ve described that as being able to, “feel the organs through the robots.” We’ve talked a lot about the precision of the piano keys and the surgical instruments. I would assume, this is an extension of the surgical instruments. Can you talk about what robotics are bringing to these surgical procedures? Why is it important? How are you implementing that in surgical procedures?
Especially in laparoscopic surgery, the instrument alone is between you and the tissue. You have to be even more sensitive to the feedback that the tissue gives you. The complexity of surgery goes up with using a robot. There are some procedures that may be facilitated by a robot or by laparoscopy but in general, surgeries tend to be more complex because a lot of the tactile feedback may be lost. It is like working in a spaceship, in outer space where you don’t have direct feedback yet, you have to do precise and small movements. Having this ability to think with my hands, to put my mind to the tip of my fingers and being receptive to the feedback that tissue gives you has allowed me to excel in this field. The instrument in laparoscopic surgery or the robot put the filter through when you are able to feel. Being able to be sensitive allowed me to gravitate and become a pioneer in this area.
The most complex of these procedures is called the Whipple procedure or the pancreaticoduodenectomy. It’s what Steve Jobs had when he was in his battle with pancreatic cancer. My understanding is that even the five-year survival rate after this surgery is only 20% to 25%. What is it that’s critical about this surgery? Also, how has the minimally invasive portion and the robotics changed your approach to the Whipple procedure?
The Whipple is a complex operation of removing the head of the pancreas but the head of the pancreas is attached to all those other organs, the duodenum part of the small bowel, the stomach and the bile duct. When you divide that area, you have to also divide those other organs and then reconstruct them. Pancreatic cancer is a challenging disease with a lot of patients having the life expectancy tremendously impacted by it. Exploring the field of doing it minimally-invasively allows patients who may have a limited time left to spend that time not in the hospital but at home with their family. We know now that a multidisciplinary team approach to pancreas cancer is important. We know now that a faster return to chemotherapy can help to improve the survival rate. It has become such a multidisciplinary team approach to be successful as a pancreas surgeon.
How has that advanced liver surgery?
Liver surgery is an interesting field because each patient’s liver anatomy is completely unique. We know liver surgery necessitates an understanding that was previously not thought to be possible where we know every little branch of the blood vessel within the liver. Being able to approach this in a minimally invasive fashion has allowed us to help patients recover faster, lose less blood while doing a high-quality cancer surgery. I’m proud that I’m part of this field. I mean, surgery in itself is a conservative field. There are many surgeons who didn’t train in this area of minimally invasive surgery who fear that this is something we shouldn’t explore. If many people say this is not a good idea, then maybe it’s a good idea.
I have a question from a future guest, Michael Scott Moore. He’s a journalist and an author. He was also a hostage of Somali pirates for a long time and will tell his story here. I was telling him that you and I were going to be speaking. He told me to ask you a question. I want to do that from one journalist to a doctor. He asked, “Why is there a rise in pancreatic surgery over the last few years? What’s driving it? Is there a way that we can slow it?” My understanding is that there are over 57,000 diagnoses per year of pancreatic cancer. There are over 47,000 deaths. One in sixty-four people will have it that if untreated, death will occur within a year. It’s 3% of all cancers. This seems to be a serious complication.
If we look at all cancers in general, we noticed that survival had improved tremendously over the last few decades. Singular cancer where this is not the case is pancreas cancer. There are various aspects within the biology of pancreas cancer that made it a deadly killer. If you have a deadly killer like pancreas cancer, more surgery is unlikely to be the answer to the problem. It is the innovation in medical oncology. I’m talking about chemotherapy, immunotherapy, targeted therapy in complement with surgery. We are living in a time for the first time that survivor for pancreas cancer is clearly improving. If you look at the survival rates at our center, they are clearly above the national and international average because we work closely with our colleagues from medical oncology to achieve good outcomes.
Interestingly, when I was a medical student, my mentors would say, “Do you want to become a cancer surgeon? By the time you’ll be graduating and in practice, cancer surgery would go away. We’ll treat everything with drugs.” It turns out that the opposite is true. The more effective drugs become and we are in a time where drugs become effective against pancreas cancer, the more we need good, high-quality surgery that can work around the challenges those therapies provide for surgeons. While pancreas cancer is a tough problem, there’s clearly hope and I’m excited about many patients we have at our center with long-term survivors who are living a normal life after the surgery. They come back and see me. We see them for such a long time. We know everything about their life because we have been following them for a long time. It is a good sign.
You spoke about the role of the multidisciplinary team in medicine. This is something that sits with me because of the team ability and characteristics that we talked about in the Special Operations Force. The characteristics of elite talent, the ability to not only build and operate in a team but contribute to that team, and then take the input from that team. It’s a big part of your work. It’s something you talked about in the textbook. You’ve given credit to those around you and everything that you’ve done in all portions of your career. Can you discuss the composition of your team? What are the characteristics that you look for in those team members both in terms of the hard skills that are trained, but also the innate soft skills that make people elite performers in their fields?
This is something we think about every day. Medicine is unusual and we can learn from the industry that talent in itself is a resource that we need to actively seek out and invest in. Personally, for my research team, clinical team and OR team, I’m looking for people who I hope are better than me at least in one aspect of their specialty. Diversity is important. You want controversial thinkers. You want people who are seemingly not an expert but bring a completely fresh view on things. You need a total expert who knows everything about a problem. Every good team needs a team leader who facilitates discussion and is aware of how team dynamics shape how effectively a team operates.
These teams, I can imagine are extremely complex in their levels and their lanes of expertise. When you build a team where you have people who are good at what they do, you have a challenge where you have to keep them in line with their own expertise, but you also need them to collaborate and provide input on other people’s thoughts. Those other people may be in slightly different disciplines. How do you define those roles? How do you enhance communication within that team where you get people to focus on what they know and their strengths, but you allow them to contribute to the broader communication and collaboration of the group as a collective?
Coming back briefly to the military where checklists are important to take some of the emotional aspects out of stressful situations and allow us to still perform well in medicine. They have become more important. We are experts in providing new checklists that may come out in a situation of crisis. My checklist, for example, at the very end opens the forum up for people to intervene. The end of my checklist is, “If there’s anything that concerns you regarding this case, you have to speak up.” Encouraging team members, may it be a medical student, a circulating nurse, your assistant, you speaking up is such an important part, especially in a structured and sometimes hierarchical environment as this high-risk surgery we are doing. When it comes to research and finding the best treatment plan, you have to encourage out-of-the-box thinking and creativity. You have to become a great motivator and find what motivates each member of your team and make them feel that there’s not a suggestion that will be criticized. There are only suggestions that hopefully will help us to achieve what we want to achieve in the research arm or finding the best treatment course for our patients.
You mentioned the word high-risk. These are extremely high-risk and complex surgeries. I would like to dovetail that into what I call no-fail. This is a no-fail environment. In these types of environments, how do you define success for you and the team? How do you evaluate performance against it, where you have such a high risk with zero bar for failure?
It is important to set realistic expectations. In that context, we have to think about what is the most important goal. It can be confusing. While there are all those competing factors that go into the decision-making, you have to take a step back and ask yourself, “What is the best for the patient?” What’s best may be moving forward or not moving forward with the surgery. That for a surgeon may often be a tougher decision because technically, you may be able to do it or feel challenged to help this patient. To take a step back and do the smart thing and the right thing has to do with keeping yourself in check and reminding yourself, “What are we here for? We are here to do the best for the patient.” If you’re guided by this principle, you will not fail because you will have prepared yourself to a degree where you will be successful.
You’ve used music as a way to bring the surgical team together. You’ve also served as the Director of Music and Medicine at Massachusetts General. You studied at the New York Academy of Science, Physiology and Clinical Music. Different types of doctors have different types of character traits that make them good at their specific practice. A brain surgeon is different from a general practitioner or an orthopedist. You have talked about the fact that different types of doctors may also like different types of music. There are surgeons who have to execute prolonged motor performance, enjoy what you have called activating music. Whereas anesthesiologists like what you call reflective music, but you’ve used classical music as the common denominator for the OR team. Can you talk about your research behind this? What drives different team members of different disciplines the type of music that they like and why you’ve chosen classical as the one that can be the common thread?
In medicine, in surgery specifically, it is an interesting field because you are in that high-stress, high-risk environment with a team that is very heterogeneous. If you roll out as a Green Beret and do a raid, everybody’s a Green Beret. They think a little bit like you do, but somebody who becomes a surgeon may be a completely different person than somebody who may become a nurse or an anesthesiologist. The mentality of a trainee is different from the mentality of a staff-attending surgeon. I observed that letting this play out and not actively managing this may not lead to the successes you want to have, working in such a high-risk, high-stress environment.
With my background in music, I have learned that music has the ability to synchronize people, if you think of marches or dancing, to a certain outcome. I explored how musical tastes differ between those heterogeneous team members. I found that surgeons who have to stand for a long time, there’s nobody coming and relieving them and a new surgeon coming in, they often enjoy activating music. We know from the athletic literature that the perceived strenuousness of athletic performance can be reduced by listening to activating music.
Anesthesiologists have to listen to auditory-encoded information, the alarms. They are often bothered by activating music. They like reflective music which helps them to tune in and follow alarms over time. I realized that we need to find a way to bring this team together. I noticed that classical music can be a good common denominator. It will not be the best for each team member but it may be the best for most people. It sets a certain climate in the operating room, a climate of perfection and striving for the best possible outcome which I use in my OR team in a strategic way.
Are there different types of music for different parts of the surgical procedures?
Absolutely. When I think about my surgeries, I compose a list that fits the routine parts of the opening that may fit the most complex part of the procedure. There may be no music on a certain part. It fits the aspect when after cancer has been removed and we are closing where it is time to get the patient as quickly as possible off the operating room table and into the recovery room, that’s where we want activating music. I think a lot about who will be involved and what their taste is. Exploring the musical tastes of your OR team can break down barriers and lead to what I mentioned earlier. It’s so important that your team members feel comfortable and approach you to speak up and encourage you. If you’re interested in somebody’s musical tastes, you are interested in that person as a person. This is important to encourage in an OR team.
Did anybody ever tell you they don’t like your music?
Yes, it has happened but it is always recognized that I put effort into it. I try it from medical students to staff to find the right music.
There’s a generational shift going on in a lot of industries but definitely in the medical industry. With the Baby Boomer medical professionals being the ones who are leading the industry to Generation X, you’re right on edge. The early part of the Millennial to the end of Generation X. I sit in this space too so you get to identify with who you think the crowd should say where you are at that time. You’re also teaching Millennials as an associate professor. You learned from the Baby Boomers. You sit in the middle and you’re teaching Millennials.
I think about my grandfather who was a general practitioner. He passed away several years ago in his 80s. Medicine has come so far even with the advancements of technologies, yet you have the medical profession, which is truly the oldest profession. We have times now where we have the rollout and development of a COVID vaccine that happened in nine months which years ago would have taken years to produce. You’re working on projects now that are bringing artificial intelligence and machine learning into cancer treatments. How is the industry adopting this change? How are they adopting the technological advancements as you have this generational shift?
When I trained at Mass General, I trained at a time where there were no work-hour regulations and we worked 120 hours a week. We were called residents because we resided in the hospital and the payback for that was that within five years because of this condensed training period, we felt comfortable approaching complex problems that medicine may bring to us. Now it is good that some of the abuse, mental wellness and well-being has become a focus of our national organizations. Now for team members and residents, that would be an unthinkable way of living. Even in the military, because of the nature of what we did, if you’re in a high Alpine Warfare Unit and you are trying to lead a team or a team member who’s afraid of heights, for us getting angry and yelling is not helping to overcome this. Even at that time in ‘17 and ’18, I learned ways of persuasion and making somebody believe in themselves to help them overcome those challenges.
Coming back to the way medicine and other industries work now, we have to adapt to how time has moved on. When it comes to surgery, there is a gymnastic component. There’s a time where you need exposure to enough sick patients to have learned to recognize the problems you will be facing once you’re on your own. We have to find ways of being creative in teaching. Simulation is one aspect and dedicated training sections. There are more that our trainees have to do now on their own like homework where they’re not in the hospital but they are still working on getting better.
You’ve done a tremendous amount in a short time. You’re a young guy and have achieved so much in the medical profession, industry leader, in music and bridging the gap between these two things. What’s next? I’m hearing about this study that you’re doing in collaboration with NASA and the effects of music on astronauts. There are opportunities in artificial intelligence and machine learning. What’s next for you?
My life is guided through innovation. I’ve learned now that a way of bringing innovation fast to the bedside is working closely with industry partners and I’ve been enjoying that. Physicians working with industry partners had gotten a bad rep at one point, but it underestimates the value it has to patients. By working with an industry partner, you can help a patient tomorrow versus if you work on your own in a lab, it will take time. That is one aspect of being a consultant working with industry partners. I’m exploring more and more. I enjoy helping industry partners getting better. Other aspects are the collaboration with NASA where we are trying to find culturally neutral music through stripping compositional elements from music across cultures. NASA teams are culturally heterogeneous. Yet, if you think of their upcoming Mars missions, astronauts will be living in a confined enclosed space for a long period of time.
We have expanded this study to medicine while we use classical music in the past and say, “It may have worked the best for the most people, maybe we can improve on that and compose our own music, through a better understanding of compositional elements of relaxation across time.” I do think that being able to embrace technology and seeking it out will help us to care for our patients better. What’s next for me is also helping my patients in a better way. When we think of artificial intelligence or machine learning, we work a lot with large national datasets where we ask questions that seem natural to us. Those are questions we have every day. I’m hoping that through the help of AI, we’ll be able to ask questions that as practitioners, we don’t think about. I’m thinking of hypothesis generation through artificial intelligence which is an important project for us in the future.
I can’t wait to see what comes. I’m excited. It has been tough for everybody. We’ve had COVID but specifically for you. You were married, you have a family now and so much of your life has been put behind building this career in these two tracks. In 2020, people didn’t stop getting cancer. You still had to perform these treatments. You still had to operate at a high level even in the face of this pandemic. How have you balanced these things? I’m sure these additional stressor has become quite different in your life in this career that you built. You talked a bit about running and taking a step back. How do you find balance now? What does that look like in the future?
The beginning of COVID and the lockdown was a challenging period. We didn’t know what the precise risks were, not just for us but also for the patients who are undergoing those extreme surgeries we are performing. We saw members in the hospital getting sick and passing away. That was emotionally draining. It felt post-apocalyptic. I would ride my motorcycle to work and those empty streets at a time where there’s typical rush hour. It felt like mankind had subsided. What helped me were music and sports. I was able to comment and help people at work. I don’t know whether you read Camus’ The Plague but there are aspects of that where we know now who is the hero of modern society. It may be Sisyphus who rolls the stone up the hill knowing it will roll back down again. While existentialist ideas on life sometimes seem a bit depressing, they helped me. It also helped me with those things we talked about at the beginning, putting one step in front of the other, going to work day after day and helping patients and trying to ignore a lot of the negativity that surrounded the COVID crisis.
You brought up your motorcycle. We can’t close it out unless we have a quick conversation about the importance of motorcycles. I have two Ducatis. This is also a world that is special to you. How often are you out riding?
I go to work either on my bicycle or motorcycle and it helps me to reset my mind. We talked about the daily mental shower and riding your motorcycle in the sense of freedom and speed. That is an important mental shower and it helps me to reset my mind. I often notice the rare times I take my car to work and I drive home. I don’t have quite this reset between work and home the same way I have when I ride my motorcycle home. I also have a Ducati and I have a Harley. Those two personalities are within me.
You get to choose the mood that you want to be in. For mine, I have a sportbike and cruiser so I get to choose who I want to be. That separation is interesting in the world of motorcycle riding. I’ve acquainted it a little bit with skiing and downhill skiing because there are these senses of freedom. There are these things that you can do where you feel like you’re there and you’re in the moment, but your mind has somewhat transcended to something different and separated. There’s an exhilaration behind that when you look at elite performers and people who hold themselves to a high-risk, low bar for failure environment. They operate in what I’ve talked about before, they rev high. There’s always a need for the thrill and for constant mental and emotional stimulation. Those activities, although high risk, it’s that level of control that you have of those systems that gives you this controlled level of freedom where you can find this inner solace.
That is an aspect of meditation riding your motorcycle because if you’re not in the moment, not expectant as to the dangers on the road, you might get badly hurt. There’s only one chance of coming home safely as in other aspects of life. You spoke about living in the moment. When riding your motorcycle, you have to live in the moment and think about the dangers on the road and being safe while perfecting your ability to ride and lean into corners and get better as a motorcycle rider.
I want to close out but before we do the Jedburgh since World War II had to do three things every day to be successful. They had to shoot, move and communicate. If they could do these three things as a foundational basis for everything they did in the day, it didn’t matter what else happened to them, what are the complex challenges they had to solve because those were the foundational elements of their profession. What are the three things that you do every day to win?
I teach my trainees the three important aspects of being a good surgeon. The three are technical skillset, personality and knowledge. I feel that as soon as one aspect is not present, it doesn’t matter how much you excel in those other two domains. You may be technically gifted but if you don’t know who to operate or if your personality is off, you will not succeed. We all gravitate to excel in one domain. Maybe the technical aspects come easy to you but you don’t like to read. You have to make that a focus and focus on your weaknesses. Maybe there’s a specific to surgery but stepping out of it, you should give yourself three goals in life and ideally, ones that you’re not already excelling in and make it a point to get better at those. By doing so, you will become a better person, I’m sure.
In Special Operations, we have a core set of nine characteristics that we assess and recruit or select high-performing elite talents. Those are drive, resiliency, adaptability, humility, integrity, effective intelligence, team ability, curiosity and emotional strength. I classify everybody at the end of each episode. For you, I would define you as number one. These work in combination. You have all of these characteristics you display at times at different levels. If I had to put one, I would call it curiosity. I would define curiosity as exploring the unknown, questioning the status quo in pursuit of better, and a continuous growth attitude.
You’ve demonstrated that in the advancements that you’ve made in the medical field and the music field, how you’ve tied them together and how you look to the future of innovation. You’re building these teams, learning from them and growing yourself. You’re truly a modern-day Jedburgh. I thank you so much for joining me here. I enjoyed our conversation. I look forward to getting out on a motorcycle alongside you here in the near future. Thank you so much.
Thank you, Fran, for having me. I’m looking forward to connecting in the future. With all the shows to come, I’m certain I will learn a lot and I’m excited about them. Thank you.