Professor Steven D. Wexner | Director of the Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
Prof Steve Wexner and Dr Jonathan Sackier sat down at the International Colorectal Disease Symposium to talk about how this meeting came to be, and more.
Jonathan Sackier: Steve, it’s a pleasure to talk to you. Once again, you’ve chaired and put together an amazing meeting, the David Jagelman Memorial Colorectal Meeting, for the first time being held in Jerusalem in conjunction with the Israel Society of Colon and Rectal Surgery (ISCRS). Can you first tell me about how the decision came to hold the meeting in Jerusalem?
Steve Wexner: In May I was here as a guest of the Israeli Surgical Association (ISA) which is another co-sponsor of this meeting. Just in talking to the 10 or so alumni of mine who I’ve trained who now run the surgical departments here, I thought: you know something, maybe we should do a meeting with these alumni, because there’s so many of them here. So that’s how it evolved, it was literally just a hallway conversation in late May and we had June through to January to get everything organised and ready. However, it seems to have been such a success that now we’ll be rotating it. So, on the odd-numbered years the symposium will be back in Florida with my colleague from our main campus in Ohio, and then the even-numbered years somewhere else. We have offers now from about half a dozen others in Asia and the Middle East to host
Jonathan Sackier: Of course, the Cleveland Clinic has a pretty massive footprint. I didn’t see it when it first opened, but it was a
Steve Wexner: Very good memory, 153 beds from when we opened until last year, the beginning of 2019, and then we had a rapid expansion, but it’s always been that number. It’s largely a surgical hospital led for many years by colorectal surgery, and then bariatric surgery by Raul Rosenthal and more recently orthopaedics led by our CEO and President Wael K. Barsoum and others. However, lately it’s more of an all-service hospital, but that number of beds worked in the USA firstly because of short lengths of stay and secondly because it wasn’t all things to all people.
Jonathan Sackier: So, when you introduced the Jagelman Oration, I remember you putting up a slide showing the number of institutions under his leadership. I guess you’ve now metastasised, if you will, all over Florida. How many total hospitals and clinics are there on the list?
Steve Wexner: There’s now five hospitals. So we’ve gone from 153 beds to just under 1,100 beds. We had one campus back in 1988–2001. Once we moved out to Weston in 2001, we had a small outpatient campus, but effective last year we now have a total of 34 outpatient campuses of different medical office buildings and hospitals in which people can be seen. They wouldn’t be able to have procedures, or major procedures at least, but they can be seen and then people are funnelled into the hospitals as necessary.
Jonathan Sackier: For the benefit of people who don’t know, where in the world does the Cleveland Clinic have bases other than Florida and Ohio?
Steve Wexner: Well the model we’ve recently done in Florida is based on what happened in Cleveland under the leadership of Fred Loop who was two CEOs ago and whose mark was expanding within Ohio, and that was continued by Toby Cosgrove who was the next CEO. Basically they started acquiring other hospitals: Fairview, Hillcrest, and then started spreading the net to Akron. So just as we’re now doing in Florida, we are bringing hospitals into the fold, gradually changing the model so that everybody’s pulling in the same direction, sharing best practices, sharing resources, sharing data, quality control, but not necessarily changing the practice model in terms of how the doctors are compensated, plus acquiring a lot of outpatient clinics. Then in Toronto there’s a Family Health Centre, and the Cleveland Clinic licenses management skills to a variety of cardiothoracic departments and also Cleveland Clinic Innovation. Those affiliates are scattered around, but in terms of full campuses, the first one that opened out of the USA is in Abu Dhabi. That relationship originally was operated as Sheikh Khalifa hospital, but then ultimately opened as its own freestanding hospital and that’s become the first hospital in that part of the world that’s been doing successful liver and kidney transplants at a very high-level acuity care. So, Abu Dhabi is a little bit of a different model; we manage it, we don’t own it as far as I know. And now, coming online imminently, is London.
Jonathan Sackier: A fabulous facility and the great news is that you’ve just got your registration with the General Medical Council: you’re going to be a token Brit!
Steve Wexner: Exactly! Richard Cohen is our Digestive Disease and Surgical Institute Chair there and there’ll be a variety of people from London who will be doing cases there. That’s the model with the exception of people like Richard who would be full-time, all of the other people are going to just be bringing their private cases there to do. It’s a beautiful hospital, there are a few offices there. The support officers are next door, but there’s no patients being seen there. Patients will be up in Portland Place and there’s a very nice facility just near the Charles Bell House of University College London (UCL). And then the next one coming online is Shanghai, which may be harder to staff in the current environment.
Jonathan Sackier: One thing that’s, I think, lovely about our profession is it is very collegial. There’s something about the atmosphere at your meetings that is very special. What do you think the magic sauce is?
Steve Wexner: I’d like to think that one major issue is when I started the meeting in 1990 I kind of broke the formula of inviting faculty only from the USA, the UK, Canada, Australia, Scandinavia, or people whose first language, or at least near first language, was English. Instead, I thought that there’s a lot to be learned from people from Latin America, Argentina, Brazil, Russia, China, Japan, Korea, and other under-represented countries. I think that I made their compatriots and colleagues in their respective countries very comfortable by being inclusive of them as faculty, and so it got a reputation that this was a meeting where you gain some respect. It’s not just being lectured at by the usual cast of characters. I think that may be a large part of it, because the days are not short, the schedule is not light, and the fact that we’re in a beautiful place doesn’t change when you’re inside a room with a window. I like to think of the collegiality and really extend it out to these people to participate in.
Jonathan Sackier: And the talks were fantastic. It’s always hard to pick a highlight, but what did you see at this meeting that has surprised you or delighted you?
Steve Wexner: In this part of the world there’s a lot of people who are in need of education that can’t necessarily come to North America or even Western Europe, such as Nigeria, Ghana, Ethiopia, some of the former Russian Republic countries, Nepal, and India. So, I raised philanthropic funds from friends which then got transmitted as scholarships to bring people from these places. Thus, a lot of this was translatable to middle- and lower-income countries. I think that, to me, that was the most important thing to see coming across. Other highlights include sessions like the ones this afternoon on mentoring, teaching, mental conditioning, and all the other things that are very low budget.
Jonathan Sackier: It’s commendable that you do that, and I think those of us who are fortunate to live in wealthier countries forget that. I know you’ve travelled extensively teaching oversees, I’m going to guess that teaching is probably your main love?
Steve Wexner: I’ve got multiple: my family, Mariana and my two sons, my mom, and then of course my trainees and my patients. I mean it all comes down to patients, and it’s the old adage: if you give a person a fish, they have a meal, but if you teach somebody to fish, they have meals for life. So, taking care of patients still is what motivates me; there is nothing quite like the gratification of somebody saying to you “thank you”. You see people with inflammatory bowel disease who after surgery live normal lives, and you see people with cancers who become cured, and so on. That’s what it’s all about. Now, the teaching part is teaching other people how to get similar outcomes so that they can experience that same gratification. I certainly do not have a monopoly on good outcomes, nor do I have exclusively good outcomes, unfortunately, because I’m honest and that’s what surgery is about. It’s also teaching people how to deal with suboptimal outcomes and adverse outcomes, from how to minimise damage to the patient as well as to the surgeon.
Jonathan Sackier: I had the privilege of meeting David Jagelman just very briefly over the years and I know that you were close. Tell me one enduring memory of David.
Steve Wexner: One of the things that I think was the most enduring was the way he would always be there for patients. He said, do not tell me why I need to see the patient, just send me the patient. David always taught me to just take care of the patient and the rest of the stuff will sort itself out. That’s a very, very important thing that I learned from him, a lot of technical things too, but certainly that one. The second one is communication, and I still maintain that habit. He used to send a note to the patient and the patient’s doctors every time he saw them in the office preop, postop, and post-hospital discharge, and I do that to this day. It’s not one of these new automated letters from the electronic medical record. That is a personalised letter and people love it because the patient has a record of what you did, the doctors all know what’s going on, and that’s a great habit I picked up
Jonathan Sackier: So, switching tack a little bit: The National Accreditation Program for Rectal Cancer (NAPRC). Can you tell me a little bit about that?
Steve Wexner: The outcomes for rectal cancer have been proven time and again to be dependent upon how the operation is done, by whom it’s done, where it’s done, and the setting in which it’s done. So surgeons who do a lot of rectal cancer surgery and are able to get circumferentially clear margins with a near total or total mesorectal excision with appropriate use of neoadjuvant therapy are going to have better outcomes with their patients or lower rates of permanent colostomy, lower rates of local recurrence, and higher rates of survival than surgeons who sort of dabble in it and/or do it independently without a multidisciplinary team and/or without appropriate preop imaging. This had been proven multiple times in Europe; that you could move the needle and you could show that there were less colostomies being created, fewer rates of local recurrence, more appropriate evidence-based guidelines being followed, and better survival.
In 2011 when I was President-elect of the American Society of Colorectal Surgeons (ASCRS), Feza Remzi prompted me to try and do something like this in the USA. It had been tried and had not succeeded in the past by one of my mentors, David Rothenberger, so I took a different approach and I got a working group together. We spent about 4 years gathering data from the National Cancer Database and other forums, put in the literature as awareness showing how outcomes in the USA were inferior to Europe, showing how, when it comes to the USA, they were tremendously variable and needed to improve so that we made the case that there’s room for improvement. Then, having been on the commission on the cancer and accreditation committee, I presented a proposal to create this programme. The accreditation committee went for it because by that point we had the evidence. I very deliberately included the radiologists and the pathologists just like they did in Europe, and we included all four surgical societies with an interest in rectal cancer. In early 2014 I presented our plan to the accreditation committee and then to the executive committee of the Commission on Cancer (CoC). After their approval, I went to the Board of Regents of the American College of Surgeons (ACS), because they have to provide the funding, and they also approved it. We then spent 3 years working on creating a standards manual, and as of October this past year, we officially convened the NAPRC. I chair the programme and I chair the executive committee. We also have a quality committee, accreditation committee, and education committee. The composition is very egalitarian, each society has one seat at the table for each committee, plus the college has four fellows at large for each committee. We also include representatives from the Resident and Affiliate Society and from the Young Fellows Association. We now have almost 20 programmes accredited, about 60 more have requested accreditation, and the programme revolves around processes and performance. You have to show that you are evaluating every patient with rectal cancer before you make a decision on how to treat them, and that decision is made as the consensus of the group and that was alluded to in the meeting today.
Jonathan Sackier: This is a mammoth task that you have undertaken and have executed. I have a final question for you: what do you believe to be the biggest challenges facing people who are just starting out in colorectal surgery in terms of either clinical practice or research?
Steve Wexner: There are several, I’m not sure there is one big challenge, they are a bit interwoven. There’s a lot of talk about burnout, so I think the best way to deal with all of that is to remember why you are doing this, and you are doing this to do the best you can for every single patient, every day. I think if you go in with the attitude that this is really unique, it’s not confined to colorectal surgery, but we have the most fabulous, most unique jobs in the world in my opinion. If you choose to do clinical care, you are going to get the opportunity to help people every day. If you decide to go into administration, you are going to get the opportunity to help direct the healthcare system, which is going to improve people’s health. There are many avenues you can take; however, the vast majority of people did go into this so they could operate on a daily basis. Just remember why you are doing it, and how you are doing it to help people out. What you need to do on a personal level to maintain your sanity, whether that is going to the gym, or yoga, or being with your family, or fishing, or flying airplanes, or whatever it is. Make sure you maintain the time to do that. Do not get discouraged; not every day is going to be great, but the vast majority of them will be.