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Neurosurgery: Rolando Del Maestro
39 Plays1 year ago
Dr. Rolando Del Maestro is professor emeritus in neuro-oncology at McGill University and is the current president of the American Osler Society. Listen to Rolando discuss the art of neurosurgery, the legacy of Sir William Osler and the use of artificial intelligence in healthcare.
Please visit the website below to read Dr. Del Maestro's essay "The Best Part Started with a Kiss: Memories and Reflections". This piece was published in the June 2023 edition of the American Osler Society's publication, The Oslerian.
Website: https://www.americanosler.org/content/the-oslerian
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Transcript
Introduction to The Wound Dresser Podcast
00:00:09
Speaker
You're listening to The Wound Dresser, a podcast that uncovers the human side of healthcare. I'm your host, John Neary.
Meet Dr. Rolando Del Maestro
00:00:22
Speaker
My guest today is Dr. Rolando Del Maestro. Dr. Del Maestro is professor emeritus in neuro-oncology and director of the Neurosurgical Stimulation Research Center at McGill University. In 1982, along with his wife, Pam, and his friend, Steve Northy,
Foundation of the Brain Tumor Foundation of Canada
00:00:38
Speaker
Dr. Del Maestro established the Brain Tumor Foundation of Canada, which has raised millions of dollars for tumor research efforts. Dr. Del Maestro currently serves as the president of the American Osler Society. Rolando, welcome to the show. Thank you very much. When I think about neurosurgery, it seems like it's a very intense field. It's very technical. I was just telling you earlier that I'm currently doing a neuroanatomy lab where I'm checking out all the
00:01:05
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nooks and crannies of the brain. But as a neurosurgeon, how do you feel that you use your creative side and your artistic side?
Neurosurgery: An Art Form
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Well, I think dealing with the brain, you're already in front of you with this three-pound object that is the most complex object in the universe, as far as I know.
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And it's actually trying to understand itself. So in one way, being a neurosurgeon, you have an incredible sort of humility associated with the object that you're dealing with. Many objects involving the human body, artificial kidneys, et cetera.
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you know, are dealt with in other ways, but we really don't have a way of sort of understanding and conceptualizing how the brain works. We sort of think we know, but all you have to do is ask any researcher, you know, where does love come from? And then they're completely stunned. You know, most, they have no idea where love comes from or caring comes from and other things. You know, it's some type of a complex interaction between multiple hearts of the brain.
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and interwoven with all kinds of other emotions and feelings. And so I think it's a complex area.
Trust and Interaction in Awake Neurosurgery
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And one thing that I thought I would mention is that I did substantial numbers of my operations on awake patients. And the reason for that is that the brain has no pain fibers. So here you have the most complex
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object in the universe, who is one of its important sort of functions is to, you know, deal with pain, understand pain, deal with pain, modulate pain, but it has no pain fibers. You know, how did this happen? And second, that allows you to actually operate in the brain without, you know, you obviously have to do some anesthesia involving the skin, the bone isn't that terribly sensitive. And you can operate on the patient awake.
00:03:11
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And this allows you to do a number of things. One, while the patient is awake, you can, for example, test the patient's intellectual function.
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You can test the individual related to their speech function if you're operating near the speech area. There's other areas of the brain, for example, that are associated with moving, how you move in three dimensions and how you see lights and things. And again, you can test all that while you're operating to try to preserve that function. But even in that environment, in a small number of cases, probably less than 1%, you have this incredible trust with the patient.
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The patient actually trusts you that you can operate on them. They're going to be awake. And during this awake time period, they're going to talk with you.
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And the fun part about that is that they're part of the operation, right? I mean, they're part of what's going on. They're part of the whole process. And I've operated on children, you know, as young as six and seven. And it's amazing that you can do that because again, they can trust you now. You have to change things because, you know, children don't like to have their head locked in a brace and all that kind of stuff. But again, you can get around that if they trust you.
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But, you know, occasionally what occurs is that, you know, patients, well, this goes on, have some stress and they get more and more stress. And I remember one particular patient a number of years ago, where I could just see that as we were operating, she was getting a little bit more stressed. She was beginning to move a little bit more, beginning to be a little bit more agitated, her blood pressure was going up a bit.
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And she wasn't as cooperative, you know, when we were talking to her, et cetera. And the anesthetist was sort of concerned. And he sort of, you know, in those situations, many times the anesthetist will decide to sort of put the patient asleep. And then one of the problems of doing that is then you have to basically stop the operation inspector if you're operating in a very complex area, because you just don't know where you are without having this impact, you know, this information from the patient. I knew, however, the patient was relatively religious.
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And I sort of asked her if she could pray. And she started to pray.
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And then what happened rather amazingly is, you know, as she's praying, she's saying the various words, Hail Mary, you know, our father, et cetera, and she went through a number of prayers. You can almost sort of hear in other people's minds in the upper room, the anesthetists, the nurses, my assistants and me, the same words going by, you know, the same sort of prayers are being said. After a few minutes, she was perfectly, she was perfectly relaxed. She said, okay, I'm good, go on.
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It just goes to show you, I think, that there's an art to medicine. There's all the technology. There's all the things we have we can do. We can stimulate the brain. We can do all kinds of fancy assessments. But still, there's an ability to understand the person themselves. And in that understanding of the person, you can get into an interesting, secret place, which allows you to sort of
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reach other areas, other sort of knowledge parts that allow you to, you know, do a better job for that particular patient in that particular situation. So I think that's part of the art that's associated with medicine. It's just not
00:06:38
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Not the technology itself, but how you interact with that particular patient using all the technology you have available.
Patient Interaction and Motivation
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And you can imagine, neurosurgeons have a huge amount of technology available to them, microscopes, you know, intraoperative CT scanners, you know, all kinds of different ways to figure out where you are inside the brain at the same time, intraoperative angiography, you name it, we've got it. But at the same time, it is still a patient and that patient's
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you know, sort of interactions and feelings both before and after the operation are important to their outcomes. And I've always told my students and things, you can do a perfect operation. But if that particular patient doesn't want to get better, doesn't call, doesn't sort of, you know, get up, doesn't move around, you know, that patient may not have a good outcome at all.
00:07:33
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Not your fault, but because you haven't, for whatever reason, been able to stimulate that patient that life's important and she or he should be engaged in life and want to get better. And that's part of a physician's job too. Sometimes things are really tough. And you can't, you know, you can't save individuals. You know, for example, if you take the most common adult brain tumor, malignant brain tumor, which is called a glioblastoma,
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You know, average life is still in the range of two and three years at best, and certainly more in certain situations where the genetics are more favorable, but still.
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many, many patients don't do very well. And so right from the first, sometimes when you see the AMR scan, you know that this particular patient is not going to do very well. So you're on an arc. The arc is from making a diagnosis to helping the patient. And sometimes part of the arc is helping that patient go through that final door, that final door, which is death. And trying to make that particular door
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let's say as easy to go through as you possibly can for that particular patient. Sometimes that involves being there when they go through the door. That involves sometimes helping other people understand what's happening. Sometimes these individuals
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begin to hallucinate. Some things, what happens near death sometimes is that some of the sort of encoded areas that associate with memory and visualization start to just fall apart. And people can see their loved ones in front of them. They can sort of see all kinds of different things. And sometimes they can be scared about what they're seeing. But in one way, it's just part of the brain is not functioning very well. And some of these
00:09:28
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are parts of the final process related to the brain's function as it's no longer functioning as well as it should be. Brains are complex and very, very complex object. And I think we're just beginning to understand it a little bit more. I think artificial intelligence is going to help.
00:09:50
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because we're gonna be able to sort of try to figure out these complex interactions that are very difficult to deal with, with sort of simple systems.
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You know, I tell the students sometimes, you know, a few years ago when we were working with, let's say, our virtual reality systems involving operations, it would take half a year, a year to do a particular experiment, you know, to do all the data, get all the data and all the rest of it. And how artificial intelligence sometimes you can do it in a few days. I mean, it's just an unbelievable change. I don't think people realize
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what's happening. You know, people are beginning to maybe, but not as much as what really is going to happen. It's really going to change, you know, medicine is going to change surgery in ways that I don't think we're ready for to be very honest with you.
Mission of the American Osler Society
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I definitely wanted to talk more about AI in a bit, but you mentioned the art of medicine. I think a person who knew that and kind of lived that really well was Sir William Osler, who was an icon at your institution, McGill University. And now, as I mentioned before, you're the president of the American Osler Society. So can you talk about what is the mission of the American Osler Society?
00:11:10
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Well, I think it's probably an initial and primary mission is engagement with other physicians and medical students, residents, and other individuals who have a particular interest in the humanities and medicine. And I think that the best way of thinking about, let's say, Sir William Oser is an individual who was deeply grounded
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deeply engaged in the world, you know, engage with his family, engage with, you know, his colleagues, engage with humanity as a group, and was really quite sort of also engaged with knowledge, and that resulted in him accumulating one of the largest libraries of that particular time period, libraries of concerning medicine and medical sort of issues.
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And so I think that particular engagement and the also his engagement with students, which is probably something that wasn't that common at that time.
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And the idea that he wasn't the first physician to be involved in bedside teaching. I'm sure that many, many, many surgeons and physicians have been associated with teaching at the bedside ever since the time of physicians initially having some role in taking care of disease. But I think he sort of institutionalized it as something that was critical to the learning process.
00:12:49
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know, the idea that you could actually be at the bedside, be involved in actually examining the patient. And again, I think it's hard for us to go back and think what it must have been like at that time where you actually had to examine the patient, you know, actually had to take the pulse, you know, take the blood pressure and look at the skin and
00:13:11
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and actually feel the abdomen and feel the pulses in the legs and actually take out your stethoscope and listen to the chest, which was not terribly as common as it was. I, in a way, have an interesting perspective because when I started neurosurgery, there was no CT scanner, no MR scanner.
00:13:35
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So I came through this incredible time period where we could do angiography, but we didn't have a CT scanner. We didn't have, you know, all the sort of technology that we have now. And therefore, you had to actually examine patients. And what was amazingly interesting was that, for example, you'd have a patient come in, who that is, and severe weakness.
00:13:59
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And you do an angiogram, and you would find not a lot of change. And then seeing the first CT scanner, which showed a hemorrhage right in the internal capsule, which was responsible for the paralysis, was then a complete eye opener. And it was like open a box, box being the brain. And we suddenly had a way of looking and sign the brain in reality. And then, of course, when the MR scanner came along, that opened the box even further.
00:14:27
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especially for the spinal cord and other areas that are nerves and things like that. The MR scan really brought it to a way that we can visualize what was actually inside the human brain and the spinal cord and even the nerves and other aspects of the nervous system. But again, we're just visualizing the movement of water. That's what an MR scan does. We don't really understand how to
00:14:58
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really get a real good handle on what actually is happening in the whole areas of, let's say, these neuronal sort of systems that are involved in speech, that are involved in emotion and other things. We sort of know where they are because if you take out certain areas of the brain, persons don't, you know, you don't speak anymore, you don't understand speech. So we know a lot of the sort of large areas of the brain that are associated with these types of characteristics, you know, how you move your hand, how you move your leg,
00:15:25
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Now you can take out a part of the brain and you can certainly find that information out in animals initially and then in humans when they had particular diseases. So again, I think what Ulster sort of concept of the patient being important and our ability to interact with the patient, I think is something that the American Horse Society is sort of
00:15:55
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let's say focused on. I don't think we're focused on him as some type of icon or anything like that. I think the modern American ultra-science is more focused on the idea that Sir William Moser was an individual who projected what the human sort of, let's say physician is capable of. What we as physicians have the ability to do
00:16:21
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to be a caring physician with a lot of humility and to do the best possible job you're able to do with the resources that are given to you.
00:16:31
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And I think he projects that and also projects the idea of humanism and what's humanism. Well, humanism is sort of an idea that humans are important, human culture is important, human sort of ideas and development and culture and all art, all those things sort of mold together.
00:16:52
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And again, you know, he was able to sort of move in the areas of medicine, the areas of culture,
Ethical Challenges of AI in Medicine
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multiple books, for example, associated with various aspects of the history of medicine, and also into the politics of things, how to get things done, you know, the idea that he was involved in developing the John Hopkins University and was very involved in McGill University, for example, and associated with
00:17:22
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and we still have many of his, you know, the pathological specimens that he was involved in dealing with at that time. So all those parts are part of the process. There's always an interesting story about him and I think it gives you some really important thing that deals with artificial intelligence too.
00:17:49
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You know, there is a story where Sir Willimoser was with a patient and Cleary the patient was going to die. And he had individuals around him, students around him, which he always did. And he obviously interacted with that particular patient sitting beside the bed, et cetera. And then, you know, he left the room
00:18:18
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and he began to whistle. And the students said to him, well, sir, why are you whistling? And the answer was, so I will not weep. Will artificial intelligence systems weep? Will they have the ability to understand the human condition so well
00:18:47
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that they'll be able to understand the concept of death, suffering, and all these things that indeed make people weep. We'll see. I'm not sure. I'm not sure. But I think my role as president of the American History Society is really three.
00:19:12
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One, I'm quite interested in getting more and more medical students involved in the American Ultra Society. And the reason for that is I think that we have things to offer medical students
00:19:24
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And they include, you know, there are being awards which allow medical students, for example, to be involved in doing projects and being paid for it. There are, we're developing what's called an international sort of medical student scholarship, which will start in 2025.
00:19:42
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individuals from North America can go to Europe and do a summer in Europe or time periods in Europe to look at particular issues not associated with medicine per se but really with the humanities, the humanities medicine. So what you can basically think of it is that if you think on one side you have medicine and on the other side you have humanities and there's a bridge between the two.
00:20:08
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And that bridge between the two is usually a library or usually somewhere that holds knowledge. And I mean, if you look behind me, you can see I've heard a big library that I
Exploring the Osler Library at McGill University
00:20:22
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have. But the important parts of the libraries is they are the continuation of a number of individuals who have striven to try to answer complex questions.
00:20:38
Speaker
And I put it down in writing. And that writing has been available since writing was available, ever since the Babylonian scripts and the Greek language, et cetera, the Renaissance. And those particular writings hold what sort of kernels of what the brain is able to do. And you can ask me,
00:21:06
Speaker
Obviously, there are issues that are changing now. We're being able to modify the brain, or we'll be able to modify the brain shortly, I suspect, using some of the more advanced techniques of artificial intelligence, et cetera. But I think that it's still critical that the person who's involved in medicine and the person who's involved in caring
00:21:31
Speaker
for patients in any way, whether that be nurses, dentists, it doesn't really matter the healthcare professions, that you have to sort of focus on the patient themselves, you know. And, you know, one of the things that Oster said was that a good physician treats the disease. The great physician treats the patient with the disease.
00:21:54
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And I think that's an important sort of aspect of, not disease per se, but the patient is the critical aspect of things. So I think that's probably in a nutshell what the American Ocean Society is. It's a group of individuals who are interested in the humanities and in medicine.
00:22:14
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and interested in helping medical students and residents and other individuals who have similar types of interests to fulfill their interests in both medicine and the humanities. And hopefully through that interaction, they can become, let's say, better physicians or interested in the patient.
00:22:38
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not the disease itself, but the patient with the disease. So I think that's how we would play that particular aspect out. You also work with the Osler Library, which you mentioned at McGill University. Can you talk about the work of that organization and what makes that a special place? Well, so really Osler, as I mentioned over his lifetime,
00:23:05
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put together a library that had almost 8,000 books. The problem really became was that
00:23:18
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really had a number of options as to what to do with his library because when he was in his early six days he began to sort of write down what he wanted to do with this library and there are options for him you know he bought books at many many auctions so one potential would be that he could have sold his
00:23:41
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his collection. Another option was that, you know, he could have given his collection to any of the four-year places that he spent a lot of his time, McGill or Pennsylvania or Philadelphia or
00:23:54
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John Hopkins or or looks for but he decided to give it to McGill. I think one of the readings he did was that McGill, you know what he says in his, in his, his, his notes and memorandum is that it sort of was where he had sort of, let's say, learned or got
00:24:18
Speaker
the essence of what medicine was. And therefore he was given back to that particular area where that particular sort of university that allowed him to do that, to really get a handle on what medicine was really about. And so after he died, his library came to McGill and he died in 1919 and then the library actually came 10 years later because it had to be all put together
00:24:48
Speaker
And it's been there ever since. It's one of the five best, or at least in that category of history of medicine libraries in the world.
00:25:00
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And it has many of his writings, it has many of his notebooks, has many of his other things that he left, including the books that he was closely related to. And it is interesting, when you look at the books, he divided the books into multiple areas. And one of the areas was associated with books that he thought were primary books, let's say, the books that had really made a big difference.
00:25:28
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and how the area of medicine progressed. Then there are all kinds of other ones that he collected that were around these primary books and how it moved forward. So, you know, when you look at the catalog that was made of Sir William Oster's books, it's still a very important catalog. You know, it has all kinds of information about the actual book, how it relates to other books, et cetera.
00:25:56
Speaker
And his interest in 2019, it was 100 years since the real monster died. It was also 500 years since Leonardo da Vinci died.
00:26:10
Speaker
So in that particular time period, I have a particular interest in Leonardo da Vinci. We put together an exhibition, which was really Sir William Osler's collection associated with Leonardo da Vinci. Sir William Osler had a number of books related to Leonardo da Vinci.
00:26:28
Speaker
And they involved flight. They had an interesting collection related to Leonardo's concepts about flight. And you might think that that might be really the fact that how flight was becoming interesting in the early part of the 20th century, the Wright brothers, et cetera, those types of things. And there was a lot of art books that were related to Leonardo and then anatomy books related to Leonardo. So again, you can see that despite being
00:26:57
Speaker
and also being a physician in various types of interests. One of them happened to be Leonardo, but many, many other areas of interest. And then the library itself has evolved. We've gone through an interesting evolution in the last year or so. The reason for that was that a number of years ago, there was a fire.
00:27:25
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involving not exactly the library, but the roof of the library. And that sort of gave us time to sort of rethink the library and what the purpose of the library was. You know, how to sort of deal with, you know, do you put this library after the fire into, you know, another library and be your library or do you keep it the way it is or, you know, what should you do with it?
00:27:47
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And I think we basically came to this conclusion to McGill through a number of systems, came to the conclusion that it was best to sort of keep the library as it is with the books together, accessible to medical students, accessible to researchers.
00:28:07
Speaker
along with all of his materials, because one of the ideas you could have had at that time is you, for example, would separate, let's say Leonardo's, sort of, let's say the books on Leonardo that were in, so were the most of his library to somewhere associated with art. Let's say his letter is somewhere else, you know, to break up the whole system and put them in different areas.
00:28:32
Speaker
But I think keeping everything together was clearly the best thing to do, and that's what's happened. And so there's a number of things that the library has. For example, it has what are called the Molina sort of awards. And they were provided by Dr. Mario Molina. And they're awards for medical students to do a project over the summer.
00:28:57
Speaker
on the Humanities Project that involves something to do with medicine and something to do with humanities. There's three of those awards every year. There are also multiple different types of awards for researchers to come from all over the world and do research in the Osler Library.
00:29:17
Speaker
There's also an essay contest. The essay contest was in Delba, my wife and myself, which allows medical students to sort of being engaged in a humanities project and do an essay and present that data. So all those particular things are, let's say, a part of this evolving, developing, continually getting better OSER library.
00:29:42
Speaker
And so I think that that's an important aspect of what we do. It's interesting to think about practice today in 2024. Physicians are very busy. They have a lot to do with their clinical practice. They need to stay abreast of a lot of new innovation, new technology that's coming out.
00:30:09
Speaker
What can physicians gain from studying, on top of all that, the history of medicine? Well, I think the advantage of knowing how other individuals have tried to deal with the complexity of disease allows you to have, I think, again, some humility when you're trying to deal with similar types of issues.
00:30:35
Speaker
And although we clearly are making substantial gains at the present time, you know, it's still a, medicine is still sort of an art. It still involves the concept of dealing with each individual patient. And I think as we develop personalized medicine, which means that, for example, if you have a particular tumor,
00:31:03
Speaker
In the future, what's going to happen is that particular tumor is going to have a complete genetic array carried out. And you're going to be treated with specific medications which attack the actual genetic malformation of that particular tumor that you have in your body. And therefore, various areas, for example, like radiation therapy, which is a much more, let's say, it doesn't really select
00:31:33
Speaker
The good cell against the bad cell, except the bad cell is the one that happens to be dividing, that the radiation is more effective with. But it's sort of a type of treatment that, but I think in the long run, it's not as personalized as actually, you know, finding out exactly what the genetic abnormality is and dealing with that.
00:31:51
Speaker
And also some of the chemotherapies are very common and are used every day now. You know, again, are not as selective as what we're going to be able to use in the future. And so,
00:32:06
Speaker
The whole idea of each person being important, and also we personalize the medicine to that person, not only to that genetic problem that that person may have, but also to the family issues of that person may have, the economic issues of that person may have, the sort of other issues of that person may have to sort of get a much more global sort of idea of how to make that person have
00:32:34
Speaker
the best life possible with the resources of that person, and we have available to us. They help that person. So I think that that's the big change that's occurring. We've got this personalized medicine, but are we moving a little bit away from what used to happen? And if you think about 30, 40, 50 years ago, physicians were,
00:33:01
Speaker
or the mayor of the town that was an important aspect of the community, was involved in delivering babies all over the place and taking out tonsils and doing all the things that people needed to be done and was sort of a very important part of that community. And then we sort of are moving on to a world where
00:33:27
Speaker
know, official intelligence systems may be able to be applied. And we may have various types of, you know, systems which do not have, let's say, are not able to weep. We may have systems that are function, but don't understand what it is to be human and what it is to be
00:33:53
Speaker
trying to deal with a very complex problem that humans have to deal with when they have disease.
Future of Intelligent Operating Rooms
00:33:58
Speaker
So we're at this interface right now. And in your life as a physician, you're going to see incredible changes. I mean, I saw changes from not having CTs, MRs, no genetic information, et cetera. And that's been in a short period of time. Imagine what the next 20 or 30 years are going to be like. I don't think we can imagine it, to be honest. It's going to be incredible what's going to happen.
00:34:21
Speaker
The other thing I think that's going to happen is that in the operating room, the operating rooms are going to become intelligent. They're going to be following the surgeon, assessing every movement that the surgeon makes with their hands, figuring out how much force is being applied, what types of acceleration, deceleration are occurring with the instruments, and we'll be able to help the surgeon be a better surgeon.
00:34:47
Speaker
by giving them information about what makes you a good surgeon and helps you improve your surgical ability by dealing with, let's say, we have the ability now with what are called classifying AI algorithms.
00:35:07
Speaker
What does a classifying algorithm do? Well, it is able to classify individuals, for example, who can do things, let's say, if you have expert surgeons and you compare them to, let's say, medical students or let's say, residents, the algorithms can sort out what is the difference between the expert surgeon and these other sort of levels.
00:35:28
Speaker
And we can then begin to think, well, how can we make that resident or that medical student develop much more quickly and learn how to do that particular surgical sort of technique in a much safer way based on applying artificial intelligence types of algorithms to these systems?
00:35:49
Speaker
And the next thing that's happened is that we now have what are called intelligent tutors. What's an intelligent tutor? Well, it's a machine that can actually talk with you, can assess when you're doing an operation, and can give you guidance and coach you on how the best way of doing that operation
00:36:11
Speaker
is because it has knowledge from, let's say, thousands of operations that it has information about and can help you sort of perform better, not to take over your role, but to help you perform better. What's interesting, if you look at Star Wars and any of these sort of, let's say, more futuristic situations, who are the physicians? Burrow robots, right? Because in one way,
00:36:39
Speaker
Surgery is a mechanical process. It's two things. It's things you do with two hands and other kinds of other instruments. And will robots be able to do that better in the future than humans can?
00:36:55
Speaker
You know, the answer to that question is for certain things, that's probably true, that they probably will be able to be better at certain parts than on certain parts of operations. I guess the problem is going to be what the human mind is able to do is to innovate on the spot. A number of times in my life, for example, when I was operating, something came up which I'd never heard about, I'd never seen before, and it was completely new and novel to me.
00:37:21
Speaker
And then you have to come up with a solution right in front of your eyes to try to deal with this particular problem. And I think that's somehow where some of these artificial intelligence systems don't work too well. Because they haven't seen it before, and they don't know how to innovate in that type of way. Although people talk about chat, GPT, and other systems, would they be able to sort of
00:37:48
Speaker
and be able to sort of take over the writing of books and the writing of poetry and all that rest of it. Well, I think what a chat GPT system does is it takes information from multiple areas and puts them together in some type of synthesis. But is it really creative? Is it creative? Can it put something together that's never been there before? Is that possible?
00:38:19
Speaker
I'm not sure. I guess we'll see. Sometimes when I've asked certain questions, I'm a little bit flabbergasted on where the answers are. Because I know some of these errors I know relatively well. And it doesn't know
00:38:33
Speaker
whether one particular bit of information is better than another, necessarily. It doesn't have an ability to know that quite yet, but it may in the future. So we'll see. We'll see. All these things are happening so fast that it's hard to know. But being someone who worked with artificial intelligence sort of all the time, I was looking at a paper from one of my students today.
00:38:57
Speaker
You know, there are these systems that are available to, you know, you have what are called, as I mentioned, these classifying algorithms that can classify people. It can sort of separate people into expertise and non-expertise group or skilled and non-skilled groups. Then you have these things that are called, you know, sort of artificial neural networks, A and N, artificial neural networks. And they sort of work a bit like the brain does. It connects a whole bunch of different systems.
00:39:25
Speaker
And those systems provide interest as a surgeon because they can identify what part of expertise is more important. In other words, if the system picks out, let's say, eight different things that are critical to expertise doing a particular part of an operation.
00:39:46
Speaker
Let's say it's the amount of force you use. Let's say it's the amount of acceleration you use on the instrument, et cetera. What it's hard to do as a human is to figure out what is the acceleration of that student's force or instrument that you're watching? Or what is the force that that particular student is using with that particular instrument? But the artificial intelligence systems can do that.
00:40:12
Speaker
And then the second thing the artificial intelligence systems and the A and N systems can do is it can sort of say, well, if you look at expertise, expertise is made up predominantly of what? And believe it, all the systems that we've looked at, it's safety. The expert is focused on safety. About 50% of expertise appears to be associated with doing the operation safely.
00:40:39
Speaker
Then later there are efficiency and other types of metrics, but the safety metrics are critical because that's what expertise is, is to do that particular procedure safely. And then, as I mentioned, your efficiency and other sort of types of metrics come after that.
00:40:57
Speaker
And then you have these very complex other systems, which are the deep learning systems. And those systems are what you do is you provide the data to the system. And then the system works in the data itself. And you can either have it supervised, which means you tell this deep learning system, these are experts. This is expert data. And this is not expert data and tell us
00:41:25
Speaker
who, you know, what are the critical aspects of it? Or you just provide the information, all the information to the deep learning system and it separates people or let's say metrics or activities itself without human involvement. It doesn't all by itself. And in certain situations, if you give it enough data, it's incredibly accurate.
00:41:51
Speaker
And that's why, you know, if you look, for example, what types of medical areas are going to be influenced most by artificial intelligence initially? It's going to be things like pathology, because the human eye has only certain amounts of ability, but, you know, the
00:42:16
Speaker
photography and its ability to be very fine and using AI system in the background can really be even more effective, can find more differences and more subtle changes. And the same thing with radiology, I think. So those systems are gonna be some of the first that artificial intelligence is involved with.
00:42:39
Speaker
And other areas, for example, like retinal scans and things like that, things that are involving with photographic information or data are the things, a lot of data, are the things that these artificial intelligence systems are going to do better. So I really have two more questions for you about AI. One would be,
00:43:03
Speaker
What are going to be the ethical implications of artificial intelligence in medicine? You were talking about earlier how will AI be able to weak? Will AI be able to understand the human condition? So what are the ethical implications of that? And I guess my second question then kind of springboarding off that would be, how can we leverage AI to practice humanistic medicine? Related to your first question,
00:43:36
Speaker
Part of AAI's ability relates to the quality of information that you're provided with. And therefore, if you provide it with information that is not well put together, not well scrutinized, it will make mistakes because it will not be able to.
00:44:03
Speaker
to sort of sort things out the way they should be sorted out. The second thing is, are all people going to be willing to provide all their information to these AI systems? Because if you want them to be, let's say, as accurate as humans,
00:44:21
Speaker
you have to provide those systems with what the person looks like, what the person acts like, all the subtle things that humans are able to see. One of the neurologists that most impressed me was an individual who
00:44:45
Speaker
You know, his name was Dr. Barnett. And, you know, he used to say that he could get about three quarters to 90% of the diagnosis just watching the patient walk in the room and shaking their hand. And, you know, a lot of that was related to his ability to very finally understand that that patient was not walking, had a bit of a shuffling gait, had their eye contact wasn't as good as it should be the way they move their mouth or the way they interact with their neck.
00:45:13
Speaker
And over a huge lifetime, he's able to put all that information together. And the question is, will AI systems be able to do that as effectively as the human brain can? Because the AI systems are not as complex as the human brain do. They do not have all the systems that the human brain has to understand emotions and all those types of things. And so we're going to have a problem with that, I think.
00:45:41
Speaker
Related to the ethics of it, therefore, will everybody allow all their information to be put into these AI systems? Will you want to be treated by a machine? Even if it's a little bit better, is that okay with you as a human? The other thing I can tell you, we do have these intelligent tutors
00:46:08
Speaker
And what we're finding is when the intelligent tutor asks the student to do something, let's say, change their behavior, sometimes the students just don't do it. And that would be very rare in the upper room for an educator to tell a particular student to do something and they don't do it. We're trying to figure out, well, why is that? Is it the way that the AI system speaks to the student?
00:46:35
Speaker
They just don't have the emotional tones and other things that are critical to the human understanding, the importance of that particular command or that particular instruction. Is it because people just don't like being trained necessarily by machines? And so there's another problem that you have, that these tutors or these instructors
00:47:00
Speaker
Are we going to be able to trust them all the time? Because they can make mistakes. And when they make mistakes, mistakes could be probably pretty serious. And the other thing is, on the ethics of it, I don't know. I don't think we're ready for it.
00:47:18
Speaker
I don't think we're ready for the complexity of the ethics that are going to be involved here. I don't think we have the sort of systems to help us, because we've never come up against such a system before that potentially could be
00:47:35
Speaker
I mean, if you look at, you know, the doomsday scenarios of the machines becoming, you know, awake, you know, there's, you know, it's interesting, there's two important concepts about consciousness, two basic ideas, but why are we conscious, for God's sakes? Why are we conscious? I mean, why? What allows us to be conscious?
00:48:01
Speaker
And so, you know, one group of sort of thinking is that, you know, all things are somewhat conscious. You know, for example, you take everything from a worm to humans, everybody's a little bit conscious. It's just, you have to get to a certain level before you're really conscious, right? For example, if you take an octopus, an octopus has a brain and has a brain in each one of its eight arms.
00:48:23
Speaker
So clearly, it has some type of conscious ability related to it, but clearly it is not sort of trying to understand the world and trying to sort of make the world better and communicate in certain types of ways. So that's one idea, that if you get enough neurons together in a particular brain system, then that brain system will indeed be awake, will be conscious.
00:48:53
Speaker
So if you believe that, what that means is that eventually, eventually machines will be conscious because all you need is enough computer systems together. And if you have enough together, then that allows you to be conscious. Does that scare you? Well, it scares, I think it scares me a little bit in the sense that, you know, here you have a situation where there's a potential reality for consciousness and think about it this way. You're dreaming at night, right?
00:49:24
Speaker
in various parts of your brain are functioning. You may be seeing things, you may be hearing voices, et cetera. And then suddenly, you get a very sudden dream that is very scary to you. And you wake up. Well, why don't you wake up? Well, because there's so much activity going on in your brain, it's really such a level that you just woke up.
00:49:49
Speaker
So is that going to be the same? Is that going to be what's going to happen? The other idea is the brain is so complex and is so unique in its development and evolution that no other system can be as complex as that. I guess these two systems, these two hypotheses are flooded out as to whether it's impossible for these computer systems to ever be as complex as a human brain.
00:50:21
Speaker
With that, real quick, I want to jump into a lightning round. So that's basically just a series of fast-paced questions that tell us more about you. So when you were a neurosurgeon, what was your favorite procedure to do? Awake radiotomies, particularly around very important areas, speech and understanding of others like that.
00:50:44
Speaker
You mentioned that you have a collection of Leonardo da Vinci artifacts. What's one piece that you would really like to acquire? To acquire?
00:50:57
Speaker
Well, getting anything related to Leonardo himself is extremely difficult because of the costs involved. We're talking about multiple millions of dollars for anything. And there's almost nothing available, of course. But from some of his students, I have a number of drawings, for example, from his students. One particular fellow by the name of Francesco Meltzi, who was his favorite student, Leonardo's favorite student,
00:51:23
Speaker
And Meltzi sort of reproduced many of Leonardo's drawings because Leonardo's drawings were sort of got worn out because so many people use them. And see where he reproduced them and I have some of those. And Leonardo was basically interested in three areas. He was interested in anatomy. He was very in painting and also in architecture and trying to mix all three of them together. And so
00:51:51
Speaker
One of the reasons I like the idea of Leonardo is it goes to show you what the human brain is capable of. Just open, if you have a second, and you go to the library, find Leonardo's codex on the flight of birds and open it. You'll be aghast what you see there. Absolutely aghast.
00:52:16
Speaker
how we went through the whole idea of flight and how all birds move and how the wing moves and how bats use their muscles and how to make a flying machine and how a flying machine would have to work and then design a flying machine and then figure out how to put flying machine together and send it off a mountain to see whether or not it would fly or not. I mean, really.
00:52:44
Speaker
Really, the human brain, what an incredible thing. And, you know, maybe once every 100 years or so, you know, the genetics of some individual get together where they are able to see further and he just happened to be one of those people. It's fun, it's fun to think about that there is the possibility that the human brain can be so productive.
00:53:14
Speaker
What is your favorite dessert? I'd say ice cream. What's your favorite activity to do with your grandkids?
00:53:27
Speaker
Well, that's a little bit different in the sense that one of my younger grandchildren is nine and we like to sing together. So we like to sing a lot of Peter Paul and Mary, for example. I happen to like some of the songs of the sixties, sort of, you know, if you had a hammer and all those types of songs and like to do that with that particular grandchild.
00:53:54
Speaker
One of my other grandchildren is very interested in electrical things. And so I interact with them related to some of those things. One of my other ones is interested in books. And so I have books that we have fun with without reading to my grandchildren and things like that is very important. I've always loved that. And lastly, what's the one change you'd like to see in healthcare?
00:54:23
Speaker
If I would consider Canada, you know, Canada has a healthcare system in which individuals do not pay for any healthcare at all. It's paid for through taxes, right? So you can go to the doctor and there's no cost to go at all for anything. One of the problems of that system is
00:54:45
Speaker
that involves, it has advantages in the sense that everybody can get medical care. It has some disadvantages that you have to have a fair amount of money to run such a system. And if the money is not available, then that system can at times be, it's very good at providing care if you have an emergency problem.
00:55:15
Speaker
Like, for example, as a neurosurgeon, if you happen to have a problem, there is no difficulty, you get in your wire right away, there's no issues about that. But it doesn't deal very well with some of the longer term issues.
00:55:29
Speaker
For example, if you have, you know, if you need a CT scan and you have very few symptoms, you know, it's sometimes more difficult to get them.
Canadian vs. US Healthcare Systems
00:55:41
Speaker
In the United States, obviously, you can just pay for it tomorrow. We don't have that system in Canada. The problem with the United States is as far as I, you know, I have multiple opportunities to go to the United States.
00:55:54
Speaker
The one problem I had was the issue of poor people not having medical care. And in one way, I don't understand it. I just don't understand how a rich country like America cannot provide medical care to everybody for free. Why not? We do in Canada. Granted, we pay more taxes.
00:56:25
Speaker
But is that so bad? That, you know, what is one of the major reasons for being going, you know, broke in the United States is medical care. Because it's so expensive. And, you know, that isn't an issue in Canada. We don't have that issue. If you're sick, you get taken care of.
00:56:51
Speaker
So I think what I would like in Canada probably would be that more money get devoted to particular areas like, let's say, rather than the hospital system, more money devoted to sort of more preventive medicine.
00:57:09
Speaker
know, how do you prevent things, how to prevent things from getting to the hospital so you can, you can sort of save systems on that, that area. And that could be, you know, better nutrition, you know, better all the things that are involved with prevention. In the United States, I think it would be great if you could have a healthcare system and took care of everybody the same.
00:57:33
Speaker
everybody the same. One thing I always relate to people is that one of my patients happened to be a member of Parliament in Canada, a good friend of the Prime Minister.
00:57:45
Speaker
She she had a brain tumor and operated on her and she would come down to see me in London from from Ottawa and sit in my clinic. My clinic was a complete disaster. There were kids all over the place. There were people that are the people having seizures. So it was just unbelievable the number of people that were involved. And she sat there as a member of parliament waiting for her place. Like everybody else. That's pretty special.
00:58:15
Speaker
She didn't think she was more important than anybody else. Pretty interesting. Dr. Rolando Del Maestro, thank you so much for joining the show. Thank you very much. Thank you very much, John, for an interesting, interesting discussion. No question about that. I hope it was somewhat useful for him.
00:58:44
Speaker
Thanks for listening to The Wound Dresser. Until next time, I'm your host John Neery. Be well.