Denise Gee, MD: Surgeon of Balance

Q: My guest on today’s episode is Denise Gee who is a surgeon here at Mass General. Can you just start out by telling us a little more about who you are and what you do here?

A: I joined Mass General back in 2006. I was a fellow and then I joined the staff in 2007. So I’m a surgeon. I specialize in minimally invasive surgery as well as bariatric surgery, or surgery for morbid obesity. In my other roles I also am director of surgical simulation as well as an associate program director for our Surgery Residency Program.

Q: Can you tell me, I’m curious how you ended up in bariatric surgery in particular?

A: I really enjoyed laparoscopic procedures when I was a resident. I was just intrigued by the technology and the ability to do these really complex operations using small incisions. Patients did better, they had less pain, they got out of the hospital faster, they had less complications, and so I was intrigued by laparoscopic surgery. And back then the field that was probably growing the most in this area was bariatric surgery. So I kind of was involved in a lot of laparoscopic bariatric operations and just saw how these really complex operations were able to be done with these five small incisions. My patients did really well. They were out of the hospital in a few days. And it was just remarkable. The patients did better after the operation itself, but then they also, a lot of their kind of medical conditions improved, so a lot of them their diabetes improved, their blood pressure improved, and they were just, he gave them a completely new life. And so I wanted to be part of that change.

Q: Can you talk a little bit more for people who maybe don’t know a lot about what it means to do laparoscopic surgery, how does it work?

A: Laparoscopic surgery is basically surgery done with small incisions. So, in traditional operations you would imagine that with an abdominal, anything in your belly you would make a cut and then perform the operation and then sew it back up. And so laparoscopic surgery is a technique where you use little incisions with these long instruments and it’s projected and you have a camera that you are watching on a screen, and you’re able to do the entire operation within the abdomen with just these small little incisions and these long instruments. And patients, you know, have less pain, because they have less kind of long big cuts on their belly, and they end up kind of getting out of the hospital faster, you have less chance for infection, etc.

Q: I’m curious, do you think it’s, as I’m thinking when you cut someone’s belly open and you can kind of see everything, you get the view of everything inside, but if you’re doing laparoscopy you have just a small camera and it seems like you would see a little piece at a time, do you think is it harder to learn to do that or is it just a different skill?

A: You actually, some would argue, can see more. So you blow carbon dioxide into the abdomen so that inflates, so you have a lot of room to work in. And then the camera technology just keeps improving, and so you can actually look all around the abdomen, look in different angles. So the view is great. And I think the difficulty is more kind of not having your hands in there, and so learning how to use those instruments to kind of maneuver the tissues and perform the same techniques that you would otherwise do open.

Q: So they can kind of feel like your hands or extensions of your hands.

A: Right, so there is, they are, they are extensions of your hands without having your five fingers on each hand and helping you out, but just learning kind of how the instruments work and getting more experience with the tactile feedback, etc. those are the things that you kind of have to practice as you’re learning laparoscopic surgery.

Q: Is there a moment when you knew that surgery was what you were going to do?

A: I think it probably was back in my third year medical school rotations, because in the beginning when I went into med school I did not think surgery was, it was not even in my field of view as something that I wanted to go into. And I think it was my third year rotation, just seeing that first week or seeing how patients come in, they have a problem, you’re in the operating room, you perform an operation, it goes smoothly, the patient does better afterwards, you see them, and then their problem is solved. That kind of series of events kind of fit totally into my persona. I think of myself as a doer, so I see a problem and I want to fix it, and that was just right up my alley.

Q: I think it’s kind of unique in that other forms of medicine, it’s over time and it’s behavior change and let’s try this treatment. I think it makes a lot of sense. You want to see it, do it, fix it.

And I guess I’m curious to know, I can’t imagine cutting someone open and messing around in their body, so is it scary to learn that?

A: I think it’s scary to kind of learn a new technique and want to make sure that you’re good at it. But as with everything I think with practice and kind of your training you gain the confidence that you’re able to do it.

Q: And how do you learn that? How do you go from kind of reading in a book, maybe watching a film or something, to being the person who is doing it yourself?

A: So that’s a long process and that’s why surgical residency is at least five years, and so you start out reading about it, maybe watching some videos on it, watching your mentors do it and learning by, you know, seeing what they are doing. And then slowly as you go through residency you get more and more opportunities to actually participate in the operation and you kind of take over little parts of it at a time so that by the time you’re done with your training you have probably done the majority if not all of the operation multiple times and it’s just kind of a step-wise progression.

Q: So it’s almost like a snowball, you’re kind of building and building and building until you’ve got the whole thing?

A: And surgery is not just the physical operation, and so all along the way as you go through training you are also learning kind of how to care for those patients and what kind of complications there might be, and kind of different ways, how patients present, what issues may come up after the operation. You get the whole picture. So by the time you graduate from residency you are ready to take on patients on your own.

Q: So it sounds like you’re almost building your “doctor senses” so you kind of can see. I think sometimes we tend to look at someone and make judgments, but it seems like you need to see more than that.

A: I mean it sounds cliché-ish, but medicine and surgery is really an art, and so it’s something that you just, it’s not all black and white, and so throughout training you get exposed to so many different patients and situations and so many different mentors and teachers, and from all of those experiences you kind of learn what it means to be a surgeon and how to take the best care of your patients.

Q: So, I’m curious, you said learn what it means to be a surgeon, what does that mean to you when you think about it?

A: Being a surgeon, I think you, it takes not only technical skill to actually perform an operation that will help the patient but it takes kind of understanding the whole patient from how they are presenting before they come to you, before they have their operation, and also all of the kind of social factors and their concerns and their fears and all of that. And then performing the operation and doing a good job and helping make them better, depending on kind of what they need. And then afterwards taking care of the patient afterwards and knowing kind of what to expect, what complications might arise, what their questions might be, what their fears may be. And so understanding all of that, kind of all those phases is what being a surgeon is.

Q: Yeah, and kind of putting them all together. I imagine you have cared for a lot of patients at this point in your career. Are there any that have stuck out or who have stayed with you over time?

A: I think bariatric surgery is very rewarding in that you can really see how patients who after having an operation to battle an otherwise very difficult problem of obesity, how patients can really after that take the ball and run with it and be really successful, and it’s just heartwarming and rewarding and you’re-- It’s just you’re rooting for them and you want them to do great.

And so I have patients, you know, one patient in particular who I remember she came in, we decided on this operation, and we performed the operation, and then afterwards she just kind of turned it all around and she was, you know, exercise was a huge part of her life. She was having this really healthy lifestyle. She started cooking in different ways. And then she started this like online video series where other patients of mine have followed her. And kind of it chronicles how she, what her strategies are and what her tips and tricks and whatnot how to life after bariatric surgery. And so I just thought it was really interesting, because I hadn’t even known that she had done all of that online stuff, and then I had other patients come in and say, “Oh yeah we saw this, and she is doing great and these are the things that we learned from her, etc.” But I think the flipside is that not everything is all perfect and surgery is really can be quite humbling. And so I had around that same time a similar patient who had an operation, and actually did great from a pure weight loss and health standpoint, but had some side effects of the operation and needed a couple of other operations afterwards that weren’t really complications of the initial operation itself but just as patients are, their bodies are changing as they’re losing weight different things can happen that require further workup or further operations. And so she had kind of a rougher course, but she ended up probably at a same place as the initial patient.

Q: I’m curious as you’re talking about bariatric surgery and the patient with her video series. You see a lot of stories in magazines and on Facebook about people who have had surgeries and lost all this weight. Do you find you have more people coming in wanting to have surgery because they have read these stories? Do they have inaccurate perceptions?

A: There is definitely an effect. I think it works both ways. So, some patients see things, see someone, a public figure who has had the operation, and that brings them in, because they’re interested and they want to hear about the operation. And on the flipside they read in the newspaper about complications that occur and they come in with a more negative kind of preconceived thought of what the operation or what the surgery can entail. And so I think it works both ways. I think it the media nowadays and all of these kind of social media, I think overall gives patients more information at their fingertips, and the question is just how to process all that information. And that’s why coming in and seeing a surgeon and sitting down and talking to someone we can help kind of dispel the myths and tell them what the truths actually are.

Q: You see something on TV and you just kind of assume as a layperson like, “Oh my god, that, I don’t want that to be me.” But we don’t realize how individual we are and how that affects not just our health but our treatment.

A: Right. No that is exactly right. And I think it’s hard to remember that. I mean I remember when I was a patient when I was pregnant every time I would hear these stories about pregnant women, this happened, or my friend this happened or whatever, and I would go in and talk to my OB and be like, “Could this happen?” And every time she had to remind me that there is a lot of information I don’t know about this said other person and that every patient is different and your story is different and you’re kind of-- So, it’s a case by case basis.

Q: You mentioned pregnancy. You’re a mom. I think a lot of people maybe have a sense that surgery is a really demanding career. What has it been like to have a career like this but also have kids and a family?

A: So, I mean it was challenging in the beginning. I think it definitely takes balance with a capital B, and so I think when I first came out of all of my training, residency, and fellowship, I was starting my career as a new surgeon, surgical attending, and at the same time I was pregnant with my first child, and so I was a soon to be new mother, and kind of figuring that out was kind of trial by fire. You know, it’s just there is no book about it and you just kind of have to start. But, you know, you figure it out. I think the key is to make sure that you have the balance and to always be cognizant of what your priorities are. And once you figured out what your priorities are and realize that it’s a zero sum game and you can’t be 100% in everything, you can’t perform, be the busiest surgeon and go out and give all the talks and be at every one of your kid’s sports activities, it’s just, it’s not possible. And so figuring out what your priorities are. And I think they change over time, but constantly reevaluating that is helpful.

Q: I’ve never really thought how physical surgery is. As you’re getting pregnant is that like a physical challenge?

A: It can be. You kind of stand farther and farther from the table, so you have to stretch more and more, and more frequent bathroom breaks. But we all, and it’s not just surgery but in any kind of job or in anything you just kind of make it work.

Q: Do you think motherhood, has motherhood changed the way that you approach your job or the work that you do?

A: It has. I think, I think in a couple of ways. It definitely has changed the way I relate to patients and whether it’s a parent bringing in their child to see me, not like pediatric child but like a patient who brings their parents in or vice-versa, and just family dynamics and the, and realizing kind of what the interactions are behind what their fears might be, caring for other family members. That whole dynamic, I think being a mom helps me appreciate that more and realize that more. I think from a work perspective being a surgeon versus being a mother, I think almost counterintuitively being a mom makes me a better surgeon as well. I’m a big fan of kind of work hard play hard. So, at home I’m devoted, I love being with my family, and so I want to be a full on mom and not be thinking too much about work and whatnot, and on the flipside when I’m at work if I’m in the operating room or I’m teaching or I’m in clinic with patients I’m all in. And so I think that, again like that kind of balance, but it allows me to kind of throw myself into my work when I’m at work.

Q: I like that. So kind of can be fully in a place at that time.

A: Yeah.

Q: So almost the mindfulness thing of being here and now and not in a million other places.

A: Right.

Q: So you mentioned, priorities. Are there other habits or practices that you have developed that you think help you keep that balance?

A: I think overall every day when I start the day, either the night before or the morning of, I like to kind of look at my entire schedule and come up with a game plan of what that day is going to look like, and so that kind of helps me enter the day. So that is on kind of a day to day basis.

But I think overall on a more global scale it really is just being aware of kind of what is most important to me in both work and home and trying to keep those at the forefront, being realistic about what is achievable and what is not, and then every so often kind of reevaluating that. And things change. And every stage, every few years you kind of have to reevaluate what are the most important things in your life.

Q: It’s almost like having a startup where you kind of iterate over time.

A: No that’s exactly right.

Q: Do you see the field of surgery or maybe medicine changing to allow people to be people a little more?

A: Yeah, for sure. I mean I think even now the field is changing in that there is more conversation and more focus on balance, for our resident trainees, resident wellness to methods to prevent burnout, and so there is a lot more focus and attention on that. And I think that’s great, because as residents are coming out of training and they all of a sudden get thrown into a new job, new family growing and kind of realizing that there are other, that first of all that you have resources that are available to you, but also coming in with some strategies that you may have learned during residency. And I think the whole culture of training residents in general as well as surgical residents is changing as well. So, there’s more women also entering the surgical kind of workforce, and so just that whole culture is changing. And it’s a more open environment to allow for what you’re saying, like people being people.

Yeah, and I think it kind of, kind of builds on itself, so as you have more female role models in the field then residents as they’re coming through can talk to female surgeons about kind of what their strategies are and how, and see how they kind of balance their home and work life. And years ago there weren’t these role models, and so now kind of the whole scene is changing.

Q: It seems like you’ve got a pretty good sense of yourself and that balance. And were there people who modeled that for you or did you kind of have to figure it out on your own?

A: Yeah I think I don’t know that I have one model per say. I think it’s from a work perspective, I think it’s just seeing all different people and how they, how their lives are and just kind of taking bits and pieces to see what would fit in my life, because every person is different. And then I think growing up seeing how my mom worked and how she took care of the family as well, that kind of was always in my mind that it’s doable. And so that kind of set the stage.

Q: Were there any negative models, things that you saw and thought, “That’s something I don’t want to do”?

A: Yeah I don’t know about negative, negative per say. I do think that there are people whose, what works for them would not work for me, and so then that certain aspects of that person or those people’s lives I probably would not incorporate into mine. But I feel like, you know it’s almost like in surgery where you’re learning surgery from different people and some people you really want to be like and some people you’re like, “Eh I’m not sure I want to be like them.”

There is something to learn from everyone, and so you just figure out kind of what would work with your priorities.

Q: I like that. So it’s almost like you’re building your personal Frankenstein with the pieces that fit together in their own unique way.

A: No exactly right.

Q: A big part of your role here is teaching young surgeons. Can you talk a little bit more about that and what you do and how that relates to your clinical work?

A: I think teaching is a huge part of what I do and as well as many of the surgeons here at Mass General, because the whole training model for residents is learning from your mentors and learning from your teachers, and then you eventually graduate and then you teach those below you. So, it’s kind of a very rewarding cycle. And I think now, nowadays residents with the 80 work week, they’re working less hours in the hospital than we used to. There is also appropriately so a lot of attention on patient safety overall, and so simulation has come kind of into the forefront of resident training as a method in which residents can practice certain skill sets, technical and nontechnical, without having to practice on patients. And in their more limited time in residency to have a way to gain experience without necessarily being in the operating room. And so that is kind of the role that I have been playing here, which is using simulation to teach, help teach residents technical skills.

Q: So, can you explain a little more what is simulation today and kind of how does that work? What are the tools?

A: So, simulation can range anywhere from simple kind of tabletop models, like if you’re learning how to suture, so you can have fake kind of skin models and learning how to suture there, all the way on up to almost like video games, like virtual reality trainers where you’re practicing parts of procedures or full procedures, like laparoscopic gallbladder removal, for example, and practicing on a machine. And then all the way on up to cadavers or animal models where you are performing operations on more real tissue. And so all of that is simulation. So anything where you’re not actually working on a patient and you’re trying to model something off of that, falls in that realm of simulation. And so we offer kind of all of that, depending on what level resident and what skill we’re trying to teach.

Q: You said sometimes it’s like a videogame. Is virtual reality something that is coming into medicine in that way?

A: Yeah, definitely. So, there is very basic virtual reality, there is very basic kind of electronic or videogame type models or machines that you can perform on, and now there is they are developing virtual reality where you put on kind of goggles and it seems like once you put those on you’re in a room with other people in the room and things are happening and whatnot. So, the technology is really advancing.

Q: Do you think, obviously it’s great to be able to practice without it being a real person who you could harm, do you think there is anything lost when we’re training with these new technologies?

A: I mean it’s not the real thing, so if you’re practicing a procedure, for example, or if you’re practicing how to interview a patient, but it’s not a real patient, it’s someone pretending to be a patient, I mean there is something lost in that. But that being said, You have to look at it a different way, and the fact of the matter is that training residents nowadays is changing and that’s for sure happening. And simulation is a tool that you use, so it doesn’t necessarily replace anything, and you still need to have patient interaction and you still need to perform operations on patients and make sure you know how to do it, but it’s a tool that can help prepare you better and in a safer way, and is really an instance where you are not at risk of causing harm to anyone and you can really kind of work out the kinks and get the basics down before you actually try to take your skillset to a real person.

Q: You mentioned learning how to talk to patients- how do you learn that skill?

A: So, a lot of that is during your residency just kind of doing it, being in clinic, watching your mentors, watching your attendings and learning good techniques. There is didactic learning. But simulation can also help with that. And so there is like a whole field of standardized patients, of people who are actors who volunteer to be standardized patients.

Q: Really?

A: Yeah. And then you actually, a lot of medical students go through courses where they interact with these patients and learn how to interview and what cues to take, what things to ask, how to break bad news, etc. So there are ways to simulate that setting and have medical students and residents learn in those settings.

Q: One thing I’m always curious about is learning to, because as a doctor I imagine you get to give people good news a lot of times, but the reality is is that sometimes you have to break really hard news.

A: And that is an area that is one of the more challenging things that we need to teach the future generation of physicians, no matter what field they’re in, and so it is something that they focus on in medical school, they focus on in residency, and also the use of standardized patients can help as well.

Q: When you think about surgery and teaching where is it headed, what do you see, what’s coming down the pike, what are the exciting things that are happening?

A: I think we’re in a time right now where there is just so much, so many advances in technology happening so quickly, and so I think there will be kind of more and more ways to deliver teaching through new platforms, through artificial intelligence, all these different new areas of research. So I think that’s a real, a really exciting kind of glimpse into the future.

I think there is a lot of attention now being placed on ways to teach residents, so it’s not just the traditional kind of lecture, have them listen, have them follow you on rounds kind of thing. There is a lot of innovative ways to teach, and a lot more research going into how learners learn. And so I think all of that research is occurring now and so that a lot will kind of develop in the future that will make it more effective and more efficient ways to teach.

And then specifically in education or surgical education there is a big move towards competency based education, and so it’s not just everyone learns the same thing on the same timeline but if you prove that you have already mastered or become competent in a certain area that you would then move on to the next step. And so that’s a little bit more of an individualized approach that also ensures that residents are really ready to go out into the world and be competent or even better than competent physicians and surgeons.

Q: You talked about virtual reality and artificial intelligence and these machines that help operating and there is a lot of discussion right now about robots taking over jobs, so in the field of surgery is it a concern? Could a robot take over the job of surgery?

A: I think that there is a lot of, that’s where the kind of art of surgery and the technical skill of surgery, there’s still art to it. I think there is a lot of decision-making and on the spot decisions that need to be made based on experience that cannot be replaced, but there’s definitely ways of using or harnessing technology to help improve the care that we deliver. So it’s not necessarily a replacement. I don’t really foresee, you know, robots operating on humans, but at the same time I’m working with one of my colleagues and one of our fellows is working on artificial intelligence, kind of, reviewing video footage of cases and being able to tell when a surgeon might be deviating from what a smooth, straightforward operation is and alerting the surgeon, for example. And so I think that would be a great example of how technology could augment what we already do on a day-to-day basis.

Q: I think it’s interesting, because I think a lot of people maybe just think of like a surgeon is in the operating room, and you don’t think of the other parts or you don’t even know about there is the pre and the post and the follow up and through the years.

A: Right, and kind of understanding, I think a lot of it is just empathizing with patients and kind of understanding what their concerns are, because it’s surgery is otherwise something that I do kind of day in and day out, or the actual operation day in and day out multiple times a week or whatnot, but for every patient it’s their first time. And so understanding or keeping that in the forefront of my mind when I interact with patients, to remember that it may seem like a low risk operation and I explain it, but then to realize that for them it’s like surgery. And so what are they worried about? What are they concerned about? What are their kind of fears? And that’s part of the art of interacting with patients and understanding kind of how to interact with surgical patients.

Q: Actually now that you’re saying that I’m curious what is your week, how many surgeries are in a day or in a week? What does that look like?

A: So it may depend on the week. It generally changes a little bit per week. But I operate about two days a week and so that runs from 7:45 in the morning until usually about 4:00, 4:30 in the afternoon. So I have those two days of operating. I have clinics that probably run one and a half or so days a week, where I’m seeing patients either who are interested in surgery or who need surgery or those that I’m following up who have had surgery. And then I have a day of administrative time where I’m planning simulation or working with residents or teaching or whatnot. So that is my general week.

Q: So in a day when you have four surgeries do you have to, do you reset in-between or do you go in there and just kind of turn your brain into like flip this switch on, do this surgery? Kind of how do you do that?

A: Every Sunday I kind of look at the schedule for the week and then prior to every day I kind of look at it again, just to kind of gear up for the day, because every day is different. I have kind of a game plan for each operation, and so it kind of, I go into operation number one mode, and then after I’m done with that then I kind of, once that is wrapped up and I’ve talked to the patient’s family and everything looks like it’s going well and the patient is in recovery then I kind of flip and I move into mode two for the second operation.

Q: What does your best day of surgery look like?

A: My best day of surgery is probably being in the room, and it’s just a day when everything is in sync. The music going. That is like where I’m in the groove and in my element.

Q: What is the music?

A: The music changes. So I have kind of a wide and varied tastes, so a lot of times I love Hip-Hop, but I love kind of Top 40 music as well, so a lot of times I’ll make, I’ll let the resident make the final decision on what kind of music we listen to.

Q: Something to get the energy flowing?

A: Yup, to get the energy flowing, yup.

Q: So you have three kids who are young, growing up, watching their parents in medicine. If you think forward to the future with them would you want them to go into medicine, and if you did kind of what advice would you give them?

A: I would 100% for sure encourage them to go into medicine. I mean whatever else they wanted to go into I would be supportive of, but sometimes I talk to other physicians who are like, “I would never have my children go into medicine.” But I think it’s one of those fields that is just so rewarding and every day you come to work and you realize that what you’re doing is helping someone in a very direct sense. And I don’t think there is any other job that could come close to being able to help other people on a everyday basis. And so all other thing aside, I think that alone is what kind of keeps me waking up in the morning and going to work, and at the end of the day thinking back of what I’ve done it’s just very fulfilling. And so if they were interested and wanted to go into medicine I would be fully, fully in support.

Q: And any advice you would give them?

A: I think the main thing that I hope and maybe I’ve in part been imparting this and I hope to continue to impart is just for them to realize that kind of no doors are closed at this point, and so anything that they dream up of or want to do that they really should kind of go for it and try their best and see if they can-- You know, they should just chase their dreams, because they’re in that phase of life where kind of everything is open to them.

Q: Great. So before I let you go I have my final five questions for you. So the first question, what is the best piece of advice you have been given?

A: The best piece of advice I’ve been given was probably all throughout growing up my parents always kind of reminded me to see the big picture and to keep things in perspective, and so I think those, that concept or that strategy is something that I have tried to keep with me throughout life, and any time something seems difficult or challenging or you’re kind of disappointed about something or whatnot if you kind of look at the bigger picture it kind of resets your perspective and helps you keep going. And so I think I have kept that in my mind throughout life.

Q: The name of this podcast is Charged. So in the context of your work what does that mean to you?

A: So I love the word charged. I feel like charged to me, the kind of things that kind of come up in my mind are like energetic, positive, being on a mission to do something. And I think all of those describe how my personality is and how I am when I’m at work. And so I think it’s a perfect descriptor of kind of me in my life.

Q: How do you recharge?

A: I recharge by, I think every person, you know, while it all sounds good and you’re balanced and everything, but you need a little bit of time for yourself, because I think that is what keeps it real and keeps you from burning out or overworking. And so my, so two things.

Working out and having that little piece to myself, whether it’s 45 minutes or an hour of my own, doing yoga or whatnot, is kind of my way of recharging. And then I think aside from my work life and my home life having time, like my husband and I really like eating, and so kind of finding time to just go out to dinner and just talk about whatever it is, but just kind of resetting from everything else that is going on in our lives. I think those pieces kind of give you a little reprieve and give me a little reset that then recharges you.

Q: When and where are you happiest?

A: I think it changes whether it’s at work or at home. At home I am definitely happiest when we have like one of those weekend days that are completely unscheduled, they’re rare, when they’re completely unscheduled and we’re just kind of hanging out, all five of us. Those are really nice. You never want them to end, and so with the kids being so busy nowadays they are fewer and far-between, but when those happen those are really the best days. Those are probably the best days. My work best days are what I had said earlier, just being in the operating room and being in the groove operating, and things going well and kind of seeing how everything is going to come together and benefit kind of the patient that you’re operating on. That’s my work groove.

Q: And do you have any rituals that help you have a successful day?

A: My ritual probably is what I had said earlier, kind of getting a glimpse of the day and kind of coming up with my game plan for the day.

Q: Alright. Well, thank you so much for coming.

A: Thank you for having me.

Q: It’s been a joy to talk to you, learn a little bit more about behind the scenes of what it’s like to be a surgeon.

A: It is really fun. Thank you very much.