We spoke with the co-directors of the Columbia Global Center for Integrated Colorectal Surgery & IBD Interventional Endoscopy—Pokala Ravi Kiran, MD, Bo Shen, MD, and James M. Church, MD—about the state of colorectal surgery and care, the challenges of improving surgical training, and how the Global Center hopes to redefine how we approach treating these conditions.
I’d like to start with the Global Center. Can you tell me what sets it apart from other programs?
Dr. Shen
Our center manages all types of complex situations; it is our bread and butter. I think we could be called the last stop for complex IBD and complex colorectal diseases.
I don't mean anything bad by this, but we take the cases others don’t want. We collect them. The cases are so difficult to do, but we feel strongly that somebody needs to take them.
We are not a group who treats anyone differently. That's against our doctrine. If you are rich, poor, Bill Gates, you come here with the same symptoms, and the same worries, and you get the same level of treatment.
Patients in our community have a tough situation. Most of these people have already had multiple surgeries that have all failed. We do the rescue.
Dr. Kiran
I think what's wonderful about the Center is what we bring together: we take what's unique about what Dr. Shen does, what Dr. Church does, and what I do, and bring it all together. It’s a combination that no other program has.
For our peers, it's about putting all that together along with the academic part and the research part and the innovative part, and pushing the envelope. At the end of the day, I think the real thing that binds all this together is a passion for providing real care for patients. That is paramount.
And that's what brings on all the research and training, it's not the other way around. It's not about each of us as individuals or about pushing boundaries or about research for research’s sake. It's all about patients; everything else drives from there. We want to do the best for them and safest for them, not what's best for us and safest for us.
There’s really no one like Dr. Shen. There’s no one like Dr. Church. I don't think anyone is close to 80% of what they are. What's beautiful about this place is that each of us does something that is very unique, and the Global Center allows us to bring it all together for the good of the patients. We all work as a team. We respect each other. We have our differences of opinion, but at the end of the day, we always come towards a common goal.
Dr. Church, your reputation certainly precedes you. How did you become involved with the Global Center?
Dr. Church
It started with coming over to Columbia after I retired from Cleveland. I've worked with Ravi before when he was a boy [laughs]. And then when he grew up into a man, he was my partner for a while. I always respected him. He was the best surgeon at the clinic at the time.
The thing about retiring is that it's very sad to just close the door on a career and walk off into the sunset. That's stupid, really. I think older surgeons have a responsibility to dispense their wisdom that they've gained over the course of their career to young people. It's a real shortcut to knowledge. People don't have to go through 30 years of practice again to find out the same things that I had found out.
So, if as a seasoned warhorse in the department, I can serve a role as a mentor, I’m happy to do it. The department needed it at the time, and still does, because there are very few gray haired people in the department now.
So, that's my role, as I see it: to educate, to help out with difficult cases that no one has ever seen before. Because maybe I've seen them. I’m eager to show people what I've learned in patient care over three decades of practice.
Do you have any thoughts on the current state of care? Is the field of colorectal surgery heading in the right direction?
Dr. Church
We've talked about this quite a lot of late. For some perspective: In medicine, there are different levels of care. There's primary care with general practitioners, there’s secondary care with local specialists, tertiary care for the cases that the specialists can't handle, and quaternary care for complex cases that even the super specialists can't handle. We're a quaternary care institution; we handle the most complex cases, cases no one else can solve.
And in our experience, the average level of care across the country has gradually become mediocre, with pockets of downright bad. We see this in the office all the time. Within the last couple of weeks, I’ve seen patients coming in who have had nine operations on a very symptomatic area. They can tell that their local doctor has no idea what to do next, and all they are offering are inadequate and wastefully expensive—and wastefully painful—options that are clearly not going to work. So either they ask for a referral or they go online themselves and find somebody who has a better reputation.
So, to answer your question, I would say, let's go back 20 years and let's not get any worse. I think we’re in a gradual and almost insidious cycle where the training institutions have fewer quality people, and so the training they offer is of a lesser quality. As a result, the people coming out of those mediocre programs set up their own programs, which are another level down, and the graduates of that will be another level down.
I wish we could go back to the time when the dinosaurs roamed the world and we had big centers staffed by big surgeons. Standards matter. Reputation matters. By taking the Cleveland Clinic reputation and bringing it here, I think we're trying to perpetuate that. We hope to train people to go against the trend of mediocrity and go out and reestablish superior care. If we start in little pockets and train superior doctors, gradually we can reverse that trend. That's my hope.
So is raising standards for training an essential next step?
Dr. Shen
Absolutely. We have the highest standards for training; we do not compromise. Because the ultimate goal is the benefit of the patient. We must always think of the patient first; not student, not fellow, not doctor. Our patient comes first.
It is not like we can train just anyone; you need motivation, you need to be caring. And you need the skill, of course. And yes, we can train somebody to be technically expert, but after you train for all the fancy techniques, you still need to be a good doctor. If the trainee does not meet our standard, I'd rather not bend on this. How can they survive our intense training and then share their expertise? If we set an example, more people will be interested.
So we have high standards; among all the people I probably trained here, I would say that 10%, maybe 15% make it. I am so proud of these doctors. Recently, one of them became the GI chief with one of the big health networks, another is now a professor in Florida.
This type of candidate is harder to come by because we have such high standards, but that is the best way to ensure good results. My mentor at the Cleveland Clinic, Dr. Victor Fazio, trained so many people over his career, doctors that would later on become famous, heads of major departments. The same with Dr. Kiran and Dr. Church. If you do not compromise, the right people will come.
What about ways to improve care with surgeons that are already practicing?
Well, one more way we’re trying to reverse the trend happens a little more informally. During my time at Cleveland, previous graduates would always call up with difficult cases for advice. We see the Global Center as a resource for second opinions, not in person, but for other practitioners calling up and saying, “What would you do with this case?” We want people to know that we would be happy to do that.
As I said, I think it happens informally; it happens with me with Cleveland graduates every few days. It can give a helpful perspective;I can't tell them exactly what to do, but I can give them my advice. It's a way of improving outcomes, and that’s the most direct path to improving the general level of quality.
It’s especially true for rare conditions, where your average community surgeon might see a condition once every three or four years. We see it once every three or four months, so we are able to provide a different perspective on it.
What does it take to be a mentor in the colorectal space?
Dr. Church
I'm always keen on the concept of emotional intelligence, which is being aware of the people that you're in contact with, what they're thinking about, what they're feeling, what they need.
I really enjoy teaching. I'm not going to stand around in the operating room talking about the Jets or the Browns, or whoever the football team is. I'm going to talk about the case, the nuances that you can't see in a textbook, details that nobody else is going to tell you about.
I'm going to ask questions. I'm going to do my best to educate. That's in my DNA basically after so many years trying to do it. Above all, I want to help the patients. That's why we're all here.
A lot of referrals that come now are self-referrals; patients look you up. I get comments all the time about two videos that I've recorded, which state my philosophy of care. That often will settle the deal. They see those videos and say, I want to go and see him.
It’s the personal approach that people connect with. I think it's the obvious compassion that you have for people, and how that dictates your approach to the patient and the family. It makes a big difference.
How do you identify who will potentially be a good surgeon? Who is going to flourish with the right mentorship?
Dr. Church
I've written a bit about what makes a good surgeon. I do this question of the week for the team here, and one of the questions just recently was, what makes a good surgeon? In that presentation, I refer to what surgeons used to be like: typically men, they think they're God, they think the patients are basically an interruption of their lives that are a necessary interruption.
They don't think about the patients as a person, but rather the gallbladder over in room four. The patient becomes depersonalized. That's the old way of doing it. There's a series of books called Doctor in the House, set in England, which really summarizes that time and mindset. I lived through it because my father was a surgeon. His peers were egotistical, arrogant, and proud. They liked to tear down the residents just to make themselves feel better.
Thankfully, things have changed a lot. They had to. Today, if you start throwing instruments across the operating room, now you're going to get disciplined. Whereas 30, 40 years ago, you could throw instruments anywhere you'd like.
I think surgeons have to have a human aspect of them that, in the old days, would have been thought of as soft. But these days we recognize the need to be sensitive and compassionate.
What part does skill play?
Dr. Church
Obviously, the skill has to be there. Surgery is based on a talent that is out of anyone’s control. You can't make a talented surgeon; they're born a talented surgeon.
They have good hands, they have an instinctive, intuitive feel for tissues. If you don't have the talent, you may as well go and do dermatology.
And with talent, there’s the need for training. Every surgeon takes with them in their surgical DNA bits of the mentors that they've encountered along the way. If you're lucky enough to encounter a series of good mentors, they're going to take your talent and help shape it, make it as good as it can be.
So those are probably the three basics: the talent you're born with, your compassionate attitude towards people, and the pattern of your mentorship as you go through your apprenticeship.
There are other helpful qualities, of course. It’s obviously very useful to be smart, but also to be curious, wondering. A great surgeon doesn't think about disease processes as a technician. You can train anyone to do an operation, but you can't train anyone to be a good diagnostician, to alter your approach based on your understanding of the disease process in front of you.
Each patient is different. So thinking about what you're doing, why you're doing it, and what the effects of what you're doing will be for this particular person, should all be part of the surgical makeup.
Could you speak about any of your own mentors?
Dr. Church
Well, I think all of us have the mentorship of Dr. Victor Fazio. I would go so far as to say this relationship is the root of our global center. I think Vic would love it. He was a one-in-a-generation mentor. He espoused everything that a good mentor should be.
If you resonated with him, then that was a unique lifetime experience and it made us what we are. I think that's speaking for the other two of us. That was the center of it.
Dr. Shen
I will give you a little bit of perspective. I would say that if Dr. Fazio was still alive, I would not be here. He meant that much to us as a mentor and teacher. He established the biggest and most famous colorectal surgery center in the world. Unfortunately, he died about 10 years ago, and our goal is to extend his legacy.
It is why we are so happy to have Dr. Church join us here. It will help us extend Dr. Fazio’s legacy. We have an annual symposium called the Dr. Victor Fazio Ileal Pouch Symposium. We just had it in the third year. But the Global Center itself is part of Dr. Fazio’s legacy.
You are all Cleveland alumni. What are some differences between the Global Center and the Cleveland Clinic?
Dr. Shen
I would say that we are close to the Cleveland Clinic in terms of what they do for complex IBD surgery. Columbia has a unique position thanks to the wealth of talent here, the larger and more diverse patient population in New York, and our expertise on the translational and basic science research side.
We also have a monthly tumor board and IBD board for complicated cases. We present the whole board to 20-30 doctors, and we let them vote on how best to proceed. That's a unique thing here at Columbia.
Now the problem of accommodating the patients that need us is a challenging one. For now, we are a new center; do we have a facility to accommodate the patients as we grow? Time will tell. But the reputation? We have that here. Our skill? The best.
How do you apply what Dr. Fazio taught you at the Cleveland Clinic to patient care at the Global Center?
Dr. Shen
I believe that as a surgeon, an endoscopist, a medical doctor, it is not about self-promotion. It is about outcomes. Dr. Fazio was such a nice person, but I think that almost every five years, he fired a surgeon because their outcomes were not good. Not because of laziness, or personality, but because their outcomes were not good.
We have the same standard at the Global Center. Here, we don't do lip service. We lead by example.
On a personal level, we have a shared mentality. In order for people to work as a team at the highest level, they need the same mentality. We may not have the same personality, but the same mentality is key. It allows us to prioritize the benefit of the patient. None of us would be bothered if somebody said they wanted a second opinion from Memorial Sloan Kettering. We would actually encourage them to do that. We want that patient to come back, armed with more knowledge, to feel more confident.
Our synergy on the personal level allows us to be more collaborative, because we work very hard. Believe it or not, we are probably the three people who work the hardest among the whole division, maybe even the whole institution.
I see patients in the hospital that I share with Dr. Kiran; he has a surgical approach, I have an endoscopic approach. We may not agree with each other all the time; actually, I think 50% of the time, we may not agree with each other. But we present our approach and compare.
Maybe endoscopic therapy is less invasive but less effective, surgical is more invasive but more effective. Each case is different: maybe you pick the Chevrolet, maybe you pick the Mercedes, But you present an option that can get the job done. All for the benefit of the patient.
Cancer treatment is a focus at your center. How do you see colorectal cancer care evolving?
Dr. Kiran
Interventional endoscopy is such a unique area; it’s adding a third dimension to treatment. Before interventional endoscopy was pioneered by Dr. Shen, there were two options: surgical or nonsurgical. Now, endoscopy is bridging the gap, allowing us to do more for our patients. And this is specific to the Global Center; no other place has it.
We believe that having more options that work together for the benefit of the patient is the future. The Global Center is based on this idea; there are lots of unique things related to cancer that we possess that no other institution has. New York is home to a number of cancer centers, of course. What distinguishes us from those groups is the ability to take on very challenging cases, the type that require complex decision making.
Cancer is an area where expertise both directly improves outcomes and gives us a chance to focus on quality of life. For example, polyposis (growth of multiple polyps), young age colorectal cancer, and genetic syndromes that give rise to colorectal cancer are areas that Dr. Church knows better than anybody else in the world. So our outcomes are very good. And with that advantage, we have simultaneously built our surgical techniques around quality of life. So it's providing both a cure and improved quality of life. That's an improvement in care that is possible only with a high level of skill in all areas of treatment.
What does that look like to a patient?
Dr. Kiran
For a very simple example, you have a patient with a locally advanced cancer which has not spread anywhere else. We have the ability to resect that because of our experience with surgery, endoscopy, and other techniques. We can redo the operation in the pelvis, but also reconstruct it at the same time.
That is why this approach is an improvement over care in a silo, and that is what is different about us. We are able to reconstruct wide ostomies for people, put them back together when other people can't. Being able to mold that with the excisional part, or resection part, is one thing that's unique about us.
And for colonoscopies, we have two world's best experts at colonoscopy and interventional endoscopy in Dr. Church and Dr. Shen, respectively. Dr. Church was one of he biggest names in colonoscopy throughout his career, so the impact he has is significant. All of this fits together into the cancer treatment umbrella.
Add to that our ability to address complications from surgery, or the interventions we offer to help avoid surgery for patients, and we are alone in the space.
Another major focus of the Global Center is fixing failed surgeries. Are there gaps in the standard of care that you’d like to see addressed?
Dr. Church
Pouch surgery is kind of a “heroic” surgery, so surgeons like to do it because it's a big deal and it makes them feel good; “I had a couple of pouches this week, so this is a great week.” They don't necessarily appreciate that things have to be done right, so their outcomes aren't as good as they could be. Unfortunately, sometimes they're shockingly bad and these patients come to us to have Dr. Kiran revise or redo the pouch and get their quality of life back.
Pouch surgery is one of our areas of expertise. There are lots of little aspects of technique and timing and decision making that have to be done right to get the best result.
If I had my wish, people would need to be credentialed at doing pouches so that the surgeons that now only do one a year would never do them. Make sure that people that do them badly never do them and pouches are just distilled down into a few centers. That would be ideal.
Dr. Kiran
I think getting others to do things right the first time is not necessarily under any of our control. But making the Global Center the place that shows how things are done will feed that idea, starting on a grassroots level.
I would like to see the Global Center establish new ways of doing things in a more coordinated manner, one that's very patient-centric. The entire thought process: coordination of care, diagnosis, and disease management algorithms that are more fluid. We need a system that better helps everybody determine the best approach for management. Because training, management philosophies, research… These are things that we can impart to residents, colleagues, surgeons, physicians, office personnel, nurses, nursing personnel, et cetera, on a one-to-one scale.
I think we can achieve this new brand of care, one that is very patient-centric and more fluid in terms of different modalities. Every area that impacts patient care, whether it's surgery, endoscopy, medical care, dietary or nutritional support, allied medical specialties like wound-ostomy-continence nursing, needs to be exceptional. By showing expertise along every modality, every area will automatically improve and promote new concepts, new ideas, new techniques, and new training within each field.
Is that something you feel is not present in the space right now?
Dr. Kiran
Absolutely. And it leaves gaps. I think that's what is unique about us. For example, Dr. Shen was instrumental in bridging this gap for pouch disorders. Dr. Church has done it for decades with polyposis hereditary cancers. When everything is streamlined across all specialties for patients and caregivers, it closes those gaps.
Showing how it can be done for each and every problem is how we can lead. We often say that this is the place that people should come to when they feel there's no hope anywhere else.
How do you go about making this type of fundamental change?
Dr. Shen
We are trying to create a culture that doesn’t take the easy way out. For some surgeons, if there is a leak or blockage, do you know what they do? They just give permanent stoma without exploring other options. They know there's endoscopy options available to treat, but that is not how they think. It’s for the ego, right? They make a decision without telling the patient that there's an option to rescue that. You need to be open-minded when you choose healthcare as a profession
Our model works very well. We say uniquely positioned; I don't think there are any competitors in New York City, or even nationwide. That’s because of this synergy. We have created a culture among all of our team and it sets a tone.
Are there any new technologies that you’re excited about?
Dr. Church
Genetics is one of my fields, and the sky's the limit there. The problem is that, as a specialty, as surgeons and gastroenterologists in general, we lack the basic knowledge and understanding. We lack the foundation to appreciate the advances that are coming up.
I've just written a paper for our colorectal journal called “The Colorectal Geneticist.” I describe an ideal person that can communicate between the basic science and the clinical. Unless you have people that can interact at that level— a colorectal surgeon that understands genetics can talk to a geneticist, and geneticists that are interested in the clinical aspect of their work—you could have all the advances in the world but they won't be applied properly. So there has to be that level of interaction, and that's what I've been doing for the last 30 years.
I've dedicated a lot of time writing and speaking in an effort to teach colorectal surgeons and gastroenterologists about genetics, especially with regards to colorectal diseases. That has to continue and be amplified.
How about new surgical techniques and devices?
Dr. Church
I think robotic surgery is going to be a big mover in the future. But it has to be well-tested and there has to be a benefit. Why spend millions of dollars if the outcomes are the same for doing it a different way that is much cheaper?
Another aspect of advancing technology is that we see many examples of technology developed for financial gain and then applied unwisely to clinical situations. For example, stapled hemorrhoidectomy sounded like a great idea, and it made a couple of people famous, but it ruined so many people's backsides that it just dropped out of use. So we have to be on our guard against that.
Another example of a so-called advance is stem cell therapy, which so far has been a lot of money spent with really very little or no benefit in colorectal disease. I think all three of us being academics, we are very fine-tuned to the literature. We go to meetings, we're up to date with what's going on, and we are well placed to evaluate it. So I think we can use trials that we can supervise as a way of testing some of these advances, but with care to not ignore what already works.
Dr. Kiran
I would echo some of the same things. Different innovations in surgery are just tools towards the same goal. Sometimes a patient has a big open surgery and may do just as well as somebody who has a tiny keyhole surgery. It is the outcomes that really matter.
I do feel that advancements such as genetics or the use of AI to identify problems sooner, earlier, and less invasively will probably be more important than any new surgical tools. Whatever helps guide the thought process and decision making is important, because at the end of the day, it's what best helps the patient. I just look at new technologies as tools towards that goal.
Dr. Shen
From the endoscopy perspective, a recent article in the New England Journal of Medicine highlighted a next-generation multitarget stool DNA test for colon cancer screening.
AI is good for the detection of colon polyp dysplasia and dysplasia associated with IBD.
Some of the latest advances are happening here. We have just published a book called Corrective Endoscopy and Surgery in Inflammatory Bowel and Colorectal Diseases. We explore the latest techniques and technologies, such as balloon-coated endoscopy to treat refractory structures.
And guidelines are as important as new technologies for improving outcomes. We developed maybe a dozen new techniques to treat IBD-associated complications, including fistula, sinus, and postsurgical complications.
We have published five guidelines in the Lancet Gastroenterology & Hepatology, and we have an article published in the New England Journal of Medicine. As leaders in the field, we provide better guidelines to show the way.
Is there a condition or disease that you feel needs more attention?
Dr. Shen
For me, it is IBD-associated cancer. With sporadic cancer, you can see the polyp, you remove it; if you can find the enemy’s surface ship, you remove it. It’s easy. IBD is like a submarine, the cancer is underneath and hard to detect. Colonoscopy is still the best way to do it, but there is a lot of work to do to detect the submarine.
This is my biggest challenge. Once every three months, I see a biopsy that is negative, but three months later, they come back with metastatic cancer. This is challenging from my perspective, as a top gastroenterologist, to see that the technology only goes so far right now.
Dr. Church
Two things come to mind. One is pouch surgery, which I spoke of earlier. The other area is anorectal infections and fistulas. If you look at the world literature, the success rate in curing these is about 50%. I hate to sort of trumpet things, but I can point to a cure rate of 98%. You can fix them if you do it right. But people very rarely do it right because they don't understand what's going on. They read the papers that are done where it's done badly, and they reproduce that.
You see it in the office every day. It is just astounding how people can be so uninformed and so technically bad and the patients pay the price. It drives me crazy. You just keep up a flurry of writing and reporting and try to get it corrected. But unless they come and watch us do it, they're not really going to learn. I remember at Cleveland, we put on demonstrating cases where we showed people how to do it, and we published videos showing not just the right way to do it but the reason for doing it that way. That's something we need to do a little bit more.
Dr. Kiran
I think along the same lines, there needs to be an overriding desire on the part of the clinician to provide excellent care for the patient. It doesn't matter what the diagnosis is,whether it's simple or complicated, or if the surgery is simple or complicated. There's nothing simple, nothing complicated; you just have to do it right and do it well.
It could be for cancer, for IBD, for anal fistulas, for hemorrhoids. Having a passion for what you do makes things better. And I think that's what I'm hoping the global center will stand for. Not only for the complicated stuff, but also the simple stuff. We’re going to do all things well.
How do surgeons get to that level?
Dr. Kiran
As a doctor, you get to that point by taking care of a lot of patients, by learning and observing what's going on with your patients and their outcomes. You get there by researching, looking at outcomes, and fine-tuning techniques based on the outcomes you see. And that's where I think clinical care, education and research as well as innovation all kind of come together.
Some clinicians have that intense interest and desire to bring all these together for the common goal of the patient. And I think that's what's important because then you'll do everything right. I mean, you could very well be a very good hemorrhoid surgeon. I would be proud to be one if I had the best results in the world.
It’s not just the technique part, it's the decision-making part. It's what kind of procedure you do. It's the perioperative care, how you get your patient through the process so that postoperative outcomes are optimized, their complication rates are low. The possibility of discharging them the same day or next day but having similar results as they would have in the old fashioned time of staying five days, six days.
It all melds into one process if you have that interest to advance treatment that benefits the patient.
The Global Center seems like a pretty demanding environment. Do you ever worry about maintaining this pace?
Dr. Shen
If not to help people, why become a doctor? I know that lots of people become doctors for other reasons: glory, income, job security. I believe that is wrong. And how will they be able to deal with burnout? To face burnout, you want to become more caring.
For me, if I am asked if someone is a good doctor, I want to see not just what they do with their spare time, but do they enjoy it? If their spare time is mainly to take care of the patient notes, working on the paper they are writing, they should enjoy it. Your work burden should be your hobby.
Once I was traveling to China with my mentors, and local people asked to golf with us. Golf? [laughs] None of us even knew HOW to play golf; in our world, what time we do have, we spend with the patients.
Dr. Church
For my perspective, I'll just tell a story. Some time ago, I looked after a 26-year-old lady who was pregnant and was thought to have Crohn's disease. When I looked up into her bowel, it looked suspiciously like cancer to me. And sure enough, it WAS cancer. But we were able to help her have the baby, then we removed the cancer and cured her.
When I retired, she gave me a watch. And on the back it was engraved, “thanks for the time.” This was 21 years later. Her little baby had grown up into a man, and she was so grateful. For me, that experience summarizes the impact you can have on people's lives. There's nothing more satisfying than that, I don't think.
Of course there are times when the disease wins. But if you've done your best, hopefully the wins are much more than the losses. But even in the losses, you can have a big impact on people's lives.
I think if you weren't supposed to be doing this career, it would be pretty obvious. I have no experience of that because I'm one of the lucky ones: each decision I've made, each path I followed along the way, has been reinforced that it was the right one. So I'm grateful for that.
Dr. Kiran
I agree with Dr. Church. This is what I always wanted to be, and I have no doubt any single day that this is what I'm meant to be doing. I can't think of any other profession that would give me the same kind of joy and personal satisfaction. It’s the reaction of the patients, seeing the patients being happy. I can't think of any other profession more fulfilling.
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