Welcome, my name is Dr Warrick Bishop. I'm a cardiologist, an author and a keynote speaker. I'm CEO of the Healthy Heart Network. I'm all about trying to help people live as well as possible for as long as possible. Heart disease is huge in Australia. Every 20 minutes someone suffers a heart attack. Most of these could probably have been avoided if only we knew what to do. This podcast is all about helping you understand blood pressure, weight, cholesterol for better health. If you enjoy this podcast, I would be honoured for a five-star review. You can share it with your family and friends. It may well save someone you love. Hi, my name is Dr. Warrick Bishop and welcome to my podcast and videocast station. Today I have the opportunity to interview Peter Tessa, a cardiothoracic surgeon. He's based in the Prince Charles Hospital in Queensland. Thank you for joining me, Peter. Hi. It's looking lovely down there in Hobart. It's been a cracker of a day, actually. Been an absolute cracker. Let's get going with this. What would you like to know from me? So for those listening, Peter, this podcast is really going to be centred around patient journeys through open heart surgery. You're a cardiothoracic surgeon, which means you perform surgeries within the chest. But let's stick mainly to heart-related surgeries. And what I was really keen to tease out from you today, Peter, is how you see patient journeys occurring and how people travel differently through that path, depending on such things as whether it's an elective case, an emergency case, their premorbid personality. What sort of observations? do you see with people travelling through these major events in their lives? Surgery is pretty confronting for people. And surgery as well is accepted by people very differently depending upon age because there's an age where you anticipate having... serious illness and there's an age where you don't anticipate yet. And so it's quite threatening. And it's also varied according to symptom status. So if you know you're unwell, so you've got, by example, heart failure or you've got significant angina, you actually want to have all of that corrected. And you've already gone through a process of, as opposed to being told by the doctor that you need an operation, you've actually already, to a degree, often negotiated in your mind and rationalized it that you want the operation, which means that you're already telling the doctor that you're going to join the team. There's a mindset where the person goes through to actually show that. Whereas if you're coming to a doctor and you're pretty much asymptomatic, you have no pain, no shortness of breath or any other cardiac symptoms, but you're being told by the doctor you need an operation, by example, because you've got a big arterial pipe and there's a risk with that that it might cause you an adverse event, then... There's an aspect of grieving and then acceptance to actually potentially have an operation. And it's a different thing because you're well, but you're being told and then telling yourself that you need something to take your health forward and keep you alive. And so it's a totally different state of mind to do that. And we confront patients like that all the time, the differentiation between them, that you're actually taking them, all of them, doesn't matter how they present, you're taking them on the journey that they want to participate and join a team. And the coach of that team happens to be the cardiac surgeon. And different personalities and different ethnic groups. and address that differently where you almost have to reel them in. You have to fish them and reel them in and get them to establish eye contact and get them to be as one with you that you can take them on that journey. And I'll leave that as my entrance to that thing. And how would you like me to take that forward from there? Look, Peter, there's probably a third group of people. You've alluded to individuals who have got some sort of cardiac issue, which has given them symptoms and progressed and presumably got to the stage where their cardiologist has said to them, look, we now need to take it to the next level. And those individuals, as you say, have probably had the chance to be aware that they need something done. Then there's individuals who you clearly operate on. And they haven't had symptoms. And obviously that's a different mindset again. But there's also going to be a group of people who emergency cases who have absolutely no idea what this journey is going to be like because it comes out of the blue and the responses are obviously emergent and rapid and there must be a real discombobulation or a real upset if they're... their sense of self and their wellbeing. That must be an incredibly stressful time for individuals and their families. You must engage each of those groups differently. How would you, what's some of the stuff you do with those emergency cases? Because they really must be raw at the time. But let's just go back to the, let's say a younger patient who's got that aortopathy, that big aorta. I think one of the things that we do with those patients, which is actually just talk them through it. There's a mindset in those people that they feel very isolated because they're not sure that anyone understands how confronting it is to actually you're confronting your mortality to do that. And you're not sure who you can speak to because no one's going to understand the mindset that you're in in that circumstance. And drawing that out and showing that you have an understanding, it's not about being empathetic exactly. It's an understanding that you can coach them through that whole process and get them to just stop some random thoughts because their minds are often twirling around. Stop some random thoughts. They can just have a clear pathway focus is actually quite an important thing. With the emergency patient, They just think they're going to die. And one of the things that with the emergency patients will draw them in to take them forward because a lot of the machinations in their mind will only occur postoperatively where you have to walk them through that afterwards. But preoperatively, they need to believe in you. And that's one of the critical things. So detailing every absolute... risk and potential adverse outcome is not what they want to hear. What they want to hear and believe in you is that you have a high prospect of making them survive. And they want to, in that moment, they want to establish a belief in you as a doctor. So some of what you're doing is actually selling yourself to a degree. You're actually getting them to believe that you as a clinician believe, because that's actually an important thing. A patient wants to see that the clinician treating them as a belief, not that it's sort of arrogance, but there's a confidence, they've seen this before. and they believe that you can get them through the operation to have a conversation after the operation. But without promising them the absolute outcome, that they want to go in believing they're going to come out the other side. And so a lot of the conversation, again, is not about, you know, as it's being taught to us over the years, going through each individual potential risk of a procedure and everything else. It's about... getting them just to believe in you as a clinician that you can draw them through that. The other critical thing that we do with all these patients and the emergency ones in particular because they're going to experience it straight up, you know, 12, 24 hours later, hopefully, and they usually do, is you want them to understand. that when they wake up, they're not suddenly magically going to feel normal, but they're actually going to feel as if they've been in a boxing game or hit by a truck or something equivalent, that in fact surgery is controlled trauma. It's just no different to anything else of that nature. You feel like you're being bashed up. The body responses which are associated with that... are no different to having the worst flu you've ever had. And so that's an additional thing which you feel like. And that when you do feel like that post-operatively, that's anticipated. Nothing's gone wrong. That's how a person feels when they've gone through that sort of trauma and that sort of emergency procedure, that you will have all those things in. And then it's a slow process, often getting worse for a couple of days before getting better. but you then go on to the slow road to recovery. And if you give them that valid expectation of how they'll feel, that's probably the most important thing for all patients so that they can then get drawn through this whole process called surgery, and particularly major surgery. And it's very easy to... to make people understand if you've got the time because almost everyone has had an injury in their life, typically in a sporting venue, and the one that you often give is a cork thigh or a sprained ankle where they have an acute injury and then two days later the pain is still there, but now it's swollen and stiff and, in fact, they're less able to use that arm or leg. And then slowly over the next week, when you're young, it gets better. Whereas when you're older, the same process is going through, but the recovery period is longer. So they'll often recover not in seven days, but in 10 days, two weeks, something of that nature, depending upon comorbidities. And it's always surprised me. Football coaches understand this. They know the natural history of traumas and recovery. And, you know, they get interviewed after a game of football, by example, and they'll say, oh, he'll be out for two weeks or he'll be out for three weeks or this is minor. They'll be back in a week's time. They all know that. In healthcare today, that sort of natural history of what goes on is actually not taught that much anymore. That trauma response and how you recover from it is not actually taught. But that's a very important thing to do. And then day by day, in the post-operative phase for these emergencies, you establish a coaching process. Now, there's a natural history which you do in the way that you manage these patients post-operatively. But the critical thing for the patient is coaching, that you can keep them, that their mind is in the right place, that they never throw in the towel, that they keep marching themselves forward in a slow and steady fashion. You relate to the patient that their progress is as you anticipate. And this is one thing which is critical. People always talk about care pathways. But the care pathway is an anticipated pathway from experience to what you think the natural history is for that individual patient. The one that cardiologists will know is if you have a staphylococcal endocarditis, you know, the question gets asked, when should they defervesce? When should the temperature go away? And the answer is you're dealing with a systemic infection where the patient has seeded around their body. And, in fact, the defervescence in those patients who are taking a normal course is 10 days. And not to worry and change your antibiotics in that time. Now, what's the normal course that you anticipate for a patient to get better after a dissection and with going through a normal recovery? And, you know, it is that... you'd anticipate that they'll start really picking up and it'll take five days or a week or something. It's not, you know, in a 70-year-old patient that they'll only suddenly get better in two days. So it's having that understanding of the natural history of what you have in front of you that you can then advise the patient that when they're feeling a little bit lousy, that if they're on the right track or not and keep wheeling them forward. If you can do that with people, you can actually get them to grab life thereafter. One of the things in healthcare we're really good at is getting people to live longer. And in the last 100 years, the life expectancy of the population has increased about 40 years. So we've done an amazing job with all the technologies, in all the specialties, with everyone in every walk of healthcare. It's actually seriously amazing. But one of the things we're not taught to do in healthcare is get people to grab life. And that's something which has become something of greater significance in the way I treat people, probably in the latter part of my career. in association with me trying to enjoy life more as well than I did when I was younger. Of course. So there's no question that the competency issue is a given. The training that you guys do across the board for cardiothoracic surgery, the quality of care across the board in all the specialties in Australia, it's a given that we've got the training under control. So I was very... Very interested in your emphasis about building confidence in the individual so that they have some belief in you. And then that opportunity to coach. So they're incredibly important aspects of that journey. Outside of that, for the patient, do you see things like their pre-morbid personality, their family support, their attendance to rehab? try and work in with these sort of aspects of their likely team to get them back to life? There are certain personalities which I suppose the most difficult personality in broad terms going through an operation is the patient who has the greatest what's the word, where it's the hardest for them, just make it simple, the hardest to relinquish responsibility of their body to you. You know, the people who are more controlling have the greatest resistance to relinquish that responsibility. And that's the differentiation of a client and a patient. So if you go and buy a pair of shoes and you don't like them and you can tell the shop assistant, you know, that's one of the beauties of shopping. You've got a great shop assistant. They'll always win. You don't, they don't. And you tell them, I'm not going to buy something. But once you actually go to a surgeon, you relinquish a level of control. And the patients who have the hardest ability to relinquish control, are people who've got CDO. That's obsessive compulsive disorder, but the letters are actually in alphabetical order as they should be. Okay. That's an OCD joke for anyone who's not paying attention properly. Thank you, Peter. But they're not used to relinquishing control. And so that's one group. And then there are groups where, and this is across a whole spectrum of people, but there are those groups where the environment of a hospital is so foreign. I see that somewhat in Native Australian people at times as a specific cultural group that I deal with. And they have to be drawn in specifically because Often they see this as a very foreign environment and you as a doctor are a fairly foreign person to them. And you have to deal with them very respectfully and get them to warm to you. And it always fascinates me is that as they warm to you and you draw them in and you go through the process of explaining maybe some of the thoughts which might be going through their mind. From my experience, whether it's an absolute that I've got doing everything perfectly, I'm not going to say, but from my experience, this is what I do. And it's amazing as you do that, they'll actually change in the way they approach you. And often for a period, they look away from you. And as you draw them in, they actually establish eye contact and actually become part of the team. They become more as one with you. that they'll trust you to actually draw them through the whole process. And that can be in any of the groups which we've just discussed. But you have to take the time beforehand, even if it's just half an hour before an emergency, rather than rush, rush, rush, just give them a little bit of time to just try to draw them into the pathway they're going down. And that this foreign environment will be fine for them and that you'll, again, walk them through this whole journey which they're undertaking. But some people find the environment of a hospital very threatening because it's so foreign for them. They've never been there before and they've never seen anything like it. And we have a disparate population in Australia between those who... are in the so-called big smoke and they accept all of this and those who work, live a very foreign life to us who are much, very distant from major cities and their lives are very different to what our lives are and we have to be cognisant that the population of Australia is not just one type, it's all types of people and they'll all approach us in a different fashion and just to... Allow that to occur and hope that in talking to them, they will join us because I find it's really important or I want it. I try to make this happen, not perfect at it, but I try to make it happen that the patients feel part of a team, that they're part of the whole process that we're going on. So they'll work for me, not just that I'll work for them, but they'll work for me in hospital and thereafter. to accommodate the process. Now, the families then, you brought the families up before, the families then become a support structure to that team to maintain that going forward when they see all of this happening. And, you know, one of the things that we did with you that you'll remember is I taught you how to cough. Remember with not putting the, yeah. So I taught you how to cough. Now, when patients and families see that you will stop to do something simple with them where you can ease the pain that the person is suffering for that special moment when they do it, because in between, they're often reasonably comfortable. That's part of the thing. When you explain to patients that they should look at not... Do you have pain? Because obviously pain is a constant in that early phase postoperatively, but you're asking questions about comfort. So you're asking the language. The language of discussion is constantly in a positive vein. That also helps the process a lot. So you always try to structure your questions in that manner. And it surprised me that that wasn't understood. So I did a psychological survey with a psychologist. So they actually did it for me. It's not that I'm that sophisticated to be able to do that. But they did a psychological survey where I put it to them that the way you ask a question will give you the answer that you're looking for. So if you ask questions in a positive manner, you get a positive answer. So it wasn't your stay-in-hospital great. Aren't you great that you've done so well? You know? and maintaining that in the go forward, then you'd get that answer. But if you say to them, what are the things you didn't like in hospital, geez, you can go on forever. So the language we use actually dictates outcome as well because the long-term outcome, and, of course, that goes into rehab. Some people clearly need rehab afterwards because they're physically deconditioned rather than... All patients need cardiac rehab because cardiac rehab to a degree, because you might get a 30-year-old sitting next to an 80-year-old, can be a little bit disenfranchising with that discordance of the population base. So some people need it more than others. Some people, the rehab I do with them is send them to go to boot camp and go to a gym. so that they can go to something which more suits their entity, you know, and they can start that at six weeks postoperatively, and they need to do that to get themselves back into life. And then when they go out of hospital, what you're actually, and you asked about the family, you're engaging the family to become then the coach of the patient to go forward, that they take a little bit of responsibility of that, not to mollycoddle the person. They're a support base, but they're the continuing coach when the patient goes home to actually help with that whole process that the patient then grabs life thereafter and is positive to it. Now, you can't make everyone positive in life, but it's a little window we have that for that brief period that you work with them, that you might get them to smell the roses, listen to a joke. have a laugh every day, make it that they see life a little bit differently thereafter. Look, this is probably one of my longest podcasts ever, but I feel absolutely privileged with the content. And I think it's covering the very information that I'm keen for people to hear. And it's about connecting. It's about... confidence it's about guidance and coaching and I think it's a a really terrific bit of information you've shared there Peter. I will jump in and for many people listening they may be aware that I've gone through the process of open heart surgery at your hand and I have to say that you went above and beyond to connect with me and reach out even way before our scheduled date in theatre, and you were definitely a hard-ass coach on about day four when you pretty well told me that you didn't want to see me in bed again, and I didn't look back, actually, after that. You know, now this will be a little bit weird, but, you know, patients whinge sometimes postoperatively, and that's fine. And most people go, oh, there, there. You know what I mean? There, there. I'm so sorry. My line generally with those patients post-operatively is to say, well, I think the tone of your voice was pretty good. I think your facial expression for a time was good. Your body language could have been upgraded a little bit. And when you finish it, that I haven't actually reacted, you start smiling at me. The acting performance is not good enough. So on today, your whinging is only at a 7.2 level. Next time I come to you, if you could slightly upgrade it and in between, this is what I want you to do and stop your whinging. Because to take you forward, I need you to do work for me. And sure, it's not easy and I understand that, but that doesn't stop the process that for you to get better. Let's get back to basics and you start working for me again. And some of the things which are irritating you, I'll go through them individually, see if I can upgrade the care process so you're better. But I don't want the mental aspect to be that you then hold yourself back for the end that we're actually chasing. And so we have to deal with the physical, which is going on, and we don't deny that. But the mental, then we have to re-engage the mental process that they're chasing the same outcome that I'm chasing for them, which is that it's positive and that they can grab life, go home eventually and grab life. And if they need some formalized rehab, they'll get that. Or if it's something which they can do with family supervision later, then that's fine as well. And maybe going to a cardiac rehab process as well. Thank you so much, Peter. Some really wise words. And thank you so much for sharing your own experience and how you take people through that process. For those listening, I really do appreciate you taking the time to tune in again. Thank you so much, Peter. Tessa, cardiothoracic surgeon from Prince Charles in Queensland. Thank you, Peter. We'll see you next time, Warren. Till next time. To everyone else, wish you the very best. Please live as well as possible for as long as possible. Take care and bye for now. 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