Fighter Pilot Keynote Speaker

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Keynote Speaker on Medical Expert Interview Podcast

Fighter Pilot Speaker Anthony ‘AB’ Bourke interviews Stephen J Ronan, MD FACS.

Both entrepreneurs, they compare and contrast fighter pilot combat & training practices with medical practices, ranging from quality control to technology megatrends impacting both fields.

Stephen J Ronan MD FACS is a board certified Plastic Surgeon with a focus on aesthetic surgery and technology development. Operating out of the AAAASF/Medicare accredited Blackhawk Surgery Center located adjacent to Blackhawk Plastic Surgery, Dr. Ronan has developed a thriving surgical practice of breast, body, face and hair transplantation. A significant portion of the practice is dedicated to revisional aesthetic surgery. In addition, BPS has a robust nonsurgical practice that involves injectables, lasers/technology, aesthetician services and skin care. Dr. Ronan has hosted several teaching courses for surgeons and allied health with respect to hair transplantation, facial aesthetics, and body. Dr. Ronan is involved with the development and FDA testing of new lasers and noninvasive technologies, usually as the Principal Investigator (many publications). He is the Medical Director of a public aesthetic company. Dr. Ronan is a strategic investor and is on several advisory boards for several companies and organizations. He has helped develop companies from beta through acquisition. He has given numerous presentations to a national and international audiences, regarding medicine, but more often the business of medicine.

Here is a full text version of their discussion:

AB:                              Hey, Dr. Steven Ronan, it’s so great to have you here today. Really excited to talk to you about your background both in medicine in your personal life, and as importantly in aviation. You fly one of the coolest airplanes out there in the world, the EPIC aircraft.  And as we just talked about, you got the latest, greatest model, which I’m envious to go fly with you one day, so hopefully we can make that happen. But I would just love to have you start out by talking a little bit about your medical background and your practice.


Dr. Ronan:                  Okay. I grew up wanting to be a doctor. Always thought I was gonna do orthopedics.  Played a lot of sports, was in a lot of orthopedic offices over the years. And went to medical school with that sort of thought in mind. Started doing research in orthopedics and was really kinda gunning for one of those positions. They’re fairly competitive, maybe even more competitive as plastic surgery, which I thought would be interesting, but the training was ridiculously brutal. I figured, do ortho, it looks just as fun.


So, when I was in medical school, you could do orthopedic as a fourth-year rotation, and third year you got a month of general and a specialty month of surgery.  And so, the specialty month plastic was an option.  So, I thought, you know, those guys teach you how to sew.  I’ll go spend a month up there and have some fun and learn to sew and it’ll help impress the ortho guys when I get there the following year.


And so, by the end of the rotation or that month, I knew I wanted do plastic surgery and I was in the chairman’s office asking how to get in and they, I guess let me through the back door and did the program.  So, I got into the plastic surgery program where I trained. We actually developed a whole new curriculum, which I don’t know if your audience will want to hear about, but I actually designed the whole sort of curriculum.  Went through that process. During medical school, also went to flight school…just wanted to learn about it, always wanted to do it.


AB:                              Had a little bit of free time, did you?


Dr. Ronan:                  Had a little free time. Actually, medical school is one of the more free times I’ve ever had actually.


AB:                              Wow. Incredible.


Dr. Ronan:                  So, I worked fulltime.  I worked, drove an ambulance full-time when I was in college and so it actually, medical school wasn’t so bad and so I did the flight school as well. Went into my residency, which was just an absolute beat down of time and abuse.  It’s like going through special forces training for a long time with no sleep and just constantly being beat on and having to produce no matter what, kind of mentality.  And took a break from flying and then during that time, becuase I couldn’t do it properly.


So, I came out to the Bay Area where I grew up in Petaluma and started a practice in the East Bay in Blackhawk.  Built up a pretty significant practice fairly quickly.  Built a surgery center, which we subsequently expanded.  I have a pretty big office, like 13,000 square feet with a surgery center, a couple ORs, five recovery beds, probably 20 clinical offices.  Pretty good staff.   So, we’ve had a really good run over the last 20 years at Blackhawk Plastic Surgery and Blackhawk Surgery Center.


When my kids were in high school, and I knew they would be moving away, I started to think about what I was gonna do. I was coaching football and lacrosse and spent a lot of time with them and my work, of course, and so, I knew I’d transitioned, I’d want something for my free time.  So, I bought the Cessna TTX and started getting back into aviation pretty seriously and eventually got the EPIC.


AB:                              Wow. Very cool.


Dr. Ronan:                  That’s been my run. Yeah.


AB:                              And you are flying that single pilot, I take it?


Dr. Ronan:                  Single pilot, yep. Yeah.


AB:                              Super high-performance airplane. That’s really great.


Dr. Ronan:                  Yeah.


AB:                              You’re one of those rare doctors, I think that has the exposure to aviation that I think many docs wish they had more, because I personally believe there are many practices in aviation that are being applied to the world of medicine today that are making doctors and their teams more effective, but also keeping their patients safer.  And I’m just curious, are there areas of your medical practice that operate better because you’ve applied aviation principles to them?


Dr. Ronan:                  For sure.  So, much of aviation is more formalized than surgery. I know that kind of sounds weird, but aviation, if there’s an accident in aviation today, all the airlines will be part of investigating or they’ll pool resources and examine it andpotentially put out new regulations so that if there’s like two runways on a V, you’ll have to have a closed loop confirmation of what runway you’re taking off of, so you don’t mess up.  And that sort of rigorous application of error identification and how this happened and what regulation change can we make in our systems to eliminate that from ever happening again or reduce the chance.  So, it’s very formal.


In surgery, we have those processes, but they’re a little less formal, and it isn’t done on such a mass scale.  So, for example, there’s at hospitals mortality and morbidity conferences where if there’s death and complications, it’s presented at a meeting, and you talk about it and why something happened and what could be done different.  And it’s sort of a learning practice for all of us, but it’s a little less formalized than aviation.


AB:                              How about the reverse?   Have you been able to apply medical training to make you a better pilot?


Dr. Ronan:                  Yes. There’s a mindset of surgeons that went through the old school training of focus, of like absolute laser focus on what your task is and eliminating the sort of fuzzy bandwidth stuff and staying on task, not being distracted, not allowing your anxiety or emotion to make decisions or influence you, but staying right on task and doing exactly what you’re supposed to do.  And so, that mentality, I think, is very helpful in aviation, because if you do get sort of task saturated, it helps you slow time down a little bit and process it all fairly quickly without allowing other influences to take a piece of your bandwidth, if that makes sense.


AB:                              That makes total sense.


Dr. Ronan:                  So, there’s times in an Operating Room when, well, when you’re flying and you’re taking off, landing, or something’s happening you might call for a “sterile cockpit”.  So, the idea is, everyone quiet – no chatter; we need to put all of our focus on whatever we’re doing.


AB:                              Critical phases of flight.


Dr. Ronan:                  Yeah, exactly. Critical phase of flight.  That happens in surgery where there’s times when you could talk and it’s leisurely and it’s more monotonous.  And then there’s other times when you really gotta focus in and perform or something’s bleeding and you have to stop it, and there’s a time consequence.  And so, on those times, we don’t call it a “sterile cockpit”.  We don’t really have a formal term. It’s like, hey, everybody, shut up and let me work.  But it’s the same sort of concept where we have that, but it’s not as formalized as in aviation.


AB:                              Yes. It was, I think Dr. Atul Gawande wrote a book called Checklist Manifesto, where he talked a lot about aviation principles, particularly around this idea of checklist usage, and talked about the value of those in the medical practice, not just in terms ofbeing more effective but actually saving patients’ lives. Are checklists a part of your medical practice?


Dr. Ronan:                  For sure. Really even starting before you get in the plane with your checklist. In both aviation and surgery there’s really an extensive preparation. You don’t just hop in a plane and fly it, and you don’t just wheel someone in the OR and work on ’em if, for non-emergency kind of things. And so, as a pilot, you become familiar with all the available information and weather and where you’re going and the FBO and what kind of fuel they have and routing and all those kind of things, right?


In surgery, the preparation is also pretty extensive.  It’s like, explore their medical background and surgical background and medicines and scheduling and making sure the right anesthesiologist there and team and preparing all the equipment, making sure it’s all good, just like your plane has to be checked out. We have to have all the right stuff there and can’t be missing anything.  And so, there’s kind of a big preparation that goes before you evenapproach the task on both sides.


In aviation, our checklists are much more formalized, where you kind of eventually develop flows and then kind of go through your checklist at the same time.  In surgery it’s very similar.  But again, probably not quite as formalized.  So, we have checklists that are done at specific times whether it’s preparation or during the surgery, but they’re not by the surgeon followed as a pilot would. There’s different team members that have different types of checklists that they’re constantly doing or reminding us about.


AB:                              Wow. Yeah. I’m curious who’s the best pilot you’ve ever flown with and why?


Dr. Ronan:                  That’s a good question.  Answer is, well, the funny thing is I haven’t flown with that many because I’ve flown with essentially my instructors and then, you know, some friends and things.  I’ve been actually very fortunate to work with a couple of people that stand out.  Michael Phillips was my instructor for the TTX, and then the after initial training in the Epic, and the guy’s fantastic. He’s in his early 70s. He’s a retired colonel from the marines and super bright, great, great guy, hardcore.


Like he asked me, “What’s your learning style?” I said, “Man, I’ve been through – you just let me have it.  I want to be better, and so, don’t hold back.” And so, he didn’t, and we had a great time. He’s very smooth, very slick, very bright.  And then with my initial with Epic, I spent some time with Cuckoo, Mike Clock, and he’s a retired F18 marine pilot.Was also fantastic.


I remember my second day of initial in the afternoon, we got on the ground. I said, “You know, I’m a better pilot now than I was when I got here yesterday.  I’m learning so much stuff. It’s fantastic.”  So, those two guys really have given me quite a foundation.


AB:                              That’s great.  That’s a lot of marine input.  We probably need to get you with some Air Force guys just to round you out a little bit.


Dr. Ronan:                  I hear it. Yeah, exactly.


AB:                              I love it though.  I’ve worked with many marines, and they are always mission focused and so effective at what they do.


Dr. Ronan:                  Yeah.


AB:                              They’re really good at what they do.  Along that same thread, who’s the best doctor you’ve ever worked with and why?


Dr. Ronan:                  Another good question.  So, I’ve worked at a lot of good – now that’s something different.  I’ve worked with a lot of great doctors over the years in different specialties, and boy, I could tell you stories all night from different sort of legends in surgery.  Maybe the one who had the most influence on me who was also a phenomenal doctor, one of the best I’ve worked with, would be my old chairman of plastic surgery. His name Austin Meyerhof. So, I essentially, I started as a medical student.


That’s the guy I talked to when I said I want to go into plastic surgery and essentially grew up internship, residency, fellowship in plastic surgery, a lot of general surgery.  Intern in residency was general surgery, so it was like general trauma, vascular, transplant, a lot of cardiac, a lot of ICU, and then plastic surgery fellowship. So, I went from essentially a baby, to a toddler, to a kid, to a high schooler all the way through this medical process with this guy and then eventually became a colleague and friend, right?


He’s retired now.  He just had an uncanny way of presenting things and making you think about things.  He wasn’t a hard ass, but he just asked you a question here or there that would already explain thingsvery well.  But a lot of times he would leave you with some questions and just make you think a little different and had a pretty big impact on me.  I still in the OR now, I’ll think about the things that he told me.


AB:                              No kidding.


Dr. Ronan:                  Yeah.  Just how to do certain technical little things or why you’re doing ’em a certain way.  So, I’ll think about them now and then repeat ’emto others and sort of pass it along.


AB:                              Sounds like he had a technique of not necessarily always giving you the answer, but making you think about it for yourself.


Dr. Ronan:                  For sure.  He would ask you questions that would lead you to the right place.  Then you’d go do your homework and come back and be like, oh yeah; totally makes sense!   I learned a lot more by doing all of that.  He also had, he pushed you a little bit.  So, when you’re in medical training as a student, intern, resident, fellow, they give you what you can handle.  So, there’s people that are more advanced, can’t handle very much.  If they don’t trust you, they just, they’re gonna be right over your shoulder.


But as you develop trust, and they know what you can handle, then they’re giving you that edge, right?  You have what you know in life and what you don’t know. You have order and then you have chaos.  The best place to live is right on the edge ‘cause that’s where you’re learning the most, and you’re turning chaos into order.  So, the good ones will constantly give you something right on that edge and it pushes your boundaries, right?


So, as a medical student I remember I was doing a tummy tuck with him, and it was just me and him and wewere doing most of it. And he closed one side and I’m assisting him, and I think he had a phone call or something he had to do, like chairman meeting kind of stuff.  He sort of looks across at me and he’s like, “You think you can close this as good as me?”    I kind of smiled and said, “Yeah, of course…Yes, sir.” I said, “Maybe not as fast, but certainly I can do it.”  So, he says, “All right, I’ll be back in a little while.”  And he just took his gown off and left, right? And here I am…


AB:                              That’s empowering.


Dr. Ronan:                  Yeah, like with this patient open.  So, I gotta close this thing up.  I’m working away.   And the anesthesia guy, at some point I hear him asking, “Hey, you wanted a gram of Anseph?”  An antibiotic. And he says it again and again.  I’m like, oh, is he talking to me?  I go, “Me?”  And he goes, “Yeah, you wanted a gram of Anseph?”  I’m a medical student. I’m not allowed to order stuff. He thinks I’m a resident because I’m in there by myself with this, opening it up and I’m like, “Yeah, sure. Give it.”


Finished it all up.  And Meyerhof, I did not see him.  I’m sure he was right around the corner, right there and peeking at me and making sure everything was fine.  He came in at the end and checked it all.  But it was fantastic.  It’s like here we are at the edge, trying to push and get better.  So, it was like that all the way along.


AB:                              It’s really interesting.  It just reminds me so much of, and I know you’ve been through it, and I’ve been through it, but the first time you solo, the first time your instructor, said, “Hey, pull the airplane over to the side.”  Opened the door and got out and said, “Okay, I’m leaving you now.”


Dr. Ronan:                  Yep.


AB:                              “I believe in you. Go do it alone.”


Dr. Ronan:                  I remember doing that.  It was at Hanover County Airport.  It was a low of five degrees and a high of nine. It was snow everywhere. Obviously, the runway was clear, and we were in the pattern and doing some work and he goes, “Hey, pull over a second. I gotta go get my camera” or something, I don’t know.  So, I pull over, let him out, and he goes, “Oh, while I’m doing that, go ahead and do a couple laps.”  And I was like, “Okay.”  I went up and did it, and it was fantastic.


AB:                              Just like the doc saying, “Hey, I’m gonna leave now. You take your time tying that thing back up.”


Dr. Ronan:                  Yep.“You’re ready. Go ahead.”  All right.


AB:                              Well, I asked these questions because you are entering into what I think is gonna be a really exciting phase of both your personal and professional life. You are actively looking into becoming a flight doctor for the 144th fighter wing of the California International Guard, my former squadron, which is now flying F15s.


So, what’s so neat about that is it’s going to expose you to aviation in a way that you’ve really never certainly actively participated in. You’ll be flying in the backseat of F15s in combat training type missions and you’ll see aviation in a whole different way.


Of course, tactical aviation goes from, we’re not so concerned about, obviously we need to take off and land and get from A to B, but you become a weapons platform and all the things that are involved with that, including G forces and technology and avionics and weapon systems.  I think that’s super exciting.


Of course, you’re not going to be doing plastic surgery there, you’re going to be practicing a different kind of medicine as a flight doc, which is, keeping our pilots healthy, but really keeping *all* the troops healthy. I’m so grateful for your looking into it because the United States Air Force, Marine Corps, Army, Navy all need people like you to help.


AB:                              Yep. And I appreciate you turning me onto it. I feel fortunate that I’ve had a good run in my practice and that I’m able to sort of do it in reverse order and go in and have a great time learning a bunch of new stuff, doing something different, not doing the same thing every day.  Being able to contribute, serving the country, filling that need when they’re really down on numbers.  I think it’s fantastic.   I can’t wait for the camaraderie.  I’m very much looking forward to it.  Hopefully the process won’t take too, too long.


Ted:                             Are you selling the practice and then you’re going to do that full timeor no part time?


Dr. Ronan:                  This would be in the reserves.  With my practice, I’ll probably have a four- to five-year period where I can kind of go very part-time after three to five years. For right now, I’d be with the reserves and do my weekends and my special training ops and those kind of things, and I’m very much looking forward to it.


Ted:                             Wow. You’re gonna have a blast. That’s awesome.


AB:                              Yeah. I can tell you Ted’s jealous. He’s an aviation junkie himself, so I know he’s jealous.


Dr. Ronan:                  Yep.


AB:                              So, there’s a lot of statistics out about this and I think the numbers are changing.  You can get different numbers from different sources, but I’ve heard that approximately 12 lives are lost every hour due to preventable medical mistakes. A, do you agree with that statement and B, tell me what’s going on there?


Dr. Ronan:                  Okay, so I don’t know the exact numbers per hour, but I did sort of look and there’s about 90,000 flights a day and there’s about close to 700,000 surgeries a dayworldwide.  Every time there’s an airline disaster or plane, it’s in the news. So, it’s magnified, whatever it is, it’s a tiny fraction really gets magnified. Similarly with medicine, so when you’re talking about those kind of big numbers,700,000 surgeries a day, you don’t really need that big of a fraction number, percentage number to make a lot of cases.


So, the risks really get magnified.  Numbers get very magnified with the reporting.  Some of the differences are, in an airline, you are essentially under ideal circumstances most of the time, right? Planes should be tip top. Lots of people have checked it. Shouldn’t be anything wrong with it or low chance, right?  And your crew is well trained in a system. They can only fly so many hours.  They have a whole team of people planning and weather and all this kind of stuff.  It’s under pretty ideal circumstances.


In medicine it’s a little different. You may be doing surgery because the guy is sick. He’s got all kinds of problems. And so, the complex machine is not in tip top shape.  You may be trying to save it, right?  You may be doing something togive them a longer life, but they’re already sort of on the edge.  Things in surgery are absolutely going to happen.  With the kind of stuff I do in plastic surgery, which is elective, this doesn’t apply as much.

Certainly, we can have complications like anyone, but in general, we’re more like airline pilots with respect to things are typically in better shape when we go in.


AB:                              Controlled environment.


Dr. Ronan:                  Yeah. But certainly, in trauma and cardiac and vascular and transplant, you’re working with some sick people and you’re trying to make them better and improve the quality of their life. So, you’re going to have more issues. It doesn’t matter who you are. You can be the best surgeon ever. You do 100 heart bypasses, you’re going to have some people who have a problem, right? It doesn’t matter how good you are, right?


So, the key is what are the things that we can do to eliminate controllable problems, right?   That’s kind of where we put most of our time, right?   There’s certain things you can do to prevent blood clots in an OR.   So, we have all that proper equipment there and we use it all the time, whether it’s a 15-minute case or a three-hour case.  We tend to focus on all of the things that are controllable and efficient to maximize our chance of having the best result.


AB:                              You know what’s so interesting about that? When I have read these statistics, I recognize that these mistakes aren’t all happening in the OR. I think a high percentage of them have to do with pharmaceutical stuff.


Dr. Ronan:                  Yep. That’s exactly right.


AB:                              What’s interesting about it is, and you probably know this, in the 60s and 70s, particularly in commercial aviation and I would say in military aviation, we were also having, I’m gonna call it an unacceptable accident rate, and I think you kinda hit the nail on the head when you said, it wasn’t because our pilots weren’t the best and the brightest.  It wasn’t because they weren’t well trained.  It wasn’t because we didn’t have the best medical technology.  In the end, it so often came down to what we call human factors.  Just people misunderstanding intentions of each other and not communicating effectively.


And so, in aviation, we started a program called CRM, crew resource management, and it took kind of an attitude of the captain was God. And no matter what he or she told you, back then, it was almost always he, you just said, “Yes, sir” and you never provided inputs. And so, for example, if you were flying into a mountain and the captain looked over at the first officer and said, “Hey, go get me a cup of coffee.”  The first officer rarely said, “Well, what about those mountain goats out there, sir?”  He just said, “Yes, sir, cream or sugar?”


And unfortunately, lives were lost that way. CRM basically takes this approach that says the captain is still in charge. But it is always his or her responsibility as the person in charge to solicit input from all available resources.  First officer, flight engineer, jump seater, flight attendant, ground crew, air traffic control to get all the possible inputs and then make the best possible decision based on those inputs.


As a crew member, and I don’t mean just a crew member, but as a TC, as a flight attendant, it is always your job to provide input, particularly when you see situations that are making you feel uncomfortable or unsafe.   I’m just wondering has this idea of, let me go back because I think CRM has saved many lives in the airlines, and actually we’ve adopted it in the military too.


Dr. Ronan:                  Yeah.


AB:                              But has that approach been adopted to any degree or to some degree or maybe to a large degree in the world of medicine?


Dr. Ronan:                  So, we are behind on the curve compared to aviation; surgeons are way less likely to admit fatigue.  My record was nine nights, ten days, nine nights without leaving the hospital.  Like 20 minutes here, 15 minutes there.  When you’re young and you do it like that basically every day for years, you kinda get used to it and you get used to a couple hours a night and it was all right. You’re sort of chronically tired, but there was a mentality of you’re not gonna say you’re tired, right?  You are going to perform no matter what.


You’re not going to forget to do this for Granny Smith on the floor. You’re not going to forget to check that x-ray and you’re not gonna mess up the surgery.  And it was just, it was a different time than now.  They have a lot of rules about how much you can work now. But it taught us a lot.  So, part of that training was that the hierarchies were very well established, and everything ran downhill, probably like the military.  Things just kinda rolled downhill.


AB:                              Yeah.


Dr. Ronan:                  And you went through that process.  It really depended on the personality of the surgeon. So, if you had one that was sort of an egomaniac, then you know, the OR is pretty quiet unless he’s yelling, and people are intimidated and are less likely to speak up. You’d have other surgeons, and I would say this was more common, like my old chairman I mentioned, who was very calm and asking you questions, making you think.  In that kind of environment it was very easy to speak up.


You’re always asking questions.  Why is there a mountain in front of us?  Like, why don’t I see those goats?  What’s going on there? And you say yeah, well, yeah, we’re gonna turn that way point before we get there, and they explain it to you, right? So, it was more surgeon dependent as to how much of the CRM approach was there or not. But it is certainly is not as developed as aviation has.


AB:                              Not standardized.


Dr. Ronan:                  Not standardized to that extent.  Now there is a standardization process that has happened over the years with outpatient surgery centers and hospitals where you have different team members that have their kind of individual checklists and are going through and if there’s something missing, then they’ll speak up right away because they’re sort of responsible for that.


And in my OR it’s very calm and casual and anyone can speak up at any time, and that’s very encouraged, but there’s still some environments where it’s the surgeons, the general and/or the admiral or whatever, and that’s the way it’s gonna be, right?  But in general, I think that’s changing over time to a more less formal CRM style.


AB:                              It’s very interesting and the things you brought up about in your early days of ten days in the hospital, nine nights, and I just, can you imagine someone getting on an airliner, a United Airlines flight knowing that the captain had not slept in three days?


Dr. Ronan:                  Yeah.


AB:                              That’s would never happen.


Dr. Ronan:                  Never happen.


AB:                              Not uncommon in medicine.


Ted:                             [Note – Ted is an assistant to AB listening in]

                                    I think something common between the two of you also is, and unlike the rest of medicine, really, when you’re doing surgery it’s like sending a couple F16s out a mission.  You’ve got a goal. You’re very focused on that goal and you’re getting it done, right?  A lot of medicine, the rest of medicine is, there’s something wrong with somebody and it’s more like solving a mystery.  In that sort of mystery context what I’ve observed is it’s all about handoffs.


It’s all about information getting lost at the at the edge between people, shift changes, someone being admitted and things not being quite right. So, I think the surgery stuff, it’s like, you’re trying to make a repeatable process with the checklist and all this other stuff, but the rest of medicine is just, it’s super complicated and not reproducible often. I don’t know, it just seems different.


Dr. Ronan:                  Yeah. I’m biased towards surgery, but I think our systems are better than the rest of medicine.  We’re more contained, like that patient is contained in an OR unit and it’s very complicated and very detailed, but I feel like there’s a lot more of the communication you’re talking about.  Less likely bad things are gonna happen for those reasons, as opposed to out on a floor somewhere in the hospital where it’s not as an intensive focus on you.  You’re just there on a team of people.


Interestingly, like what I do every day, faces, noses, breasts, body, hair transplants, that’s sort of like being an airline pilot where everything’s at sort of optimal conditions, and you’re gonna go from A to B and almost every time it’s gonna be pretty routine, right?  You might have to make a couple changes along the way, but in general it’s pretty straightforward.  Where the kind of surgery I used to do in training, or more like the fighter pilot conditions where you’ve got your equipment and that works, but you’re in suboptimal conditions.


You may not be able to see very well. There’s lots of unknowns.  There’s risks lurking out there and really more maybe pressure at that point and potentially anxiety and those kind of things.  And so, if you’re doing transplant surgery, you’re more in the fighter pilot zone.  Or if you’re doing some of the trauma surgeries or things that we would do, you’re more like a fighter pilot.  But the things that I do and most of the routine surgery would be more like an airline.


AB:                              SFO to LAX. Probably gonna go pretty well.


Dr. Ronan:                  Yeah, exactly.


AB:                              It’s interesting, Ted though, you bring up this point about, and I know you have this recent experience because of both your mother and father spending time in the hospital. This is one of Gawande’s great points is that if you standardize these handoffs was one thing you brought up, if you use checklists and people live and die by these checklists, the handoffs do go more smoothly. The information is communicated correctly, and nothing is missed.  And I think both Steven and I would agree that as you use checklists more and more, you develop really good habit patterns and you’re able to do many things, we call them normal procedures, by memory.


What I’ve learned, and I know Dr. Ronan probably knows it as well, when I’m maxed out, when I’m not thinking clearly, when I’m behind, that’s when I need to pull that checklist back out for my normal procedures again, becauseI know I’ve only got two minutes to get this handoff done, and I want to do it right, and I’m not thinking clearly.  So, let’s use that checklist and make sure, okay, we’ve talked about this.  We’ve talked about this.  Ooh, I missed the third thing; so glad I looked at my checklist!  Now the handoff is complete.  Now the patient is probably in better care than they would’ve been if I just tried to wing it.


Ted:                             It’s not about me, but I just have to say, putting up ads on Google, I have a checklist.  It’s like 30 points.  And if I miss any of those points when I’m putting up a campaign, Google’s going to take your money hand over fist, and your campaign’s not going to do that well. So, I can completely 100 percent relate.


AB:                              Yeah, that’s a great example.  You’re a perfect straight man too. Talk a little bit about technology, Dr. Ronan.  How has technology impacted your business in your specific field of plastic surgery?


Dr. Ronan:                  In lots of different ways.  I don’t know.  You probably don’t know this, I’m the medical director of one of the largest aesthetic laser companies called Cutera.


AB:                              Oh, what’s the name of the company?


Dr. Ronan:                  Cutera.  They’re out of Brisbane.  And so, I basically am the, usually the principal investigator of most of the studies and will help work with the R&D team and then the clinical team on really the development of products, the research on them, development, the clinical process to get them approved through the FDA, commercialization of the products. And so, a lot of these technologies have had or will have a big impact.  So, for example, our latest is a laser that cures acne or significantly reduces it.


AB:                              Wow.  Wish that was around when I was 18.


Dr. Ronan:                  Yeah.  So, think about what so many people go through with years of the medicines and the Accutane and maybe some acne scarring or maybe being made fun of, or whatever other sort of tortures people would go through.  Now you can have three laser treatments that take 15, 20 minutes and have most of it gone. That’s a new technology that is just rolling out and hasn’t really hit the public that much yet but one that we’re pretty happy with.


Other kinds of technology, we have technology now to go after reds or vessels on your face or body or brown spots or wrinkles or texture or tightening up skin.  We have sort of all these great technologies that have really expanded the way that we can help people.  So, that’s pretty fantastic.  In the OR we have newer ways of keeping people warm andmore advanced anesthesia machines. It’s sort of like more advanced avionics that can do more and give you more situational awareness.


We sort of have that with some of our technology now.  The medicines keep getting better so they’ll make things that have less problems, less nausea, kind of wear off faster so you can give it to ’em and have ’em wake up quickly and be alert and oriented very quickly after surgery.  So, there’s a whole variety of technologies that are impacting us pretty regularly.


AB:                              Yeah. Just like in aviation, certainly in tactical aviation, but I’m sure flying your airplane as well, you gotta stay up to speed on that stuff because I flew for the airlines for a while too, and they kept upgrading our software andI can’t tell you how many times I looked, either I or the captains go, “What’s it doing now?”  And you think that’s not how it’s supposed to be.  We’re supposed to “get” this stuff.


Dr. Ronan:                  The good news is that you were picking up on it.


AB:                              Oh yeah.


Dr. Ronan:                  And it’s the same thing in surgery, right?  When I’m working, like my zone, like almost all my attention is on this spot where I’m working and someone walks in the room, I don’t stop, “Hey, how you doing?”  I can say, “Hey, how you doing?” But never come off my zone of attention. At the same time, you have like one invisible eye going everywhere, watching everything.  Why is that door still open or whatever and pointing out where your automation is not doing what you want. So, it’s a very similar sort of thought process that goes on of, I know it’s a program, but that’s not right.  Let’s fix this. Yeah.


AB:                              And I think for pilots, and I’m sure for doctors as well, becoming too reliant on the technology can be very dangerous.  In those situations where you say, what’s it doing now or it’s not working the way I expect, you need to know how to override it, shut it off, and just go back to flying the _____ Cessna 152. I think you never wanna lose those skills.  If you become too reliant on technology, the technology can actually fly you right into the ground before you know it.  So, I think it’s super important.


Doctor, we’ve only got about ten more minutes and I know you had some things that you had prepared or that maybe I hadn’t covered. And is there anything you want to talk about right now before we wrap up?


Dr. Ronan:                  One of the things is simulators.


AB:                              So powerful.


Dr. Ronan:                  EPIC just built an EPIC simulator, which I got to use for my recurrent training about three weeks ago.  Flight simulators are fantastic, right?  That’s this giant room with HD screens all the way around an actual cockpit set up exactly like the plane with the avionics, the whole thing.  There’s a server stack of like 20 servers running this simulator.  It’s absolutely fantastic.  And you can do commercial checkout rides in a simulator in aviation. You can do lots of training in them. One of the things that’s beautiful about them is you can do things in a simulator that you’d never do in an actual plane.


It’d be too dangerous.  Break things, put you in situations that you would never want to go into, but maybe you should have experience in. Fantastic on aviation with that.


Our simulators are not so good and really harder to do. We can’t build a fake human and then do these surgeries and then undo it and just start it over, reset it, and we’ll do that again until you cut it down.  It doesn’t work like that.  We have cadavers and we use those for some surgeries.


If you want to try something new, you might try it on a cadaver or you might have a visiting professor and he or she might take you through some complicated surgery that they do on a cadaver so that everyone can see it and walk around and touch it and play with it.  With laparoscopic surgery and the robotic, those tend better to simulator or simulations and are pretty good, but they’re not like aviation simulators.


It’s going to be a long time before we catch up, because you have to make, essentially, an avatar, like an avatar person that we could work on.  We’re nowhere close to anything like that.   But that is definitely something aviation has.  It’s a tremendous tool.  In doing my initial, they didn’t have a simulator.  My recurrent they did and just going up and having them kill the engine and just different things, fires and –


AB:                              _____ failures.


Dr. Ronan:                  All kinds of stuff.  Yeah.  It just was, and what’s interesting is because we talked about checklist, right?   You’re up there and the engine goes out or electronics or this or that, and you have time to, first thing is I’m gonna take a deep breath.  Shit.  Then you get your checklist, and you start doing your memory items.  Get those started, and then you grab your checklist, and you go through every single thing, and you have time to do it.  But the simulator is fantastic for drilling, all that kind of stuff.


AB:                              Yeah. I love the sim. Simulator and aviation is amazing. The other thing I learned about simulator is particularly in the airlines, but also in the military. When you’re not flying, you often get to watch someone else fly.


Dr. Ronan:                  Yeah.


AB:                              And watching other people in the simulator is so useful because you learn so much from other people’s mistakes and other people’s, excellent best practices.  And you’re not in the moment. You’re watching from a God’s view above.


Dr. Ronan:                  Yes.


AB:                              You’re like, oh my gosh, I could have made that mistake a hundred times.


Dr. Ronan:                  That’s exactly right.  You don’t have any bandwidth in the knob turning and button pushing, right?


AB:                              Yeah. You’re lasered in like you talked about.


Dr. Ronan:                  2,000 feet watching and seeing things develop and not spend any of your time on the details.  And then it’s oh, what is this guy doing?  I’ve done that. You can see it all coming.  And it’s the same with surgery, because you really spend a lot of time growing up watching.  At first, you’re just like, happy to be in the room and then you’re scrubbed in, then you’re holding a hook.  And then it’s little by little more and more, depending on like your comfort level and trust and all that kind of stuff.  But you spend a lot of time learning by watching people in surgery.


AB:                              Yeah.  How about other stuff?  Any other stuff you have on your list there that you wanted to talk about that we didn’t cover?


Dr. Ronan:                  We covered most all of it, I think. Yeah. We covered a lot.


AB:                              Yeah, really. Super, super fun talking to you. Ted, anything we missed on your end?


Ted:                             I think the only thing would be, we talked about technology, but do you, there’s this fear, I think, on the aviation side of being replaced, right?  With the loyal wing man stuff and all that.


Dr. Ronan:                  Yep.


Ted:                             Do you see surgery as being 100 percent robotic at some point, you guys are out of a job or you’re just –


Dr. Ronan:                  Long time.


Ted:                             Preparation guys or what?


Dr. Ronan:                  Long time, I think before that’s gonna happen.  I’m sure that there’s gonna be some things that’ll be robotic.  Okay.  I can give you examples of things that are happening.There’s a robot that we use for hair transplantation that can harvest grafts. So, that’s happening today, right now in my office.  We don’t use it all the time, but the technology is very good to remove grafts.  It’s coming.  It’s in process, not quite as good yet where it can place them.


There’s going to be robotic technology running some of the lasers that we do.  So, you might have a robot doing laser hair removal for you or something.  So, some of that’s here now and on the horizon.  As far as doing surgeries, I think that’s gonna be a little while because of the sort of complex thinking, complex and abstract thinking that has to happen in the moment while you’re doing theseprocedures. So, it might be a little while.


AB:                              Well, I want to be sensitive to your time, doctor. I can’t thank you enough for taking the time and also, just sharing all these great ideas and what you’re about to do with the military to really giving back andhopefully getting a little as well, because I think just knowing you the way I do the first time you jump in the back seat of an F15 it’s gonna change your life and –


Dr. Ronan:                  Can’t wait.  I’m looking forward to it.


AB:                              I know. So, I’m looking forward to keeping in touch and thank you for your time today and also, congratulations with the success of your business.  It sounds like you’ve really built an incredible practice and we didn’t get to talk about it, but it sounds like you are in a phase where it may grow very exponentially over the next several years.  So, congratulations on that.


Dr. Ronan:                  Definitely. All right, well, thank you so much. I appreciate it.


AB:                              All right. Thank you. Have a good night.


Dr. Ronan:                  Bye.




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