The Team Behind the Surgeon: Efficiency Lessons From Canada

Dr. Sebastian Rodriguez-Elizalde built a same-day anterior hip program inside a Canadian public hospital — not a private surgical center. This conversation covers what it actually takes to change your approach, your team culture, and your system all at once.

Sebastian trained in posterior approach at HSS and transitioned to anterior approach early in his independent career. In this episode, he talks honestly about the ego hit of relearning something you were already good at, the anxiety of operating without a safety net, and the decision to go all-in without giving himself the option to retreat. He describes surgery as choreography — a measured cadence where every team member understands the beats of the day.

What makes this conversation different is the emphasis on system change. Sebastian didn't just get faster in the OR. He brought his entire team to observe high-efficiency programs run by surgeons like Charlie DeCook and Kristoff Corten, then built a hybrid Canadian model from what everyone learned. He explains how overcoming institutional inertia in a public healthcare system requires patience, proof of concept, and the ability to speak the language of administrators, nurses, and anesthesiologists — not just surgeons. Whether you are early in your career or rethinking how your OR runs, this episode offers a practical blueprint for building something better without burning out.

⏱️ Chapters:
00:00 Introduction and guest background
01:39 Why surgery is like choreography
05:58 Why team rhythm matters more than surgeon speed
08:03 Real constraints of a Canadian public hospital system
10:37 Overcoming institutional inertia to drive change
14:11 Post-fellowship growth and learning to lead system change
16:27 How measuring every surgical step changes your practice
18:41 Switching from posterior to anterior approach mid-career
23:19 Going all-in and what it teaches you about ego
26:00 Why the whole team needs to see high-efficiency surgery
30:09 Mistakes surgeons make building rapid discharge programs
32:04 Three non-negotiables for a high-efficiency OR
36:50 Evaluating new technology when every dollar matters
43:18 Career advice and the five percent growth rule

Listen to the AHF Podcast on your preferred platform:

Buzzsprout: https://ahfpodcast.buzzsprout.com
Apple Podcasts: https://podcasts.apple.com/us/podcast/ahf-podcast/id1749521487
Spotify: https://open.spotify.com/show/5CrGJyvRiQFTCU3FFFVvHc
LinkedIn: https://www.linkedin.com/showcase/ahf-podcast
YouTube: https://www.youtube.com/@anteriorhipfoundation
Homepage: https://anteriorhipfoundation.com

This podcast is intended for educational and informational purposes only.

The content discussed does not constitute medical advice and should not be used as a substitute for professional judgment. Clinicians should rely on their own training, experience, and clinical decision-making when applying information from this discussion.

#AnteriorHipFoundation #AHFPodcast #TotalHipReplacement #AnteriorApproach #SameDayHipReplacement #SurgicalEfficiency #RapidDischarge #ORTeamwork #HipArthroplasty #THA #SurgicalEducation #PublicHealthcare #RoboticsInSurgery #SebastianRodriguezElizalde

Transcript

Joseph M. Schwab 0:22

Hello and welcome to the AHF podcast. I'm your host, Joe Schwab. Today we're joined by Dr. Sebastian Rodriguez-Elizalde. An orthopedic surgeon at Humber River Health in Toronto, and Dr. Rodriguez has helped build rapid discharge pathways within a large public healthcare system in Canada using anterior approach. He's also deeply involved in surgical education and the evaluation of emerging technologies, but today's conversation goes a bit beyond technique. We're talking about what happens after fellowship, how surgeons evolve, how teams can shape your consistency, and how to adopt innovation without losing judgment. Sebastian, welcome to the AHF Podcast.

Sebastian Rodriguez-Elizalde 1:12

Good morning, Joe. Pleasure to be here. Uh, really excited. It's been a long time. Been watching you guys obviously with my involvement with AHF and, and pleasure to be on the show today.

Joseph M. Schwab 1:22

So before we get too technical, I wanna start with something you've said in one of your interviews in the past. You've described surgery as choreographed, almost like a dance. And I just want to ask simply what do you mean by that?

Sebastian Rodriguez-Elizalde 1:38

I compare surgery to a lot of things, first of all. But yes, I, I've, uh, I do compare it to a dance in terms of when you plan out your day, right? So. By the choreography, I mean that you've prepared and rehearsed if you will be that practice experience or learning, uh, many different techniques. Um, and then you put it all together when a time comes, time for surgery and while every performance, if you will, is a unique experience. It's sort of based on that collective understanding, knowledge and experience of the surgeon to get through that procedure. And even that day, the whole day is a choreograph, right? And if you're trying to move through a large number of cases. So, um, that's why I like that analogy a little bit.

Joseph M. Schwab 2:20

Hmm. So people who are thinking choreography, thinking dance, they're thinking of following a beat. Are there particular beats that you're paying attention to throughout your day?

Sebastian Rodriguez-Elizalde 2:32

Absolutely. And I mean, some of these things are things that, uh, you know, I've learned from witnessing other surgeons in terms of lots of surgical efficiency sort of discussions and, and mentorships that I've gone through and. I think the key thing is, is measurement. So in terms of those beats that you're talking about, that cadence of, of surgery in a surgical day, I think is important. So that cadence involves the preparation and then bringing someone into the operating room, the cadence of getting ready and every step that's part of that procedure, how you're gonna approach that. So, um, I think it is important to maintain a healthy cadence, uh, that you're aware of. During the surgery and during your day. Where am I? Where should I be at at this point during the day, assuming everything is going well, um, assuming everything is going well in the surgery, are we, are we near the end of the procedure? Are we near the end of the day? Am I mentally sort of thinking about the next case and the next patient as we're closing? That kind of thing.

Joseph M. Schwab 3:27

And when you're sort of appreciating this choreography throughout the day, appreciating this dance, when you notice it's starting to break down, where does that usually happen first? Where do you see the, the biggest issues?

Sebastian Rodriguez-Elizalde 3:44

I mean, that can be a lot of thi, I think most important is that you notice it breaks down, right? Because previously and before you'd be going through a day and then all of a sudden you realize. Hey, I think we're behind by a couple hours. Am I gonna finish on time? And here in Canada, in a public healthcare system, obviously there's constraints, you know, um, in terms of finishing at a certain time, uh, will your last case get canceled? Um, that kind of thing, which, I mean, it could be for, to a lot of my US colleagues. If you own a surgical center, you just do whatever you want to do to, to finish the day. So. You know, in the past, you know, it was very important for us to make sure that we were on time, but without measuring and being aware of it, you could easily lose track of where you were in that day. I think now we're much more aware on a per case level where we should be and on, uh, you know, even per procedure level, like how often, how long does it take for me to get to reaming the cup, or how long does it take for me to get to, you know, putting in the broach or to close the wound even. So all those little steps you have to be aware of. If you notice your day is breaking down a bit and you're falling behind, I think two things is one, don't panic.'cause the last thing you wanna do in surgery is rush. You know, you wanna make sure that you know that. Napoleon once said, I'm in a rush. So go slowly. When he was asking someone to get'em ready for war, when they're a surprise attack. And my, my dad loved that quote. So I think the key thing is if you are falling behind, make sure that you're still prepared and following protocol. You don't want to cut corners at any given time. Uh, but I think you do have to be aware of, you know, maybe this case is going a bit slower. Maybe this patient has a higher BMI or is more muscular, or I'm struggling a little bit more for exposure. That's not gonna be every case in the day and understand that, well, you know what, maybe we'll make up that five, 10 minutes on the next one or two patients if they're a bit slimmer. So you have to understand that within a day there's guidelines, but there's still variants and flux so that you can go, you know, you can go fast to slow if you need to, as long as the overall average of that day gets completed. Um, but the biggest thing you wanna do is just make sure that those, those. Mileposts, if you will, that you establish for yourself are are being respected. They don't have to be adhered to a hundred percent, but respected to the point where you can be like, okay, well I know I have to get to point B from point A, uh, we're a bit behind. Then the next one will be a little bit faster. That's all.

Joseph M. Schwab 5:57

Hmm. And how important is it to you, um, when you're looking at those, those mileposts that you talked about? How important is team rhythm in keeping a, a adhering to what you wanna accomplish for your day?

Sebastian Rodriguez-Elizalde 6:12

I think that's paramount to your success. I think what we've really learned in the surgical efficiency work that we've done here at Humber is that the success is not surgeon success. The, you know, the surgeon can be captain of the ship. The ship still has an entire crew, which makes it run, and, and in that we, the more you understand that everyone has to be motivated and understand the goals of the day and be the leader in that front, I think. That is the key takeaway that we have learned. Um, if, if your surgeon is unaware of time, uninterested in time savings, uninterested in efficiency, um, you know, or unaware of what's going on during the case, you can't expect the team to be able to all of a sudden help you out from that perspective. You have to be the leader in that regard and, and set the pace and having people that are all understanding what your goals are for that day. And our goals are, let's say, to treat 10, 12, 14 patients in, in an eight hour window. Safely here at Humber and get them all home that same day. Everyone understands that before they walk into the operating room and everyone picks up where we are going on. Sometimes it involves our assistant helping take out the garbage. Sometimes it involves having an extra pair of hands to clean. Um, sometimes it involves, you know, uh, for one of the cases, maybe the staff person will close that wound and not the fellow or not the learner, if they wanna make sure that we're done on time. So those little modifications, the entire team understands. But having that. Team first philosophy, I think is paramount to success.

Joseph M. Schwab 7:36

Hmm. And we're gonna get a little bit more into your team philosophy in just a little bit. But you did mention, you know, you're working within the constraints of a public hospital system in Canada and a lot of surgeons, a lot of people listening might not fully appreciate what that means. So can you tell me a little bit about what sort of real constraints you deal with on a daily basis?

Sebastian Rodriguez-Elizalde 8:02

So I often think, you know, there's this huge misunderstanding of the Canadian healthcare system versus the American healthcare system, right? The reality is actually they're much more similar than people will give credit to or understand, right? The Medicare world and the OHIP or Ontario health insurance plan, as we call it here in in, in Ontario, at least in our province. Are not dissimilar. So in this case, this is a, a taxpayer system where everyone contributes taxes to have a healthcare system whereby healthcare is provided, you know, for free, but really it's taxpayer funded, so it's nothing is for free in this world, as you know. What that means is the hospital is allotted based on regional populations, a volume of procedures to do during a given year. Within that volume, there's still some variance that happens year to year where you're allowed to do more procedures or less procedures based on performance incentives if they have more money from another budget. So that number is not set on ironclad stone. That being said, generally speaking, OR days run at a set time, so it's not a surgical center where you can run overtime and pay people more if you want to. Things like overtime for staff, we're sensitive to. Prices of implants we're sensitive to. Additional technologies and their costs we're sensitive to, so the per case cost in Canada until recently was not well understood or analyzed. A lot of these financial sort of motivations and, and, and understandings are now coming to light about how we can be more efficient and, and more time saving and more economical and the procedures that we do. So it's not necessarily at. Surgeon discretion at any given time, what they're gonna be able to do. You can't put a ceramic hip in an 89-year-old meal. That's, you know, so you have to understand that there's give and take in the system overall with the mindset of being that the more fiscally responsible we are, the more people we can help treat, which translates to the more volume of cases that can be done globally as a, as a system. So all that being said, we have constraints in terms of the day and when it finishes constraints, uh, from some of the technologies that we used and mean. These are all fiscal things, right? And in terms of the implants that are used, and you have to have generally good scientific backing or understanding of why you're gonna change any one of those things. Be that for research education purposes or a younger patient needs a different type of implant, or I feel a robot or an additive technology makes me a better surgeon, that kind of thing.

Joseph M. Schwab 10:20

So as you were starting to increase efficiency and maybe push the envelope of the number of cases that you could do in a given day, what was the hardest part of sort of pushing change in this type of system?

Sebastian Rodriguez-Elizalde 10:36

I think it's inertia, right? Because I, I think any system change, especially, you know, a bureaucratically run provincial healthcare system here in Canada is, is, is like dealing with your government, if you will, right? So any change at a government level is hard to implement. And then the other thing is, uh, having a proof of concept, right? Because, uh, you know, whenever you do more volume or try to look at efficiency, that generally translates into more procedures per given day. The number one thing for resistance that we encountered was a lot of safety concerns is can you do these procedures safely in a shorter time span and more in a day? And are you as a surgeon still able to guarantee, you know, responsible clinical outcomes? Is your anesthetist feeling safe enough to be able to deal with these patients and, and the nurses who discharge these patients don't feel so rushed that this is unsafe? So we, we addressed a lot of the safety concerns individually. I think a lot of that brought. Stakeholders to the table to say, Hey, what are you worried about? Because often, and I, I was guilty of this, seeing something from my lens as a surgeon, I didn't understand why other people were so resistant to this idea. To me, it seemed like a great idea, but you have to understand what it is that their motivations are and what their concerns are and address those. And maybe they're not important to you as a surgeon, but you have to understand that these are all barriers in the system that if you don't address, you won't be able to progress forward. So I think, you know, addressing. All the potential roadblocks and barriers, be it anesthesia, nursing, administration, um, even things like porting EVS or housekeeping in your room. You have to be able to talk to all those stakeholders and understand what it is that you need to do your job safely. Is there a way that we can potentially be more efficient or do it better or potentially do it faster, um, without causing undue stress? And, and trim the fat, if you will, out of any system. And when you break down any process into all those little pieces and look to see how you can make each part of it better and talk to the stakeholders that are in the best position to understand the problem, you can really make a lot of change.

Joseph M. Schwab 12:34

Hmm. Was there a moment during this process where dealing with that inertia felt too difficult?

Sebastian Rodriguez-Elizalde 12:42

Yeah. Every step, obviously. I mean like inertia is inertia like you have to be. You know, like I tell my fellows and residents, you can't be a small wave. You know, that's just crashing against the shore. It makes a lot of noise. You have to be that one tidal wave, which is just a slow moving but immovable object that's constantly moving forward. And that's what you gotta be, is just you have to keep going, um, and start low and slow and it builds to a point where you realize you just can't change the change of that tide, if you will. And so inertia is one of those things. I think I learned number one is you can't get frustrated, right? Because I think as surgeons generally, don't say we have short fuses, but we have, you know, we like to fix things in orthopedics, we like to fix things quickly. Some of these things take time and you have to let some ideas pollinate and gain traction. Have proof of concept. You won't convince everyone all at once is the other thing I learned. You have to convince a few key stakeholders create proofs of concept. Uh, be able to expand those ideas and make them scalable. And I think that's really what I learned about change was that you're not gonna convince everybody on the first day, but by the 10th time you've done it, or on the hundredth day, you'll realize that this is the new standard of care.

Joseph M. Schwab 13:55

Hmm. Did you come out of your fellowship training with this sort of plan in mind that you were going to be seeking this kind of efficiency? Or was this something you developed after you became sort of fully independent? I.

Sebastian Rodriguez-Elizalde 14:11

Definitely after I became fully independent after my last fellowship here in Canada, we do several fellowships, as I'm sure you're aware, you know, and I, I went through the rigors of three actually in, in trying to land on the right job, I did my master's in health administration and essentially that's a parallel stream to an MBA, if you will, with a lot of healthcare. In the second year, that's when they really got a new appreciation of. Especially in Canada, system change because you have to be able to talk to administration and politicians and people that, as surgeons clinically, we're not educated on that. You know, we're educated on how to be technically very good, how to learn, but anything that extends beyond the O operating room. But to the care of the patient, we're not well versed in. So my Masters of Health administration gave me a lot of tools to, to speak about what, what is a business case? How do you put together the business case? Who do you talk to when you have a business case? Um, where do proposals go and how do you affect change? A lot of that came from my master's in health administration. Um, and then from experience. And then finally for efficiency, it came from the Anterior Hip Foundation. I mean, a few years ago we had a talk on, on efficiencies, and I was up there listening to, you know, Charlie and Kristoff, and they're talking about banging out 14, 16, 18 cases in a day. I. I was like, holy shit, I'm fast, but that's really fast, you know? And so I, I, it led to emails and conversations and then, you know, and surgical site visits, um, and bringing our surgical team to those visits. So it wasn't just a surgeon saying he or she wants to do more. It's about the entire team understanding that we can be better and that that's all they challenge people to do is like whatever we're doing, we have to constantly. You know, seek to evolve to be a bit better version of ourselves. And if everyone takes that mentality, you can achieve amazing things.

Joseph M. Schwab 16:01

When you were thinking about those efficiency tactics and, and sort of reflecting on what Charlie was doing and what Kristoff was doing, was there a case or a moment not necessarily. The hardest case that you've done, but one that changed how you started to think about efficiency or how, uh, a case that maybe reshaped your judgment about this whole process. I.

Sebastian Rodriguez-Elizalde 16:26

What really reshaped, to be honest, was probably when I visited Charlie, I remember. The thing that I took away the most was Charlie. I mean, and Charlie has an amazing practice and I think everyone should go visit Charlie if you're in the US, to get an idea of efficiencies in the, in the surgical setting, uh, was, you know, the software and how we mapped out. Measuring every process of that. So, you know, I'm not sure if we can use like, you know, but it was basically an, an Ospitek or you know, a one team type solution, if you will, that broke down the surgery, had the entire surgical plan on a board for everyone to see and timed each part of the procedure whereby you had your average time for that procedure and then your average time for each part of that procedure. And that's when I started thinking about surgery a bit differently. I thought not about it as a procedure, but as the, the cumulation or the sum of a lot of small. Parts that have to get to you to that next step. And when you start to think that way and you start to measure that way, then you become aware of yourself. And when I came home, the first thing I did is I got someone to measure. I said, look, these, we don't have that software yet, but I'm like, write down all these time points every time. And because. We as surgeons are always the greatest or the fastest or the best, or never have complications if you talk to any one of us, right? But it's very humbling when an objective person will measure you. And so we have a lot of data for a lot of the measurements that we do in surgery, and I'm sure they're the same in the US and Canada, if you look at infections or dislocations or reoperations. But the pieces of that surgery and to get there. Don't really measure or historically have never looked at that, right. And so, um, that data to me is quite fascinating and quite enlightening in terms of, um, procedural improvement because based on that, when I even went to go see Kristoff in Belgium, just technique wise, a couple of the things that he did, I started adopting. And I realized, you know, in this part of the operation, I'm actually faster and I can tell because even the anesthetist said. You know, your, your procedures are faster. And we broke down. We were able to figure out which part of the procedure I was faster at because I had adopted, you know, new learnings to. So yeah, it was very interesting to see the data that I made on myself and be able to make on a procedure to be able to self-improve.

Joseph M. Schwab 18:31

I, I'm gonna get to those, um, efficiency sort of mini fellowships that you did in just a minute. But before we get there, you didn't start out doing anterior approach. You started in posterior approach, is my understanding.

Sebastian Rodriguez-Elizalde 18:45

I did

Joseph M. Schwab 18:46

And

Sebastian Rodriguez-Elizalde 18:47

so in,

Joseph M. Schwab 18:48

yeah. Tell me about that.

Sebastian Rodriguez-Elizalde 18:49

go ahead. Well in, I trained in Ottawa, uh, which is the capital of Canada, and Dr. Paul Beaule brought anterior approach from Joel Matta there. I guess that's now, I don't know, 25 years ago or something when I was in the middle of residency. So as we all know, Joel is sort of credited being, you know, the. The godfather, if you will, of, of anterior approach, you know, on the west coast of the US And his disciple, Paul Beaule, was actually working in, in California with him for several years before coming back to Ottawa. So Paul really is credited for bringing, uh, anterior approach philosophy, uh, and, and that surgical technique, which is sort of experimental and very, you know, limited in all of North America at that time and brought it to Canada, made it part of the residency and fellowship training. So we were exposed to that as residents. Um, and so I had seen the anterior approach and knew about the anterior approach and the purported advantages. At the time, I mean this is so historic. Patients were kept in hospital with for four days, right? Three or four days. So, you know, people seemed to have less pain, but it didn't seem to lead to a faster discharge just'cause, you know, we thought mentally all these patients had to be in hospital. Um, and then when I went to HSS, uh, everything was posterior approach. So back then they were just starting to dabble in anterior approach. You know, Jose Rodriguez and Dr. Alexiades. A couple guys just starting, but it was still very much in its infancy. So I came out trained. Is a, a posterior revision and primary surgeon. Um, and started my career that way. Then it was really in the early days of my career that our administration was, uh, had gone down to Colorado and, and seen a surgical center and they said, Hey, these guys go home the same day. They're doing anterior approach hips. How come we don't do this in Toronto or in Canada? And so administration wise actually approached me and said, can you do this? And I said, well, you know, actually I was trained to do that. We need a special table. Um, if you support me in getting a table and doing a trial, maybe we can start to, to do this surgical technique in Toronto in our hospital. So they did, we, we trialed a HANA, a table. We, I went back and relearned anterior approach, uh, with some site visits with some colleagues. Uh, my first few days they came and helped me out and then started doing everyone anterior approach. Back in 2016 or 2015, I guess we just sort of switched and everyone went to anterior at that point. So it was relearning something that I was aware of, uh, but I had to get comfortable in again to do it.

Joseph M. Schwab 21:08

So, uh, speaking of that, what part of that was harder? Was it the learning, the technical learning curve, or was it more the psychological learning curve? I.

Sebastian Rodriguez-Elizalde 21:18

I think it's both. I mean, when you're, I was still a few years out of fellowship, so it was still pretty early on. But even, you know, what struck me is at that point I felt like I had refined my posterior technique. I felt like I had a very small incision. Really? Is there a difference between anterior and posterior? I'm really good at posterior now. That's how HSS trained me. Um. I was comfortable and I realized that you can very quickly become, you know, we, we always said like, oh, those old guys are novel to change what they're gonna do. You know, like I'm a new young guy. But very quickly that mentality I had was, you know, you can get very comfortable and see why people don't want to change later on in their careers. So it was a struggle because you feel like you're finally, you're very good at one thing and you're going into the unknown. So. It's an ego hit because you realize you're not gonna be as good doing something new, that you're very good at doing something old. You have to promise yourself that you're doing this because at the end of the day, it's gonna be better for patients and, and hopefully better for me as a surgeon to offer better quality care. And there's a reason that I'm changing my technique. Um, and you have to stay that course. Then technically to relearn stuff that you haven't seen. And now you're looking at it through the eyes of I'm the attending and not the learner. I have to do this fully without someone watching me. Yeah. Those are big steps and big, you know, anxiety provoking things. Um, and as much as everyone, every hip surgeon says, you know, I know how to do a hip, but when you do it from the front, it's, it's like a new operation. You can't think of it as like, well, I do a hip, this is the same thing, but I'm just changing a couple of things. So you have to really. Rethink the way you think about the hip when you do it from the front. So those things all caused a bit of anxiety. I think part of it was I was young enough and naive enough that I assumed it would be easy and could do it. You know what I mean? Like. I didn't overthink it. You know, you, you just sort of do it. And that's sort of like, you know, like, like children, right? They just adopt a new thing and they just, they don't overthink it. Whereas, you know, trying to learn to ski when you're 45, you're gonna way overthink that, right? About what if I fall? So, um, I think I was still young enough that it seemed like it would, should be easy enough to do. And lo and behold, here we are.

Joseph M. Schwab 23:18

So did you ever have significant doubts about the decision to do that?

Sebastian Rodriguez-Elizalde 23:24

In the first couple of days, uh, you know, the first few days that I was operating on, I had Brent Lanting, who was a colleague of mine from London, Ontario, who does a lot of anterior approach hips. Good friend. He came up and helped me and so I felt comfortable, like he let me do the cases and was there to bail me out, give me tips and tricks. I'd been to a variety of training courses, but, um. For sure the first day that I was on my own about, you know, you have a bit of a harder case and you're wondering like, why am I doing this? This is so much harder, right? And then, uh, I made the decision to go wholesale all anterior early because I know myself and I know that if I pick and choose, you can always make an excuse to not do something hard. This patient's a bit bigger, this patient's a bit more osteoporotic. This patient's overweight, this patient's too muscular. We're behind on the day. Maybe I should just do it from the back. I didn't give myself those crutches. I, you know, I burned the ship, so to speak, you know, and I just stayed on the beach and just kept going. So, uh, there was no retreat at that point. And, but many a time that I have doubts during a case if things were taking longer. Um. You are gonna be frustrated when you learn something new. And especially I think when you're a more experienced surgeon trying to relearn something new because you've spent years honing and mastering that craft that you're very good at doing in one particular way and relearning something has to involve the fact that you are going to make mistakes and be slower and not as good as that guy next door that maybe has been doing it for a long time. You have to stay that course. And I think for a lot of surgeons, maybe they dabble in anterior approach hip after a weekend course. This is too hard. Or they have a complication and then they, they bail on it. They don't do it. You know, and we saw that in Canada and, and even in the us like a lot of people, early adoption, uh, failed. And I think that now with better training programs, better support, better mentorship, uh, a lot of those fears are taken away and we're able to support those surgeons better and have better education so they don't fail.

Joseph M. Schwab 25:16

If you are doing anterior hips or if you're thinking about it, let me just say this, a HF events are different. You won't be sitting in the back of a dark room watching slides all day. The content is practical and technique driven. And the A HF is a real community. You can stop anyone in the hallway and ask, how are you handling this exposure? Or What are you doing in this revision? And they'll walk you through it because that's the culture. If you're early in your anterior experience, there's a fundamentals track focused on technique and complication management that you can use Monday morning in your own or. But if you're extending into complex primaries or revisions, we're already there having honest conversations about what works and what doesn't. And we have pre and post meeting anterior hip labs. For every stage of learner, there's something for everyone. More importantly, it's a group of surgeons serious about continuous improvement. A HF 2026 entitled Consensus and Controversy is June 5th and sixth. You can see the program and register@anteriorhipfoundation.com. If you've been thinking about coming, come, you'll leave better than you arrived. I'll see you in Nashville. So you spoke about this kind of, I would say a bit generally, but specifically was there something you learned about your own ego going through this whole process?

Sebastian Rodriguez-Elizalde 27:04

Yeah, that it's more fragile than I would've ever admitted to. You know what I mean? Because it's a, I think that's, that's, that's all of us as surgeons, but certainly for, for me, is that like. It's humbling, like learning something new, uh, is humbling. And I think going through that made me more aware of one as you teach other people things, and two, awareness of myself to be able to adapt to new things as I move forward.

Joseph M. Schwab 27:31

Hmm. So I do wanna go back, um, now and talk a little bit more about the time that you spent with Charlie and with Kristoff, because not only did you go, but you made sure that your team went with you to see how those clinics function. So I, I wanna start with why was it important to you that your entire team saw what was happening?

Sebastian Rodriguez-Elizalde 27:57

I think that was key because I've seen. So many times surgeons go see something new or have a new technique or toy, and they wanna bring that back to their institution. I mean, this happens in Canada periodically. And you know, you have to validate it to the administration and say, why? Why should we change? Or why is this costing more? Why can we do this? And that relies on the surgeon explaining why he or she has done something. Without everyone else understanding that it could be done and could be done safely, I didn't think it would get off the ground. And so, because we had a lot of fears of trying to push the boundaries of going from three, four, or five cases in a day to to double or more of that, there was gonna be a lot of friction and resistance. And so I thought it was important that the people in the Recovery Bay that take care of these patients, the pre-op nurses. Our Zimmer rep, even I wanted him to come administration to come, uh, in, in subsequent visits we've taken anesthesia down because, you know, the anesthetic process that he has there compared to what is normative in some other places is totally different. Um, I think it was, and even our scrub nurses and or nurses. So the girls that set stuff up for you Right, and, and take things down and just for them to see what could be possible. Again, my takeaway wasn't to have the team come back saying, okay, we're doing 16 cases on Monday. The goal was to come back and say like, look, we learned that we can measure and be better at what we do, and maybe we can do my, my, my idea is sort of like 20% more, right? So if, if you do three, do four, if you do four, do five. You know, you know, just be one extra case better and see where that takes you. And by having everyone there to see it, um, and I really think that. Charlie talks about it, but you have to see it like you have to see how fast things are and how fast things can be and still done at a very high standard and safely. Once you see that, it totally changes what you think can be done, and at least for me, part of this process wasn't just if I could operate faster, it involves the entire system changing. So we needed people from the system to be there to witness it.

Joseph M. Schwab 30:01

Were there things that your team, um, identified or noticed that you hadn't?

Sebastian Rodriguez-Elizalde 30:09

A hundred percent everything. So I'm focused on Charlie and the surgery.'cause I'm trying to feel, what can I do better for my surgical technique. But the, the scrub nurses came up to me and they're like, you know, Dr. Rodriguez, we, when we come back, we're gonna do this and we're gonna do more and a debt. One of my favorite scrub nurses here at Humber said, I'm gonna make sure that you don't ever ask for an instrument, and we hand it to you right when you need it before you even ask for it. Every time she's like, we can do this. And she's like, we can help do the take down before while you're closing to help get the case done faster. Um, you know, uh. The nursing and administration all identified areas that, you know, some things could be replicated and some things can't. So this is a, a hybrid Canadian version of which you will of, of, of surgical efficiency. Um, there's less bodies in the room compared to what Charlie has, if you will, in terms of the number of people. So everyone had to pick up extra jobs. So our surgical assistants here, um, you know, help with some of those roles. So everyone actually identified stuff that. He or she could do and brought it back. It, it was actually not me dictating it. And to be honest, it worked out better than I could have ever thought because it wasn't me telling people they needed to do things. It was people identifying like, Hey, we can do this and make it better. And I think that level of engagement, I think is really what made the whole program a success.'cause without that engagement, you, you don't have the, you know, a team centered mentality.

Joseph M. Schwab 31:35

And as you're hearing from surgeons nowadays who are trying to implement these sort of anterior uh, rapid recovery discharge protocols, what are the mistakes that you're. Hearing that surgeons are trying, specifically in terms of if they're not aligning their entire team.

Sebastian Rodriguez-Elizalde 31:56

I think that's big because you have. Big resistance in terms of safety, right? There's a misperception that's because something is efficient and fast, it's unsafe. And I argue personally that look, the, the more you do of something in a day, and the more it's replicated, the more standardized it has to become. And standardization is the key to any successful operation. I mean, like, that's why pilots have a standardized flight checklist, right? And they go through everything at the same time. We do a pre-op checklist, but like. Surgically, you know, there's a lot of variance. And so the more we can decrease that variance intraoperatively and the way we approach things, the safer it'll be, um, to the point where if we're running two rooms, we often make sure that one room's all right side one room's all left side. So there's no confusion. Um, there's no setting up of the C-arm or moving the tables over from right to left. Everything is very seamless, as much as possible in that regard. So I think, um, you really have to understand that. There's gonna be a lot of resistance, mainly in terms of safety, mainly in terms of, you know, can we get things turned around just as fast. But you realize if everyone pitches in, you don't need 35 minutes or 45 minutes to clean a room, you can do something very. Safe to the appropriate standards in 10 minutes or 15 minutes. And even your anesthesia colleagues, getting them on board and seeing how long a spinal anesthetic lasts, you know, you don't need them to be paralyzed till the next day. Like what we used to do, we used to give them such a long spinal for pain control and epidural that they wouldn't walk until the next day. So there was no thought processes to How long does this spinal last? Now that we're getting people at the same dates, we've reevaluated the role of spinal anesthetics and the medications we use for those and how long they last.'cause we, we need this guy to walk in three hours or in two hours, right? So totally changes the way we've approached those things.

Joseph M. Schwab 33:40

So as your system becomes more efficient, are there things that to your mind are not negotiable? Like what would be your three non-negotiable? Can't change these, no matter how much more efficient we want'em to become.

Sebastian Rodriguez-Elizalde 33:56

That's a great question. I think non-negotiables, number one is I think it is anesthesia. You need to make sure that your anesthetist or whoever's providing that is on board. Um, and you know, in terms of blocks or per articular blocks or anything that's done by the anesthetist, they have to understand that they, you need to have this person fully mobile and walking within, you know, two to three hours and however long it takes you to establish that preoperatively, be it a spinal anesthetic if you need. 20 minutes to do a spinal, then you have to leave the room and get ready for that patient like 25 minutes ahead of time so that you're ready to go. So I think having a good relationship with your anesthetist and being able to communicate what you need and making sure that they can deliver that. Consistently is the other thing, um, I think is very important. Uh, the second thing I think you need in terms of that is having an experienced team. It you can do a hip anywhere, at any given time, doing it like you do back home or whatever with your normal team. And setup, I think is, is, is like home field advantage. So you need to be able to have a core group of people that you work with, be it, you know, a scrub tech in the US or an assistant. Some of that makes you better and I think good assistants make you better. So that be it, a scrub tech or a nurse or a physician that's helping you, if they can anticipate your next move before you're doing it and help you, that makes you much more efficient. So having a familiar face in that regard where you're not having to explain every step of what you're doing and what you need them to do, but they can, they know what it is that they're doing, I think is very important. Um, and finally, I think your nursing team that's with you. So on any given day, the nurses on the back table. The people that understand the implants and how to open them. Um, the people that understand that you take every, you know, screw hole out and you need to have that prepared before you put in a cup or not. Um, do you have a screwdriver ready, things that are ready on the back table? And even beyond that, they have to be consistent and understand your flow. So if you have those things like your nursing, your assistant in anesthesia all there, they're on the same page and, and have worked with you and understand what the goal is, you'll have success.

Joseph M. Schwab 36:01

Hmm. So you did this, um, change of your own practice moving from posterior to anterior, and then you undertook this culture change moving towards a more efficient operating room. What was harder, um, refining your femoral exposure when moving to anterior approach or changing the culture of your public hospital?

Sebastian Rodriguez-Elizalde 36:26

You know, I think it was both. Both have different challenges. One is. You personally are challenged technically, right? How can I become better? And anyone who's ever learned to anterior approach also has this aha moment when they realize, oh, how I can deliver the femur. I just have to remove this capsule here, and things pop up and I can see it. Right? You have to go through those iterative changes where you're just like, oh, I, I didn't realize or appreciate that, and now I can do that better. So. Definitely there's those challenges there that one day either you discover or someone shows you a trick and you're much better at doing it now all of a sudden. Uh, there were a lot of those for me personally, obviously over the years. Um, and then even after when I went to go see those other surgeons again, you know, really reinvigorated me, Joe.'cause I, I was watching someone else do these procedures again and again. I was. I never thought of doing that and I started implementing little tips and tricks because even after several years you think you've developed your own technique and is very good, but then you go see a couple other people and you pick up things and if you can adapt that and constantly like learn, I, that was refreshing to me that there's always room for improvement and enlightening to me to be like, you know what, just'cause you've done something well, doesn't mean you can't get a little bit better if you start to adopt or look around to see what else is being done. In terms of the system change, that's harder because a lot of that's out of your direct control when you're operating. You have direct control of what you're doing. When you're trying to get a process and a system change, that's much more challenging in some regards, right? Because you're, you're, you're limited if you will, in terms of how much you can convince other people. So you have to put your best case forward and, and, but it's out of your power, which is, I think, hard for surgeons to give up because they can't just say change, you know? It has to be accepted by all.

Joseph M. Schwab 38:06

A bit of a negotiation sometimes even.

Sebastian Rodriguez-Elizalde 38:09

Life is a negotiation. Is, is is. Voss told us, I think at the last meeting, so yeah.

Joseph M. Schwab 38:15

So, um, you, you've touched on the use of, um, surgical technology and, and, um, innovation within, um, the efficiency space. And like you mentioned, in a public hospital, every dollar matters. So when you're evaluating some new technology, what sort of internal filter do you use? How do you go about that process?

Sebastian Rodriguez-Elizalde 38:39

You know, I think we, we struggle with this because. All new technology and innovation comes with an upfront cost a lot of the time. So you have to justify that either by research or by education and understanding that this may not be efficient or save you money upfront, but we anticipate that with this implementation, it will down the road. And so you have to get people to buy into the fact. Efficiency doesn't mean today in the operating room. It means like, what does this look like in two years, five years, 10 years? What does it mean at a societal level if we have less revisions and less complications in a public taxpayer sort of scenario? Being able to sell that idea and that vision and then being able to make compromise. Whereas like, you know, we, let's say we want to use ceramic heads, metal cobalt, chrome heads are, you know. Half the price or less here in Canada. Um, and using a ceramic, you know, a bearing surface is much more expensive, but we're allowed to do it. But to be able to do it on everybody isn't necessarily, you know, feasible, nor is it necessary as we know. So it involves making compromises to be like, look, we're gonna use. Better implants or newer technologies, but understand that maybe not everyone gets it. Um, and be able to make compromises down the road of like, okay, well maybe we'll do a little bit less of X if we wanna really get Y. So you can't have everything all the time, is really what it comes down to if you want to use technology or, and innovation. Um, so it means picking your battles and it also means being able to create. A model where you can prove what it is that you're doing has value to the system. Um, it's just hard to see that value for tomorrow or when you're first starting.

Joseph M. Schwab 40:21

Have you ever been really excited about a piece of technology and then suddenly realized maybe it's not the right move.

Sebastian Rodriguez-Elizalde 40:31

Uh, for sure. I mean, you know, lots of stuff like we're, um. Let me think of a good example of that, but I feel like that's almost every day. But yeah, in terms of new technology that we wanted to use, I mean, I don't wanna get into specifics with that because of, you know, companies and devices and stuff like that. But for sure, like, you know, the implementation of. Navigation technologies and both hip the knee replacement. Obviously, you know, I'm a tech guy. I love tech. Um, and you know, initially when we started doing that, even on the knee side and, and, and navigational technologies, as you know, on the knee side, never really bore out. Huge clinical advantages, you know, 10, 20 years ago when we were using them, even though intuitively made sense to be more accurate. Um, and then, you know, and, but took a lot longer with some of the early versions of, of, of navigation in knees, if you will. Now we have a new generation of robotics where you can, it's a whole different story in terms of what you can evaluate and how you can do it, let's say a knee replacement. And so we're being able to revisit that and, and hopefully now have proof and, and show how it makes the surgeon better and the patient better. But it's easy to get excited about new technology sometimes. And then you're right, you have to take a step back and evaluate like. Is it worth it? Is the juice worth the squeeze? Is the financial cost, uh, involved? Is the learning curve, is it all better or not? And that can definitely take some honest, reflective feedback that you might not always like the answer to, right? Because you invest time and effort and, and, and money to get some of these things. And then to realize that you may not actually need them or be, you know, benefiting from I, I think is humbling. But I think you have to be open to that.

Joseph M. Schwab 42:11

You know, it's interesting you mention the sort of navigation in total knees.'cause um, it, some of the, some people online, certainly and some surgeons that you talk to, would argue that the technology was great, the alignment strategy was what was off. And you, you know, it's, it might not be that the technology is the problem, but that our understanding is, and what's

Sebastian Rodriguez-Elizalde 42:33

agree with that.

Joseph M. Schwab 42:34

Yeah. And what's what's interesting about that is, you know, people, I, I think there's a lot of concern going forward about technology replacing surgeon judgment instead of enhancing it. So as you're looking at different pieces of technology, how do you, how do you think about that concept of enhancing your judgment as opposed to substituting for it?

Sebastian Rodriguez-Elizalde 42:59

Well, I think, I think we're getting there, to be honest with you. I mean, um, uh, I think technology is accelerating at a pace that, uh, not many of us fully understand, I would say. And the learning algorithms of machines, I think is going to far exceed surgical judgment in my lifetime for sure. And, and probably pretty quickly. Um, and I say that respecting all our, you know, knowledge of surgeons and our experience, but. Any process that's a mechanical process that involves, you know, us doing stuff naturally seems like a navigation or robotically assisted will, will slowly penetrate that market. The judgment, I mean, some of these tools to be able to discern, you know, alignment strategies and knees, cup placements, and hips. AI is gonna be able to do that a lot better than we are. Like, you know, the imaging AI like that they have to read x-rays and cts is, is just now, you know, getting as good as radiologists and shortly will probably be better. The natural extension of that is that, you know, for us clinically to make a judgment on positioning soft tissue tension alignment, I think it's natural that these technologies are gonna evolve to the point where they can better. Do some of those processes than we are, I think you'll need a surgeon to be able to guide the robot, to make the clinical decision, to approve a surgical plan, to understand the nuances of that patient's. But I think very quickly, a lot of those decisions that we were taught, you know, that relied on years and years and years of experience, that's basically all experience that can be fed to a machine and the machine can do at some point.

Joseph M. Schwab 44:35

So you're, um, certainly still young in your career, but you've had enough of a career that you have the ability to kind of reflect back on how far you've come and you're probably at the point where you get to start thinking about what type of legacy you get to leave behind. So a couple of questions regarding that. If a surgeon, um, much like you is now just a year or so out of fellowship and in a public hospital, let's say in Canada, and they're feeling overwhelmed with their system, um, and overwhelmed with what they're asked to do to take care of patients. Is there any advice or anything you would want them to know or anything you would want to tell them?

Sebastian Rodriguez-Elizalde 45:17

I had say one, uh, talk to your colleagues or talk to somebody that's been there, or someone like myself or whoever isn't around your milieu to be able to reach out. I don't, I think being frustrated with the system and keeping that to yourself is unhealthy in probably many different ways. Um. I think understand that early in your career you're gonna have frustrations and your career is not a linear thing. Your career go has ups and downs like the rest of our lives do, right? And there's good days, bad days, and it's how you deal with the bad days that give you the ability to have success and create more good days. And, and really that's what you have to take away from, you know, when everything's great. You don't learn anything from that. You learn from when things aren't great and what you did to dig yourself outta that hole. And so people wanna avoid conflict and avoid stress and avoid setback. But that's when our greatest learning happens, when your resilience is built, when you, you can reshape what your goals are in life. So I think I. Don't, you can welcome those things, understanding that they all play a part in your future development and, and not wanna avoid them, but you don't have to do it alone. You know? I think that's the biggest thing is that if you are experiencing those things or you have challenges, talk to somebody, talk to the system, talk to the nurses, talk to your administration. I think we develop narratives in our own mind. Sometimes a surgeon is like, I'm just not allowed to do this, or no one understands me. But being able to communicate those things. You know, respectfully and meaningfully to the right people and engaging them, I think makes it better. And I wish I'd done more of that earlier on in my career.'cause seeing now how it's able to affect change, uh, I've really been able to learn a lot from that.

Joseph M. Schwab 46:53

Hmm. You, you've said in the past that if you're not expanding your knowledge by, I think you said 5% per year, that you risk becoming a dinosaur. So what's the 5% you're chasing right now?

Sebastian Rodriguez-Elizalde 47:07

So, first of all, I learned that from Chit Ranawat, God bless. You know, he was the one who said, like you, he said, um, you know, Sebastian's like, you gotta be expanding your mind like by, by one to 5% every year, otherwise you're falling behind. And I. You realize that later on, like with everything, if you're not moving forward, you're, you're gonna fall behind a little bit. And I think that's important. I think, you know, we like to be comfortable. Being comfortable often means not doing anything right, but that's inertia. And I think you have to constantly challenge yourself, be it professionally, uh, be it a technique, be it socially, be it, you know, in your hospital system of how you can do better. think that if you just adopt that mentality, I think generally in life, you know, that's what lets you go to the gym and try to be a bit better than the next day or, you know, read the paper and become better educated about world events in certain areas that you don't know about. Like I think being able to constantly learn, I think is, as surgeons, we all have a level of competency where you've shown academic prowess to a degree, where you're able to learn. That doesn't stop when you start practice. And I guess when I first started I sort of thought that did like, okay, I'm done, I'm done. My fellowship. And people always said like, well, you know, medicine is a lifelong learning journey, but you really have to be active in that. You can't be passive in that. You have to seek out new opportunities. You have to seek out, um, things that make you uncomfortable to be better.

Joseph M. Schwab 48:29

What part of your practice are you, let's say, most proud of that your patients never get to see? I.

Sebastian Rodriguez-Elizalde 48:38

Um. I think if the relationship well, they never get to see. I think it's sort of like the, the mentality here of the hospital. When we first brought in like the, the first Anterior hip program in, in this whole region of Toronto and we brought in the first same day hip program, you know, what I was proud of was that the nurses and people involved were proud of it. So everyone from registration at the desk to the nurses to the OR people, they had ownership of that program knowing that they were exclusive in the entire region and that they were teaching other people. They had a sense of ownership. That, I don't know, makes me almost emotional because they liked the program almost more than I did. And it really showed in their work,'cause patients would comment on me, they're like, you know, we go to a lot of public hospitals, or we go here and people aren't. As happy as they are to be working where they are or, or notice those things And those kinds of comments really, uh, you know, highlight all the people that are part of that process, uh, for that patient journey. But the fact that they owned it and, and love it and are proud of it, I don't think there's any way I couldn't be more happy with that entire process because I can't teach that. But to know that. They were able to achieve that. And it echoes with patients though they don't know why exactly, but they know people are better here. That, that I'm really proud of.

Joseph M. Schwab 49:58

And one last question for you, Sebastian. When your fellows leave your program, what do you hope that they carry with them? That has nothing to do with implants or approach or even efficiency. I.

Sebastian Rodriguez-Elizalde 50:16

I think. Patient care I think is very important. I think being able to have a relationship with a person, I think we forget bogged down sometimes in terms of volume and numbers and, and x-rays and behind. Every x-ray is a person, right? And they have a life story. They wanna play with their grandkids, they wanna go back to work, they want to heli ski. Whatever their story is. Don't forget that that story is what brought them to you and respect the fact that they're trusting you to operate on them. And I think that you, you have to remember behind everything that you do is a person. And so you have to have a relationship when you talk to'em in consultation, when you see them in follow up and respect that. Everyone recovers and prepares differently for surgery and their experience will be very varied. Um, but be open to learn from that and respect the person to try and, you know, you have to remember why they're here and get better. Um, and sometimes we say, well, your x-ray looks fine. You're fine. We have to address what their issues are, their concerns are. And that took me a long time to, to realize is that like even if you do something and everything is right, if it's not right for the patient, then maybe we haven't done everything right.

Joseph M. Schwab 51:24

Well, Sebastian, I really appreciate you taking the time to be with us today on the AHF Podcast.

Sebastian Rodriguez-Elizalde 51:31

My pleasure. I can't wait to see you in Nashville.

Joseph M. Schwab 51:34

That's all for today's episode of the AHF podcast. If you found some value in this conversation, I would asked you to share it with a friend or colleague or just drop us a comment to let us know and make sure to connect with us on LinkedIn to join the discussion between episodes. There's a link to our brand new LinkedIn page in the description. Find us every Friday with new episodes on Apple Podcasts, Spotify, YouTube, and all major podcast platforms. I'm your host, Joe Schwab, reminding you to keep those hips happy and healthy and home the same day.