Episode Summary

Dr. George Tolis, section chief of coronary and general cardiac surgery at Brigham and Women's Hospital, joins Drs. Koka and DiGiorgio for a wide-ranging conversation on the state of cardiac surgery. He makes the case that TAVR — while genuinely transformative for the right patient — is being systematically applied too broadly, driven by industry incentive and the erosion of meaningful surgical consent. He discusses his collaboration with John Ioannidis that found no statistically significant mortality benefit for any new cardiac surgery technique introduced over the past 35 years, the paper's rejection by every major surgical journal, and what he paid out of pocket to make it open access. The conversation moves to the collapse of surgical training — fragmented pathways, work hour restrictions that leave residents unprepared for attending life, an academic promotion system that ignores teaching, and a culture that routes incompetent trainees around rather than out — and closes with a brief on Vasily Kolesov, the Soviet surgeon from Leningrad who performed the world's first documented coronary bypass years before Favaloro, and whose work was buried by the Cold War.

Chapter Markers

00:00 Introduction

01:02 Air-cooled VWs, concert piano, and how Dr. Tolis got here

02:40 TAVR: genuine breakthrough or being abused?

08:02 Finding the TAVR threshold — and why informed consent is the real problem

11:46 Collaborating with John Ioannidis: no mortality benefit for 35 years of new techniques

20:02 Why the major surgical journals wouldn't touch the paper

21:52 Minimally invasive surgery: minimal access vs. minimally invasive

26:24 When do CABG survival curves diverge — and what does it mean?

30:05 Surgeons signing off on TAVRs in young patients

33:51 Health system economics and the heart team dynamic

37:50 How to actually pick a good surgeon (ask the scrub nurses)

40:36 Cardiac surgery training: the three pathways problem

44:04 Work hour restrictions and the residency simulation gap

51:16 General surgery is like MTV — they don't operate anymore

53:21 A resident who finished training without ever applying a cross-clamp

56:34 How to evaluate if a program actually trains

59:27 Academic promotion has nothing to do with teaching

01:01:33 Dr. Tolis's resident outcomes database and three papers nobody cared about

01:05:32 The training timeline: finishing at 49, no runway left

01:07:08 One-size-fits-all RRC rules for cardiac surgery and psychiatry

01:09:16 Cardiac surgery as a disposition, not a therapy

01:12:24 When ECMO becomes the final common path

01:13:38 How you become nationally recognized without being a good surgeon

01:17:16 Vasily Kolesov: the Soviet surgeon who did the first bypass

Co-Host Handles

@anish_koka and @drdigiorgio

Show Handle

@drsloungepod

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