MetaCast

Rhanderson Cardoso
Hello, everyone, and welcome to one more episode of Metacast, the podcast of the Metanalysis Academy. I'm honored today to welcome to the stage Dr. Rafael Ayala, straight from Germany. He's a cardiac surgeon there. He's come here to Boston for a conference, and he's going to share with us his incredible journey as a cardiac surgeon, as a foreign graduate. He's from the country of El Salvador. and he's also going to talk about his research experience, career, making it into residency in Germany and so many relevant topics that may help you in your own career. So before I go on any further, Rafael, thank you so much for joining me. We've known each other for a couple of years now probably

and it's an honor for me to meet you in person finally and also to hear and share your story here on Metacast.

Right. Thank you, Rhanderson, for the invitation.

It's an honor for me to first finally get to shake your hand

thank you for everything you've given me the opportunities i really really appreciate it

thank you for the opportunity it's my pleasure you know i'm your story is so inspiring you guys

are going to hear all about that today before i start asking rafael questions just a few important

announcements as you know medicast and the meta analysis academy are not affiliated with the

institutions where i work here in boston where rafael works in stuttgart germany the opinions

here are exclusively our own make sure to hit that like button and subscribe to the meta analysis

Academy channel here and also share this with your friends so they can also learn incredible

career trajectories. We're going to talk about research and the Meta Analysis Academy. Remember,

if you ever want to learn how to do impactful research, make sure to join our wait list. The

link will be below here in the video. So Rafael, let's do this back from like your upbringing.

You know, where'd you grow up and what was it like, you know, growing up and why'd you decide

to go to med school? Did you think of being a surgeon

when you were a kid?

I get this question

a lot and it's

been quite a journey. I think

if I had planned it this way

it would never come out this way.

So, well I was

born and raised in El Salvador. It's been

a pretty popular country

in the last couple of days.

We could do a podcast just on that.

Just hours long

about it. So I was born and raised there.

Had a normal upbringing

working class family. And I think I was a little biased because both my parents are doctors.

Nice. Mom was a pathologist. Dad was a colorectal surgeon. So I always got to

go and play with mom's instruments at her lab and go to my dad's. So when I was 15,

dad told me, looked me in the eyes and said, okay, let's see if you're made for this.

wow so he brought me and i got to help him in a hemicolectomy wow you went to the OR i went to

the OR i washed up uh and and i helped him and it was right on that moment where i said okay this is

what i want to do the rest of my life i want to do surgeries that's incredible incredible so one

thing led to the other trial by fire yeah right so he said if you don't faint in your first surgery

then you're made out for this.

So it just lighted my fire.

And one thing led to the other.

And then I told him, hey, I want to be a surgeon.

And he said, well, first, you're going to have to go through fire.

You have to go to med school.

And after med school, you have to do residency.

And I was like, oh, no, I just want to go directly to surgery.

So future surgeons and the artists will relate, you know, like it's very long.

Right.

It's long.

But let me tell you, it's worth the while.

It's really worthwhile.

Nice.

So, and then you went to medical school in El Salvador.

Right.

I went to med school in El Salvador.

Eight years long.

Eight?

Eight years long.

Wow.

That's normal there.

Does that include like social service here?

Right.

Like a lot of countries in Latin America?

Right.

That includes one year of social service.

You get sent to a small town or near Guatemala or Honduras.

Is med school in El Salvador public or private?

They're both.

They're both. I went to a private one.

It was great.

Yeah, it was great.

And then when you were thinking about options to decide where to do the next step of your career,

I suppose you maintained this steadfast commitment to surgery throughout.

Right.

And how did you land on Germany as an option?

And did you consider other places as well?

Yes.

Well, I always explored some options.

Of course, one option was coming here to the States.

But then in the middle of med school, I did some practical months.

I spent two summers in cardiac surgery in Germany.

Oh, you went to Germany during med school?

During med school, but just to do some rotations.

So I didn't do anything, well, just basics.

And then I got to know the hospital, the system, had contacts.

That's really, really important.

I think everywhere where if people want to come here, I heard tons.

You have to make some contacts and rotations.

So it's very, very important to do those and leave a good lasting impression.

So I already knew the language.

I was a little biased.

I went to a German school in El Salvador.

Oh, like before med school?

Since kindergarten.

Wow.

So I already knew the language.

That's another story.

Is it popular, like in El Salvador?

Because in Brazil, there's a lot of bilingual schools, but it's English.

English, the second.

Like it's Portuguese and English.

Right.

In El Salvador, there are some bilingual schools.

There are private schools that are really, really expensive.

And my parents, well, the idea was my parents wanted, I have one older brother.

so they wanted us to learn a second language and that was only possible in a in a bilingual school

in a private school it was really really expensive so at that time the german school was

the least expensive one because the whole personnel and at least the teachers the german teachers

they came from germany they kept receiving their salary from germany okay so we only had to pay

some staff, Salvadorian staff. Gotcha. Yeah. Understood. So you learned German as a kid,

and then you went to Germany during med school in the summers and your vacations from med school.

Right. And what, if you remember, what caught your attention? What did you like so much about

Germany when you did those rotations that made you decide to do a career in Germany?

Well, that time, people, residents were really, really friendly with me. They let me do anything.

Well, within the limitations.

Yeah.

So small stuff.

Yeah.

But small stuff is what lights your fire when you're a student.

For sure.

So I kept my fire up and finished med school.

And then after that, I already had some contacts.

And they had told me in two different hospitals, hey, whenever you're ready, we need people.

We like you.

Whenever you finish, we will welcome you and should apply.

Which hospitals were those during Mexico?

So I went to the University Hospital in Regensburg, that's in Bavaria,

and then to the University Hospital in Freiburg when I ended up doing most of my residency.

Really?

Right.

And then one summer, some days I spent it in University Hospital in Tübingen.

So walk us through what's it like to apply to residency in Germany.

Obviously, I suppose you need to speak German, but that's just one of the requirements.

Do you need to take an exam or do you need to go for an interview?

Do they look at your CV?

What makes an applicant a strong applicant to be a good candidate for residency in Germany?

Right.

It's changed something over the last 11 years that have been in Germany.

At that time, they were really lacking residents.

people interested in cardiac surgery or in any surgical field because German culture,

the new generations coming out of med school, they want to have it easy.

They want radiology.

They want dermatology.

They want, not that they are easy professions.

I mean, they're, but they want to stand eight hours long or the whole day in surgery.

Yeah.

And they saw me.

I was motivated.

I spoke the language, and I left a long-lasting impression.

I draw blood samples.

I did EKGs.

Wow.

I did everything.

I brought patients to x-rays.

Wow.

So I did everything nobody wanted to do, but I made myself available,

and that's what maybe caught Chief's eye.

That made you stand out.

Yeah.

Very good.

And what you just described is, I think, a universal phenomenon.

And I don't mean, neither you or I mean to say that, you know, the new generations are weak or failing.

Not at all. Of course not.

But it's something that the older physicians share all the time.

And I've been a doctor. I've graduated med school for 12, 13 years now.

And it's very noticeable, the shift towards a more focus on quality of life and work-life balance.

And I'm not saying this as a bad thing.

You know, certain fields like cardiac surgery, neurosurgery, they're extremely demanding.

And I think people do need to take this into account, just how much they're willing to give up for that dream of becoming a surgeon and so forth.

But I think more and more people are less willing to, you know, work the 100-hour weeks, you know.

And again, I'm not criticizing that.

I'm just stating it as a fact that people are less likely, less prone to paying that price.

Right, right.

I think so.

So after, well, in order to apply, going back to answering your question, you have to take two exams.

The one exam, well, three.

You have to take a normal German exam that you speak the language, you can write the language in a high level.

then you need to do a, like a German medical language exam, oral exam.

Wow.

Right.

And then you have to do a whole day.

It's a practical exam, as if you say, as if it were here, the steps.

Maybe like the, I haven't done the USMLE steps,

But from what I hear, it might be something more like the 2C.

Step 2 CK.

2 CK.

Yeah.

2 CK, C, S, like a mix.

Yeah, so they would test you on internal medicine, surgery, OBGYN, pediatrics, like general medical knowledge.

Right.

But you get a patient at 8 a.m., so you go to a normal ward.

Oh, so it's not a multiple choice.

No, no, no, no, no.

It's a practical exam with real patients.

Yeah.

So you go to an attending, for example, my boss does that.

I do that also.

Now I'm on the other side.

I get to do an examiner.

I'm an examiner right now.

So I come, I give the candidate a patient in the cardiac surgical, in cardiology ward,

and I tell him, okay, here's your patient.

You have to talk to him about why he's here and his illness,

and then you have to do a

exam, a

physical exam

and they get about

three to four hours to do all that

and

then it gets to the practical part

where we come, we do rounds with them

they present the case

and then we ask them

okay, do this or this or that

show me how you examine the heart

the lungs

and after that, that's just

half of it

And after that, then you have to, there are four candidates and we are four examiners there sitting across each other.

And then you get asked any question that comes into your mind.

Wow.

And do the German med students or doctors when they graduate, do they also have to go through the same process?

Right.

Or is it just for four?

No, it's the same.

Wow.

It's the same.

That's really intense because like you're saying four applicants, four examiners.

It's like a one-to-one thing, right?

You have one interviewer.

Right.

You have the four examiners get to do three rounds with each candidate.

That's intense.

And these three exams that you said, are they a pass-fail exam or do they give you a score?

Pass-fail.

Pass-fail.

Okay, obviously you have to pass all the three exams.

Yeah.

But how do they select the residents once you've passed these exams?

Because I suppose these exams are hard, but how can you differentiate between people who just passed the exam?

like if they don't give you a score, how do the programs for cardiac surgery, for cardiology, for, you know, whatever,

how do they decide which residents they want to pick or not? Is there an interview? What do they look at?

There's an interview, but it's very subjective. It's nothing written.

I see.

And it depends on the chief. It depends what qualities he sees on the candidate.

Okay.

And depending, is he motivated enough?

Wow.

Research is also a big topic.

Are you doing a doctoral thesis?

So that's another.

Research is another topic we'll get into there.

Wow.

So there really isn't one exam that you get a higher or lower score that stratifies people.

Like in Brazil, that's mostly how people get chosen into residency.

You take a test, you get a higher score, you're more competitive, a lower score, less competitive.

Right.

But in Germany, it sounds like it's multifactorial.

Germany has maybe the peculiarity, if I may call it that way, that there's this aging population.

So you have like an inverted pyramid.

Yeah.

There are few younger people going into residency.

So that's why it's, I don't know, I don't want to say it's easier to go into residency in Germany,

because if you don't speak German, it might be very difficult for you.

but once you get the language done if you if you if you do it if you speak the language

you don't have to pass eight hours step one and so it's challenging but maybe another kind of

challenge gotcha now that's really interesting and then so you did all that and then you got

selected or chosen into cardiac surgery which hospital in germany did you do i was in the

at University Hospital in Freiburg.

Freiburg, okay.

And how long is cardiac surgery residency in Germany?

I asked Rafael that before we started and said too long.

Well, the formal requirement to apply for the specialty exam

is at least six years.

Six.

Six years.

It might be like integrated six program here.

You go straight into cardiac surgery.

You go straight.

You don't have to do, nobody has to do general surgery in Germany.

I think from about 10, 15 years ago, they changed the law.

Okay.

Yeah, at least six years.

But then it's not like, okay, I endured the six years of hell,

and now I'm a cardiac surgeon.

No, no, no.

There's a quality filter.

You have to show your operations catalog.

You have to do so many cabbages.

You have to record all these.

You have to present your operating reports.

So nobody gets to, hey, I'm a cardiac surgeon just because you've been tired.

Just because you endured.

No, you have to show that you can do the surgeries.

And when you're at the end of the, well, it depends, but at my own university hospital, the boss, the chief went and scrubbed in with you when you were about to finish your catalog.

He was saying, okay, is he ready to present the exam or not?

And if you weren't ready, even if you have the logs, you still had to do so.

Yeah.

So it's very subjective, but there's a quality filter.

That's incredible.

Yeah. So I took eight years. It took me eight years and that's average.

You were telling me that's average. Most people do it in nine to 12.

Wow. Yeah. That's a long time.

It's awesome. It's peculiar because, you know, in cardiology.

You have the EKGs, you have the echoes, you have these old rotations that you need to do.

but it doesn't matter if the patient is old i mean the patients are getting sicker the older

the sicker but the surgeries are getting more difficult yeah you don't get to do more for

example the my first surgery was a aortic valve replacement the one i did it on the patient i did

and was a 47-year-old guy with a bicuspid aortic valve.

So nothing much normal.

Ejection fraction, no coronary artery disease, so low risk.

But now, you know, the average guy, 70 years old,

it's getting a TAVR.

So it's more difficult to get your AVR cases

because people are getting a TAVR.

So it's challenging.

We could talk a lot about this, but I got this question a lot by med students.

They're considering cardiac surgery.

Like, oh, do you think interventional cardiology and structural heart disease is going to, you know, take over and cardiac surgery no longer exists?

What I tell them always is that the demand for cardiac surgery, good cardiac surgery, at least as I see it, has only been increasing.

Right.

Because, you know, cardiology is doing more and more.

But then you always have patients who are not good candidates.

Population is aging.

You have more centers which are doing these things, and then you need cardiac surgery backup.

So there's demand for cardiac surgery, and especially good surgeons.

I was telling Rafael before we started, every single place where I've worked in the U.S., Miami, Hopkins, Brigham,

everywhere they're always looking for good cardiac surgeons.

The demand, at least as I see it as a clinical cardiologist, is always there.

Right.

Yeah.

And I'm sure you've seen this where your skills are in demand.

You know, so people want good cardiac surgeons.

Yeah.

I think it's, cardiac surgery is always going to be there.

Yeah.

It's always going to be there.

Yeah.

But the population is changing.

The population is changing.

They're high risk.

It's getting trickier.

You still, you know, taverns still get endocarditis.

So you still need good, very skilled cardiac surgeons who can take out the whole stent where the TAVR is in the middle of calcium and infection and abscess, aneurysm abscess.

So you still need cardiac surgeons.

You need cardiac surgeons for these non-high syntax patients, coronary patients.

You need it for aortic surgery.

For sure.

No, absolutely.

Like I said, we're always going to need great cardiac surgeons.

I get this question all the time from people in Brazil or other places around the world.

Like, you're a foreign graduate, you know, in the United States.

Did your whole career there?

Did you ever notice, like, disrespect or I don't want to use the word racism or just did you ever notice anything?

In the U.S., I just want to take the opportunity to answer.

I've been treated well, extraordinarily well everywhere that I've trained.

You know, there are cultural differences, like the Northeast and Florida are very different, you know, but people have been incredibly nice.

There's a lot of foreigners in the academic environment in medicine.

Right.

I don't know the exact number, but a large proportion of doctors in the U.S., even in major academic centers, are foreigners.

So in the U.S. have never felt anything.

And I suppose in Germany, like you said, you've been treated generally like very well as well, being a foreigner.

Of course.

Of course.

You know, there's always going to be differences between some colleagues, I think.

But I think the rule is there's respect also for foreigners.

Of course, there's this pressure.

You have to show you are as good as them.

So there's also this pressure because everybody, you know, Germans,

they go also through med school and all of a sudden they say,

hey, there's a lot of foreigners coming in, but we need them, so I hope they're as good as us.

So you get this intrinsic pressure you have to perform.

And that's a good thing.

That's a good thing.

Yeah, for sure.

This is so good.

So, Rafael, let's talk a little bit about the work-life balance in Germany.

You know, I get a lot of people who want to come to the U.S.,

But then they have this impression that doctors here work nonstop all the time and you don't have time to do anything else in your life.

And I tell people usually, you know, residency is very busy in the U.S.

I worked up to 80 hours a week as a resident, very rarely more than that.

I always still had time to do other stuff, but not a whole lot of time.

And then when you finish residency, you sort of get flexibility.

You could work more, make more money, go to private practice where you work more.

You could stay academia, work a little bit less, have a stronger footprint in research and education.

So there's a lot of flexibility once you finish training, but training is tough.

But I hear, and I have no personal experience in this, but I hear that European culture is different.

I see people want to go to the UK despite the challenges in the NHS.

I hear people want to go to Germany with this impression that, you know, work-life balance is just better for a doctor in Europe than in the U.S.

How do you see that both in residency?

What was it like being a surgical specialty, which is typically very demanding?

Yeah.

And also later in your junior career, early career, what's that work-life balance like?

Well, I haven't had the experience here in the United States.

work-life balance wasn't really a concept with that that tells you everything that no i i'm just

starting i'm just starting um it wasn't really a concept that was in my mind when i when i started

doing residency yeah i was it my motivation was i have to spend as much i would like i would love

to that that was my wish my personal wish i don't know how any other residents went into it to

But my wish was I want to be as much time with the patient in the OR, in the ICU, on the work, so I can be better.

There's no way.

And I think that's one principle, and I got it from my parents.

They told my dad, who's a surgeon also, and they both told me, you're not going to learn.

Of course, you have to read articles and your books and stuff, but you're going to learn with the patient.

You're going to learn to operate with the patient.

You're going to learn ICU in the ICU.

Of course, some rules, basic rules in Germany, you're not allowed to work over 24 hours continuously.

If you work, and after a 24-hour shift, it's a mandatory 24-hour pause between a new shift.

So that's a golden rule.

You're not allowed to work over 24 hours.

The other rule is if you work more than 12 hours continuously, you need an 11-hour pause.

So if I work from 7 to 7, then I'm not allowed to come at 7 a.m. or before 7 a.m., sorry.

So I need at least 11-hour pause.

Vacations, I think it's better.

In Germany, you get six weeks vacations as a resident or as an attending.

Everybody in Germany gets at least six-week vacation.

Monday through Friday

not calendar, that's good

yeah

it's

I think

there's a big

of course work life balance

it's an important concept

I think, you need to take care of yourself

in order to take care of

others, you cannot forget

about you because

then you're

start underperforming right burnout and right you have to you have to do something for your body for

mind for your soul you have your family spiritually it's a it's a big topic also um but there's no way

around it and i'm not i i don't think it's only for cardiac surgery every specialty in medicine

you need to put in the work you have to put in the hours yeah you're not gonna learn on the beach

you're you're gonna learn with the patient yeah right this is such incredible advice and valuable

advice there's certainly a lot of younger folks watching us and and like we were talking earlier

about this how there is a more and more focus on work-life balance and and i think what you've

just described is the perfect mentality. It's like you don't want to push it to the limit where you're

burnt out, not sleeping, not taking care of yourself and working 120 hours a week. Like we know in the

past, many places around the world this used to be a reality and even today in some places. But also

the focus has to be on learning and spending time in the hospital, spending time in the operating

room with the patient. I think this is great advice. This is how people think people should go into

residency. It sounds like you worked a lot, but also that you didn't feel like you were

like you were burned out or you couldn't do, you know, other things in life.

If I had, if I have to do, if I had to do it all over again, 1000%, I would do it all

over again. I loved it. I loved my residency. I got so, so much hands-on experience and

also so many connections. I'm not the same person before residence, you know. I loved it. I wouldn't

have done it any other way. I can say the same. I did nine years of residency and fellowship,

internal medicine, three years, one year of chief resident, three years of cardiology,

two years of imaging. Loved it every day. Yeah. Yeah. I think it's my advice to maybe to younger

generations is choose a specialty that where you have fun, where you wake up every day and you want

to go and work in that specialty. Don't let it scare you. Don't let the, oh, cardiac surgery,

you have to stand up for five hours. I don't know. No, it's fun. If it's fun for you and if you

feel you have this connection you want to do it then then do it everything else is gonna it's

gonna come along someday you're gonna have enough money to provide for your family you're gonna be

happy it's way better to be to be um um how you call it to to be exhausted at the end of the day

but you're going to have a good feeling because you come from work that's accomplished.

You're going to have a very good feeling and you're going to be ready to go to bed

and then to wake up for the next day and do it all over again.

This is amazing.

Rafael, I want to talk about an important topic here as we move on,

which is the role of research in your career.

You joined the Meta-Analysis Academy, I think, probably about two years ago, more or less.

Yeah.

Right?

And at that time, you were a resident.

cardiac surgery. Again, very busy. We were just talking about this. What motivated you,

you know, almost done with your residency, certainly a great surgeon, having already made

it from El Salvador to Germany, what motivated you to seek more in terms of research, publications,

and develop that side of your career? In El Salvador, there's not that

pressure to do research as a student.

And it wasn't until I got to Germany.

My experience was I did my doctoral thesis

while being a resident.

I did it on LVAD patients.

And I noticed right the day after,

the week after I defended my doctoral thesis

at the university,

my chief started to give, I got my first AVR.

So it was an unspoken rule.

If you did your doctoral thesis, then you're allowed to start operating.

Wow.

So if you didn't do any research, you would still have a job.

You would still go and close up and do some other stuff.

But it wasn't until you were actively doing research that you were going to do your cases.

This is in Germany already?

This is in Freiburg.

Wow.

This is in Freiburg.

And maybe it was because it was a university hospital.

The hospital I work right now, Robert Bosch Hospital in Stuttgart, it's not a university hospital.

So research, it's secondary.

And I know colleagues that are very good surgeons that did residency just six years,

no doctoral thesis, no research, and they are great surgeons, operators.

Right.

They're great operators.

I like to do that.

I love to do that, to highlight that difference.

Yeah.

They're great, great persons, great people.

But at University Hospital, you have to do research.

If you don't, you don't get to operate.

Yeah, you're a second class.

Right.

So you joined the Meta-Analysis Academy as a surgeon.

I mean, you were super busy.

And what drew you to meta-analysis?

You know, why pick meta-analysis as a research method

and then share some of your results in these years?

Well, the motivation of doing research was there.

After my doctoral thesis, I went to my doctoral godfather, we call it in Germany,

and, hey, I want to do more, please give me something.

And he was the second before the boss, so he didn't have any time.

Then I went to other faculty, and I hear this story over and over again.

Everybody tells you, all right, yes, yes, I'm going to call you.

The call never comes.

And then you start doing, oh, maybe this case report, and it doesn't get accepted.

And you get, you're trying.

Or there's no value, too, you know?

Like, you do a case report, and there's little value.

Right, right.

So, and I saw this good friend of mine.

He's now the second after the boss in Freiburg right now.

And he started residency just one year before me.

Okay.

But this guy, hey, he was a rocket doing research.

He does aortic research.

I love it.

Max Kribich, I love you.

He's great.

The whole team in Freiburg are great.

And I wanted to do research, but I didn't have any open opportunity.

I was praying with my wife.

We wanted to do research.

Please, I'll even consider pause in residency.

Oh.

And maybe do some research fellowship here in the States.

And I was right in the middle of this small crisis.

What do I do?

Should I stop operating and going to the research?

Because research is so important.

Time-consuming, too.

And then I saw in LinkedIn, I saw a post from Amanda Godoy.

Amanda, I love you, too.

Thank you.

Got used to change my life with Meta Analysis Academy.

And then I chatted with her, some stuff, and I didn't believe it.

It's not possible.

You cannot have an idea and publish six weeks later.

I didn't believe it.

And she told me, Rafael, it's possible.

Do it.

Okay.

So I did it.

I did the course.

Amazing.

I learned it.

And then I got selected for an expert group in cardiac surgery.

And everybody was struggling with, okay, should I have an idea or should I don't have an idea?

And then I came up with my former boss in this new hospital about patients with ischemic cardiomyopathy

who were appointed for a cabbage,

bad ejection fraction, 30%.

And a lot of people in Germany or in Europe,

there was this concept, Levo Simendan.

It's a calcium sensitizer.

I think it's not FDA approved.

Right, we don't use it here.

Well.

We're missing out, maybe.

Yeah, you're missing out.

You're coming.

So my former boss was, it doesn't work.

It's just orange juice because it's yellow.

It's just orange juice.

It doesn't work.

And there were some other folks who were, no, they're really good people.

Patients are really good.

Levo C. Mendano.

I said, okay, let's look into this.

Let's look into it.

If there's controversy, there may be an idea for metanalysis.

That's the best situation where you can get your ideas off.

So I looked into it.

There were some RCTs, some randomized controlled trials.

But everybody was just evaluating either mitrals or aortic valves with bad ejection fraction.

And I noticed that all these RCTs had subgroup analysis.

But there wasn't any meta-analysis published on only this patient population of ischemic heart disease.

So that was the idea.

I submitted the idea to Prospero.

We talked it over in the research group.

Everybody was, hey, it's doable.

Let's do the triage and everything.

It was viable.

And all of a sudden, I had a viable idea.

And you published?

And I published.

I published.

Thank you for the whole team.

It was great.

Douglas.

Douglas Mesadri.

It's a fantastic guy, my friend.

I love you, too.

He helped me a lot.

I published in the Journal of Cardiothoracic and Vascular Anesthesia,

the impact factor 2.8 at that time.

It's a good impact factor for cardiac surgery.

For cardiac surgery, it's very good.

Just take into account the European Journal has now a 3.5, 3.4 something.

It's huge.

So it's good for cardiac surgery.

Got published.

My first, well, I did some other papers as a first author,

but were retrospective and never made analysis.

And I was so impressed because the idea, I had my idea in August

and I submitted in December.

But I finished writing the manuscript, it was October.

So it was eight weeks.

From idea to submission.

And I couldn't believe it.

See, I tell students, on average, five to seven weeks, this was Rafael's first paper.

And it took eight weeks.

I mean, surely now he was still learning and doing it for the first time.

It's incredible.

And take into account, I was still doing 24-hour shifts.

I was still doing type A, the sections during the nights or end STEMIs.

So it was in the middle of work.

But like we said before, you have to put in the hours.

You have to put in the effort.

It doesn't get done on itself.

You want to do it?

If you get something done, you have to do it.

So it was nice.

So that was good enough.

And then on February this year, so it got published online on December 2023,

then on paper on March 2024.

And one year later, February this year, 2025, Douglas writes me a message.

My friend, congratulations.

And I was like, hey, what's going on?

I haven't published anything.

No, no, no.

Your paper got cited.

What?

A citation.

Nice.

And I was happy.

It was a citation, you know.

But it wasn't any citation.

It was cited in the new guidelines.

Which guidelines?

The guidance of the European guidelines for cardiopulmonary bypass and perioperative medication.

Wow.

So now there is a 2A.

EACTS?

Right.

EACTS, European guidelines.

There's now a 2A, level A.

Wow.

A recommendation for levocim and then pretreatment for this patient population.

Thanks for your meta-analysis.

Right.

That's incredible.

Thanks to your meta-analysis course.

That's incredible.

We have a lot of papers now from our students that made it into the guidelines.

And I'm glad you brought this up.

I wasn't remembering this one.

EACPS, that's the European Academy of Cardiothoracic Surgery.

European Association for Cardiothoracic Surgery.

Yeah, that's incredible.

Congrats.

And that has opened a lot of doors.

And that's what research is.

It goes hand into hand with your professional practice.

One of my motivations why I did want to do research was because I looked into other colleagues who did research,

and they always had, when we were doing rounds or discussing some cases, they always brought up papers,

Hey, but remember, that guy published in this journal on that day, there's an article describing this with very good outcomes with this technique, for example.

And I looked, hey, they are citing, they have reasons, they have data that impact their everyday clinical decisions.

And you saw that the patients were doing good.

So I wanted that.

I wanted to give my patients the best care.

And that's what research does and meta-analysis of all.

If you have an idea, for example, me, you become an expert on that topic

because you've read hundreds of papers just to see if the idea is viable

and then to write the manuscript, you become an expert on the topic.

Yeah, for sure.

I always tell this to students, you don't have to be an expert on the topic before,

but you become an expert as you go along.

Right.

You learn so much about these topics.

And the other point I want to highlight is,

with this example of the paper that made it into the guidelines,

is that it's meaningful research.

It's impactful.

Everyone's seen the meta-analysis at the top of the pyramid of evidence,

but people don't actually grasp what that means until you see a case like this

where there's a good meta-analysis published in a great journal.

It helps Rafael's CV and career, his co-author, Shoe,

but it also helps patients.

It helps the literature.

It changes a recommendation from something you shouldn't do

to something that may be considered a class-to-A recommendation.

So it really impacts patient care.

Right.

So not only your patients because you had the feeling it was good.

Yeah.

So now it's science.

It's published science.

And now it's also a recommendation from a higher society.

You should do it.

So now this whole patient population in all of Europe, so every cardiac surgeon, every cardiologist should, it's a 2A recommendation,

should think of doing this treatment with Levosim and Dan prior to surgery.

So that's the extent of your research.

Yeah, it's incredible.

Yeah, the impact.

And Rafael, you're here in Boston now for a conference too, right?

Right.

Right, that's for the conference,

annual conference of the International Society of Heart and Lung Transplantation.

So after I published that, I became an expert on the Meta Analysis Academy.

And I got to work with incredible students.

Susi Marpicao from Costa Rica, Laura Luis from Brazil.

And then some other guys.

But everybody, everybody got abstract accepted in international conferences.

Wow.

Every student of mine.

So your team is here presenting?

Like your team has an abstract here?

Actually, my team has an abstract here accepted.

Unfortunately, Susie Mara, who was the first author or is the first author of this idea,

she couldn't make it and present it.

So she asked me as a favor if I could come and present it.

So I presented it.

But it was her idea.

She's a resident.

She's a resident, not even in cardiac surgery.

She's a resident in perfusion.

And she gets accepted an abstract in the biggest transplant meeting of thoracic organ transplantation in the whole world on heart transplant.

Yeah, it's amazing.

It's amazing.

It's mind-blowing.

It's mind-blowing.

That's what I love about the Mad Analysis Academy, the method and the people.

It's like you, Sue Simar, and Douglas, Amanda.

I love this.

Everybody.

know the meaningful connections that you that you get the meaningful the impactful impact this

being free you know if you autonomy autonomy freedom freedom to do your ideas freedom because

you have the tools you learn the tools did you notice you mentioned that in residency it's

important to get some research you know did you notice any practical shifts in how people treated

you and the cases you got after this case, for example, with this big paper or other publications

and abstracts presented in these conferences?

Yes, of course.

And I, well, my boss started noticing because I got to the, well, the last European conference

in Lisbon in October.

We also got another abstract.

Oh.

And then on December in Buenos Aires, the joint conference of the European, American, Latin American conference, we also got an abstract acceptance.

And all of a sudden, my boss was, hey, why are you asking to have three days for conferences?

I've never known you've done research.

And I was, well, I do now.

I do know.

It was like he was really, really happy.

So, you know, destiny, God, whatever you want to call it.

I started doing my research with my doctrinal thesis in LVADS.

It's also heart failure and stuff.

And then all of the research that I'm doing right now, it's also in heart failure and transplant,

DCD, DVD, ECMOs, Impelas, everything.

So, all of a sudden, my boss asked me, hey, you know, I have an idea.

Let's do, in Germany, there's only one certified ECMO course in whole Germany.

And it's in Berlin, you know, Charité.

Biggest university hospital in Germany.

I want to do a certified course here in Stuttgart.

Let's get it done.

So we started and we organized it with some other guys, cardiology, nurses and stuff.

And now Stuttgart is the second course out of two in all of Germany

who is approved by the four biggest societies,

cardiology, anesthesiology, cardiothoracic surgery, perfusionist.

And you're an expert because you publish on this.

I'm an expert.

So I was not only organizer, I'm a faculty on the course.

And I have four talks in the course about left ventricle unloading, about what we do with Susimar.

So it's amazing, man.

The doors that get open, you know.

God bless you, man.

This is incredible.

Congratulations.

God bless you.

Really, you are an instrument to bless all of us.

And you have no idea the reach that you're having.

Yeah, I'm really grateful to all the people who make the MetAnalysis Academy happen.

All the names you mentioned, a lot of them are from our team, like Amanda, Douglas.

And it wouldn't also happen without the support of students like you, who actually put in the work.

You were talking earlier about putting in the hours.

I mean, it's your work and Susimar and Laura and all these great students.

I'm so grateful.

Right.

No, I'm happy.

Rafael, I'm so inspired by this talk.

We could go on and on.

There's so much to talk about.

Just to wrap things up, you know, it's been two years since you've done the MetAnalist Academy.

You've had all these abstracts accepted.

You're an expert now.

You're giving courses on ECMO there in Germany.

Like, what's next in your career?

Like, what's the next step?

Well, my boss just asked me to take over the heart failure mechanical circulatory support section of my hospital.

That's huge.

Congrats.

Yeah.

So above doing cabbages and aortic valves and ascending aortes, well, starting May, just before coming here, and he asked me, Rafael, I'm having my second kid.

I don't have much.

I have so much stuff going on.

You should take over.

Wow.

You should take over.

So there was already a program, but we want to potentiate.

We want to do it better.

We want to do it bigger.

We want to do it science-centered.

So we don't be only operators.

We want to be surgeons.

We want to be academical surgeons with impactful decisions on the patients,

positive decisions on the patients.

And it only gets done hand-in-hand with research.

So that's what I'm going back to Germany right now.

Fantastic.

I mean, it's just unbelievable.

Congratulations.

When you left El Salvador to the residency in Germany, I don't think you could have anticipated these incredible results.

I mean, five years ago, I wouldn't even dream of it.

I would be happy if I finished residency and finished my catalog and my chief says, OK, you don't have two left hands.

So I would have been happy with it.

Now you're chief.

No, not.

I was joking.

That's amazing.

You have an amazing career.

Actually, also, before we wrap up, also a big shout out to our other star in cardiac surgery in Germany, our friend Tulio.

Tulio Caldonasso.

Big shout out to Tulio.

Amazing guy.

Yeah.

Also a cardiac surgeon.

Soon to be cardiac surgeon.

Soon to be.

I think he's still in residency, but just published a ton.

Great guy involved with all of our students and doing great research projects.

Right.

If you ever get to work with Tulio, you're going to have a great experience.

He's a great guy.

Rafael, thank you so much for joining.

It's been an honor to help you here at Metacast.

Your story is really inspiring.

As a foreign graduate, went to Germany, did extraordinarily well,

very busy residency, hard work, dedication, extremely nice guy,

and also did research in the midst of all of that,

and now transitioning to your faculty careers.

So congratulations.

It's really an inspiring story, and I thank you for sharing it here with us.

Thank you.

Thank you for the invitation.

Thank you for the tools you give us, man,

to do the meta-analysis with autonomy.

Nothing of this would have been possible

without my family, mom and dad.

Thank you.

They were the first that believed in me.

I want to thank my wife also.

We don't talk about them a lot in these spaces,

But if our spouses don't support us, we cannot achieve this, man.

They're a big, big part of it.

Thank you for bringing it up.

Big shout out to my wife.

And I don't know, I just say it, but spiritually, I'm a spiritual person.

I want to thank God publicly.

his grace my my my life with blessings i have never thought of so nothing of his of these would

have been possible without him yeah so thank thank you yeah no thank you i share all of that you know

also god has been incredible in my life and opening so many doors that i didn't believe it was possible

and one of them is the privilege of meeting people like yourself meeting you specifically

working with you. I'm very grateful for all of this. Thank you so much. Guys, that's it. That's

Metacast, the podcast of the Meta Analysis Academy, where we share incredible, incredible career

stories like the one from Rafael. Make sure to check our other episodes. Make sure to join our

wait list for the Meta Analysis Academy if you haven't joined the team yet. I hope this story

will inspire you to also do great things in your career. Send me some feedback. Send me a message

on how this helped you.

It really drives us to keep moving this forward.

Rafael, thank you again one more time.

Thank you.

And good to have you here with us

on a podcast of the MetaNalysis Academy on Metacast.

See you next time.