Wednesday, July 23, 2014

Sisters by choice: A community Woman surgeon leading charity since 1989








A native Georgian, Dr. Rogsbert F. Phillips-Reed is a general surgeon specialized in breast surgery. I had the pleasure to meet her last week and was inspired to write about her great work.When I first mentioned Association of Woman Surgeons (AWS), she smiled mischievously and recalled as being one of the first few AWS resident members.

She graduated from Columbia University School of Physicians and Surgeons in 1977 and in 1982 became the second woman and first African-American woman to successfully complete Emory University's surgical Program. When she started her general surgery practice, majority of her referral was Breast related. She welcomed all patients alike and gave best care possible. Over a period of time she was successful in building a  very broad based general surgery practice. Her caseload ranged from Hernias to Whipple. All that only inspired her to learn more, do better and keep up with new innovations in surgery. While midway in her practice, she trained herself to do complex laparoscopic as well as oncoplastic procedures. Forapproximately 30 years she has practiced medicine in metropolitan Atlanta area, serving a diverse patient population. Today she heads Metro Surgical Associates, a community-based surgical practice with offices in downtown Atlanta and Lithonia.

Georgia ranks 10th in population among the fifty states, but 40th  in physician supply per 100,000 population. In fact, latest figures tell us that 15% of Georgia's population is medically underserved for primary care. Access to more specialized services is even worse. Since majority of  Dr Rogsbert-Phillips's practice was breast related she soon realized the need for programs that would not only increase public awareness of breast cancer but also bridge the gap in care. So, in 1989 she founded Sisters By Choice (SBC). Initially formed as a support group for women diagnosed with breast cancer and their families, SBC has evolved into a multi-faceted organization serving women in Georgia.SBC provides over 800 free mammograms and breast exams to uninsured, unemployed and homeless women each year as well as free educational seminars, workshops, and health fairs to promote breast cancer awareness.

Realizing that there are health care disparities surrounding access to quality breast care in rural Georgia; Dr. Phillips-Reed has started an initiative to address this disparity by developing a Mobile Breast Clinic. This unique mobile breast clinic will facilitate remote screening and diagnostic services. It will provide screenings, diagnostic services, treatment referrals, education and access to clinical trials to medically underserved men and women in rural and urban Georgia. This complete diagnostic care will make this clinic historic. It will be the first of its kind in Georgia, and among the first in the nation.

I was pleasantly surprised to see how much her patients admire her for her care and compassion. One can also see that most of her family and friends either work or volunteer at her practice. Of all the people, her husband Mr Reed and son Kasim Reed Mayor of Atlanta, are one of the biggest supporters of her mission. With pure good intentions, she has not only earned loyalty of her patients but devotion of her family for a cause that is dear to her. She has proved that all it takes is one dedicated woman community surgeon to change the way care is provided to vast section of the community underserved or uninsured.
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Bharti Jasra is a Breast Surgical Oncology Fellow at UTSW 2014-2015. She completed General Surgery residency at Saint Louis University Hospital in June 2014.

Thursday, July 17, 2014

Sub-internship Success: A How-to Guide

by Callie Thompson, MD and Jane Zhao, MD

For those who are not familiar: A sub-internship is a rotation that a medical student does, in their fourth (and last) year, in which they are expected to function as an intern. We lovingly refer to such a person as a sub-I, sub-intern, or acting intern. Usually, at least one of these rotations is done at an outside institution. And typically, this is considered a month long job interview.

What follows are our tips/suggestions for a successful rotation.

Keep in mind that these are general guidelines, and that each medical school will have slightly different expectations of their surgical sub-interns.


Away rotations: Only do a sub-internship at a place that you might want to train at for residency if you are ready to work, work, work. This is your chance to knock the socks off the people you are working with. You need to show them how good you are and they need to come away from it thinking "we want her/him in our program." Because of these odds, many attendings and residents will tell you that the underwhelming returns of matching at a program where you have completed an away rotation are not worth the amount of money and effort you pitch in.

On the other hand, do an away rotation if you want to take advantage of the opportunity to gain some perspective on how residency programs may differ and which characteristics of a program you absolutely need and which you may be willing to sacrifice when push comes to shove, e.g. location, demographics, prestige. Furthermore, obtaining a letter of recommendation from an away rotation is a great way to gain invitations to programs that typically only interview regional applicants. This holds especially true for those who stayed in one location from undergraduate and medical school and have a desire to move elsewhere for residency.

Another word on away rotations: Do not ever turn down an away rotation you applied for at a hospital where you would like to interview for residency. Turning down the opportunity to visit a program for a month after you have taken the time to apply for it and after the program has taken the time to approve you is the single quickest way to blacklist yourself from the program when interview season rolls around.

Scheduling and letters of recommendation: Generally speaking, the earlier you schedule your sub-internship the better because most students take advantage of this time to also ask for letters of recommendation from faculty members they work with. Make sure the faculty member knows you, make sure they are going to say something good about you, and give them enough notice so that they aren’t rushing to meet a 48 hour deadline. Thus, July, August, and September are prime months. Keep in mind that if you schedule your rotation in the midst of interview season, you may have to request numerous absences, which will detract from your experience and even possibly reflect negatively on you. Scheduling a sub-internship earlier in the school year also provides faculty who have worked with you a greater level of comfort to advocate strongly for you if programs use a democratic process to create their rank list. This comes in handy if you absolutely need to match to a particular program or city.

Choosing the site of your rotation: Numerous programs request a letter from either your medical school’s chair of surgery or program director. If you haven’t had the chance to meet with either of them during other occasions, you may want to figure out which service they belong to, and try to rotate through there.

Given that a good surgeon should also have a firm understanding of medicine, a strong letter from a respected attending from a different department such as internal medicine can also go a long way in making your application shine, so if you have enough time, it certainly would behoove you to attempt a sub-internship in medicine.

A sub-internship is also a great chance to try out a particular surgical subspecialty you might be interested in pursuing further down the road, e.g. colorectal, trauma and critical care, or pediatrics. If you end up falling in love with it, you now have a stronger incentive to match to certain programs, or if you end up hating it with a passion, you have saved yourself from years of potential misery.

Set yourself up well: This starts by developing a full understanding of the dynamics of the system setup and the people on the service you will work with. Will you be working on a high-volume service with fast turnover? Will you be working on one where the norm is one to two elective cases every other day? Are the attendings known for their Socratic style of teaching? Do the residents go out of their way to include students in the work up of patients? Play to your strengths, particularly if you are trying to obtain a letter. Some sub-interns’ strengths come out in chaotic situations, when their reliability and collected composure are a sweet breath of relief to ragged residents working in a hectic environment. Some sub-interns love being pimped and shine best when being grilled with question after question while their classmates stare gape-mouthed and hopeless. Do you rock at presenting and working up patients? Are you better with procedures? Figure out how your strengths will complement the needs of the service you are joining, and make sure you choose and prepare accordingly. For better or worse, your performance will be evaluated subjectively, and it doesn’t take much for a poor impression to be wrongly formed of a usually wonderful sub-intern or a positive one of an otherwise average sub-intern.

Eliminate distractions: This is your opportunity to take on the responsibilities of an intern. Help manage the list. Know every patient. Unlike your third year clerkship, you do not have assignments or a shelf exam to worry about during your acting internship (disclaimer: this is not true at every medical school). Plan out your year to avoid having to work on your personal statement, ERAS application, away rotations, scheduling interviews, or study for the USMLE Step 2 during this time. You can take full advantage of the freed up time to play an active role on the team and gain more hands on patient care experience.

Presentation: If you are expected to give a presentation (many rotations require them), get started on it early, and identify both a resident and a faculty member to advise you. Be sure that you already have an idea in mind before you speak to them and get your presentation done early enough that they can help you make improvements if need be.

Prioritizing: A real intern probably spends more time on the wards than in the operating rooms, while a third year medical student gets the best possible snapshot of what it’s like to be a surgeon by being in the operating room whenever possible. What’s a sub-intern to do? As a fourth year medical student, you are somehow expected to find the happy medium between both.

Some pearls:

You need to be able to function like an intern which means you need to have a good idea of how to manage your time and balance multiple patients at a time. You aren't a third year student anymore, so you need to carry more than two to three patients at a time. Ideally, you should know the entire service, just like the intern does. Even if there is a third year medical student on your service, you should know everything about their patients too without stepping on their toes.

In the mornings, do your best to help the third year medical students and interns collect vitals and pre-round on patients. Chat with the nurses and ancillary staff for events that occurred overnight.

For rounds, you will most likely follow steps for success that won’t have deviated much from your third year clerkship: Carry marking pens, suture removal kits, gauze, tape, and consent forms in your pockets. Split up patients with the other medical students on your team, and take down dressings on all patients who are postop day two. Have a penlight at the ready to shine on the incision for your resident to have better visualization. Propose alternative treatments for patients who appear to quickly be running out of conventional options. And so on.

Go into the patient’s room with the senior resident or fellow, and gain a sense of what the plan for that day will be. You have no idea how helpful you can end up being when you run the list with the other junior residents later or when you spare the time to follow up on labs and imaging while the rest of the team is occupied handling tasks that only they can do with the MD or DO behind their name.

The intern may not be able to make time to be in the operating room, but you do. Since you are a sub-intern and not an actual intern, your priority is to get the most of your undergraduate medical education. However, you should be demonstrating your ability to be an intern in less than a year so don’t ignore the floor work. Also, not helping the intern and going to the OR the entire time will be noticed and not in a positive way since that isn’t really the function of a sub-I.

When you do go to the operating rooms, first (as always) you must know the patient you are operating on. Help roll the patients into and out of the rooms. Retract. Answer questions about anatomy, pathophysiology, ethics, or whatever else the attending or resident wants you to answer. Drive the camera. Again, this part won’t be much different from when you were a third year medical student. Let third year medical students have opportunities to scrub into cases you have seen before. If you desperately want to be involved in a case, and there are two students, ask the attending if both of you can scrub. Teach the third year medical student basic skills, and share opportunities to do procedures in the operating rooms and by the bedside with them. You had great residents and sub-interns when you rotated through that made surgery rock your world. Now it’s your turn to pay the favor forward.

If the team is short-staffed, your priority is to take care of the floor patients or clinic patients depending on where your are assigned. If you are done with your tasks on the floor, then make your way to clinic (even if you weren’t assigned), and see patients and present to the attendings. Come up with plans for the patients. Look out for your third year medical students and have them present to you before they present to the resident/attending, and help them polish their presentation.

Be proactive rather than reactive, and let your residents know what you are up to, especially once you have completed a task. If you ask if you can do anything to help, they will invariably reply, “No thanks. You really don’t have to. Seriously.” So if you see that they have a million and one tasks to complete, take the initiative to tackle a task within your ability that doesn’t put patients at risk, and provide your upper level with the completed result. That is the difference between a stellar, unforgettable sub-intern and one who is great.

Ask for help when you are unsure, and take advantage of this time to ask questions that may seem silly or dumb. Now is the time. While it sometimes may not seem to be the case, you shouldn’t be expected to know everything about surgery. Residency is after all a training process. It’s better to clarify what you don’t know now, rather than wait later when you have actual responsibility over patients.

Remember, not always knowing the answer is forgivable. What’s important is being reliable and teachable. Surgery is one of the most exhausting specialties out there, and not everyone has the physical or emotional fortitude to pursue the field. This has led to a phenomenon where even 80 hours per week are sometimes perceived as not enough. Thus, we don’t think we’re remiss in stating that a honest hard worker of above average intelligence is often preferred over a genius who can’t be relied on, a statement true for most walks of life but one that sub-interns should particularly take to heart.

Read: Just because you don’t have a shelf exam to prepare for anymore doesn’t mean you should stop studying. Read up on your patients. Find relevant articles. Create treatment algorithms and cheat sheets.

There are some folks who function well on three hours of sleep. If you are not that type of individual, give yourself permission to crash when you return home in the evening. Instead, set aside time early in the morning to jot down notes about the patients who will be operated on for the day. Be smart about it. If there are too many cases for you to scrub into, and you’re pressed for time, then concentrate on those whom you know for sure you will be operating on. For those patients, know the following:

o pertinent details from patient’s history, labs, and imaging

o indications for the operation

o crucial anatomy and steps of the operation

o possible short-term and long-term complications

o important details of perioperative management

Hopefully, if you have read up about each patient prior to their operation, then as the rotation goes on, you will be able to anticipate the general management and time course of all the patients on the service during their post-operative stay in the hospital.

Share what you have learned with the other medical students on your service. It helps guide their studying and cements the knowledge further in your mind. Remember the big picture. By helping others, you indirectly improve the care of those patients who will be one day be treated by other members of your team.

Pay it forward. Take the third year medical students under your wing. Teach them how to tie surgical knots. Share with them stories of your own frustrations and triumphs from your time as a third year. Remind them to eat. Buy them coffee, or share a granola bar. Help them with their presentations. Let them know when it is okay to text the upper level and ask, “is there anything else I can do to help?” which we all know is universal student code speak for “may I please leave?”

Lastly, if you really want to stand out, give the sub-intern and third year medical students who will trade you out for the next month a heads up about what to expect once they come onto service. This will make not only their lives easier but also relieve a weight off the shoulders of your upper levels. Your patients may even benefit from safer care.

You will impress everyone if you show them how helpful and kind you are to others, even when it doesn't directly benefit you.

In conclusion:
what does it take to succeed as a sub-intern? If you can in anyway make the service run as smoothly as possible and life better for the residents then you can be rest assured that you’ve done a good job.

Did we miss anything? Let us know your own suggestions for sub-internship success in the comments below.

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Medical students, click here for more information on how to succeed on your third year medical student surgical clerkship.

Surgical interns, click here for advice on how to build the foundation for future success by starting off intern year the right way.


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Callie Thompson is a chief resident in general surgery at the University of Washington. Callie aspires to be a burn and trauma surgeon and a translational scientist. Her research interests include genetic variations and their associations with the development and outcomes of disease and illness. Callie is married to an internist and has three children ages 1, 3, and 7.

 








Jane Zhao is a general surgery resident at the University at Buffalo, State University of New York. She obtained her medical degree with a scholarly concentration in Clinical Quality, Safety, and Evidence-based Medicine from the University of Texas Medical School at Houston and completed her undergraduate studies in Medicine, Health, & Society at Vanderbilt University. She was the 2012 recipient of the Shohrae Hajibashi Memorial Leadership Award and chaired the AWS Blog Subcommittee from 2013 to 2014. Her interests include healthcare social media, quality improvement, and public health. She can be followed on Twitter.



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Thursday, July 10, 2014

Mentorship

By: Shilpa S. Murthy, MD, MPH

Socrates mentorship of Plato lead to advancements in philosophy and science. William Halstead’s mentorship style, based on Socrates’ teaching methods, lead to Harvey Cushing’s success in creating the field of neurosurgery.1For centuries, mentorship of surgical trainees has been critical to progressing the field of surgery. Strong mentorship and devoted development of a surgical trainee can lead to advancement and innovation in the field.  As a medical student, one may not anticipate the crucial role a mentor plays through transitions in their career. A trainee goes through three transitions where guidance is critical to the development of a skilled surgeon:  the transition from medical student to surgical resident, surgical resident to surgical researcher, and resident to surgical attending.  All three transitions come with their own challenges as well as rewards.  During these phases, it is important to gain direction from knowledgeable individuals who already experienced these transitions. They will guide trainees through un-anticipated challenges. Similarities in personality and background are important in mentorship interactions but common goals and values create a successful relationship.  I was fortunate to meet three mentors whose life’s work aligned with my own goals of training the next generation of physicians and reducing the inequalities in health care.

In 1998 the percentage of female surgeons was 21.8% and in 2008 that number increased to 32.3%.2In a field where the female voice is sparse and still growing, strong female mentorship can be fruitful for young women surgeons.  In medical school I was fortunate to have a female mentor who was a dean and pediatrician who shared a passion for medical education. Few women in science have been able to reach the prominent academic position she holds.  As a professional woman, she experienced the unique challenges that women face as they continue to advance professionally in the medical field. With her female voice, guidance, and insight borne from years in the profession, I have been better able to navigate my career as a surgeon. The female perspective is important for women in medicine, but excellent mentorship comes from both genders.

During my research years as a surgical resident, I am pursuing oncology projects in Rwanda in global surgery. Making waves to define a new academic field, global surgery, can be rewarding but extremely challenging. It is complex since there are numerous cultural and ethical issues. I am privileged to be mentored by a surgeon who is a pioneer in the nascent field of global surgery. Modeling his cross cultural interpersonal communication skills and sharing our passion for equity in surgery, I have been able to successfully develop a breast disease training course with my Rwandan colleagues. But even with this success, the field is severely underfunded and due to funding challenges our projects almost fell through. However, his guidance and experience on how to navigate philanthropic meetings and administrative hurdles ultimately led to successful outcomes. His kindness, altruism, and passion towards reducing inequities in surgical care globally is to be modeled and commended.

During surgical residency, a trainee also needs a mentor who is invested in developing their technical and cognitive surgical skills. In my clinical residency program, I met a hepatobiliary surgeon who has pushed me to strive harder. His engagement and experience in my development has been un-wavering through professional and personal hurdles. I always trust his advice because I know it is coming from someone who truly cares about me.

Although each mentor has a slightly different background than my own, pieces of their personality, experiences, and backgrounds resonate with me as an individual. Their trust and belief in me has led to fruitful relationships and they are like family. My mentors have been crucial in my transition from medical student to surgical resident and as a surgical researcher. Their un-wavering support during hurdles I didn’t anticipate have strengthened our bonds. Recognizing my passions for surgery, education, and equitable care for impoverished populations they are guiding me towards concrete goals that will hopefully make a lasting contribution to society. While the line of Socrates mentorship continued in Plato and eventually worked its way to William Halsted and Harvey Cushing, so too will the teachings of my mentors. I hope to pass on our shared values, goals, and their kindness to those I mentor in the future.

References
1.) Assael, Leon. Every Surgeon Needs Mentors: A Halsteadian/Socratic Model in the Modern Age. J Oral Maxillofac Surg. 68:1217-1218, 2010.
2.) Association of American Medical Colleges Accessed June 6, 2014 https://www.aamc.org/download/53502/data/wimstatisticsreport2009.pdf


Dr. Shilpa S. Murthy is currently a second year research fellow at the Center for Surgery and Public Health, Brigham and Women's Hospital in Boston, Massachusetts. She recently completed her MPH at Harvard School of Public Health and has interests in global surgical oncology, surgical disparities, and medical education. She is a general surgery resident at Indiana University.

Wednesday, July 9, 2014

My International Surgery Elective

by Jane Zhao, MD

In April 2014 I spent a month with the Department of Surgery at the Affiliated Hospital of Qingdao University – Huangdao Branch. It was a marvelous experience, and I was asked to share a snapshot of my time there.

Qingdao, which means Green Island, is a major coastal city of approximately three million people in the Shandong province of China. The city boasts the world’s longest sea bridge, Tsingtao Brewery, and Lao Mountain. Reminders of its time period under German colonization in the 1800s remain visible in Qingdao’s wide streets and architecture.
View from Lao Mountain



German Governor's Mansion, a prime example of Qingdao's colonial architecture. The construction was said to be so extravagant that the Kaiser fired the governor once he received the bill.
The Field Hospital of Germany first opened its doors on the shore of the Yellow Sea in 1898. As Qingdao modernized and grew, the Field Hospital transformed into the Affiliated Hospital of Qingdao University. Today, there are three hospital branches that provide patient care to all of Qingdao and its surrounding areas. The vast majority of my time was spent at Huangdao Hospital, the newest branch, located a 40 minute drive outside the heart of Qingdao.
The outpatient entrance of the Affiliated Hospital of Qingdao University, Huangdao Branch which formally opened its doors in 2011 (picture source)
During the week, my mornings started with morning report at seven o'clock, with rounds following shortly after. The rest of the day would be spent in the operating theatre. Cases usually began around nine o’clock, with the occasional earlier start time. Rooms turned over quickly, and it was not unusual for the team to schedule multiple gastrectomys and low anterior resections each day (the department of general surgery was colorectal heavy). Elective cases took place through the weekend, but I used my Saturdays and Sundays to attend local conferences, visit a community health clinic, and observe other services, such as emergency medicine, critical care, neonatology, pediatric surgery, and hepatobiliary surgery.
Outside the Huangdao Community Health Service Center, where patients can receive preventative care or chronic care management
I learned an incredible amount during my month in China. I was given multiple opportunities to see surgery practiced differently, more cost-efficiently, and most importantly, without detriment to the patient, which made me pause, take mental notes, and ask why on a frequent basis. Take laparoscopic appendectomies for example. In the US, the cost of appendectomies including hospital stay, conservatively speaking, can quickly add up to a bill of $30K. In China, the cost is approximately 3200 RMB, which if converted to US dollars would be less than $1K. Same disease process, same step-by-step operation, but a drastic reduction in cost.
An infographic that breaks down the typical appendectomy bill generated from a US hospital (picture source)
There were plenty of other differences that I found intriguing. One of them was the observation that the hospital did not stock scrub brushes by the sinks. Instead, faculty and staff prior to each case will rinse once with a chlorhexidine solution, dry off with nonsterile paper napkins, and then Avagard. The rationale for eliminating scrub brushes is that the constant scrubbing leads to skin abrasion, increasing the risk of bacterial growth. On the other hand, if the epidermis stays smooth and intact, anything other than normal skin flora is unlikely to grow. The hospital infection control team has been swabbing the hands of random operating room personnel monthly and growing the samples for culture, but so far nothing beyond typical skin flora has grown.

Another observation led to the realization that I have been spoiled by the scrub nurses back at home. In the operating rooms at Huangdao Hospital, everyone with the exception of the attending was expected to gown and glove themselves. Also, every effort was made to conserve and reuse. Gowns, needles, and even the laps used to soak up the betadine solution used to prep the patient were recycled through the system for future use. Face masks and caps are rationed out to those entering the operating rooms by a nurse who stood guard outside the locker rooms.

An additional fascinating discovery was in learning which types of cases were considered too risky for residents to perform independently and which were not. Residents were given exceptional autonomy in performing upper gastrointestinal and colorectal cases, but if a patient needed a gallbladder out due to symptomatic cholelithiasis or choledocholithiasis, attendings and chief residents were the only ones allowed to manipulate the biliary tract during laparoscopic cholecystectomies. The most action junior residents could hope for was to drive the camera. They were shocked when I gave them examples of the types of cases US residents at their similar level were allowed to perform.

Catching a close-up glimpse of a different training structure gave me some added perspective into what mine would soon be in the US. Given the controversy in the states regarding how work hour restrictions have led to an increase in hand-off errors, it was of particular interest to me as a soon-to-be intern to see what life without work hour restrictions looked like. The residents lived in or around the hospital--most unmarried or living separately from their partners and children. Their attention was channeled 100% into become better surgeons each and every day, which showed. The residents in Huangdao were technical wizards in the operating room. They were able to dissect their way into the correct plane in seconds, without a single wasted movement. No bleeder or atypical anatomy fazed them. They knew all the patients front-to-back. Many of my mentors in the US have spoken to me of what surgery was like in the good ol' days without work-hour restrictions. Being in China gave me a glimpse into their past, and it was awe-inducing.

The thing is, the past is almost always seen through rose-colored lenses, and after the initial rosiness died down a bit, I started to better understand the rationale for why residency training in the US has undergone such tremendous changes, even if the changes have resulted in their own challenges. The residents at Huangdao Hospital had little time to stay up-to-date with the literature, spend time strengthening family ties, or maintain interest in meaningful outside hobbies. It was not unusual for residents with families to take the bus into the city to visit wife and child for half a day, spend the other six days of the week in the hospital, and then send as much of their income as possible home to help pay the bills. The residents were at the beck and call of the hospital and their department around the clock. It was only by their good fortune that they had a Chair known throughout the hospital for his fairness and kindness.
My classmate from UTHealth Amy Wang and I with the Chairs of Surgery from each of the three hospital branches affiliated with Qingdao University. Dr. Yun Lu on the far left of the screen, next to Amy, was the Chair of Surgery and our faculty mentor at the Affiliated Hospital of Qingdao University, Huangdao Branch.
I spent a significant amount of time with the Chair of Surgery discussing the differences I noted between residency training in the US and at Huangdao Hospital. He was particularly interested in the way training was standardized from program to program, so I told him that, in US teaching hospitals, each specialty is usually represented by one or more services, each composed of a mix of junior and senior residents and headed by an attending. During rounds, the senior resident comes up with a plan for each patient based on the clinical presentation, touches base with the attending for any changes he or she wants to make, and then the junior residents see to it that the final versions of the plan are carried out. By having residents rotate through different services, each with a standardized hierarchy, the residents can gain similar opportunities for graded responsibility throughout their training. By the time residents graduate, they are expected to have received comparable training, regardless of where they completed their residency. Another upside to the US model of training, I told the Chair, was that by minimizing the micro-managing, attendings can devote more of their nonclinical time to research, teaching, or other administrative tasks. The Chair of Surgery was so enthusiastic about what I shared with him that within days he had morning rounds changed, and as far as I know, they are still being conducted via the revised approach.

My conversations with the Chair of Surgery were rewarding. I was able to pick his brain on how to become a better leader based on his own his triumphs and tribulations, and he had an opportunity to learn new methods by which he could try to improve the quality of his residents' training. Our conversations were numerous, but one particularly meaningful impact I made didn't require me to make any fancy speeches. My mere presence was enough because it caused people to talk. By April, I had already found out that I would be at the University at Buffalo, the State University of New York for my next half decade of general surgery training. Women pursuing surgery in China is a once in a blue moon phenomenon—essentially unheard of. They were shocked and impressed to find out that I was one of multiple women in my class at the University of Texas Medical School at Houston who matched into a surgical specialty for residency. One circulating nurse rushed home that evening to share the news with her daughter. It was mind-boggling to see the people around me attempt to grasp the concept of a woman not only pursuing surgery but also having that accepted as normal within society. I could see the beginnings of a paradigm shift taking place in many of their minds.

There are so many more remarks I can make about my experience abroad. The 60-70% 5-year survival rate for patients diagnosed with resectable gastric adenocarcinoma at Huangdao Hospital compared to the dismal 30% in the US. The occasional traveler or expatriate who spoke English. The sick patient who still appreciated whatever counseling I provided in my broken Mandarin. The Chinese government's firewall of social media platforms like Blogger, Wordpress, Facebook, Youtube, and Twitter that allow real-time communication to take place, now so heartily embraced by our surgical community. The pay-for-service approach. The paternalism. The around-the-clock walk-in clinic. The heavy reliance on radiographic imaging. The lack of tort reform or Good Samaritan laws. The lateral rigidity in career transfer. The integral role played by family in the perioperative management of patients. There are some aspects of surgery in China that have my utmost admiration, others nothing but frustration. But that goes for most things in life.
Here I am checking up on my patient. No identifying features of the patient are shown out of respect for the patient’s privacy
My observations are all anecdotal and limited by my experience being predominantly at only one hospital. I can hardly say if the hospital where I rotated is representative of other hospitals in China or even Asia. That being so, I have had such an expansion of my worldview that I would not have had otherwise, and my undergraduate medical education has benefited tremendously.

I would never have had this opportunity without the mentorship and sponsorship of Dr. Anil Kulkarni, whose recommendation of me to his friend and former colleague paved the way for me to establish my own special project to rotate in China. Dr. Yun Lu, the Chair of Surgery at the Affiliated Hospital of Qingdao University, Huangdao Branch has invited me to return, and I definitely plan to take him up on his offer. Eventually I would like to bring other students along with me to show them how amazing of a profession surgery is, and what a comfort it is to know how quickly and easily it can be for a surgeon or aspiring surgeon to feel at home in any country simply by walking into an operating room.
An aerial view of Qingdao (picture source)



Have you ever completed a surgical rotation in a country different from your own? If so, what was that experience like? Share in the comments below.


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Jane Zhao is a general surgery resident at the University at Buffalo, the State University of New York. She obtained her medical degree with a scholarly concentration in Clinical Quality, Safety, and Evidence-based Medicine from the University of Texas Medical School at Houston and completed her undergraduate studies in Medicine, Health, & Society at Vanderbilt University. She was the 2012 recipient of the Shohrae Hajibashi Memorial Leadership Award and chaired the AWS Blog Subcommittee from 2013 to 2014. Her interests include healthcare social media, quality improvement, and public health. She can be followed on Twitter.

Tuesday, June 24, 2014

My Quest for a Masters in Medical Education

By: Jean Miner, MD, FACS; Co-Chair of the AWS Clinical Practice Committee

“See one, do one, teach one.” Most, if not all surgical trainees heard this throughout their residency years.  Was this the best way back in the day? Probably not.  Is it the best way now? Certainly not. 

The dynamics of surgical education have changed drastically over the past decade.  A combination of duty hour restrictions, new learning initiatives, technological advancements and stringent requirements have necessitated that educators adapt new methodologies of teaching.  When we all think back to our favorite professors and instructors, it seems as if teaching came naturally to them, but as we now know, teaching is hard.  And it is even more difficult to do it well.

Over the past few years, I realized that my formalized knowledge of curriculum development, assessment methods and teaching practice was inadequate to teach the next generation of surgeons.  Coming to this awareness, I determined my own need for training to become a better educator.  At that point, I started to search for formal opportunities and found a multitude of options for pursuing further education. 

I wanted to share some me of my findings in the hope that it may make it easier for colleagues interested in a structured curriculum to find their perfect match.  Below, is a summary of the options that interested me most.

After careful deliberation and a year of procrastination, I chose to pursue a Master’s in Medical Education at the University of New England’s program for several reasons.  The completely online aspect was essential as I didn’t want to worry about travelling for any portion and I can complete assignments at whatever time works for me.  Secondly, the format is such that assignments are always due on Wednesdays and Saturdays for each course.  This has allowed me to develop a routine to meet the deadlines.  The cost is reasonable for advanced education.  Finally, the most important feature is the flexibility.  After four credits in one of the two disciplines, a student is awarded certification.  I particularly liked this option because I was uncertain whether I would be able to keep up the pace for the traditional two year structure.  The program allows for a student who has gained certification to complete the full Master’s program within 5 years.

I have now completed my first course, “Improving Instructional Effectiveness” and have thoroughly enjoyed every aspect.  Already, the knowledge gained from the course has allowed me to implement effective changes within my daily teachings.

Master’s Programs

University of New England
The master's degree in Medical Education Leadership is a two-year web-based program designed especially for working professionals that utilizes asynchronous, distance learning within a professional community. The 33-credit hour MEL curriculum is designed to enhance your skills in a variety of professional areas of academic medicine—curriculum, instruction, assessment, personnel development, organizational development, leadership skills, business and finance, and research and evaluation—through professional application and scholarship. The master’s degree also allows for two electives (three credits each) and culminates in an applied project. The final requirement of the program is a professional portfolio that is a longitudinal integration and application of learning.

 

Online Graduate Certificates

Program Development in Academic Medicine 

This twelve-credit hour program provides you with the core program development concepts in curriculum, instruction, learner assessment, program evaluation and research methods in academic medicine. This set of courses is one of the foundations for the UNE Master of Science in Medical Education Leadership.

 

Leadership Development in Academic Medicine

This twelve-credit hour program provides you with the core leadership development concepts in personnel development, organizational development, leadership skill training, and business/finance in academic medicine. This set of courses is one of the foundations for the Master of Science in Medical Education Leadership.

Approximately $23,000 for full Master’s degree

The Master of Academic Medicine is offered through the Keck School of Medicine of the University of Southern California in collaboration with the Schools of Dentistry and Pharmacy. Our program employs a blended model, combining on-line coursework with on-campus face-to-face sessions, one week each March.

A Master’s Program for Today's Challenges
Our goal is to cultivate leaders who will develop and advance educational programs for healthcare professions globally. Health professions education is continuously evolving, which requires leaders that are process experts with a broad repertoire of approaches that can be applied to varied content arenas and situations. The program addresses a challenge in health professions' education - the need for qualified educators who can model and lead change in their respective schools and programs. Graduates will be positioned to guide future generations of health professionals toward better meeting the health needs of our global society.

Approximately $50,000 (not including travel for one week in CA)

The Johns Hopkins University, through an innovative collaboration of its Schools of Business, Education, Medicine, Nursing, and Public Health, is offering a world class degree - the Master of Education in the Health Professions (MEHP) - that prepares a new generation of health professionals to teach effectively for schools and training programs related to medicine, public health, nursing, and other health professions.

The MEHP program consists of an 18-credit core in Evidence Based Teaching--which can also be taken as a stand-alone post-master's certificate--and a 15-credit option to focus on educational research or educational leadership. The program format is entirely online.

Approximately $40,000

Additional Master’s Programs

Courses/ Fellowship

The six-day intensive course is designed to provide surgeons with the knowledge and skills to enhance their abilities as teachers and administrators of surgical education programs.
The course emphasizes the needs of adult learners and the techniques necessary to develop an effective learning environment for medical students, surgical residents, colleagues, and others in the health profession. The maximum class size of 32 allows highly interactive sessions

$3,950 for American College of Surgeons members
$4,450 for nonmembers

A one year, home-site fellowship designed to equip investigators with the skills and knowledge needed to plan, implement and report research studies in the field of surgical education. Following acceptance into the SERF program, each fellow is carefully matched by the program's faculty with a SERF Adviser, a respected and knowledgeable researcher who will serve as the fellow's mentor and consultant on their particular project. ($1700)



Jean Miner, MD, FACS is the Program Director for General Surgery Residency at Florida Hospital, Associate Professor, UCFCOM & FSUSOM and serves as the Co-Chair of the AWS Clinical Practice Committee. 


This is My Story: The Power of Mentorship

by: Katherine Jeffress, MA, MPH

Earlier this month Dr. Minerva posted on the “Importance of Mentoring” on the AWS Blog.  At the end of her post she asks, “What has your own mentorship experience been like?” This is my story…

It begins in a rural village in Ghana West Africa where I was serving as a Peace Corps Volunteer. Originally placed there to teach science at a junior secondary school I quickly found myself starting a large multi-site adult literacy program for women and doing community outreach visits while working at an HIV/AIDs treatment center at a district hospital. While there I met a surgeon who was doing a locum at the hospital from South Africa. It was his mentorship and example that initiated my desire to be a surgeon. He was one of the lost boys of Sudan who after walking many miles to a refugee camp was eventually resettled in Canada. There he studied to become a surgeon and then later he returned to work in Sub-Saharan Africa. Although based in South Africa he did locums in areas all over the content that had surgical shortages. His life story had really moved me so one day I finally mustered up the courage to asked him for some career advice. I asked him if I wanted to work in global health in Sub-Saharan Africa after the Peace Corps what skills and expertise were most needed.

He replied, “In Sub-Saharan Africa we need surgeons. We have many great doctors here but many countries don’t yet have the capacity to fully train surgeons or equip operating theatres for complex procedures. Some are lucky enough to go overseas to train and bring the technical expertise back but many many people here still do not have access to basic surgical care. You should become a surgeon.”

 That night he provided me with many pieces of life advice (some of which I’ve forgotten) but I couldn’t remove the ideal of becoming a surgeon from the back of my mind. It was such a foreign and strange idea to me. Later I returned to the USA a very different person and went back to my graduate studies in psychology and anthropology feeling a bit lost and completely out of place. I knew at that point that I wanted a career in global health but had no clue about the variety of jobs that were out there or what skills and qualifications I actually needed to get those jobs.

It was also at that point that I started working with a career advisor at my university who taught me how to network and set up informational interviews with people who had jobs I was interested in. These informational interviews consisted of 15-20 minute conversations where I would listen to the story of how they got to where they are now, what qualifications and attributes someone would need to succeed at what they do, and what their job was truly like. Every conversation I had was extremely helpful and some even led to long-term mentoring relationships. 

During this time I also formed another mentoring relationship with an Anthropology Professor of mine who was originally from Australia. The support and guidance she provided me set off a cascade of life events that ultimately lead me to Australia where I ended up obtaining a Masters degree in International Public Health and working as a researcher to help develop estimates of gynecological disorders for the most recent update of the World Health Organization’s Global Burden of Disease Study. It was happenstance that I ended up working on genital prolapse a condition that requires surgery to ultimately treat it. I was shocked by how prevalent the condition is in many poor countries with high birth rates. What was even more shocking was how few women outside of developed countries ever received treatment for it. I again became painfully aware of the lack of access the worlds poor have to basic surgical procedures. The influence of my Sudanese mentor combined with this experience finally resulted in me deciding to apply to medical school so that I could one day be trained as a surgeon.

Since I’ve started medical school I have continued to seek out mentors for advice and guidance. In my search for surgical mentors I’ve participated in a formal mentoring program at my university and found mentors through my prior university’s alumni database and through the Association of Women Surgeons database.  Some of my mentors have had me shadow them while they work. Others I’ve meet for coffee or over Skype. Notably, I’ve found the Association of Women Surgeon’s Annual Meeting to be a particularly great place to meet with women in surgery face to face for mentorship opportunities.

Many unexpected opportunities have been opened up for me through mentorship. One mentor that I met through my prior university’s alumni network was incredibly generous and offered me the opportunity to do research with him over the summer break between my first and second year of medical school. While there I quickly feel in love with research in vascular surgery. I also met another wonderful mentor who gave me more great advice about how to become a competitive applicant for a surgery residency and what programs would be a particularly good fit for me given my interest in global surgery. She even invited me to a brunch with other female surgeons in the area.

I’ve found it incredibly helpful to have mentors at varying points in their career that work in a variety of different practice settings. Some of my mentors have come and gone others may stay for years. I would not be the person I am today without these mentors. Their support, example, advice, and guidance have and are providing me with a safety net for my success. These relationships have cultivated innovation and creativity in my research endeavors and life pursuits.

Their stories and example have played an integral role in helping me get a clear vision of what I want to do professionally. Their advice and guidance has been pivotal in enabling me to identify tangible and achievable career goals that are consistent with this vision. These mentors have also shown me how to obtain these goals by outlining a clear path to take.  

They’ve done this by:
·         Sharing their story with me
·         Outlining the specific skills and expertise I need to build
·         Indicating the vital research or leadership experiences I need to have at each training level.
·         Sharing great resources to study to efficiently obtain the scores I need.
·         Teaching me how to be a valuable member of the team even at the medical student level.
·         Providing opportunities I need to develop myself so I’m prepared to enter the profession or by introducing me to people that can. 

When the journey has become difficult and I’ve questioned the path I’ve chosen to take my mentors have helped me keep prospective, given advice to increase my resilience, and shown me that there is a place for me in the surgical world even if at times I may feel like I don’t belong. It is their support and inspiration that led me to medical school and pushes me to work hard to pursue a career in surgery.

I really don’t know what words to use to express the deepest gratitude I have for the amazing people who have come into my life as mentors. They have had a profoundly impact on the course of my life. They have shown me that mentoring is an extremely powerful tool for career success.

If you don’t have the right set of mentors I strongly encourage you to seek them out. If you’ve had amazing mentors or want to provide the experience you never had the privilege of having I encourage you to pay it forward. I for one can’t wait to pay it forward.


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Katherine Jeffress, MA, MPH is a 3rd year medical student at Sydney Medical School. Prior to this, she received a Masters of Liberal Arts degree in Psychology from Harvard University where her thesis focused on the effectiveness of culturally adapted treatments for post-traumatic stress disorder in refugee and internally displaced children. She also received a Masters of International Public Health from The University of Queensland and while there worked as a Research Officer at the Centre for Burden of Disease and Cost-Effectiveness. Katherine served as a United States Peace Corps Volunteer from 2007-2008 in Ghana, West Africa.  She is passionate about global surgery and the provision of high-quality health care to poor and marginalized people around the world. She can be followed on Twitter.

Tuesday, June 17, 2014

The Importance of Mentoring

Last month, the Healthcare Leadership Tweet Chat (#HCLDR) invited me to participate as guest moderator to discuss The Changing Face of Medicine. You can read the accompanying blog post here

The weekly Tuesday evening #HCLDR chat engages a diverse community made up of patients, medical students, doctors, surgeons, residents, nurses, healthcare executives, and many others with a shared interest in healthcare leadership. Some international colleagues also joined from Europe, the Philippines, and Australia.



For many Tweeters, it was also the first time joining the #HCLDR Tweet chat. We were very proud to have the support of the American Medical Women’s Association (AMWA) and the Association of Women Surgeons (AWS).






The #HCLDR platform resulted in an engaging conversation on the importance of diversity in medicine. One question we discussed was how can we encourage women and other minorities to pursue careers in medicine/surgery or any non-traditional field?


Among the many excellent responses, a common theme emerged of the importance of mentoring.




Another important factor is to expose students to careers in medicine and surgery early. "Building the pipeline" can be achieved through personal interactions and through support of outreach programs and organizations. One of our AWS members recently wrote on her experience in showing young students what she does daily as a surgeon on The Power of a Stitch.



Demonstrating that diversity is important to the organization and showing students that doctors are also people they can relate to are other important aspects of mentoring. 

 


How do you find mentors? We previously tackled the topic of finding a Mentor in our Lean In Book Review, which you can find here.  A quick recap on working with mentors: 

1.            Be mindful of the mentor’s time
2.            Strangers can be mentors. Don’t be afraid to seek out someone no matter how much you admire them.
3.            “Excel and you will get a mentor”
4.            Have more than one mentor.

What has your own mentorship experience been like? Have you been a part of an organized mentorship program? How can mentoring be fruitful endeavor for faculty?

If you have not downloaded the AWS Pocket Mentor you may do so here. You can also read our AWS blog post for good advice passed down from our mentors.