Monday, September 15, 2014

What Quality Metrics Should Be Measured for Breast Cancer in Low and Middle Income Countries

By: Shilpa Murthy MD MPH, Robert Riviello MD MPH

Every time she took that cool bucket bath shower, she anxiously felt the large, irregular bump bulging out of the side of her breast. If she walked the twenty miles to have it examined, who would maintain the house, feed the children, take them to school, and put them to sleep at night? If she went to the hospital she may never see them again—the hospital was a place where people went to die. Or worse she could return home without her breast only to ultimately die from metastasis of her cancer. How would her husband treat her afterwards, how would her children view her—as a disfigured and deformed woman?

These concerns are voiced by millions of poor and disenfranchised women in low- and middle-income countries (LMICs). Once a woman finds a mass she considers it a death sentence since she has never seen anyone cured from breast cancer, all her relatives and neighbors die from late stage cancer or inadequate surgical treatment. For women in high-income countries (HIC), mortality due heart disease far outweighs breast cancer due to strong health care systems where access to high-quality breast cancer services (e.g., early detection through radiologic services; core needle biopsy and pathology services for diagnosis; surgical, chemotherapy, and radiation treatments) are available. In contrast, women in LMICs often present late to hospitals with advanced-stage cancers, where nothing can be done. Even pain control and palliative care is limited due to procurement and funding challenges for pain medications, a small and inadequate medical workforce, and limited resources needed for psychosocial support. If patients do gain access to a surgeon or OB/GYN doctor they may receive inappropriate medical and surgical treatment due to medical educational deficiencies regarding the appropriate management of breast disease.  So how do we reduce this inequity for such a curable cancer? While this problem is complex, as LMICs move towards strengthening care around breast cancer, it is critical to determine the appropriate quality metrics that will be integrated into the health care system in order for women to receive the right types of surgical and medical treatments. By monitoring and evaluating health care services that breast disease patients are receiving, nations can ensure patients are receiving improved access to care and that this care employs quality services where the correct surgical and medical treatments are being administered.

Recently, the National Quality Forum (NQF) cancer care consensus endorsed standards of care for breast cancer management in HICs including post breast conserving surgery irradiation, adjuvant chemotherapy, adjuvant hormonal therapy, protocol readings by pathologists according to the College of American Pathologists, needle biopsy diagnosis, and evaluation of the axilla. Many of these quality measures are not feasible metrics in LMICs due to issues with infrastructure, funding, supply chain management, procurement, and training of medical personnel in breast disease management. Therefore, the question arises as to whether NQF measures are appropriate for LMICs at all and if different quality measures should be created for LMICs? We propose that when a nation is starting their breast disease care management program, the NQF quality measurements for breast cancer care in LMICs will need to be different due to the infrastructural infancy of the health system.  As LMICs health systems continue to strengthen, these metrics will evolve over time eventually reaching all the current NQF standard measurements.

One of the most-employed metrics, measuring post breast conserving radiation therapy, as a quality metric is inappropriate in many LMICs. Although there are exceptions, breast-conserving therapy is performed for cancers that are detected on mammogram followed by radiation treatment. In many LMICs countries like Rwanda, mammograms and radiation machines do not exist. In order to provide mammogram and radiation services, strong policies around buying, installing, and having technicians readily available for maintaining these machines, and determining what type of hospital (local health center, district, provincial, or tertiary hospital) to install these machines is a large undertaking. Furthermore, increasing the workforce of radiologists and radiation oncology physicians, nurses, and technicians to operate this machinery is a large human resource undertaking. These programs take time to plan and implement and measuring post-conserving radiation therapy is inadequate because no radiation infrastructure exists within many LMICs countries.

Additionally, adjuvant chemotherapy, adjuvant hormonal therapy, needle biopsy and appropriate pathology is challenging. Chemotherapy, hormonal therapies, core needles, and pathology stains are expensive materials and many LMICs cannot afford to keep and distribute a consistent supply of these resources. When supplies do exist, there is an overwhelming number of patients who need these resources for treatment and diagnosis. Physicians have to prioritize which patients receive these resources and face an ethical dilemma as to who receives treatment and who is left to die. Many of these funding and supply chain issues could be potentially resolved if international agencies collaborate to reduce the cost of chemotherapy and medical supplies globally, similar to the way that HIV/AIDS medication costs were reduced. These changes could, in turn, save millions of lives for the poorest patients.  Given the inequality in resource distribution to LMICs and patients, it may not be fair to measure all of these NQF metrics in each country. For example if radiation does not exist in a country then it should not be measured, rather that the metric should be if the patient received the correct type of surgery---modified radical mastectomy rather than breast conserving therapy with radiation. On the other hand, NQF may be important measurements as they will inform ministries of health and doctors exactly where the gaps exists within the healthcare system in order for regional policy makers and physicians to address and strengthen the system gaps.

Due to the infancy of breast disease care management systems in LMICs, we propose the following metrics. The key tool in breast disease diagnosis, especially in LMICs, is clinical breast examination (CBE). This examination is not performed at all or performed incorrectly in many LMICs. But it can be readily taught to medical personnel and integrated into medical education. We propose that CBE emphasizing palpation of the clavicular nodes and axilla be one of the global metrics used for breast cancer in LMICs. Additionally, documentation of whether the patient received an ultrasound-guided needle biopsy for diagnosis, whether pathology was performed at all on the biopsy specimen, was subsequent appropriate surgical management performed including axillary dissection, was chemotherapy and radiation therapy provided, and was post-operative training to the patient conducted to prevent postoperative infection, shoulder contracture or frozen shoulder. This documentation will then allow for comparison against NQF standards. These metrics will be starting points that can be used globally and tailored regionally as per the resources available within each country. Over time, as economic development drives improvements in health care development, new measures that strive toward NQF measurements should be used. However, at this moment we believe the above metrics should be a starting point catered to the regional resources available within each country.

Dr. Shilpa S. Murthy MD MPH 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 an MPH at Harvard School of Public Health. She is also a general surgery resident at Indiana University. Dr. Murthy's interests are in surgical oncology, surgical care delivery and its intersection with health policy in order to improve access and quality surgical care to marginalized populations globally. She also has interests in medical education and simulation based training.   

Special thanks to Sarah M. Gray. 

Dr. Robert Riviello MD MPH is an Associate Surgeon in the Division of Trauma, Burns, and Surgical Critical Care at Brigham and Women's Hospital, the Director of Global Surgery Programs at the Center for Surgery and Public Health and Human Resources for Health Rwanda, and an instructor in surgery at Harvard Medical School. His clinical and research interests are in global health, specifically in the reduction of disparities and the expansion of surgical delivery for low-income populations by developing the  surgical workforce and surgical infrastructure in sub-Saharan Africa. He currently spends 3-6 months of his time annually in Rwanda engaged in the Human Resources for Health program of Rwanda.

Friday, September 12, 2014

Women Surgeon Leaders for the 21st Century Part II: Profiles in Leadership

By: SreyRam Kuy, MD, MHS


We had the privilege of interviewing several influential women surgeon leaders.  Patricia Numann, MD, FACS, Barbara Lee Bass, MD, FACS and Susan Moffatt-Bruce, MD, FACS shared their wisdom, their experiences, and their inspiration with us.   Spanning a spectrum of specialties, roles and backgrounds, these women leaders have changed the face of surgery in America. We thank Drs. Numann, Bass and Moffat-Bruce for their generous time and their invaluably candid answers.  Hopefully, these stories will inspire the next generation of women surgeons to continue this incredible legacy of strength, courage and resilience.  We salute the Women Surgeon Leaders who have defied obstacles, made their own path on their own terms, and paved the way for generations of women and men to come.  We are indebted to these surgeons who have been leaders, educators and mentors to so many young surgeons.  And, we are indebted for their courage in sharing their journey in taking the roads less traveled.       


Dr. Patricia Numann

Dr. Patricia Numann is an endocrine surgeon and the Lloyd S. Rogers Professor of Surgery Emeritus at SUNY Upstate Medical University in Syracuse, New York.  She earned her medical degree from SUNY Upstate Medical University in 1965.  She then did a combined medicine and surgery internship, and then stayed to complete her surgery residency there in 1970.  Dr. Numann started as an Assistant Professor of Surgery at SUNY, and then quickly rose through the academic ranks at SUNY Upstate, serving as Associate Dean of the College of Medicine and Medical Director of the University Hospital.  Dr. Numann founded the Association of Women Surgeons in 1981 when she invited as many female surgeons as she could identify to a breakfast at the October meeting of the American College of Surgeons in the San Francisco Hilton Hotel. Up until this point there was no formal organization serving specifically the needs of women surgeons.  Since that first breakfast in 1981 the Association of Women Surgeons has grown into a powerful national organization serving the needs of women medical students, residents and surgeons.  Dr. Numann was the first woman to serve as Chair of the American Board of Surgeons, Founder and President of the Association for Surgical Education, and a President of the Association of Women Surgeons.  In 2011 Dr. Numann became the 92nd president of the American College of Surgeons and its second woman president.

Interviewer:  What do you see as the greatest skills need to be successful as a leader in academic surgery and in surgical organizations?
Dr. Numann:  Optimism, Integrity, Thick Skin, Moral Courage.  The ability to give more.
Good listening skills. Curiosity and diverse interests.  Pride in other’s success.  High Standards

Interviewer:  What are the biggest challenges and obstacles you yourself faced in your career? What are challenges you saw your female colleagues in surgery facing in their careers? What do you see as the challenges women surgeons face today in advancing as surgical leaders in academic institutions and in national surgical organizations?
Dr. Numann:  I guess if I had viewed things as obstacles or problems, I do not think I would have done well.  [Instead], I would think "Now isn't that a silly thing to think or say." I would then decide whether I wanted to deal with any of it or ignore it. Most could just be ignored. I then found a statement by Dawn Steel who was the first woman executive of Paramount studios. "Never try to teach a pig to sing, you waste your time and annoy the pig." I kept it taped to the side of my desk. When people were outrageous or intractable I would think "Pig" and change the topic and strategy to solve the problem. You cannot want to win every battle or convert every person to your way of thinking.

[Rather], I found being useful to whoever or whatever got me through many a tough spot.  No one would accept my application for a surgical residency in 1964.  So I made a deal with my chair to do [an internship] with 6 months of Medicine and 6 months of Surgery.  If I did not want Medicine and had done well enough in Surgery, I could have a spot in our pyramidal program.  In those days prejudice was very open.  I think in some ways that is easier than now where much is unconscious bias that diminishes women's contributions.

I think women still face unconscious bias [in that people assume] that they are not fiscally as wise, that they are too conflicted when they are mothers, that they are not physically or mentally as strong as men.  I also think that they are not put on the list for promotion as commonly as men.  In several cases I have seen women have a great deal of trouble when a child had problems or when they faced divorce. The part time position is still viewed very negatively.  It is hard to get back after a period of part time work. [Research] granting agencies are fairer, but still I think when [reviewers are] unblinded to gender [they] favor male applicants.  I think more objective data is needed to prove women’s equality is some of these issues.

The old boy's network is still in good standing in many, if not most surgical organizations.  Even when women get to be represented in good numbers the leadership positions more frequently go to men.

Interviewer:  What are ways that you overcame those obstacles? Can you give concrete examples? What did you learn from these obstacles?
Dr. Numann:  I think hard work and being useful helped overcome many obstacles.  I had one chairman who fired me regularly.  Fortunately I had tenure and many colleagues who supported me and respected me professionally.  I decided to mostly ignore him and continue to work, participate in organizations, and be sure that my quality was excellent. I was always a bean counter. I would count cases, publications, abstracts, requests for presentations and keep track of my quality so I knew I was as good as anyone around me. It made it hard for him to get rid of me. He never did.  I felt very vindicated when he left and [also by the knowledge that] other really terrific people also had trouble with him. I wanted to start a Breast Center when he was chair. He refused to fund it so I went to the Hospital Auxiliary and they had a fund raiser to begin the program, then we became self-sufficient. [This would later become the Patricia J. Numann Center for Breast, Endocrine & Plastic Surgery at SUNY Upstate].  There is always a way around an obstacle. Only if you are stubborn and want it just one way will you fail.

Interviewer:  What are the greatest rewards you believe you've gotten from being a leader in a surgical organization?
Dr. Numann:  I could not put one as greatest. I always loved taking care of patients, whether for trivial problems or great ones. I loved the technical aspects of surgery. Doing a complex operation perfectly is such a joy. I loved teaching essentially everyone, patients, nurses, med students, residents and peers.  If I got a complicated referral, I would offer the referring surgeon the opportunity to come to the surgery. I loved administration, planning new things, resolving problems. I think the only thing I never really liked was writing.  I never considered it something I did well.

The greatest rewards have been the things that I have helped develop or facilitate that made life better for individuals.  Whether it was that they had more fulfilling careers, went through difficult problems more easily or actually impacted the well-being of masses of people.  I have gotten great recognition from organizations in the form of awards and election to office but what gives me the greatest pleasure is when I run into someone and they tell me what a difference I made for them.

Interviewer:  What do you see as your greatest achievement as a surgeon? And what is your greatest achievement as a leader?
Dr. Numann:  As a surgeon, I believe I changed the standard of breast and endocrine surgical care in my area, by not only being a good surgeon but also by teaching many surgeons to be good as well.  I would always follow the literature and scientific developments and bring them to the care of patients in our area.

As a leader, I think through AWS and my advocacy for women I have made it easier for women to become surgeons and to be treated as equals.  I believe in my role on the Council of Scientific Affairs of the AMA, I saw that standards for mammography were implemented.  As President of the American College of Surgeons I helped raise awareness and facilitate support for the WHO to include surgical care in its public health mission.  As associate dean of our medical school, I helped improve the logistics of navigating our curriculum for our students.  I began the Women in Medicine Committee.  As Medical Director [of our hospital], I took a hard stance on bad behavior but I always listened to both sides.  I always tried to allow people to save face.

Interviewer:  Do you have any regrets from your experiences as a surgeon leader, or would you do anything differently?
Dr. Numann:  I have no real regrets.  If I would do anything differently, I may have chosen to look at being a chair and should have written more.

Interviewer:  What mistakes would you advise mid-career women in surgery to avoid in order to be successful in pursuing leadership roles in academic surgery and national organizations? What mistakes would you advise young women in surgery to avoid?
Dr. Numann:  Keep Calm and Never Give Up.  I think many young men and women want too much too quickly.  I think many do not respect those before them who have made so much possible for them.  I think some do not deal well with adversity and give up.  When this Chair was firing me regularly, I was talking with a patient who was a successful business man about my difficulty and my interest in leaving. He said, "I would help you do whatever you wish to do, but let me tell you, I wouldn’t respect you much for letting one rotten SOB run you out of your home."  I must say that changed my thinking - probably forever.  No one ever ran me off.

Interviewer:  What additional words of wisdom do you have for mid-career women in surgery? For young women surgeons just entering practice? For residents in training?
Dr. Numann:  I believe it is important to try and make things work but if they will not, [then] look to change the situation.  There is no best time to have children so do it when you want to. Do not be afraid to be a single parent if you want a child and do not want a spouse.  Choose your spouse carefully.  Do not be afraid to stick your neck out.  For residents in training, I think it is very important to have a local support system.  Sometimes you really need to be fed a good meal, taken away from the work or have a shoulder to cry on.  [You need someone] who loves you unconditionally and will not judge you.  I found most of them outside medicine.  I also think throughout life it is important not to be an elitist. You learn so much by having friends of all kinds.  For all, I think it is important to have interests beyond medicine.  I have found that people whose only identity is their professional self are often not as successful or happy in the long run.

Interviewer:  Are there specific leadership courses or organizational training resources you'd recommend to women surgeons interested in pursuing a leadership role in academic surgery or national organizations?
Dr. Numann:  I think the ELAM course is very good.  I think public speaking courses such as Dale Carnegie’s are good.  The Harvard course for Chairs.  The ACS Surgeons as Leaders and Surgeons as Educators are great.  I have also found it very helpful to serve on Board of Directors where you meet many talented people who look at the world a bit differently than most doctors.

Dr. Barbara Lee Bass

Dr. Barbara Lee Bass, MD, FACS is a gastrointestinal, breast and endocrine surgeon, and the John F. and Carolyn Bookout Distinguished Endowed Chair at Methodist Hospital in Houston Texas and Professor of Surgery at Weill Medical College of Cornell University.  Dr. Bass did her undergraduate studies at Tufts University, attended medical school at the University of Virgina School of Medicine, completed general surgery training at George Washington University Hospital and a fellowship in gastrointestinal physiology at the Walter Reed Army Institute of Research, while serving as a Captain in the US Army Medical Corps.  Dr. Bass has been a fellow in the American College of Surgeons since 1989, and has served in many influential capacities, including the Chair of the ACS Board of Governors, as member of the ACS Board of Regents, and surgeon champion of the ACS NSQIP.  Dr. Bass was honored with the American College of Surgeons’ highest honor, the Board of Regents 2013 Distinguished Service Award, which recognizes Dr. Bass’s commitment to the initiatives and principles embodied by the American College of Surgeons.  Dr. Bass was also a guest speaker at TedMed, one of the premier conferences focusing on thought provoking and novel approaches to health and medicine.  

Interviewer:  What do you see as the greatest skills need to be successful as a leader in academic surgery and in surgical organizations?
Dr. Bass:  There are two sides to that coin.  The first piece is the academic piece.  You have to have academic credibility.  You have to do the hard work of building that academic credibility yourself.  You have to write, you have to network, and you have to have some credibility as a thought leader in that area.  My area of academic credibility was in gastrointestinal cell biology.  I was funded early in my career with VA Merit and Career Development awards.  I had the gastrointestinal surgeons’ career development award and the College’s career development award. 
You have to have some credibility as an academic surgeon and you have to think about what your contribution to that field will be.  It can be in translational research, it can be in educational research, etc.  But you have to demonstrate that you have the chomps to do that piece.  Then people will say, “she’s done the hard work to get there.” 

The other side of that coin, of being a leader in surgery is similar to leadership in any other venue.  You have to have a profound sense of optimism in people; that you are making it better for everyone, not just for you.  Successful leaders can really inspire others with that sense of future and optimism.  A good leader really has a sense of service; you’re there to serve the cause.  And, you’ve got to be able to communicate.  You’ve got to build bonds.  You build bonds by listening to people and gathering people together. 

Interviewer:  What are the biggest challenges and obstacles you yourself faced in your career? What are challenges you saw your female colleagues in surgery facing in their careers? What do you see as the challenges women surgeons face today in advancing as surgical leaders in academic institutions and in national surgical organizations?
Dr. Bass:  I’m old enough that I didn’t have obvious people to look up to, to think “I want to be like that person.”  When I was a medical student at the University of Virginia in the 70‘s there were no women residents or faculty.  The obstacle is not knowing how to do “this”, when there isn’t anyone who looks like you, and you want to do “this”. It was very hard to figure how to get where I wanted to go. 

But here was a transplant surgeon there, Dr. Leslie Rudolph, who helped me.  I didn’t take surgery until the end of my third year.  Then, Boom!  I realized I was a surgeon!  So very late in the game, I went to talk to this guy [Dr. Rudolph], and he was wonderful.  He said, “This is wonderful.  We haven’t had any girls go into surgery.  You must meet Olga Jonasson and Kathy Anderson.”  He managed to get me hooked with one of them.  I actually ended up training where Kathy Anderson was a faculty, and she was kind of a distant guardian angel and was a great source of advice.  It took 8 or 10 years before I met Dr. Jonasson and was “adopted” by her. 

Interviewer:  What are ways that you overcame those obstacles? Can you give concrete examples? What did you learn from these obstacles?
Dr. Bass:  Blossom where you’re planted.  I decided to stay where my family was.  You have to realize that you can’t necessarily have the freedom to go where you want to go, because you need the infrastructure.  There were times where that made me angry, but in the end it preserved me.  I saw my other women colleagues who didn’t have that infrastructure. I was very lucky to have parents and in-laws and a husband who supported me.  And my payback to them was that I never left them. 
Sometimes we get caught up thinking we have to do it the traditional way, and we don’t focus on what keeps us grounded and successful as people in our lives.  Then we get turned upside down. 
There are promising women who started out in surgery, and are no longer in the field.  Maybe they jumped too high, or they got lost.  When I look at my colleagues who have been successful in their careers, they’ve each done it in different ways.  We’ve meandered.  Find the pathway that’s consistent with who you are. 

Other obstacles are the structures that we all have in our institutions.  We all have these structures in our institutions - they have inertia, they don’t have leadership teams that evolve in the way we’d like them to or they don’t share our values.  People automatically look to that more familiar and regular progression.  We see that men get promoted more rapidly than women.  We have to recognize that these structural barriers in our institutions are still in evolution.  But you have to remember, it’s a marathon, not a sprint!  Try to keep your eyes on the big picture.  You have 40 years in this business; don’t prematurely think that you have to jump to the next step or next opportunity.

Interviewer:  What are the greatest rewards you believe you've gained from being a leader in a surgical organization?
Dr. Bass:  My favorite reward is when you go someplace and you run into some med student who you have no recollection of them in your life, and they tell you they are so appreciative of what you’ve done for them.  Then you realize you made an impact on this person’s life.  You make a lasting impact when you didn’t even realize you touched them.  I think being a leader gives you a voice and an impact that goes beyond your title.

It’s nice to see some of the things that you’re demonstrated become the scenery.  See the success you’ve had spill over to those behind you.  I don’t want to hear about how unusual I am; I want this to be very normal.  We want that critical mass.  It’s no longer odd [to be a woman surgeon].  Now it’s becoming normal, even in a demanding surgical field.  I think the most important contribution I’ve made is just being “there” and doing it. 

Interviewer:  What do you see as your greatest achievement?
Dr. Bass:  I’m proud of my boys, of my family, and the incredible relationship I have with my parents.  Having many siblings, I’m the only one that stayed close.    

Interviewer:  What mistakes would you advise mid-career women in surgery to avoid in order to be successful in pursuing leadership roles in academic surgery and national organizations? What mistakes would you advise young women in surgery to avoid?
Dr. Bass:  Don’t be prematurely sensitive or aggressive, or feel that you’re not getting there.  However, occasionally you do feel that you’re up against the wall and you’re not getting where you want to be, whether due to the leadership or the infrastructure. Then you start the slow burn, you start looking.  Sometimes you have to say, this is not working, then move on

Interviewer:  Are there specific leadership courses or organizational training resources you'd recommend to women surgeons interested in pursuing a leadership role in academic surgery or national organizations?
Dr. Bass:  I never took them; I just did it by osmosis and learning from the good people around me. 

Dr. Susan Moffatt-Bruce

Dr. Susan Moffatt-Bruce, BSc, MD, PhD, MBOE, FACS, FRCP is a cardiothoracic surgeon at the Ohio State University Medical Center.  Dr. Moffatt-Bruce completed her undergraduate studies at McGill, her medical school and general surgery residency training at Dalhousie University, a PhD in Transplant Immunology at the University of Cambridge and a Cardiothoracic Surgery fellowship at Stanford University.  Currently, Dr. Moffatt-Bruce is the Associate Dean of Clinical Affairs, Quality and Patient Safety at Ohio State University, where she oversees process improvement at a 6 hospital, 1100 bed academic medical center.  Dr. Moffatt-Bruce is also the Associate Director for the Center for Lean Healthcare Research at the Ohio State University Fisher College of business. 

Interviewer:  What do you see as the greatest skills need to be successful as a leader in academic surgery and in surgical organizations?
Dr. Moffatt-Bruce:  The best trait or most important attribute is the flexibility to be accommodating.  Leaders have to react quickly to many situations and so really being accommodating and flexible is key to the organization.  Also, leaders have to be available.  The people you lead want to have access to you.  The greatest skills needed to be successful as a leader in surgery are being available, accountable, and accommodating.

Interviewer:  What are the biggest challenges and obstacles you yourself faced in your career? What are challenges you saw your female colleagues in surgery facing in their careers? What do you see as the challenges women surgeons face today in advancing as surgical leaders in academic institutions and in national surgical organizations?
Dr. Moffatt-Bruce:  One of the biggest challenges is that if you start going down a pathway that seems reasonable, everyone is happy to help.  However, if you start going down a pathway less traveled, people are less likely to help.  I started as a physician scientist and was doing well.  Then I became a physician administrator and it was difficult to find a mentor who really understood the challenges and what changes I would need to make.  I believe this particular challenge may be specific to women.  Because you’re a woman, they think you’ve changed your mind, that you’re finicky.   Changing paths may be a challenge but it is so worthwhile when you know it is the right choice. Being able to share that with a mentor that understands and embraces change is the challenge. 

Interviewer:  What are ways that you overcame those obstacles? Can you give concrete examples? What did you learn from these obstacles?
Dr. Moffatt-Bruce:  First off, I didn’t know there would be obstacles. The first part was realizing there were very real obstacles that would have to be overcome.  When I became an academic administrator, I had to go out of my comfort zone and engage with women and men outside the medical profession.  Biophysical engineers, people in health care reform, etc.  That is always perceived as “Why is she here?  You’re a surgeon, why are you here?”  I had to embrace them and assure them that I was there to learn and to collaborate.  By leveraging research opportunities and proposing joint ventures, particularly around Surgical Outcomes Research, I was able to create “Win-Win” situations for them and for me.  How cool is using Google Glasses to train residents!!!

Interviewer:  What are the greatest rewards you believe you've gained from being a leader in a surgical organization?
Dr. Moffatt-Bruce:  Oh gosh, there are many rewards.  Just realizing my potential to not just influence a small cohort of residents and patients, but to touch so many other domains of health care is the reward.  So many people ask me why [be a physician administrator]?  Hands down, its’ because I can influence so many patients and that’s a tremendous privilege.

Interviewer:  What do you see as your greatest achievement as a surgeon? And what is your greatest achievement as a leader?
Dr. Moffatt-Bruce:  My greatest achievement has been in instilling in this large academic medical center a culture of accountability and safety.  As a result, we’re now influencing residents and medical students in a culture of accountability and safety.  And now I’m starting to influence that on a national scale.  Its’ unusual to have a thoracic surgeon willing to be a spokesperson for these things.  We have nationally accepted quality metrics, which are frankly very challenging indicators.  I’m able to sit on these committees and say, “These are not good metrics”.  We as surgeons have that ability to shape what is measured as “quality” but we have to go and engage. The National Quality Forum is the national committee that actually endorses the CMS metrics, and I’m a member of that committee.

Interviewer:  What accomplishments are you personally most proud of in your career or in your personal life?
Dr. Moffatt-Bruce:  My children.  My children now never accept the status quo, they ask about everything.  They make sure that what I’m telling them, what their school teachers tell them, what their music teachers tell them is accurate.  They’re not afraid to question (although it can be quite exhausting!)

Interviewer:  Do you have any regrets from your experiences as a surgeon leader, or would you do anything differently?
Dr. Moffatt-Bruce:  Would I do anything different?  I would have taken the same path.  But, I would have been more appreciative during my residency and during the junior faculty years about what the hospital/academic mission is. I was in a silo during the training just trying to make it through.  I never appreciated what it was to have a mortality index; to not meet a SCIP measure.  I never was inquisitive enough.  Absolutely, there would have been opportunities to be involved as a junior faculty or resident.  You have to make those opportunities. 

Interviewer:  What mistakes would you advise mid-career women in surgery to avoid in order to be successful in pursuing leadership roles in academic surgery and national organizations? What mistakes would you advise young women in surgery to avoid?
Dr. Moffatt-Bruce:  I think that women have to really think what their priorities are.  You have to weigh the pros and cons about what you’re asked to do.  Be thoughtful about what you engage in and what you commit to.

Interviewer:  Are there specific leadership courses or organizational training resources you'd recommend to women surgeons interested in pursuing a leadership role in academic surgery or national organizations?
Dr. Moffatt-Bruce:  Lots of great resources that women can use to improve.  The AAMC early career development courses; they’re really super.  Young women faculty should think about taking that in their first 1-2 years.  In the professional societies, anytime they offer courses on coding, etc., take them, and take them a couple times to really benefit. ELAM is also a great experience when you become an Associate Professor

Interviewer:  What else would you like to share about surgical leadership with members of the AWS?
Dr. Moffatt-Bruce:  I’d want to share with other women that sometimes circumstances and opportunities pose themselves at inopportune times; and our resources have to be used to assess them or embrace them, but not to be anxious.  You have to make choices and there will always be opportunities to seize that.  It all depends on what you make of it. 

We are indebted to Patricia Numann, MD, FACS, Barbara Lee Bass, MD, FACS and Susan Moffatt-Bruce, MD, FACS for having the courage and generosity to share their hard earned wisdom, experiences, and inspiration with us.   As the face of surgical leadership evolves, we know that taking the road less traveled is a challenging feat, but well worth the effort.  And the rewards of the journey enrich not just the intrepid explorer, but also pave the path for every future dreamer to come. 


SreyRam Kuy, MD, MHS was born in Cambodia, grew up in Oregon, graduated from Crescent Valley High School as Valedictorian, and attended Oregon State University where she earned dual degrees in Philosophy and Microbiology.  Dr. Kuy’s passions are healthcare policy, physician leadership and health services research.  After college she worked as a Kaiser Family Foundation Barbara Jordan Health Policy scholar in the Senate, writing speeches and policy briefs for Senator Tom Harkin on women’s health, coverage for breast cancer screening and treatment, and health care instrument safety.  She attended medical school at Oregon Health Science University, then finished general surgery residency in Wisconsin.  She earned her master’s degree in health services research at Yale University School of Medicine as a fellow in the prestigious Robert Wood Johnson Clinical Scholars Program.  She is also a writer.  Her first book, Soul of a Tiger, describes her family’s survival during the Cambodian Genocide known as the Killing Fields.  Her second book, 50 Studies Every Surgeon Should Know, will be released in 2015 by Oxford University Press and describes seminal research in the surgical field.  Dr. Kuy is an Assistant Professor of Surgery at Louisiana State University and the Overton Brooks Veterans Affairs Medical Center.    

Thursday, August 21, 2014

Self Care and Meditation

by: Betsy Tuttle-Newhall, MD, FACS

When one mentions the word “meditation”, images of saffron robed monks and lotus flowers come to mind for many; however, meditation is simply the act of quieting the mind and focusing the attention.  Meditation is a practice, no one starts the practice being perfect and “doing it right, (which is an important concept for surgeons!). It is by doing and making space for attention that one learns.  For those of us who work all hours of the day or night, and are constantly bombarded by phone calls, texts, pages, and other people’s needs, a moment of calm is invaluable to our own health and well-being.  Meditation is about training your mind to be in the moment either for that purpose alone, or for the other benefits of well-being- calm, relief of anxiety, cooling your anger and frustration, opening our own heart and preventing compassion fatigue.  It is about being in the moment- not worrying about the past, or planning the future- is it about being mindful of the present; it is about focused living. It is ironic that we all can “do this “ practice in the operating room. For many of us, we are “in the moment” with the gunshot wound to the abdomen, or the breast cancer in the breast or whatever our focus in the operating room. Where we are often not focused however, is on ourselves. Meditation has many benefits including promoting internal energy (or “prana” the life force), compassion, forgiveness, courage and patience with others, and most importantly, ourselves. Meditation comes in many forms and is often tied to the religious discipline with which it is associated although it doesn’t have to be religious in nature. There is active or walking meditation or sitting meditation, or even what I call the “office meditation” where you can sit in your chair and take 5 minutes to clear your head and re-orient. You can take advantage of any moment in which you can calm the mind and be “aware”. The practice is about being in the moment.

Meditation has been practiced by Christians, Doaists Buddhists, Hindus, Islamists and many other religious disciplines. One of the earliest references to meditation as a practice comes from the Hindu Vedas, the ancient Indian texts. It is here that one of the oldest mantras was written, the Gayatri mantra. “ Mantra” simply refers to a sound or phrase used during prayer or meditation.  The Buddha described meditation as a way to relieve oneself of suffering. A disclaimer- I am not Buddhist, and struggle with my relationship to the Divine either in the traditional Judeo-Christian faith in which I am raising my family or in any other form. I am grateful however, that God (in whatever form you believe in Her) is patient with me. I found myself more than 15 years ago traveling with my friend Dr. Shelly Stelzer, who now resides in Potsdam New York, to the Omega Institute for a week long yoga and meditation retreat. I had no idea where I was going with her, or what this all meant. I never got to spend much time with her, and it was an opportunity for another adventure. I found myself immersed in a weeklong instruction with Sharon Salzberg from the Insight Meditation Society regarding meditative practice and John Friend studying Anusara Yoga. To say it was a transformative week, is an understatement. It was a week that changed my life for the better although the bar was set pretty high for my next week away with my friend. It was a challenge for me to incorporate what I had learned into my daily life (and certainly, my surgical colleagues at that time were a little wary of my experiences. However, they were my experiences and I kept them to myself unless you asked me about them). Being more aware and having that invaluable instruction lead me to attend several other courses with Sharon Salzberg and inviting her to Duke for a weekend retreat regarding Meditative Practice as a prevention of Compassion Fatigue. We sold out tickets 2 days after we posted the conference. She is a Buddhist trained meditation teacher, and her training was in the classic Buddhist tradition.

There are 4 noble truths in Buddhism which make a nice context in which to discuss meditative practice, its goals and the benefits for those of us who spend energy on many people, and often have little left for ourselves.

The first noble truth of Buddhism is that life is about suffering; suffering loss, instability, dissatisfaction that things just haven’t turned out right for us, our friends or family, and our patients. The second noble truth suggests that suffering is related to attachment and ignorance-attachment to things that are not permanent and are not really that important in the big picture or things that are in constant flux, and ignorance about who we really are. Most of us have this ideal of who we “should be” – certainly I do, and more times than not, I fall short of who I think I should be. My suffering comes from my lack of awareness of who I really am and the acknowledgement that I am “good” and usually, doing the best I can at whatever moment in time. I hold myself up to an ideal that if I do not meet, I am afraid of being “less than” in this culture of high achievers and for me, that I may not really “belong” or “deserve” to be here (wherever here might be). When I am tired, or sleep deprived or had a busy day, I am often ignorant of my inner light. Of course most days, I know that I belong and deserve to be “here”. Like most, if not all the women surgeons I know, I have worked hard to be where I am and care for the patients I care for and teach the students and residents for whom I am responsible.  Sometimes the struggle with work and family and other issues can be overwhelming. Sometimes, I just need a little reminder of who I really am underneath the superficial layers of wear and tear and underneath all the work and responsibilities. Really all suffering is, is the practiced art of denial- denial to our real situation, denial to who we are and denial about what we can or cannot do. 

The third noble truth is about the possibility of the cessation of suffering and the fourth noble truth is about the path to take to relieve suffering.  In Buddhist teachings, the relief of suffering is through the noble eightfold path, but basically it is about the “right view, right intention, right speech, right mindfulness and concentration”. All of this sounds like Surgery to me- being where you are at the moment and “doing the right thing”. Staying focused on the task at hand, and solving the problem for your patient. Finding your “rightness” or center, and enhancing your courage can be enhanced by having a practice of quieting the mind and just being aware, learning to step back, and observe. It really doesn’t take a lot of time and the benefits to you and those around you are priceless.

There are several community forums and meditation centers that can help one develop a practice; however for most of us, that is impractical to fit one more thing into our already crowded schedule. From a practical standpoint, for busy surgeons, you can practice the “stepping out’ of your busy schedule and just focus on your breath. What follows is certainly not a complete description of a meditative practice, just a simple way to start; references are added at the end for your perusal. The key to the practice is making time, and space for it in your daily life. The simplest form of meditation is to focus on your breath. Taking a comfortable seat, closing your eyes (and turning off the radio, TV to make where you are quiet) and feeling your breath moving in and out is a simple way to start. Take 5 minutes in the morning at the breakfast table, to sit and just breathe -bringing your attention to the in and then out breath. Let the distracting thoughts about what the day requires come and go. The practice of meditation is the letting go and returning to the breath. You can sit in a chair, cross legged on the floor or use a meditation bench- it doesn’t matter. Just be comfortable and quiet the mind. There are many type of practices that you can pursue and both formal and informal instruction, however the one that I am most familiar with and what I use in my own practice is that of “Metta” meditation. 

I have had the great fortune to attend several workshops with Sharon Salzberg of the Insight Meditation Institute over the years, and this is her type of practice. Metta refers to “loving kindness” meditation and centers around the heart literally and figuratively. It is about fostering compassion in ourselves for ourselves and those around us. Again, in taking a comfortable seat, take a few breaths and center the breath on the center of the chest. Sitting quietly, in your mind – steadily repeat “ May I be happy, may I be healthy, may I be safe, may I live my life with ease”. Use the intentions of kindness for yourself to restore or enhance your reservoir of energy that you expend on others. I find that by using this kindness mantra focusing on myself, then my family, my friends,  and most importantly, and finally, for the people I don’t like and that challenge me- enhances my ability to keep an open heart, my compassion and equanimity. It also allows me to “see “the challenging people in a light that allows me to deal with them, in fashion that doesn’t drain me and makes me less judgmental of them. When stray thoughts butt into my mind, which they always do, acknowledge them and let them go. Restore  your focus on your mantra.  It really is that simple-set your phone for 5 minutes, and try it.  I reach for this practice daily and whenever I just can’t “find it” (whatever “it “is). There are many mantras available for you to repeat, or you can just focus on your breath, the practice is of quieting the mind. I also find that when I have had a particular challenging day, or am about to face one, and I am busy, I can find 3-5 minutes to listen to a guided meditation or spiritual music in my office or on my iPod driving in. (I know you are not technically supposed to multi-task while meditating, however, you do what you have to do to find the space.) I believe that even if you do not pursue formal instruction or delve into this further, the practice of just making 5 minutes daily for you just to “be”, will be transformative for you. I encourage you to care for yourselves as well as you care for others.

Betsy Tuttle-Newhall, MD, FACS

  1. Insight Meditation Kit: A step by step course on how to develop a meditative practice by Sharon Salzberg. One of my favorite gifts for people who ask me about meditating.
  2. Unplug: Books and Audio by Sharon Salzberg. This is a set of cards, and audio you can use whenever you have time and listen to and from work. It is a set of restorative practices that simply teach you to let go. Included is a guidebook as well.
  3. Voices of Insight, written by the teachers at the Insight Meditation Institute. This is a group of stories about how these regular people found their way from the West to a mostly eastern based meditation practice and guidelines for assistance in developing your own practice.
  4. Any of the following books by Sharon Salzberg: Loving Kindness: The revolutionary art of happiness. Real Happiness at work: meditations for accomplishment, achievement and peace. Faith (my favorite). Quiet Mind: A beginner’s guide to meditation. Love your enemies. Heart as wide as the world.
  5. CDs or iTunes purchase, Don’t bite the hook: findingfreedom from anger, resentment, and other destructive emotions. This is more Buddhist in nature as it is taught by Pema Chodron as a weekend retreat that was in part recorded. Again, easy to listen to in the car or as a Podcast. She teaches about the concept of patience, and focuses on what we can practice to change our habitual response. I find her incredibly funny and very wise.
  6. CD or ITunes purchase: Mantras for Life. Deva Premal. It is a very beautiful rendition of some ancient Hindu Mantras with specific intentions.
  7. For retreats or more focused time :
    1. Omega Institute in located in Rhinebeck, New York and offers multiple type of retreats regarding spiritual practices, yoga, meditation, or leadership development.
    2. Insight Meditation Society, located in Barre, Massachusetts. Their schedule is located on line and the website is a fabulous resource.
    3. Shambala Sun. A predominantly Buddhist magazine , online and by subscription. Great resources for finding good meditation communities where you live.

In Memoriam: Thomas R. Russell, MD, FACS

AWS lost a long time friend and supporter this month. Dr. Russell is remembered fondly by those Council members who had the privilege to interact with him during his visits to the annual Spring Council meeting that was held at ACS headquarters in Chicago. 

He is seen in this photograph accepting the AWS Nina Starr Braunwald award on behalf of the ACS in 2006. He worked hard to support women in surgery. Read more about Dr. Russell here.

Some thoughts from AWS members are included here.  Please comment below or visit our Facebook page and share your stories about Dr. Russell or comment on this story.

"Dr. Russell was very accessible, even to the resident. He came to speak at our institution, and in his answers, he discussed how he attempted to answer as many inquiries or problems as possible in his position as executive director of the ACS. He understood that medicine was changing, and tried to make sure that no surgeon was left behind. He acted as both guardian and muse."

“[Dr. Russell’s first interaction with the AWS as Executive Director of the ACS came at a Spring Council meeting in Chicago.] When he had the politically sensitive task of mending the fence [after a prior meeting of the AWS with a colleague had not gone as well as expected]. The look on his face as he entered the room was not unlike the ones I've seen on residents walking into an operating room to discuss a difficult situation with an edgy attending. It was clear he was trying so hard to let the AWS know he really felt bad about what happened, that all is defenses fell away and he spoke from the heart. He talked about how his own daughter wanted to be a surgeon and how he really and sincerely wanted the AWS and ACS to work together to make things better for all women surgeons. He was so genuine and earnest in his talk that no one had the heart to re-hash the hurt feelings. We thanked him for his sincerity and have appreciated his efforts on the part of the AWS ever since.”

“I have been fortunate to mentor and train Katie Russell, Tom Russell’s daughter, as a general surgery resident for the last 6 years. Katie is truly her father’s daughter, someone who approaches every situation with kindness and enthusiasm, and someone whom you can unequivocally depend upon. Although I peripherally knew Tom before Katie joined us at Utah, I got to know him better during her time here, which was a genuine privilege. Every time I would run into Tom at a meeting, I would get a warm hug and he would express his gratitude for my mentorship of Katie. What I couldn’t ever explain to Tom was that Katie is one of those superstars for whom I feel like I have had to do relatively little - I’ve simply encouraged, provided opportunities, and enjoyed being within her orbit. I see his grace and humility in all of my interactions with her, and I am better for knowing them both. Tom will be deeply missed. I’m grateful that another generation of the Russell family is part of our wonderful profession. He leaves us an amazing legacy in many ways.”

We look forward to reading more memories from our members.  Please respond of below or on our Facebook page.

Tuesday, August 12, 2014

Book Review: Success Under Stress

The AWS Clinical Practice Committee reviews Success Under Stress: Powerful tools for staying calm, confident, and productive when the pressure’s on by Sharon Melnick, Ph.D.

“The best time to plant a tree was 20 years ago. The second best time is now.” – Chinese proverb

We recently reviewed the book Success Under Stress, by Sharon Melnick, Ph.D., a business psychologist affiliated with Harvard medical school that works with leading business professionals nationwide.  The subtitle of the book sums up the reasons to read it: “Powerful tools for staying calm, confident and productive when the pressure’s on”.  While her examples are very business oriented and may be difficult to apply directly to our daily lives, the principles and ideas behind her examples are very applicable and resounded with many of us on the committee.  One of the key points she makes early on, is that we cannot control (or be responsible for) everything in our lives.  We must focus on the things over which we can influence the outcome, and do those well.  Take ownership of your contribution, and don’t stress over portions not within your control. 

A key to succeeding in stressful situations is in understanding the source of the stress.  She defines stress as an internal response “when the demands of a situation exceed your perceived ability to control them”.  When she describes the average business professional as having 30-100 ongoing projects, being interrupted 7 times an hour, and facing communication from multiple technologies 24h a day, suddenly their lives seem a little more similar to ours!  She also emphasizes that you cannot give 100% of your effort for 24h all day every day. Your mind and body need recovery time.  Planning “off-button” activities not only decreases your level of stress, but makes you more productive when you are “on”.  The key to surviving, and succeeding, is in how you perceive your role, how you exert control over your day, and what you consider to be success.

Friday, July 25, 2014

2014 AWS Conference Details - SAVE THE DATE

Sunday, October 26 – Tuesday, October 28, 2014
Complete Brochure COMING SOON!

Registration is now open. Register today!

Sunday, October 26th | 2014 AWS Conference: Transitions – Thriving Amidst Change
Westin St. Francis | 335 Powell Street, San Francisco, CA
6:30 am - 3:00 pm 

AWS thanks our Platinum Sponsors:


Conference Highlights Include:
  • Sunrise Scientific Session
  • Medical Student and Resident Starr Poster Presentations
  • Green Solutions for the Operating Room Presentations  
  • Presentations: 
    • Challenges to Leadership in Surgery, Nancy Ascher, MD, FACS, University of California, San Francisco
    • The Changing Face of US Healthcare: How to Optimize Your Career, John E. Hedstrom, JD, American College of Surgeons
    • The Challenge: Transition to a Healthier YouCarol E.H. Scott-Conner, MD, FACS, University of Iowa Carver College of Medicine
    • Transitions and Resilience: Growing and Thriving Throughout Your Life and Career, Janet Bickel, MA, Janet Bickel & Associates, LLC
    • Directed Networking Sessions: Tools for Personal Success, Topics include: Strategies for Family planning, Work/life Balance; Success under Stress, Financial and Retirement planning, Private Practice: Navigating a successful career, Social Media “How-tos,” Alternate/nontraditional career paths, Successful negotiation strategies, Mentorship and Career advancement

Interested in participating in the 2014 AWS Green Solutions for the OR Contest? Click here for details. Deadline to submit is August 3, 2014.

Monday, October 27th | AWSF Awards Dinner & Reception
Westin St. Francis | 335 Powell Street, San Francisco, CA
6:00 pm - 10:00 pm  

The American College of Surgeons’ Women in Surgery Committee sponsors the reception for women surgeons attending the Clinical Congress and their guests. The AWSF Awards Dinner follows. The reception is complimentary. Individual dinner tickets must be purchased in advance. 

Tuesday, October 28th | AWS Networking Breakfast
Nordstrom Café| 865 Market Street, San Francisco, CA
8:00 am – 10:00 am          

Networking Breakfast for AWS members and non-members. No pre-registration required. The breakfast is complimentary.   

Hotel reservations can be made through the American College of Surgeons' travel agency. 

Stay tuned… a complete brochure is COMING SOON! 
Registration is now open

Women Surgeon Leaders for the 21st Century

By: SreyRam Kuy, MD, MHS

Part I: The Status of Women in Leadership Roles, Changing Culture and Leadership Training

“If you're offered a seat on a rocket ship, don't ask what seat! Just get on.” -Sheryl Sandberg, Chief Operating Officer of Facebook, from Lean in: Women, Work, and the Will to Lead

“When you ask women, they do want these things [leadership roles] and they want them as much as men do.” - Patricia Numann, MD, Former President of the American College of Surgeons and Association of Women Surgeons Founder

“I used to walk down the street like I was a super star… I want people to walk around delusional about how great they can be – and then to fight so hard for it every day that the lie becomes the truth.” -Stefani Germanotta, entertainer known as “Lady Gaga”


A century ago Orison Marden published, “How They Succeeded: Life Stories of Successful Men Told by Themselves,” describing the leadership and career success stories of prominent late nineteenth century US leaders such as Alexander Graham Bell and John D. Rockefeller.  Among these profiled nineteenth century leaders was Helen Gould, an heiress, philanthropist and a law school graduate.  Ms. Gould remarked upon the confines of nineteenth century America upon opportunities for upward mobility available to women, “I do not see, for my part, how any child from the poorest tenements could ever grow up and develop into strong, successful men or women…  And it is harder on the girls than the boys!  The boys can go forth into the world and probably secure a position… but the poor girls have so few opportunities.”  And yet, she had the prescient foresight to say, “But I don’t think it matters much what a girl does so long as she is active, and doesn’t allow herself to stagnate.  There’s nothing, to my mind, as pathetic as a girl who thinks she can’t do anything.”  A century later, the first woman to be inducted as president of the American College of Surgeons proved that “girls” can indeed do anything. 

Dr. Patricia Numann remarked on leadership roles that “When you ask women, they do want these things and they want them as much as men do.”  Clearly, there is a wealth of talent among women surgeons.  What is the status of women in leadership roles in medicine today?  And, what are the resources to assist women medical students, surgical residents and surgeons in advancing in leadership roles in their hospitals, communities, universities, and professional organizations?

The Status of Women in Leadership Roles in Medicine

In 1960, only 5% of medical students were women.[1]  Today, at least half of medical students are women.  Has the advancement of women in leadership roles in medicine kept up with the growth of women entering medicine?  In a cohort study of all US medical school graduates from 1979-1993, women were more likely than men to pursue an academic career (10% more women than would be expected with proportional representation of men and women, with women significantly over-represented among medical school graduates entering academic medicine).[2]  However, the percentage of women who advanced to associate or full professor were significantly lower than their male counterparts.  The percentage of women medical school faculty members holding full professorship has grown slowly over the years, from 7% in 1978 to 15% in 2005.(Nattinger)  This is in contrast to the fact that 30% of male faculty have held the rank of full professor consistently over this time period and that in 2005 only 11% of department chairs were women.  

Some of the factors that have been suggested for this gender disparity in leadership roles in medicine include less preparation for an academic career, fewer resources at the beginning of the career such as salary disparity either due to sexual discrimination or ineffective negotiation, lack of mentoring, less supportive institutional environment, and societal norms dictating home life and child care responsibilities which impact career trajectory.[3],[4],[5]  To close the gender leadership gap, a multifaceted approach is necessary.  A number of strategies have been suggested.  Changing the culture of medicine, disseminating knowledge about resources for leadership training, increasing awareness of promotion criteria, improving mentoring of junior women surgeons and developing negotiation skills are several other avenues that empower women surgeons in emerging as leaders in academic and organized medicine. 

Changing the Culture of Medicine

Valantine and Sandborg describe one institutional model which aims to change the academic culture to allow integration of work-life balance and flexibility policies into the promotion process, such as parental leaves and tenure clock extensions, which would enable institutions to better recruit and retain the best and brightest of both women and men.[6]  Fried et al. describe another multifaceted institutional intervention to address career advancement obstacles faced by women faculty.[7]  By targeting problem identification, leadership involvement, education of faculty, mentoring, reduction of isolation and increased integration of women faculty into the scientific community, they reported a significant increase in the number of women promoted to associate professor rank over a 5 year intervention period.  Other institutional change frameworks emphasize the need to increase the visibility of women and the work they do by tracking and publishing institution specific data on women in leadership positions and valuing women’s relational skills by training deans and other administrators to look for and recognize the value of women’s behind the scenes relational expertise in collaboration.[8]  The National Institute of Medicine (NIH) developed a tool to assess if an institution has a Culture Conducive to Women’s Academic Success (CCWAS).[9]  The CCWAS consists of four elements, equal access, work-life balance, freedom from gender biases and supportive leadership.  This can be a valuable tool for institutions seeking to reinvigorate their culture to enable women to flourish in academic medicine.      

Leadership Training

Sonnino describes valuable resources available for professional development and leadership training, available on the Association of Women Surgeons Website[10] and the American Journal of Surgery.[11]  These opportunities of professional development described include courses provided by the AAMC (Association of American Medical Colleges), the ELAM (Executive Leadership in Academic Medicine) program for women, ACPE (American College of Physician Executives) Leadership Development Program, Harvard University MBA training programs, and the Robert Wood Johnson Foundation Fellowships.  ELAM offers senior women faculty at medical and dental schools a year-long fellowship training experience to enable them to develop the skills need to competitively seek higher level administrative positions at academic medical centers.[12]  Research has demonstrated that women physician who participated in ELAM were more successful than non-ELAM women physicians in attaining department chair or Dean level positions.[13] 

Leadership training needs to begin early, in medical school and residency training.  Taking an active leadership role to enable effective teamwork and patient care during residency medical school is the training grounds the future surgical leaders.[14]  The American College of Surgeons hosts an annual Residents as Teachers and Leaders Course at their national headquarters in Chicago, Illinois at no cost to surgical trainees.[15]  Residents are taught effective teaching skills including learning how to give feedback to learners, establish time for teaching, and seeking teaching opportunities in the operating room and on the wards.  Residents are also taught techniques for successful leading such as conflict resolution, integrating diverse working styles, and leading productive teams.  The American College of Surgeons also has course of practicing surgeons, Surgeons as Leaders: From Operating Room to Boardroom.[16]  This three day course teaches surgeons about consensus building, changing culture, conflict resolution, emotional intelligence in order to have personal insight, and practical translation of leadership principles into daily action.    

By incorporating a multifaceted approach of fundamental change in institutional culture, leadership training, negotiation skills, development of mentoring relationships and awareness of promotion criteria, hopefully we can one day see more women surgeons following in the footsteps of Dr. Numann in leading our hospitals, communities, and professional societies.  Check out next month’s AWS newsletter to learn read the second segment of this two part article, “Women Surgeon Leaders for the 21st Century: Part II – Negotiation Skills, Developing Mentorship Relationships, and Promotion Criteria”.

Parting Thoughts from Women Leaders

“Always aim high, work hard and care deeply about what you believe in.  And when you stumble, keep faith.  And, when you’re knocked down, get right back up and never listen to anyone who says you can’t or shouldn’t go on.” - Hillary Rodham Clinton, Former US Senator, First Lady and Secretary of State

“I always did something I was a little not ready to do.  I think that’s how you grow.  When there’s that moment of ‘Wow, I’m not really sure I can do this,’ and you push through those moments, that’s when you have a breakthrough.” 
–Marissa Mayer, Chief Executive Officer of Yahoo

“As a leader, I am tough on myself and I raise the standard for everybody; however, I am very caring because I want I want people to excel at what they are doing so that they can aspire to be me in the future.” –Indra Nooyi, Chief Executive Officer of PepsiCo

SreyRam Kuy, MD, MHS was born in Cambodia, grew up in Oregon, graduated from Crescent Valley High School as Valedictorian, and attended Oregon State University where she earned dual degrees in Philosophy and Microbiology.  Dr. Kuy’s passions are healthcare policy, physician leadership and health services research.  After college she worked as a Kaiser Family Foundation Barbara Jordan Health Policy Scholar in the Senate, writing speeches and policy briefs for Senator Tom Harkin on women’s health, coverage for breast cancer screening and treatment, and health care instrument safety.  She attended medical school at Oregon Health Science University, then finished general surgery residency in Wisconsin.  She earned her master’s degree in health services research at Yale University School of Medicine as a fellow in the prestigious Robert Wood Johnson Clinical Scholars Program.  She is also a writer.  Her first book, Soul of a Tiger, describes her family’s survival during the Cambodian Genocide known as the Killing Fields.  Her second book, 50 Studies Every Surgeon Should Know, will be released in 2015 by Oxford University Press and describes seminal research in the surgical field.  Dr. Kuy is an assistant professor of surgery at Louisiana State University and the Overton Brooks Veterans Affairs Medical Center.    

[1] Hamel M, Ingelfinger J, Phimister E, Solomon C.  Women in Academic Medicine – Progress and Challenges.  NEJM. 2006;355:310-312.
[2] Nonnemaker L.  Women Physicians in Academic Medicine: New Insights from Cohort Studies.  NEJM. 2000;342:399-405.
[3] Nattinger A.  Promoting the Career Development of Women in Academic Medicine.  Arch Intern Med.  2007;167:323-324.
[4] Bickel J, Wara D, Atkinson B, Cohen L, Dunn M, Hostler S, Johnson T, Morahan P, Rubenstein A, Sheldon G, Stokes E.  AAMC Paper:  Increasing Women’s Leadership in Academic Medicine: Report of the AAMC Project Implementation Committee.  Acad Med.  2002;77(10):1043-1058.
[5] Allen I.  Women doctors and their careers: what now?  BMJ. 2005;331:569-572.
[6] Valentine H, Sandborg C.  Changing the Culture of Academic Medicine to Eliminate the Gender Leadership Gap: 50/50 by 2020. Acad Med. 2013;88(10):1411-1413.
[7] Fried L, Francomano C, MacDonald S, Wagner E, Stokes E, Carbone K, Bias W, Newman M, Stobo J.  Career Development for Women in Academic Medicine.  JAMA.  1996;276:898-905.
[8] Morahan P, Rosen S, Richman R, Gleason K.  The Leadership Continuum: A Framework for Organizational and Individual Assessment Relative to the Advancement of Women Physicians and Scientists.  Journal of Women’s Halth.  2011;20(3):1-10.
[9] Westring A, Speck R, Sammel M, Scott P, Tuton L, Grisso J, Abbuhl S.  A Culture Conducive to Women’s Academic Success: Development of a Measure.  Acad Med. 2012;87(11):1622-1631.
[10] Association of Women Surgeons.  Accessed 6/10/2014.
[11] Sonnino R.  Professional development and leadership training opportunities for healthcare professionals.  The American Journal of Surgery.  2013;206:727-731.
[12] Richman R, Morahan P, Cohen D, McDade S.  Advancing Women and Closing the Leadership Gap:  The Executive Leadership in Academic Medicine (ELAM) Program Experience.  Journal of Women’s Health & Gender Based Medicine.  2001;10(3):271-277.
[13] Dannels S, Yamagata H, McDade S, Chuang Y, Gleason K, McLaughlin J, Richman R, Morahan P.  Evaluating a Leadership Program: A Comparative, Longitudinal Study to Assess the Impact of the Executive Leadership in Academic Medicine (ELAM) Program for Women.  Acad Med. 2008;83:488-495.
[14] Kiesewetter J, Schmidt-Humber M, Netzel J, Krohn A, Angstwurm M, Fischer M.  Training of Leadership Skills in Medical Education.  GMS.  2013;30(4).
[15] American College of Surgeons.  Residents as Teachers and Leaders Course.  Accessed 6/10/2014.
[16] American College of Surgeons.  Surgeons as Leaders: From Operating Room to Boardroom.  Accessed 6/10/2014.