Association of Women Surgeons: Inspiring and Encouraging Women Surgeons Since 1981: 2014

Tuesday, December 30, 2014

Cold hands, bright eyes, and tuberculosis… Happy New Year!

We asked our Women Surgeons to share with us their Holiday traditions and some of their favorite memories of the holidays.

Please enjoy these delightful stories from fellow AWS members -- and feel free to share your own in the Comments.

Happy Holidays from all of us on the Blog team and the AWS!
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Lauren Poindexter
MD Candidate, Class of 2015
Virginia Tech Carilion School of Medicine

Nearly every child lining the Pasadena Tournament of Roses Parade route on New Year’s Day in Southern California is bundled up to their noses in oversized parkas, gripping onto their parents hands tightly so as not to get lost in the excitable mass of humanity. Long before the start of the parade at 8:00am, bright-eyed children pull adults this way and that in attempts to touch the vibrant flowers, seeds, and grasses of the floats, stare at the huge costumed parade horses, and say hello to the perfectly-positioned musicians of the marching bands. Fascination and wonder predominates. Families are honored, a community gathers, rival football fans cheer, the nation celebrates a new year. Since the first Rose Parade in 1890 and the first Rose Bowl Game in 1902, the scene has only grown larger and more fantastic. New Year’s Day is my favorite holiday!

However lighthearted the modern festivities appear, few know of the original purpose of the Rose Parade and its roots in medical history: it was a nineteenth century small-town public relations stunt to entice the families of tuberculosis patients to relocate to Pasadena. Their target audience was East Coast citizens trapped in frigid, blustery winters.

The founder of Pasadena’s exclusive society, the Valley Hunt Club, was, himself, an East Coast transplant, former “consumptive,” and mastermind of the first Rose Parade. He established his club in 1888, the same decade when Prussian scientist Robert Koch identified the Mycobacterium tuberculosis organism, and at a time when physician specialists in America espoused the healing benefits of “climatic therapeutics” for tuberculosis sufferers.

Physicians in those days recommended their patients receive modern tuberculosis treatment and rest in temperate locales – ideally ones offering drier climes, mild winters, and warm temperature ranges. Through the late 1800’s and early 1900’s, international medical journals, textbooks, and newspaper articles included the Greater Los Angeles Area in their purported list of ideal regions. The Valley Hunt Club’s goal was to capitalize on this movement.

The 1890 Rose Parade featured a festival atmosphere of many athletic competitions and a parade of floral-bedecked horse-drawn carriages held under a sunny blue sky in the “dead of winter.” Vivid roses draped over horses necks and bundles of bright juicy citrus fruits wowed the 8,000 attendees. Foot races were run, children rode ponies, and visitors gushed in letters to their families.

Amidst the sprawling citrus groves and well-established ranches, newly constructed mansions sprouted in Pasadena. A residential spectacle dubbed “Millionaire’s Row” consisted of an impressive line of winter retreats commissioned by Eastern magnates desperate for a seasonal escape. Famous residents included the Wrigleys of chewing gum fame and the Gamble family of Proctor & Gamble. Average citizens also sought treatment for tuberculosis in this region. Pasadena’s “Ballard Pulmonary Sanitorium” was well-known for its excellent outcomes and its success was complimented by donations of dollars and volunteer time from members of local women’s clubs. By 1910, Pasadena was one of the fastest growing cities in the US.

When the Valley Hunt Club could no longer financially sustain the wild success of the Rose Parade, the non-profit Pasadena Tournament of Roses was created, eventually choosing William Wrigley’s winter mansion as its home base. Today, the parade progresses down the original “Millionaire’s Row” (now Orange Grove Boulevard) and past the Wrigley Estate. As a young child, I, too, was overwhelmed by the fantastic experience of the Rose Parade and fondly remember the years when we would spend New Year’s Eve at my grandfather’s townhouse across from the Wrigley Estate. He had ventured to Southern California as a young man to start his family in this beautiful region and was a strong supporter of the Tournament’s community involvement.

Though I’ve since migrated back east for medical school, and my grandfather has passed away, I look forward to every opportunity to head home to Pasadena for this annual celebration. Spending time with my family on a crisp January morning watching scores of floats, marching bands, and equestrian units, plus a raucous college football competition, is my favorite way to start a new year. Now I know to credit this event to the Valley Hunt Club… and tuberculosis!

* Tradition dictates that no parade will be held on a Sunday, therefore January 2nd is an alternate date.

Sunday, December 28, 2014

Happy Holidays from the AWS!

Thursday, December 25, 2014

Happy Holidays from the AWS!

Wednesday, December 24, 2014

Happy Holidays from the AWS!

We asked our Women Surgeons to share with us their Holiday traditions and some of their favorite memories of the holidays.

Please enjoy these delightful stories from members of the Association of Women Surgeons -- and feel free to share your own in the Comments.

Happy Holidays from all of us on the Blog team and the AWS!
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Amalia Cochran, MD, FACS, FCCM
Blog: amaliacochranmd.com
Twitter: @amaliacochranmd

One of my favorite traditions during residency grew up from a tradition back home in Texas. I’ve long believed that tamales are Christmas food, and when I moved to Utah for residency, I started the tradition of a tamale dinner at my house on Christmas night for my co-residents, friends…anyone who wanted to drop by.

At first, quite a few of them thought it was an intriguing and strange tradition, but it was always a fun evening. By Christmas of our PGY-6 year, one of my classmates looked at me as she was eating her tamales and confessed, “I’m going to miss this next year when I’m in Minnesota.” While I got to have my Christmas tamales with my Mom the next year- and was back in Texas for my fellowship - it definitely wasn’t the same.
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Brittany Bankhead-Kendall, MD, MSc
Resident

This Christmas my family and I will be navigating the waters that the "Match" has bestowed upon us- living on separate sides of the country. My surgery residency is in Michigan, and my husband's emergency medicine residency is in Texas. He and my son decorated our tree while we "FaceTimed." No parent likes to be away from their children, especially during holidays. But I think Christmas is about traditions, making traditions, and yet sometimes breaking them to remember what's really important.

AWS' Clinical Practice Committee pilots a TweetChat

Over the past few years, the Clinical Practice Committee has periodically read and discussed books which have provided beneficial tactics for added success in the management of our professional and personal lives. This activity has truly been enjoyed by the committee members. In search of ways to share this activity with the larger membership, we decided to pilot a tweet chat.

The committee’s experience with twitter ranged from zero to those who frequently tweeted. Armed with some basic guidelines from the Healthcare Leadership blog and the buffersocial blog, the CPC had its first Tweet chat on November 10.

The book for discussion was Success Under Stress by Dr. Susan Melnick. This book was reviewed by Dr. Sasha Adams in the August issue of eConnections. Dr. Adams led the discussion for the tweet chat. There were seven participants. A few of us had some problems initially seeing the stream of conversation, especially if we were using Tweetchat.com. Those who used HooteSuite.com as the platform for the chat had absolutely no difficulty following the stream.

In the end, everyone was able to contribute final thoughts about key messages gleaned from the book:

Prioritize
Pick your battles
Control what you can- your 50%
Be intentional rather than reactive
Don’t just be reactive; anticipate
Have control of your time; be purposeful
Don’t let stress control the situation

Though a little challenging, we successfully made it through our first tweet chat! We look forward to hosting another Tweet chat early next year featuring the Surgical Career Guide, due to be released in January, 2015.

Tuesday, December 23, 2014

Ergonomics-A Call to Action-When Helping Others Harms the Surgeon

By: Celeste Hollands, MD, FACS

Why was everyone shocked when shortly after my partner retired I told them he was only 62? He had had a heart attack and back surgery during his career. He walked with a limp and had to sit to operate due to years of standing in the operating room without regard to his own well being so he could provide outstanding surgical care to the children he served. We give our time selflessly, our reimbursement is diminished, there are certain health hazards to a job where you stand on your feet, but must we sacrifice our health? Isn’t there a better way to partner with industry to develop instruments and devices that are ergonomic or can be made ergonomic for all that use them?

We all remember our childhood and think back to what has changed as we have grown up and grown older. I remember riding in the “way back” of our Volkswagen beetle-3 little kids delighted to be in that special secret place where only us kids would fit. Did my parents love us? Of course they did. Were they smart and educated? Yes. Safety devices such as seatbelts were neither widely available nor used at that time. When safety devices were developed, they were designed for the 50^th percentile male. So seat belts, especially the 3-point restraint systems naturally did not “fit” many smaller men, most women and almost all children. Car seats and booster seats were designed, kids were moved to the back seat to avoid injury from air bags which were the newest “safety” device and on and on it goes.

Surgical devices and surgical instruments are largely similar in design approach. Those of us with smaller hands cannot operate many of the instruments in the manner that was intended. We have adapted in many cases-that is what we do-to provide the best care for our patients. Many of the adaptations result in work related injuries-either from misuse or repetitive use injuries in instruments that were not designed for small hands. Some injuries are not related to hand size at all, just repetitive use of instruments or surgical systems that were not designed with the user-the surgeon-in mind.

Injuries related to the ergonomics of minimally invasive surgery (MIS) have been investigated and reported. Youssef and colleagues (1) analyzed the risk to surgeons from side standing and between the leg standing positions during laparoscopic cholecystectomy. They concluded that the American side standing position posed risks of injury to the surgeon due to increased physical demand and effort resulting in ergonomically unsound conditions for the surgeon. Esposito and colleagues (2) reported on work-related musculoskeletal disorders (WMS) of the upper extremity in pediatric laparoscopic surgery. Their work parallels the work of Park and colleagues (3) in that the longer you have been performing MIS and the larger your caseload the more symptoms you report and experience.

Women performing laparoscopic surgery report more hand and shoulder symptoms than men and seek treatment for these symptoms more often even though they have been in practice a shorter time. This finding is from work by Sutton and colleagues (4). These findings seemed to be independent of glove size and probably more related to instrument handle size and design and/or table height.

A recent discussion thread on the ACS Women Surgeons community focused on flexible endoscopes and the lack of ergonomics for those with smaller hands. A number of good suggestions came forth for adapting safely to this challenge. These tips included how to best use an assistant; how to position yourself, the patient and the table; and how to manage the dials and grip and manipulate the scope. This is all very valuable information however the tips do not solve the issue for those with small hands. One discussant brought forth the knowledge that there was an adapter available that could be obtained from the company rep that helped with manipulating the dials.

If surgeons are discussing ergonomics and these work related injuries at all, it is likely behind closed doors, in a more private, more intimate setting-like the locker room or lounge since that is often where you immediately feel the mental and physical strain of the operation or procedure you just completed. It is when you have the time to readjust your focus for a moment to yourself that you are more likely to share your symptoms with those around you.

Ergonomics and surgeons’ work related injuries are an important topic. Some of the ergonomics are relative to all surgeons and some will be unique to those with smaller hands and of smaller stature. Identifying the magnitude of the issue and then designing studies to document it while partnering with industry to fix it is the next step.

We can wear support stockings, “sit when you can”, adjust table height, assume good posture and be mindful of our physical and emotional health. I remember when I was a resident one of the cardiothoracic surgeons was taking off his support hose in the lounge after the case and he told me that if I stayed a surgeon long enough that eventually gravity and low pressure systems in the body would be my enemy. He could wear support hose to help his legs but there were other things he could do little to manage. After 16 years in practice following 9 years of training, Mark, I get it! We can do our part to manage and control these ergonomic issues. We cannot remanufacture instruments and devices.

I encourage you to share your experiences here on our blog. Let’s have a very powerful conversation that leads to meaningful results. If someone has already stated an issue you have experienced-acknowledge it and be counted. There is power in numbers and we need power to begin to get industry to respond and partner with us.

Youseff Y, et al. Laparoscopic cholecystectomy poses physical injury risk to surgeons: analysis of hand technique and standing position. Surg Endosc (2011) 25:2168-2174
Espositio, C et al. Work-related upper limb musculoskeletal disorders in paediatric laparoscopic surgery. A multicenter survey. J Pediatr Surg (2013) 48:1750-1756
Park et al. Patients benefit while surgeons suffer: An impending epidemic. J Am Coll Surg (2010) 210:306-313
Sutton et al. The ergonomics of women in surgery. Surg Endosc (2014) 28:1051-1055

Happy Holidays from the AWS!

We asked our Women Surgeons to share with us their Holiday traditions and some of their favorite memories of the holidays – both at home and work.

Please enjoy these delightful stories from members of the Association of Women Surgeons -- and feel free to share your own in the Comments.

Happy Holidays from all of us on the Blog team and the AWS!
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Stephanie Bonne, MD, FACS
Assistant Professor
Trauma, Acute, and Critical Care Surgery
Washington University in St. Louis

What holiday do you celebrate and what is the special meaning of this
holiday to you?
We celebrate Christmas - I was raised Catholic and that's just the way it is!

What are some family traditions you have related to this holiday?
My mother's family is Polish, so we have a very traditional dinner on Christmas Eve with mushroom soup, fish, pierogi and picked Herring.

Do you have a good memory of patient care during a time you worked during
the holiday?
For the past several years, I've worked 6pm-6am over Christmas in the ICU. I kind of like it - there is a ton of food to eat, everyone is kind of cozy and happy. We watch NORAD tracks Santa at the nurses' station. The patient's families are usually in in the evenings and you can walk around and say hello to everyone.

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Callie Thompson, MD
Resident

What holiday do you celebrate and what is the special meaning of this
holiday to you?
We celebrate Christmas. For me, the holiday is a time of new beginnings and hope. I love spending this time of year with my family and seeing my children enjoy the same traditions that I loved as a kid.

What are some family traditions you have related to this holiday?
My family is very big on tradition so we try to do the same thing every year. We start by going to church on Christmas Eve and this year, my two oldest children are both in the Christmas play so I am really looking forward to that. On Christmas morning we open stockings and then have to have breakfast before we move to the presents from Santa. We are open-one-at-a-time-while-everyone-watches people.

Do you have a good memory of patient care during a time you worked during
the holiday?
My favorite holiday memory in the hospital would be from Christmas day my R2 year in the cardiothoracic ICU. All of the patients were critically ill but the nursing staff decorated and had a potluck that they invited the families to participate in. I just love the memory of the atmosphere in the unit that day.

Thursday, November 20, 2014

2014 AWS Conference Breakout Session - Mentoring & Career Advancement

by Nancy L. Gantt, MD, FACS

Our packed table energetically discussed mentoring, sponsorship and career advancement. The discussion highlighted challenges some of the members were having at their own institutions.

We spent a lot of time talking about the difference between mentorship and sponsorship, and why both are necessary for academic success. Dr. Emina Huang provided her insights about the difference between those two roles and how to find a sponsor. She noted that sponsorship is different than mentoring - the former helps with providing opportunities and exposure; the latter helps you with the steps to get there.

The discussion about Mentorship highlighted the following points:

Mentorship is valuable in all aspects of your professional AND personal life.
You will likely need more than one mentor, as a single person may not be able to meet all your needs.
Selecting a Mentor will be facilitated if you approach someone that you have worked well with, as your values have to be similar.
A mentor, or sponsor, can be someone outside your home institution.
If you are being stymied in your career progression by your Mentor because of their insistence to "follow specific channels" you may need to creatively develop a plan to include your current Mentor and a potential sponsor figure to further your career.

Members were directed to the Career Development Resource on the AWS website: “Strategies for Building an Effective Mentoring Relationship”.

In closing - you can have it all - just not all at the same time. Mentors and sponsors can help you achieve personal and professional success.

The Year of Mentorship

by Betsy Tuttle-Newhall, MD, FACS

As we start a new year of eConnections, and continuation of the mission of the Association of Women Surgeons (AWS) Foundation, the members of the Foundation Board want to dedicate this year of fundraising in honor of Mentors and the Concept of Mentorship. The overall mission of the AWS Foundation is to provide opportunities for the educational and professional growth of women in Surgery. Many of the signature programs of the AWS are supported by the Foundation including the Kim Ephgrave Visiting Professor program as well as several national awards including the Nina Starr Brunwald Award, Olga Jonassan Distinguished Member Award, Honorary Member Award, Hilary Sanfey Outstanding Resident Award and the Patricia Numann Medical Student Award. The Foundation also supports the Resident and Poster Competition at the Annual AWS meeting to encourage and facilitate interaction between students and residents training in Surgery. The Foundation was started in 1996, and has provided many of the AWS members ways to heighten their visibility and created advancement opportunities. The Foundation and its board have been and continue to be the “mentor” organization for the AWS.

What is mentor? What is mentorship? And why is this important? A mentor is defined as a “wise and trusted teacher, an influential sponsor or supporter”. Many of us during our careers have benefited from people who have taught us, encouraged us and supported us during specific or all phases of our careers. Mentors are often responsible for bringing Surgery to our attention when we are students. They are also responsible for teaching trainees, especially in Surgery, those lessons that are not described in a text or journal article- lessons in such things as rules of surgical culture, compassion, professionalism, communication skills, and ethics. They also knowingly or unknowingly teach us about personal matters, and self-preservation or lack thereof. Mentors are responsible for teaching us, often lessons that are transferred across generations.

"Mentoring is to support and encourage people to manage their own learning in order that they may maximize their potential, develop their skills, improve their performance and become the person they want to be." Eric Parsloe, the Oxford School of Coaching & Mentoring

There are many ways to mentor- formally via programs in your institution or via society programs such as the American College of Surgeons, or informally, by establishing a relationship to support a trainee or trainees in professional or educational matters. Mentorship relationships can involve formally assigning a faculty member to a trainee, and setting up a schedule for meetings, for adequate time to discuss issues. As for the trainee, there are many themes in a mentor-mentee relationship. These can include issues of the mentor being the professional role model, being compassionate and supportive, acting as a critic or a career counselor. Mentees often need specific goals for their relationships with mentors and they need to appreciate that their goals and expectations must be kept in the context of their training program and their expected level of professional performance.

There are many difficulties in establishing a successful mentor and mentee relationship. The most prevalent barrier to this relationship is lack of time. Mentors are often overcommitted with busy clinical or academic schedules, and trainees have their own time limitations with training hour restrictions and mandatory lectures and labs. Scheduling time in advance and scheduling those meetings at regular intervals can help make these meetings a priority for everyone involved. Secondly, there are often a limited number of faculty members who are interested or qualified to be a mentor. In the current era of declining re-imbursements and lack of funding for educational activities, faculty members are pressured to produce clinically and academically, limiting their time for non-reimbursed or credited activities. Similarly, issues of different generational priorities, gender and cultural differences in the available mentors can adversely affect the establishment of the relationships between the trainee and the mentor. While more and more women, gay and lesbians as well as international trainees are currently training in surgery, the diversity of the academic faculty has not kept up with the diversity of the training population. It is imperative that available mentors are sensitive to issues in the diverse population of trainees that are different than their own, and that issues are evolving over time to ensure that any mentor can have a mentorship relationship with any trainee. Often, it is not one person that is a mentor to a developing surgeon but a group of people over years, that train, influence and support the trainee. It does take a village to raise a child, and I would argue a well-trained surgeon as well.

As an example, for many years, early in my career, I was one of the only women I knew, interested and eventually training in Surgery. Women in Surgery were few and far between in the Southern part of the United States at that time. During my third year medical student rotation, I happened to be on service with teams of all male residents, and all male attendings. I spent a lot of time with several individuals that were professional role models for me including Chuck Harr, MD, Curt Mosteller, MD and Gary Craddock, MD. There was one woman trainee when I was student- Ginger Chiantella, MD and I thought she was marvelous. There were more over time including Catherine Share, MD who had a great influence on me as well. I also started a life-long friendship with one of the Surgical Attendings, Dr. Jesse Meredith, the “old dad”. When I was student, I would often round with “Old dad” at night, where he would tell me stories, and teach me about what was important to Surgeons- patients ( “who always come first”), compassion (“you can never have enough”), integrity and work ethic. When I was a fourth year student, I did not match in Surgery for post graduate training out of medical school mostly due to my own lack of insight into how the system worked at that time, but also due in part to the attitudes of the program directors and some of the surgeons I interviewed with. I often heard in interviews that as a woman, I did not have the “stamina to train “as a surgeon. I was also accused by some of trying to “take a man’s position”. Despite, the disappointing turn of events, I eventually found my way to Boston to train with the help of many faculty along the way including the Dean of Students at Wake Forest, Patricia Adams, MD who at the time was a transplant nephrologist who would go on to become the first woman President of the United Network of Organ Sharing, a Pediatric cardiac surgeon at West Virginia University, Robert Gustafson, MD and of course, Dr. Meredith. I have never forgotten their support and frankly, their ability to judge my performance not my gender. Training in Boston opened many doors for me with the help of all of the Surgical Faculty at The Children’s Hospital of Boston (especially Drs. Hardy Hendren, Jay Schnitzler, Jay Wilson, and Bob Shamburger). Drs. Al Bothe and Glenn Steele gave me a chance to train at the Deaconess and Dr. Roger Jenkins told me I could do anything I wanted to but to try transplant. It was Dixie Mills, MD that reminded me that there are still issues for women in Surgery, and Susan Pories, MD who taught me a lot about grace under pressure.

As I have progressed over my career, I have had many challenges, and while there has been a significant increase in the number of women training in Surgery, the number of senior women in Surgery in leadership positions academically has not kept pace for many reasons. At the completion of my training in Boston, I eventually completed a Transplant Surgery fellowship at Duke University Medical Center. I was the first woman fellow in Surgery at Duke, and the first woman attending in General Surgery to be pregnant and have children. Without the support of my chairman Dr. Robert Anderson and my Division Chief and friend, R Randall Bollinger, MD it would have been impossible for me to continue my career and have my children. My mentor and fellowship director, Dr. Pierre A. Clavien, now Professor and Chief of the Department of Surgery in Zurich Switzerland, taught me many things clinically, as well as teaching me how to be academically productive and know “how” to support and mentor junior faculty.

I never had a formal relationship with any agendas working with these people who were and are my mentors, but I learned by listening and watching, occasionally asking for guidance and support. I still call the “old dad” often who is now 90 to discuss issues of management and development as he has more common sense than anyone I know. As for mentors in how to progress in academic rank, time management and my career, I have the members of the AWS to thank for that guidance and support. Without the support of past and present members of the council, the Foundation Board and the management personnel, I would never have known how to write a real CV, a letter of recommendation, a division chief and chairman prospectus, a budget and many other things. Thank you Drs. Ephgrave, Hooks, Numann, Walsh, Scott, Bergen, Cochrane, Sanfey, Dunn, Nuemeyer, Gantt and so many others. I have had the opportunity to be supported and work with so many wonderful mentors. How do I honor them? By being a mentor myself. I have tried as I have risen through the academic ranks, to support, encourage, and train women with a focus on teaching clinical care, and precise operative skill. I have a list of trainees with whom I feel particularly close on my CV and who I have advised and promoted during my career. I now find myself the only woman Division Chief at my institution and have been a woman chair. In order to honor our mentors, we must work tirelessly to make sure no matter where we are, that there are the basics for equitable treatment (ex: a maternity leave policy and paternity policy), and performance based assessment for every trainee. We as more senior members, need to take advantage of our seniority and position to often place ourselves “in the line of fire” to demand justice and fairness for all of trainees and junior faculty- if the need arises. We need to be the mentors that some of us didn’t have and give out career advice and support, and make phone calls to ensure that the all of our trainees, but especially the women, have access and opportunities to train at the best places they can train. Times are changing and it is a great time to be a surgeon. We are all beneficiaries of the people who have supported us and trained us over our lifetimes, and we can honor them by being mentors to our cadre of students. I would encourage all of our members to honor their mentors with a donation to the foundation, so that the AWS can continue what we do to support all of us. This is their year !

My favorite “old dad” story:

Dr. Jesse H. Meredith is currently Professor of Surgery, Emeritus at Wake Forest University. He was a pioneer in many aspects of surgery including portal hypertension surgery, renal transplantation, reattaching severed limbs and the formation of Critical Care Units. He won the AMA’s distinguished service award in 2011 for his meritorious service in the science and art of Medicine and the Order of the Long leaf Pine in 2010, from then Governor of North Carolina Beverly Purdue. However, he is originally from Fancy Gap Virginia, plays a great fiddle and speaks with the native tongue of the South. He is a man of few words but when he speaks, everyone listens. When I was a third year medical student, I was rotating on trauma surgery of which Dr. Meredith attended. Being my first rotation, and being extremely uncomfortable and not knowing how to actually “do” anything, I would stand as close to the wall in the trauma bay when our team had a trauma patient, hoping no one would notice me and I could watch but not be in the way. One night, a young man came to the ED with a stab wound to the chest and was rolled in the trauma room in full arrest. There was a flurry of activity and everyone seemed to be moving at once, drawing blood, giving blood, examining the patient, achieving IV access. It was a hive of activity. Finally, the chief resident called out that there was a stab wound over the left nipple and he was going to open the chest. The chest tray was opened, calm came across the room and the incision was made, the retractor placed and the pericardium opened. A large hemopericardium was released with some improvement in the patient’s hemodynamics; however a small laceration was noted in the right ventricle that started spurting blood over the patient and the tray. It seemed like time stood still, with everyone watching the blood spurt when a gloved hand came through the back of the crowd, and a long gloved finger plugged the hole in the heart. Suddenly you heard the “old dad” say “well.., y’all know what to do now don’t cha…..” and off they went to the OR in a rush. He had appeared as if he were out of nowhere to solve the issue and save the patient. I do not remember to this day if anyone called him, he just knew when he was needed and he showed up.

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Do you have a story to share about your mentor? Email us at info@womensurgeons.org or tweet us @womensurgeons and #HonorYourMentor.

Or make a donation to the AWS Foundation to #HonorYourMentor today.

2014 AWS Conference

The annual Association of Women Surgeons Fall Conference was held at the stately Westin St. Francis in San Francisco, California on Sunday, October 26. The 2014 theme was “Transitions: Thriving Amidst Change.” The conference was attended by 124 people, 33 of which were medical students and residents. Presentations were interspersed by opportunities for networking with other attendees and corporate partners.

Celeste Hollands, MD and Lois Killewich, MD moderated the Sunrise Scientific Session. Five abstracts of excellence were presented from among those manuscripts accepted for publication in the American Journal of Surgery:

Hillary Braun, MD “Perceptions of Surgeons: Women Surgeons Prefer Female and Communal Surgeons”
Courtney Collins, MD “Effect of Pre-Injury Warfarin Use on Outcomes after Head Trauma in Medicare Beneficiaries”
Amy Liepert, MD “Protecting trauma patients from duplicated CT scans: the relevance of integrated care systems”
Lisa McElroy, MD “A Meta-Analysis of Complications following Deceased Donor Liver Transplant”
Betsy Tuttle-Newhall, MD “Prognostic impact of mechanical ventilation after liver transplantation: A national database study”

Ethicon has supported our Grant program since 1996 – enabling us to award over half a million dollars in research grants to AWS members. Heather Yeo, MD, the 2014 AWS Foundation/Ethicon Endo-Surgery Fellowship winner presented her study: “Clinical trial on the efficacy of sacral neuromodulation (SNM) with Interstim for fecal incontinence following surgery for low rectal cancer with sphincter preservation”.

Simultaneously, the 20 residents and medical students whose posters had been accepted for the 2014 STARR poster competition were being judged. The volunteer judges had a difficult assignment however eventually chose exemplary winners. The overall winner in the resident category was Dr. Fariha Sheikh for her poster entitled “Anesthesia Induced Neurotoxicity” and the overall winner in the medical student category was Martha Henderson from Emory for “Gender Differences in the Correlation of Objective and Subjective Assessments of Surgical Frailty.”

The keynote presentation of the conference was graciously provided by Nancy Ascher MD, FACS, the Professor and Chair, Department of Surgery Division of Transplant Surgery Isis Distinguished Professor in Transplantation, Leon Goldman, MD, Distinguished Professor in Surgery, University of California, San Francisco. Dr. Ascher has devoted her career to organ transplants and transplant research and has had a distinguished career of public service that includes appointments to the Presidential Task Force on Organ Transplantation and the Surgeon General's Task Force on Increasing Donor Organs. She also served as Chair of the Advisory Committee on Organ Transplantation for the Secretary of Health and Human Services from 2001 - 2005. She was also the 2007 AWS Nina Starr Braunwald Award recipient. Dr. Ascher’s presentation focused on women in leadership roles in surgery. She described the influential role artistic works in Detroit had on her while growing up, statistics of women in all leadership roles and the work yet to be done to achieve position and pay parity for women in surgery. She discussed the roadblocks to success-patients, employers and ourselves. Evaluation of our performance can be stilted due to the “abrasiveness trap”: high-achieving men and women are described differently in reviews. How we are perceived matters, and issues of family concerns, pregnancy and work-life balance need attention at every level of training. View Dr. Ascher's presentation here.

Attendees next heard “The Changing Face of US Healthcare: How to Optimize Your Career” presented by Patrick Bailey, MD, Medical Director for Advocacy, American College of Surgeons. An Arkansas native, Dr. Bailey is Chief of Pediatric Surgery at Maricopa Medical Center in Phoenix, AZ. He is completing work towards a Master of Legal Studies degree at Arizona State University’s Sandra Day O’Connor College of Law and is a Captain in the U.S. Navy Reserve. Dr. Bailey’s presentation focused on several topics of interest to the practicing surgeon. He discussed the implementation of regulations under the ACA, funding proposals for GME and the important role of advocacy in ensuring patient access to quality care. Dr. Bailey inspired many attendees to pay attention when opportunities for their expertise arise.

As a surgeon, balancing personal and professional demands while maintaining some semblance of personal wellness can seem impossible. The next speaker, Dr. Carol Scott–Conner MD, PhD, MBA, Professor of Surgery, University of Iowa Carver College of Medicine is armed with a wealth of both personal experience and unique insight into success as a female surgeon. Dr. Scott-Connor, whose clinical focus is Surgical Oncology and Endocrine surgery, is the consummate surgical educator, the author of innumerable papers and texts and the recipient of many awards. She was named a “local Legend” by the National Library of Medicine and will be awarded the Honored Member Award from the American Association of Clinical Anatomists (AACA) in June 2015. In her spare time she serves as a Governor of the ACS.

Dr. Scott-Connor’s inspiring and grounding presentation “The Challenge: Transition to a Healthier You” focused on the oft-neglected areas that require attention in order for women to be personally successful and enjoy it! She discussed organizational skills, ergonomics, mindfulness, exercise, companionship, reflective writing, burn-out and many other topics. Her addition of personal anecdotes gently drove home her bottom line- that many areas of our lives need tending if we are to be healthy. View Dr. Scott-Conner's presentation here.

The final formal presentation of the morning was by Janet Bickel, MA a nationally recognized expert in faculty, career and leadership development with 40 years of experience in academic medicine and science. In addition to a wide-range of individual coaching clients, organizational clients have included United American Nurses, US Department of Commerce, and US Department of Health and Human Services. She is an Adjunct Assistant Professor of Medical Education at George Washington University School of Medicine and has also taught Leadership and Innovation at the CIA and the National Reconnaissance Office. During the Executive Leadership in Academic Medicine [ELAM] Fellowship Program's first 15 years, she served on its Advisory and Selection Committees; among her many other roles she continues to serve as faculty and is a Principal Member of its Executive Development Council. AWS recognized her contributions and support of the goals of AWS by awarding her the AWS Honorary Member Award in 1992.

Janet’s presentation "Transitions and Resilience: Growing and Thriving throughout your life and career" focused on how women professionals are inequitably evaluated, the challenge of balancing short-term benefit with long-term satisfaction, success traps and important decision criteria for taking on something new. Multiple small group breakout sessions inspired discussion about the challenges facing women professionals as they advance through their careers. Issues discussed included: How aligned are your professional goals with your current roles and your vision of “success”? How do you effectively communicate your goals and accomplishments in a 30-second “elevator speech”? How can you increase your influence in ways important to you? What is standing in your way? What interferes with adaptability? How can you become more agile?

Janet emphasized preparing for success, transitioning, sustaining success, and then transitioning again all the while interweaving self-efficacy, political savvy, personal/professional growth and “communities of practice”. She emphasized that attendees needed to identify what resilience-promoting practice they were willing to commit to-and what supports were needed for this to work. View Ms. Bickel's presentation here.

After the AWS Business Luncheon, including election of 2014-2015 AWS officers, attendees reconvened in the Ballroom for directed networking sessions. Table topics included:

Financial management: Meredith Duke, MD
Work-Life Balance: Joyce Majure, MD and Lauren Paton, MD
Private Practice: Yvette LaClaustra, MD and Shirin Towfigh, MD
Alternate Career Pathways: Liz Robertson, MD
Family Planning: Sharon Stein, MD and Stephanie Bonne, MD
Social Media: Erin Gilbert, MD
Contract Negotiation: Jennifer Rosen, MD
Mentorship: Emina Huang, MD and Nancy Gantt, MD

Discussion and networking at each table was lively-the session moderators found that once settled none of the attendees wanted to move!

Overall the 2014 AWS conference was fun, informative and provided attendees with valuable skills to achieve personal and professional success. Please join us in Chicago for our 2015 Fall Conference on Saturday October 3, 2015.

Respectfully submitted by Nancy L. Gantt, MD FACS

Tuesday, October 28, 2014

The Art and Science of Touch

Recently one of our own Women Surgeons, Dr. Carla Pugh, was an invited speaker at the popular TEDMED 2014 event. In the session “Play is not a waste of time,” Dr. Pugh discussed Haptic Learning – the Art and Science of Touch – and her own experience with integrating this concept in surgical education.

Dr. Pugh started her talk with a powerful recollection of a difficult procedure in the emergency room – a thoracotomy. Dr. Pugh noted something made her seriously worried: the resident working with her seemed to have missed a critical finding while leading the thoracotomy, cardiac massage, and evaluation of the patient.

“As a surgical educator I am worried why my resident missed the blood clot around the heart, and things were moving so quickly that there was no time to discuss this great learning opportunity.”

I had the opportunity to interview Dr. Pugh to discuss her TEDMED talk and more.

In regards to the education opportunity that was missed with the resident, Dr. Pugh notes that providing feedback to residents is not built into the system. “The goal is to take care of patients & make money... Nobody gets paid to teach. Feedback is not built into the system... People who enjoy teaching do it, but it is not well-integrated. How do you teach residents how to be assertive? How to learn points of the operation? This is something that happens every day in medicine."

Unfortunately, Dr. Pugh has noted that this is something that has not changed since even her days in surgical residency. Despite high expectations, she notes that it is rare for people to provide direct detailed information/feedback.

This is how she got into Haptics.

Dr. Pugh holds a patent to a sensorized clinical exam model. She landed her first patent in 1998 during her postgraduate studies at Stanford University. The models can sense aspects of the physical exam such as tactile technique. One exciting finding to be published soon, was a model adapted for the clinical breast exam (CBE).

Dr. Pugh’s team was collecting data on CBE from experienced clinicians to help identify which technique was most sensitive to detect a mass in the breast. The data was supposed to help teach medical students the appropriate technique for CBE. A surprise finding was that 10-15% of clinicians were missing the mass in the model! Upon review of the data from her sensorized model, it was found that a specific examination technique was associated with being more likely to miss the mass.

Dr. Pugh notes, "We must go beyond the paper and pencil test." The technology is now available to help assess clinical exam and surgical skills. Incorporating this type of feedback into medical education and continuing medical education will likely make a big difference for patients.

Dr. Pugh grew up in Berkeley, California, and has long been interested in science and medicine. At 5 years old she received her first stethoscope and "was listening to people's ankles at the grocery store." As a child she had her first run-in with the power of touch “I was always taking things apart,” she notes. It was during one of these play sessions in the living room, she was electrocuted at 5 years old. “My hand was stiff!”

How do I get involved?

Dr. Pugh has an active research lab, which usually consists of engineering students. She has had two residents working in her lab. In addition to traditional surgical meetings, Dr. Pugh attends conferences usually dominated by engineers, like NEXTMED where Medicine Meets Virtual Reality.

Thank you, Dr. Pugh, for reminding us to dream big and never forget the art and science of touch.

Minerva A. Romero Arenas, MD, MPH is a General Surgery Resident at Sinai Hospital of Baltimore. She recently completed a research fellowship in the Dept. of Surgical Oncology at The University of Texas MD Anderson Cancer Center in Houston, TX. She received her MD and her MPH from The University of Arizona College of Medicine and the Zuckerman College of Public Health in 2009. She studied Cell Biology and French at Arizona State University as an undergraduate.

Her interests include surgical oncology & endocrinology, global health, health disparities, quality improvement, and genomics. A native of Mexico City, Mexico, Dr. Romero Arenas is passionate about recruiting the next generation of surgeons and is involved in mentoring through various organizations.

She enjoys fine arts, films, gastronomy, and sports. She enjoys jogging, swimming, and kickboxing. Most importantly, Dr. Romero Arenas treasures spending time with her family and loved ones.

Thursday, October 16, 2014

Networking = Connectivity

by: Sharon Stein, MD, FACS

To me, networking is all about connectivity. It is about finding people with whom I have something in common and forming bonds. Sometimes it gives me opportunities, sometimes it allows me to connect colleagues, and sometimes it allows me to help someone out. But it is focused on having a network of people who I feel comfortable talking to, learning from, and asking help from.

There are tons of places to network. I see networking opportunities in meeting patients, in speaking to referring physicians, and at work cocktail parties. I also see opportunities at my daughter’s school, at the grocery store, pretty much anywhere. Don’t think about networking just in terms of fellow physicians, power players. The wife of colleague might be the one to put a bug in someone’s ear and provide a great opportunity.

I never go into a networking opportunity with an agenda. I look for interesting new people that I enjoy speaking with and have something in common with. In fact, networking “how to lists” say look for opportunities to help others. If I can help someone finish a project, find a mentor, point out a job opportunity, it creates great bonds, which are often reciprocated.

Most networking lists say take business cards, add them to your phone and follow up with an email. One of my colleagues goes one step further. She always writes down the names and information about the family members of people she meets. The next time she sees a colleague she can ask how Junior’s tennis match went, or how her daughter’s wedding was. When she meets that new person again, they feel a personal connection because she remembered. I thought this was a great idea and it has worked well.

For me, Association of Women Surgeons has been a great place to network. For starters, we all have something in common – we are female surgeons trying to make our way in the world of surgery. In general, we tend to be doers, interesting people, and motivated by our jobs. Although I can bond with surgeons at ACS, and other surgical society meetings, the large group setting can be intimating. The smaller setting of AWS has provided me with the courage to approach senior surgeons, I wouldn’t otherwise have access to. This has been a great way to meet some of my role models. Prior to introducing myself, I practiced my opening, who I am, what I wanted to discuss with them. To take things a step further, I volunteered and have participated in committee work. This brought me into even smaller group situations working for a common goal. Just last year, I met someone at AWS who took the time to introduce herself to me. Now we have worked on a number of projects, very successfully and it has turned into a great opportunity for both of us to advance our professional goals.

Networking is about making friends, just like in high school. It’s easy to be intimated by the group of cool kids sitting at the lunch table. But now that we are grown ups, I have found that my role models and colleagues are really open to talking to me. Even if I am tired at the end of a day of conference, I always try to go to the social event and speak with one new person. You never know when those new contacts will turn into a great opportunity, or a great new friendship. When I look back at people who have assisted me with creating opportunities, some of them had formal relationships, people I worked with. Just as frequently, they are folks who I met in casual settings, maintained a relationship with, and now have become friends and supporters of my career.

Come network with me at AWS Conference…I’ll look forward to meeting you.

Here are some resources for networking.

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Sharon L. Stein is an Associate Professor in the Department of Surgery at University Hospitals/Case Medical Center in Cleveland Ohio. She is a member of the division of Colon and Rectal Surgery. She serves as associate program director and surgical director of the inflammatory bowel disease center. She did her training in general surgery at Massachusetts General Hospital and fellowship at NewYork Presbyterian Hospitals Cornell and Columbia.

Thursday, September 25, 2014

Quality and Safety

by: Christine Laronga, MD, FACS

As surgeons we have been doing Outcomes research (Quality and Safety) since the beginning of time. In today’s forum, the most common example is Mortality & Morbidity conference. Although we don’t think of it as such and that is true in the past as well. (Breast) cancer will serve as my model but any disease entity could equally be utilized. In the 1st century A.D., a Greek physician, Leonides, performed the first operative management of breast cancer called the “Escharotomy” method. The technique used a hot poker to make repeated incisions burning the entire breast off the chest wall. The outcome was not so good. Most women died from surgery of infection.

So in the Renaissance era, we developed newer sharper surgical instruments to remove the breast swiftly. Unfortunately most women died of exsanguination from the “Guillotine” method. Fortunately in the late 1800’s we developed anesthesia and learned an appreciation of antisepsis. Pioneers like Halsted could then safely and meticulously perform a radical mastectomy to cure breast cancer. The successful outcome of this operation, opened the door to clinical trials; clinical trials that have shaped and molded the treatment of breast cancer for the last 50 years.

However these medical advances were accompanied by a relentless growth of expenditures devoted to health care. All nations struggle with inefficiencies in their healthcare system and a perceived lack of value. Value is a word often interchanged with the word quality and the diagnosis of cancer is increasingly the focus of quality discussions. It is an incident diagnosis with most of the lifetime benefits accomplished within the first year of treatment. As such in 1999, the IOM recommended that cancer care be monitored using a core set of quality of care indicators. Quality of care indicators can encompass structural, process and outcomes measures. Process indicators have the advantage of being closely related to outcomes, easily modifiable, and provide clear guidance for quality of improvement efforts.

Therefore in order to improve the quality of cancer care, we would need high-quality data, mechanisms to feedback the information to hospitals or practices, systems to act upon the data, and participation of the providers themselves. This could be done on a national, regional or local level. For example the American Society of Clinical Oncology (ASCO) established the National Initiative for Cancer Care Quality to develop and test a validated set of core process quality of care indicators which could be abstracted from the medical records chart. In 2006, ASCO established QOPI to conduct ongoing assessments of these validated indicators within individual oncology practices of ASCO members. The abstracted data is submitted via a web portal and is analyzed in aggregate and by individual practice. QOPI provides a rapid and objective measurement of practice quality that allows comparison among practices and over time. Currently QOPI has over 300 practice groups participating and participation over time was highly correlated with improvement in performance measures.

Now ASCO is not the only national organization to examine quality of cancer care. The American College of Surgeons has their Commission on Cancer (COC) which accredits more than 1500 cancer programs that collectively treat more than 70% of all cancer patients in the United States. Accredited programs meet organizational and quality standards and maintain a registry of all patients who are diagnosed and or receive initial treatment in that program. This registry called the National Cancer Data Base (NCDB) includes initial cancer stage, treatment data, follow-up data and vital status. Currently, there are over 1 million new cancer cases that are entered annually to the already 29 million cases in follow-up. The primary focus of the data base was on the retrospective evaluation of care and to date over 350 publications are in press.

In 2005, the COC developed a set of quality measures for breast and colorectal cancer that could be measured from cancer registry data. The National Quality Forum endorsed the COC measures in 2006 and re-endorsed them in the fall of 2012. Similar to QOPI, each practice can follow their performance over time on these measures and compare themselves to other COC programs regionally or nationally. Each site can easily click on any one of these measures to identify which patients did not meet the standard. Understanding the reasons why the standard was not met will allow development and implementation of quality improvement efforts. Reassessment will then become the next key step to determine effects of improvement plans.

The 2 previous examples were national efforts at quality outcomes research but one could perhaps more easily conduct regional studies. For example, in 2004, my institution established the FIQCC which is a consortium of 11 institutions (3 academic/8 community) in Florida participating in a comprehensive practice-based system of quality self-assessment across 3 cancer types – breast, colorectal and non small lung cancer. Our Quality indicators were scripted based on the accepted QOPI, NCCN, COC, and site-specific PI panel consensus indicators. An evaluation was done to assess adherence to performance indicators among the sites. An average of 33 quality measures was examined per disease site. An abstractor trainer from Moffitt Cancer center traveled to each of the 11 participating sites to train the site abstractor by using sample charts. Quality control was maintained through audits, which were performed by the abstractor trainer when each site was one-third and two-thirds complete. A random sample of medical records charts was abstracted per site for patients first seen by a medical oncologist in 2006. In 2007, the participating sites met for an annual conference where the results were disclosed. Each site only knows which letter they are represented by but can see how they compare to the other Florida participating sites. Any quality indicator with adherence less than 85% was discussed at length. Each site was then given homework to investigate why their site was below 85% in adherence to any quality indicator and enact their own quality improvement plan. To assess success of the quality improvement plan, a random sample of medical records charts was abstracted per site for patients first seen by a medical oncologist in 2009. When the results were disclosed at the annual conference each site explained their quality improvement plan so that the other sites may benefit by lessons learned.

What we have learned so far is that performing outcomes research with regards to quality of care is no piece of cake. To be successful you will need:

• High quality data

• Mechanisms to feed back the information to the participating practices or hospitals

• Systems to act upon the data

• Participation of providers

• Ongoing re-assessment to monitor success of quality improvement plans and establish new plans of action

We also learned that there was no “Best” Practice in terms of what quality improvement plan to implement. What worked well with one site may not work at another site for various reasons. There is also no single “Best” Practice type of outcomes research to utilize. We must learn from each other. Two years ago, ASCO hosted their first Quality of Cancer Care Symposium which was met with resounding success. Highlights of the meeting are included in the May issue of the Journal of Oncology Practice. Hopefully attendees and readers will take away the importance of engaging in quality of care outcomes research regardless of the field of medicine. As surgeons we can lead the charge. One limitation we have already identified is the lag time from data abstraction and analysis to feedback of results to participating sites. This was evident with all 3 examples I showed you. This delay may help improve the quality and safety for patients of the future but doesn’t help the current patients.

Therefore, a key tenant of quality measurement must be timeliness. As such the COC has developed and has begun implementation of the Rapid Quality Reporting System (RQRS). Data entry begins as soon after diagnosis as possible. This will allow the clock to begin for a given metric. For example if chemotherapy should be administered within 4 months of definitive surgery, the RQRS will alert the facility of an approaching deadline if data has not yet been received documenting initiation of chemotherapy. This will allow the program to intervene for the current patient, not just a future patient. Other advancements coming down the road include: 1) adding new standards for breast and colorectal cancer to the 6 they already have; 2) expanding to other disease sites, such as non-small cell lung, gastric, GE junction tumors, and esophagus; 3) increase adoption of the RQRS by the 1500+ participating hospitals (currently only about 25% have initiated the RQRS); 4) exploring ways to expand public reporting of quality data; and finally the COC is Partnering with Livestrong foundation to develop a tool for the RQRS to auto-populate an end of treatment summary report and survivorship plan.

Ultimately the goal of all healthcare is to improve patient health outcome. In this context, value is defined as the patient health outcomes achieved per dollar spent. This definition integrates quality, safety, patient-centeredness, and cost containment. There is no one “best” practice method for outcomes research just what works “best” in your institution’s hands. The key is to engage in some kind of quality of care initiative in your respective discipline.

Christine Laronga, MD, FACS is a Surgical Oncologist at the Comprehensive Breast Program at the Center for Women’s Oncology at Moffitt Cancer Center and currently serves as the Treasurer for AWS.

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.

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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.

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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.

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