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.

Featuring 2013 ACS Surgical Forum Excellence in Research Award Recipient: Nicole Tapia, MD

General Surgery Resident Nicole Tapia, MD was honored a Surgical Forum Excellence in Research Award at the 2013 American College of Surgeons Clinical Congress held in Washington, D.C. Her work entitled "PACT Project: Standardized Resident Hand-off Implementation Improves Hand-off Quality" was also chosen as one of the top three resident presentations at the American College of Surgeons South Texas Chapter Meeting held in Austin, Texas during February 2014. The Association of Women Surgeons is proud to present Dr. Tapia’s work—in her own words—on the blog.

Standardizing Resident Hand-offs to Improve Hand-off Quality

by Nicole Tapia, MD

Morbidity and mortality conferences allow us to review our complications and ask ourselves if it was preventable, how it happened, and what we could have done differently to achieve an alternate outcome. There is usually a lesson to be learned during discussion of the adverse patient event, and a new best practice can develop as a result of such dialogue.

I have come to believe that the question of “what could I have done differently” is applicable to many realms of surgical life – struggling in the operating room with a new task, juggling management of a surgical team as a senior resident with both junior resident and attending expectations, and even balancing home and resident life. Recently, my institution offered an Advancing Clinical Excellence (ACE) in Health Care research grant which challenged residents to propose a study to improve health care delivery. They asked us to approach health care with a unique resident perspective and hypothesize and test our ideas.

Brainstorming with another research colleague and my research mentor, we agreed that a current hot topic which is omnipresent in resident work-life is the unintended consequences of the ACGME work hour requirements. In particular, our residents and staff have noted challenges that come with increased patient handoffs as we transitioned to a night-float system. We all agreed that anecdotally, we thought quality of patient care was likely worsened by this change.

Our research group determined that to test and study our hypothesis and improve handoffs, we needed to focus on verbal communication of patient information, as we work at several hospitals with varied electronic medical records and wanted our approach to be independent of a computer system. We set out to improve patient handoffs using a three-pronged approach: (1) determine current limitations and shortcomings of patient handoffs, (2) develop an ideal handoff, and (3) test the new handoff comparing subjective and objective quality measures.

Utilizing a focus group of residents and surgical staff to determine current limitations as well as the ideal handoff, everyone agreed that patients should be discussed based on acuity -- communication of events and plans of the sickest patients should occur first. This should be followed by in-depth discussion of the newest admissions, then changes to the current patients. Finally, a task review for the on-coming shift would be reviewed in top-down fashion. We developed a mnemonic, PACT (Priority, Admissions, Changes, Task review), to help our residents remember this discussion based on acuity.

Measuring pre- and post-PACT implementation, we found that with PACT implementation, residents had lower incidence of incomplete tasks and lack of patient knowledge on morning rounds, decreased discrepancy between junior and senior handoffs, and senior residents reported junior residents were better able to handle emergencies.

We were encouraged by our findings, but in true reflective fashion, thought we could further improve our handoffs. One limitation we found was that there were considerable interruptions during the handoff process. Additionally, we found that although residents were discussing the PACT content, they preferred to discuss patients based on list order – organized by patient location – rather than true acuity. Achieving complete buy-in to the new process has not been without resistance, even though our outcomes were excellent with improved handoff practices. As a result, we developed a second iteration of the handoff process (PACT 2.0) to address these limitations, and we are testing it head-to-head with our current PACT system, in a randomized controlled trial. We are currently analyzing the results and hope to report soon on our outcomes.

As a previous research resident and now third-year clinical resident, I have witnessed the junior residents transfer care of their patients with improved communication and feel confident that the night float residents have better knowledge of the patients on their census as a result of the work we have done so far. We introduced the PACT handoff system to our interns at orientation this past year and intend to do so again when they show up in late June. I feel privileged that through a unique grant opportunity at my institution, we were able to review our handoff process and ask ourselves not only what we could do differently, but also, were able to institute change.

Our experience has made me curious: How does your program do handoffs? Do you do handoff training?

~~~

Nicole Tapia, MD, is a general surgery resident in the Michael E. DeBakey Department of Surgery at Baylor College of Medicine, currently in her third clinical year. She recently completed two years of research, focusing on trauma and resident education. Nicole hopes to be a trauma surgeon at an affiliated academic center, where she can work with residents and medical students.