Wednesday, May 21, 2014

Making Time for Arts and Humanities in Medical and Surgical Education

by: Susan Pories, MD, FACS

I became interested in working with medical students on reflective writing when I was a tutor in the Patient Doctor III course, for third year students transitioning from the classroom to the clinic. In 2004, I began the Writers’ Circle, a group of faculty and students that continues to meet regularly during the academic year to encourage student writing. Out of this came our book, The Soul of a Doctor:Harvard Medical Students Face Life and Death, a collection of medical student writing, published by Algonquin in 2006 and now in its fifth printing, with over 27,000 copies in print. This has been translated into Chinese and is now being published in Japanese as well. This book is used as part of the medical student curriculum in several medical schools. I am also the Reflections Editor for the Journal of Surgical Education (previously Current Surgery) and over the years, I have helped many medical students publish their essays in this venue as well. Most recently, one of my students published her essay in the New England Journal of Medicine (Mourningon Morning Rounds by Mounica Vallurupalli, B.S.: NEJM 2013; 369;5).

Over the years, we have had many wonderful physician writers, such as Atul Gawande, Rafael Campo, and Jerome Groopman come and spend time with the students, which has been inspirational and educational. Our writers group was filmed and interviewed by PBS in November 2013 when the Poet Laureate of the United States, Natasha Trethewey, joined us for a discussion, which was a thrilling experience. Watch student physicians embrace poetry to hone art of healing. Most recently we had a two day visit with Dr. Danielle Ofri, prolific and thoughtful author and the Editor of the Bellevue Literary Review. As part of her visit, Dr. Ofri gave a taped interview for the Cambridge Forum which was broadcast widely Danielle Ofri: Why Doctors Write. I have become convinced that this sort of interaction and opportunity for reflection is integral for maintaining balance in a medical career. As such, I have joined forces with like-minded educators at Harvard Medical School and we now have a Committee on Arts&Humanities@HMS, dedicated to the eventual formation of a Center for the Arts, Literature, Music, and Humanities at HMS.

Working with student writers is a labor of love for me and I am currently working on two other book projects with the students. One is a collection of narratives from the Mentored Clinical Casebook project at HMS which is a project that pairs first year students with patients they follow for an entire year. The second is the Harvard Intern Project, where we are collecting reflections from interns. I am especially delighted when students who are interested in surgery participate in the arts and am very proud of our AWS medical students and residents such as Sophia McKinley, who recently published a beautiful essay in the Journal of Surgical Education (Too Nice to be a Surgeon by Sophia Kim McKinley, EdM; JSE Volume 71/Number3  _ May/June 2014) and Christina Grassi, who plays viola with the LongwoodSymphony Orchestra, an orchestra of physicians here in Boston. 

I will be moderating a panel for the October 2014 ACS meeting in San Francisco entitled Surgeons as Artists and look forward to broadening the discussion on this important and timely topic. 

Susan Pories, MD, FACS is the co-editor of The Soul of a Doctor and co-author of Cancer: Biography of a DiseaseShe is an Associate Professor of Surgery at Harvard Medical School, Immediate Past President of the Association of Women Surgeons and the Vice-Chair of the American College of Surgeons, Women in Surgery Committee. She is the Medical Director of the Hoffman Breast Center at Mount Auburn Hospital. Dr. Pories co-chairs the HMS Academy Writing for Scholarship Interest Group, she is Faculty Advisor to the HMS writers' group, and is the Co-Chair of the  Arts & Humanities @HMS  Planning Committee.


Thursday, May 15, 2014

Creative Writing for Surgeons

By: Carol EH Scott-Conner, MD, PhD

If you keep a journal, you are familiar with the process of putting words to an event. Writing down what happened allows you to place the event into a kind of context, externalize it, reflect upon its significance, and maybe remove some of the heat of emotion from it. This brief article deals with the logistics of transforming those journal entries into published creative fiction or nonfiction.

Think back to those early years when you, as a young person, began to formulate life goals and when you first heard the vocation (in the truest sense of calling) that led you to surgery. Perhaps you were influenced by a life event, an encounter with a charismatic surgeon, a family member in the business, or maybe your goals were shaped by things you read. By books and stories. Stories capture the imagination by tapping into a cultural heritage that goes back to the days when our distant ancestors gathered around the fireside to tell tales. Physicians who write for a wider audience dare to share their own stories with the public.

We work in a time of severe fiscal and administrative constraints. Much of our time and energy is spent dealing with these issues. It can become joyless. Somewhere along the line, patients became consumers, and physicians and other members of the healing professions became providers. Creative writing is a way for you to renew your own passion and to communicate the passion – the drive that keeps us in our careers – to the next generation of potential surgeons and to outsiders.

Any writer needs material. Fortunately, as surgeons we are surrounded by the deepest mysteries of life and death. We routinely encounter people in crises, and are able to observe a great range of humanity up close and person. It is no accident that some of our greatest writers, such as Checkhov, were physicians.

The best place to start is simply to keep a journal. There is no pressure to ever share what you have written with a broader audience, but if – at some future date – you wish to do so, you will have material.

If you have never kept a journal, I recommend the “Morning Pages” approach described by Julia Cameron. She suggests that you begin every day by writing three pages of anything you wish. Three pages – no more, no less. I have been doing this for about 14 years. I spend about 30 minutes at the start of each day with a cup of coffee and my journal. I write one or two significant events that I recall from the day before, or I write down my dreams, or I write down some possible solutions for writing projects that I am stuck on. Sometimes I can only finish one or two pages before I have to go to the OR. In that case, I finish my three pages at the end of the day.

Over the course of the day, I might make a note or two of something that caught my eye or captured my imagination. Let’s say, for example, that when I shook hands with a patient’s husband after surgery, I was struck by how strong and warm and blunt his hand was, and that (like many farmers) he had lost the terminal part of a finger or two. I might note down simply “farmer’s hands.” The next day, I might journal for a page or two or even all three about how that hand felt and about all the hands over the years, all the family members (husbands, primarily nowadays) I’ve spoken with, all those interactions.
Or, on my bike ride home, I might catch a glimpse of migrating white pelicans in flight. That becomes something to note down, and write about the next day.

Why not just write about it when it happens? First of all, usually there isn’t time. Second, the delay allows reflection, and you have a topic or topics in mind when you sit down to write. You aren’t simply facing a blank page with a fuzzy mind and a cup of coffee in hand.

Over time, material accumulates and the habit of writing becomes engrained. Maybe you will start to get the urge to share your experiences with a broader audience.  The material that follows deals with various aspects of creative writing for publication.

About twenty years ago I started to get inquiries from male colleagues (most of my colleagues, in those days, were men) who had daughters – “my daughter is thinking of going into surgery. What can I give her to read?” and when I tried to come up with a list, I realized that the very few books available at that time written by female surgeons, mostly memoirs, although very true were largely written from a place of bitterness and struggle. There was very little I could come up with at that time that conveyed the sense of joy and vocation that I would want to pass along. So I set out to write.

I began thinking I would write a memoir. So, let’s start with memoir as an exemplar of creative nonfiction. Creative nonfiction is a term used to apply to the general body of writing the truth, in which the writer uses some or all of the techniques of fiction. The one thing that is not allowed is trampling on the facts. Memoir is particularly tricky. The inevitable editing that has to occur – simply winnowing down the events of a lifetime into a handful worthy of inclusion – is of necessity subjective. Memoir says, here is the truth, as best I remember it. It is a window into a period of time, a way of life. A memoir that is perceived as self-serving is self-defeating. Memoir needs to tackle the difficult issues – it is the tension between the narrator and the world that brings it to life. Think back to the hardest times in your professional life and ask yourself if you are willing to bring these to the page.

Ask yourself also if you have kept good enough records (or have access to good enough records) to accurately reconstruct what happened. Ask how you will incorporate patient-specific details. How will you portray administrative struggles? How will you deal with family issues? Add to that the difficulty in reconstructing the past, in the absence of accurate records, and you may start to see the appeal of fiction.

Creative nonfiction for surgeons goes much farther than memoir, however. It encompasses a spectrum ranging from essays such as “A Piece of My Mind” in JAMA that explore the humane aspects of the practice of medicine through pieces that explain various aspects of medicine and healthcare for the public. There is an almost insatiable appetite for this kind of material, and it forms an easy segue from the writing you have already done in your professional life to the creative writing realm.

Let’s talk specifically about “A Piece of My Mind.” It’s one of the first things I turn to when each new issue of JAMA arrives. The vast majority of these pieces are clinical vignettes and feature a physician and a patient – sometimes the physician is the patient. The guidelines specify that the piece must be nonfiction. Information can be withheld, but nothing can be changed. The permission of the patient is required, if the case is in any way identifiable. The piece must be short – the word limit is 1800. Increasingly, in this kind of writing, the consent of the patient or family (and the opportunity to review the piece of writing) is required. Most of the time, consent is readily granted and leads to a new dimension in the patient-surgeon relationship.

Physicians are sometimes driven to write after they experience the health care system themselves, either as a patient or as the close relative of a patient. Often the experience is a negative one. The thing that distinguishes the best of these pieces of writing is a sense of distance, a dispassionate objectivity that can only come with time. Indeed, one medical literary journal noted that this was the single largest failure they noted in rejected pieces.

Fiction affords greater latitude. The first thing to understand about fiction (and it took me a while to get this basic point) is that it has a structure. Much of what we encounter in the course of our work as a surgeon is simply anecdote. Something happens. Fiction needs a protagonist, and the protagonist must have a goal. Something intervenes to thwart attainment of this objective, and there is conflict with resolution. Often the protagonist emerges changed in some way. So for the typical clinical encounter, the protagonist might be a patient, a surgeon, a trainee, a family member. The possibilities are endless.
Simply taking a clinical vignette and changing various aspects to make the patient unrecognizable is not enough to make something fiction. And this gets me to a key point. If you are really serious about creative writing, you would do well to take advantage of opportunities around you to learn the craft.

Poetry is a thing apart. Poetry, more than other forms, demands attention to the shape (form) as well as the content.  My experience as editor-in-chief of our literary journal, The Examined Life, has convinced me that writing poetry for publication requires specialized skills and knowledge which I do not possess. Writing poetry for yourself, of course, is another issue. I included some references at the end that may be helpful, but the remainder of this short article with deal exclusively with prose, especially in expanding upon some of the key issues in writing for publication.

I come from Iowa City, the home of the famous “Writers Workshop” – now, I’m not part of the workshop and I haven’t studied there (it’s an extremely competitive MFA program). But I subscribe to the philosophy behind the name. Workshop implies a place where things are made; and part of the philosophy is that writing is a craft, and that aspects of the craft can be learned, taught, and practiced. Studying these aspects of craft allow you to express yourself far more effectively.

As surgical educators, we know that some trainees come to surgical residency with a greater degree of eye-hand coordination and learn operative skills faster than others, but none of us would expect a raw trainee to go into the operating room and perform an appendectomy without study and practice.

Similarly, we need to lay to rest the myth of the born-writer, who sits alone in a room and is visited by a creative muse. The words just flow, and you either have it or you don’t. Just as we all learned how to operate, how to perform scientific experiments, so too creative writing is a set of skills to be studied.
How do you get started? It’s not that different from the search for a collaborator with specific expertise when you embark upon a research project. All universities have creative writing programs. An increasing number of medical schools incorporate creative writing into the curriculum for the medical students. Once you start asking around, you are likely to find a core group of physician-authors at your own institution. There may even be a literary journal, either on-line or print, at your college of medicine. For sure, there’s a good chance your university has one. At the University of Iowa there are at least three. The University hosts the prestigious Iowa Review, a well-established literary journal. The College of Medicine hosts the new The Examined Life Journal (of which I am the editor-in-chief), now putting together its fourth issue. And there is at least one student-run journal at the University.

Writing conferences such as the Iowa Summer Writing Festival provide a variety of short courses and the opportunity to interact with fellow-writers, most of whom are not physicians. There are, in addition, specialized conferences designed for medical writers, such as The Examined Life Conference held at the University of Iowa Carver College of Medicine.

How do you work with the material at hand? Obviously, respect for confidentiality and feelings of patients and colleagues must rule. This is why I went the fiction route! It’s not enough just to change the names. Remember, you aren’t writing a case report. The part that we as physicians may find most compelling - the medical details of the case - really matter the least. What matters is the interaction between individuals. How people change.

Use a writing group (preferably non-physicians) or writing courses to “workshop” your writing. Get your piece as good as you can get it, and then let your group have at it. Take careful notes! Notice what they found incomprehensible (jargon!) or what fascinates them. Correct the jargon (I had a group get hung up on “laparotomy pad” for several minutes) and expand upon the fascination. For example, several years ago I wrote a short story called “The Sound of Thunder,” about an unsuccessful resuscitation. Initially I thought it was about the tension between a surgical resident (who wanted to go all out and take a dying elderly patient to the OR) and an attending who decides otherwise. I live in a rural area so I often mix bits of nature into my stories - I threw in a snapping turtle (“once they bite, only the sound of thunder makes them let go.”)

The piece was triggered by an actual event, but I drew on a lifetime of these decisions to invent a composite resuscitation scenario that was pure fiction. Protecting the patient was the easiest thing in the world, because the medical details of the scenario (although they had to be true to life) mattered the very least. When I shared this story in a writing workshop, the non-physicians in the group liked the medical details, but they were fascinated by another aspect - how do you go home at night after a day like that? How do you interact with your spouse? What do you say? (Read the completed piece here.)   

There are a variety of excellent books out there for the neophyte (or even the experienced) writer. I particularly recommend Robin Hemley’s  Turning Life into Fiction. At heart, all writers are magpies and thieves, picking up bright jewels from the sidewalk, stitching them together into some kind of narrative. All writers deal with issues of disclosure and respect for that which should not be written. For the nonmedical writer, it may be issues related to family or friends. For us, it is patients.

For many medical writers, a short story starts with a clinical anecdote. This problem also occurs with beginning fiction writers who are not physicians. The problem is that an anecdote is not a story. A story has a structure, but an anecdote is just something interesting, bizarre, or amusing that happened. Many of the tales we tell our friends are really anecdotes. You can take an anecdote and shape it into a story, but you have to do the work and you have to understand the structure and conventions of a short story – these shape the expectations (consciously or unconsciously) of your readers.

That odd thing that happened during your last call night? It’s an anecdote. Put it into the structure of a story – add a protagonist (hero), a task, a complication, and a resolution; change the clinical facts, and it might be a short story. When I think of the structure of a story, I remind myself of the fairy tales I read as a child. Most of them began something like this: “Once there was a ____. Every day, she _____. Then one day, _____. So she ____” etc. and so on until “And they lived happily ever after” Your story doesn’t have to state those parts explicitly, but your clinical anecdote might provide the interruption – the “then one day…” element. How did that occurrence complicate your life, change your life, or change your outlook? It doesn’t have to be a huge change, but there must be some kind of transformation.
The nice thing is that it’s fiction! So the clinical details, all the identifying information, are easy to change, once you set your mind to it. Was it a case of a critically injured burn patient? Well, change the mechanism of the injury, the age and gender of the patient, the distribution of the burn over the body, the clinical issues; create a composite out of all the experiences you have had, and draw essential truth of the story from how you were affected. Or maybe change it to a critically injured non-burn trauma patient. The possibilities are limitless.

The best creative nonfiction draws on techniques used by fiction writers to create interest, suspense, or to move the reader. The difference is that nothing has been changed. As I noted above, there is an increasing trend to involve the patient (or patient’s family) and to get consent, rather than to omit identifying details and simply press on.

Creative nonfiction for surgeons actually encompasses a wide range of forms. There is memoir, clinical vignette, reflections on your own illness or professional experience, the transformation of going from medical student to resident, or the clear explication of medical facts in such a way as to fascinate the lay public (Gawande, Oliver Sacks).

I ventured into creative nonfiction when, a little over a year ago, I was diagnosed and successfully treated for Stage I breast cancer. At this point in my career, my practice consists exclusively of patients with breast disease, so there was a certain irony. When I began to reflect on the experience, nonfiction narrative offered the perfect vehicle. I started to think about scars, the scars of burn patients, the scars of surgical patients, physical and emotional scars of all kinds. I wrote a rambling lengthy reflection on scars which I submitted to Pulse – Voices from the Heart of Medicine. A generous-hearted editor went through several iterations with me and the final piece, balancing fact and reflection, was published in their online journal.

What I learned from the process was the importance of emotional distance from the experience, and the balance between the triggering event or events and the internal reflection on those events.

Let’s shift gears and talk about getting published. And I ask you to forget for a moment the world of The New Yorker, Paris Review and the Atlantic. If you are publishing in those, you really don’t need my advice. For the rest of you, follow me into the world of small literary journals where many creative writers are happy to find a niche.

Getting published in the world of creative writing follows a completely different set of rules than the kind of scientific, or technical writing that we are used to. To start from the most basic rule – when you submit a paper to one of the surgical journals, you follow the rule of “no simultaneous submissions.” When I send a story to a literary journal, I (and all the other creative writers out there) routinely send it to five, ten, sometimes twenty at the same time. This is just simply reality. I have had stories accepted for publication on the first go-around, and I have had others accepted after 50 or 60 rejections (and some revision).

It can take a journal a year to decide to reject a story – and life is short. Because the literary journals have failed to exercise draconian rules, each small but established journal may receive thousands of submissions for an issue, of which they may publish 30. You can do the math.

In some ways, publishing in literary journals is very similar, however. Just as some surgical research papers are ideally suited for the Annals of Surgery and others belong in Transplantation (or some other subspecialty journal), so too literary journals have niches. To take a clear example, there is a literary journal called The Healing Muse (see below) that is housed at the Center for Bioethics at SUNY Syracuse. That journal occupies a clear niche that will be different from, say, The Chicago Review. Look through some copies of the journal before you submit.

A complete listing of literary journals can be found at New Pages (see resources at the end of this article).

Here is a short list of small literary journals that concentrate on medical humanities and that accept submissions from individuals outside their own institution:

This all usually culminates in the desire to write a book and have it published. Books have a kind of permanence and heft, a gravitas that pieces published in periodicals do not. As with shorter pieces, if you are going to write a book, it needs to fit into one or another type or genre. Will it go on the Memoir shelf or the Novel shelf? Will it be history, or historical fiction? Maybe you are going to write science fiction. Choose a genre and study the forms, expectations, and best examples of that genre.

Generally you will need a completed manuscript before you approach an agent or publisher. University presses are natural publishers of nonfiction books (such as memoir, or the history of a department of surgery or a specialty), but tend to shy away from fiction. A third option, besides commercial publishers and academic presses, is self-publishing. Options such as CreateSpace and Kindle Direct have made this easy, painless, and sometimes the best option. There are a large number of excellent books about the process of writing (and getting published). I recommending going to a large local bookstore (or public library) and browsing the “writing” section.

As I said in the beginning of this piece, writing is a learned art just like surgery. You can learn how to do it, if you wish. Three elements for success as a writer are:
  • Material – we have no shortage of that as surgeons!
  • Writing – in other words, sit down and write. Perseverance helps here
  • Knowledge of, and respect for, the craft – study the craft of writing, and READ, read, read

As surgeons, we have unparalleled access to the human experience, and the demonstrated ability to persevere when we take on a task. Take time to add some knowledge of the craft and go forth and get published! It is so much fun to send something out into the world and then hear back from an old friend at another institution (or a colleague at your own institution) who just read it.


Carol Scott-Conner is Professor and former Head of the Department of Surgery at the University of Iowa Carver College of Medicine. As she grew older, she turned to creative writing as a way of conveying the rich and varied experiences she has had as a surgeon. A collection of her short stories was published as A Few Small Moments and other short stories are available at her website.

How to Become a Wildly Successful Researcher

by: Marie Crandall, MD, MPH, FACS

So, I can’t honestly claim to be a wildly successful researcher, but I understand, in principle, the effort required. I have slogged away at an academic career for the past decade, becoming modestly successful. With that disclaimer, I think some of this might be helpful to those starting out.

The world of academic surgery is absolutely broadening. Historically, academic surgeons wrote about a particular clinical question or perhaps ran a basic science lab. Now, there are many paths to academic achievement; some of the more common being public health, outcomes research, innovation, business, and policy. When I was a resident, I was selected to go into the lab and I said, “Bleah! Can’t I get an MPH instead?” Well, it turned out I couldn’t do it then, but three years later, I was fortunate enough to be selected as the trauma fellow at the University of Washington. UW had an NIH-funded training grant that paid for my MPH, which laid the foundation for my ensuing research in topics like domestic violence, gun violence, and disparities.  

Which leads to the first principle: 
  • Figure out something you like. If you HATE staring at Petri dishes or massacring rats, and find endless negative studies unrewarding, then you should probably not pursue basic science. Conversely, if you are deeply passionate about toll-like receptors, but the idea of testifying before Congress members about gun violence researchers makes you want to heave, then the lab is the place for you.

I will detail a few common research career paths. However, understand that there are ALWAYS exceptions to these rules, and your most heartfelt passions of today may seem, I don’t know, trite in a decade. Anyway, that was my second disclaimer.

Basic Science: To become a successful basic science researcher, you must somehow obtain the skills and the mentorship to pursue this path. If you want to go down this path, generally, you must match in a residency program that will allow you to do research. That area of research may not define your career, but the 1-2 years will help you learn how to design experiments, understand rigorous research methodology, and the importance of persistence and repetition. If you enjoy it, as you finish your residency, think of areas of research interest that are relevant to your career, and look toward mentors at your institution or other institutions for potential research fellowship or junior faculty positions. The mentors are absolutely key because basic science research is EXPENSIVE. You will need grant money, and most of it comes from sources like the NIH, DOD, or major foundations. The 3-, 5-, and 10-year plans for basic science researchers are outside the scope of this blog, but a simple Google search can provide more information.

Clinical Research:  This is probably the most familiar type of research.  Ask a clinical question, devise a retrospective or prospective study to answer the question. It seems fairly straightforward, yet can be challenging to do well. Most high-impact researchers today have advanced degrees in statistics, health services research, epidemiology, or other such disciplines. Or, they have research partners with PhDs in one or more of those areas. If there is a productive clinical research team at your institution, and you have the time and interest, it can be an invaluable experience to participate in one of these projects. It can afford you basic statistical and data manipulation skills, as well as let you know if sitting on your butt in front of a computer all day during your research time is the right career path for you. Many residency and fellowship programs are supporting residents to obtain Master’s degrees during their research years, while working on clinically relevant projects. Areas like public health, public policy, and outcomes research would also fit into this category. 

So, let’s say now you’re on this path.  What next?

Writing is deeply under-appreciated. Some people enjoy it, others hate it, some are wonderful wordsmiths, others are abysmal writers. You would think enjoyment or at least being prolific would correlate with skill, but you instinctively know that’s not the case if you've been forced to read Dickens ever in your life.  

Anyway, the key is to keep it simple and here is my formula:  
  1. Abstract = usually structured, usually <250-300 words
  2. Introduction = 1-3 pages that state the importance of the problem, overview of the current literature, GAPS in the current literature which inspired your research question, hypothesis
  3. Methods = 1-3 pages, your methods.  Really, I can’t help you with that
  4. Results = 1-4 pages that iterate your important findings.  Don’t hesitate to use graphs and tables, but try to keep it to a total of 5 or 6.  That’s the max that is usually acceptable for print
  5. Discussion = 1-3 pages summarizing the MOST important of your findings, then the limitations of the study (after the biggest limitations, state arguments right there why that limitation is irrelevant), then come back around to the importance of the work and future directions
  6. Cardinal rules:
    • Do not plagiarize
    • Authorship is intricately political and complicated, figure it out ASAP!! I have been irate at people for years (and people have been justifiably irate at me) for author order disputes. Don’t let it happen to you
I just realized I’ve used up two single-spaced pages, which is really excessive for blogdom. Ah, well, the topics of “finding an academic job,” “finding grant money,” and “shameless self-promotion” will have to be covered at another time.  In the meantime, keep researching and remember the fame-worthy words of my former Chair, Ron Maier, “Success is directly proportional to your ability to tolerate rejection.”

Marie Crandall, MD, MPH, FACS is an Associate Professor of Surgery and Preventive Medicine in the Division of Trauma and Critical Care at Northwestern University Feinberg School of Medicine. She is originally from Detroit, MI, a product of Head Start and local public schools. Dr. Crandall obtained a Bachelor’s Degree in Neurobiology from U.C. Berkeley in 1991, and completed her M.D. in 1996 at the Charles R. Drew/U.C.L.A program in Los Angeles. She finished her General Surgery residency at Rush University & Cook County Hospital in 2001, and in 2003, completed a Trauma & Surgical Critical Care Fellowship at Harborview Medical Center in Seattle, WA. During her fellowship, she obtained a Masters in Public Health from the University of Washington. Dr. Crandall performs emergency general and trauma surgery, staffs the SICU, and is an active health services researcher. Dr. Crandall loves travel, triathlons, hiking, and is a passionate animal rights activist; you can follow her on Twitter @vegansurgeon 

Monday, May 12, 2014

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.

Friday, May 9, 2014

The Power of a Stitch

Reflections from the Association of Women Surgeons' Booth @ the 3rd USA Science & Engineering Festival
By: Shannon F. Rosati, MD

As a surgical resident, I have spent countless hours arduously laboring on my craft – in my intern year, it was knot tying and holding perfectly still in the OR to maintain exact retraction; in my second year, it was central line placement and the art of the sub-cuticular skin closure; now in my third year, it is operating, fascial closure and having a team of junior residents looking to me to help them learn.

It was with these lessons in mind that I spent the weekend volunteering at the 3rd USA Science and Engineering Festival. Amongst hundreds of booths, led by teams from NASA, the NIH, the EPA and the National Science Foundation, to name a few, I went to represent the Association of Women Surgeons. Our booth was not flashy- there were no robots, no gravity defying experiments, no inflatable cadaver lungs. We sat with few simple tools: needle drivers, Adson pickups, scissors, foam boards, and suture.

As the first child approached, a young girl no older than seven, I looked around, nervous – what did I have to offer that could compare with the amazing experiments and innovations that surrounded me? There was a ROBOT one row over after all! The child asked, “ What does your booth do?” And so I answered her with a question of my own- “ do you want to learn how to place a stitch?” Immediately, her eyes lit up, eagerly nodding her head “yes”, after looking to her mother, who said, “This lady is a doctor. She can teach you.”

I demonstrated for her what I have come to take for granted over the past several years – load your needle, place it perpendicular to the skin, turn your wrist and drive it through to the other side of the incision. Next the tie (here we did instrument ties) – place the needle driver in between the two ends of the suture, loop one end around, and pull through. After loading the needle for her (not one child stuck themselves, respecting my instruction on the sharpness of the needles), and painstaking concentration, she was able to place one suture, with one knot.  “See?” I told her. “You’re ready to be a surgeon!” The look on her face and her excitement at having completed the task was echoed throughout the weekend – more and more children, all immediately engrossed in the placement of one single, interrupted stitch, all smiles and excitement when their task was accomplished.

Who knows if any of the several hundred children I encountered this past weekend will have a future in the medical field. What I do know is that this experience for me not only reaffirmed my desire to teach others, but also, and more importantly, reminded me of how much I can learn from the simplest of tasks. We owe it to our patients to remember that each and every stitch is important, that everything we do can make a difference and has an impact on those for whom we are charged with caring.

As I journeyed home from Washington, DC, more exhausted from my weekend of suturing with these children than from my last 80 hour workweek, the words of one of my “junior surgeons” resonated in my mind. This young boy, having finished his stitch, surveyed his slightly less than perfect knot quizzically, while his mother asked him “what would you tell your patient?” He stated simply: “I would say that I did my best.” And therein lies what I will continue to strive for, as a resident, a future fellow, and attending – to do my best, at each and every stitch, for each and every patient.

Shannon F. Rosati, MD is a General Surgery Resident at the Medical College of Virginia (Virginia Commonwealth University). 


Wednesday, May 7, 2014

The Changing Face of Medicine

by Minerva A. Romero Arenas
We cannot all succeed if half of us are held back.
– Malala Yousafzai

Elizabeth Blackwell, a teacher and immigrant to the U.S., turned to medicine after a friend confided on her deathbed that she would have been spared much suffering had her physician been a woman. She went on to become the first woman to earn the Medical Doctorate in the U.S. She was admitted as a prank by the all-male students on the faculty – who allowed the students to vote on Elizabeth’s admission never thinking they would allow a woman to become their peer. The face of medicine has changed significantly in the 160+ years since Dr. Blackwell graduated from Geneva Medical College (now Hobart and William Smith College/SUNY).

Women are pursuing medical careers in record-breaking numbers. Female applicants to medical schools went from less than 10% in 1965, to approximately 50% in 2005. In 2013, 48 schools had a female majority of the class.

The changes seen in medical schools, however, are not representative of the currently active physician workforce. Women make up less than one-third of all physicians, and only 15% of general surgeons, and 4-6% of neurosurgeons, urologists, and orthopedic surgeons. Data of gender representation in residency reflect similar trends. In 2011, nearly half of female residents were training in primary care (pediatrics, internal medicine, family medicine) and less than 10% in surgical specialties.

Why are women doctors more often choosing primary care than surgical fields?

About 5 years ago, I was talking on the phone with one of my lifelong mentors when she asked me, “Minerva, why not?” I was unable to come up with an answer. I was nervous about a realization I had just a few weeks before: I loved surgery. I had just spent 2 months working long hours with excellent residents and surgeons. They had a great work ethic, were cool in the face of chaos, showed compassion toward their patients, and had a passion for their work that I had not seen in any other field. What should have been an exciting moment actually terrified me. Did I have what it takes to be a surgeon? And would it be worth making the sacrifices it would take for possibly 5-10 years of training?

Just days away from starting what we call “audition rotations” in the fourth year, switching to surgery was also a scheduling nightmare. I personally called the clerkship directors to apologize for a late cancellation. Thankfully, they were graceful and encouraged me to “figure it out,” even offering to allow me back later in the year if I ultimately decided against surgery.

It was not surprising that they were perhaps a bit skeptical of this decision. Surgery had crossed my mind during college, but fell off my list at some point in my first two years of medical school. I had planned to pursue a residency in internal medicine and eventually subspecialize in a field like medical oncology or infectious disease. These fields were friendly to women, and most importantly, I thought would help me merge my love of medicine and public health. Many of the mentors and role models I met were primary care physicians.

When I announced my interest in surgery, nobody hesitated at trying to save me/tell me why it was so hard – after all, surgery programs have one of the highest percentages of residents quitting training. “You won’t have a personal life.” “Do you want to have children?” “What does surgery have to do with public health?” The issue of lifestyle differences for surgeons is serious. In a 2009 study (the year I graduated medical school), women surgeons were less likely to have children and more likely to have their first child later in life. Male surgeons were more likely have a spouse who was the child’s primary caretaker. Reassuringly, 82% of women in that study would choose their profession again.

If I had a nickel, for every time I heard “but I never met a woman surgeon” maybe I would have paid off my student loans by now.

As a member of two key underrepresented groups in medicine (woman and Latina/Hispanic), I have felt the need to share my story with students who may have similar doubts about pursuing careers in medicine and surgery. I am involved in mentoring & leadership through several organizations (National Hispanic Medical Association, Latino Medical Student Association, Alliance in Mentorship, Tour for Diversity in Medicine, and Association of Women Surgeons). Many of the premedical and medical students I meet at mentoring events are surprised to meet a 1) surgeon, 2) woman surgeon, or 3) Latina surgeon. I was too when I met them in medical school.

In fact, many of my patients are too. When making rounds at the hospital, I have frequently heard patients tell someone on the phone, “Let me call you back, the nurse just walked in the room.” I have the utmost respect for my colleagues in nursing and do not take offense to these innocent remarks – after all, since 9 out of 10 nurses are female it is more likely that a patient will encounter a woman who is a nurse than a woman who is a doctor.

As I continue my training to become a general surgeon, I have come up with a couple of answers that I was so worried about years ago. More than halfway through my training, I can confidently say, Yes, I do have what it takes to be a surgeon. And it IS worth all the sacrifices.

Please join me on Tuesday May 13, 2014 at 8:30pm Eastern (for your local time click here) as I guest moderate the weekly #hcldr tweetchat.
  • T1: How important/beneficial is diversity in health care (e.g., gender, age, ethnicity, background, etc.)?
  • T2: How can we encourage women and other underrepresented minorities to pursue careers in medicine/surgery, or any non-traditional field?
  • T3: What can we, as healthcare leaders, do to stop discriminatory comments or behaviors in healthcare, esp. to women doctors, minorities?
  • CT: What’s one thing you learned tonight that you can use to help a patient tomorrow?
This article was originally posted on the Healthcare Leadership Blog on May 7, 2014. 


Minerva A. Romero Arenas, MD, MPH is completing a research fellowship in the Dept. of Surgical Oncology at The University of Texas MD Anderson Cancer Center in Houston, TX. She is a General Surgery Resident at Sinai Hospital of Baltimore. 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.


National Library of Medicine. Dr. Elizabeth Blackwell Biography on “Changing the face of Medicine.” Accessed April 2014.

American Association of Medical Colleges. Women in Academic Medicine Statistics and Medical School Benchmarking, 2011-2012. 2012.

American Association of Medical Colleges. Table 1: U.S. Medical School Applications and Matriculants by School, State of Legal Residence, and Sex, 2013

American College of Surgeons Health Policy Research Institute. The Surgical Workforce in the United States: Profile and Recent Trends.

Troppmann KM, et al. Women surgeons in the new millennium. Arch Surg. 2009 Jul;144(7):635-42. doi: 10.1001/archsurg.2009.120.

Health Resources and Services Administration. The U.S. Nursing Workforce: Trends in Supply and Education. 2013.

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