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.

Dr. Shilpa S. Murthy MD MPH is currently a second year research fellow at the Center for Surgery and Public Health, Brigham and Women's Hospital in Boston Massachusetts. She recently completed an MPH at Harvard School of Public Health. She is also a general surgery resident at Indiana University. Dr. Murthy's interests are in surgical oncology, surgical care delivery and its intersection with health policy in order to improve access and quality surgical care to marginalized populations globally. She also has interests in medical education and simulation based training.   

Special thanks to Sarah M. Gray. 

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

Friday, September 12, 2014

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

By: SreyRam Kuy, MD, MHS


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


Dr. Patricia Numann

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Barbara Lee Bass

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Susan Moffatt-Bruce

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

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

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

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

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

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

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

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

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

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

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

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


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