The Art and Science of Touch

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

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

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

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

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

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

This is how she got into Haptics.

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

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

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

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

How do I get involved?

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

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

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

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

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

Changing the paradigm

by Robert Swendiman

Whether I am at Grand Rounds, a department meeting, or the American College of Surgeons Clinical Congress, it is often like looking into a mirror. I cannot help noticing the abundance of white men – especially at “the top.” While I meet numerous female and minority surgical residents and junior faculty, most of the chairs, program directors, and full professors are men.

Outside of the medical profession, surgery has an “old boys club” reputation. But I come from a school of leadership where difference and diversity are more than just opportunities for social progress – they are requirements. So I was disappointed when I perceived the stereotype affirmed. The more I look around, the more men I see.

Constant inquiry (or “quality assessment and quality improvement” in medical terminology) is an important component of leadership. Without it, we fail to analyze, understand, and improve the systems in which we are a part. Thus, I began my investigation, and what I found was shocking. Despite the increasing number of women entering general surgery residency programs – from 10% in 1980 to 36% in 2011 – as of last year, women only represent 9% of all full professors, 17% of associate professors, and 25% of assistant professors in surgery. 1, 2 While these numbers are obviously disproportionate, what is perhaps more concerning is that they also remain stagnate. In the last 15 years, these percentages have not changed. 3

Despite the fact that men and women enter academic medicine at equal rates, the rate promotion is uneven. 4-6 Though men and women start at similar ages, the mean age of attaining “Professor” status in approximately five years younger for men. 4 “Even after adjusting for number of publications, amount of grant support, tenure versus other career track, number of hours worked, and specialty, women [remain] substantially less likely than men to be promoted.” 4

Thus, female surgeons remain impressively underrepresented in the ranks of surgical faculty at 21% of the workforce (the average across all medical departments is 37%). 2 Of all academic departments in the basic and clinical sciences, surgery ranks second to last in percentage of total female faculty members (orthopedics, 15%). 2 However, in other specialties, women hold more than half of all faculty positions (obstetrics and gynecology, pediatrics, and public health and preventive medicine). 2

The famous surgeon, Dr. William Halsted, once quipped that the issue with surgeons taking call every other night was that residents would miss half of the cases. In the same manner, when we exclude 51% of the population from top leadership positions, we are missing out on half of the talent. If fewer than 10% of professors of surgery are women – and that figure has not changed in more than a decade – I wonder, “Is our academic community really moving surgery forward?”

Fellow colleague, Sophia McKinley, wrote about her own early lessons in leadership. She states, “Individuals at every position in a hierarchy can exhibit leadership.” I agree, and I see this lack of diversity as an urgent opportunity for real-time leadership at every level. As a white male, I think it is my job to participate in changing this paradigm – chipping away at the explicit and implicit barriers that male surgeons still espouse in surgery, advocating for and leveraging diversity, and staying curious about surgery’s present and future challenges. As an inspiring academic surgeon, this also meant research, which is why I joined a multi-institutional team from UNC, Harvard, and Stanford to better understand how we can change the status quo. I know it’s not enough, and change will not happen overnight, but doing nothing is not a viable option.

I was often asked on the interview trail, “Can an intern or a medical student really be a leader?”

This is the answer I give them.

~~~

References

1. Cochran A, Freischlag JA, Numann P. Women, surgery, and leadership: where we have been, where we are, where we are going. JAMA Surg 2013;148(4):312-3.

2. Association of American Medical Colleges. “Women in Academic Medicine and Science: Statistics and Benchmarking Report 2011-2012.” Table 3: Distribution of full-time faculty by department, rank, and gender, 2012. < https://members.aamc.org/eweb/upload/Women%20in%20U%20S%20%20Academic%20Medicine%20Statistics%20and%20Benchmarking%20Report%202011-20123.pdf>. Accessed November 6, 2013.

3. Sexton KW, Hocking KM, Wise E, et al. Women in academic surgery: the pipeline is busted. J Surg Educ 2012;69(1):84-90.

4. Zhuge Y, Kaufman J, Simeone DM et al. Is there still a glass ceiling for women in academic surgery? Ann Surg 2011;253:637–643.

5. Schroen AT, Brownstein MR, Sheldon GF. Women in academic general surgery. Acad Med 2004;79:310

6. Buckley LM, Sanders K, Shih M, et al. Obstacles to promotion? Values of women faculty about career success and recognition. Acad Med 2000;75:283-8.

~~~

Robert Swendiman is a dual-degree M.D./M.P.P student at UNC School of Medicine and the Harvard Kennedy School of Government. He spent his time at Harvard as a Dubin Fellow for Emerging Leaders at the Center for Public Leadership, researching how leadership principles can be applied to medical education. Robert is participating in the 2014 Match cycle, and is interested in pediatric surgery.