The Art and Science of Touch

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

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

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

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

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

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

This is how she got into Haptics.

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

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

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

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

How do I get involved?

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

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

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

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

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

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

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

Standardizing Resident Hand-offs to Improve Hand-off Quality

by Nicole Tapia, MD

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

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

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

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

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

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

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

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

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

~~~

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

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.

Resources

National Library of Medicine. Dr. Elizabeth Blackwell Biography on “Changing the face of Medicine.” Accessed April 2014. www.nlm.nih.gov/changingthefaceofmedicine/physicians/biography_35.html

American Association of Medical Colleges. Women in Academic Medicine Statistics and Medical School Benchmarking, 2011-2012. 2012. https://www.aamc.org/members/gwims/statistics/

American Association of Medical Colleges. Table 1: U.S. Medical School Applications and Matriculants by School, State of Legal Residence, and Sex, 2013 www.aamc.org/data/facts

American College of Surgeons Health Policy Research Institute. The Surgical Workforce in the United States: Profile and Recent Trends. http://www.acshpri.org/documents/ACSHPRI_Surgical_Workforce_in_US_apr2010.pdf

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. http://bhpr.hrsa.gov/healthworkforce/reports/nursingworkforce/nursingworkforcefullreport.pdf

Image Credit

https://www.nlm.nih.gov/hmd/about/exhibition/changingthefaceofmedicine.html

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.