AWS BLOG

Prioritizing Palliative Care in Surgical Management

By Connie Shao

During my third year rotation, I experienced the terror of an anastomotic leak. This patient had previously had a resection of his colon cancer and had undergone chemotherapy. Three weeks later, he was coming in with respiratory distress and was urgently taken to the operating room for an anastomotic leak. The surgery was done in two parts. The edematous bowel, of which some was resected, did not allow for a complete closure of his abdomen. Having never seen a Bogota bag before, I watched in amazement as we took him back to the ICU, sedated. The next day, the procedure was completed, his abdomen closed.

He remained in the surgical ICU for weeks, receiving treatment for complications that seemed to change every day. He remained on the service after I left my rotation, and months later, I saw that he had passed. Throughout his postoperative recovery, I had gotten to know him, his family, and how painful treatment could be. Our discussions with palliative care, his family, and himself helped me understand medicine beyond the naive understanding of a medical student, freshly emerged from board exam studying.

Oncologic care has been the subject of national discussion, as the cost of treatments become a financial burden to the survivor and/or their family. Treatment can be continued to the detriment of the quality of the patient’s few remaining days of life. Without sufficient conversation about goals of care, treatment options become oriented to flowchart algorithm for a much different patient with very different goals.

Palliative care focuses on management of symptoms and psychosocial support, providing patients with options to achieve their personal goals for their remaining days of life. In the 1950s, Dr. Cicely Saunders first articulated the concept that would eventually become modern hospice care. From careful observation of dying patients, she advocated that the ‘total pain’ of dying could be relieved by an interdisciplinary team in the context of the patient’s family (1). This concept of teamwork is very much alive today in palliative care, where teams consist of nurses, social workers, pharmacists, chaplains, physicians, and most importantly, the patient and their family.

Unfortunately, this can be mistakenly perceived as ‘giving up’ instead of an opportunity to have informed discussions between patients and providers. It has also been traditionally delivered late in the course of care when hospitalized patients have uncontrolled symptoms. In those cases, it is often too late for palliative care to alter the quality and delivery of care provided to patients.

Pancreatic and lung cancer are diseases that have a high burden of symptoms and poor quality of life. The prognosis for metastatic non-small-cell lung cancer is less than 1 year after diagnosis (2). Early introduction of palliative care has been found to improve both quality of life and mood, as well as leading to less aggressive care at the end of life with longer survival (3).

In a retrospective study done in 2016, McGreevy et al found that for the 205 adult, nontrauma patients who had gastrostomy tubes placed, there was an 8% in-hospital mortality rate and a 19% 1-year mortality rate. Of the patients who survived to discharge, 69% were not able to live independently. Of the patients who suffered acute brain injury or respiratory failure, 90% died in the hospital or were severely disabled at discharge. For the 205 patients who had gastrostomy tubes placed, only 12% of patients received a documented palliative care assessment preprocedure (4). Gastrostomy tubes are just one example of a ‘trigger’ that can be used for a palliative care assessment. Utilizing certain interventions that alter the patient’s quality of life as the impetus to have a discussion about goals of care can help patients have a better understanding of their condition and care to guide the course of interventions throughout their hospital stay.

Palliative care is challenging for patients and providers alike. Coming to terms with what the future has to offer, as predicted by studies and interpreted through experience, is an honest conversation that tests the patient’s and family’s self-knowledge, as well as the physician’s ability and knowledge to provide the best clinical support. In life and in death, suffering may be inevitable, but it is within our realm as physicians to lessen it to the best of our ability.

Connie Shao is a fourth year medical student at the University of Chicago Pritzker School of Medicine. She is originally from Michigan and enjoys swimming, reading, biking, and painting. She is applying to general surgery residency and has been meeting incredible applicants and inspirations along the way.


Our blog is a forum for our members to speak, and as such, statements made here represent the opinions of the author and are not necessarily the opinion of the Association of Women Surgeons.

Lessons About Healing After Hurricane Harvey

By Jackie Olive

I hail from the foothills of Los Angeles County, where natural disaster comes in the form of forest fires and droughts. Having lived in Houston for over four years for college and now medical school, I’ve learned that disaster here comes in practically the opposite form. Hurricane Harvey was the first significant tropical storm that I have experienced.

Initially, my colleagues and I hadn’t predicted the magnitude of the devastation that our city and neighboring Texas coastline would ultimately face. I remember we first became worried when we heard of friends who were leaving town and grocery stores that had completely empty shelves. We later became shocked when we couldn’t leave our homes because the water levels had dangerously risen and cars had been deserted in the middle of streets.

The immediate aftermath of the hurricane was devastating, as homes were destroyed, families relocated, and stress levels rose high. However, the road to recovery appeared bright, as the volunteer response was overwhelming, even to the point of being in excess at times. Temporary shelters at George R. Brown Convention Center and NRG Stadium actually had to send potential volunteers away. The positive energy and generous spirit of the Houston community were palpable, and it was absolutely vital to cultivate such camaraderie in these most trying of circumstances.

We may think that the biggest hurdle has been overcome. After all, months have passed since the hurricane wreaked immense physical damage on our city. Yet, I’ve learned to appreciate that healing is a dynamic and lengthy process. Sustainable recovery of this kind requires months, even years.

As members of a service-oriented profession like medicine, we anticipate the days when we can discharge our patients after witnessing their labs return to normal or wounds fade. And as surgeons and surgical trainees, we, in particular, feel encouraged when the procedure goes well and we are able to acknowledge the immediate fix and patient’s relief of symptoms. Subsequently, however, what happens after he or she is discharged? Where is home? How will he get there? Who will take care of her if there is a complication? I observe a parallel between post-operative care at some public hospitals and post-Harvey relief efforts: those with fewer resources, including various indigent groups, have a longer road to recovery. Houston’s diversity is one of its strengths, but we must also recognize that it comes with a heightened responsibility to maintain the health of this community.

We are continuing to rebuild homes on the ground in Houston, but I would like to offer the opportunity for others to help in a variety of ways. Most charities prefer monetary donations, as these are more flexible to accommodate changing needs. Please visit this site for specific references to organizations that are supporting the post-Harvey relief effort. I am personally also raising funds for the hurricane relief efforts as I train for the Houston Marathon in January 2018. Any form of support is dearly appreciated and will make a positive long-term impact on our community!

Ultimately, while donations of this kind are always welcomed and productive, it is also important to care for one another on a daily basis. It shouldn’t take a tragedy to build compassion and empower generous acts. I’m humbled by what’s already been done to rebuild our amazing city, and I hope that we may all stay engaged in the future stages of healing from Harvey and other natural disasters throughout the world.

A message from the AWS Blog Team: This is part of a series of blog posts from surgeons who wish to share their experience during these trying times. If you wish to share your story, you may email blog@womensurgeons.org.

 

Jackie K. Olive is a first-year medical student at Baylor College of Medicine. She graduated from Rice University in May 2017 with degrees in biological sciences and policy studies. Jackie is an aspiring surgeon and researches surgical outcomes and therapies in cardiac regeneration. She is also passionate about healthcare and public health advocacy initiatives.

Twitter: @JackieKOlive

Blog: jackiekolive.com


Our blog is a forum for our members to speak, and as such, statements made here represent the opinions of the author and are not necessarily the opinion of the Association of Women Surgeons.

Hand ties & Heartbreak: My Experiences as a Puerto Rican Surgical Residency Applicant during Hurricane Maria

By Mariela Martinez

News channels have been flooded with images of the devastation caused by hurricane María in Puerto Rico. There are numerous stories about the damages to the health system, infrastructure and economy of the Island. Yet, have you wondered what it was like for Puerto Ricans who experienced this devastating storm? I am a medical student from Puerto Rico and this is my story.

NASA Earth Observatory, Image by Joshua Stevens

Hurricane Maria made Landfall in Puerto Rico

It was 4:00am and I was wide awake for the fourth day in a row. My mind filled with despair as images of the beautiful island I call home  were replaced with destruction. I made another frantic attempt to call them one more time. No success. Calling my loved ones had become a stubborn attempt to restore some normalcy in my life and to re-establish a sense of balance, to pretend this disaster never happened.

I was completing surgical “away rotations” in mainland US when on September 20, 2017, my life changed completely. Hurricane Maria, a category V storm plowed through Puerto Rico causing massive destruction. The delicate power and communications systems in the Island could not withstand the harsh winds and collapsed. Puerto Rico became silent and dark during the aftermath, and I watched in horror from afar as images of the Island showed my home in a state of destruction. I saw buildings collapse and families lose their homes. Places that were all too familiar to me become unrecognizable. The green scenery that characterizes the Isla del Encanto was substituted by murky brown as trees were stripped of their leaves and mud replaced grass.

Power lines scattered across the streets of Humacao, PR on September 20th, 2017. Photo by Carlos Giusti/AP CNN

No communication

In the midst of all this destruction I could not communicate with my loves ones to know if they were safe. I kept calling frantically in an effort to somehow get a response from their phones. When I finally heard their voice in the answering machine,  I was transported back to a state of calm and completeness, and for a split second I forgot that it had been more than 4 days without knowing if they were safe.

While I am safe in the continental US, the destruction of my home breaks my heart while I watch all that I know be torn to the ground. I watch in horror as supplies begin to dwindle and basic needs such as water become scarce. In the midst of all this uncertainty, all I have from my loved ones is silence… no familiar voices, no reassurance. There is no worse feeling of helplessness than knowing that your loved ones are going through the worse moment in their lives and you can’t help. There is no greater sorrow than the uncertainty of not knowing what is needed by those you love in moments of disaster.

Damaged road in Toa Alta, west of San Juan after hurricane Maria. Image by Ricardo Arduengo/Getty Images

Shifting my focus

As I  undergo this painful process of uncertainty for the future of my home and those I love, I suddenly become more aware of others’ misfortunes. Suddenly the cystectomy patient in room 1425 becomes the mother of two who is struggling with depression. I begin to develop a greater sense of what is needed from me as student and I begin to focus my energy on helping patients recuperate. I follow their progress as if they were my own family members, I speak with them as if I was speaking to those I miss dearly back home. They open up their greatest fears and concerns as I also share my own. During the time I spent without being able to confirm the wellbeing of my loved ones I was able to witness hope being restored in the life of a cancer patient who underwent major surgery and the devotion of loved ones during her challenging moments. This terrible experience taught me that sorrow unites people and that we can make a positive impact in the lives of patients despite our own personal struggles.

I  learned that a good stress relief technique was practicing my hand ties. When I felt the sense of despair taking over me, surgeon hand ties helped my mind focus on a different activity and refocused my energy on the task at hand. I devoted my time and energy to learning as much as I could, to keep my mind occupied. I was having excellent days in the operating room and great interactions with my patients, yet at night I stayed up and cried.  My mind was ridden with guilt, with being too tired to answer those late night calls, for being “too busy” to call and hear my family’s voice when I had the chance. The pain of knowing that once I returned home, it wouldn’t be the same beautiful place that I was born and raised in was truly devastating.

My parent’s apartment in Rincon, PR after hurricane Maria. The deck and pool were torn down by the strong swell caused by the storm. The water levels rose and dug under the base of the apartment complex.

The Aftermath of Maria

When I finally heard from my loved ones their words were almost as painful as their silence. “We love you and we miss you, but don’t come back.” They went on to tell me how essentials like food and water had become scarce, how they had to spend the whole day in line for gas, how banks were limiting the amount of cash given per family, how overwhelming the darkness was at night and how difficult (if not impossible) it was to fly out of Puerto Rico after the hurricane. I heard that my best friend’s family lost their house after the hurricane, how supermarkets were empty, patients in the critical care unit were dying due to lack of electricity, and all these things seemed surreal to me. It almost felt like I left Puerto Rico in 2017 and was going to return to an island that was now in the 1900s.

Maria was called the fifth strongest storm to hit the United States and its landfall was described by Jeff Weber, a meteorologist from the National Center for Atmospheric Research, “as if a 50-to 60-mile- wide tornado raged across Puerto Rico, like a buzz saw”. If hurricane Maria was rough, the aftermath has been even more devastating. There were parts of Puerto Rico that saw 30 inches of rain in one day, the equivalent of the amount Houston received over three days during hurricane Harvey. A total of 48 people died during the storm and the death tolls continue to rise exponentially as power and water continue to dwindle.

Residents from Cayey, P.R. seeking water from a local spring. Photo by Carlos Garcia Rawlins, New York Times.

Three weeks after hurricane Maria hit the Island beverage shelves stand mostly empty. San Juan, Puerto Rico. Photo from Mario Tama/Getty Images. Source: ABC News

One month after hurricane Maria, more than one-third of Puerto Rico households (about one million people) still lack running water. This has caused communities to search for water at local streams and water wells exposing themselves to water-borne diseases such as Leptospirosis. At least seventy six cases of suspected Leptospirosis and two confirmed deaths have been reported by Dr. Carmen Deseda, state epidemiologist of Puerto Rico.

Meanwhile, hospitals are currently operating with back-up generators. Roughly three million Puerto Ricans still lack power because less than 20% of Puerto Rico’s power grid has been restored. Photos have surfaced of surgeons operating with cellphones as flashlights due to sudden malfunctions with the hospital generators.

Surgeons using cellphones as flashlights during surgery. The photo was taken by a surgery resident in Puerto Rico and was published at @agarciapadilla Twitter.

Communications continue to be challenging within and outside the Island as seventy five percent of cell phone antennas are still down. There are people still living in their houses without a roof fearing that they won’t receive the help they need if they abandon their homes. Physicians have had to discharge patients knowing that they will probably live on the street because they lost all of their belongings. As I learned more and more about the devastation and the aftermath of Maria, my desire to serve has become stronger and deeper.

The Road Ahead

After undergoing some of the worst moments in my life I am convinced that this has made me a stronger person and better surgical residency candidate. Now I know I have the resilience and the dedication to overcome any challenges thrown at me during my surgical training.

People walk in flooded waters next to damaged houses in Cataño, PR after hurricane Maria. Photo by Hector Retamal/Getty Images. WSJ

We have a long road to recovery but this experience has allowed us to remember we have the strength needed to overcome the challenges we are facing as a country. Our hearts are torn for the loss, the devastation, the catastrophe that is going on in our island. We encourage you to help us rebuild our country by supporting local organizations in Puerto Rico and by joining relief groups.

We will never forget that fateful week of September 20, 2017 and it will inevitably change the history of our island forever but I am optimistic that together we can restore the health of the Island. As a medical student trained in Puerto Rico during this critical time in our history, it will likely take time to emotionally recover from this experience, but I am confident that it has helped me become more sensitive, empathic, and more dedicated to my future patients. After all, like my brother said the first time I spoke with him after the hurricane, “después de la tormenta sale el sol (the sun will always come out after the storm).” For now, I keep my head up high and continue carrying my suitcase from one airport to another as I travel for interviews hoping for the light at the end of the tunnel, not only for me but for all of those back home who are suffering.

Puerto Rican woman with what is left of her home on September 27, 2017 in Corozal, PR. By Joe Raedle/Getty Images (Vox.com)

A message from the AWS Blog Team: This is part of a series of blog posts from surgeons who wish to share their experience during these trying times. If you wish to share your story, you may email blog@womensurgeons.org.

 

Mariela R. Martinez Rivera is fourth year medical student at Ponce Health Sciences University (PHSU) in the city of Ponce, located in southern Puerto Rico. During her medical training, Mariela has become a recipient of the American Medical Association (AMA) Minority Scholar Award and has been inducted as Junior Member of the Alpha Omega Alpha and Gold Humanism Honor Society for her commitment to serve communities in Puerto Rico. She studied Biology at University of Puerto Rico Mayaguez where she conducted research in Genetics and Admixture of the Puerto Rican population. Mariela then completed a Masters Degree in Human Genetics at the University of California-Los Angeles where she received the prestigious Eugene Cota Robles Fellowship and the NSF Graduate Research Fellowship.

Her interests include urology, oncology, surgery, health disparities, health advocacy, non-profit leadership, genetics and molecular biology. A native from Puerto Rico, Mariela has spearheaded diverse initiatives to increase leadership and advocacy among Latinos throughout her involvement in the Latino Medical Student Association. She is also passionate about increasing the representation of women in medicine and in surgical fields.

She enjoys painting, photography, and singing. Mariela also loves going to the beach and spending time with her family.


Our blog is a forum for our members to speak, and as such, statements made here represent the opinions of the author, and are not necessarily the opinion of the Association of Women Surgeons.

So you want to be a Surgeon in the United States? 6 Tips to Succeed as an International Medical Graduate (IMG)

By Sristi Sharma

Congratulations! Your ambition of becoming a surgeon in the United States has finally brought you to this country. You have left your family, your life and everything behind to train in an environment that is completely new to you. You know that you have a steep learning curve ahead of you-be it clinical, personal or social. So how do you navigate this new phase of your career?

There are unique challenges that come with being an IMG in the States. Here are 6 tips that will help you become the best surgical trainee you can be:

  1. Be good…no excellent…at what you do! Know your subject inside out and practice your surgical skills . Challenge yourself to learn more everyday. There is no substitute for hard work, and as a foreign medical graduate you will have to work even harder to prove yourself everyday.
  2. Learn the system: Do everything you can to understand the system you are trying to enter. Surgery is a very fast paced specialty and it is unforgiving to those who are slow to catch up. The goal for foreign medical students intending to start their residency should be to be at the same level as a US 4th year medical students. You are not necessarily behind on the clinical knowledge, however the medical students here know how the system works-right from electronic medical systems to how patient care works. To get upto speed familiarize yourself with the lingo. Observe how everyone behaves in their work environment. It does not matter what country you come from, things are different in the United States. As a trainee, you need to be able to hit the road running when you start. Your preparation will go a long way.
  3. Find a mentor: A common piece of advice you will get right from the beginning is to “find a mentor who can guide you”. I cannot stress this enough. Your life will become much easier if you find someone who has been in the same place as you recently. It may be a student from your country who has successfully matched into a residency program or an attending who now has a successful setup. This person may not necessarily be the mentor you are looking for, but they will be your first step to finding one. Ask questions, ask for help. Many people want to help and will even go out of their way if you just ask them. This is especially helpful as you start talking to your potential mentors. The surgeons you meet are busy people who wear multiple hats in their careers and personal lives. They are open to mentoring you as long as you prove that you are in this for the long haul. You are also not limited to one person. You should work with several mentors to achieve your goals. Your motivation will show through in your actions.
  4. Value your uniqueness: One of the worst pieces of advice I received when I first landed in this country was, “make sure you do not tell people what you went through in India. The clinical community will not appreciate it and will think you are not adequately-trained and incompetent”. For the next 3 months I wallowed in doubt and self-hatred. It showed in my interactions with people. I came across as an under-confident individual who was unsure of herself. Very quickly I realized that my approach was wrong. My experiences were unique, and for the most part doctors and surgeons were curious to hear about how I practiced medicine back home. At institutes such as Hopkins and Harvard, I have been working with and learning from the surgeons who share my goal of making the surgical systems better in my country. At every step they want to learn about my experiences to effectively understand the changes that are needed. This experience has taught me it is very important to find a mentor who will appreciate your unique experiences and will encourage you to learn new things while being yourself.
  5. Speak up and take a risk. While working towards my MPH at Hopkins, I was looking for a job. I had heard that one of my professors was looking for a student to help out with his project. But his requirements for the job were very specific. I didn’t have the technical skills that were needed for the job but I had enrolled in classes to learn them at the very moment the job was being advertised. The fear of not getting the position was crippling and I hesitated even to approach the professor. When one of my friends heard about my dilemma she gave me advice that has completely changed my life. She said to me, “You may not get the job if you ask him, but if you do not ask you will definitely not get the job”. Since then, I have made this my mantra. There have been many moments when I have been turned away, but there have been many more when people have gone out of their way to help me out. All that stood between me and them was my willingness to ask for help. It is by speaking up I have found the best of my mentors. Oh and for those of you still wondering-I did get the job!
  6. Don’t fake it. Insincere stories, praises, gifts and fake accents? Just…no!

Being a foreign medical graduate in the US is tough. Being a foreign medical graduate AND a surgeon in the US is even tougher. So, if you want to be a good resident and a successful surgeon, work hard, reach out for help, be genuine and embrace your uniqueness.


Sristi Sharma MD, MPH is a General Surgery Resident at University of Colorado, Denver. She is a previous Paul Farmer Global Surgery Research Associate, Harvard Medical School, a graduate of Johns Hopkins University and a proud alum of Sikkim Manipal University, India. She is an passionate about advocating for global surgery. She was born in the Himalayas and is a Gorkha to the core.

Twitter: @drsristisharma

Our blog is a forum for our members to speak, and as such, statements made here represent the opinions of the author and are not necessarily the opinion of the Association of Women Surgeons.

 

For When the Pipe Bursts

By Shree Agrawal

Approximately half of matriculated medical students identify as female with numbers in surgical training steadily increasing to potentially also account for half of postgraduate trainees. Unfortunately, these figures are still dismal for underrepresented minorities, who at the medical school level may, at best, represent one in twelve students. I can only hope this changes for my underrepresented peers in my lifetime as we continue to redefine the culture of medicine.

Within AWS and in medical training, the metaphor of “building a pipeline” represents creating greater access and entry to medicine among women and underrepresented minorities. In this context, I often wonder about the students and trainees who currently have the courage to enter fields in which the majority is homogenous. Advances in gender equality and diversity representation within other fields of medicine, such as pediatrics, OB/GYN, psychiatry, and geriatrics, has not yet translated to inclusion in leadership and academic positions. I believe mentorship is key to addressing this paucity of diverse role models.

This brings me to some of the great posts I have recently seen on Twitter about mentorship within academic surgery. My feed has been populated with retweeted clips, links, or visual abstracts from Dr. Caprice Greenberg’s address, “Sticky Floors and Glass Ceilings”, Dr. Keith Lillemoe’s address, “Surgical Mentorship: A Great Tradition, But Can We Do Better for the Next Generation?”, and “Characteristics of Effective Mentorship for Academic Surgeons: A Grounded Theory Model,” by Drs. Amalia Cochran, William B. Elder, and Leigh A. Neumayer. In 2017, I view these pieces to be the first sign of preparation for when the pipeline to surgery eventually bursts.

As more diverse medical students develop interest in surgery, dynamic and supportive mentorship becomes even more essential. From Drs. Cochran, Elder, and Neumayer’s work, four major themes for effective mentorship emerged: the need for multiple mentors at different points in a professional lifetime, mentors who provide strategic advising, who are unselfish in their attitude, and engage with diverse mentees. In addition to these basic principles, self-awareness of implicit bias and efforts to reduce its effect, as stated in Dr. Greenberg’s talk, is paramount in effective mentoring, especially of non-traditional mentees.

In medical school, this may translate to finding a mentor who is willing to meet often and create plans for successfully matching or perhaps engaging in academic research. An unselfish attitude may be a sincere interest in helping achieve one’s potential, regardless of institutional interests or personal/professional gains for the mentor. Finding mentors who engage with diverse mentees does not mean identifying faculty members who represent similar backgrounds, but finding someone who understands distinct challenges faced by students from wide-ranging backgrounds. A single mentor may not be able to espouse all of these characteristics, but finding individuals who can contribute in each area facilitates personal and professional development.

What are your strategies for identifying and establishing effective mentee-mentor relationships in your medical training?


Shree is a fourth year medical student at Case Western Reserve University, where she also completed her bachelors of science degree in biology. Currently, she is completing a clinical research fellowship in genitourinary reconstruction at the Glickman Urological and Kidney Institute at Cleveland Clinic and serving as the Chair of the AWS National Medical Student Committee. Shree is passionate about research surrounding patient decision-making and medical education. In her free time, she enjoys blogging for AWS, practicing yoga, and boxing.

Our blog is a forum for our members to speak, and as such, statements made here represent the opinions of the author and are not necessarily the opinion of the Association of Women Surgeons.

AWS Day of Service 9/9/17

By Simin G. Roward

Being a medical student is challenging: between studying, rotations and research, it seems there isn’t enough time for everything. Often, it’s easy to lose track of why we chose this profession in the first place. Community service and engagement are put on hold amidst other pressing responsibilities. The goal of the AWS National Day of Service is to designate a day on which medical students from all over the country would come together with residents and attendings and make service to others a priority.

The members of AWS are compassionate, humanistic leaders, who chose the field of surgery because of the ability to make lasting improvements in people’s health and to provide a vital service to communities. These positive characteristics were exemplified in last year’s AWS National Day of Service event, where students nationwide provided much needed services and donations to their community. These service events differed from state to state- some schools put on educational sessions with high school and middle school girls to talk about medical school or to provide mentorship to students from disadvantaged backgrounds. Other schools organized clothing drives to provide supplies for shelters helping domestic abuse survivors or immigrant .

Each service event was specific to the needs of the community: in Washington, students raised funds for a local non-profit organization after it had been broken into and vandalized. In Arizona funds were raised to provide pre-employment TB testing to refugee women. In Texas, cookies were baked with the residents of the Ronald McDonald house, and students in North Carolina helped girl scouts earn badges by teaching them First Aid. Students in DC spent the day packing meals at a local food shelter and Boston students volunteered at a clinic for the homeless.

The participating schools should be proud of the events they organized and the important contributions they have made to their communities. The spirit of volunteering and community service are well aligned with the mission of the Association of Women Surgeons. As the AWS day of service will become an annual event, each year will build on the strengths of the previous year. This year’s AWS National Day of Service is September 9th, 2017, please contact us for additional resources or questions about participating!

Pictures:

 

 

 

 

 

 

 

 

USUHS put together bags of food donations at Food for ALL

 

 

 

 

 

 

 

University of Texas Medical Branch  hosted a Valentines cookie baking event at Ronald McDonald house

 

 

 

 

 

 

 

Paul L Foster School of Medicine (Texas Tech-El Paso)-organized a clothing drive for Anunciation house, a migrant shelter

 

 

 

 

 

 

 

 

 

University of Arizona- Fundraising for pre-employment TB testing for Syrian refugees

 

 

 

 

 

 

 

Boston Chapter-Hosted a game night with patients from their clinic


Simin G. Roward is a recent graduate of University of Arizona college of medicine.  She is currently a general surgery intern at University of Texas at San Antonio and she is planning to pursue a career in pediatric surgery.  She served as the community service chair for the Association of Women Surgeons during the 2016 school year and began the AWS day of service event. Her interests include global health, running marathons, traveling and participating in community service.   

Our blog is a forum for our members to speak, and as such, statements made here represent the opinions of the author and are not necessarily the opinion of the Association of Women Surgeons.

My First Delivery Was My Own: A Medical Student’s Journey into Motherhood

By Grace K DeHoff, MS III

I had my first child in November of my 2nd year of medical school. My husband and I tried to plan for a winter break baby but were surprised a little earlier. With plenty of open communication with my school, an unbelievable support system in my husband and my classmates, and more multitasking than I ever knew was possible, I had my child and was able to return to school full time after two weeks off. I was able to make up the missed work over Christmas break. The experience taught me a lot about why so few women decide to have children during medical school. Unfortunately, the alternative to waiting until after residency leaves many women delaying pregnancy to their their late 30s to 40s. Complication rates, infertility and genetic disorders all increase with increasing maternal age. This leaves female physicians with a difficult decision in terms of attempting to balance a career as a physician and the desire to have a family. This piece is meant to highlight this struggle and my own journey with my decision to have a baby in the thick of medical school.

Challenges women in medicine face with family life
My mentor, a male neurosurgeon, once told me I needed to have my children while in medical school. When I asked him why I needed to have kids in medical school he explained that as a woman I would face a challenge that none of my male colleagues would face, especially in the field of neurosurgery. I would most likely be in the minority as a female in the program. In addition, if I had a child during residency, when I left for the labor and recovery, my colleagues would be faced with picking up my workload and shifts, resulting in probable resentment from them. They would be working while I was home with my baby. They would be getting more hours in the OR, seeing more cases, honing their skills as surgeons, and adding to their resumes by further expanding their experiences. Meanwhile, I would be at home, knowing that I was falling behind in my program, which would drive me to return to work to get back on track sooner than when most new mothers usually return to work. He posited I’d then face continuous guilt over leaving my child and missing out on the joys of being a mother. The thought of motherhood in medical school still terrified me, how would I have the time?!

Though he drew a very simplified scenario with many assumptions, I took it to heart and did constantly wonder about how I would manage to have both a family and a career I loved. Even if I do not end up in neurosurgery, I knew any residency, particularly a surgical one would pose a significant challenge on creating a family. Regardless of the residency, there is only a finite amount of time any resident can take off in a calendar year before they are considered to have missed too much to graduate on time and are required to repeat a year or complete a research year. In the best scenario, it is quite possible for a woman to have a baby and get back to work in only a matter of days or weeks. From our experiences in medicine, unfortunately we know that best case scenarios don’t always happen. For those women who do not have the optimal pregnancies, deliveries and recoveries, they face the very real possibility of sacrificing their medical education and accepting that they have fallen behind and must take time off to graduate later than expected. This can have longer term consequences affecting finances, future job offers and marital stress.

Medical school policies for time off
Most medical schools have no official maternity leave policy in place, owing to the changing curriculum throughout medical schools. In the vast majority of US osteopathic and allopathic schools, the first two years are didactic years requiring lecture attendance and regular exams. It is challenging to have a child during this time because of the rigorous schedule and lack of time available to make up missed work. Some schools will allow a certain amount of time off–usually no more than 2 weeks before requiring an official Leave of Absence. Others require students to either take a full year off or to complete a research project during their postpartum period without an option for attempting to keep up with the required schoolwork. My school, Pacific Northwest University of Health Sciences, was more lenient in their policy. The time off that I took for my postpartum period was excused as an “illness” would be and the coursework was understood to be made up at the end of the academic year before I would be eligible to take my board exams.

The clinical years in the last half of medical school are out of the classroom and occur on the wards with variable schedules and hours. Again, each school is different in how they handle requests for time off during this period. Some schools have established electives appropriate for time needed both pre and post partum. Certain medical schools schools permit a breastfeeding elective to support a pregnancy. My school allows up to 6 weeks of a newborn elective (available to both mothers and fathers) as long as the student’s child is less than 1-year-old. In the absence of any of these options, many students will save vacation time, taken as a maternity leave; others will pack their schedules with light rotations, like research rotations to allow flexibility and less clinical responsibilities and to create more time during the newborn period. In general, there seems to be more flexibility for having a child in the last two years of school when compared to the first two.

Breast feeding time commitments
The American Academy of Pediatrics recommends all infants be breastfed exclusively for the first 6 months of life. For new mothers attempting to breastfeed, this introduces a major time challenge, especially upon returning to work in any field. On average, an infant eats every 2-3 hours around the clock or roughly eight times in a 24-hour period. The amount of time the baby spends actually at the breast varies greatly, but averages to about 20-30 minutes. In addition to the physical time it takes to nurse or pump, a mother in medical training must also factor in her study schedule around her nursing schedule.

I found myself pushing past natural study breaks in my study schedule to wait until I nursed, using the time to nurse as a study break. On long days on the medical school campus, I would take a headset intended for those hard of hearing to use during lecture so that I could continue to listen to the lecture while I pumped in a separate room. This allowed me to still hear the information, but it was impossible to take notes or do any active learning while I pumped since it’s actually a pretty hands-on task. I would often have to be very careful about my exam schedule and change my pumping times to ensure I would not have to leave an exam to pump because that would result in time lost from the exam. Additional factors such as the baggage needed to pump, logistics of storing cold milk and the stress of making sure I produced enough milk every day to send with my son to daycare the next day, were some of the biggest challenges of being a mom in medicine. I know plenty of women who chose not to nurse for long or even at all due to these difficulties. Even so, their time commitment was no less than mine, but without the obstacles to pumping during the day. I think any time saved from the decision to formula feed comes specifically from the pumping time commitment.

Male colleague responses
I was on my first rotation as a third year medical student when I found myself with a male resident who had four children, his last child was born within only a few months of beginning his first year of medical school. He went on to tell me that he “completely” understood how difficult it was to have a baby in medical school. When I hesitantly pointed out the difference between becoming a father in medical school versus a mother in medical school, he scoffed and said that he had taken his fair share of the midnight feedings, enough to understand the difficulties of being a new mother. His response hurt me more than I cared to admit and though I know his attitude is not representative of all fathers, the comment left me feeling resentful and intolerant of my male colleagues. In reflecting on this topic, it is difficult to tell any father that he doesn’t understand what it’s like to be a parent, and to a point, it’s impossible. Fathers are invaluable pieces of the family dynamic and I would never have been successful without my son’s father in our lives. Men often want to be valued for their contribution in parenting, which they justly deserve. Women want the same thing. We want support and recognition for the role that we play in carrying, birthing, and nursing a child. Mothers in medicine keep the same schedules as fathers in medicine, the same workload and the same standards, but the gestational and postpartum part of our parenting journey cannot be ignored or brushed off.

“Statistics” When women have a baby in medicine
In an unofficial Facebook survey taken in a private group of physician moms totaling over 61,000 members, over 2000* women responded to the question “when did you have your first child?”. Of those respondents, only 15% of them had their first child in medical school. 25% of women waited until residency and 25% waited until they were in an attending position. The remaining 35% had their child outside of these time frames. These statistics reflect that women chose to have children all throughout their medical education and career and no one time seems to be better than another. The challenge can significantly affect family planning and many female physicians and students feel that waiting sometimes up to 10+ years after beginning medical school to actually start a family is their best option.

Policy Change
As a whole, medical schools in the US do tend to support women who decide to start a family while in school. There are a variety of options available to help students complete their studies on time and most schools are willing to be flexible so long as there is open communication along the way. The women who choose to take on motherhood and medical school are often some of the most driven and hardest working students, but even so, a little help can go a long way. Schools can encourage and support mothers by providing lactation rooms, providing child support resources and being a child friendly campus. Many schools allow children to be on campus but do not allow them within the lecture halls during class time. Some schools allow the option of following along with lectures remotely, which can be invaluable with a newborn. There are even schools that provide childcare on campus for parents!

As a new mother who is not able to be a stay at home mom, childcare is probably the most important planning point in terms of successfully returning to school after having a baby. Planning early for daycares and inquiring about waitlists as well as the minimum age that the baby must be before they can start is an essential part of your family planning. In medical school the financial burdens often make hiring a nanny or in home child care too expensive but enroll family and friends to help out in the early stages. If you plan on nursing, make inquires early about nursing accommodations at your school. Be sure to see how far away nursing rooms are from classrooms to be factored into your pumping schedule. The combination of a newborn and medical school will definitely cut into dedicated study time so the most honest reflection you must make before embarking on this joint path is whether you are in good academic standing and not struggling to be in good standing. If you are a borderline student, having a baby can easily tip you below the passing line. At the end of the day, every second as both a student and a mother is worth it in my humble opinion.

*Statistics:
Total number of respondents: 2037
** This survey specifically asked only about when women had their first child to attempt to determine when women felt prepared enough to start a family.

 

 

 

 

 


Grace DeHoff is a third year osteopathic medical student at Pacific Northwest University and is interested in pursuing a career in Neurosurgery. She is a Denver, CO native but currently lives in Boise, ID with her husband and one-year-old son. She is the Diversity Chair with the National Medical Student Committee for the Association of Women Surgeons. In her free time, she enjoys running and has completed several half marathons and relay races.

Our blog is a forum for our members to speak, and as such, statements made here represent the opinions of the author and are not necessarily the opinion of the Association of Women Surgeons.

How Medical School Turned Me into a Runner

By Hilary McCrary, MPH

Prior to medical school, I considered myself athletic but never a runner. I could not run more than a few miles without an overwhelming sense of discouragement. When I began medical school in 2013, I found myself surrounded by individuals that had been running most of their lives. It was inspiring that people were able to juggle the demands of school and still properly train for a half or full marathon. Before long, I had set my first goal of running a half marathon. This race took place during my second year of medical school, which for me was the most academically challenging year with USMLE Step 1 looming in the distance.

I was lucky to have a group of classmates that became my running buddies. We called ourselves the “wolf pack”, meeting after studying to run on the local river path. I found that training runs were always easier to complete with a group of friends. It is this companionship that keeps you going when you have a double-digit training run to accomplish. After several weeks of training, I ran the A-Mountain Half Marathon in Tucson, Arizona. This scenic trek around Tucson also takes you up a small mountain at about mile 6, which at the time was less than enjoyable, but once up the mountain you gain great panoramic views of the city. After completing the race, I distinctly remember thinking to myself, “Well, that was horrible. Maybe running isn’t for me”. Hours later, I was texting my running group to plan our next half marathon. That is the thing about running – no matter how difficult a race is, it always has a way of bringing you back in to go for another.

Over the next two years of medical school, I completed six half marathons in various locations across the United States. Some of my friends and I even traveled to San Francisco for the Nike Women’s Half Marathon, which awards each finisher with a Tiffany’s necklace – a prize I still cherish today (Image 1). At first, my goal was to get through each race, yet I found myself gaining a certain level of competitiveness with myself. This led to me signing up for my first full marathon – the Nashville Rock n’ Roll Marathon. Not only is this hilly race known for the great live music along the course, it was also conveniently at the very end of my fourth year of medical school. With up to three months off during the end of fourth year, I knew I would have the time and dedication needed to properly train for running 26.2 miles.

Among all things, having a realistic training schedule might be the most important. I used a Hal Higdon (http://halhigdon.com) novice running schedule, which I found to set weekly goals that I could accomplish. I also learned that it is okay if you miss a run; after all it’s a marathon not a sprint. It is the work you put in over the course of several months that matters, not days. One thing I did prioritize was my weekly long runs. I strategically placed those runs on days I had off, knowing it would take several hours out of my day.

 Image 1: The Nike Women’s Half Marathon in San Francisco with four medical school friends.

I also relied on my wolf pack during these long runs; an 18-mile training run didn’t seem possible without the support of friends. Each long run was harder than the last, but you learn how to emotionally outrun the joint pain and mental exhaustion you experience, knowing that it is making you just that much better in the end.

Soon after the flurry of Match Day and a post-match vacation, April 29th was here. I traveled to Nashville alongside some of my closest friends from medical school. Arriving at race day was invigorating and terrifying. The forecast for the run was 90 degrees with 70% humidity, which are conditions that even for someone from Arizona found brutal to run in. The first half of the race was about as expected. Running several half marathons gets you conditioned to become comfortable with this distance and type of race. It is the last 13.1 miles that I experienced a whirlwind of emotions. I went through feeling like I can finish the race to thinking I had made a massive mistake signing up for this. This is where running really becomes a mental game, which I found similar to some of the mental struggles I faced during medical school. What really got me through the race was walking when I needed to. Finishing a marathon doesn’t mean you need to run the entire race – in fact regular walking breaks can bring you to the finish line at nearly the same time as if you had run the entire race, typically with fewer injuries and pain. The feeling of crossing the finish line is a feeling you will never forget, because at that moment you are officially a marathoner (Image 2).


While I initially would have never imagined myself finishing a marathon, I learned a lot about myself through this process. First, I can accomplish much more than I thought I could. Having a goal is the first step. Second, having an outlet from a busy, stressful life in medicine is healthy and necessary. Even though running takes a great deal of time out of my week to train, the rewards to my physical and mental health are well worth it in the end. Last, it is ok to not be so hard on myself. Taking a week break from running if I need to, walking if I need to – we all have different paths to get to the same place.

Image 2: After finishing my first marathon in Nashville!


Hilary McCrary is the Chair of the AWS Medical Student Committee and is a fourth year medical student at the University of Arizona College of Medicine – Tucson. She will begin her Otolaryngology – Head and Neck Surgery training at the University of Utah this summer. She hopes to practice in an academic setting where she can operate, teach, and conduct research. hcrees@email.arizona.edu

Our blog is a forum for our members to speak, and as such, statements made here represent the opinions of the author and are not necessarily the opinion of the Association of Women Surgeons.

The History of the Match and the Perspective From One Medical Student’s Journey

By Hilary McCrary, MPH

Throughout all of medical school, I always looked up to the current fourth year students. They seemed so seasoned and prepared to make the transition from student to doctor. The fourth year of medical school is also highly anticipated, as it is what medical students perceive as the first time they are solely focusing on their chosen career and traveling across the country for either away rotations or interviews. Now that I am towards the end of this process, I have had time to reflect on all of the components that go into the Match and what is takes to get there.

The Match process was created in 1952 as a way to address concerns related to institutions offering a spot for residency training earlier than other competing institutions.1 This previous design put pressure on applicants to accept multiple appointments, as positions were typically offered over the phone with the intent of providing the institution an immediate answer or losing that training spot.1 This process was followed by attempts to make a uniform time for institutions to release intern positions. Ultimately, F.J. Mullin from the University of Chicago School of Medicine suggested that both students and institutions create rank-order lists that would end in a match between that individual and a hospital.2 There were growing pains associated with this transition, but the Boston Pool algorithm created a stable process in which the rank-order lists were updated as each student went through the matching process. This program became known as the National Resident Matching Program (NRMP) and is the program that is still used today.3 The most recent change to this matching algorithm came in 1998, which was aimed at making the outcomes as favorable as possible for the applicant.4 In fact, in 2012 economists Alvin Roth and Lloyd Shapley would go on to win the Nobel Prize in Economics for their contributions to creating a stable match process through their work on match theory.5 While some controversy surrounded the inception of the Match, it does provide applicants and hospitals a sensible system to determine where new physicians will spend several years of training. As attested by several students, even though not all individuals may get their top pick on Match Day, the system has a way of finding the program best suited  for each individual.

While every specialty has its own unique aspects to the Match, there is one piece of advice that I always listened to – apply broadly. As a student applying to Otolaryngology, I knew that I needed to apply to a large number of diverse programs. This serves two purposes. It allows the student to see enough programs to know what aspects of a training program will most suit their needs and it sets you up for success statistically, as the more programs you apply to the higher your odds are of matching. I applied to 70 programs across the nation, which seemed daunting at first. The process of receiving interviews was exciting and stressful. In the fall months, students receive a flurry of interviews via email, and typically must respond within minutes or that interview spot may be taken. As someone who was on a surgical rotation during this time, I found it hard to be in the operating room without worrying about what emails were popping up on my phone.

Then comes the fun part – the traveling. As someone who loves flying and exploring new places, I was most excited for this aspect of applying to residency. In total, I attended 17 interviews, in 13 different states, over the course of three months. What no one prepared me for was how exhausting this process is. There were periods of time where I had four interviews in just five days, often associated with several flight delays and arriving at my destination city in the early hours of the morning. Furthermore, this process was financially difficult as well, as this entire process cost thousands of dollars. While in the thick of the interview trail I felt challenged, however, looking back it was an incredible experience that I felt lucky to partake in. Especially since I was given the opportunity to meet my future colleagues that I will collaborate with in the future, whether this is clinically or on research endeavors.

Now I join thousands of other medical students and wait to see where this process leads me on Match Day – March 17, 2017, which happens to land on St. Patrick’s Day this year. After a lot of thought and reflection, my rank-order list is certified and waiting for processing. What I have learned is there is no right way to navigate the Match and at the end of the day it’s best to go with your gut. Really listen to what your intuition is telling you on an interview day and make sure to ask questions that are important to you. Take risks, as programs you never thought would be what you are looking for or be within your reach might be the perfect fit for you. Finally, seek advice from your mentors who understand your career goals; their insight can be invaluable in helping create your rank-order list. Best of luck to all medical students and future surgeons participating in the Match this year!

 

References:

1)    Roth AE. The Origins, History, and Design of the Resident Match. JAMA. 2003;289(7):909-912.

2)    Mullin FJ. A proposal for supplementing the Cooperative Plan for appointment of interns.  J Assoc Am Med Coll.1950;25:437-442.

3)    Roth AE. The evolution of the labor market for medical interns and residents: a case study in game theory.  J Political Economy.1984;92:991-1016.

4)    Roth AE, Peranson E. The redesign of the matching market for American physicians: some engineering aspects of economic design.  Am Econ Rev.1999;89:748-780.

5)    Rampell C. “2 From U.S. Win Nobel in Economics”. The New York Times. Published October 15, 2012. Accessed on February 11, 2017.

 


 

Hilary McCrary is the Chair of the AWS Medical Student Committee and is a fourth year medical student at the University of Arizona College of Medicine – Tucson. She is currently applying to otolaryngology and hopes to practice in an academic setting where she can operate, teach, and conduct research. hcrees@email.arizona.edu

 

Our blog is a forum for our members to speak, and as such, statements made here represent the opinions of the author and are not necessarily the opinion of the Association of Women Surgeons.

The Greenberg Spike: How speaking out on implicit bias and gender equity in surgery continues to trend

By Marissa A. Boeck

When #ILookLikeASurgeon went viral in August 2015, many expected a short lived hashtag. Yet Dr. Caprice Greenberg, the president of the Association for Academic Surgery (AAS), has shown the conversation on diversity, inclusion, and equity in surgery is far from over. During the recent AAS and Society of University Surgeons (SUS) 12th annual conference in Las Vegas, Nevada around 2,000 medical students, residents, fellows, and attendings gathered to network, mentor, collaborate, and discuss academic surgery. Despite the abundance of stiff competition, the AAS Presidential Address “Sticky Floors and Glass Ceilings” by Dr. Greenberg stole the show.

All those packed into the large event hall immediately knew the focus: women in surgery. This subject continues to be pertinent and necessary to discuss despite many notable advances, such as both the current and incoming presidents of the AAS and SUS being female. Yet Dr. Greenberg steered the conversation away from traditional topics of “women in surgery” as she asked us to rethink what issues actual female surgeons face. She argued the challenges do not boil down to only those associated with parenting. This is especially true since 40.5% of female surgeons do not have children, while 91.8% of male surgeons do, which is why we need to talk about parental challenges and leave versus simply maternity. She then spoke about widespread biases and discriminations against women seen throughout society that also resonate in medicine and surgery, using the Audi #DriveProgess 2017 Super Bowl ad, Huffington Post Pinksourcing video, and The Daily Show’s American Soccer’s Gender Wage Gap video as poignant examples. She showed data from a study of academic science faculty exemplifying hiring gender biases for lab managers based solely on applicant names.

Dr. Greenberg then honed in on specific items most relevant to surgeons: differences in salaries, promotions, and grant funding. The fact that in 2017, based solely on gender, with all other factors held equal or superior in females, women still earn less, fill fewer leadership roles, and have lower grant funding than men is unacceptable.

The impact of Dr. Greenberg’s talk was palpable. From individual goosebumps and frequent murmurs, to occasional outbursts of disbelief and, finally, tears. No one in the room appeared unaffected, women and men alike. An objective measure could be visualized on social media, where metrics for the conference hashtag showed a large spike of almost 750 tweets during the 45-minute talk, greatly overshadowing the other subjects of the day (Figure 1). The diversity-championing hashtag #ILookLikeASurgeon showed a similar increase during the same period (Figure 2), disseminating Dr. Greenberg’s important message to a global community that has likely faced similar challenges in their careers.

Figure 1.


Source: Symplur

Figure 2.

Source: Symplur

Besides firing everyone up for action, the most important part of Dr. Greenberg’s talk was the discussion of potential solutions. The global social media community agreed, as this appeared to be the most shared slide from a quick glance of the Twitter feed. Her suggested systemic interventions for surgery included:

  • Transparent, objective compensation plans
  • Blinded manuscript, grant, hiring, and promotion practices
  • Explicit, purposeful, and fair distribution of uncompensated teaching and service workload
  • Equal leave policies and tenure clock extensions
  • Objective measures of success and milestones for promotion that are defined a priori so everyone knows the rules
  • Institute educational programs on implicit bias and its impact

Only through the wide adoption of targeted actions that aim to recognize and address surgical workforce inequities, such as those listed above, can we actually hope to erase them. This includes organizations speaking up, such as the Association of Women Surgeons’ Statement on Gender Equality. Although frequently labeled as women in surgery problems, these issues cast a wider net, encompassing all those affected by implicit bias; in other words, potentially anyone. Yet together we can make surgery a field that accepts and promotes anybody who has the passion, stamina, and drive to succeed within a challenging but rewarding profession, irrespective of personal characteristics that have no bearing on one’s potential or worth.

Photo credit: Dr. Danielle Sutzko @LoupesLoveMD

Dr. Greenberg’s final slide starkly projected #ILookLikeASurgeon and #HeForShe in large white font on a black background, inviting the audience to continue the conversation, both on social media and in real life, until we all receive equal compensation and consideration for opportunities for professional and personal success.

From left: Nelly-Ange Kontchou, Heather Logghe, Caprice Greenberg, Marissa Boeck. Photo credit: Dr. Susan Pitt

Resources:
2017 AAS Presidential Address By Dr. Caprice Greenberg, Introduction by Dr. Rebecca Sippel
Ladies Get Paid (@ladiesgetpaid) – Helping women advocate for themselves to get recognized and rewarded
He For She (@HeforShe) – United Nations Women’s mission for gender equality
Why So Slow? The Advancement of Women by Virginia Valian
Carnes, Devine, Baier Manwell, Byars-Winston, et al. “The Effect of an Intervention to Break the Gender Bias Habit for Faculty at One Institution: A Cluster Randomized, Controlled Trial.” Academic Medicine 2015; 90(2): 221-230. Link


Marissa A. Boeck MD, MPH is a general surgery resident at New York Presbyterian Hospital – Columbia. She is passionate about diversity in the surgical workforce, the power of social media in medicine, and global public health, especially as it relates to injury prevention, emergency response, and trauma and surgical system strengthening in low-resource settings.

Our blog is a forum for our members to speak, and as such, statements made here represent the opinions of the author and are not necessarily the opinion of the Association of Women Surgeons.