AWS BLOG

Defining the Resident Role in the Operating Room

By Heather Logghe, MD

In recent years, expectations and requirements for attending supervision of residents in the operating room has increased. This has led to ambiguity for both residents and attendings as to how and when operative autonomy is earned, appropriate, and safe. Another area of uncertainty is when, how, and by whom the resident’s role should be described and explained to the patient. Research in thoracic surgery by Meyerson et al. showed that while trainees’ and attendings’ expectations of resident autonomy did not differ, both groups expected higher levels of autonomy than were observed.
The January #AWSchat will explore these issues through facilitated questions led by three distinguished moderators:

  • Dr. Shari Meyerson (@lungteacher), thoracic surgeon and Program Director for the General and Thoracic Surgery Residency Programs at Northwestern, Feinberg School of Medicine
  • Dr. Nell Maloney Patel (@MaloneyNell), AWS member, colorectal surgeon, and General Surgery Residency Program Director at Rutgers Robert Wood Johnson Medical School
  • Dr. Rebecca Hoffman (@drbeckyhoffman), Vice Chair of the Resident and Associate Society of the American College of Surgeons Executive Committee as well as Research Fellow at the Center for Surgery and Health Economics and Chief General Surgery Resident at the University of Pennsylvania Perelman School of Medicine

In the chat, scheduled on January 15 @ 8PM EST using the hashtag #AWSchat, we will explore the following questions:

  1. As a resident, how much should I “do” in a case? Who gets to decide?
  2. As an attending, what metrics do I use to decide how much a resident does in a case?
  3. How should the discrepancies in expectations of autonomy in the operating room between resident and attending be resolved?
  4. How much transparency is owed to patients regarding the resident’s role in the OR?
  5. Who should discuss the #surgresident role in the #OR with the #patient?

Dr. Logghe is a longtime member of AWS and currently a Surgical Research Fellow at Thomas Jefferson University. She graduated medical school at the University of California, San Francisco and has completed two years of general surgery residency at the University of North Carolina, Chapel Hill. As founder of the #ILookLikeASurgeon social media movement, she is passionate about creating an inclusive and supportive environment for surgeons in training and practice. She believes that supporting physicians in optimizing their own physical and emotional health enables surgeons to take the best possible care of their patients.

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.

A New Year – A New You?

By Susan C. Pitt, MD, MPHS

Every year close to half of Americans make New Year’s Resolutions. They commit to losing weight, eating healthy, exercising more, going to bed earlier, and on and on. Many of these types of resolutions revolve around improving health and wellness. As surgeons and as women, we surely benefit from these types of resolutions. But we should also ask ourselves, what resolutions can I make at work? So you’re probably asking, “What do you mean, ‘work resolutions’?”

In my mind, work resolutions can come in many forms. Some work resolutions may lead to improved wellness by creating time for activities outside of work, like exercise or travel. Perhaps you could master a few shortcuts within the electronic health record to speed up orders and documentation. Maybe you could fully plan your week to take advantage of small periods of down time, thereby improving productivity. Or maybe you could finally master email management, so email doesn’t take over your life (ughh!).

Your work resolutions could also involve incorporating small efforts towards wellness into your daily activities that may increase your productivity. Could you meditate at lunch? Take the stairs every day? Or do push-ups and wall sits between cases? You could download an app with a short workout that you do once or twice a day between meetings. I’ve been enjoying my morning and afternoon 7-minute high-intensity interval training (HIIT) workouts so far. Can you say, “burpees and mountain climbers?”

Other types of work resolutions may involve patient care. You could resolve to improve patient communication or education by making any number of interventions, such as adding a new pamphlet in clinic or learning the teach back technique. You could even make a concerted effort to listen better. I know I’m frequently distracted by noises or other thoughts when I’m in clinic. Alternatively, you could resolve to trying make each of your patients laugh on rounds. After all, laughter is the best medicine.

Work resolutions could also involve learning or research. Perhaps you would like to read more or write more manuscripts. Maybe you would like to review articles in a timelier manner. Hopefully, by now, you can see the endless possibilities for resolutions in all facets of work and are encouraged to try incorporating one or several into your new year.

We all know that not all resolutions are successful, but we can help ourselves out. According to experts in the field, to help make your resolutions a reality, consider using these strategies:

  • Make the resolution specific (i.e., ‘I will finish my charts within 24 hours of clinic,’ instead of ‘I will finish my charting sooner.’)
  • Make the resolution realistic (i.e., Don’t resolve to read one surgical text each month when you only read one textbook last year.)
  • Have a strategy and a metric for evaluating your success (i.e., Keep track of every time your patient laughs on rounds and check your progress on Fridays.)

Ultimately, the resolution also needs to be important to you, your work, and/or your patients. Sharing the resolution with a friend or colleague may also keep you accountable and contribute to your success.

In this New Year, whether you pursue a resolution or not, consider incorporating strategies for building resilience and satisfaction at work, improving your wellness, and decreasing your risk for burnout.



Susan C. Pitt, MD, MPHS is an Assistant Professor of Endocrine Surgery at the University of Wisconsin. In addition to her clinical practice, Dr. Pitt is a health services researcher focused on reducing unnecessary surgical care and overtreatment. While she always strives to eat healthier, exercise more, and go to sleep earlier, Dr. Pitt’s “work resolutions” involve implementing strategies to make more space for her research and better manage her energy. She is looking forward to the challenge.

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 Semmelweis Reflex: Consideration of a Gap in Theory, Practice, and Ethics

By Connie Shao

Surgical site infections (SSIs) continue to ail today’s physicians, despite centuries of advancement in aseptic technique. Patients are constantly cautioned about the risks of hospital-acquired infections, while it seems every effort has been made to reduce them. The rigorous focus on foaming in and out to patient rooms has been all too familiar to the medical student sporting a recent paper cut. Straying from the sterile field is met with a quick warning and a heightened sense of vigilance throughout the operating room. And yet, as of 2014, SSIs continue to plague 2-5% of patients undergoing inpatient surgery.

In the 1840s, a young obstetrician named Ignaz Semmelweis felt that there was a connection between physician contact with cadavers, regardless of the lack of visibly transferred matter, and the risk of infection. At the time, the leading cause of death within obstetrics was puerperal fever. He introduced a chlorinated lime solution to the hospital and mandated frequent hand washing. With hand washing, the rate of puerperal fever dropped from one in ten to one in one hundred. While the outcomes improved, the lack of a strong theoretical explanation resulted in a backlash. Louis Pasteur’s germ theory of disease would not be discovered until the 1860s.

At the time, his work was severely criticized. Danish physician Carl Edvard Marius Levy wrote a passionate letter against Semmelweis’ work, pointing out that the decrease in mortality was merely part of a continual ebb and flow that was natural to the fluctuations of healthcare, similar to current interpretations on climate change. He argued the improbability of anything small enough to be invisible having the capacity to kill someone and questioned the methods of this study. Despite Semmelweis’ seminal work, people continued their practices, resulting in the continued deaths of thousands of people. The backlash can be understood as a critique against the threat of the practice, as the honorable name of medicine would be tarnished were it true that physicians were the ones causing disease.

This tendency to reject new evidence or knowledge because it contradicts established beliefs has been referred to as the Semmelweis reflex. In psychology, this is referred to as belief perseverance, a phenomenon described as “beliefs [that] are remarkably resilient in the face of empirical challenges that seem logically devastating”. While it is known that handwashing causes a significant reduction in the carriage of potential pathogens, as well as patient morbidity and mortality from nosocomial infection, compliance remains low. A study found that while self-reported a handwashing rate of 73%, the actual measured rate was 9%.

The theory-practice gap is often cited as a lack of integration of environmental factors that are responsible for the difference between the idealistic and the realistic. However, athethird dimension of ethics can be added to this bridge, the moral duty and obligation to integrate theory and practice, not allowing for external factors to continue dictating unacceptable outcomes within healthcare practice. The beneficence of a physician’s care is not limited to pharmacological prescription or surgical decisions – every aspect of care is an opportunity to create a better health outcome for patients, and every aspect must be considered with outcomes are not at the ideal complication rate of 0%. When quantifying hand hygiene through direct observation, self reporting, and indirect calculation from product usage, compliance at baseline has been found in one study to be 26% for intensive care units (ICUs) and 36% for non-ICUs. With monitoring and feedback, compliance increased to 37% for ICUs and 51% for non-ICUs. There is opportunity to create systems that bridge the gap between theory, practice, and ethics.

From the reception of Semmelweis’ findings, it seems prudent to remain mindful of the biases that can persist regarding the physician’s role in patient’s healthcare, being aware that physicians can harbor pathogens as well. Handwashing at the time was a novel concept to prevent complications, but has now been accepted as fact – unfortunately, it has yet to be put into universal practice. Just as every surgeon must scrub into a surgery, there is an ethical imperative to bridge the gap between practice and theory by maintaining the self-direction to protect the patients’ well-being with every facet of care, handwashing not excluded.

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.

Clean Hands Deserve Two Thumbs Up

By Fatima S. Elgammal

The Hungarian obstetrician and a father of modern antiseptic techniques, Ignaz Semmelweis, risked his reputation when he took to stage at the Vienna Medical Society’s meeting on May 15, 1850. He was beseeching his colleagues to participate in a simple but a provably effective method of diminishing disease transmission: hand washing. The rates of puerperal fevers on wards covered by medical students, whose morning autopsies on women who died from the fever preceded examinations on the day’s laboring women, far outnumbered the rates on wards monitored by midwives, whose responsibilities did not include autopsies. Semmelweis attributed rates of the former group to poor hand hygiene. Ever the scientist-at-heart, he implemented a protocol whereby students and physicians washed their hands with a chlorinated lime solution after dissection. The results were groundbreaking: mortality rates of mothers seen on those wards covered by students and junior physicians plunged. Despite the evidence, Semmelweis’s conclusions were not as readily accepted, and would not be so for years to come.

Hand hygiene is one of the most important methods of preventing transmission of healthcare-associated infections. The Centers for Disease Control and Prevention asserts that hand washing prevents diarrheal illnesses by 30% and respiratory infections by 20%, for which antibiotics are, consequentially, overprescribed and overused, lending to a rise of antibiotic resistance. Rubbing alcohol-based solutions and washing with soap and water are the most popular and widely used techniques for hand hygiene.

Newer hospital wards are especially equipped with sinks and sanitizer dispensers inside and outside patient rooms, while older wards, especially emergency departments (ED) and intensive care units (ICU), are being similarly retrofitted. Still, low hand hygiene compliance plagues healthcare workers. Surprisingly, the World Health Organization (WHO) 2009 Guidelines on Hand Hygiene in Health Care lists physician status as a leading risk factor for poor adherence. The same set of WHO guidelines studied predictive factors for good adherence to hand hygiene, and cited peer pressure and the awareness of being watched as leading determinants. Another positive determinant for good adherence: being a woman. Few of us can objectively contest anything less than 100% compliance, especially when Infectious Control personnel are making their rounds, but consistent efforts to wash in, wash out, and wash in between encounters (for the double-occupancy rooms) can be more difficult to achieve. The five critical moments of a patient encounter during which hand sanitation must be attained are:

  1. Before touching a patient (e.g., prior to examination, or assisting patients to move or walk)
  2. Before a clean/antiseptic/sterile procedure
  3. After body fluid exposure risk (e.g., handling Foley bag, IV sites)
  4. After touching a patient
  5. After touching a patient’s surroundings (e.g., bed rails)

The above measures not only prevent exogenous germs on your hands from colonizing the patient or their room, but prevents us from carrying infectious particles to other patients or healthcare professionals. Cold weather and large crowds makes the holiday season an especially vulnerable time for germ spread, even just by walking through a hospital lobby, cafeteria, or the ED; pocket-sized sanitizer bottle come in handy when no wall mounts are available or should we become the unsuspecting victim of a wet sneeze, ours or someone else’s. The busyness of a surgeon’s day is on par with the delicate state of our patients’ health. The sense of criticality with which we adopt sterile techniques in the operating room should be translated just as readily in the clinics, inpatient wards, ED, and the ICUs, and beyond the weeks of Infection Control monitoring our movements. We do not think twice about it in the OR, we should not think twice about it outside it.

This National Handwashing Awareness Week (December 3-9), spread the word, not the germs. Alert those who walk in without washing into a patient’s room.


Fatima S. Elgammal is a fourth-year medical student from St. George’s University School of Medicine. She developed an interest in critical care and trauma/acute care surgery following four years of studying neuronal changes in traumatic brain injury models of epilepsy and her time at Hackensack University medical Center as an emergency physician scribe then later as student completing clerkship. An alumna of New Jersey Institute of Technology, she enjoys illustrating, baking, reading, 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.

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.

When the Storm Clears: A New Perspective

By Dr. Ainhoa Costas-Chavarri

For 14 days after Hurricane Maria hit Puerto Rico, I had no way of knowing if my parents were dead or alive. They’re fine, I told myself. Our house is not in a flood-prone area. The roof and walls are solid, and won’t blow away. I’m sure they’re ok, I replied to the rising tide of emails, texts, and phone calls from concerned friends and colleagues – there’s just no lines of communication. I’m sure they’re fine, they have to be, I reassured myself, resting my hand on my second trimester and growing belly.

I grew up in Puerto Rico. Every summer my mother would unearth the free NOAA hurricane tracking map and place it on the bulletin board we had hanging in our kitchen. She’d catch the coordinates on TV or the radio and my brother and I would fight over who got to place the pushpins on the map. Pin by pin, every morning we followed the hurricane’s trajectory, and then went about our school day.

As surgeons, we live with similar daily acknowledgements of looming potential complications. We learn anatomical variations and control for risk factors, following the steps that will hopefully see the twin storms of morbidity and mortality veer off course. When I last heard my mother’s voice, we were going down a checklist: batteries? Check. Electronics charged? Check. Radio? Canned food? Water? Check. Candles? Mama? Mama?

For the next two weeks the only things I could pretend to control were the news and my Facebook feed. It was devastating to watch: 3.4 million Americans living on the island without water, electricity, and telecommunications. The images of massive destruction and flooding filtering through unable to fully capture the scale of this humanitarian disaster. Even after 40 days, the statistics are mind-numbing: less than 30% of all people have electricity and ~70% have access to drinking water. More heartbreaking, however, is the reality down at the individual level –  stories of families that are still without food, of people washing their clothes in and drinking from polluted water sources, and in hospitals, surgeries compromised as the power goes out in the OR. On Facebook, there was a new-found sense of community: my Puerto Rican friends and I ranted over government officials placing politics above human lives, commiserated over losses, and celebrated whenever any of us had good news.

Finally, it was my turn: 14 days after we’d lost contact, my mother called to say she was in the hospital. A small inflamed area had morphed into an angry abscess, necessitating an I&D and IV antibiotics. “It’s like being at a spa,” she proclaimed, ecstatic, “they have light here and clean water and wifi…that’s how I was able to call you.” She had been seriously considering, she also revealed, traveling to Colombia. Colombia? Para que? Well, she explained, I’ve always wanted to go – and your father and I, we have worked so hard, we did all these things to prepare for the hurricane, for the worst, and still we suffered all these unforeseen problems. Y sabes que? I think we need to put in just as much effort into living.

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.


Dr. Ainhoa Costas Chavarri is a General Surgeon and Hand Surgeon who does full-time academic #globalsurgery. She has been living and working in Rwanda for the past four and half years, teaching Rwandan surgery residents and medical students as part of the Human Resources for Health Program. Her focus is on surgical oncology, especially breast and gastric cancer. She enjoys foreign films, modern art, poetry and now more than ever, the beaches of her home island of Puerto Rico. You can follow her on twitter: @ainhoac63

 

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.

 

Why I Joined AWS

By Dr. Tom Varghese

Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.” – Margaret Mead

I have been incredibly blessed in my life. My parents have been, and continue to be amazing role models. One of my Mom’s favorite sayings was, “Always seek and surround yourself with people who are smarter than you. They will stretch your viewpoints of the world.” My dad on the other hand had colorful proverbs and parables to emphasize learning points (I continue to joke with him about writing a book entitled, ‘My Father the Philosopher’). One of his favorites, loosely translated from our local Indian language of Malayalam, was “Beware of continuing to climb up the same coconut tree behind a baboon. Your view will always remain the same.”

Diversity is a buzzword these days. There are numerous examples of the power of diversity in multiple fields of work. Heck, the United States is a testament to the power of immigrant diversity (or at least it has been till date). The conversations traditionally have centered on ethnicity and only recently, gender. This of course is important. But, can we have true diversity when we only pay attention to how we look? What about diversity in thought? This has been difficult to do in healthcare.

In the field of Medicine, it starts with the admission process. High Board Scores – Check. Volunteering to work in clinics – Check. Recommendation letters from those in the field – Check. Straight A’s, Honor Rolls, and Dean’s Lists – Check, Check, Check. Admission committees, overwhelmed with an ever increasing volume of applicants, have to make difficult cut-offs for admission. With the knowledge that certain types of students have succeeded in the past, this knowledge flavors the admission criteria of today. And we as students embrace this mission and mantra. Study hard, deep dive into our books, relentlessly try and figure out the the various signs and symptoms of disease. Along the way we are influenced by various specialties, which ultimately lead to our final paths of training and establishment as Attendings. But where’s the time to diversify our thoughts?

In Medicine, the world around us was historically encountered one patient at a time, one workplace environment at a time, one organization at a time. Experience was solely a personal journey. And this worked in a world that succeeded (and made lots of money) by homogenization, decreasing variation, and converting aspects of healthcare into assembly lines. Departments in Academia prided themselves on success in the form of traditional metrics – papers published, grants received, Blue Ridge Institute for Medical Research (BRIMR) rankings and clinical reputation as publicized in traditional media reports. Past success influenced the current metrics, all of which are important, but should they be the only ones?

Social Media has turned the learning experience on its head. There is no longer a need for your views and experiences to be confined to the walls of your institution. You can connect with anyone in the world at any time. However, there is a downside. Though you can find differing opinions, it is so easy to confine your experiences and thoughts to like-minded individuals or groups. Finding your tribes of course is reassuring and empowering. But the same traps of ‘homogenization of thought’ can occur on social media due to evolving algorithms aimed at user-targeted ads and personalized experience. If your timelines are filled with those who echo your same thoughts, who don’t offer differing opinions, are you truly diversifying?

My journey to AWS came predominantly from social media. I was able to connect with many thought leaders who shared their wisdom with the world at large. They opened my eyes to the struggles they had in their work environments. Many of these struggles transcend boundaries – whether they be gender, ethnicity, or social backgrounds. Several took the step of forming groups, and transforming existing organizations to more pragmatic and powerful instruments of change. I was able to learn at a distance of the efforts of AWS, including their work on gender pay inequity, work-life balance, and how to empower others. I was thus inspired to learn more about their work up close. I had live-tweeted their conference last year, and hence thought, why not?

I turned to one of my close friends, who I first met on social media – Dr. Amalia Cochran (@AmaliaCochranMD ). Amalia and I had first connected when we were at different institutions. Our first in-person meeting was when I had the opportunity to give Grand Rounds in Salt Lake City. One thing led to another, and now I’m on faculty at the same institution. I brought up how I had admired AWS from afar, and admitted that I only had a superficial knowledge about several issues such as inequity. Amalia, in classic Amalia fashion, had a mischievous grin on her face while she asked, “So why don’t you become a member?” My response – “I can be a member of AWS?” Hers – “Why not?”

Image of #HeForShe support at the AATS annual meeting 2017

My only prior experience with issues on inequity had been with the #HeForShe movement. The speech that Emma Watson gave is inspiring. This past year, the department of surgery at the University of Michigan embraced #HeForShe and challenged others to follow. Quickly, other organizations such as SAGES, ASE and APDS followed suit. In Thoracic Surgery, our national AATS meeting was about to take place in May, and hence I turned to the Women in Thoracic Surgery organization to ask about interest. With overwhelming support and the help of then president Dr. Jessica Donington and the leadership team, we were able to pledge our support for the movement by our specialty. Awareness is of course the first step. But what happens next?

I joined AWS. Their creed – Engage, Empower, Excel – is something that all of us can benefit from. Engaging with those who have lived and overcome barriers is uplifting. Learning the skills to empower those around you to reach for greater heights is inspiring. And relentlessly applying the skills you learn to excel in your environments can change the world. We’re assembling a #HeForShe task force within AWS, with the goals of teaching the skills for men to effectively mentor and sponsor women surgeons. I personally am still learning, and in my heart believe that many men want to help. They just need to be taught how to do so effectively.

I want to close with some quotes from those I admire:

Reminder to us all in healthcare. We do not do this alone. Ever. I love having a team of superheroes to work with.” – Dr. Amalia Cochran @AmaliaCochranMD

Even those above you have knowledge deficits.” – Dr. Julie Silver @JulieSilverMD

If you want to know the secret of success, it is not being better than everyone else. It is showing up more than everyone else.
– Dr. Sasha Shillcutt @SashaShillcutt

Embrace diversity at all levels. Connect with those who come from different backgrounds. Constantly seek to diversify your thought. And of course, join us in the work ahead.

Dr. Thomas Varghese Jr. is the Head of the Section of General Thoracic Surgery, Co-Director of Thoracic Oncology, and Program Director of the Cardiothoracic Surgery Residency at the University of Utah. Dr. Varghese holds leadership positions in the Society of Thoracic Surgeons, Thoracic Surgery Directors Association, American College of Surgeons and the Surgical Outcomes Club. Views expressed in this post are personal, and do not represent official positions of these organizations. You can follow on Twitter @tomvarghesejr.

 


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 2017: A Few Ships By The Bay

By Natalie Tully

The AWS Conference on October 21st was a full day with a scientific session, professional development panels, and a broad range of networking opportunities that originated as a simple sign for a breakfast with women surgeons 36 years ago.

This year we took mindfulness and self-care from the abstract into practice with a yoga session and run along the San Diego Embarcadero. With the excitement buzzing around the day’s events, I deeply appreciated having a moment to appreciate the sunrise and to sync breaths with other attendees.

This past year we accomplished new milestones and new trends on social media. We had the opportunity to realize how much better we truly are together. The conference made broad use of multimedia, including an introductory video by student member Emily Chen.

 

Members’ academic endeavors were highlighted in the Starr Research forum, AWS/AJS Best Manuscript Session, and a presentation from AWS Foundation Fellowship Awardee, Dr. Nasreen Vohra. Projects from a broad range of topics were presented, including “SOX9 in irradiated rectal cancer: a potential marker for tumor regression?, and Evaluation of TRB-N0224”, by Lindsay Nowak, “Improving Outcomes with Minimally Invasive Aortic Valve Replacements” by Anna Olds, and “A Chemically Modified Curcumin for Osteoarthritis Treatment” by Josephine Coury. Likewise, the resident forum featured excellent projects from a variety of surgical research areas. To complete the scientific session, Dr. Nasreen Vohra spoke about the project she’ll be working on with the AWSF Ethicon Fellowship “Relationship between the transcriptional profile of the sentinel lymph node and outcomes in triple negative breast cancer”.

The keynote speaker, Lara Hogan, Vice President of Engineering at Kickstarter, challenged us to “Be a Mentor, Find a Sponsor”. She encouraged all in attendance to critically evaluate how we seek out and provide professional guidance and support. She spoke to the value and crucial need for senior surgeons to sponsor their trainees and more junior surgeons for leadership positions. While the seat women earn at often unfriendly tables, she underscored She highlighted that for surgery to move toward gender equity, there must be increased sponsorship but also self-assertion that women belong at the table based on merit.

There is a reason why we are the Association of Women Surgeons, why we are not tied to a country or geographic region. It is because our international collective of members experience the same themes globally as women in medicine. The global panel on women in surgery highlighted the social exclusion, implicit bias, challenges in mentorship, and pathways to promotion we all inevitably encounter in the spectrum of medical training. Featured speakers included: Dr. Suad Abdul (Kuwait), Dr. Ainhoa Costas-Chavarri (Rwanda), Dr. Vikisha Fripp (USA), Dr. Avril Hutch (Ireland), Dr. Kazumi Kawase (Japan), Dr. Sherry Wren (USA), and Dr. Cheng Har Yi (Malaysia).

The official conference activities ended with a networking event in the new-for-2017 “Surgeon’s Lounge”- with a ribbon cutting ceremony by AWS President Celeste Hollands. The event offered a unique opportunity for all attendees to relax and network with each other and with our generous corporate sponsors. Following the conclusion of the conference, residents and medical students headed to a local restaurant for a taco-infused mixer. Medical Student and Resident Committee Chairs Shree Agrawal and Andrea Merrill spoke to the group to welcome all to San Diego and to encourage anyone interested in becoming more involved with AWS to take take the leap in becoming a member and make their mark on AWS.

As the day ended and American College of Surgeons Clinical Congress (ACSCC) began, AWS members continued to show the incredible work they are doing in advancing the surgical field, having myriad presentations, panel discussions, and leadership positions given by members. To highlight this and make use of the “Amplification” strategy used by other groups of women, appearances by AWS members were posted with #AWSatACS. This allowed for an extra level of visibility of the number of women speaking at ACSCC, and as a result, greater visibility both of each individual’s message and of women as leaders in surgery overall. Another trend that began during the Congress was a surgical #HeForShe– which started by Tom Varghese joining AWS subsequently followed by many other male surgical colleagues. The AWS conference’s close temporal and spatial relationship to ACSCC provided opportunities to engage with our biggest allies in our plans moving forward.

As the Clinical Congress continued on, there were myriad wonderful moments for women in surgery-Dr. Barbara Bass being installed as the 3rd female President of the College, Dr. Eileen Bulger installed as the first female chair of the Committee on Trauma, and Drs. Leigh Neumayer and Diana Farmer installed as the Chairs of the Board of Regents and the Board of Governors, respectively, just to name a few. On the evening of October 23rd, AWS held it’s AWS Foundation awards dinner, recognizing remarkable accomplishments by members at the medical student, resident, and attending level, as well as non-member allies. It was a truly spectacular evening celebrating how far we’ve come as women in surgery and reaffirming our commitment to the AWS mission. The next morning, AWS activities wrapped up with our annual Stryker Networking Breakfast, in honor of the origins of AWS and Dr. Pat Numann’s original breakfast meetings. The morning gave those still in town one last chance to come together in an informal setting and network…or be gently encouraged to take on one more AWS committee project.

This was my second ACSCC and my first of what I hope to be many AWS conferences, and for all of the things I imagined the experience would be, somehow it exceeded them. AWS seeks to inspire, encourage and enable women to realize their professional and personal goals. For at least this n=1, I left San Diego inspired by the accomplishments and ongoing work of #Sheroes I was surrounded by, encouraged by friends new and old, and enabled by new opportunities to lead and to pursue a career in this field, so that someday I may have the joy and privilege of being a surgeon.


Natalie Tully is a 3rd year MD/MPH student at Texas Tech University Health Sciences Center in Lubbock, TX. She plans to pursue a career in surgery, and has particular interest in applying her dual degree in Surgical Research, Pediatric, and Trauma Surgery. In her free time, she enjoys running, cooking, and playing with her 4-legged study buddy, Sadie.

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.

The Ideal Team Player

By Jean Miner, MD

In all aspects of our lives, we are members of a “team”. We are members of our family “team” first and then head to school at a young age and are paired off on the playground. Many of us joined teams throughout our lives for sports, debate, math, dance, etc… As we get older, we start to value the importance of teamwork to accomplish goals or projects. Think about the college chemistry lab partners or the members of a committee who helped (or hindered) meet deadlines or complete tasks. As surgeons, we are always members of a team- in the operating room, clinic, and patient wards. Ultimately, in life we belong to numerous teams.Recently, the members of the AWS Clinical Practice Committee (CPC) held a book club discussion using The Ideal Team Player by Patrick Lencioni. Our lively discussion quickly turned into a focus on leadership and building the ideal team. Based on the importance of this topic, we will be hosting a tweetchat on November 27th focused on Leadership and The Ideal Team Player. Three virtues, humility, hunger, and people smarts, are what we look for in those alongside of us taking care of patients, in our office, on a committee and even at home.

  • Humility: Characterized by lack of excessive ego or concerns about status. Humble team players share credit and emphasize team over self.
  • Hunger: Defined by self motivation and diligence. Hungry team players are always looking for more things to do and learn.
  • People Smarts: Depicted by possessing common sense about people. Smart team players are intuitive around the subtleties of group dynamics and the impact of their words and actions.

What do we do when we lead a team with members deficient in one, two or maybe all three areas? Should we give up on them? Are we able to teach these qualities or is it nature vs nurture? If we want to be good and effective leaders, we need to try and help our team members before kicking them to the curb. First, we should assess our colleagues to establish where they rank on the three traits. As both team leaders and members, we should do this ourselves. Other key members of the team can (and should) also be included. Next, we meet with the teammate to discuss our findings and develop a game plan. Often when there are deficiencies identified, people are unaware and improvements can be made just by bringing it to their attention. For more challenging situations, we need to set small achievable goals paired with frequent feedback. Finally, after a set period of time, we must reassess the situation and determine if we now have a set of ideal team players. If not, just like in professional sports, we must consider trading members to other teams where they would be a better fit and acquiring new players that fit the project.

Most importantly, we also need to turn the microscope on ourselves. Are we good team players? Most of us would like to think we are, but it is definitely worth a few minutes of self-reflection or use of a self-assessment tool in determining if we are indeed good team members. Or just like we did with our own team, we can ask a leader or mentor to evaluate us. After identifying areas to improve, we need to set our own goals based on the three virtues. If humility or people smarts are issues, we need to make a point to listen and learn more about our team members. This allows us to exercise humility but also gain insight into our counterparts as we take the time to hear their opinions. Hunger can be more difficult to achieve without an interest in the project. If this is a deficient area, we must consider alternative methods for achieving the same outcomes with a process that will motivate us. Or we may need to request off of a project in exchange for one which inspires us to do our best work.

Ultimately, for the development of a high performing team ALL members should embody the virtues of humility, hunger and people smarts and the process of building our team can be as enlightening as what we accomplish together.

Please join the CPC on November 27 at 8pm EST for a tweetchat on “The Ideal Team Player” to discuss your own strategies and experience as a leader and ideal team player.

https://www.tablegroup.com/books/ideal-team-player


Jean Miner is Assistant DIO at Guthrie Hospital in Sayre, PA and a Surgical Attending with Guthrie’s General Surgery Residency. She also has a Masters in Medical Education Leadership from the University of New England. Her work life is in equilibrium with her personal life as a mother of three girls who loves spending time with her husband and family traveling the country and world. In her “spare time” she loves to cook, be outdoors and read as many books as she can.

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.