AWS BLOG

Practice Building for the Young Surgeon: Putting the Three A’s into Practice

By Feibi Zheng

It is often said that the keys to building a successful new practice are the three A’s: availability, affability, and ability. But what does that actually mean? What are the practical steps a surgeon can take in order to operationalize the 3 A’s? I’ve spent a lot of time over the past few months collecting advice from mentors and senior surgeons at my hospital, observing how others run their clinic as I set up my own, and have tried to consolidate the principles into the following:

Availability
Provide fast and good service. One of my senior partners told me that I should be prepared to see patients in clinic every day. While I have not gone to that extreme (as it it creates too much chaos for our clinic manager) I do have clinic multiple days a week so patients requiring urgent appointments can be accommodated within 48-72 hours.

Find the gaps and move upstream. Understand where your referrals will come from. Is it primary care or GI or nephrology or endocrinology? There is a shortage of endocrinologists in Houston, leading to long wait times for new appointments. After meeting with multiple endocrinology groups in my area, I realized that they don’t mind if I do my own fine needle aspirations of new thyroid nodules or do the biochemical work-up for an adrenal incidentaloma because otherwise these patients would have to wait months for an appointment. Furthermore, I have the luxury of onsite adequacy check for FNAs whereas many private endocrinology groups do not. Therefore, I also am referred more complex biopsies or biopsies that were previously inadequate for interpretation.

Communicate. When meeting a new physician, always exchange cell phone numbers. Ask them how they want to receive information after they send you a patient. Do they want a quick text after surgery or do they want a faxed copy of the operative note report and path results? Make their jobs easy. I use a templated H&P but I also make sure to write something of substance in the assessment and plan to the primary care and the referring physician. Referring physicians care that you are a thoughtful surgeon.

Organize. Actively look at your clinic schedule on a weekly basis in order to maximize convenience to the patient and the referring physician. Can you schedule tests and other consultations on the same day as the new patient appointment? Make sure that your medical assistant and schedulers have a good working relationship with other offices so that you can consolidate appointments for your patients.

Affability
We hear all the time that “networking is key!” As a relatively introverted person, one of the most challenging social situations for me is to stand in a room full of unfamiliar faces, trying to approach a friendly group to make small talk. There are a couple of strategies I use to overcome this issue:

Find a buddy. I joined my practice around the same time as one of my partners, a surgical oncologist. We take new physician meetings and go to networking events together. Women are often too modest to talk about their accomplishments or if they do, they can be perceived as being “too confident.” When we meet new physicians, we talk each other up.

Network virtually. Most of my referrals come from young women physicians. Where did I meet these physicians? Online. There are bevy of online groups that can be sources of contacts. The popular Facebook group Physician Mom’s Group has regional subgroups in your area. Additionally, there are patient support groups who welcome physician members. As an endocrine surgeon, I am part of a Facebook group dedicated to promoting awareness of primary hyperparathyroidism. There is undoubtedly a Facebook or Google group for the condition(s) that you have dedicated your career to treating. Ask your colleagues at national meetings if they know of these secret groups. Additionally, if your institution helps you put on a webinar for a topic that you are an expert on, you will have a ready audience from the support group.

Network the old fashioned way. Even when you meet someone online, it is still a good practice to shake their hand in person and visit their office and meet their staff. Their medical assistant may be the person who processes the referrals so it is crucial that they know how to reach you or your medical assistant if they are having difficulties scheduling with your office. Other networking opportunities include events put on by your local medical or surgical society, university or company sponsored health fairs and church events. It is unlikely that I am going to find a thyroid nodule or a patient with primary hyperparathyroidism at a health fair, but I go to meet the other physicians.

Ability
Know what makes you different. Most young surgeons will be fellowship trained. Make sure that your website and other marketing materials clearly articulate any special skill sets you may have. If you are fortunate enough to have a business development office or marketing department, meet with them regularly. They are not clinical people and have no idea what you do. Similarly, if you have a centralized call center, meet with the schedulers to give them a quick talk about the types of patients you wish to see.

Know your limits. It goes without saying that you should do all you can to avoid having a major complication in your first years of practice. There is a good chance that unless you are in rural practice, you have a senior partner who will be happy to mentor you and help you with difficult cases. They may not be fellowship trained like you, but good surgical technique is good surgical technique. Look for these people before accepting a job. Know who you’re going to call in the middle of night to help if you need it.

I’d love to hear practice building tips from others out there!


Dr. Feibi Zheng is an endocrine surgeon at Houston Methodist Hospital in the Texas Medical Center. She attended medical school at the University of California, San Diego. During her surgical residency training at Houston Methodist, she helped to establish the General Surgery Leadership and Health Care Administration Track, an 8 year program which blends clinical surgery training with practical experience in optimizing hospital systems for improved patient care and safety. She then completed her endocrine surgery fellowship at UCLA. In addition to her clinical practice, she is the Assistant Clinical Program Director of Surgical Quality and Population Health for Houston Methodist Hospital, where she is leading the development of a telemedicine program for surgical patients who live long distances from specialized centers of care. She also currently serves on the Committee for Perioperative Care of the American College of Surgeons which works to improve the quality of care for surgical patients across the country.

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.

Thyroid Cancer Awareness

By Elizabeth Shaughnessy

In my training as a surgical oncologist, I certainly performed my share of thyroidectomies and node excisions for thyroid cancer. My practice quickly focused on breast cancer once in academic practice, given the demand in the community. Yet, my patients will report thyroid cancer frequently enough that I felt I should revisit this topic, to fill in the details of our growing knowledge.

We should all be aware of this cancer. Not only is it the fifth most common cancer, it affects three times as many women as men! Only 2% of the cases will occur in children or adolescents. In adulthood, women present usually in their 40’s or 50’s, whereas men will present later, in their 60’s or 70’s.

There can be a hereditary component; RET gene mutations are associated with the development of medullary cancer of the thyroid, which may be part of familial medullary thyroid cancer (FMTC) and multiple endocrine neoplasia type 2 (MEN2). Thyroid cancer is present in the spectrum of malignancies of several different cancer syndromes. These include familial adenomatous polyposis (FAP) where the APC gene is mutated; Gardner’s syndrome; Cowden’s Syndrome, where the PTEN gene is mutated; and Carney complex type 1. Even if a cancer syndrome has not been identified, a family history is still significant in raising the risk of cancer in a patient being evaluated for thyroid nodules.

The histologic subtypes include papillary, follicular, medullary and anaplastic. Staging for papillary and follicular tends to be predominant Stage I and stage II; they are more frequent and slow-growing. In contrast, medullary and anaplastic are far more aggressive, and may require more resection. Statistically, disease that is limited to the thyroid has a five-year survival of 99%. Local disease that extends beyond the thyroid has a five-year survival of 98%. Metastatic disease has a 5-year survival of 55%.

Lifestyle issues, such as radiation exposure or low iodine diet, still play a role in risk and outcome in addition to family history and histologic type. No excuses for those of us who need to don a thyroid shield during fluoroscopy!

In a month known for its garnet birthstone, carnation flower, and traditionally bed linen & towel sales, sharing this exercise has sharpened our awareness for the coming year!


Elizabeth Shaughnessy is in an academic practice at the University of Cincinnati, with an emphasis on breast cancer and breast disease. She serves as Surgical Director of the multidisciplinary breast cancer program. In her free time, Dr. Shaughnessy likes to garden, hike, and do yoga.

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.

Global Surgery: An indivisible, indispensable part of health care

By Faith Robertson

Global surgery is an area of study, research, practice, and advocacy that seeks to improve health outcomes and achieve health equity for all people who require surgical care, with a special emphasis on underserved populations and populations in crisis. It uses collaborative, cross-sectoral, and transnational approaches and is a synthesis of population-based strategies with individual surgical care (Dare et al., Lancet 2014).

In today’s information age, an abundance of technology, data, and innovation has enabled more global interconnectedness than ever before. This has allowed for a better understanding of the health inequities that exist in the world. This is not limited to low resource settings as they exist in divisions of high-income countries like the United States and United Kingdom. The vision and mission of achieving health equity for all is the ethos of Global Health. However, until recently, surgery was largely omitted from that equation. The field of Global Surgery has recently gained attention for its efforts to meet the global need for surgical care.

Why Global Surgery?
Global health has historically focused on mitigating infectious diseases such as HIV/AIDS, malaria and tuberculosis, while surgery remained largely absent from the global health agenda. Traditionally, it was believed that incorporating surgery into

Figure 1: Proportion of the population without access to safe, affordable surgery and anesthesia by Institute for Health Metrics and Evaluation region. Image taken from the Lancet Commission on Global Surgery. Image from Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development.

global health would be too expensive, complex, and unsustainable, and moreover, that the global surgical demand was low. However, the burden of diseases that require surgical treatment outnumber HIV/AIDS, malaria and tuberculosis combined. The 2015 Lancet Commission on Global Surgery concluded 5 billion people worldwide do not have access to safe, affordable surgical and anesthesia care when needed (Figure 1). Surgical conditions account for 30% of disability-adjusted life years lost (DALYs), a measure of overall disease burden, expressed as the number of years lost due to ill-health, disability or early death (Shrime et al., Lancet Global Health 2015). Leading conditions requiring surgery include pregnancy, traumatic injuries, and digestive diseases. In low-income and lower-middle-income countries (LMICs) 90% of people cannot access basic surgical care. This amounts to 143 million surgical procedures that go unmet in LMICs each year. Despite this health disparity, the United Nations Millennium Development Goals for improved health by 2015 failed to incorporate surgery in their health plan, and today, the majority of global health funding goes toward infectious disease efforts. With the 2015 Lancet Commission, Dr. Jim Yong Kim, President of the World Bank, called for a “shared vision and strategy for global equity in essential surgical care,” and firmly stated that “surgery is an indivisible, indispensable part of health care.”

 

Is Global Surgery Feasible?
The Lancet Commission established a target for countries to be able to deliver 5000 operations per 100,000 population by the year 2030, and denoted the workforce density of surgeons, anesthesiologists and obstetricians (SAOs) should be at or above 20 per 100,000 population (Figure 2). For example, according to the World Bank data in 2016, Rwanda had 0.75 SAOs per 100,000 population, compared to 54.7/100,000 in the United States. The estimated cost of increasing surgical care in LMICs by this target is $420 billion. However, the alternative would continue to drive losses in economic productivity, costing $12.3 trillion. Therefore, investing in surgical services in LMICs is both a financially and morally sound investment to save thousands of lives.

Figure 2: Specialist surgical workforce density and maternal survival. A surgical workforce density of more than 20 per 100 000 specialist surgeons, anaesthesiologists, and obstetricians is a goal put forth by the Lancet for 2030.Image from Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development.

What Types of Projects are Ongoing?
At present, numerous multidisciplinary efforts are ongoing. Zambia and Ethiopia were the first to take on the challenge of creating a National Surgical Plans to meet Commission goals. Others are working hard to describe the current state of surgery in various regions by collecting information on the World Bank World Development Indicators, WHO Global Reference List of 100 Core Health Indicators, and the United Nations Sustainable Development Goals. Multiple partnerships are being developed between high-income countries and LMICs to team together for research, training, and health systems strengthening (e.g. Human Resources for Health in Rwanda, King’s Global Health Partnerships in Sierra Leone, Somaliland and Democratic Republic of the Congo). Start up companies like LifeBox are working to ensure safer surgery through pulse-oximeters. No matter your specialty, there is a place in global surgery for you.

 

How Can I get Involved?
There are many ways to get involved! Here are a few ideas to get you started:

  • At your own institution:
    • Investigate whether there is ongoing research or dedicated experiences in global surgery and reach out via email.
  • Medical student groups:
  • Social Media
  • Further Education
  • Careers
    • There is no dedicated career path to becoming a global surgeon. Some surgeons have volunteered with Medecins Sans Frontieres (Doctors without Borders), Mercy Ships, or other surgical groups for short or medium term rotations. Others are enveloping global surgery into their academic career as there is a growing body of funding for and interest in peer-review publications in global surgery. There is also the critical point that global health begins locally – you can get involved with improving affordable access to surgery in your neighborhood as well.

Overall, it is an incredibly exciting time to be interested in surgery and its importance in global health. As Jim Kim, President of the World Bank, stated: “surgery is an indivisible, indispensable part of healthcare and of progress towards universal health coverage.” I encourage you to join the movement today!


Faith Robertson is an American medical student, aspiring neurosurgeon, and global surgery enthusiast. She is presently taking a year out from Harvard Medical School to obtain an MSc in Global Health with Global Surgery at King’s College London to gain skills necessary to positively impact the field of global surgery, and be a leader in global neurosurgery efforts. Faith also serves as an International Representative for the Association of Women Surgeons National Medical Student Committee. She plans to pursue a career in Neurosurgery and Health Systems Improvement.

Twitter: @FaithCRobertson
LinkedIn: https://www.linkedin.com/in/faithrobertson/

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 from the Michigan Women’s Surgery Collaborative (MWSC) Women in Surgery Leadership Development Conference

By Andrea Merrill, PGY5, MGH

Growing up I never idolized traditional movie stars and celebrities; my heroes came in the form of Hillary Clinton, Mia Hamm and Kerri Strug, women who through hard work persevered and succeeded in their careers. As I matured and shifted into the field of surgery, new heroes emerged. These heroes were women who had paved the way for me to be where I am now, women who took the first steps to demonstrate that women deserve leadership roles in surgery, women such as Dr. Julie Freischlag. I have to admit, I was a bit “star struck” during my residency interview with her at Johns Hopkins. So when I saw the all-star lineup of Drs. Julie Freischlag, Rebecca Minter, Melina Kibbe, Amalia Cochran, Aurora Pryor, Heena Santry, Julie Ann Sosa, and Sandra Wong a the Women in Surgery Leadership Development Conference run by the Michigan Women’s Surgery Collaborative (MWSC) I knew I had to attend.

This is a very exciting time to be a woman in surgery. While things are still far from where they need to be, many events have laid the groundwork for tangible future change. Twitter and social media campaigns such as #ILookLikeASurgeon, #NYerORCoverChallenge and #HeforShe have brought much awareness to implicit gender bias in surgery, which is certainly the first step. This was further highlighted in the captivating AAS Presidential Address by Caprice Greenberg in February 2017. In 2014, there were 4 women chairs of surgery in the United States. Today, there are 20. The gender pay gap has become a more prominent issue with a joint American College of Surgeons and AWS Statement on gender salary equity this past summer. With all of these changes occurring so rapidly in the past few years, we seem to be approaching a “tipping point” to achieve equality for women in surgery.

One way to get past the tipping point is to teach women surgeons, early on, the skills they need to become leaders. This was the goal of the MWSC’s Women in Surgery Leadership Development Conference held early November in below-freezing temperatures in Michigan. The MWSC was founded in 2016 by Drs. Dana Telem, Dawn Coleman, Janet Dombrowski, Erika Newman, Jennifer Waljee, and Gurjit Sandhu. As Dr. Telem explains it, “It started as a conversation between us […] about how we never really felt gender until we started approaching mid-career shifts. We wanted to address the issue of advancement of women in surgery since it is not just a pipeline issue.The goal is to figure out how we promote each other and how we develop the essential skills we need to get to the next step and [..] how do we disseminate this knowledge to others.” It wasn’t just about addressing issues facing women in surgery. It was born out of the idea of creating leadership.

Conference registration was free for attendees and completely funded by the University of Michigan Department of Surgery (incredible visible support #HeforShe!!!). All section heads also sponsored travel scholarships. I was lucky to win one of these scholarships via a Twitter contest. The first day of the 2-day conference focused on self-improvement with a session entitled “From Surviving to Thriving”. We learned tips for resilience from Dr. Dawn Coleman who talked about both individual and system-level strategies for preventing burnout. Dr. Erika Newman shared personal stories to exemplify how to maintain interpersonal relationships, both personal and professional, to help your career soar. Next we moved on to personal wellness advices from Dr. Amalia Cochran. “Be strategic in your yes’s and definitive in your no’s; every yes is a no to something else in your life,” she advised. Surgical education scientist Dr. Gurjit Sandhu talked about pushing yourself out of your comfort zones to find your zone of proximal development and grow. Finally, women-in-surgery champion, Dr. Justin Dimick, gave a talk on amplification and sponsorship. The first night ended with a networking reception where I got to meet some of my surgery “heroes”!

The next day focused on giving us tools to become an effective leader. All participants were asked to fill out behavior surveys prior to the conference to analyze our personal and leadership styles and our conflict management styles. Executive coach, Janet Dombrowski , then used the results of our surveys to give two interactive talks about how to harness our leadership and conflict management styles to be effective leaders. Her advice can be summed up by tweeter extraordinaire, Dr. Susan Pitt:

Interspersed with Janet’s talks, we heard from women trailblazers in surgery who have succeeded in becoming leaders in the field: Drs. Jennifer Waljee, Aurora Pryor, Julie Ann Sosa, Rebecca Minter, Sandra Wong, Melina Kibbe, Heena Santry, Rebecca Minter, Julie Freischlag, and Amalia Cochran. The list reads like a “who’s who” of women in surgery! Each shared their personal hard-earned advice for advancing in surgery, ranging from topics of negotiation and conflict-management to navigating career challenges. The talks can best be summed up with the amazing visual abstracts created (on the spot!) by University of Michigan resident, Chelsea Harris.

While there have been many conferences dedicated to women in surgery, many have focused mostly on defining the issues that women face (such as gender bias, pay gaps, etc.). This conference was unique as its goal was to give junior women in surgery the tools to overcome these problems in order to achieve leadership roles. To say I left the conference inspired would be an understatement. There was so much positive energy buzzing throughout the entire conference. Everyone was genuinely supportive of each other and dedicated to the mission of advancing women in surgery. The strategies we learned for communication and conflict management are tools I have already started incorporating into my everyday life as a chief resident. The rest, I will keep in my mind as I start searching for my first job in the next few years. And in the meantime, I will remain in awe of the opportunity to meet some of my real-life heroes!

@JFreischlag
@MinterWiscSurg
@kibbemr
@AmaliaCochranMD
@AuroraPryor
@heenastat
@Jasosamd
@sandralwong
@MIchiganWSC
@DanaTelem
@ColemanDM_vasc
@JCDAdvisors (Janet Dombrowski)
@EAdamsNewmanMD
@waljeejenn
@GSandhuSurgEd
@CAHarrisMD
@JDimick1


Dr. Andrea Merrill is a chief resident in general surgery at Massachusetts General Hospital. During her residency she did a year of breast surgery outcomes research followed by a yearlong editorial fellowship at the New England Journal of Medicine. Next year she will be starting a surgical oncology fellowship at the James Cancer Hospital at Ohio State University. She is currently serving as the AWS Resident and Fellow Committee representative. You can find her on twitter at @AndreaLMerrill.

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 Fastest Growing Cancer in the USA

By Anya Costeloe, DO

In honor of thyroid cancer awareness month just wrapping up, I will give a brief overview of the epidemiology, diagnosis and treatment of thyroid cancer.

In terms of incidence, thyroid cancer is the fastest increasing cancer in the USA. The number of cases has tripled over the last 30 years. Women have a significantly higher incidence of thyroid cancer than men; about 75% of thyroid cancers occur in women. Other risk factors for thyroid cancer include increasing age, history of radiation exposure (especially if at a young age), iodine deficiency and family history. Approximately 5-10% of thyroid cancers are hereditary. The four main types of thyroid cancer are papillary (60-70% of all thyroid cancers), follicular (10%), medullary (3%) and anaplastic (<1%).

The US Preventative Medicine Task force recommended against routine screening for thyroid cancer starting in May 2017. However, physical examination of the neck is still an important part of a yearly wellness exam and any palpable thyroid nodules should be further investigated with a thyroid ultrasound.

How does thyroid cancer present?

Thyroid cancer most commonly presents as a painless, palpable solitary nodule. It is typically asymptomatic but patients may present with a feeling of fullness in the neck, hoarseness, a change in voice quality, difficulty swallowing and tightness in the lower neck.

Thyroid stimulating hormone (TSH) level is a sensitive measure of hyperthyroidism or hypothyroidism, however, thyroid malignancy cannot be diagnosed or ruled out based on it. Hyperthyroidism can be caused by a “hot” nodule, meaning it is producing thyroid hormones and usually hot nodules are benign.

How is it diagnosed?

When a patients has a suspicious nodule, the first step in the diagnosis is a fine needle aspiration biopsy (FNA). A pathologist will look at the cells from the FNA to determine whether the nodule is malignant and determine what type of cancer is it. It is not uncommon for the FNA to be inconclusive, which means that cancer can’t be ruled out. Previously, these patients would have a total thyroidectomy. However, in 2011 a new test called the Afirma Thyroid FNA Analysis was created. This test reduces the diagnostic uncertainty in patients with inconclusive FNA results.

How do you treat thyroid cancer?

In almost all types of thyroid cancer except for thyroid lymphoma,the main treatment for is surgery . Usually a thyroidectomy is performed, but in some cases a thyroid lobectomy may be done, in which only half of the thyroid is taken out. If the cancer has spread to any lymph nodes, then a neck dissection will be done to remove those nodes.

After the thyroid is removed, patients need to take thyroid hormone replacement tablets because they no longer have the cells that make this hormone. In papillary and follicular types of thyroid cancer, replacement hormones are important because they tell your body that there are sufficient thyroid hormone levels. This prevents the re-growth of cancer cells.

Another form of treatment is radioactive iodine, which is taken up by thyroid cells after being swallowed in pill form. It is toxic to the thyroid cells. It is used in papillary and follicular types of cancer and it is usually used in addition to surgery.

What’s the prognosis for patients with thyroid cancer?

The prognosis for different kinds of thyroid cancer varies, however, thyroid cancer has a good prognosis overall, 98.2% survival at 5-years.

  • For follicular and papillary cancers age is the most important prognostic factor and patients younger than 45 have a better prognosis.
  • Age is not as important in medullary cancer. Patients with medullary cancer that has not spread beyond the thyroid have a 95% 10-year survival.
  • Patients with medullary cancer that has spread to the lymph nodes have a 75% 10-year survival.
  • Survival decreases dramatically if there are metastases, which is why early detection and treatment are so important.

Check out the following websites for more information about thyroid cancer:

https://www.thyroid.org/thyroid-cancer

https://www.cancer.gov/types/thyroid/patient/thyroid-treatment-pdq

http://www.thyca.org/how-to-help/awareness/

https://www.veracyte.com/our-products/afirma

References

Haugen, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. Jan 2016, 26(1): 1-133.

 

Anya Costeloe, DO is a first year otolaryngology resident at St. John Providence in Michigan. She was born in Russia and immigrated to the US when she was seven years old. Dr. Costeloe received a bachelor’s degree at University of Colorado, Boulder in molecular, cellular and developmental biology and in Spanish. She attended medical school at Western University of Health Sciences College of Osteopathic Medicine in California. Outside of medicine, Dr. Costeloe enjoys traveling, snowboarding, hiking and yoga.

Implicit Bias

By Doreen Agnese, MD

As the deadline approaches for this blog, I again wonder what topic will be interesting to discuss. I try to gather inspiration from prior blog posts, and as I scroll through the list of recent blogs, the one thing that I notice most acutely is how much older I am than all of the other contributors. Maybe this blogging is a young person’s game….but as I sit here thinking about what to say, I see a reminder about surgical grand rounds this week. The topic this week is “Unconscious Bias in Healthcare—A Primer and Strategies to Reduce the Impact of Unconscious Bias.” Included in the announcement is a link to the implicit association test, a well-validated web-based test to determine unconscious associations or preferences (https://implicit.harvard.edu/implicit/). I realize that we have come a long way with respect to explicit bias since I was a trainee, but women are still underrepresented in academic medicine. I took the gender-science IAT and was surprised to learn that I had a moderate unconscious preference for women in liberal arts and men in science. I did counter that with a moderate association with male with family and female with career. These results did surprise me, but point out the fact that implicit bias runs deep and it’s not something that we can really control. The times are changing, but how can we get at something unconscious? Is there hope? I think so.

Thinking of implicit bias made me think of 2 things that happened to me recently, one of which really fills me with hope for the future. The first was a pretty typical story. I had some time between cases and met a colleague in the café for lunch. She is also a female surgeon (urologist) and we were both in scrubs with our bouffant caps on. As we enjoyed our lunch, an elderly couple came in. The gentleman was in a wheelchair and his wife was trying to navigate between the tables. We came to her assistance clearing the tables out of the way so they could enjoy their lunch. She of course thanked us for our trouble and asked, as so often happens, if we were nurses. “No,” we replied, “we are surgeons here.” This situation is not a new one to anyone, and despite the widespread appearance on social medial of the “I look like a surgeon” campaign, all too often male nurses are confused for physicians and women in medicine are assumed to be nurses.

The second situation was a much more surprising one. I was leaving the hospital after a long day in the operating room on the same evening that there was a One Direction concert playing at the stadium. As you might imagine, campus was filled with quite young One Direction fans and my car was parked between the hospital and the stadium. As I left work in my scrubs (please don’t tell anyone—I know I’m not supposed to!), I saw some very cute kids, a boy and a girl who I assumed were siblings, who couldn’t have been more than 5 or 6. They were hurrying to the concert carrying their carefully crafted signs. As I walked up behind them the little boy turned around, saw me in my scrubs, and said to his sister “Look, a surgeon!” That was certainly a first for me! It renewed my faith that these stereotypes can be broken. We are not born with implicit bias. It is learned. And if we can adopt these biases, then I am sure we can employ strategies to address them. The first part is in recognizing the problem figuring out how to overcome our unconscious biases. The other key part is focusing on our young people, who have not yet developed these biases, and help them to keep an open mind.


Doreen Agnese, MD is Associate Professor of Clinical Surgery in the Division of Surgical Oncology at The Ohio State University.  She was born and raised in New Jersey.  She attended Drew University in Madison, NJ, and completed medical school and surgical residency training at Rutgers Medical School in Piscataway/New Brunswick, NJ.  Dr. Agnese completed a surgical oncology fellowship and training in clinical cancer genetics at The Ohio State University.  Her clinical practices focuses on care of patients with breast cancer and melanoma and those with significant personal or family history of cancer.  She cycles in Pelotonia every year to raise money for cancer research.

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.

New Therapies for Childhood Cancer

By Madeline B. Torres M.D.

Arriving at the National Institute of Health (NIH) as a surgical oncology research fellow this summer felt like winning the golden ticket into Willy Wonka’s factory. I entered with high hopes to tackle one of the multiple roadblocks to the treatment of one of the many adult cancers. Little did I know that my path would lead me to investigate therapy options for the treatment of neuroblastoma. Neuroblastoma is the most common solid childhood cancer outside of the brain1, with an incidence of 9.5 cases per million children; that is approximately 700 new cases per year diagnosed in the U.S. alone. Standard of care includes surgery and adjuvant chemotherapy. Recent studies have shown a new promising target for neuroblastoma therapy, Glypican-2 (GPC2), a cell surface oncoprotein that may play a role in neuroblastoma growth and development. In studies by Li et. al. and Bosse et. al., neuroblastoma tissues showed high expression of GPC2 but it was not detectable in normal tissues, making it a promising therapeutic target.

However, neuroblastoma isn’t the only childhood cancer. The five most commonly diagnosed cancers in are: leukemia, brain and central nervous system tumors, neuroblastoma, Non-Hodgkin lymphoma and Wilm’s tumor. There are multiple subtypes of leukemia, the most common are Acute Lymphocytic Leukemia (ALL) and Acute Myelogenous Leukemia (AML), both have a high 5-year survival rate ranging from 80% for ALL and 60-70% for AML. Despite the high 5 year survival rate, some children are resistant to treatment needing more research to develop new treatments. Tisagenlecleucel, is a recent breakthrough in treatment for chemotherapy resistant acute lymphoblastic leukemia (ALL) recently approved by the FDA. Kymriah is a type of Chimeric Antigen Receptor (CAR) T cell therapy, a form of adoptive cell transfer, a type of immunotherapy. CAR T cell therapy is often called a “living drug,” it consists of giving patients genetically engineered T cells (cells are usually obtained from a donor) designed to recognize and kill tumor cells. CAR T-cells therapy unlike Tumor Infiltrating Lymphocyte (TIL) therapy does not require the use of the patient’s own cells to create the medication.

Despite all these advances, scientists continue to work tirelessly to find new therapies for childhood cancers. September is childhood cancer awareness month. This month, I ask that you consider contributing to developing new therapies for childhood cancer. You can call your state representative and ask them to continue to fund childhood cancer research. Over the next two years, I hope to make the best of my time at the NIH and make a small contribution to the treatment of neuroblastoma.


Madeline B. Torres, M.D. is a research fellow in surgical oncology at National Cancer Institute (NCI) in Bethesda, Maryland. She completed two years of general surgery residency at Penn State Milton S. Hershey Medical Center in Hershey, PA. Dr. Torres was born and raised in El Salvador. She immigrated to the United States with her mother and brother at the age of nine. She then went on to obtain her B.S. in chemistry from the University of Colorado at Denver and earned her medical degree from the University of Utah School of Medicine. She became involved with AWS during medical school after working with AWS members Amalia Cochran M.D. and Leigh Neumayer M.D. whom she considers mentors. Her interests include: surgical education, surgical oncology, work-life balance and encouraging women and minorities to pursue surgery and careers in medicine.

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 to Maximize your CV in Medical School

By Faith Robertson

The curriculum vitae (loosely translated from Latin as “Course of life”) is a concise overview of your experiences and academic achievements over time. As a medical student, you will often be asked to provide a CV during applications for awards, grants, and scholarships, and on sub-internships for your specialty during 4th year rotations. Starting this document early on, and updating it periodically during your medical school journey, will not only help you prepare for those last minute grant opportunities, but also elucidate where you can continue to improve.
The rules for outline style and content are inexact, but we will briefly discuss pertinent points on how to Reorganize, Reevaluate, and Revive your CV.

1. Reorganize

Your CV should be easy to read. Period.

A study published by The Ladders (2012) tracked the eye movements of 30 professional recruiters as they reviewed job applicant’s resumes and online profiles. The results demonstrated the importance of how text organization dictates a reviewer’s course, that is, where and how long a person focuses when digesting information. Shockingly, this study revealed that while recruiters self-reported spending 4-5 minutes per resume, the study results demonstrated that most spent 6 seconds on their initial “fit/no fit” decision. Granted, this study’s credibility has been questioned due to method quality, but many agree, organization is key.

In general, your format should mirror the following:

• Education
• Honors/Awards
• Research Experience
• Service/Volunteer Activities (+/- Leadership within section or separate)
• Publications
• Submissions (for articles submitted but not yet published. Do not include articles in progress, as this work is covered under Research)
• Presentations (can divide into Oral and Poster)
• Professional Organizations
• Other Interests

If a category or heading does not apply to you, omit it; you can maintain a separate master version of your CV that contains these categories as placeholders for future updates. The AAMC has an excellent page on Preparing Your Curriculum Vitae that includes additional tips and templates, as does Vanderbilt School of Medicine.

2. Reevaluate

Now that you have augmented the aesthetics and organization of your CV, it is vital to assess the story you are telling. Yes, your CV represents the continuity and temporal accuracy of your current (and past) accomplishments, but it should also guide the reviewer in understanding your mission and vision. As mentioned above, maintaining a “Master CV document” can help you tailor your CV to the present goal/viewer to strengthen the impression you leave.

Request feedback from faculty or specialists in your desired field. Elicit whether or not they can clearly interpret your trajectory thus far, and envision where you are going. Where are your shortcomings, and how can you improve?
3. Revive

Taking feedback into consideration, it is time to reevaluate where you can spend time making your CV more robust. Perhaps there is a research project you can pursue to demonstrate your knowledge of and dedication to your desired specialty that can bridge your interests from college or pre-clinical years to the interests you hold now. Or if you notice that the majority of “Awards” listed were from high school and college, try surveying announcements for award opportunities; it might be worth sitting down to write for that essay contest you have seen advertised in the weekly student news.

Overall, continuous improvement and innovation are requirements for success in today’s hyper-competitive environment. At the 2016 AWS New England Exchange, Dr. Sandra Wong, Chief of Surgery at Dartmouth Hitchcock, discussed “What got you here won’t get you there.” This concept of continuous improvement is central to our journey as surgeons, and I hope this brief discussion about relaying your “course of life” will help you along the way.


Faith Robertson is a 4th year at Harvard Medical School, was the previous Vice Chair of the AWS National Medical Student Committee, and currently serves as an International Representative while taking a year-off to get an MSc in Global Surgery at King’s College London. Faith plans to pursue a career in Neurosurgery and Health Systems Improvement.

Twitter: @FaithCRobertson
LinkedIn: https://www.linkedin.com/in/faithrobertson/

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.

#DearIntern: Social Media Mentorship to the Max

By Marissa A. Boeck

In April 2015, Dr. Amalia Cochran had an idea. The United States Match Day had come and gone, and while most fourth year medical students were enjoying their last moments of unbridled freedom before the oft feared start of intern year, Dr. Cochran was thinking ahead. As a burn surgeon and Vice Chair of Education & Professionalism at the University of Utah, she was well-versed in the significance and misperceptions surrounding July 1st, and knew it would come sooner than most would imagine. To ease this seemingly overnight transition from student to doctor, she reached out to gather intel on how to prepare for the big day from one of the best (and arguably still untapped) resources in medicine: Twitter. The initial message asked:

 

Dr. Cochran’s followers and interconnected community took it from there, and #DearIntern was born.

Since the first post and subsequent blog, the hashtag has re-appeared annually as the new year approaches. Although typically surgery participants predominate, the advice applies broadly. Related messages have used #DearNewIntern and #WelcomeToMS3, among others. This also includes #TipsForNewDocs, started back in August 2011 in the United Kingdom as an advice hashtag for rising junior doctors across specialties, which has successfully maintained a nearly year-round presence since.

Upon reviewing expert posts from the past couple of years, broad themes emerge that can be organized into a Top 12 #DearIntern List of Advice:

  1. Medicine is a team sport: Be open to and respectful about input from others; this applies to nurses, physician assistants, colleagues (both in your specialty and others), superiors, and students. Sometimes you know more, sometimes others do, but diversity of input is always valuable. Show appreciation when and where it is due. Also, if someone calls for help, help them, don’t ridicule.
  2. Golden rule: treat others as you would like to be treated…or as you would want your grandma/important person in your life to be treated. It is almost always better to be working in the hospital than to be admitted to it; try to keep this perspective in mind during hard times. After all, we do this for the love of patients.
  3. Load the boat: Find help from senior staff members early and don’t be afraid to ask, this is not a sign of weakness. It is better to call for help when not required, than to not call when required or when a rescue opportunity is lost. Also always have a plan…and a back up plan.
  4. When in doubt, look at the patient: Electronic medical records have replaced a significant proportion of physician interactions with patients. An assessment for potentially acute changes in status requires actual facetime with your patient. Know them well and listen to them, they can teach you invaluable lessons. Keep a running list of interesting cases and patients you learned something new from; it’ll come in handy later.
  5. First impressions can be lasting: Guard your reputation with your life, but also know there will be chances for clarification and/or redemption.
  6. Immerse yourself in your craft: Scrub when the opportunity arises and be prepared (diagnosis, indication, anatomy, procedure, skills). Remember that you can learn a lot by observing an operation; never underestimate your opportunities.
  7. Show up (early) and do your best everyday: Work hard, as there is no substitute for due diligence. Be affable and available.
  8. The truth shall set you free…or at least keep you out of trouble. Be humble and admit when you don’t know something. We all make mistakes; and then learn from them to avoid making them again. You’re going to be yelled at. Don’t try not to be yelled at, just try to do the right thing for your patients. Trust but verify, never assume.
  9. Write down everything: Trust us.
  10. Ask questions and be curious: Read everyday, even if just for 10 mins, and learn a new fact. Be flexible, as medicine is always changing.
  11. Take care of yourself so you can take care of others: Keep a hobby and do it. Your wellness is important; eat sensibly, exercise, and find support in your family and friends.
  12. Have fun: Surgery is an awesome privilege. You’ll have good days and bad days, but the best moments in your professional life are ahead of you. Always try to keep your head up. Remember you are a valuable asset to the team.

Through posts associated with the hashtag, additional valuable resources and commentary have come to light, which include:

How to be the Best Intern in the Hospital by Dr. Mary L. Brandt (June 5th, 2010)
Hints For New Residents by Skeptic Scalpel (June 20th, 2011)
Internship: Ready, Set, Go! By Dr. Callie Thompson (2013)
What Every Resident Should Know on Day 1 (July 7th, 2014)
Stuff Surgery Interns Should Know, Behind The Knife podcast (June 23rd, 2015)
The “July Effect” and Tips for New Doctors by P.F. Anderson (July 1st, 2016)
#JulyOpportunity by Drs. Kevin Sexton & Julie Duke (July 28th, 2016)
You’ll mess up but save the day: advice to new doctors as they start work as interns by Dr. Ilana Yurkiewicz (June 29th, 2017)

Overall, this crowd-sourcing exercise highlights one of the many strengths of Twitter and social media: to generate global conversations connecting experts to those just starting out, and everyone in between. You’re able to shed the limits of location, time constraints, and hierarchies, and have the opportunity to connect with anyone, anywhere. Unlike published works, which retain their value for certain uses, these platforms uniquely enable a free flow of information that is constantly being revised and expanded, maintaining relevance to the here and now. On the flipside, the seemingly no-holds-barred rules to participation reinforces the need for discernment by the receiver, which is a useful skill to cultivate throughout one’s career both on and offline.

So what’s stopping you? Join the conversation, add your voice and knowledge, and impact the #NextGen of surgical leaders across the globe!

Acknowledgements: Thank you to Dr. Amalia Cochran for her original idea and blog post input, and to the dozens of #SurgTweeting community members who contributed to the #DearIntern hashtag over the past few years. This post would not have been possible without your contributions and wisdom!


Marissa A. Boeck MD, MPH is a chief general surgery resident at New York Presbyterian Hospital – Columbia, after which she will pursue a fellowship in trauma/critical care. 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.

A Medical Student’s Perspective: Reflections and Lessons from Rural Surgery

By Kaylynn Purdy

I am, as far as anybody is aware, the first person from my small mining town in British Columbia to go to medical school. Growing up, my town was often in a state of physician shortage.We relied on a few long-term physicians who spent their entire careers there, but the rest seemed to come and go like the seasons. Whenever we lacked physicians, the suffering and frustrations in my community was evident.The rural doctor shortage in Canada is part of what motivated me to pursue a career in medicine. I wanted to serve the often-forgotten rural/remote communities, much like my hometown in Canada.

Early in my second year of medical school, I felt like I had won the medical student lottery. I had gotten my top choice for my first month-long “Integrated Community Experience” in a rural town in Northern Ontario with a population of about 10,000 people. I chose this town because it was one of the few rural Northern communities that had a fully functional operating room (OR) staffed by GP anesthetists, one general surgeon and another general surgeon with a specialization in vascular surgery. Students were expected to spend at least one day per week in the OR, and often, as first assistant. As a newly minted MS2, the prospect of being a first assist was both exciting and terrifying. It was during this month that I discovered my love for surgery. Yet, it wasn’t until well into my third year of medical school that I began to appreciate what it truly means to be a rural surgeon.

It was a Saturday night when I got a call for an emergency appendectomy that was to happen in about 20 minutes. My only regret that night was not eating dinner sooner. As I rushed out the door of the retirement apartment complex I was assigned to live in for the month, I stuffed a granola bar in my mouth and waved hello and goodbye to an elderly woman walking outside with her dog. It was Halloween weekend and I frantically scraped frost off my car, worried that I would be too late to scrub in.

I sprinted up the 4 flights of stairs to the OR, feeling the grooves worn into each step by the catholic nurses, who ran the hospital in a bygone era, under my feet. One of the scrub nurses was setting up- she let me know that the surgeon was waiting in the doctor’s lounge and that the patient would be coming up from the ER soon. Being an old hospital and modeled after a more male-dominated medical profession, the doctor’s lounge was also the men’s changing room. I cautiously opened the door, fearing I might see something I didn’t want to see, and saw the surgeon sitting on the couch eating baby carrots. He gestured for me to sit, and offered me a carrot. Given that he was known to rarely acknowledge the presence of medical students, I felt as though this gesture was a sign of appreciation for coming in when the rest of my colleagues had gone home for the weekend. We chatted about cycling, and doping in le Tour until the patient was in the OR. As we walked out of the lounge he looked at one of the scrub nurses and said “Kaylynn is going to drive the camera tonight.” I didn’t even know what that meant at the time as this was the first laparoscopic surgery that I had scrubbed in for.

In true rural medicine form, I also had the opportunity to learn how to administer anesthetic, put in the patient’s Foley catheter and then shave his abdomen before it was finally time to scrub. Since that day, I have come to see scrubbing as a moment of calm and meditation, a moment to collect myself before walking into the OR. It is my three minutes of tranquility to calm my nerves.

I focused on controlling the camera like it was the only thing that mattered in the world. Soon my nervousness dissolved and I was fully engrossed in what was unfolding on the screen before me. It was like being absorbed into a Netter’s textbook. Time stood still. As the appendix was removed, I was asked to take a “sweep” look at the rest of the abdomen. The gallbladder was massive, inflamed and angry looking. The patient was just a teenage boy and of course being Canadian, also a hockey player. That night he had both his gallbladder and appendix removed. I felt simultaneously devastated for him, but in awe of what I had just witnessed and had been a part of at 11pm on a Saturday night.

At the time, I was on a high from the surgery itself. As I reflect on that night more than a year later, however, the awe of the surgery is less, but a different kind of amazement has replaced it. To me, it is almost magical that a surgery team can be called in from home and ready to operate in 20 minutes.With one surgeon on holidays, the other was at the beck and call of the people of his community 24/7. During my month-long placement, this single surgeon was the keeper and protector of health for an entire community. The respect that that the community has for its surgeons was incredible, because without them they would have to travel to a regional centre hours away for a surgical consultation, to have a wound checked, or to take care of a sick child.

No matter the size or centre that a surgeon practices in, there are uniting features of surgeons across the world. These include being able to quickly gain the confidence of your patients, trusting your gut and your training, knowing when to push the boundaries in a “Hail Mary” situation and knowing your limits. In rural surgery, these characteristics seem to be even more important, as there is often no back-up, nobody to call in for help. In rural surgery and rural medicine, often it is just you, your small team of people who are also your friends, and your patient who just might be your neighbor or an old high school teacher. There is simultaneous isolation and profound intimacy in rural surgery.

Some people might consider rural surgeons the “Cowboys” (and Cowgirls) of medicine because of how they try to save a life with limited resources. These surgeons feel compelled to try to reduce the suffering and burden that is imposed when patients are forced to seek care far from home. After living and breathing rural surgery for a month, then spending eight months of my clerkship in a semi-remote city, I see these surgeons as the quiet heroes of medicine. Nobody tweets about them, they didn’t just publish the latest research about cancer or develop a new technique to improve healing after bowel resections. They don’t work at prestigious university hospitals, but they are on call often for weeks at a time, ready to operate and ready to serve. They are often the hearts of the hospital and the lifeblood of a community. They are what allows people to retire and grow old in their communities knowing that they will have reliable essential medical/surgical care at home when they need it.

I might not be a rural surgeon “when I grow up,” but I hope to one day be a pillar in my own hospital and community. I hope that my surgical team are also my friends and that I think of each patient like my neighbor and not just as a case. I still have the picture of the gallbladder from that Saturday night surgery. I kept it because it is a reminder of who and what I want to be one day: A surgeon who places her community before all else.


Kaylynn Purdy is now a 4th year medical student at the Northern Ontario School of Medicine in Thunder Bay, Canada. She hopes to pursue a career in Neurosurgery with a focus on timely access to surgical services. When not in the OR, she can be found skiing in the winter or out riding her bike in the warmer months.

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.