To mammogram, or not to mammogram?

A slightly personal blog entry today in an area of medicine that’s a bit outside of my scope of practice.  I hope you’ll bear with me because it’s an area I care deeply about- just one in which I happen not to specialize.  I’ve lost a couple of friends to breast cancer and have seen friends lose spouses and parents to it.  I’ve watched survivor friends go into remission then cure.  I’m proud of my involvement for the last 5 years in the Susan G. Komen 3-day because it has managed to give me a sense of doing something about this rotten disease.  However, I do cringe when I see the signs on the route about mammography because they are just a bit misleading…

I’m 45 years old.  I’ve been getting annual screening mammograms for the last 5 years, since I turned 40.  At age 41, I paused to wonder if I really “need” an annual mammogram, particularly because that’s the year that the highly controversial USPSTF recommendations came out; as a woman in my 40s with essentially no clinical suspicion, best evidence says I probably don’t need an annual mammogram, and may not need a biennial one.  If you risk assess me using the Gail model, I’m below-average risk for my age.  And, of course, as a clinician who tries to be mindful of resource utilization, there are all of the issues that come with over treatment for many lesions found on mammography (discussion of this is around 26 minutes in if you want to fast forward- but it’s a great PBS show and worth the 50 minute watch).

Then, last week more fodder in the form of the 25 year follow-up from the Canadian National Breast Screening Study. Conclusion?  “Annual mammography does not result in a risk reduction in breast cancer specific mortality for women aged 40-59 beyond that of physical examination alone or usual care in the community.”  Please recognize that this says NOTHING about diagnostic mammography, which is an entirely different study and one that is both meaningful and helpful.  The issue here is screening and how that should be handled.  As a woman with a less-than-average risk of breast cancer, do I really need annual screening, or even every-other- year screening? The more I think rationally about this question, the more I realize the answer is probably not.  But if I read the American Cancer Society recommendations I do, and if I read the National Cancer Institute recommendations, I should have annual or biennial screening.  Yet the science keeps telling me that both of those sets of recommendations are wrong, at least for me.

Now, for the influence of logic on behavior, did I go get my mammogram this morning that has been scheduled for the last 3 months?

I did.  But I’m not sure I’ll do the same next year.


Academic surgery

Is tenure making us irrelevant?

First, a disclosure:  I am a tenured surgery faculty member at the University of Utah.  That said, I think that the bias I bring to what I’m about to write is quite the opposite of what might be expected based upon that fact.

An op-ed by Nick Kristof in last Sunday’s New York Times has touched off a firestorm debate in the blogosphere and on Twitter regarding the role and relevance of tenure for those cloistered in the ivory tower of academia.  This column hit home for me for two reasons, both quite personal.

A significant portion of Kristof’s column digs into the fact that in political science in particular that those in academia have largely removed themselves from the public dialogue about politics.  Some want to argue that putting oneself into the public arena via Social Media is anathema to academic productivity (n.b.  a significant portion of my scholarly efforts right now are focused on demonstrating this is a myth).  The International Studies Association, an organization at which I presented research in one of my prior incarnations, recently proposed that editorial board members for their journals not be allowed to blog.  Perhaps the reactionary nature of what Kristof describes in his essay serves as a solid reminder to me why I left my graduate studies in political science and have looked back with no regret.  I simply could not see how my complicated econometric models were going to effect political change since they were incomprehensible to the Mothers marching in the Plaza de Mayo.  I was fortunate to work with some incredibly brilliant minds during my graduate career in political science, particularly having Mike Ward as my research mentor, but I do have a sense of frustration that most people have no knowledge of this community of individuals hard at work on issues of peace, human rights, and conflict resolution in international relations.  I know I could have had a good and intellectually challenging life in political science; I just happened to have an epiphany during my 2nd year of graduate school at CU that it wasn’t the life that I was supposed to have.

Then, there’s this issue of tenure in terms of how it relates to academic medicine.  The whole debate about tenure’s appropriateness and relevance is nothing new.  Kristof, however, quote Anne-Marie Slaughter that disciplines “have become more and more specialized and more and more quantitative, making them less and less accessible to the general public.”  I can think of no field for which that is more troubling than in medicine, particularly with the current push for patient and families to participate in shared decision making.  Participate in a little thought experiment with me here, if you will:

  • Criteria for academic promotion is scholarly activity on arcane things
  • Arcane things are, by definition, inaccessible and incomprehensible to the general public (and, for that matter, to people outside of a given specialty)
  • Patients and families are supposed to use what information to participate in “shared” decision making?

Summary:  Traditional scholarly activity in medicine is contradictory to what is being proposed as a best practice in social medicine.

While that may be an exaggeration, it sets up what we all really need to think about- why do we do what we do in terms of our scholarly work, and how can we make sure that those who most need to know about it (i.e. the patients, if we’re doing clinical and translational work) know what we’re learning?  Because if we’re in medicine, isn’t the focus supposed to be on the patient and what is best for them?


Academic surgery Leadership Surgeons are surgeons

Recharged and recommitted

Last week was the Academic Surgical Congress, the annual joint meeting of the Association for Academic Surgery and the Society of University Surgeons.  I’ll start by being very honest:  as someone who didn’t go to medical school or complete my residency at a “powerhouse” program, I’ve historically been a little intimidated by the meeting.  There are LOTS of heavy hitters there with long pedigrees.  The other issue for me has been that I’m in a somewhat unusual clinical specialty (there simply aren’t that many in academic who identify as “burn surgeon”), and my scholarly focus has been education.  Historically, that education focus has not been something enthusiastically welcomed by the Academic Surgical Congress.  Justin Dimick, the President-Elect of the AAS, and I were discussing being at this meeting many years ago when I was one of two or three people presenting education work.  He was building his already-impressive career as an outcomes/ health services researcher, something which also wasn’t quite yet in vogue (though certainly was moreso than education research).  It was a lonely-ish place for both of us, something that is blissfully no longer true.

In 2013, I got plugged in to be part of the official “Twitter Team” for the ASC, which threw me together with this amazing crew:

2013 twitter team

For the record, those are my illustrious coauthors for the presentation I posted last Thursday on the use of Twitter at the 2013 Academic Surgical Congress.

This year,  I arrived and almost immediately got to reconnect with these two friends and colleagues:

photo 1


And, of course, we had our mandatory “Tweet-up” (which only captures a handful of those who engaged with social media during the meeting):


I attended paper sessions, I participated in a panel on Transitions to Practice Programs in surgery (more on that in a week or two!), I got far more credit than I ever expected for being innovative with my use of social media, and with this blog in particular.  I got to catch up with friends and I made some new friends.  We’re incubating some more SoMe projects (Twitter journal club, people- hang on to your hats!) and kicking off some new research collaborations.  I helped a couple of people get started on Twitter.  I had a fangirl moment meeting Skeptical Scalpel.  I got teased by a colleague for having my iPhone open to my Twitter account- while it was sitting on top of my Bullet Journal (which is, yes, entirely analog, and I love it).  I was moved by a quote from Hiram Polk, in which he stated, “Build your friendships…because these are the people you will know and work with for the rest of your life.”

In short, I built my friendships.  I engaged.  I had fun- yes, fun- at a surgical meeting.  There was a vibrancy, an enthusiasm at this meeting that was invigorating.  New ideas weren’t just being tolerated, they were being embraced.

Oh, and I wasn’t intimidated at all by those people with “better” pedigrees than mine.  As it turns out, we all put our pants on one leg at a time, and we’re all just trying to push surgery forward in terms of patient care and mentorship for those coming behind us.

Take risks. Create. Care. Connect.  That’s what I brought home from San Diego.



Academic, my Dear Watson

Yes, Social media can be academic.

I’m making a heartfelt effort to bring this forward in Surgery, and I believe that many are starting to drink the Kool-Aid (R). We got a great response to the talk I’m posting here, and there has been SO much buzz about how the AAS is thinking forward with what we’re doing.  It’s great to be in a place of leadership, of innovation, rather than being reactive.

Enjoy the show!

#AcadSurg2014 Twitter Talk from Amalia Cochran
Academic surgery Leadership

Can we negotiate that?

Did you cringe when you read the title question?  Was it the word “negotiate” that caused it?

And how are your skills at asking for things you need in your work environment?

Sure, salary is important, but what about other resources?  Office or lab space, technology, support staff…the list is almost endless in academic surgery.  Ordinarily, I like to remind my mentees to be grateful for opportunities.  Negotiating is the one exception- while it’s okay to be a bit grateful, don’t let that gratitude stand in the way of getting what you both need and deserve.

So, how good are you at asking for those things?

Chances are if you’re a woman, the answer is, “Not very good,” and that’s if you ask at all.  This isn’t a problem isolated to women surgeons, but one that impacts nearly all women in business- and one that certainly impacts quite a few men.  I first became cognizant of the extent of this problem when Evelyn Murphy from The WAGE Project spoke at an Association of Women Surgeons meeting.  One of the important things that Evelyn did during that meeting- and again when we had her speak at a regional women surgeons’ conference- was make all of us boldly state, “I want my two million dollars!”

Where does that number come from?

Over a professional lifetime, what starts as a $34,000 difference (per annum) adds up to $2 million.

Wage gap by education

US Census Wage Data from The Wage Project

How does this happen?

Quite honestly, the root of the problem is that women are less likely to ask/ negotiate.  One statistic that sticks with me is that while 57% of men will negotiate salary for their first job, only 7% of women will. Nice girls don’t ask for things in the workplace, right?


Yes, sociology says that as women we are more likely to expect to simply be recognized for our good work (author’s note:  I am absolutely, positively guilty of this, and it’s a topic we’ll have more of on another day).  Unfortunately, that’s not how the world works.  If we’re going to succeed, we must negotiate.

How do I change my mindset-because I really do NOT like negotiating?

So much of this is simple semantics.  Maybe you tend to view negotiation as a zero-sum game, one in which there is a clear winner and loser.  The truth is that it’s not simply about getting to an agreement- it’s about achieving a good agreement.  Negotiation is best when it is conducted with the idea of a positive-sum game, in which all parties win.  I’ll share something from Margaret Neale later that might just help you become more comfortable negotiating.

How can I better negotiate?

Plenty of resources exist out there, and all of them point to a few common themes:

  • Bring objective data supporting your request
  • Know your “ideal” position as well as your preferred alternative (BATNA- Best Alternative to a Negotiated Agreement)
  • Try to understand the motivation or interests of the other party, as well as their likely positions
  • It’s NOT personal.  Not even close, and don’t make it personal (or take it personally)

Women Don’t Ask is widely recommended, and should probably be mandatory reading for every female chief resident or fellow as they navigate their first faculty position.  Getting to Yes is another classic, and one that is less gender-specific.

And if you simply want a 15-minute reset, here’s a great talk from Margaret Neale of Stanford Business School teaching you how to use negotiations in both big and small areas of life.  It seems to me that practicing in the small-stakes settings sets you up for success when the stakes are big- such as your 2 million dollars.







Have you had your flu shot? Why not?

I’ll open with a confession:  One of my annual fall complaints involves getting a flu shot.  I’m one of those people who tends to get low-level flu-like symptoms after my shot, so I invariable set aside a day or so to not feel great afterwards.

That said, if I weren’t required to get a flu shot for work, this is the winter when I would have made sure to get one. It’s been a brutal influenza winter.  Want proof?  Here’s the CDC map from week before last:

usmap3 January 18


It’s bad.  It’s really bad.  I have heard countless tales of woe from my MICU colleagues about how many flu patients are in their ICU, and many of them do not fit the profile of who you would normally expect to be critically ill from flu (younger, no chronic diseases); this is likely because the most common strain this year is H1N1.  The common theme for almost all?  No flu vaccine.

How can you prevent yourself from getting the flu?

Obviously, the first thing I’m going to tell you is…get your flu shot!  I simply can’t emphasize that enough this year.  If you are over 6 months of age, you need one (with exceedingly rare exceptions). If you want to see if you’re an exception, look here.  The list of who should not get one is really, really short.

Other helpful tips for all of us?  Wash your hands.  Get rest.  Eat well.  Cover your nose and mouth with your sleeve when you sneeze or cough.  In other words, do all of those things that your Mom always nagged you to do (she was right).  Oh, and if you’re still smoking, the flu is another reason to quit.

How do I know if I’m getting the flu?

The video is far more efficient and effective than anything I can say.

Then what do I do about it?

First, be kind to those who work or go to school with you- STAY HOME!

Contact your physician.  If it’s early in the course, treatment with antivirals can reduce the length of time you’ll be ill with the flu.


For a great review of preventing and controlling flu, this NEJM Perspective piece provides an excellent summary.


Running with scissors?

Today I got into a conversation with an anesthesia colleague about bullying behaviors displayed by surgeons and the impact of that behavior on the perioperative work environment.  This is an area I’ve been doing research on for a couple of years now, trying to push our definition of disruptive surgeon behavior past “I know it when I see it,” and (more importantly) trying to understand why this behavior happens and how we move past it.  I’ll confess that part of my motivation is purely selfish- I’m a believer in having a pleasant workplace where everyone can work together for the same goal.  The more altruistic motivation lies in the impact that disruptive physician behavior has on patient care.  Any modifiable factor that can negatively impact the care of patients should be removed from the system, and this is clearly one.

In 2008, The Joint Commission released Sentinel Event Alert Issue 40, which included disruptive clinician behaviors as a key factor impacting patient safety.  A multicenter survey conducted that same year showed disruptive behavior to be nearly epidemic- and that my own people (general surgeons) were apparently the most disruptive.  Fortunately, this study also included a list of recommendations to help institutions address cultures that have historically permitted disruptive behavior.

Have the intervening years brought significant improvement, now that this issue has been named?  According to an Institute for Safe Medication Practices report released last year, not really.  In fact, this report notes that physical abuse, while rare, increased in frequency over the last decade.  Obviously, we can’t determine if it’s simply that people are finally willing to report it, or if there has been a genuine (and disturbing) upswing.  Respondents to the ISMP survey also indicated very clearly that prior experiences in which they had been intimidated of disrespected impacted future interactions, and would make them more hesitant to approach a disruptive provider about a safety concern with a patient.  In my mind the most unfortunate finding from the ISMP report was the frustrating expressed by responding providers in terms of redress of disruptive clinicians; 25% of respondents felt that their organization had an effective process for dealing with disruptive clinicians.

The ripple effect of disruptive behaviors on our trainees and students cannot be underestimated.  In my own research, medical students consistently identified that they were deterred from pursuing careers in surgery primarily due to negative role models.  While I know that these talented students will do well in their chosen fields, this represents an unnecessary loss from the potential talent pool for surgery, academic or otherwise.  For learners to self-select out simply because they are nice people who don’t want to turn into “THAT” surgeon  is embarrassing.

Do I have a solution?  Not yet.  The issue is complicated, with variables that have lots of shades of grey.  Am I committed to finding a solution?  Absolutely.  What we’re doing now isn’t working.  It’s impacting the safety of our patients and the future of surgery- both things I am passionate about.


“Why are the surgeons so quick to trach?”

The title question was asked of me by a pulmonary intensivist about a month ago.  My pulmonary colleague simply said, “The evidence doesn’t seem that great for it, so I don’t see the harm in waiting.  We keep people on the ventilator for a month sometimes in the MICU without a trach.” I was fascinated because I hadn’t really given the subject a great deal of thought (probably because I am one of those dreaded surgeons!), and the good news was that it drove me back to the literature to see what we really know.  I try my best to practice based upon evidence, acknowledging that in burns and critical care that evidence is limited at times.  And while I was pretty certain that a patient who has been on the ventilator for a month deserves a tracheostomy, I wasn’t sure when the best timing really is.

A great deal of the early literature on the benefits of early tracheostomy came from the trauma world; while early trach didn’t influence mortality in trauma patients, duration of mechanical ventilation and ICU stay were both shortened.  A recent propensity analysis in patients with traumatic brain injury confirmed these findings, but also added decreased rates of pneumonia, DVT, and decubitus ulcer to the benefits of early trach.

A 2005 systematic review that included a more broad ICU population demonstrated again that duration of mechanical ventilation and ICU stay were shortened, albeit with no reduction in mortality.  This lack of mortality benefit has been repeatedly confirmed, and was also shown with the 2012 Cochrane review of early versus late tracheostomy.  The Cochrane review appropriately noted the generally low quality of most studies in this area and the need for multicenter RCTs to provide definitive information.

Two posters at the recent Critical Care Congress addressed the issue of early tracheostomy, one in pediatric patients, the other in adults (but bringing a new angle in to the discussion).  As someone who does care for critically ill children who can and do have prolonged ventilator courses, the reduction in length of stay with early (<14 days) tracheostomy in pediatric ICU patients was notable to me.  However, I also recognize that their patient population in a “regular” PICU is very different from the pathophysiology of our pediatric burn population.  The Hopkins study that evaluated quality of life is the one that I find the most compelling, and is the most likely to inform my practice.  The simple fact that adult patients who underwent tracheostomy reported better quality of life than ventilated patients who did not, much less that early trach showed a significant quality of life benefit over late trach, encourages me to look at 10 days as a “fish or cut bait” point for tracheostomy, both in the Burn unit as well as the oncology ICU.

Now if I could just overcome my irrational fear of percutaneous tracheostomy…but that’s a blog for another day.


And now a word about sponsors

The idea of needing sponsors, in addition to mentors, is one that has received increasing attention over the last year or more.  We have all been taught throughout our careers that we need mentors- those people who talk to you, who help youy with our strategy for career development.  Mentors are the people who help you navigate the shark-infested waters that didn’t have a warning sign posted.

While sponsors may perform the same functions as mentors, there’s an important difference- a sponsor is that person who recommends you for a position or award, who connects you with other leaders, who helps you get to where you want to be.  In short, they’re someone in a position of power who puts your name in front of people in a good way.  They talk about you.  For women in surgery the idea of having a mentor is particularly crucial; data from the business world shows that a woman with a sponsor is more likely to ask for big opportunities, more likely to seek a raise, and more likely to be satisfied with her rate of advancement in her career.  We have no reason to believe this would be any different for a woman in academic medicine.

Sponsors, according to Sylvia Ann Hewlett, have three key characteristics:

  1. They believe in your potential and are therefore willing to take a risk for your benefit,
  2. They have a powerful voice at the table, and
  3. They provide you with the cover to take risks that you need to take to advance your career.

One of the important qualities to note about sponsors is that you need to earn their respect.  If they don’t believe in your abilities, they simply aren’t going to stick their neck out for you.  That means that your part of the sponsor relationship is to make the person who sponsors you look good; you don’t want their peers (other people in positions of power) to ever question why they keep your name in front of them.  As one of my own mentees has explained what you need to do as someone being sponsored, “Say thank you, get things done that you committed to, and say thank you again.”  I would assert that her attitude is completely appropriate, and I don’t say that simply because I have sponsored her for a variety of activities.

Where is the pitfall in sponsorship?  Quite simply, it’s in the fact that we tend to sponsor people who “look like us.”  This is a particular challenge for women and/or minorities who are in a field where they have not traditionally led (see: surgery).  One partial solution to this difficulty has been developed my two women colleagues who are more senior and myself in the form of a sponsorship group:  we all look for opportunities and awards that are suitable for other members of our small group (as well as women we all know who are following in our footsteps), and we co-nominate one another.  This strategy has consistently proven a successful one for our group, and one that I would highly recommend to others.  While we may not be able to rely on the “good old boys” network, our solution has been to create a “good old girls” network instead.  It doesn’t resolve all of the issues related to needs for sponsorship, but it’s an important start.

How has having a sponsor benefitted you?  What do you see as the practicalities and pitfalls of sponsorship- either as a sponsor or someone being sponsored?





Choosing Wisely in the ICU

It’s Thursday, so it’s clinical blog day.  As you are aware, I just got back from the SCCM Critical Care Congress in San Francisco, and while I’ve said that this Congress left me a bit less excited than they traditionally have there was still some great material to share.

The single item I am the most excited about is the extension of the Choosing Wisely campaign into the ICU setting.  Choosing Wisely is an ABIM initiative designed to encourage discussion between patients and physicians about the necessity of tests.  Because of my life as a medical educator, I also see it as consisting of important things we need to be teaching our learners.  There’s a terrific list for many different areas of medical care of things we probably shouldn’t be doing routinely, all of which are driven by evidence and by the specialty societies in the various fields.  The general surgery list was released as part of the initial group; as someone who hasn’t taken general surgery call in a while, I was delighted to see the Critical Care Societies Collaborative list.  And without further ado, the list with some comments…

1.  Don’t order diagnostic tests at regular intervals (for example, every day), but rather in response to specific clinical questions.  I’m a bit notorious for grilling my residents with the question, “What are you looking for?  And what are you going to do about it?” If the answers are “I’m not sure, and nothing,”  then a test isn’t worth ordering.  Cathy DeAngelis, the former Editor-in-Chief of JAMA uses a phrase that’s less eloquent but equally effective:  “It’s like picking your nose- what are you going to do if you find something?”

2.  Don’t transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 mg/dL.  I’m debating between two stories here.  One is that of a self-assured neurosurgery intern who, when I was the burn fellow, made an independent decision early one morning to transfuse a child with a hemoglobin of 8.5.  When I questioned him on it and he told me, “Well, it’s my practice…”  he was cut off promptly.  While there was also a bit of chastising that went on, I promptly referred him to the TRICC trial that’s referenced in last week’s blog.  All of that being said, in burns there is currently a prospective RCT replicating TRICC to see if the rules are the same for us (we were excluded as TRICC patients).  I promise a big, glittery blog post when that study is published.

3.  Don’t use parenteral nutrition in adequately nourished critically ill patients within the first seven days of an ICU stay.  That said, if someone is profoundly malnourished and they cannot tolerate enteral feeds, go for it.  Remember, though, if you can feed the gut…you should.

4.  Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.  Because of my anti-benzodiazepine bias, also discussed last week, I would add “Thou shalt not place a patient on a continuous infusion of a benzo for sedation unless you have exhausted all other options.”  We know that “Wake up and breathe” works, both in terms of delirium and in terms of pulmonary complications.

5.  Don’t continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.  One of the toughest parts of my job as an intensivist is working with families to make the move from our goals of care being cure to our goals of care being comfort.  Obviously this is the one of the recommendations that requires the most discussion with families, but for those who agree that their family member would not want a prolonged and somewhat terrible ICU course or would not want the functional result likely to come, it’s the most compassionate recommendation.  Palliative care makes a real difference when done well.

Choose wisely, readers, and I would love your thoughts on these recommendations.