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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.

 

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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
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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.

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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?

 

 

 

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Beware of the treadmill!

Parents, beware that awesome new holiday gift that you got.

You know, the treadmill?  The thing you got so that you can run indoors when it’s bitterly cold or when the inversion is awful?

Probably not an ideal use of your new gift...
Probably not an ideal use of your new gift…

(Photo credit to normanack)

That treadmill, which we all want to believe is a great tool for improving health, is a hazard for little hands.  Some of the earlier research on this came from our group almost 10 years ago, when we demonstrated that the 48 injuries that we saw over a 6 year period that almost half of treadmill friction injuries in children required skin grafts.  The children involved in these accidents are typically 3-5 years old, and while the injuries are typically small and limited to the hand surgery is required for half of more.  Further, long-term issues with scarring may complicate the care of these children.

A 2012 publication shows that this is not a uniquely American issue, with similar findings reported in the UK.  A more recent examination of US data looking at all home exercise equipment re-confirmed the specific relevance of treadmills and the impact they have on children under age 4.  Perhaps most importantly, when I speak with parents of children who have sustained a treadmill injury, they simply had no idea that this is a relatively common occurrence.  They weren’t told about it when they were sold the treadmill, nor was information about the risk of treadmills to little hands anywhere in the box.

As a burn surgeon I struggle with these injuries because I believe they are almost entirely preventable with good education, but with bad care they can have devastating functional outcomes.  I’m not going to tell you to haul your treadmill out to the curb if you have a preschooler in your home; that would be a Draconian response to something that is largely manageable.  Remember that for the many treadmill injuries that we see in our clinic every year, there are many, many more treadmills that are safely used in homes.

How can you equip your home for safe treadmill use if you do have a preschooler?

  • If your treadmill has a key that is required for it to work, remove it when you’re not using the treadmill and put it somewhere that little hands can’t get to it.  Trust me, your 3-year-old is smart enough to use the key if they find it.
  • Make sure that your preschooler isn’t nearby when you’re using the treadmill.  Preschoolers are by definition a curious lot, and they don’t necessarily respond to being told not to touch something (sometimes it’s more of an incentive, rather than less, based upon my experience).  About 1/4 of documented injuries in two different studies occurred when a parent was on the treadmill, which means that it’s best to separate the treadmill and your preschooler.
  • The treadmill should be in a location where the operation of it can be supervised OR it should be in a location that can be preschooler-proofed against entry.
  • Be aware!  Reading this was already a first step for you.
  • And finally, we’re here if you need us.
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“Flesh-eating bacteria!”

It’s honestly a bit impressive how much we hear about “flesh-eating bacteria” in the news.  Truth is, in the United States in a given year there are fewer than 3000 cases; our estimates aren’t very good because Necrotizing Soft Tissue Infections (NSTIs) are not a common disease.  NSTIs are just common enough that almost every physician will see a case at some point in their career, but they are not common enough for most physicians to develop true familiarity.  This lack of familiarity represents a true diagnostic challenge for many physicians when they evaluate a patient with cellulitis or a complex soft tissue problem that is not an NSTI- while they don’t want to inappropriately ask for help from the surgeon-specialist, they also don’t want to miss a disorder that is life-threatening in the face of inadequate management.  We do know that the reported incidence of NSTI has increased over the last 20 years.

So, what is an NSTI?

An NSTI is an aggressive soft-tissue infection that results in the skin and tissue below it dying.  This infection may be cause by a single type of bacteria or by multiple types of bacteria.  NSTIs are often life-threatening, and they require early and extensive removal of the infected tissue.  Patients with NSTIs also require post-operative care that can be quite complicated and usually have wounds from the tissue removal that require specialized care.

Who gets NSTIs?

Sometimes we can’t predict this; I have taken care of completely healthy women in their 30s who have an NSTI.  However, most patients who get an NSTI have some known health problem.  Our group’s study using NSQIP data showed that obesity, hypertension, and diabetes are all more common in patients who develop an NSTI.  Similar findings were generated by analyzing the NIS, which showed that obesity, diabetes, and liver disease were associated with NSTIs.

What does an NSTI look like?

Common signs and symptoms include redness, swelling, and tenderness of the infected area.  Unfortunately, these signs and symptoms are essentially identical to the clinical findings with cellulitis, which is not a surgical disease- it simply needs treatment with antibiotics for a full recovery.  A patient with an NSTI may present with an elevated white blood cell count and a decreased sodium level, but this is not always true.  The LRINEC score has been used to estimate the likelihood that a patient has an NSTI by giving point values for various laboratory values, with a score >6 having a 92% positive predictive value and a 96% negative predictive value.

What are the risk factors for mortality with NSTIs?

First, it’s important to understand that mortality from NSTI seems to be decreasing; two different recent analyses showed mortality rates of 9% and 12%.  This is likely attributable to better recognition of the disease, allowing for more aggressive early intervention, as well as improvement in critical care and wound care.

Patient age is clearly related to mortality, but severity of illness at presentation also plays a role.  Two different studies using NSQIP data have shown that emergent surgery is a risk factor for morality.  Last year, our group created a risk calculator for mortality consequent to an NSTI; the biggest flaw in our calculator is simply that it caps at an 85% probability of mortality.

Should I worry about my patient having an NSTI?

Usually, no.  These are rare infections.  I do say that with some hesitation because I know a disproportionate number of NSTI survivors…but that’s a product of what I do in my work.  Distinguishing the patient with an NSTI from a patient with “just” cellulitis is a genuine diagnostic challenge, particularly for those who don’t care for these patients often.  The important thing is that if the idea that something might be an NSTI enters your head, it’s worth it to talk to an expert.  If they do have an NSTI, the sooner they get to surgery, the better they are likely to do clinically.

Bonus information: Our SlideShare about the mortality calculator from the 2012 Western Surgical Association meeting.

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Does surgeon = jerk?

For those of you who follow me on Twitter, you’ve seen my feed the last few days filled with thoughts and comments from the AAMC Mid-Career Women’s Professional Development Course (#MidWIMS- storify from the meeting coming next week!).  The opening talk on Saturday was given by Julie Lien Wei, Professor of Otolaryngology and Division Chief at UCF.  One of her statements during her discussion of her career trajectory resonated deeply with me.

“I thought that becoming a surgeon was synonymous with being a (((jerk))).  One woman surgeon changed that.”

I’ll confess that I entered medical school with the image of surgeons as being less kind, less humanistic, and definitely less well-rounded than other physicians.  I was also very determined when I started medical school that I wouldn’t be a surgeon when I finished.  Fortunately during my 3rd year I came under the influence of a pediatric surgeon who epitomized a happy, enthusiastic, kind surgeon.  As a result of his influence and that of a couple others here I am, almost 20 years to the day from my acceptance letter to Texas A&M College of Medicine, happily ensconced in my career as a surgeon.  More importantly, I want to believe that I didn’t sell my soul to get here, and that I am every bit as kind, humanistic, and perhaps more well-rounded than my colleagues in other fields.

Even with the 20 years that have elapsed since my own decision-making, as surgeons we still have an image problem.  When I tweeted Dr. Wei’s statement, I had a student respond, “They are jerks.  The woman was an exception.” Ouch.

So this is all the further we’ve come?  As recently as 2010, one study showed that medical students enter with a negative perception of surgeons (good to know I wasn’t alone in that!). The perception that physician/ patient relationships are lower quality is a negative influence on selection of a career in surgery.  And we know that personality fit plays a role in specialty selection, meaning that if students consistently see behaviors that they perceive as incongruent with their values, they’ll vote with their feet.  However, the surgical clerkship appears to offer an opportunity for mitigation of these negative impressions.  Nevertheless, the perceptions appear to return to baseline within a year of the clerkship.

Clearly we aren’t yet where we should be.  We’re definitely not where I want us to be, and I’m basing that on information I see from my own students about how some of my colleagues and our residents behave at times.  Caveat:  I’m not saying I’m perfect every day because I’m not…but I try hard to be a good example, and if I sense I’m not being one I’ll own it.  I’m also generous with apologies if I’ve dropped the behavior ball.

Here’s my request for you, fair reader.

-If you are a medical student, what is your perception of surgeons?  How can we improve it?

-If you are not a surgeon but work with us, what do you see that we could change?

-If you are a surgeon, what do you see behaviorally in our specialty?  I know that bad behavior is significantly influenced by environmental tolerance (blog post for another day), but what else do you observe?

The bottom line, what I really want to resolve, is how do we fix our image so we’re not scaring off folks who would be incredibly talented?