Tuesday, November 10, 2015

#JuniorContracts - #NotFairNotSafe: We need your support!

by Roshana Mehdian
11/11/2015: Junior Doctor Contracts - Where are we now?
A lot has happened since I last wrote about the threatened imposition of a junior doctors contract in the UK. Opposition has been so widespread that we are being covered in one form or another in the media almost daily. Despite the uproar and the near unanimous condemnation of this contact; our government plans to press on with its implementation.
We are now at a stage where the British Medical Association, our union, is balloting for strike action, with results expected in the coming weeks.
Other developments:
  • A protest rally in London drew 20000 junior doctors and supporters calling for the halting of this contract imposition, this was followed by protests in cities up and down the UK
  • The shadow health secretary Heidi Alexander announced her condemnation of the contract
  • The Conservative party’s own member of parliament and Chair of the Parliamentary Health select Committee rejected this contract in its current form
  • Ireland, Wales and Scotland have all rejected the use of this contract for their doctors
  • Letters of support from thousands of consultants and GPs have been written to junior doctors and to the health secretary advising him against this unsafe contract imposition
  • Our Royal Colleges, in an unprecedented step, have written to the health secretary advising him not to impose this contract
  • Press heavily allied to our Health Secretary has now started sensationalist smear campaigns against visible figures in the junior doctor movement including the chair of the BMA and myself
At this time, whilst we ballot, I would ask for your support. Everyone who reads this contract knows it is unsafe and unfair. The voice has been unanimous: ‘STOP!’ they say. Our government won’t listen.

As a female surgeon I followed the #ILookLikeASurgeon campaign with much excitement; what a worthy and relevant cause for a global movement! Women being mothers, daughters, sportswomen, fashionistas, etc... AND being surgeons.
I couldn't have known that just a few weeks later, I would be contacting the organisers of this movement to help me demonstrate that the world stands in solidarity with junior doctors in England, as they face the imposition of a contract that threatens patient safety and is unfair to dedicated professionals. I feel that the values imbued in our campaign against this contract – the primacy of patient care, fair treatment and conditions, and an end to gender discrimination – are relevant globally and not just in the UK.
The government has announced it will impose a draconian contract on all junior doctors (any doctor who is not a consultant or general practitioner) in England from August 2016, in the middle of one of the worst retention and recruitment crisis the country has ever seen. Needless to say, with such poor conditions on offer, physicians will vote with their feet, leaving the system even more understaffed and overstretched. This will have a profoundly deleterious effect of patient safety. Those that are left will have to cover the gaps and work unchecked hours. Tired doctors make mistakes. Patient safety is hit again.
Please watch this video for the story to date.
Why is the contract so bad? 
  • It removes the mechanism for safeguarding (monitoring hours and fines for overworking) - to ensure doctors are not too tired or overworked and therefore do not harm patients by being so.
  • It is even more unsociable than the current contract, further disruption to our private lives will not properly be renumerated - Pay rates for Saturday evening are to be classed the same as working Tuesday morning. Who will provide childcare on Sat evening? Do doctors not deserve to be renumerated for working the most unsociable hours? A hit to morale, our ability to pay our mortgages or look after our children and thus a massive hit to recruitment.
  • It is potentially discriminatory - it penalises those who take maternity leave, part time working or researchers; leading to potential financial hardship for women bearing children and discouraging lifesaving research. How can we allow such a step back?
Our union, the British Medical Association, voted to ballot us for industrial action. The government should never have let it come to this, but I'm afraid they only have themselves to blame.
We will fight this - not just for us, but for those on the cutting block next, our nurses, for those across the world facing similar battles, and ultimately for our patients!
I am truly in awe of how, as a profession, we fight through adversity (be it the challenging situations at work, the emotional toll or this latest contract saga) with such resilience. All of us, including our colleagues; nurses, physiotherapists, cleaners, clerks, pharmacists etc...in the healthcare world deserve recognition for what we do, not least a fair and safe contract.
Please stand with us in solidarity this Saturday, October 17th and tweet to make your voice heard!
Sample tweet: "I stand in solidarity with the #ILookLikeASurgeon community and oppose the #NotFairNotSafe #JuniorContract!"
Thanks for reading.
Roshana Mehdian, MBCHB MRCS BMSC PGCEMedEd
Trauma and Orthopaedic Registrar, Concerned Junior Doctor

Sunday, November 1, 2015

#ILookLikeASurgeon: Creating an "Upward Spiral of Happiness"

by Paula Ferrada, MD, FACS

While reading an article about finding happiness, I found one reason to always smile: Gratitude! Finding things to be grateful for, stimulates your brain in a way that act almost as a natural antidepressant.  For all foreign graduates reading; you know how hard it is to become a surgeon in the United States and the things we did and still do to become one… so regardless of the situation I am on, I always take time to remind myself: I fought for this position because I wanted with passion to become a surgeon- and I won! This was my choice!  And immediately things are better (or at least better in my brain which is the beginning for improvement in other places).

#ILookLikeASurgeon VCU Department of Surgery thank you all! ‪#‎diversitymatters‬

So I made a list of amazing things our profession offers, things that I am grateful for while being a surgeon.

  1. Immediate Gratification: I am a trauma surgeon. Immediate gratification for us is evident- I don’t need mountain biking or bungee jumping to have an adrenaline rush… There is not highest high that saving someone’s life! And this feeling,  is totally irrespective of what anyone else thinks or say- even if no one pats you in the back. There is no better satisfaction than walking out of a room and knowing you did it!

  1. Wonderful Patients: The satisfaction to see patients that are grateful, and more importantly that recognize that they are a pivotal part of the team; patients that want to get better, that participate and are engaged in their healthcare. This is for me, especially true after I see them recover from a life threatening event. When after being in the ICU for months they come to clinic with their families, and back to their normal life! I feel privileged to be part of their recovery.  

  1. Team building and leaderships skills on the go: I truly believe surgeons since early in our training are placed in situations where leadership skills have no other choice but to develop- sure; it would be amazing if we all had formal training, and I am not saying all surgical training programs will prepare you to be a Chairman or CEO; BUT; you will learn to prioritize, to triage information and clinical urgency, to manage a team, to deliver information to patients and colleagues effectively. For all residents: You know all those extra hours preparing morbidity and mortality conference? They will serve you well as public speaking training; time management and control of your audience. Seize these opportunities!

  1. Job security: Surgery in one of the specialties that thus far is irreplaceable. The best cure for cancer in most cases is a complete resection, the best way to stop life threatening bleeding is in most cases,  in the operating room; the only way to control sepsis from bowel necrosis is resection; and I can go on and on with examples. We are blessed to be in a field in which we are needed! And likely for many years to come!

We have so many reasons to stay strong! If we are proud of who we are and what we do- If we maintain a sense of belonging, and camaraderie, we have more chances in moving the walls that prevent us from reaching higher; we have better chances at making this profession even more rewarding and change the things that discourage many talented professionals from staying in it.

These are the reasons I’m grateful to be a surgeon--what are yours?

~Paula Ferrada, MD, FACS

Sunday, October 18, 2015

#ILookLikeASurgeon, Not an Imposter

By Dzifa S. Kpodzo MD, MPH

Born to a family of scientists --  my father an engineer and my mother an  oral surgeon -- I was given a clear message  that I could do anything. Case in point: at age nine when I declared my career goal of being “president of the world” nobody batted an eyelash. Their unwavering confidence followed me through college at UC Berkeley and medical school at Harvard and continues to be a sustaining factor in moments of doubt.  Entering medical school, I was certain I would not become a surgeon. The stereotypes and messages about surgeons being malignant and aggressive deterred me. Independent of the people and the culture, I fell in love with operating and treating surgical disease. I followed my heart, my passion, and my talent to the field of plastic surgery and did not turn back. Countless mentors (most of whom did not look like me) were vested in my success and allowed me to grow in this challenging field.  To my surprise I was the first black woman to complete the Harvard Combined Plastic Surgery residency program. I didn’t know there were still “firsts” like that.  While I was fortunate  to train with four female plastic surgery attendings over the course of my residency, there were some aspects of my experience as a “first” which felt unique, lonely, and difficult to share.

Being a surgeon is challenging for anyone.  However being a female surgeon and a black woman add additional layers of frustration.Verbally, the message can be clear: “Are you going to do my surgery?” or  “When is the doctor coming?” from a patient; or as stated by a colleague, “We really have to get you into a white coat so that you can look like an attending.” In actions, the sentiment can be even more explicit and hurtful. Patients hand me the meal tray when I enter the room, or continue talking as if I had never entered at all. I speak to an anesthesiologist who is so focused on determining  the title on my name badge that she misses all of my instructions about the case.  

During residency I remember receiving a page at 3AM for what would be my seventh consultation that night.  There was a family who came in for treatment of a small laceration on their child’s lip.  They seemed confused as I entered the room. Their demeanor questioned my abilities and they stated outright that they were transferred from another hospital because they needed “one of the old white male surgeons” to take care of their child.  I was tired and definitely not in the mood for this exchange. I was there to provide care and to help, not to deal with their racism and sexism. Even more aggravating was that these false expectations had been validated by my fellow medical colleagues.  I willed my lips into a smile, channeled my inner nine-year-old President, and told them that luckily for them, they got me tonight and that they were in the best possible hands.

Yet another experience occurred as the chief resident. I entered the room with my team which happened to be comprised entirely of males with the exception of the nurse practitioner and myself.  We had been rounding on this particular patient for the last 3 weeks dealing with a challenging abdominal wound.  I informed the family of the plan for the day and delegated one of my junior residents to return and change the dressings. Later on I returned to check on the patient and to verify that the task had been successfully completed.  As I started looking at the dressings the patient’s mother anxiously requested that I consult with “Dr. Junior Surgeon” before making any changes. I laughed and informed her that as a member of my team “Dr. Junior Surgeon” reports to me and not vice versa.  It was interesting to watch the awareness slowly manifest itself upon her face. She blushed, apologized profusely and said she hoped she had not gotten “Dr. Junior Surgeon” in trouble. She was an extremely lovely lady and until that moment, I believe she was unaware of the degree to which she was influenced by these stereotypes.

On top of all the pressures already inherent to being a surgeon, each of these moments required emotional restraint and redundant explanations that I was, in fact, the surgeon.  While it is rewarding to make people (patients and their families, colleagues and hospital staff) aware of their biases and shatter stereotypes it can also be frustrating, burdensome and repetitive. My energy should be focused upon caring for my patients, not defending my position. Contemplating the amount of time and energy spent on these interactions makes me feel resentful and cheated out of some of the joys of being a surgeon.

Constant messages that you are not the right person for the job can be particularly damaging in a field where confidence is key.  I realized that I was not alone with fleeting moments of self doubt when a surgeon well known to be tough as nails described to me how a medical error brought him to tears as he hid on one of the back staircases at the hospital. Many highly successful professionals suffer from impostor syndrome, and highly successful female professionals disproportionately so. In spite of the quantitative and qualitative proof of success, there persists an internal voice that wonders if you will soon be discovered and everyone will know that you do not belong. In surgery, confidence is essential, but the truth is that surgeons have moments of doubt. When I am daunted by a particularly difficult case, or perhaps recovering from a recent complication and trying to get back on the horse, it is taxing to muster the additional energy needed to enter the hospital and overcome the verbal and nonverbal messages challenging my position, knowledge and training; telling me I do not belong.

Heather Logghe's “ILookLikeASurgeon” hashtag has been a rousing call to action about diversity in surgery. The response in social media has been inspirational and indeed overwhelming at times. #ILookLikeASurgeon is the loud answer to the subtle but insistent question that hovers over women and other under-represented groups in surgery...do you belong? From the outpouring of responses to  #ILookLikeASurgeon, it is very clear that surgeons have been aching to look that 100lb gorilla in the room squarely in the eye and say YES!! Even patients are weighing in and expressing that they are tired of the stereotypes, and that race and gender should not affect care. Seeing my fellow surgeons of all ages, genders, ethnicities and backgrounds share who they are inside and outside of their surgical masks has been magnificent.  Their tweets and photographs show complex women and men like me with amazing talents, interesting hobbies, families and successful careers. With every tweet I am reminded that I am not alone; I am not an imposter.  There are many others in the ranks, and we share a powerful collective experience. Thank you Heather, for distilling the problem in such a compelling way and giving it voice. Being a surgeon is not determined by age, race or gender. Regardless of societal expectations and stereotypes, #ILookLikeASurgeon, along with countless surgeons the world over who have shared their image and voice in the movement. May we continue to post our pictures, celebrating the diversity of our profession and our lives.

 Dzifa S. Kpodzo MD, MPH

A native of Ghana, West Africa, Dr. Kpodzo also grew up in Germany, the United Kingdom, and Canada, and moved to the United States during high school.  After graduating with honors from the University of California at Berkeley with a B.A. in Integrative Biology, she completed a dual medical doctorate and master in public health at Harvard Medical School and the Harvard School of Public Health.  Dr. Kpodzo has received unparalleled education by world-renowned surgeons.  She trained in plastic surgery at the Harvard Plastic Surgery Combined Residency Program where she also served as a chief resident and became the first African-American woman to graduate from her program.  She then completed her fellowship in oculoplastic (eyelid surgery) and aesthetic (cosmetic) surgery at Paces Plastic Surgery in Atlanta.

As an Assistant Professor at Morehouse School of Medicine, Dr. Kpodzo is proud to be the first full time plastic surgeon on faculty.  She is dedicated to teaching, academics and service. She has received numerous academic awards, published book chapters and peer-reviewed articles, and presented to national professional medical organizations.  She had the honor of participating in 3 full face transplants during her residency training, and received recognition through the Partners in Excellence Award for Teamwork.  She has shared her skills internationally providing care in Ethiopia with Operation Smile, as well as spending time in her homeland Ghana. She is a member of Delta Sigma Theta Sorority Incorporated and remains involved and active in the community in various ways.

Thursday, September 3, 2015

#ILookLikeASurgeon: Breaking the silence on hard topics

Surgical Families

by Heather Logghe, MD
With over 100 million impressions on Twitter, the #ILookLikeASurgeon movement demonstrates the diverse faces of surgery. The #ILookLikeASurgeon Twitter feed also makes it clear that the topic of family is at the forefront of many surgeons’ minds.

In 2015, it is imperative that surgical culture embrace an inclusive and progressive definition of family. In order to define family this way, we need only look at the broader community of which we are a part. So far, we have heard from Dr. Chris Porter, who at first glance appears the stereotypic surgeon--white, male, forthright, confident. But beneath the surface he struggles to balance the responsibilities, pride, and joy of being a single parent with his passion for and dedication to his surgical career and patients. We've also heard from Dr. Elinore Kaufman, a queer resident-in-training, who shared her experience as a mom whose female partner carried their child. Family transcends gender and orientation.
Luke Selby, MD and his son
Balancing career and family commitments is no longer a “women’s” issue. Male and female residents ask senior colleagues for advice on work-life balance in equal numbers. Furthermore, male surgeons have felt progressively more comfortable expressing the distress resulting from not being allowed time to witness and celebrate their child's birth or to help care for their infants. Fathers and mothers both agonize over when to have children. Both partners grieve when one suffers a miscarriage. Even single, childless surgeons can face family obligations when caring for aging parents. These modern voices offer a perspective that is vital to enriching our discussion about family in surgery.

Pregnancy Then and Now

I have been passionate about this topic since hitting the interview trail for residency 6 months pregnant. As a medical student I heard the legend of a well-known woman surgeon continuing to suture through contractions as she went into labor. It was an unspoken but clear precedent for others* who might become pregnant. The part of this legend that is frequently omitted is that these contractions led to premature labor, resulting in the first weeks of her child’s life being spent in the NICU. As women surgeons, we take pride in our strength, but sometimes to a fault. It worries me that appearing “tough” and “committed” in the OR can be in direct conflict with our own health and that of our offspring. One resident begged a colleague to place a foley catheter in her so she could operate without bathroom breaks. Her co-resident acquiesced and she went into labor and delivered the next day, a month early. These stories send the message that accommodations for pregnancy are unwelcome, if not blatantly rejected.

When I learned I would be pregnant during the residency application process, I consulted multiple mentors on how to address this “issue” during interviews. I was advised by two of my most respected female mentors not to mention a word about the pregnancy, despite the fact that I would be 6 months pregnant and likely showing. While this recommendation was evidence-based, I did not feel comfortable following it. The sacrifices of women who came before me made it possible for me to question this status quo. I have the utmost respect for the women who did not have the option of publicly discussing their pregnancies and the inherent challenges, likely out of a realistic fear that it would jeopardize their careers. I am happy to report that I received no negative comments on the interview trail. I’ll never know what role my pregnancy played in the match, but I ended up with a prelim position.

My husband and I had timed the pregnancy to ensure that pregnancy did not interfere with training. Little did I know that the impact of pregnancy on one’s body can last long after the labor pains are over. I’ll never forget when six months after giving birth during intern year, I sprinted a few steps to the ER, and on the fifth step I felt my cystocele protrude, with my bladder literally falling out of my body. Fortunately the women’s clinic was housed within the hospital, and the female nurse practitioner on our team allowed me time to step away. I remain grateful to the administrative assistant who recognized the fear and concern on my face and convinced one of the gynecologists to see me without an appointment. In 15 minutes I was back on the wards with a pessary in place.

The Future of Pregnancy in Surgery

Throughout #ILookLikeASurgeon, we have heard stories and seen pictures boasting women operating with nine month baby bumps, accompanied by encouraging hashtags such as #RoleModel and #MakingItWork. While this may be perfectly safe and appropriate for some women and their pregnancies, it is not a healthy model for all pregnancies or all surgeons. Studies** show that surgeons have poorer pregnancy and birth outcomes compared to average American women. Clearly the current approach is not working. It behooves us to acknowledge that growing a human being takes significant energy and an undeniable toll on women’s bodies.

At the top of La Honda at 38 weeks
Achieving healthy pregnancies and newborns should not require women to avoid becoming surgeons or surgeons to forgo pregnancy. The cultural and professional expectations we place on women both in the operating room and as life-giving human beings must account for the hard work and dedication it takes to be successful at both surgery and parenthood. Neither is accomplished without community and institutional structures of support.

As physicians, and as surgeons in particular, we rely on our bodies to be vessels of healing. Taking care of ourselves, such as with my cystocele and visiting the doctor for a legitimate medical emergency, should not require luck or fortuitous circumstance. While the pessary served as an effective “band-aid,” it is only now, during my research years, that I have time to return to a physical therapist for pelvic floor rehabilitation. After the traumatic loss of one of its residents, Stanford launched an innovative “Balance in Life” program that facilitates regular primary care and dental visits. They also required interval psychologic evaluation to identify and mitigate burnout. Other programs shouldn’t wait for a resident death to actively create an environment that promotes the health of its residents.

My Story

Ride for World Health 2006
The challenge of family planning that has touched me personally is how to create a professional work culture that fosters healthy pregnancies, labors, and newborns for surgeons and surgeons’ partners. Before I delve in, I’d like to disclose that I am no stranger to physical pain and endurance. I have trained in Brazilian Jiu Jitsu, completed multiple marathons including two Ironman Triathlons, and cycled across the country (SF to DC). Yet, I was shocked by the heavy physical toll the first trimester took on my body. Of course, there does exist the rare, lucky individual who sails through pregnancy, but we cannot predict or expect this. Even my “healthy” pregnancy was not without significant challenges.
My husband and I had originally hoped I would become pregnant during my 4th year of medical school. When that didn’t happen, I decided to take a year between medical school and residency to have a child. It is notable that we conceived the first month after graduation. I cannot help but conjecture that the stress of clinical rotations and the competitive nature of medical school inhibited our ability to conceive.
Brazilian Jiu Jitsu
I was alerted to my pregnancy when I had cardiac pain while cycling up a mountain days before my period was due. Thus the physical impact was evident within days of conception. In addition to seeing stars every time I stood up and frequent urination, I also suffered severe shortness of breath and debilitating low back pain requiring chiropractic care. Mind you this was all during the first trimester, before I had gained a single pound.

The low back pain shocked me. I was only 10 weeks into my pregnancy when I noticed shooting pains upon shifting positions in my seat. It literally hurt to move. I called my midwife based on the sheer terror that I would not be able to move for the remainder of my pregnancy. She hypothesized that I had had a tailbone injury years earlier (true) that was somehow reactivated by the hormonally-driven ligamentous and muscular relaxation of pregnancy. After Googling possible solutions, I decided to seek care from a chiropractor, which made a huge difference. Ultimately I found that once or twice weekly deep tissue massage treatments (“torture” sessions in my opinion) enabled me to continue the active lifestyle to which I was accustomed.
I also found an online group of pregnant “mommas” who ran, which was invaluable. It was one of the internet “mommy boards” that reassured me that my shortness of breath was normal, encouraging me to continue running throughout the first and much of the second trimester. Around week 25, I began to notice a fullness in my pelvis, prompting me to cut back on my running. Soon after, the feeling morphed into the peculiar sensation of a tampon falling out. At that point I decided to inspect things, only to realize that I had developed a full blown cystocele! In addition to once or twice weekly chiropractic care, I now added weekly sessions of specialized physical therapy to keep my insides, well, inside! I remain eternally grateful that I was without clinical responsibilities at the time, allowing me time to attend deep tissue massage and physical therapy appointments in addition to normal prenatal care.

Proud parents
My saving grace throughout this was that while riding my bike, aside from some significant huffing and puffing, I barely felt pregnant! I continued cycling throughout my pregnancy, completing a century ride at 16 weeks. I even tried mountain biking at 22 weeks, but after two crashes and a concussion, decided it maybe wasn’t the best idea. Up until the day I delivered I was able to cycle mountains and complete rides of up to 40 miles. The day I didn’t feel “up to it” turned out to be the day I went into labor.

In the end, I delivered a healthy, 5 lb 12 oz baby girl, full term, but 10 days early, just as my “Exercising Through Pregnancy” book predicted. I had three months with her before starting residency and was able to pump and continue breastfeeding still today. It’s hard to imagine residency without her :-)

Share Your Experience

Now I’ve shared my story. To realize how #ILookLikeASurgeon can transform our profession, I encourage you to share yours. These may not be  pregnancy or infertility stories, but also stories about how we create and support families; the challenges, barriers, and creative solutions we can replicate. Only through an open and authentic conversation, with participation from all genders, can we set the foundation to create lasting solutions. You can share your story through your own personal blog, a guest blog post on Allies For Health, or even a simple email or direct message. Now is the time to finally speak up and let your voice be heard.

*Given there are transgender and gender nonconforming people who bear children, I have intentionally aimed to use gender-neutral language in reference to pregnancy. Special thank you to Dr. Elinore Kaufman for this recommendation.

**Articles on pregnancy outcomes among surgeons:

Hamilton, A. (2012). Childbearing and Pregnancy Characteristics of Female ... Retrieved from http://jbjs.org/content/94/11/e77.

Lerner, L. (2009). Birth Trends and Pregnancy Complications among Women ... Retrieved from http://www.journalacs.org/article/S1072-7515(08)01455-5/abstract.

Phelan, S. (1988). Pregnancy during residency: II. Obstetric complications. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/3043291.

Phillips, E. (2014). Does a surgical career affect a woman's childbearing and ... Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25260684.

Turner, P. (2012). Pregnancy Among Women Surgeons: Trends Over Time. Retrieved from http://archsurg.jamanetwork.com/article.aspx?articleid=1150115.