To say that my psychiatry clerkship did not go as planned would be an understatement. What I thought was just a sick day turned into an ED visit, which extended into a three-week long hospital stay with multiple surgeries and a wound vac.

This was exactly half-way through my clerkship year, and I was starting to realize that surgery was the field for me. However, my hospital stay was my first exposure to the field of general surgery, and there were times during this experience where I feared it would steal my desire for this career. Instead, my experience gave me an invaluable perspective on what patients and families wanted from their surgical team, and this left me feeling inspired. I learned tangible ways to contribute to patient-centered care, and I brought these things to the wards when I started back on my clerkships.

So for the medical students, residents, pre-meds… or honestly anyone involved in the surgical care of a patient, here are 5 things that I appreciated/wanted as a patient that you can do to help.

1. Hold the patient’s hand as they undergo anesthesia or any bedside procedure

The OR is a terrifying place for the patient. Although we are desensitized as members of healthcare, the concept of entrusting a stranger to make decisions about your body is unnerving and leaves you feeling powerless. I felt this way as I sat on the cold metal table with everyone bustling around me. But when the anesthesiologist grabbed my hand, it felt like he was acknowledging the fear of the situation. I can vividly remember the comfort brought by squeezing his hand as I drifted off to sleep.

And this isn’t limited to the OR. Once back on clerkships I held people’s hands during bone marrow biopsies, epidurals, spinal taps, NG tube placements, wound dressing changes… literally anything that is painful for the patient. It was always met with a grateful smile.

2. Walk the hallway or do incentive spirometry with your post-op patients

As a patient in significant pain and on a lot of narcotics, it is HARD to find the motivation to get out of bed. I was lucky to have family and friends visit who encouraged me to walk and use my spirometer, but many of our patients don’t have this kind of support system. This is the perfect job for the medical student as it contributes to patient care, and it relieves the stress of the overworked/understaffed nurses and residents. Even on days that I couldn’t go on long walks with patients, I would spend 5 minutes in between cases doing spirometry with them. Of course, check in with your team first to make sure this is okay, as some patients are not cleared to walk around the hall.

3. Check-In with your patients in the afternoon

Patients rely on the updates from their team during morning rounds, but the afternoon and evening is often empty as teams are charting or operating. Especially when a question from morning rounds goes unaddressed, that afternoon silence can often feel like neglect. This silence changed for me after my second surgery. The surgeon would come in every single afternoon, squat by my bedside, and just chat with me for 5 minutes. This second opportunity to ask questions and advocate for myself made a huge difference in the level of care I felt like I was receiving.

Even if you’re not the attending, you can still provide this extra layer of care by stopping by the patient’s room in the afternoon to ask if they have any questions you can relay to the team.

4. Advocate for your patient when they’re in pain

In health care, we deal with so many people in pain that it can feel like the norm, but we forget how debilitating and consuming that pain is for the patient. I spent several days fruitlessly self- advocating for a better pain regiment when I was in the hospital, but consistently felt like I wasn’t being heard.

As a medical student, you can be another voice for your patient’s pain by suggesting a switch in pain management during your presentation in morning rounds. This brings the issue to your team’s attention from an “objective” source, and also presents a learning opportunity.

5. Don’t be scared to admit to the patient how much it sucks

As a patient, I became extremely frustrated when terrible experiences like NG tube insertions or wound vac changes were prefaced/summarized as “uncomfortable”. Minimizing the pain of these experiences by describing them as uncomfortable felt very invalidating. Just once, I would have loved if someone told me “This will hurt like hell”.

Although this phrasing is not everyone’s style, you can demonstrate awareness for the patient’s experience by avoiding the word uncomfortable when describing something objectively painful.

There are myriad lessons I took from my time as a surgical patient, but these are a handful of action items that anyone can implement which truly contribute to patient-centered care. These practices have given me great insight as to what kind of surgeon I want to be, and through them, even the darkest parts of my journey have become a source of light for others. I share this article with you today in hopes that this light can extend beyond my own reach.

Gianna is a medical student who aims to build a culture of person-centered care within the field of surgery.

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The opinions expressed in the article is not affiliated with any institution, company or product. The article should not be interpreted as medical advice.

The Boeing B-17 fighter jet was the crown jewel of the United States Air Force in the Second World War - or at least, it was supposed to be. Despite its remarkable performance in combat, the plane suffered over a thousand crashes during routine landings, which were initially attributed to “pilot error”. Training modules aimed at educating pilots proved ineffective and forced the flight engineers to look more critically at the process of landing. A thorough investigation ultimately revealed a simple design flaw at the center of the crashes. The controls for two different operations - lowering landing gear and pulling wing flaps - were identical. In both routine and more urgent circumstances, pilots would reach for one control, meaning to reach for the other. This insight prompted a redesign of the instrument panel with distinct controls that prevented this misperception and eliminated the problem. The process of discovering design flaws inherent to the B-17 not only ushered in the ascendancy of the U.S. Air Force but also gave way to the new field of human factors design - the idea that systems, not people - were responsible for errors and inefficiency, and could thus be modified to keep humans safe.

In an operating room 87 years later, I, too, found myself fumbling with the instruments in my hands. We were in the middle of a laparoscopic inguinal hernia repair - a minimally invasive operation in which long instruments are placed through keyhole incisions to repair a hole in the abdominal wall through which internal organs extrude. A key step of the operation is to use a long instrument called a tacker to fire small thumb tacks into a mesh to affix it to the abdominal wall around the hole, effectively covering it up. As usual, I was struggling to use the tacker - I could stabilize the instrument in my hand or fire it with my fingers, but it seemed that I could not do both. Normally, this lack of finesse would earn a sharp rebuke. But on this day, the attending (with whom I was operating for the first time) pointed out how horribly mismatched the bulky instrument handle was for my extra small glove sized hands.

This realization led to similar findings in other operations. An hour of dissecting, dividing, and reconnecting vessels while wearing magnification loupes was routinely followed by an afternoon of neck pain. No number of step stools seemed to put me at the correct height to operate comfortably. A string of gallbladder operations during which I was tasked with pushing a 60cc syringe of contrast through a 1mm wide cholangiocatheter left me with golfer’s elbow. In speaking with my peers, I heard my concerns echoed in their experiences. “How am I going to do this procedure for 8 more weeks?” and “I need a back transplant” were all too common refrains. What I had previously written off as the growing pains of surgical training now appeared to be flaws in the designs and processes of surgery itself. Such were my informal introductions to the field of human factors design and its corollary discipline of ergonomics.

While both of these named disciplines originated during the Industrial Revolution and gained prominence in the WWII era, the concepts have existed since Antiquity - even within the field of surgery. Hippocrates described lessons on posture, positioning, and instrument handling over two thousand years ago:

“The most appropriate posture for the surgeon is to be seated, with his knees at a right angle and close together. The knees must be a little higher than the bubonic area and slightly apart, so that the elbows can be propped on them or spread wider than the thighs…[instruments] may not impede the work, and there may be no difficulty in taking hold of them…”

The clinical and technical advancements in surgery - not only since the time of Hippocrates, but in the last few decades alone - have outpaced similar advancements in ergonomics. While the last century saw the advent of sterile technique and minimally invasive surgery, surgeons are in as much pain as ever. Innovations in robotic surgery have made tremendous strides to improve surgeon comfort and patient outcomes, but even this modality is not immune to its own profile of ergonomic risks, spanning from hand and finger symptoms to neck pain. Furthermore, the robotic platform’s applications remain limited to a small but growing number of operations at this time.

Regardless of the operating platform used, surgeons have to continually adapt to an environment that was not built for them, operating for hours in uncomfortable positions and performing repetitive movements with poorly designed instruments. As a result, our workforce sustains high levels of musculoskeletal strain, with 87% of surgeons reporting work related pain, 15% requiring surgery to treat related injuries, and an estimated 15% retiring early. All of this amounts to tremendous personal and systemic cost, much of which is not yet quantified and understood fully. There are no established avenues for reporting work related injuries for surgeons, and even if there were, fear of retribution fosters a culture in which surgeons opt to work through their pain. There are no claims databases that filter by surgical occupation, and so the true cost of poor workplace ergonomics remains nebulous. While many of these effects are felt down the line in lost work years and treatment costs, their roots take hold in training.

Residents enter surgical training with an understanding that not only are they embarking on a grueling journey, but also that they must quietly tolerate the discomforts along the way. It is unclear what historical truths this culture stems from, but one could look to the model of surgical residency first pioneered by William Halsted at Johns Hopkins Hospital at the turn of the twentieth century. This era was marked by dedication to the craft at high personal cost - for all his contributions to surgery, Halsted himself suffered from a severe opioid addiction that rattled his life and career. Furthermore, the pyramidal structure of residency that he established fostered a cutthroat environment in which only those with nothing left to sacrifice would be privileged enough to advance. Since Halsted’s time, notable transformations have brought surgical training to the modern era, such as adopting the rectangular residency structure and, more recently, the institution of duty hours. Still, a tacit culture of hierarchy, personal sacrifice, and adherence to the status quo remains. Even as the days of the toxic surgeon are fading out, trainees are largely reticent when expressing their basic needs (sleep, food, and physical well-being).

Our field is now catching up to its realities, though, and conversation is moving towards honest, solutions-oriented discussions. This is evidenced by the growing body of literature dedicated to topics such as wellness and surgical ergonomics. In fact, publications on surgical ergonomics have skyrocketed from 34 in 1990 to 662 in 2020, and new forums for this topic in academic surgery have emerged. In 2021, Dr. Geeta Lal, an endocrine surgeon at the University of Iowa, founded The Society of Surgical Ergonomics after seeing her own experiences with pain and injury mirrored in so many of her colleagues. In the Society’s inaugural conference, 26 researchers presented on topics ranging from educational workshops to exosuits. One of the keynote speakers was Dr. Susan Hallbeck, a human factors researcher from the Mayo Clinic, who presented their group’s seminal work on microbreaks. Their work showed that incorporating microbreaks into cases is an effective strategy to combat the sustained physical stress of operating for hours. That this strategy is effective should come with no surprise - it borrows from fundamental principles of workplace ergonomics that have been established for years in other industries. Its low cost, low tech approach makes it attractive to implement at any institution.    

While introducing microbreaks during cases is a promising start, it still puts the onus of harm prevention on the surgeons themselves. To truly revolutionize our practice to be safer and more amenable to a diversifying workforce, we should seek out solutions that restructure our environment and eliminate hazards in the first place. This framework for harm reduction, termed the hierarchy of controls, has been adopted by the National Institute for Occupational Health and Safety (NIOSH), the government agency overseeing workplace safety and health. It describes five levels of interventions aimed at reducing workplace hazards. Interventions aimed at the higher controls that eliminate the hazards (including innovations such as robotic surgery) will produce more substantial risk reduction compared to lower controls that target the individual worker (such as behavioral changes).

The long game is redesigning everything. In the meantime, there are practical, albeit imperfect, solutions that we can implement to ease the burden of ergonomic stress.

First, we must measure our pain. While survey based studies describe this problem at a point in time, we must continuously measure our ergonomic stress and risk of injury to make meaningful changes. This is mostly done with surveys today, but new technologies that assess motion (such as video analysis, accelerometers, or inertial measurement units) and directly quantify muscle strain (such as electromyography) are being tested. These data can serve as the basis for guiding interventions, tracking their effectiveness with scientific rigor, and ensuring transparency to incentivize systems to invest in their workers.

Next, team leaders (such as the operating surgeon or the circulating nurse) can propose an ergonomic time-out, both at the beginning of the case and throughout, to allow the team to reevaluate and address ergonomic issues in real time. These adjustments can include repositioning monitor screens, requesting equipment such as step stools or anti-fatigue mats, or even rotating labor intensive roles, such as retracting, to offer respite to the most at-risk members of the team, such as medical students and junior residents.

Lastly, we can democratize the design process itself and give every surgeon and trainee the opportunity to collaborate with engineers and human factors scientists. Surgeons and trainees are best poised to identify pain points and potential solutions, and we should use our own expertise to effect change. Much as we invite industry sales representatives into our operating rooms, we can and should invite the engineers who make our instruments to observe and interview us. In this way, we can close the chasm between the people who design instruments and the people who use them every day. 

Surgeon and ergonomics are derived from the same etymological root, ergon, the Greek word for “work”. While the fields of surgery and ergonomics should go hand in hand, they have instead evolved to be at odds with one another. Many of the short and long term solutions to bring them back in alignment will take time, resources, and perhaps most valuable, buy-in from leadership. However, the stakes are too high to relegate this issue to the backburner. With a looming surgeon shortage, astronomical burnout, and increasing rate of injury and early retirement plaguing our workforce, protecting surgeon health and wellbeing will be instrumental in recruiting and retaining the best and the brightest. Recognizing this notion will unlock the next century of innovation in surgery.

I would like to acknowledge my friend and coresident, Tejas Sathe, without whom this article would not have made it from idea to paper.

Additional Readings:

https://medium.com/swlh/the-flying-fortress-fatal-flaw-694523359eb

http://ergou.simor.ntua.gr/research/ancientGreece/AncientGreece.htm

Prevalence of Work-Related Musculoskeletal Disorders Among Surgeons and Interventionalists: A Systematic Review and Meta-analysis

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1856533/#r18-1

https://www.societyofsurgicalergonomics.org/

https://pubmed.ncbi.nlm.nih.gov/28059962/

https://www.cdc.gov/niosh/topics/hierarchy/default.html

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Dr. Meghal Shah is a General Surgery resident at Columbia passionate about global health and human rights

The opinions expressed in the article are not affiliated with any institution, company or product. The article should not be interpreted as medical advice.

If you are interested in contributing, email us at: themodernsurgeon@gmail.com

Reader Goal: Pause and Reflect on Your Own Internal Dialogue

Long before I was a cardiac surgery resident, I was a competitive gymnast.

Gymnasts are dedicated to the pursuit of perfection, honing one skill at a time. As a gymnast I learnt to flip once, before learning to flip twice. It was an exhilarating process, a passion.  

However, in some ways, the circumstances in which I first learned to chase perfection were less than ideal. 

There was a lot of yelling in gymnastics, even when we nailed our routines.  The culture of the sport relied on constant yelling, punishment, and occasional beratement to drive us to perform better. 

Sometimes that did work.  A threat of a rope climb if one did not stick a landing, would drive us to focus and work harder.  Being yelled at for a bent knee or flexed foot would motivate us to fix it.  I began to internalize this type of rhetoric in which I was surrounded, believing that success is forged in a toxic and exhausting state.

One of the many reasons I find surgery incredible is that it mirrors gymnastics with its similar dedication to the pursuit of perfection and the necessity of strong foundations.  

However, within a few weeks of intern year, I noted that I was inadvertently internalizing the same mindset that I had developed during my time as a gymnast. 

For example, one day I was in a cardiac case that I had been in multiple times as a medical student, but for the first time as an intern and first assist. Even though I recognized the steps of the case, I struggled to catch on to the flow of the case. 

As I felt myself getting frustrated, a dialogue began to unfold in my mind: ‘I should be able to do this, why can’t I do this?.  I am not doing a good job. I should be doing better.’  Each thought  reflected  my own self-criticism.

Meanwhile,  no one around me was actually disappointed with me, and instead were very encouraging. My negative mindset was purely internal, serving no productive purpose. 

Four months into intern year, I have had more learning moments than I can count. And too often, I still find myself overcome with  negative and critical internal dialogue, reminiscent of that from my time as a gymnast.

However, residency is already exhausting enough in and of itself, without negativity and self-doubt. This kind of thought process  is often more destructive than constructive. 

Through conversations with peers and with mentors, both inside and outside of cardiothoracic surgery, I know I am not alone in this dialogue. So here are a few ways I have begun to pause to try to shift my thought process:

• Am I being patient with myself at this moment?

• Am I going to let myself keep moving forward, or will I let this moment fester?

• Will it serve me to process this experience with negativity?

• Am I being kind to myself?

I make a conscious effort to try to list a number of positive events from the day, and not just the negative. I hope that after reading my experience, that you can also jot down a few stopgaps to help you pause to build a productive internal dialogue. 

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Dr. Jenna Aziz is a cardiothoracic surgery resident at the Ohio State University.

The opinions expressed in the article are not affiliated with any institution, company or product. The article should not be interpreted as medical advice.

If you are interested in contributing, email us at: themodernsurgeon@gmail.com

I didn’t know who to air my grievances at—the large hospital corporation that signed my paycheck? My hapless general surgery program director who had no control over my health coverage? My ovaries? I went for accessibility.

This is what my program director wrote back:

Linda,

Sorry for the frustrations. I will forward to the proper people at [hospital administration/graduate medical education] as well as to Dr. [Chairman] (if that is OK with you). To my knowledge, you are the first to try this as a resident in Surgery, and since most other residencies are much shorter, you may be one of the first in GME [graduate medical education] to try to sort through the insurance issues with this, if not the first […]

Sometimes it is good to be special. As surgical residents, we spend years neglecting ourselves and our families to receive external feedback that we are special for our achievements and performance. But this was not a good special. It was a very isolating special.

But how alone was I really? The truth is, in the US, 1 in 10 women in the general population experience infertility. The rate is much higher amongst female physicians, with 1 in 4 female doctors reporting infertility with an average age at diagnosis of 33 years. Sadly, the rate is highest amongst female surgeons. According to an article published in 2014 by Philips et al for the Journal of the American College of Surgeons, one in three female surgeons experience infertility, of which two-thirds go on to use assisted reproductive technology, such as in-vitro fertilization (IVF), to achieve pregnancy.

I didn’t know any of this when I started my journey, but in hindsight, I had to wonder: why is it that seven years after this publication was printed in one of our most prominent surgical journals, at a major training institution boasting over 50% female surgical trainees, I was being told that it was unheard of that a 33- year-old trainee was navigating IVF?

At that time in my general surgery program, there were 71 residents, 39 of whom were female. Statistically speaking, 13 of those women will experience infertility at some point if they choose to start a family through biological means. Now, most of them were blissfully not yet 33, and thoughts of fertility might be understandably distant.

But after receiving that email, it became my mission that no other female surgical trainee having to wade through infertility should feel so undesirably ‘special.’

**

These pervasive beliefs that marginalize ‘normal’ experiences of trainees, such as needing medical care to achieve pregnancy, keep the field of surgery sterile and unwelcoming of outside experiences. During that summer, I cried a lot. In the last 12 months, I had discovered that I loved cardiac surgery. When I was in those operating rooms, it felt like everything in my life had clicked into place. But I was also in love and wanted to start a family, and it wasn’t happening. As we progressively failed medicated cycles, intrauterine insemination (IUI), and moved closer to IVF, I was gripped by the thought that going through IVF would not be compatible with being a cardiac trainee. This led to a spiral of pervasive thoughts – Did I make the wrong career choice? Should I choose cardiac at all? Should I choose having a family or doing what I loved for work? Was I guilty of causing my own infertility by working, operating and taking call?

Why did I think that IVF and surgical training were not compatible? For one, I had never seen anyone do both before. Secondly, I had a poor understanding of the physical and time requirements that IVF needed, but I knew as a resident I had little control over my own schedule. And lastly, as a young person who formerly had few personal needs outside of work, I had previously been unforgiving to those who did. Now that it was my turn, I felt like I needed to apply the same stringent rules to myself.

The truth of the matter turned out to be far better than I expected. When I asked to change my schedule to a lighter rotation during the month of our IVF cycle, I was met with immediate support by my program. When I asked my cardiothoracic fellowship director if I could move my general surgery and cardiac rotations around to accommodate procedures (a luxury of being an integrated 4/3 resident), he said that he was committed to whatever I needed to take care of my family, and that fellowship would be waiting when I finished.

I was floored. I realized that the months I spent worrying about the imminent end of my career due to infertility was a false narrative I had told myself, created of ignorance and incomplete interpretations of what I saw people doing around me. I learned that we have to work hard on a personal level to explore and create truths that are better than the received wisdom, and that as organizations, we can also change the contexts that younger generations see.

When I was a fourth-year medical student, I rotated as a sub-intern with the chief of cardiothoracic surgery. I loved my time in the operating room, but I didn’t think cardiac surgery was a possible career for me. Even after years of higher-level schooling, research experience and statistics courses, the human brain, or at least my human brain, is a simple one. On service, I saw two male fellows going into cardiac, and two female fellows going into thoracic. There was one female faculty member in the division of 18. I internalized a message that no one spoke aloud to me: cardiac surgery is for boys, not girls who want to start a family.

Now, I’m grateful every day that life gave me a second chance to find my way back to cardiac surgery. After realizing my own cognitive limitations that prevented me from choosing cardiac surgery as a student and then questioning that choice again when faced with infertility as a resident, I take every chance I can to show female students and trainees that it is not either/or. I want them to learn suturing and one-handed tying, think about drainage and cannulation strategies, and only ask themselves: do I like this or do I not, with no barriers in their mind that it would not be for them, simply because they are girls.

**

I’ve been lucky in my life to have had little interaction with health insurance before all this, but this was my introduction. Before we could start IVF, we needed what was called “financial clearance” from the billing office of the reproductive endocrinology department. This turned out to be a phone call where they looked through my insurance coverage and immediately cleared us. In return, I got little clarity for myself.

They told me that my insurance coverage through my hospital employer included a $7,500 lifetime benefit for fertility treatment, and a $2,500 lifetime benefit for fertility medications. Was this a good amount of coverage? I had no idea. I learned that a lifetime benefit means that once you use it, it doesn’t start over the next year. It also means that “out of pocket max” does not apply. Once the insurance has completed $7,500 in payments, they would not pay any more. The financial office asked us if we wanted to use the insurance benefit. I was confused by this question. Why wouldn’t we? It’s like free money. Except it isn’t free, because I pay the premiums out of my biweekly paycheck for each 160 hours worked. I asked them what a round of IVF costs in total. This seemed like a reasonable thing to want to know. They told me there was no way to tell us this. What they could tell me was, without insurance, an out-of-pocket round with no frills (intracytoplasmic sperm injection, genetic testing of embryos for example, which would be extra), was $15,000, not including medications.

I thought ‘Ok, $15,000, we have a $7,500 benefit, so … we should plan on owing $7,500.’ Basically, I was covered for half the round. The lady told me, ‘Oh no, it doesn’t work like that, if you use insurance, we bill the insurance a different total amount.’ I told her that I have the insurance that the people who work at this very hospital gets. Can you tell me how much will be billed for my cycle then? She said this was unknowable. So, what we would owe out of pocket remained a mystery.

My husband and I had two choices. Proceed without insurance, as if I was unemployed and uninsured, or with my hospital insurance, as if I was a surgery resident who had been training at this very hospital for the last seven of my most fertile years. At that point in time, only Option 2 seemed reasonable to us.

After one failed round of IVF, this is where we stood with Option 2: $83,957.25 was billed to insurance, of which $29,214.61 was deemed to be our responsibility, along with the grief of no baby.

It was around that time that I sent that angry email.

I felt like I had worked hard, I had paid my insurance premiums, and this so-called coverage was a cruel joke that added insult to our heartbreak. After our first failed round of IVF, I was fortunate to be able to switch onto my husband’s insurance, which treated women’s health issues as human health issues, and provided complete coverage for fertility services. With this coverage we were able to complete a second round of IVF, which resulted in the birth of our rainbow daughter, Nora.

**

After my message had been forwarded to the higher-ups, a response was forwarded back to me. This was an anonymized comment from a high-ranking female faculty member. She shares that she also did IVF, that it cost her $50k, and asks if I had considered taking out a personal loan to do this:

“I feel for the resident.  Background:  I had to go the route of IVF myself.  That was before there was any insurance coverage through [major university] for it.  But it was the best $50,000 I ever spent. However, I recognize that an expense like that is a big stretch for a resident.  I know that back in the day when I went to [local IVF clinic at major university] they told me about a company that extended credit for fertility treatments with a reasonably low interest rate. Not sure if the resident has been given that option.”

This made me realize: things are improving, because we’re having this conversation. But we’re not there yet. Though half the trainees in our general surgery program are women, does that mean we truly support women? Though we have Instagram posts showcasing the women who made it ‘all the way,’ to chief, chair or full professor, have we accounted for the era of strife misogyny through which they trained to arrive there? Does the success of women today prove that the system supports women, or is their success proof of how they prevailed despite the challenges placed before them?

To me, the proof is not in the Instagram post showcasing beaming female professors standing before a neatly manicured bed of flowers. It’s on page 109 of the organization’s health insurance policy, in the small print. It’s evidence of whether the leadership selecting coverage sees women’s issues as human issues, or whether the suggestion from the brass to a young woman struggling with infertility is to take out a personal line of credit for $50,000, at a reasonably low interest rate, in order to treat her medical condition and continue working.

We talk about the leaky pipeline, and it turns out I almost washed myself out of that pipeline because I thought I couldn’t keep training in cardiac surgery and grow my family at the same time. I’m lucky that didn’t turn out to be true. At the end of the day, I was fortunate to be buoyed by the blessings that kept me in that pipeline: my co-residents who provided me coverage when I went for ultrasounds and procedures, my incredible husband who gave me an intramuscular shot followed by a bowl of ice cream every night for 12 weeks, my program that accommodated last minute schedule changes based on how (un)cooperative my ovaries were with medication.

Today, my husband and I are fortunate to be parents to our miracle daughter, who is worth every penny and tear spent to arrive here. There are many others for whom the struggle of growing a family far exceeds what we experienced, for whom the destination of their journey ended somewhere very different than planned or remains unknown to them now. These stories within surgery need to be told. My hope is that by sharing our unique story, young women in a similar position will not have to experience the fear and panic I did, nor the financial burden, should they find themselves in a similar crossroads.

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Dr. Linda Schulte is a cardiac surgery fellow who wants to inspire change in the makeup of surgery.

The opinions expressed in the article are not affiliated with any institution, company or product. The article should not be interpreted as medical advice.

If you are interested in contributing, email us at: themodernsurgeon@gmail.com

How much does pedigree matter in the field of surgery? It's easy to question whether or not we have what it takes when there is so much emphasis on prestige and legacy.

To answer this question, just look at where some of the most accomplished surgical pioneers have come from.

Here are 3 stories that will convince you of what really matters.

Aldo Castaneda grew up in Europe during WWII fearing for his safety and moved to Guatemala to study medicine. When he eventually came to the University of Minnesota for residency, it was only for a one-year trial period at first. But he became one of the most celebrated cardiac surgeons.

Lall Sawh grew up selling produce at the market in Trinidad and Tobago and used brown paper bags as notebooks. But he worked hard to finish medical school in Jamaica, then eventually completed training in the UK and at the Mayo Clinic as a urologist, and pioneered kidney transplants in the Caribbean.

Vivien Thomas never had a chance to go to college or medical school due to the Great Depression, He worked as a surgical research assistant and lab supervisor. But he was not discouraged, and helped pioneer a procedure to save children with Tetralogy of Fallot.

The theme that ties these successful surgeons together is not pedigree. In the long run, it is commitment to excellence, grit, tirelessness, passion, and other internal traits that set them apart.

It is not about what the names of schools enable you to do, but rather about what your name will come to signify. It is not about being born into a legacy, but rather creating the one to come.

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Jason J. Han is a cardiac surgery resident who talks about his work plainly and openly.

The opinions expressed in the article are not affiliated with any institution, company or product. The article should not be interpreted as medical advice.

Staring out at the long and intimidating journey called residency, I know you’re wondering if you’ll ever make it to the other side. It’s natural to be nervous.  You’ll be okay. There are a thousand challenges ahead, but you’ll make it. I know that because I’m you, many years from now, and we did make it after all. And I wanted to tell you this because when I was in your shoes, I wished someone had. 

This isn’t the first time you weren’t sure whether you could make it past something. Remember the night before starting medical school? Or the night before you immigrated to this country, uncertain of how everything would unfold? Our whole lives, when up against something seemingly insurmountable, we wondered if we could overcome it. 

Each time, we got through it somehow, and you will get through it this time, too. In truth, you don’t need me to tell you that from the perspective of your future life. Deep inside, you already know.   

But if I could also tell you some things that only your future self would know, it’s this.  

1. Don’t be overly certain that you know exactly what you want in your career and your life. 

I know you like to have a plan for everything, and think you possess above-average self-awareness. But you have yet to experience the moments that will completely level your assumptions and overturn your perspective. And you’ll never have these moments unless you leave yourself open to being deeply moved by the people and ideas you don’t yet realize are missing in your life. 

So, don’t be so strict and rigid with yourself.  

2. It’s always about the people

I know that from your perspective, medicine can seem like it’s mainly about science, and the pursuit of knowledge, and skills. While true in some ways, you will soon learn that the most rewarding—and challenging—parts of this profession have been, and will always be, about the people you encounter. 

As you become more knowledgeable and skillful, as you collect more titles and awards, you may be tempted to believe that they set you apart from others. 

But don’t forget – knowledge and skills are only meaningful insofar as their ability to serve you in the care of people. 

3. Reflect constantly and adjust

I know that you’ll be busier than you have ever been before. But the more strained you feel, the harder you should strive to make time for reflection and self care, and to connect with the people and the activities that make you whole. 

Constantly ask yourself who you are and who you want to be. Say no to things that do not align with those values. 

• Many things you think you have to do to survive are not actually essential to your survival. 

• Many things you have been told are required, it turns out, are just recommendations at best.  

Most importantly, this feeling that you have at the onset of training – the palpable excitement and the nervousness – hold on to them with everything you have. You feel because you care. 

You have an exciting journey ahead of you. Now get some rest!

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Jason J. Han is a cardiac surgery resident who talks about his work plainly and openly.

The opinions expressed in the article are not affiliated with any institution, company or product. The article should not be interpreted as medical advice.

Social media has become one of the most active communication methods in the world of surgery. Just in the last 5 years, our virtual engagement has evolved so much. 

We’ve begun to share:  

1. News, like publications, and promotions  

2. Debates about the evidence-base

3. Educational threads on clinical pearls, history

4. Humor 

But we are still far from using social media to its peak potential, which can disseminate information in a way that is more efficient, accessible and digestible.  

To do that, we have to experiment with new ideas or styles. We have to explore new platforms that feel unfamiliar at first but can reach an exponentially larger audience. 

We need to keep trying because the potential of SoMe in surgery is whatever we want it to be. 

Here are 3 simple ideas from @themodernsurgeon: 

1. Share stories from surgery to the rest of the world 

1. People are drawn to and connect with stories more deeply than with just facts. Whether the stories tell us something about mind bending science, humanity or just the day-to-day in the life of surgery, we are only scratching the surface of what we can accomplish in surgical communication with storytelling, and social media is the window.  

2. Share insights from medicine that are relevant to other disciplines, and vice versa!

Too often the surgical social media space is an echochamber. What if we could learn more from the rest of the world to change the way we operate (both literally and figuratively)? What if people in other areas could glean insights from surgery that can further their own crafts? 

3. Shape the public perception 

Military recruitment in 1986 increased by 500% after the release of Top Gun. In that vein, a movie is not just a movie. The content we share helps shape our brand in the eyes of the public. These are the preconceptions our patients bring with them when coming to the hospital. It changes behavior. How many children growing up watching Grey’s Anatomy became inspired to go to medical school after seeing surgeons that looked like them? In the same way, we can do our part by creating a more accepting, curious perception of surgery through what we post! 

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In the past, we have expected everyone else to just adapt to one “right” way. But are they really that hard to change if we put our minds to it?

1. @1001cuts is wondering why the OR table can’t go any lower.

I know tables that can go up high enough to be comfortable for surgeons who are 7 ft tall but have yet to see one that can go low enough to make surgeons 5’2’’ comfortable

2. @Adaezae_1 is wondering why we cannot just purchase instruments designed for left-handed surgeons?

The Miller-Meyerson maneuver is clever, but do you really want to hold scissors that way for the rest of your life because you’re left-handed?

3. @JMSoegaard is wondering why we never seem to be able to find XS gloves even though so many providers would benefit from them today.

How often do we just suck it up and wear gloves that do not fit well and make it harder to do procedures?

4. @TsengJennifer is wondering why we don’t have surgical instruments that fit different hand sizes.

There is probably a very simple manufacturing solution to this that would help so many surgeons feel more comfortable every day.

5. @g_lighthall is wondering why scrubs have to remain so dysfunctional and poorly fitting for providers of different body types (although those suspenders are super fashionable!)

What other examples of functional biases and outdatedness do we live with on a daily basis?

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Jason J. Han (@JasonHanMD) is a cardiac surgery resident in Philadelphia and is part of the TMS leadership.

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The opinions expressed in the article is not affiliated with any institution, company or product. The article should not be interpreted as medical advice.

“One of our residents graduated with more than 100 publications! If you come here, we can make you that superstar.”

Wow, more than 100 – my jaw dropped.

Then as the year went on, it kept happening. When introducing the grand rounds speaker or the society president, academic surgeons or clinicians would say: “This surgeon has over 300 peer-reviewed publications.”

Sometimes the number was frankly unbelievable.

“Over the course of their career, this surgeon has published over 800 papers in addition to co-writing 50 textbook chapters.”

As an impressionable student, I came to believe the “# of publications” was the most important way to get ahead and open doors. It was clear to me that the people who rose to positions of academic leadership, both at the level of the institution as well as national societies, were all publishing constantly.

But after participating in this trend feverishly for nearly a decade, I now feel this perception is toxic, especially for students and trainees.

It turns out, perhaps intuitively, the number of publications does not encapsulate whether you’re a good provider, resident, teacher, teammate, or partner. It’s just one metric, and a crude one. It does not measure quality, impact, or the number of hours you spend helping others.

What it has done, instead, is start some very alarming data trends in the world of medical education. In 2011, students who matched in dermatology and plastic surgery had 7.5 and 8.1 academic items. By 2020, in just one decade, those numbers were 19.0 and 19.1, respectively.

In 2011, 17.2% and 12.2% of the applicants matching in dermatology and plastic surgery had a Ph.D. or other graduate degrees. By 2020, 29.9% and 24.2% of them did, respectively.

In its extreme, the pressure to publish has led to people simply replicating studies, prioritizing easy, low-impact work, falsifying their academic records, and exploitation of labor from people in positions of powerlessness. Many people are leaving academia. Authors are literally paying money, instead of being paid, to publish their hard work. We have created an arms race in academia.

The new application cycle is coming up.

Can we please stop this harmful race, and stop glorifying this metric?

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Jason J. Han (@JasonHanMD) is a cardiac surgery resident in Philadelphia and is part of the TMS leadership.

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The opinions expressed in the article is not affiliated with any institution, company or product. The article should not be interpreted as medical advice.

This is a thread dedicated to those moments with a hope that more will follow.

1. One Sat morning an elderly patient who was about to go home died suddenly from a terrible complication. My attending surgeon hugged and comforted the grieving family members for the next 20 minutes. I will never, ever forget how rare and powerful that was.

2. One very late Wednesday evening, I made a mistake while closing the skin, and everyone in the room grumbled. The fellow at the time who had not eaten anything all day patiently taught me how to do it better and handed the instrument back to me, and I haven’t made that mistake ever again

3. One Mon morning, while rounding briskly on over 20 very complicated patients, the attending surgeon stopped by one of the rooms just to say, by the way, you helped save this patient’s life, don’t’ forget that. It reminded me of what this is all about.

4. One Sun morning around 2AM, I woke up the attending surgeon at home to let him know about a patient who needed to go to the OR urgently. Without any sign of being annoyed, he said OK, let’s do the right thing. I never worried about calling him again at any hour

5. One Friday evening an attending surgeon called me. I thought I had made a mistake or missed a deadline. But she called just to thank me for having taken good care of one of her patients, and I will always remember how that made me feel.

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Jason J. Han (@JasonHanMD) is a cardiac surgery resident in Philadelphia and is part of the TMS leadership.

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The opinions expressed in the article is not affiliated with any institution, company or product. The article should not be interpreted as medical advice.

1. No one is invincible or impervious to change

We start out believing we may be the exception.

“He burned out, but I’m different”

“She changed, but I won’t”

Do not give into exceptionalism, and instead be more mindful of your environment. Not all things bounce back.

2. The most obvious problems are the ones worth working on

You may be tempted to distinguish yourself by coming up with “rare,” “prestigious” or “novel” ideas. But sometimes what the world needs more of are people who are willing to humbly work on the obvious, day-to-day problems. If we already have a solution that works, why re-invent the wheel?

3. As you become more successful, try harder at the basic things

Some of the most successful (and busiest) people around me still reply to emails kindly and reliably, remember people’s names, and offer help to others. This is not a coincidence.

4. No one else will say no for you

You might think that someone out there will tell you when you’re doing enough. But that’s not always in their interest. Only you can tell yourself when you’re doing enough and good enough.

5. Integrity matters

Some people around you will cut corners or take dishonest shortcuts to success. It never stops hurting to see jerks get ahead. But people notice sooner or later. Integrity matters. Character matters. And they always will.

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Jason J. Han (@JasonHanMD) is a cardiac surgery resident in Philadelphia and is part of the TMS leadership.

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The opinions expressed in the article is not affiliated with any institution, company or product. The article should not be interpreted as medical advice.

Certainly, if you measure the distance from sea level to the top, Mount Everest is indeed the tallest, standing at 8,850 meters or 29,035 feet.

But if we choose to measure the total elevation, even including the part that is underwater, the tallest mountain in the world is Mauna Kea in the Hawaiian archipelago. From sea level, it is only about 14,000 feet tall, but if we measure from the point where it rises directly from the seafloor, it is 32,696 feet in all.

Sometimes, I wonder if the way we talk about Mount Everest and Mauna Kea inadvertently carries over to the way we think about people, too. Often, we can only see the titles and the achievements on the surface. Therefore, it is easy to assume that everyone started from the same place, and that those with the most visible peaks have done the most. And in some cases, that may be true.

But perhaps we should try to be the types of people who can appreciate the stupendousness of Mauna Kea. We should try to gaze below the sea level, though the water hiding our pasts can be murky and mysterious at times, recognizing that all individuals begin their climb from different starting places.

Some may not get to reach the top of Mount Everest; however, they may have climbed higher than that in total.

They may not seem the tallest, but they, in fact, may be.

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Jason J. Han (@JasonHanMD) is a cardiac surgery resident in Philadelphia and is part of the TMS leadership.

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The opinions expressed in the article is not affiliated with any institution, company or product. The article should not be interpreted as medical advice.

But as a community, we need to challenge the assumptions we allow in our lives that prevent meaningful change.

1. “You’re naïve if you think that’s possible”

Just because you want to change something that does not have an easy solution, it does not make you naïve. Being wise does not mean always choosing the path of least resistance.

2. “Someone else is working on it”

When everyone assumes that someone else is working it, then no one will be.

3. “I will change it one day when I am in a position of power.”

Students wait until they become residents. Residents wait until they become fellows. Fellows wait until they become attendings. Attendings wait until they become Chairs. There is no perfect time, so don’t postpone change.

4. “The risks are too high.”

We always fixate on the risks of doing something, but too seldom ask ourselves about the risk of not doing something. Also, the consequences are never as catastrophic as you fear.

5. “The people in charge will never allow it.”

The people who we think are diametrically opposed to our values may share some of your values more than you think. But they are also trapped in their own assumptions and circumstances. They also think they have no choice. Give them a chance to express how they really feel by asking them.

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Jason J. Han (@JasonHanMD) is a cardiac surgery resident in Philadelphia and is part of the TMS leadership.

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The opinions expressed in the article is not affiliated with any institution, company or product. The article should not be interpreted as medical advice.