Sarah Sherwood

In this age of the 15-minute appointment, it's difficult to address the emotional component of a patient’s condition. As we know, emotions can be integral to a patient’s sense of well-being, their healing, and the perception of quality health care. Many patients leave their doctor's office feeling rushed, not having had enough time to process information and ask appropriate questions. And fair or unfair, this can leave patients with the impression that clinicians are uncaring or unfeeling.

One way to address patients' emotional needs in a time-efficient way is through technology (

). There are several tools/apps that can assist physicians with patients who are trying to cope with illness and potentially difficult treatment processes. Some have a support group feel, and others focus on patient engagement. The purpose of all of them, however, is that they give patients a platform to tell their story. Feeling "heard" can go a long way in patient care and healing.

Created by behavioral scientist-turned-software exec Bob Quinn, HerStory is a 

 for patients who need support while going through treatment. Still in testing, this app helps women dealing with breast cancer and mastectomy. (Other women’s disease categories will follow.) Built with input from patients, doctors, and support groups, HerStory allows patients to easily record their personal stories to help other breast cancer patients with advice and emotional help.

“Patients who have gone through similar situations can provide the greatest support,” says Quinn, who points out that the app is set up to review stories before they are published to make sure that the community is helpful and supportive.

Clinicians and behavioral scientists from Stanford and George Washington University have played a role in advising the developers of HerStory, which provides immediate, real-time support and practical advice via story telling and story sharing in a community of women going through the same challenges. For physicians looking for tools to help patients with emotional support outside of the office, this can be a helpful therapeutic tool.

“Research shows that with any illness, there is a tremendous need for social support,” says Dr. Sarah Adler, PsyD, clinical instructor, Psychiatry and Behavioral Science, Stanford University Medical Center. “The mind has a significant impact on physical health. Support, empathy, and connections are fundamental to reducing the stress that comes with needing medical care.”

Adler mentions that shorter appointments do not always leave time to empathize or to listen actively, even when caregivers have the best of intentions. However, some conditions require that kind of support, she said.

“Illness is stressful. Apps and other technologies like HerStory provide a place to get the support that might get missed in a 15- to 20-minute appointment,” she said.

OB/GYNs often deliver stressful and complex information to women who are afraid, confused, and sometimes even angry or heartbroken. These emotions can be palpable, but clinicians generally don't have adequate time to address sufficiently this emotional side of patient care. Information presented in a narrative form has been shown to help, reports Adler.

The value of story telling and sharing experiences and emotions has been documented by doctors and scientists,

 and it may be a safe bet that mobile technology that allows adults to join a community where they can receive immediate support not just for the day-to-day challenges of their disease, but for the sometimes difficult process of treatment, can be the answer. Allowing story telling to “come to life” for the millions of women currently going through medical treatment can be an important, effective supplement to clinical care.

 was created by a nurse with the concept of eliminating the clipboard from patient care and providing a convenient platform for patients to self-manage their experience. It is a cloud-based method of sharing information through all care levels, from primary to specialty, acute, and hospital care.

When physician practices or hospital systems use IngagePatient, they are able to reach out to patients where they spend much of their time-on their smart phone. This mobile platform offers support to the patient so that they can participate in their care in a more convenient way. Available on any smart phone, this app allows patients to schedule their own appointments and request medication refills without the hassle of phone calls or being on hold. This is especially helpful for patients when they are in pain. After logging in, patients can access their prescription and dosage levels, set reminders and alerts to take their medication, and set up their appointments. It also allows for chronic disease management.

The benefit for physicians is convenience.

“The doctor can check on patients remotely,” says Amanda Ceccloni, vice president of marketing for IngagePatient. “It provides a very busy OB/GYN with many needed options, taking away the administrative burden.”

The company uses a secure hosting cloud-based infrastructure, which is HIPAA compliant. Since it is built with newer technology, it can integrate with any EMR.

Facebook is often overhyped, but it can offer women community support in real time. During the 

 earlier this year, more than 10,000 women from around the world logged on to endometriosis communities on Facebook to share experiences and listen to others with endometriosis. Roughly six months after the event, endometriosis groups on Facebook are still going strong, with new communities such as 

, which have evolved to offer support and connections to women with the disease.

“We still use Facebook as a central point for discussing our pain, our successes, and challenges," said Lindsay Murphy, freelance writer for 

. On Facebook, Lindsay shares her own battle against stage 4 endometriosis, which has resulted in four surgeries.

“Many of these women have had to have multiple surgeries, so Facebook communication has become a way for women to fact-check their doctors. Everyone is communicating about what is done during treatment. We’re sharing so many things, including treatment protocols, what doctors are saying during appointments, and how we’re doing day to day.”

Murphy insists that this forum is forcing consistency in the industry.

The strength of Facebook is its familiarity, so it is easy to refer patients. Its weakness is that unlike HerStory, the content is not screened, so there is a potential for misinformation. Still, it remains a strong resource for support.

Recommending Facebook communities that are condition-specific, such as 

, can be helpful for support. However, patients must fact check the information using credible medical sites and, most importantly, with their doctor.

Public Health Resources / Community Support

Health care providers today simply do not have the time to provide the kind of emotional and community support that many patients need. Offering resources to communities that can provide more in-depth support is a way to show patients that you recognize a need that you are sensitive to but that you personally are unable to meet. In addition, visiting these sites can offer insight into the patient experience beyond what you see in your practice.

Han Le, MD, a consultant for HerStory and other technologies, points out that each physician is coming from an intellectual level, not a peer-group level.

“Many physicians are very good at providing counseling for their patients, but patients still gain a lot of insight from being able to connect with others. Those shared experiences allow them to speak on a peer-to-peer level."

She adds, “It’s tremendously helpful to physicians to be able to recommend a safe, secure community where patients can share their collective wisdom. It means that a physician is able to help arm patients with the best tools that they can turn to, even when the physician isn’t available.”

Directing patients to resources that allows them to tell their story and that can offer them the emotional support that they need goes a long way in the healing process. It also lets patients know that you do empathize and understand that their diagnosis goes well beyond the clinical.

1. Gowan J. Why sharing stories brings people together. Available at: 

http://www.psychologytoday.com/blog/you-illuminated/201106/why-sharing-stories-brings-people-together

2. Campion-Smith C, Austin H, Criswick S, et al. Can sharing stories change practice? A qualitative study of an interprofessional narrative-based palliative care course. 

http://www.ncbi.nlm.nih.gov/pubmed/21043556

3. Greenhalgh T, Campbell-Richards D, Vijayaraghavan S, et al, for the National Institute for Health Research Service Delivery and Organisation programme. The sharing stories model of diabetes self-management education for minority ethnic groups: a pilot randomized controlled trial. Available at: 

http://www.nets.nihr.ac.uk/__data/assets/pdf_file/0018/64503/FR-08-1504-111.pdf

Articles

Addressing the emotional component of a patient's diagnosis isn't often feasible, but these tools can help patients with this important aspect of healing.

Story Telling and the Emotional Component of Healing

When the economy showed signs of instability in 2007, Lindsay Murphy was laid off from her job at a hospital. Two years later, still with no job and no health insurance, she had to file bankruptcy and lost her home. But tough finances were not the main source of her anxiety-even more difficult for Lindsay was not knowing the cause of her severe bleeding and pain. Without insurance, she began to visit a popular clinic dedicated to women’s health for her care.

What transpired was a long road of misdiagnosis, which she later learned is common in endometriosis patients. The clinic’s doctors said she had pelvic inflammatory disease. They gave her a shot, but she continued to reel in pain. Upon return, she was put on antibiotics and asked to leave.

I had a hysterectomy at 33 years old. It truly released me from my pain and gave me a chance at a high-quality life. To this day, there is no pain. My surgeon removed my endometriosis, but there is still no cure for the disease. It's been a long road to recovery, and I've had to learn to manage the damage the disease has done. I've made tremendous progress. Although I’m not the athlete I was years ago, I am active. After years of no answers and four surgeries, I now have a pain-free life. I feel good that I helped the medical community learn more about the disease, but there are still many more questions than answers.

After a job interview in Denver, she collapsed on the street; when she woke, she called her mother. “That is no UTI,” she said. It would take another three years of misdiagnosis and botched surgeries before Lindsay would finally recover, finding relief from debilitating pain. She eventually found a trained specialist and endometriosis was finally diagnosed.

“This is a specialty disease,” says Mary Lou Ballweg, president of the Endometriosis Association, a worldwide group dedicated to research and awareness of the disease. “It is the characteristic of determination that I have come to appreciate-those doctors who keep coming back to understand the disease.” She points out that 89 million women around the world have endometriosis and are searching for effective treatment, concerned about pain and infertility. “It 

Even more women, one in four, have fibroids. And there are many other undetected, misunderstood diseases that are complicated to treat. Lowering the numbers and the costs that go with them actually requires investment that will lead to better detection and surgical training.

“A four-year residency is not enough,” says Mona Orady, MD, director of Robotic Surgery Education at Cleveland Clinic: “I see women after they have had unfinished, poorly performed surgeries every single day.” Orady believes hospitals need to adopt stratification where they designate what is routine and what requires simulation and other forms of surgical training. “There are higher levels of care and, for that, high-quality training is essential.”

Orady encourages simulation training by incentivizing it. She sets the bar and requires passage in order to operate. Many other centers of excellence are now setting their own requirements. The Robotic Training Network (RTN) has unified robotics training and testing at over 50 institutions, with participating hospitals including Johns Hopkins and Harvard. The RTN curriculum, which includes cognitive testing and skills evaluation through physical models and simulation, is growing rapidly in popularity.

At Columbia, we have begun implementing the RTN curriculum on both the resident and fellow training level. As the Vice-Chair & Chief of Gynecology at Columbia University Medical Center, I can tell you that the days of learning-as-you-go on patients are not acceptable. Surgeons must simulate to proficiency before entering the actual operating room.

® robot also use simulation training to some degree. This technology, created by Mimic Technologies, has been independently validated by research and academic medical centers around the country. Mimic has also recently developed training technology for traditional laparoscopic surgery that supports the surgical assistant in robotic procedures. The goal is to help all members of a robotic surgical team perform at a high level.

Mimic’s training director, Todd Larson, is a former Walter Reed Army Medical Center specialist, and agrees with Orady that most surgeons coming directly out of residency have not reached a level of competency that allows them to perform advanced surgical procedures. Consequently, they will seek Fellowship training or some other advanced training to acquire those skills. Mimic Technologies has partnered with the Florida Hospital Nicholson Center to develop simulation training to aid the specialist in safely acquiring advanced skills. 

According to Larson, most surgeons who participate in simulation training note improvement. They are evaluated through technology called M-Score, which measures performance and provides an actual score on areas that represent their strengths and weaknesses. This type of assessment is meant to improve training efficiency, since the surgeon can then focus on his or her own specific deficiencies.

Once surgeons complete their training, they must meet the credentialing standards of the hospital where they are practicing. Currently, there are no universal standards or benchmarks for robotic surgery. Each individual hospital has its own standards for credentialing and privileging. There is an effort through the American College of Surgeons to develop the Fundamentals of Robotic Surgery; however, these standards are still in development. Since the Joint Commission requires ongoing professional practice evaluation to ensure surgeon competency, simulation can serve not only as an objective performance measure but also as a tool to maintain competency utilizing advanced technology, such as robotics. Surgeons claim that individual high surgical case volumes lend themselves to maintaining one’s skills. This is why objective-based simulation can serve as a great tool for skills maintenance and overall competency. As Orady and Larson point out, surgical skill is individualistic and skills decay will vary with each individual practitioner. However, by continuing to use simulation, a surgeon can continue to evaluate and maintain his or her skills.

“There is a lot of equipment in the hospital that has the potential to cause harm. Robotics is certainly no different," says Larson. “What is unique about robotics is the means to safely acquire and maintain a surgeon’s skills through simulation and advanced training." [[{"type":"media","view_mode":"media_crop","fid":"27424","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_582556338049","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2662","media_crop_rotate":"0","media_crop_scale_h":"223","media_crop_scale_w":"300","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; float: right;","title":"Screenshot of augmented reality surgical training software.","typeof":"foaf:Image"}}]]

Since gynecology is becoming more specialized, the need for advanced training is even more necessary. Mimic is also working on an augmented reality product that will simulate hysterectomy, coming out this fall. Augmented reality combines three-dimensional (3D) computer-generated objects and text and superimposes them onto real images and 3D surgical video footage, all in real time. The surgeon then has the feeling of being in an actual surgery. This 

 provides a brief example of how this augmented reality training software will work.

Larson says this is needed because the current controlled basic training environment is incomplete: “The current animal model used in training does not adequately emulate actual practice. What would be ideal is to perform the procedure in a simulated environment and be objectively evaluated on your performance.” Hospitals are constantly looking for the safest way to acquire skills, learn the specifics of the surgical procedure, and learn how to manage potential complications.

“We believe this is the future of GYN training,” says Mimic CEO Jeff Berkley, PhD. “Practicing surgery on animals will only take us so far. Through augmented reality, we hope to expose surgeons to a wide variety of surgical scenarios that they would not normally encounter as a part of the typical case load. This approach may help limit the amount of learning that must not take place on real patients.”

Berkley explains that it was gynecologists who were the first to make the aggressive push toward simulation testing to gain surgical privileges. This is due, in part, to the access issues of training in the OR. “Gynecology training is special-it is tougher to get to the volume of surgeries you need,” he says. “It can be tough to keep up those needed skills. That is why we have made women’s health a priority, because skills maintenance through simulation should play a larger role in gynecology.”

Another development that is being scientifically supported by The New European Surgical Academy (NESA) is a European robotic system called 

, which allows the surgeon to indirectly “feel” the tissues they are manipulating during surgery. The system is already certified in Europe and more than 100 clinical studies are under way. Experts are predicting that many new surgical robots, which will enable the sense of touch, will become available. The additional market competition should help bring down the cost of robotic surgery.

Speaking of cost, Berkley recommends that hospitals begin looking at education and training as an investment rather than simply an expense. Despite reports that claim that hospitals profit from some errors, repeated surgeries and residual damage from poor surgeries have been shown long term to be quite expensive for both patients and hospitals, with cumulative annual estimates nearing $1.5 billion.

 In the United States, it's been reported that patients undergoing surgery experience "never events" about 80 times each week-mistakes that safety advocates say never should happen.

 These mishaps add up to $1.3 billion in medical liability payouts alone over 20 years. The study’s surprise was the conclusion that surgical errors involve surgeons of all experience levels.

The advantage of practice on the simulators and mentored cases is improved OR performance that prevents these costs. Studies are showing that simulation testing can help hospitals gauge whether a surgeon is ready for the OR. Such a proactive approach can be more cost effective than reacting only after a surgeon makes a mistake. Much of the new, independent rules that hospitals are implementing now require more training such as this. It appears that administrators are listening to the argument that quality of care and costs are associated.

The other important area of training is through 

. “Depending on the case, if there is damage to the colon, for example, I may want a general surgeon with me in the OR because it is not my normal expertise," says Melinda Henne, MD, former head of infertility at Walter Reed and a consultant for the Air Force. Richard Satava, MD, a general surgeon and Professor Emeritus of Surgery at the University of Washington, Seattle, agrees that bringing on either a generalist or a specialist helps a great deal with training. “If there is an area the gynecologist feels uncomfortable with, we can be helpful,” he says. “The ureter can be unfamiliar, the kidneys, the bladder. But the colon is a particularly uncomfortable area for many GYNs because if you injure the bowel and there is leaking, it can be catastrophic.”

Satava also mentions that with the trend of super specialization there is less and less emphasis on the role of the general surgeon. But since they operate so often and have very broad experience in the many aspects of abdominal surgery, it can be quite helpful to include them as partners in the OR. “This is a time when there are more requirements and pressures on specialists. And, at the same time, there are fewer hours of experience for newer surgeons. In anticipating a difficult operation, there is no question that a general surgeon will increase the quality of the surgery and the safety for each patient.” And it’s not just a general surgeon. Satava also recommends specialists, “You may want to include a urologist in the room.”

As a surgeon, I know firsthand that when implementing this team-based approach, it is important to ensure that all members are equally skilled in their areas of focus, otherwise the whole process breaks down. For example, if the colorectal surgeon is not competent at managing bowel endometriosis, then the work performed by the infertility specialist is compromised and patient outcomes are impacted.

Patients such as Lindsay have come to learn that for tough surgeries, a better-trained surgeon is essential.

1. Encinosa WE, Hellinger FJ. The impact of medical errors on ninety-day costs and outcomes: an examination of surgical patients. Health Serv Res. 2008;43:2067-2087. Available at: 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2613997/

2. Cabrera M, Cavanaugh M, Pico P. How hospitals can avoid surgical mistakes. March 1, 2013. Available at: 

http://www.kpbs.org/news/2013/mar/01/how-hospitals-can-avoid-surgical-mistakes-do-not-p/

3. Mehtsun WT, Ibrahim AM, Diener-West M, et al. Surgical never events in the United States. 2013;153:465-472. doi: 10.1016/j.surg.2012.10.005. Epub 2012 Dec 17.

Complex GYN surgeries require a competency level that traditional training often can't provide. Here, the latest trends in surgical training are discussed.

Augmented Reality, Other Trainers for Complex Disease

As rounds began on an inpatient floor early one morning, a team of surgeons rushed in to visit a fragile 75-year-old woman. The attending surgeon, too busy to think of the patient, abruptly told her,

 “Your MRI shows you have colorectal cancer, so we plan to take you to the OR for surgery tomorrow. Alright, see you later,” he said, rushing out of the room just as fast as he arrived. But Ms. A, who had been resting on her hospital bed, reacted with fear and confusion. A nurse noticed her immediately turning pale after she heard those words from the attending. She tried to open her mouth, but the gravity of the news she had just learned left her speechless. Finally, she slowly raised her shaking arm and squeezed out a few words, “I … I don’t … understand.” But by then the entire surgical team had left.

a nurse ran into the surgery dictation room, angry and determined, “Who is Ms. A’s doctor? Did you guys know she has depression, and today is the first time she’s heard she has cancer? She just attempted suicide by cutting her wrist in her room!”

The team reacted with silence. “Well, I thought somebody had already told her,” said the attending, while scrolling down numerous progress notes in the electronic record. “Aren’t GI, oncology, and ID all on board for her case?”*

*This incident did not occur at any of the hospitals mentioned in this article.

We have heard “teamwork” uttered throughout the GYN community for at least 10 years, especially since 2004, when a 

 issued by the Joint Commission revealed that most cases of perinatal death and injury are caused by problems with an organization’s culture and communication failures. As a result of many difficult cases such as this one, it was recommended that hospitals implement teamwork training programs in an effort to improve communication and outcomes.

As the case example illustrates, simply forming teams is not the answer; it is a pointless exercise unless there is a good plan with effective implementation. Teamwork means many things and, too often, it is applied superficially. What is needed is effective teamwork for the benefit of everyone involved, especially the patient. So, ten years after the Joint Commission issued their recommendations, how is the industry doing? How can we improve? And, most importantly, in 2014, what can we take advantage of so that incidents such as these do not recur?

Certainly hospitals have implemented required training, but some training programs amount to only a few hours of lecture. Let’s look at 

 that can help develop an improved program for both multidisciplinary and internal teams.

[[{"type":"media","view_mode":"media_crop","fid":"25180","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_8880718767177","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2264","media_crop_rotate":"0","media_crop_scale_h":"150","media_crop_scale_w":"144","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; float: right;","title":"Louise P. King, MD, JD","typeof":"foaf:Image"}}]]“Every single time I interact with my team, it is beneficial,” says Louise P. King, MD, JD, gynecological surgeon at Beth Israel Deaconess Medical Center and instructor at Harvard Medical School. “The more we work with the same people, the more we learn and the better we’ll do.” King says the most significant benefit to effective teamwork plays out in everyday interactions that lead to better overall care. At Harvard, she says, “The operating room roles are very important. I’ve learned a great deal from other surgeons. Through effective communication, checklists, protocols, and standards of practice executed daily by teams that work together help us provide excellent care.”

She remembers a particular case earlier in her career at another hospital where she had a larger team come together during a complex surgery. “The patient did so well she actually went back to work three days later-because our team, made up of great people-helped us to get it done well.”

King also mentions psychiatric patients she attended to earlier in her career, people with developmental delays and borderline personalities, who presented special challenges that required a team approach. “When I began practicing, working with psych patients was challenging.” But she learned early on how to work with them through their frustration. She reaches out to the hospital’s psychologists/psychiatrists, who serve also as social workers. “I learned from them about how to respond in this special situation.” She says they will team with her to talk to the patient, saying things like, “This doctor is trying to help you.” King has learned how to respond in difficult circumstances. “I realized that if I don’t have a particular way to address the issue, I’ll turn to these professionals.”

[[{"type":"media","view_mode":"media_crop","fid":"25183","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_5778944159392","media_crop_h":"292","media_crop_image_style":"-1","media_crop_instance":"2263","media_crop_rotate":"0","media_crop_scale_h":"150","media_crop_scale_w":"122","media_crop_w":"237","media_crop_x":"0","media_crop_y":"31","style":"line-height: 1.538em; float: right;","title":"Camran Nezhat, MD","typeof":"foaf:Image"}}]]“We certainly learn from each other,” says Camran Nezhat, MD, chair of Association of the Adjunct Clinical Faculty at Stanford University School of Medicine and an adjunct clinical professor of OB/GYN and surgery also at Stanford University. “Progress takes place when there is collaboration between different disciplines.” Nezhat says it is as if the other specialists are handing you some of their experience. He adds that it’s more than the communication-it is about the relationships you have with other physicians.

Nezhat also advises sitting down and talking with the team prior to surgery. “Have an honest and frank discussion.” He follows up by having the patient meet the other physicians in person. He, too, recognizes the contribution that every team member makes. “When I work with Mark Welton and Andrew Shelton of our colorectal team or Ben Chung and Harchy [Harcharan] Gill from urology, for example, there 

 better outcomes-because their skill adds to my abilities and, together, we really help the patient.”

[[{"type":"media","view_mode":"media_crop","fid":"25197","attributes":{"alt":"","class":"media-image media-image-left","id":"media_crop_2483318890444","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2274","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; float: left;","title":"Mary Lou Ballweg","typeof":"foaf:Image"}}]]Mary Lou Ballweg, president of the 

, speaks with surgeons almost daily about the complexities of endometriosis, which she calls “a specialty disease.” She says the reality is that, because of the lack of knowledge-sharing, the patient is often set up for multiple surgeries. “This is not an acceptable solution,” she says. “We can address the problem of diagnosis and treatment much better with teams.”

Ballweg reasons that multidisciplinary teams serve as a check-and-balance system, where surgeons can learn the very best from each other. “Not every hospital can bring together the right people. Patients need GYN specialists working side by side.” Her experience has taught her that patients need the right team working together, and there are times when “rebuilding teams” needs to be considered.

Nezhat makes the same point. “I’m always respectful, yes, but it is better to work with a colleague that you like and admire.” He says that if you are working with a team you don’t enjoy or you disagree with, it can cause too much stress for both sides, and the patient doesn’t benefit. Nezhat also advises administration to provide the best available equipment for the team to ensure success. “I cannot play the piano without a piano or with a broken piano.” There is new technology that can help teams operate better.

[[{"type":"media","view_mode":"media_crop","fid":"25182","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_1318221213296","media_crop_h":"268","media_crop_image_style":"-1","media_crop_instance":"2265","media_crop_rotate":"0","media_crop_scale_h":"150","media_crop_scale_w":"117","media_crop_w":"209","media_crop_x":"5","media_crop_y":"4","style":"line-height: 1.538em; float: right;","title":"Paul Wetter, MD","typeof":"foaf:Image"}}]]Paul Wetter, MD, chairman of the Society of Laparoendoscopic Surgeons, is working on using brand-new technology to accommodate teams in surgery nationwide. He is working with academic centers to develop technology that will help surgeons track, monitor, and diagnose patients better and more quickly.

“Every patient has a super computer in their pocket with an infrastructure that allows for progress in medicine,” says Wetter. “For example, studies could be conducted via cell phones. We’re asking how we can work together to help each patient-all we need is the right kind of application where multi-disciplinary teams can come in and make all the difference.”

According to Wetter, this is the future of team surgery. In real time, patients could be tracked to identify the hotspots in the body. The surgical team can compare notes and talk with each other. This doesn’t exist today. But it is the future. We’re just beginning to think of all of the possibilities. “We are right on the cusp of technology that will change everything,” he says.

At Stanford, Wetter is working with senior fellows who are studying endometriosis so that they are better exposed to other specialties. “Stanford is the first institution to adopt our new one-year program,” he says. “This new multi-specialty approach will improve training so that physicians can more easily coordinate and set up multidisciplinary teams. We are working on the best way to bring new technologies to teams.”

However, the very best technology won’t make a difference if team commitment and structure is lacking. Wetter advises us to put safety and cost considerations first, without compromising quality. “What is critically important is that physicians talk and share records.” He adds, “We need to continue to develop systems that foster cooperation, systems that encourage second opinions.”

But how can this be accomplished? Primary care physicians know a lot, but they are not recognized for their knowledge across disciplines. Like most physicians, their biggest fear is what they don’t know. Teams alleviate this fear and help each physician acquire knowledge. Nezhat likes to encourage his fellows with the advice that in order to conquer this fear, teams must have mutual respect for each other.

Later on, “Ms. A” was rescued and stabilized from her suicide attempt. Had there been a better team building program, improving the communication of each multidisciplinary team, there wouldn’t have been an incident. The buck wouldn’t have been passed. The patient’s life wouldn’t have been in danger. We are becoming more specialized, and for that very reason physicians need to become better communicators, verifying, verbalizing, and each time noting the history of the patient.

“Think of everyone else in the OR as an important member of the team. You will do a much better job getting feedback and help from them,” says Wetter. “All those professionals have information that could, in some ways, help you.”

http://www.emeraldinsight.com/journals.htm?articleid=17095307

http://www.european-hospital.com/en/article/11130-UK_Multidisciplinary_teamwork_will_stay.html

http://patientsafetycouncil.org/uploads/Multidisciplinary_teamwork_and_communication_training.pdf

http://www.ncbi.nlm.nih.gov/pubmed/21190951

Drs Louise King, Camran Nezhat, and Paul Wetter discuss an effective teamwork model, agreeing that patients have better outcomes when clinicians work as a team.

It Takes a Village: Making the Case for Teamwork

 training is taking on new meaning. For those who prefer using the robot over traditional laparoscopic surgery, the news over the past year has been less than positive. Unreported adverse effects, the cost of the robot, and doubts about surgical skill have been a concern to hospitals, medical professionals, and patients who have read negative reports.

 have been hoping for new studies that would showcase the advantages they claim to see firsthand, studies that prove that training surgeons results in measurably better outcomes. Well, now the data is in. Just last month, a 

 out of the Icahn School of Medicine at Mount Sinai and Morristown Medical Center, called “the Morristown Protocol,” demonstrates that surgeons who followed its training protocol on a simulator perform at a much higher level than those who use the more traditional means of training for the 

The study is the very first trial of a gynecological robotic simulation protocol that shows results in a live surgical environment. It also shows measurable improvement in clinical competency with live patients.

"Proficiency is something every novice robotic surgeon is looking for,” says study leader Patrick Culligan, MD, FACOG, FACS, division and fellowship director, Atlantic Urogynecology Associates, Morristown Medical Center. “Our study has found that surgeons can become ready much more quickly by using the simulator, potentially saving time, blood loss, and costs for each hospital robotic program."

Arnold Advincula, MD, vice-Chair of Women’s Health & Chief of Gynecology at Columbia University Medical Center, says that this is common sense-there is no question that training for the 

 is required. “Why would I want to have surgery with someone who isn’t ready? Why would I want anything other than an excellent surgeon doing my surgery? Either we’re excellent or we’re out.”

 robots have been purchased, the questions hospital administrators have been asking have to do with what kind of robotic training is necessary, how much is needed, and in what kind of setting.

The best type of training is also critiqued by the new study. “The current model for getting surgeons ready for surgery is a broken model,” Advincula insists. “But with this study, we know that we can train on a simulator and reach a high level of proficiency without sacrificing an animal. We also know that we can now do away with what is not working.”

The study shows that surgeons begin at different levels, and it may take a different path of commitments to gain competence on the robot. In other words, it proves that some surgeons need to work harder than others to gain proficiency. Some understand the mechanics of the robot right away, while others need more time on the simulator.

We have not seen a model showing competence in live surgery because such a model is logistically difficult, requiring necessary attention to scheduling, time, and effort. Culligan’s commitment to solving the question is appreciated by his peers. “This is the first study in gynecology that asks if simulation really improves performance in live surgery,” says Paul Tulikangas, MD, FACOG, FACS, an ob/gyn and urogynecologist affiliated with the University of Connecticut School of Medicine, who has adopted the new findings into his program. “Pat took it further than anyone when looking at expertise. He asked, ‘We think you’re better, but we don’t know for sure, so let’s examine live surgeries and see if the simulation program really improved performance.’”

What distinguishes this paper from previous studies is that it more carefully evaluates and then separates the various skill levels among the surgeons. “We used this study to set minimum skill levels that must be met before operating on live patients. This is important because surgeons develop their skills at different rates,” says Tulikangas. But in this latest study, the control group was experienced in robotics.

Surgeons who reviewed the study say it is the methodology that is different this time, because subjects are separated by skill level, which was not done in previous studies, such as the controversial 2013 

 that the surgical outcomes don’t justify the cost of the surgical robot.

John Lenihan, MD, who has publicly challenged studies based on poor methodologies, is also now using the Morristown protocol for new surgeons. He says the recent studies showing problems with the robot when compared with traditional laparoscopic surgery have been blown out of proportion. His remarks echo those of others who prefer the robot to standard laparoscopic surgery. “The 

 robot is not the problem,” he says. “Many of us have reviewed the literature. The number one cause of problems with the robot has to do with surgeons doing surgeries that they have not yet acquired the skills to do.” He claims that some surgeons have a lack of respect for the need for training in general.

This time, board-certified laparoscopic surgeons who had no prior experience with robotic surgery were, after the training, able to meet and even exceed the rigorous requirements of the study set by a team of experienced robotic surgeons who, according to researchers, averaged over 75 robotic cases each year. Study participants required between eight and 40 hours of simulation training to achieve the required benchmarks.

Culligan’s study involved 14 ob/gyns and two sets of comparative benchmarks. Its “expert surgeons” each performed supracervical hysterectomies, as did a group of “control surgeons.” The control group had full robotic hospital privileges but was not averaging more than two cases per month and had not trained on the simulator. Operating time, estimated blood loss, and a blinded skill assessment of videos were compared using 

-tests for all cases across the three surgical groups.

Surgeons engaging in their first-ever robotic surgery, who used the training simulator, had a much better outcome than the control group, the investigators found. Compared with the control group, the surgeons trained with simulation completed their cases approximately 33% faster, had less blood loss, and scored better during the blind video review. Not only did the simulation-trained surgeons achieve the benchmarks set by the experts, they did so quickly. Each surgeon was required to reach expert status on the simulator before they could move to performing a human hysterectomy.

Champions of the robot want it to be available to surgeons because they believe that they should use the tools they like best. “We developed this simulation technology because we felt surgeons need easily accessible training outside of the operating room so that they can become comfortable and confident when using the robot” says Jeff Berkley, founder and CEO of Mimic Technologies, the company that designed the training platform for the 

 robot is an enabling technology that allows surgeons to achieve expert levels of performance faster than with traditional laparoscopic surgery. This said, there is still a learning curve, and it is better to start climbing it before operating on patients.” Many surgeons believe that the robot is worth the cost if surgical outcomes are positive.

Does that mean we should allow each surgeon to operate using the tools that help he or she perform best regardless of cost? “The way I like to operate, with the robot or without, definitely plays a role in how surgery is performed,” says Tulikangas. But he insists that one of the important criteria that drive these decisions is cost data: “Quality outcomes are so important, but so is cost.”

Lenihan agrees that surgeons need to be honest with themselves and assess their own skills. “Not every surgeon can do every surgery.” Instead, because of overwhelming evidence in favor of patient safety, the goal for any surgeon should be a minimally invasive solution for the patient, a method for resolving the issue in the most expeditious way. After all, there are many ways to perform surgery. Lenihan says we need to rethink who is doing surgery, and how they are trained and evaluated. With fewer errors, we can be much more cost effective-and a lot safer.

The future of surgery is using a new method of training: group practice through simulation. Teamwork itself is new. Innovative studies such as Culligan’s will help pave the way for a group effort regarding safety and risk management around robotic surgery.

Tulikangas says they have incorporated the protocol into their training program, using Mimic’s technology. If a surgeon is doing a low volume of surgeries, he or she is now required to engage in the simulation training-and this is because of the study. “It’s a study a lot of people thought about doing. We’re very fortunate that Pat had the resources and commitment to do it.”

The reported outcomes for the da Vinci robot have been disappointing, but a new study shows that surgeons can achieve expert-level results using the Morristown Protocol.

Improved Training Is Key to Better Outcomes for Robotic Surgery

• Endometriosis affects an estimated 1 in 10 women during their reproductive years (ie, usually between the ages of 15 to 49), which translates to approximately 176 million women in the world.

Often Called an “Invisible Illness” with Severe Consequences:

• Depression is 15% to 20% higher for the chronically ill than for the average person.

• Various studies have reported that physical illness and uncontrollable physical pain are major factors in up to 70% of suicides.

• The 2002 US Census Bureau reported that approximately 96% of people who live with an illness have an illness that is invisible. They note that these people may look perfectly healthy.

• Endometriosis is one of the top three causes of female infertility. While it is one of the most treatable, it remains the least treated.

• Up to 30% to 50% of women with endometriosis may experience infertility.

Serious Delays in Diagnosis and/or Serious Problems of Misdiagnosis:

• Anglo-American studies have shown a delay from 3 to 11 years between the onset of pain symptoms and the final diagnosis of endometriosis.

• The National Endometriosis Society claims that around 2 million women in the UK have undiagnosed endometriosis.

• Studies carried out in the USA, the UK, and Australia have demonstrated that the difficulty in timely diagnosis of endometriosis is universal. 

The delay in diagnosis was recorded as 9.28 years in the North American Endometriosis Association Survey (NAEAS) of 4000 members

; this includes a delay in the patient seeking help from a physician for an average 4.67 years and a delay of 4.61 years in the physician making a diagnosis of endometriosis.

• The length of time from the onset of symptoms to the definite diagnosis is often an average of 6 to 10 years. This delay is even longer in young patients and in severe cases.

• A range of problems may result from this delay in diagnosis, including deterioration of patient's quality of life, progression of the disease, the impact of absence of an explanation of pain, and the financial burden on the budget of medical services.

• Studies show adolescents usually turn to their primary care physician for evaluation of dysmenorrhea (painful periods) and chronic pelvic pain.

• Many arguments exist to organize the clinical care for women with advanced endometriosis in centers of excellence, but continuing education of primary care physicians also remains a priority.

• In survey findings, 63% of general practitioners indicated they felt ill at ease in the diagnosis and follow-up of patients with endometriosis. One half could not cite three main symptoms of the disease out of dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility. Only 38% of general practitioners indicated that they perform a clinical gynecological examination for suspected endometriosis, and 28% recommended MRI to confirm the diagnosis.

• Painful bowel movements during periods

• Other gastrointestinal upsets such as diarrhea, constipation, nausea.

In addition, many women with endometriosis suffer from:

Endometriosis is an estrogen-dependent disorder that can result in substantial morbidity, including pelvic pain, multiple surgeries, and infertility. Affected women are at higher risk than the general female population for ovarian cancer, and they also may be at increased risk for breast and other cancers as well as autoimmune and atopic disorders.

 It is recommended that clinicians assess and follow up affected women for these and other associated disorders.

There will probably be a new repertoire of approaches for treatment of disease-associated pain and infertility and perhaps cure of this enigmatic disorder as researchers better understand the science behind the genetics, the possible roles of the environment and the immune system, intrinsic abnormalities in the endometrium of affected women, and secreted products of endometriotic lesions.

1. Rogers PA, et al. Priorities for endometriosis research: recommendations from an international consensus workshop. 

2. Adamson GD, et al. Creating solutions in endometriosis: global collaboration through the World Endometriosis Research Foundation. 

3. Rifkin A. Depression in physically ill patients: don't dismiss it as "understandable." 

4. Mackenzie TB, Popkin MK. Suicide in the medical patient. 

5. Olive DA, Schwartz LB. Endometriosis. 

6. American Society for Reproductive Medicine fact sheet. Endometriosis: does it cause infertility? Available at: 

http://www.asrm.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Info_Booklets/EndoDoesItCauseInfertility.pdf

7. Husby GK, Haugens RS, Moen MH. Diagnostic delay in women with pain and endometriosis. 

8. Ballard K, Lowton K, Wright J. What's the delay? A qualitative study of women's experiences of reaching a diagnosis of endometriosis. 

9. Hadfield R, Mardon H, Barlow D, Kennedy S. Delay in the diagnosis of endometriosis: a survey of women from the USA and the UK. 

10. Matsuzaki S, Canis M, Pouly JL, et al. Relationship between delay of surgical diagnosis and severity of disease in patients with symptomatic deep infiltrating endometriosis. 

11. Zrubek H, Sikorski M, Nasser M, et al. Endometriosis in adolescents and young women. Can we afford to delay the diagnosis? 

12. Slack A, Child T, Lindsey I, et al. Urological and colorectal complications following surgery for rectovaginal endometriosis. 

13. Youngster M, Laufer MR, Divasta AD. Endometriosis for the primary care physician. 

14. Simsa P, Mihalyi A, Kyama CM, et al. Future of endometriosis research. 

15. Ballard K, Lane H, Hudelist G, et al. Can specific pain symptoms help in the diagnosis of endometriosis? A cohort study of women with chronic pelvic pain. 

 Chichester, West Sussex: Wiley-Blackwell; 2012.

17. Quibel A, Puscasiu L, Marpeau L, Roman H. General practitioners and the challenge of endometriosis screening and care: results of a survey. 

 Epub 19 Apr 2012. doi:10.1016/j.gyobfe.2012.02.024.