Building Organs Even the Prudish Can Handle
[New York Times, 12 February 2008]
By RICHARD MORGAN
The human breast comes in wondrous varieties. Good luck learning that in medical school. There, students practicing on training dummies mostly encounter the same set of perky 36Bs. Many students become doctors never having learned the nuances of checking for cancerous lumps in larger, smaller, flatter, fuller or droopier breasts.
So Dr. Carla Pugh, a surgeon at the Northwestern University medical school, takes matters into her own hands. She builds fake breasts in her lab from everyday off-the-shelf items. Lima beans, it turns out, are excellent facsimiles for tumor tissue.
Medical schools have a dirty secret: they can be just as puritan as the rest of us. Training is often handicapped by a combination of shame, embarrassment and hyper-etiquette — even as cancers of the breast, testicles, cervix, colon and prostate kill tens of thousands of Americans each year.
In a report in The Archives of Family Medicine in 1998, doctors invariably evaluated themselves as “very comfortable” performing breast and prostate exams, regardless of the doctor’s sex, even though very few of the same doctors evaluated their skill as “excellent.” Among male doctors performing breast exams, for example, 78 percent said they were very comfortable but only 35 percent rated their skill as excellent. Interestingly, though 98 percent of female doctors were very comfortable, just 37 percent said their skill was excellent.
Dr. Pugh, 39, has worked nearly a decade to bridge that gap. Her first creation, in 1998, was a “vaginal vault” made of a cardboard toilet-paper roll, Play-Doh and a badminton shuttlecock (a makeshift cervix). She has also constructed a scrotum using two wood balls linked by a rubber band (vas deferens) and suspended in an extra-large condom filled with oil and peanut butter.
She often buys penises at adult “novelty” shops, though they are all erect and circumcised, and sometimes welds on rubber tubing used for synthetic intestines when a foreskin is needed. Blessed with an education that took her through Stanford University in the tech-frenzied late 1990s, she attaches sensors to the models so teachers can know whether the students are touching the right areas and using correct pressure.
Her models are perhaps not as polished as some simulators on the market, but they are realistic enough that she hides them from male friends. She patented her pelvic simulators in 2002, and her maverick MacGyver-meets-Dr. Ruth approach was honored last year at a celebration of pioneers in academic medicine at the National Library of Medicine that is currently touring the country.
“Just because you’re smart enough to get into medical school, you’re not smart enough to outwit the social restraints we all grow up with,” Dr. Pugh said recently between meetings at a conference in Las Vegas. “It’s not like med school students are gifted to the degree that they can touch a stranger’s genitals and look them in the eye and have a calm conversation without feeling weird about it.”
When it comes to surgery, the hardest part of the human body to remove turns out to be the fig leaf.
In 2003, Dr. Pugh’s model for a simulated pelvic exam gained a licensing agreement for wide-scale manufacturing. It was good timing. That year, The American Journal of Obstetrics and Gynecology reported that medical students routinely learned how to conduct pelvic exams by practicing on anesthetized patients — sometimes without the women’s knowledge or consent.
Dr. Richard M. Satava, a surgeon at the University of Washington in Seattle and a pioneer in surgical methods that rely on electronic measurements, says much of the problem lies in the way medical education is financed. Medical schools do not receive federal funds to support educational improvements. Although Medicare and Medicaid pay teaching hospitals $8 billion a year for medical education, the money almost always pays for residents’ or faculty members’ salaries.
“We need permission to fail in a safe environment,” Dr. Satava said. “Aviation has used simulators since 1955 that are now almost indistinguishable from flying real airplanes and have achieved a remarkable safety record. It’s time that health care followed.”
The models need not be particularly high-tech. “A very sophisticated simulator would be too much for a student,” he said. “For simple tasks like a pelvic exam, a simple simulator like Carla’s is actually preferable. You don’t teach a teenager to drive in a million-dollar Ferrari.” The analogy is not far off. The devices are expensive, prohibitively so for smaller schools. “So we have to keep in mind that this is just one way to teach,” said Dr. David Feliciano, the chief of surgery at Emory University’s public teaching hospital and a skeptic of surgical simulators. “And there’s a historical way. We were able to educate people without them, with textbooks and surgical atlases.”
His concerns are not merely financial or technophobic. When surgical simulation began, around 1990, with laparoscopic gallbladder removal, doctors noticed that students were making many more mistakes, with some fatalities, and needed longer proctoring than students who used the older scalpel method.
Meanwhile, Dr. Pugh is branching out, developing models of the throat, lungs and intestines. And in January, the Accreditation Council for Graduate Medical Education said medical schools “should include simulation and skills laboratories.”
But hearts and minds are harder to change than policies.
“Doctors graduate with the same squeamishness over naughty bits as the rest of us,” said Dan Savage, the syndicated sex-advice columnist, whose readers fretfully send him pictures of their genital ailments even though he lacks the medical education to offer diagnoses. “The difference is that normal people can be squeamish about touching strangers’ scrotums without it being a life-changing situation. The onus is on doctors. What good is a mechanic who doesn’t like getting greasy? If you have a squeamish doctor, get a new doctor.
“That’s America,” he continued. “Canada got the French. Australia got the convicts. We got the Puritans and we never got over it.”
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