The Forefront of Surgical Innovation with Carla Pugh, Professor of Surgery at Stanford University School of Medicine
Welcome to the outcomes rocket podcast where we inspire collaborative thinking improved outcomes and business success with today's most successful and inspiring healthcare leaders and influencers and now your host so marquez welcome the maximum podcast that i have the privilege of hosting dr carla pugh. She's a professor of surgery at stanford university school of medicine. She's also director of the technology. Technology enabled clinical improvement center. Her clinical area of expertise is acute care surgery and her research involves the use of simulation and advanced engineering technologies to develop new approaches for assessing and defining competency in clinical procedural skills. Dr pugh holds three patents on on the use of sensor and data acquisition technology to measure and characterize hands on clinical skills currently over two hundred medical and nursing schools are using being one of her sensor enabled training tools for their students and trainees her work has received numerous awards from medical and engineering organizations in twenty eleven eleven. Dr pugh received the presidential early career award for scientists and engineers from president barack obama at the white house. She is considered to be a leading international. Oh expert on the use of centers and motion tracking technologies for performance measurement in two thousand fourteen. She invited to give a ted talk on the potential uses of technology to transform how we measure clinical skills in medicine recently dr pugh was introduced into the american institute for medical and biological engineering as as well as the american college of surgeons academy of master surgeon educators so it is a true privilege to hear her thoughts today's podcast we're going to be focusing on what she believes is most important in healthcare and hearing some of her ideas and beliefs on where healthcare is going today so without further ado just want to give you a warm welcome dr few thank you so much saw i look forward to <hes> our minutes and time together that we have this morning so excited to be here. Thank you. It's a privilege now. I i'd love to ask you what is it that got you into the medical sector that happened when i was five one of those sort of street and focus the persons who after hearing a number of family i'm stories about my great aunt and great grandmother grandmother one on my mom's side one of my dad's side of the family they were actually midwives and veterinarians <hes> both of them you know on the farm farm in the rural south and as a five year old my interpretation of what they did and the stories heard about them. I assume they were doctors and so ooh that was gonna be like those two abeysinghe women. You know that was my interpretation and never gave up that is wonderful. I i love that story and and it's so neat that you just got fixated on and said this is what they're doing. I'm inspired and i'm going for it and you haven't looked back since out crackling awesome. That's so neat in one of the things that i find really interesting about your work. Carla is is your focus on sensors and measuring today. Were were in this value based care world where we're trying to get there so measurements have never been more important. I'd love to hear from you what you believe needs to be on health leaders agendas and how you're approaching that well i it's two areas i mean everything to me centers around data and creating being new data streams that actually quantify things that were previously or currently only qualitative and and you know i think when you look at what guides some of our healthcare decisions treatments and policies today it's based on years years of what i would say good data but there's still a fair amount of subjectivity and different ways of interpreting that data and i think we've learned a lot but i think that now instead of trying to improve upon some of those areas patient surveys and things like that for example. There's different data. There's different technology that enables us to collect data that kinda takes out the human and turpin nation emotion part of it and i and i don't see mean to be one of the young persons who totally believes in data and the world takeover new data and get rid of the old. I think there's i think you have to pay history. I think that there is some truth definitely truth in qualitative and survey and interview data and policies that were handed down but i think if you take a look at the decisions we've made based on that data and combine it with new data. We could get a lot further and it's such an interesting thought and so oh. I love to hear some examples of what you're thinking here. Well i mean i think just for example. Wow there's one thing that i've just funny because it just happened sort of serendipitous lee but weak in my life there was just a preponderance of comments questions a news articles and things that have come up regarding blood pressure and simply me as a physician who uses sensors for everything i came in for my physical collect zam and had a nurse practitioner take my blood pressure and it was just searching interesting experience for me to be aware eric how she placed the blood pressure on my arm. I thought it was loose but anything yeah. I didn't say anything. I'm like wow that's interesting. I teams a little more loose within the previous. Ten years of you know going in with year to get an exam and a team more loose than other times too. I just let it go because 'cause i was curious like what blood pressure she would come up with when it was loose. I don't even remember what it is 'cause. It's not a big deal but all i know is that when i got home because i have a home blood pressure cuff i did the <hes> miniature experiment in one i put it on tight and looked at the blood pressure and i put it on loosely and looked at the pressure and there was a thirty point difference in nisa thirty point. I was blown away. That's a big difference. So then i go back to okay great. There are a whole lot of companies that have have it is the mainstay for people that have high blood pressure or wanna know they buy these cars from walgreens and c._v._s. and all these places and there are millions millions of people who are taking their blood pressure at home. Yeah that's interesting so is there. A system is is based on yes. Take the blood pressure but we haven't gone back and look at. Are we actually getting accurate data and now we're i mean we're giving medications for years based on a protocol. You take the blood pressure three times. If it's elevated then that means you actually have high blood pressure and then you start your medication that is really interesting so this gap ride and is very very ability right. A lot of folks are saying hey take the variability out and you'll improve <music> outcomes. I mean how do we do that in this particular instance. There's so many devices out there yeah. I mean it's so so there. There are what i was excited to see. Is that the a._m._a. Again that same week like i said it was to syrian deputy and i was inundated with all of these things but the a._m._a. American medical association team week put out this call for proposals in terms of local health systems making it their focus to try and get could blood pressure and it was just interesting you know this and this is after you saw the article it was after i saw article after i had just come from there and then did my own personal experience experience but anyway i think all that to say that the conversation has come back to surf isn't looking at what we've done in the past and i think there was an article that came out that that said there's two parts of it one people who take their blood pressure medicine at nighttime actually have lower blood pressure during the day and that was one of the recommendations and then there were some arguments about what is considered hypertension and revisiting all of that data and should it be you know should be shooting for one twenty over eighty or should we actually be shooting for one ten head and then others said it should be when thirty should be more lose. What's so amazing to me is that all of those recommendations and this is the example. All of those recommendations are based on manual blood pressure cuffs or even the computer blood pressure cuff but there's still a human in the loop in terms of applying that cuff right and so then i'm looking at all of these companies that are trying to get into space of using sensor technology to actually capture blood pressure so forget because but some of them as i looked more deeply they're actually just miniaturizing the blood pressure cuff and putting it on your wrist. I think there's a company omron that has an it looks like it looks like a watch and it's really cool but when you get down into the specs of it actually it's still a blood pressure cuff but even that instance because it's a watching because it standardized raced that means that you're actually not you know once you decide. You know what loophole to watch fits your wrist. Then at least it's consistent data if that makes sense uh-huh so that just kind of is an example where all of our research for the past thirty years on blood pressure is based on <hes> using a blood pressure cuff and with the story that i told you that we know that it's inconsistent but if you think about a wearable blood pressure sensor that can actually change the whole game right because now we we don't really know what could only only data that we have of continuous blood pressure monitoring is invasive ace of monitoring within a hospital system when we actually put catheters inside your artery yeah but those are usually under it's usually when you're in the intensive care unit then you're very sick. Obviously we can't do that. Invasive study on a healthy person but now i'm like this whole week i was like oh i wonder what my blood pressure is over twenty four hour period or are- month period and how's it different when i'm exercising and on my game it really getting you know my five days a week exercise in or what is it like when i in writing a grant for n._i._h. For four weeks of the bro and not sleeping exactly like like and then i believe that we actually have to challenge our system like our i mean our health our body and so some of those challenges to your body probably actually makes it better so when is high blood pressure sure for a certain number of hours okay. We have no idea 'cause we don't have the data so anyway get off our high horse on that but i would expect him to go down that route but that's interesting and it's a perfect example to me of how we've done things to story clearly we have years and years of this excellent research but it's based on a specific way of capturing information that does have some human in the loop potential and now there's new technology and new data dad that actually could completely revamp some of that research but also further there'd be searched that we could do so what's the potential of having a sensor that that does measure blood pressure again. I think that we don't even have a picture of a twenty four hour period in the life of a healthy person. What what is their blood pressure in fact. I actually have spoken to a few companies again. It just kind of crazy. I just got inundated which i think when that happened that means. I need to get in their space jason do but i did meet a company did meet a company. That has a wear bowl sensor. That's actually not a tough but it's really it's i can't disclose clues all the details but it's just a sensor that can actually detect blood pressure and do it continuously without actually having a press a button library fast fast and they it's a start up and they actually got over a hundred adults to wear it and they were shocked. They compared none of them have been diagnosed like knows exactly but none of them have been diagnosed with high blood pressure but there were times during the day when their blood pressure was high and i think that it gives us a potential to have a better understanding yep human physiology and how the environment impacts our bodies and i think spark research in other areas you know how does your your lungs respond when you're spinning a week and downtown new york and a you know an area that has car exhaust versus middle of wisconsin in the woods like how does your body adjust. I mean i think our body does work lungs cleanup dirty particles and and we're fine afterwards but it's different for someone who's visiting someone who lives there. You're situational factors i think about have you ever seen the movie emily. I'm ali. I'm ali. Yes a french movie a so. It's one of our favorite song to add that yeah. It's a quirky film and it's discworld. Bags are grows up in in in france and in paris and it's her story break. It's a really neat story but the thing that came to mind as her her father a physician would examine her and because he never touched her like he never like showed her her love or anything like that the only time he would touch her was during her examinations and her heart would just like pound very rapidly and because of that he felt like she had a heart condition goodness no dad you're freaking me the hell out because like everyone has some anxiety because you actually wanna know you want comfirmation formation immediately that you're actually doing okay so that's interesting yeah. I have to watch that when i left those kind of stories. I think you'll enjoy it. It's it's one of our favorites. It's a really good one but regardless yeah. I mean you bring your bringing up some really great points right and so we're going to have to really examine i and some of the basic assumptions that have been made for to us like you said you know quantitative over the qualitative that we've been using for while this data atta so maybe you can share with us <hes> a project or research that you've done. That's helped improve the way that we do things in healthcare. Wow i think that i like that. You feel that i've done to improve health care. I see myself as very much a researcher and despite all of the amazing being opportunities awards and high accolades i am. I feel like i was still just beginning seriously. How about a project out as like this. This is wonderful like this is something that you felt proud of. Oh i have a lot of those i'm i'm i i will i mean i because it is so exciting. I'm i'm kind of mad scientist type and then you know we go out. There are sensors and do things and learn in every single time we go out. We find something that ah we are truly excited about so sticking with cardiovascular health. We had a project where we in a simulated environment heart simulator. We partnered with <hes>. There's a company called a kind heart and they make pretty sort of like hybrid simulations and i think okay i'll just be clear so similar to airline pilots where they have flight simulators to learn you know rare and unusual circumstances stances in case you have to land on the hudson river right <hes> they practice those things and so they've been doing that to the nineteen i but i think the link <music> system came out like the nineteen thirty nineteen forties but healthcare and medicine. We've only really started getting into simulation probably around the nineteen eighties so they've got fifty year lead on us but this one company called kind heart and has a high band right right. I mean it's a standard everyone standards exactly there or some standards that are coming in you know in a different areas but it's definitely not a holistic standard across healthcare and medicine so that's why i mean once that happens then. I feel i will have a chief michael. I that's the answer to that question. Why don't believe that i've arrived yet because it's not but it's not as a standard across all of healthcare to use relation training before we interact or to complement our healthcare training. It's it's not a standard so the example kind heart does hybrid simulations where they <hes> three d print body cavities out of you know various if silicon's latex and hard plastic material and then they actually use <hes> bovine organs that they get from the butcher talk about dual use their eating beef or bacon or whatever we actually go and get some of the other part of that people don't eat so that we can actually practice procedures on so they found a way to actually fuse a bovine heart and actually give it electrical signals that make be like a heart so you're looking at this heart that's sitting in fabricated human chest and they have done a great job of being able to train and assess assess heart surgeons that are in their early stages of their career cardiothoracic fellows and so what we did and was put motion sensors on the fellows as well as the assistance when they're putting be simulated patient on cardiopulmonary bypass and we did it for three early heart surgeons and three very experienced senior heart surgeons with fifteen eighteen years of experience under their belt row measuring for we were looking we were just looking at their movement how they use the right hand how they use your left hand what what is it that they're doing digitizing all of the steps and maneuvers that they make when they're placing a patient on cardiopulmonary bypass wow oh it confirmed for us as it has using sensors and motion tracking data that there is a signature almost is like a beautiful faux painting. There is a specific signature. That's created for each medical procedure that may do when you're doing it correctly directly. It looks a certain way at the every time if it's yeah wow every time what's really amazing about that. Is that if you ask the surgeons what they do. They always think that they do things differently than others because they were trained differently. They're trained to do this or do that. Use this type of instrument start on the left wbt and progress to the right and other say we always start on the right and progress to the left and you know we use the right angle we use a tunnel cramp and so when the surgeons describe gripe what they do they tend to use descriptors that focused on their tools and their steps whereas the motion data actually really is more pure data that it just shows the direction and the velocity of their movement and it's really cool as the direction of the velocity of their movements movement's ironically has nothing to do with this surgeon itself but it has to do with the anatomy and the hearts always in the same place mostly unless if you have a disease where your heart on the wrong side but what that means is that doesn't matter if you start on the left doesn't matter if you start on the right but because you're still doing a sequence of maneuvers around the heart the final ping ping are pitcher is the same zero zero painting <hes> it is. Is that what i call them painting because that's the easiest way to explain it because you have to see the data so when i'm going in the the painting that's created. It's like great. It's like two painters to paint tattoo artists talking about painting the mona lisa right. I wonder where all yellow okay good for. You and i'm gonna use this size brash and all variations of yellow yellow tones well great. I'm gonna i used orange tones but in the end if it all looks like the mona lisa who cares about the color right right until that has been well you talk about data the data that exist in healthcare regarding hands on procedures in medicine when is verbal data that physicians shouldn't dictate in a use their own descriptors because there's no standard. That's interesting well. You know what would be interesting to hear from you. New carlisle is is is now that you have this data set. Is there a way to save do a test to determine aptitude in potential capability ability of a student. That's take a career down a certain path definitely nice. There's some people that are gifted in terms of their happening haptic ability of touch perception and situation awareness. There are some people that are we've seen it a medical student. You can't tell by looking the at them but you know when they're coming in what comes out of their mouth that would you see their touch data. It's amazing yeah. That's fascinating well. I appreciate you and taking us down that road and and folks you're sitting in your car or maybe you're running listening to this working out and you're like wondering what would happen but if you put some centers on me right now and that's lead dr pugh does she she dives into the things that later become and technologies that change healthcare for the better and so give us a an example carla of of a time when you set back and what you learned from that wow i had that all planned out. You know i'm like yeah. Failure is the key to success and like i've made a whole bunch of mistakes. I'm human right and and i've learned a lot along the way and i kind of think about failures. If you will for me it's setbacks in terms of achieving my dream in an efficient manner so must've my failures for me or actually defined because i'm impatient. I wanna you know once. You have some level of success. We've found this. Let's go team and i was like okay. Let's cute so for me. I look at i love them. You know failures of communication <unk>. I that's the biggest thing like so. That's been my you know. How do i learn how to communicate. How do i learn to tell the story in different ways such that the engineers see this is really cool and that this is something that they can actually derive career and making a huge discovery and partnering with the same thing with the data scientists and those that are doing artificial intelligence so i think that when you are passionate in an area that's not quite quite mainstream have to slow down and find ways of communicating that such that you can then uh-huh build the team and the interest in the support to carry it across the finish line. Love it yeah that communication's key so if you had to say out of all the neat things that you're working on dr pugh if you had to say decide on one which one would you say is the most interesting and exciting project right now yeah. There's something something. I can't tell because i have i._t. At attendee and it's very tempting because the communicate <hes> i i think that people are starting to get it regarding the use of sensors to assess human performance broadly so whether it's human physiology or whether it's actually surgeons performing complex procedures in the operating room. I think that what's been most exciting is that there are a number of people who have looked at motion tracking data and i find it interesting right because that's the golf swing data at the same thing right right but to apply that process to healthcare which is what we're doing. We've done it for a number of different procedures. The one that's been newly exciting for us is to applied in the field of ophthalmology and the reason being is that all of the other procedures teachers we had done to date have large gross motor movements moving your hand putting in sutures grabbing instruments from a table using using a variety of instruments for a variety of different movement and so when we had an ophthalmologist express interest for like oh my goodness what am i they do because they're under the microscope and they have these instruments in their field. Is this so much smaller even their operative deal to smaller or the eyeball right. I'm in the abdomen women around with my whole hand there with the eyeball like such a smaller steeled. That's one thing smaller instruments and then really really fine motor movements so we were a little intimidated and weren't sure we were wanting a failure but then we were so curious areas so yeah. It didn't take long. We thought about it for like nanoseconds. Okay great. Let's do it yeah. We'll say five days no no. We're kind of compulsive not this. I mean we thought about it for five nanoseconds. It took five days scheduling away so to get across campus with our equipment. We went to and you know this. Ophthalmologist already had a cataract surgery stimulator like a perfect so very forward thinking partner you found yes and already kind of thinking about beta and using artificial artificial intelligence to analyze <hes> his operative data and so we went in we went to his lab. We looked at what he had. We instrumented him be instrumented his instruments and we instrumented the cataract surgery simulator and we're smiling to this day so yeah yeah so it's the same it's the same they have. I wish i could i need to partner with an artist so that i could name all of these standard pictures that come up with motion data from surgical procedures 'cause it all they all look different but they're meeting the heart. Surgery cardiopulmonary bypass beta create a pattern that looks different than a cataract surgery but i need. I need a partner with some artists to help me name these things because they're just amazing but to be able to capture that data and obviously we had to increase the gain so that we can actually see all the interesting idiosyncrasy. The nuances bounces within the data that actually represent what he was doing. It's beautiful so that was really exciting because that was a bar indyk stream of different surgical movements. It's yeah no that's <hes> the other end of the spectrum as far as movement <hes> space where the surgeon is working. Can you get a similar output that obviously looks different because of the particular type of surgery but fascinating fascinating motion data people. This is a okay fascinating place to be working today. A so this interview while i'm just looking at the time and it's already flown so let's dive into the lightning round got a few questions for you in a lightning round fashion and then we'll we'll finish that with a favorite book that you recommend the listeners snazzy ready sure okay. What's the best way to improve. Healthcare outcomes. Get better outcomes definition. Outcome metrics redefined the outcome metrics. What what is the biggest mistake or pitfall to avoid blanket application of results from qualitative or mixed data. That's not validated of that one. How do you stay relevant as an organization despite constant change listen collaborate and create a culture of innovation. What's one area of focus that drives everything in your work that data is. It's all about the data about the data like these next two or more on a personal note. What's your number one. Health habit may never when health habit interesting so i am currently hacking my sleep habits nice using the oregon. Oh which one's the arranged. Oh you are a oh okay and data ever. Unfortunately i have no <hes> no <hes> i was gonna say unfortunately i haven't invested in the company. I have no ties with it but <hes> it has the best sleep data ever and kelly compared compare this data they wear both or ring and the fit bit little less on the exercise because it does have an accelerometer but it's only on your finger okay so if you're using a stairmaster we're not moving your arms or something you know last but temperature heart rate movement the they've phases of sleep. It's amazing and i can tell jill how my sleep is affected by what i eat after six p._m. Wow they don't know that i know it right. They don't have they don't have any envy until creation but never had the food data right but i'm a foodie and believe that food like from a health perspective. The definite based intake of food affects your health in so many ways and it definitely affects sleep fascinating the orange. Something look definitely put it on my list and what's your number number one success habit number one success habit. Oh try try again. Reflect forgive yourself. Forgive others do it again yeah and do it better well. That's that's a great message. And what book would you recommend to the listeners carla. Oh my goodness. I have one that i had right from childhood. I know people like new books all the time but my all time favorite siddhartha by hermann has love that i think that's been recommended once other times. It's poetry right. Oh it's a story. It's a game taken of a different book than yeah. No sit arthur is kind of a life journey story story and just amazing yeah <laughter> with him you know you have to it's a short read too and so something you you can read it in a weekend but it's it <hes>. I think what's interesting. Is you know that book was probably written over forty years ago and it's still the life lessons and the story is still applicable. Today is that right of that or a great recommendation folks for all of the show notes <hes> from today's meeting with dr carla a pew goto outcomes rocket that health and type in carla in the search bar. You'll see a full transcript as well as links to sidharta and and also the work that dr pugh up too so make sure you check that out at outcomes rocket that health search bar type in carla and carlo wow this has been a a really fun conversation and love if you could just leave us with the closing thought in the best place where the listeners could learn more about you and your work yeah no my my closing thought is really back to you. Thanks so much for reaching out and thanks for taking the time and i'm a static that you have insight and interest in to to the work that we're doing being in helping that communication thing that we've been working on terms of getting the word out and collaborating. I think yeah there's no way to hide my professor at stanford university. You can find me carla c._p._u. Per day eighty you outstanding will appreciate you very much carla and appreciate you sharing in your your passion and the insights gained and definitely looking forward to staying in touch thank you thanks so much have one day thanks for listening to the outcomes rocket podcast be sure to visit us on the web at w._w._w. Dot outcomes rocket dot com for the show notes resources inspiration and so much more.