Carla Pugh Pioneers Next Frontier of Medical Education
Carla Pugh, MD, PhD, FACS, is an iconoclast, determined to simultaneously respect the long-held traditions of medical education while revolutionizing the field. Hers is a largely unconventional approach, but one for which the time has come. And few people are as determined and dedicated as she is to get the job done.
As vice chair of education and patient safety in the University of Wisconsin School of Medicine and Public Health’s (SMPH) Department of Surgery, clinical director of the UW Health Clinical Simulation Program and a prolific researcher and inventor, Pugh is responsible for training the next generation of doctors and surgeons, and for wedding the previously disparate disciplines of engineering and medicine.
This combination results in new, innovative ways to measure skills and improve performance of health care professionals, while ensuring better patient outcomes.
Pugh’s passion was fueled by all the usual suspects: an influential family member, an insatiable curiosity and a Hollywood-inspired science fiction doctor with lots of cool gadgets.
"Star Trek" has no doubt motivated more than a few imaginative kids to reach for the stars. But for a young Pugh, the sci-fi technology used by the intergalactic doctor, Leonard “Bones” McCoy, as well as some inspiring tales about Pugh’s grandmother (a midwife and veterinarian) brought her sights down to Earth. In many ways, she’s been working to bridge the gap between the two worlds ever since.
Enterprising Early Years
In kindergarten, Pugh decided to become a doctor, and in ninth grade, she decided to specialize in surgery. While such ambitious declarations are common among kids, few pursue their earliest childhood dreams with such singular dedication.
“I never really wanted to be anything else,” Pugh says. “I’m aware of how rare that is, because I know many people who’ve struggled with career decisions well into adulthood. But for me, there was never any question.”
In medical school at Howard University in Washington, D.C., Pugh discovered that all the childhood hours she spent watching Star Trek re-runs were, perhaps, more than just a way of passing idle time. Rather, she realized, they provided a glimpse into how science fiction can sometimes inspire new ways of thinking about our world without the constraints of tradition.
“I grew up wanting to have a handheld CT scanner — you know, like the one that gave Bones a patient’s vital signs just by waving it over the person,” Pugh says, only half-joking. “I wanted all that cool stuff and believed I was going to have it, but then got to medical school and found out that I was still supposed to learn by reading textbooks, listening to lectures and trying to piece patient information together. It was frustrating, to say the least.”
Pugh made it her mission to find another way. In doing so, she realized that one of her other childhood interests — sports — offered a much better model for improving training and performance than the field of medicine.
“Doctors go through many years of training to become top-notch professionals, but when you look at our training, it pales in comparison to other professionals,” Pugh told an audience at a TEDMED conference in San Francisco. “Athletes, for example, have access to instant replays, video reviews, and years and years of performance data and metrics that have helped them understand exactly what it is they need to master their craft. The best we have in the medical field is the tried-and-true board examination — a test of cognitive and declarative knowledge. We don’t have a test for hands-on skills, and we desperately need one.”
That missing piece in her profession inspired Pugh to pursue a doctorate degree in education after her surgical residency. Unlike her peers, who were starting careers, Pugh headed to Stanford University’s School of Education, where she soon discovered how the technological advancements that were revolutionizing sports performance, engineering and computer sciences could perhaps play a critical role in the evolution of medical training.
Watch Carla Pugh's TEDMED talk, in which she discusses her passion for haptics - the art and science of touch - and the use of technology in medical education.
Her first class at Stanford covered human-computer interactions, and it confirmed her belief that technology had the potential to dramatically improve the way educators could measure and teach expertise. She gravitated toward sensor technology, which wasn’t exactly new when she used it in a college project, but it had been almost entirely ignored by the medical establishment.
“You have silos in groups of people and fields of work, and sometimes it just takes somebody to walk across the street, look under the hood and say, ‘Wow, I can use that,’ ” Pugh describes.
That’s exactly what she did. Using some low-tech components like plastic cling wrap, empty toilet paper rolls, Play-Doh and badminton birdies, Pugh created a crude prototype for a clinical exam model. She convinced a classmate to help develop her first sensor-guided clinical exam simulator.
That project led to the first of Pugh’s two patents related to using sensor technology to measure hands-on performance during procedures and exams.
Pugh was hooked. Soon after, she started building other training simulators and became one of the profession’s leading advocates for haptics (the science of touch) and the use of tactile feedback in training.
“It’s one thing to get feedback from a faculty member,” Pugh says, “and another thing altogether to receive a detailed computer readout about your performance.”
Pugh envisions a time when surgeons will receive daily computerized feedback about that day’s cases and learn about ways in which they can improve their performance — such as instrument selection, operative time and blood loss. She hopes such feedback also will be incorporated into the antiquated board exam.
“When we finally do that, instead of asking me if I’m board certified, you’re going to want to know my haptics score because that’s what matters in the operating room,” Pugh predicts.
Getting the medical profession to that level, she says, will require expanding the use of existing technologies for medical purposes; increasing the number of researchers, designers and innovators who have a passion for health care; and finding a way to address the delicate legal issues that accompany the use of video review and assessment in the hospital environment.
“When we solve those challenges, we will be able to take education and assessment to the next level,” she says. “That’s the final frontier.”
To Boldly Go ...
Meanwhile, since Pugh’s days at Stanford, sensor technology, simulators and other forms of high-tech training methods have come a long way. Medical and nursing schools around the United States are embracing the concepts, with many of them investing in multimillion-dollar training programs and simulation centers that employ the kinds of technologies that Pugh pioneered.
At the UW Health Simulation Center, Pugh oversees educational opportunities for students, faculty and staff from the SMPH, UW Hospital and Clinics, UW Medical Foundation and many departments across UW-Madison and the state.
Capable of conducting interdisciplinary health care scenarios, the program brings together current simulation activities and ensures that UW Health takes advantage of the latest simulation techniques and technologies. It’s a program seemingly created for and by Pugh’s lifelong work.
Pugh came to UW-Madison in 2012 after spending nine years at Northwestern University, where she served as director of its simulation center. She wasn’t looking for a new job — she considers herself pathologically loyal — but a colleague in Madison recognized that her expertise and innovative approach would be enormous assets, and recruited her. It’s only fitting that Pugh became the first clinical director of the $6 million, state-of-the-art UW Health Simulation Center when it opened later in 2012.
One of the things that initially intrigued Pugh about the center was its focus on interdisciplinary collaboration — a hallmark of her professional philosophy from the start.
“One of the most important things is that the center is centrally located and governed, which is much different from other programs, which are department-owned and not always interdisciplinary,” Pugh explains. “Here, the program was designed to serve units from across the entire enterprise, from surgery and respiratory therapy to environmental services and nursing. Because few departments in a hospital work in isolation, it doesn’t make sense that people should train that way.”
Pugh’s vision for the simulation program reflects how innovative thinking can result in meaningful change.
Take, for example, the Ebola outbreak in Africa and the urgency required by many U.S. hospitals to prepare for a potential domestic outbreak. Pugh and her simulation center team worked tirelessly to help prepare the hospital to be one of only three facilities in Wisconsin designated to handle confirmed Ebola cases.
“We organized training and advised the hospital on how to do it right by incorporating best practices, integrating Centers for Disease Control and Prevention protocols and providing critical feedback,” Pugh says. “But our work also went beyond the technical to making sure we appreciate and are sensitive to everybody’s fears and concerns. It was an incredible team effort that included numerous disciplines and professionals.”
Preparing for Re-Entry
Perhaps the best evidence of Pugh’s innovative spirit and contribution to the field can be seen in her research lab, where she and a bevy of researchers are working on several projects that are already impacting the future of medicine. Her research is supported by grants from the National Institutes of Health (NIH) and the Department of Defense (DOD).
For the DOD project, Pugh is using motion-tracking technology to model and understand skills decay among physicians who rarely perform certain procedures or who endure prolonged absences from practice — such as those who become ill or take maternity or paternity leave. The study will be particularly useful for understanding ways in which military doctors can more smoothly make the transition back into practice after deployment, especially when the mission kept them away from the specialty-related procedures they usually conduct back home.
“Regardless of the reason, there is no formal process for re-entry into this high-level profession,” Pugh says.
She knows because it happened to her.
After earning her PhD, Pugh found herself back in the operating room facing some uncertainty about things that had once been second nature. For instance, she forgot names of instruments and second-guessed some of her operative choices.
Her study subjects are surgery residents, many of whom have recently taken the requisite two years off from surgical training to pursue research projects.
“This planned absence from surgery is a natural, recurring phenomenon in many surgery programs because residents typically take time off from their residencies to do research,” Pugh says.
Another project, funded by the NIH, examines surgeons’ decision-making skills during critical intra-operative moments. For example, Pugh and her team will create a generic task — such as dissecting a pelvic tumor — then use sensor technology to capture and measure surgeons’ movements, reaction times and decisions they’re making to address the problem.
In 2011, Pugh received the Presidential Early Career Award for Scientists and Engineers (PECASE) for her research on a sensor device that judges whether people are performing breast exams correctly, and thus detecting abnormalities. And in the February 19, 2015, issue of the New England Journal of Medicine, she published a research correspondence demonstrating that approximately 15 percent of doctors were not properly identifying tumors because they were using a widely taught but ultimately ineffective method.
Pugh believes her research on the efficacy of sensor technology in breast exams could influence the way some physicians look for lumps and tumors.
“I hope this study will spark a serious conversation about clinical performance standards. Once the general public understands this technology’s potential, they will begin to demand change,” Pugh says. “Because sometimes change from within this profession is more difficult than a change that everybody wants.”
Live Long and Prosper
While the journey from being a precocious child to being a pioneer in her field has not been conventional, Pugh says she is more committed than ever to revolutionizing the only job she ever wanted and improving the lives of those she’s been called to serve.
She concludes, “When we are able to make assessments as comprehensive and as interactive as our everyday work experiences as clinicians, we will have finally achieved justice for our profession and our patients.”
By Gian Galassi
This article appears in the winter 2015 issue of Quarterly.
Date Published: 03/13/2015