Carla Pugh is Professor of General Surgery at Stanford University School of Medicine and Director of the Technology Enabled Clinical Improvement Centre. Her main clinical interests and expertise are focussed on the field of Acute Care Surgery. Despite her outstanding clinical contributions however, Carla is perhaps best known for the development of sensor enabled simulators which allow medical students to practice breast and pelvic examinations. But these major innovations alone cannot simply define Carla so easily with her research interests being far more eclectic and which centre on the use of sensors, motion tracking and simulation technology to quantitatively define hands-on clinical skills. And with these innovations in hand her mission is clear – to change the face of medical and surgical education.
Carla took time out from her busy schedule to talk to SURGERY about her achievements, inspirations and future plans.
Carla, who was born and raised in Berkeley, California, knew by the ninth grade she wanted to be a surgeon, yet as an American woman of colour, the path she chose for herself was never going to be an easy one.
“I grew up in a single-parent home and I'm the first physician in my family on both my mom's and my dad's side. It was not expected for a black female to become a doctor. “At that point in time, I had never met a black female physician. So you wonder whether society would support you.” Undeterred, Carla completed her pre-medical degree (in Neurobiology) at the University of California, Berkeley, before attending the Howard University College of Medicine where she both earned her degree and completed her residency in general surgery.
Carla said she was already a physician by the time The Cosby Show aired and Dr. Huxtable became the first black physician to be broadcast on primetime US TV. “You have these inherent desires and most of the people that occupy the things that you want or are getting the things that you want don't look like you,” she said.
Following her own early training and educational experiences Carla was motivated to pursue a PhD in Curriculum Studies and Teacher Education – ostensibly to ‘learn about learning’. During this time she constructed model breasts to teach students how to undertake breast examinations. Importantly she incorporated sensors into the models so that assessment could determine whether students were examining the correct areas and applying the correct amount of pressure to yield appropriate clinical information. Significantly Carla and her team also generated data about applied pressure and tumour identification success rates. She subsequently developed a pelvic mannequin which was similarly equipped and which was subsequently licensed for manufacture as a student’s skills aid.
Does she find her research interests more fulfilling than her clinical work?
“The process of research is definitely not as fun as being in the operating room or talking to a patient and helping them in their new life after surgery. Some of the management parts of research are not extremely exciting, but I definitely do it because I love the results, I love the data and I am committed to the impact it may have.”
Following a spell at the University of Wisconsin Carla returned to her alma mater, Stanford. The carrot appears to have been not only the post of Professor of Surgery but also the role as Director of the Technology Enabled Clinical Improvement Centre. Here Carla continued her research interests ultimately collaborating in a Surgical Metrics Project to assess data from recordings of surgeons wearing sensors assessing not only motion but also tactile pressure and brain waves. In 2011 Carla’s long-standing work in the field was recognised by a Presidential Early Career Award for Scientists and Engineers and specifically for her ‘novel research to develop the first physical test that measures medical students and physicians’ ability to perform a clinical examination of the breast to diagnose cancer’
The experience of meeting President Barack Obama has stayed with her. “It was surreal, dreamlike,” Carla said.
“I didn't live my life saying ‘okay, I'm going to meet the president one day’. Then when it happens and he’s standing there right in front of you, he's even better in person than he is on TV. You can see his facial expressions, how tall he is, he's so personable and so passionate.
“There are parts of it that just felt absolutely normal, but you’re also in awe, because he's the President and he is super-inspiring and forward-thinking - and a little pushy! He’s saying: ‘this award is not just a celebration of what you have already done. It is an opportunity for us to personally let you know what we expect you to continue to do for our country.’ When you are standing there listening to this, you want to sign up for the military right away.”
The Presidential encounter has clearly inspired her onwards and upwards. By 2014 Carla was delivering the keynote TEDMED talk on the potential uses of technology to transform measurements of clinical skills in medicine. By 2018 Carla had been inducted into the American Institute for Medical and Biological Engineering.
Carla - like many people - may have been a little star-struck by the former US President, but her own success has also thrust her into the spotlight. When asked if she sees herself as a pioneer, she replied: “I have learned to understand that that is the perception of other people.
“I honour it and I realise the responsibility that I have and I think that's great, so I do whatever I can to inspire others.”
Her high profile brings with it certain pressures, as she explained: “it’s more decision-making on my side. I'm already at the point where I see the benefit and the responsibility to inspire others. The only difficulty is trying to do it all. It's impossible to meet with 20 medical students every day of my life. It's just not humanly, physically possible.
“Plus, I have to split my time between mentoring and inspiring and still taking care of patients and still doing my research. So the pressure is more on scheduling.”
Not that she’s grown accustomed to being well known. “I am definitely an extrovert around innovation and ideas,” she admitted, “but it's quite humbling when someone says to you or thinks that you're famous. I would say it does catch me off guard.”
Although there’s been a shift toward greater diversity, equality and inclusion (DEI) in many sectors, there’s still a lot of work to be done. Carla explained: “I think that the part that's moved in the right direction is that the conversation around it is becoming more mainstream. The part that is still wanting is that people haven't figured out what to do.
“What action needs to happen? What's fair? What do we do? How do we change policy? How do we get normal routines that allow us to hack and undo? We’re not there yet.
“There's parts of our routines that enable the status quo to persist. How do we come up with routines and measures and ways of forming committees and decision teams? How do we come up with ways of checks and balances and say ‘that's our old routine’?”
She continued: “that resulted in these problems and exclusions of certain groups of people, whether it's race, gender or all of these things. What is the new protocol that allows us to be more holistic and inclusive? I don't see those conversations happening, so we've got to be in this for the long haul.
“But there is a group of people that are tired of the basic DEI training and they want to move on to the new world order. We're all for it but where are the instructions? We don't have them yet.”
Diversity isn’t the only challenge Carla faces. The Affordable Care Act - better known as Obamacare - has yet to democratise the notoriously expensive US healthcare system, and technology isn’t providing any solutions.
“We have a more basic social order problem of ‘my team versus your team’, '' she said. People are taking the position that, 'even if my team is doing something wrong, I'm still going to stick with my team'. So we've almost got a clash of loyalty versus humanism. It's a difficult thing, and I don't know the answer. But I see that we're stuck.”
Carla’s day-to-day work with patients, as fascinating and rewarding as that is, can sometimes shield physicians from the outside world. “You only touch down on the realism of world affairs when you watch the news,” she said. “But when you're in the hospital and you're going around to see patients, you're swimming in the particulars of the workflow of providing care.
“So I don't know my patient's insurance, we don't talk about that on rounds. We talk about their creatinine. It's not a daily conversation or a moment-to-moment conversation on whether this patient can afford care or not.”
She went on: “I'm seeing all these patients, but who am I not seeing because they can't even get in the hospital because they don't have health care?”
Rather than focus on the negatives, she and her colleagues are busy doing their work, while also working just as hard to avoid getting COVID. “I suppose there's just more simple, germane things we are exposed to moment-to-moment as opposed to the bigger healthcare business issues,” Carla said.
Those ‘simple, germane things’ can be distilled into three areas: spending time with her patients, being in the operating theatre and conducting research. When asked which she likes best, Carla replied: “Oh, wow, that's a tough question. They're different and they're all exciting.
When it comes to putting her finger on her biggest achievement, Carla cites two. First: her research team. “Being able to hire a top-notch team of researchers with a wide variety of academic backgrounds in engineering, computer science, education, basic science… and they all work together and they love what they do.”
As for the second? “Being able to inspire and attract a group of people that love the research as much as I do is also a big achievement. They're devoted to it and they're so proud.”
Given everything Carla’s accomplished so far, are there any goals left unfulfilled? “That's a lofty question for me because I am one of those world peace-type of people. How do you inspire humanity, how do you change the world? I have those types of thoughts and dreams that motivate me,” she said.
“I know that you inspire people through people and through stories. I definitely see myself one day writing a book, partnering with other people or teams or groups,” she adds. “My dream opportunity is to come up with the team that wants to enact the next book-turned-movie on science, humanities, communication, love and life.”
When asked what technologies are currently piquing her interest, Carla’s response is surprising: “I go back and forth in terms of what excites me,” she said.
“You know, technology will always be there and there will always be something new and cool. What I find exciting is actually innovation around ways to implement and use it. I mean you can have something incredibly interesting, but if it's on the shelf and no one uses it, then it's a 10 second commercial. It's a fleeting thing that you get to see, and then you dream about how it could be used.
“We can get to the point where folks are figuring out how to use it and how to integrate it to the workflow, what to do and change behaviour and change experiences. That's what excites me - actually figuring out how to integrate it and make it part of daily life.”
That includes developing systems enabling a real-time information exchange in the operating room. “Surgeons always talk very fast and you don't know what they're thinking,” she said. For colleagues in the operating theatre whose attention momentarily wandered, it could ensure they have a piece of equipment ready, without the surgeon having to wait around or ask.
It would be easy to think Carla, who aside from her day jobs as a surgeon and researcher, is also president of the Society of Black Academic Surgeons and a member of the American Board of Surgery Council, had more than enough to occupy her time, but she’s also turned her surgeon’s hands to another field: art.
“I enjoy painting,” she said. “I rarely get a chance to do it, but I enjoy it. I enjoy mixing colours on a brush - I'm very visual. I took art classes when I was at UC Berkeley and learned from a number of different artists about paint strokes, brush sizes and how you can layer paint for texture.
“I have at least one painting that I had professionally framed and I have a few that I hung myself, including one big project a while ago. But as I begin to balance my career more, I’ll definitely have my paint brushes out.”
We can’t wait to see what she creates next.
