this Oct. 16th photo, Dr. Carla Pugh, director of UW
Health's Clinical Simulation Program, center, shows,
from left, Jacqueline Israel, a second year resident,
Laura Fischer, surgery resident, and Jennifer Wilson,
physician assistant, right, the components of a
simulation model for pancreas surgery at UW Health in
After Dr. Carla Pugh and a resident, or doctor-in-training,
cracked open the chest of a crash victim, the patient's heart
squeezed the heart through her fingers, causing beats to
return. But then the heart stopped again.
in and felt something hard. She cut open the area, and a blue
clot of blood gushed out.
resumed beating, robustly this time, allowing Pugh to send the
patient to the operating room while she examined others with
injuries in UW Hospital's emergency room.
incident last year, Pugh wondered: Why did the resident miss
the clot? Maybe, she figured, the resident hadn't been taught
how a clot feels.
director of UW Health's clinical simulation program, is a
champion of haptic technology, the science of touch, a news
students must pass oral and computer-based exams to become
doctors, but they aren't evaluated on how well they can feel a
cancerous tumor in a breast, a blocked duct in a pancreas, a
clot in a heart.
don't have a test for hands-on skills, and we desperately need
one," Pugh told an audience in San Francisco in September
at the TEDMED conference, an annual gathering of innovators.
developing anatomical models embedded with sensors and using
motion-tracking systems to monitor doctors' movements, steps
that could help shift medicine toward more tactile training
include sponges, balloons and squishy balls she finds at craft
and fabric stores whatever feels like a particular organ,
growth or tissue layer to her. To mimic lumps in breasts that
can mask tumors, for example, she uses lentils.
scoured most of the hobby shops in the city," she said.
Board of Medical Examiners, which oversees the country's
medical licensing exams, agrees that hands-on simulation
should become part of the process, said Dr. Kim Edward
LeBlanc, executive director of the Clinical Skills Evaluation
Collaboration, which administers part of the licensing exam.
looking at that quite heavily," LeBlanc said. "We
want to simulate abnormal (physical) findings in our
grew up in Berkeley, California, and went to Howard University
College of Medicine in Washington, D.C. She was surprised that
medical school and surgical training relied so much on books.
found it odd that I was expected to read about what I'm
supposed to do with my hands," she told the TEDMED
medical school, she observed a surgery to remove a prostate
gland, she recalled in an interview.
least two hours, all I saw was the back of the surgeon's
hand," she said. "I'm like, are you kidding
dare break protocol by talking directly to the surgeon. She
asked a resident, "How are you learning what he's
surprise, the surgeon responded, saying she had asked a great
grabbed my hand and shoved it into the pelvis," she said.
"He said, 'Do you feel that little ball?'?"
She did feel
it, and the experience gave her a better sense of what a
prostate feels like similar to a walnut, but softer, she
medical school graduates undergoing years of additional
training before they can work on their own get chances to
feel healthy and irregular tissue, such as the clot in the
emergency room patient's heart.
this Oct. 16th photo, Dr. Carla Pugh uses silicone gel,
lentils and other materials in a breast model to
evaluate doctors breast exam skills at UW Health in
Madison. The lentils mimic fibrocystic changes in
breasts that can make it difficult to find tumors.
But in the
rush of patient care, when the patient's well-being takes
precedence over training, teachable moments can vanish
quickly, Pugh said. She never discussed the clot with her
resident, for example, because they had to treat other
patients that day and then the resident moved to a different
lost opportunities happen every hour," Pugh said.
That is why
she believes simulation is the solution. After her surgical
training, she got a PhD in education at Stanford University,
where she obtained the first of two patents on medical
applications of sensor technology.
clinical simulation program, which Pugh became clinical
director of in 2012, features a $6 million facility on the
first floor of UW Hospital.
facility's high-tech manikins anatomical models used in
health care, as opposed to storefront mannequins enable
students and health care workers to learn how to put breathing
tubes in patients, insert catheters, tie stitches, lift
patients out of bed, respond to emergencies and use new models
of equipment such as defibrillators and surgical tools.
?But it is in
Pugh's research lab, on the third floor of the hospital, where
most of her innovations unfold.
which has 18 researchers, is supported by two federal grants:
$1.6 million from the National Institutes of Health to develop
sensor-enabled breast models to quantify breast exam skills;
and $2 million from the Department of Defense to examine
"skills decay" what can happen when doctors
spend time away from regular work, such as for military duty.
both projects, Pugh said, "I bring mistakes to life that
people don't realize they can make."
breast model made with silicone, silicone gel, lentils, two
types of cotton and a hard clay ball to mimic a tumor, Pugh
evaluated experienced doctors while they conducted a breast
percent of the doctors missed the tumor, meaning their
technique was ineffective, she said.
military project, she has developed "box trainers"
partial anatomical models made of box-like material
for four procedures: placing a central line, inserting a
bladder catheter, connecting two portions of intestine and
repairing a hernia.
testing medical residents in Wisconsin, Illinois and Minnesota
who already planned to spend two years away from surgical
training to do research, a proxy for military duty.
evaluating the residents at the beginning of their leave,
midway through it and at the end. "We're looking at what
gets lost when you have time away," she said.
could someday lead to hands-on tests of doctors' skills, Pugh
students must pass three computer-based exams to become
doctors. To assess communication skills, the National Board of
Medical Examiners added encounters with patient actors to the
second exam a decade ago.
groups such as the American Board of Surgery generally require
a computer-based exam and oral exam for certification, and a
computer exam for re-certification every 10 years.
assessments could be added during medical school to weed out
students from certain specialties, and for experienced doctors
to be sure they keep up with the latest techniques, Pugh said.
She would like to see national medical boards adopt hands-on
evaluations and hospitals use them when granting privileges to
It might not
be easy to get experienced doctors to agree to such scrutiny,
Pugh acknowledged. But if they want to ensure the best patient
care, they should, she said.
going to require a culture change," she said.