1 Paradigms in Surgery April 30th, 2015Hospital General Dr. Manuel Gea González México City Tamara R. Tilleman, MD, PhD, MPA Dean of Clinical Medicine Professor of Surgery Medical University of the Americas SKYPE: DeanTilleman
2 Tamara Raveh Tilleman, MD,PhD,MPA
3 Tamara Raveh Tilleman, MD,PhD,MPA
4 Paradigms In Sport Drugs, Alcohol and Sport: A Critical History Paradigm “Conservation of energy was the basic paradigm in athletic training in the early twentieth century”
5 20 years ago – first day of my Plastic ResidencyParadigms in Surgery 20 years ago – first day of my Plastic Residency How can you Survive/Thrive any “paradigm period” (residency, marriage, prison)
6 Paradigms in Surgery ObjectivesParadigm definition - paradigm shift - paradigm period / paradigm paralysis Understand the limiting beliefs paradigms induce (in medicine) Costs/Benefits Analysis How can you Survive/Thrive any “paradigm period” (residency, marriage, prison)
8 Paradigms in Surgery Leading Questions What is a Paradigm ?Dictionary: a model or pattern for something that may be copied - a theory or a group of ideas about how something should be done, made, or thought about. Filter of the objective world translate it to your (Emmanuel Kant) Practical Definition: A paradigm is a set of assumptions governing how people interpret the world and interact. Paradigms condition our mind, programming us to think the way we think and to operate the way we do. Every individual, or a group, have paradigms that are influenced by outside forces acting on them and their own experiences in support of the paradigm. Once you have a paradigm (and everyone has, we will see soon), your thoughts and your actions are biased toward this “super believe” that is tattooed in our brain.
9 Paradigms in Surgery Leading Questions Concept of Paradigm?Introduced by Thomas S. Kuhn in his work : The Structure of Scientific Revolutions (1962) Paradigm regarding how science advances: According to Kuhn, science advances by alternating between “normal” and “revolutionary” phases. (dismissed incremental advances of science) A paradigm shift (or revolutionary science) According to Thomas Kuhn is a change in the basic assumptions/or paradigms, within the ruling theory of science. His examples: The acceptance of Mendelian inheritance, opposed to pangenesis The transition between the worldview of Newtonian physics and the Einsteinian relativistic worldview. Note- all used to be “normal” science until the shift..
10 Paradigms in Surgery Leading Questions Concept of Paradigm?Introduced by Thomas S. Kuhn in his work : The Structure of Scientific Revolutions (1962) Paradigm regarding how science advances: According to Kuhn, science advances by alternating between “normal” and “revolutionary” phases. (dismissed incremental advances of science) A paradigm shift (or revolutionary science) According to Thomas Kuhn is a change in the basic assumptions/or paradigms, within the ruling theory of science. His examples: The acceptance of Mendelian inheritance, opposed to pangenesis The transition between the worldview of Newtonian physics and the Einsteinian relativistic worldview. Note- all used to be “normal” science until the shift..
11 Paradigms in Surgery Leading QuestionsParadigm examples What do you see? (Half class closed eyes/half class)
12 Paradigms in Surgery Leading QuestionsParadigm examples What do you see? Half class/half class
13 Paradigms in Surgery Leading QuestionsParadigm examples What do you see? Half class/half class
14 Paradigms in Surgery Leading QuestionsParadigm examples What do you see? Half class + half class
15 Paradigms in Surgery Leading QuestionsParadigm examples Rashomon 1950 period drama film (Japanese history) Name Kyoto’s city gate Directed by AK The film is known for a plot device which involves various characters providing alternative, self-serving and contradictory versions of the same incident. The term Rashomon effect refers to real-world situations in which multiple eye-witness testimonies of an event contain conflicting information.
16 Paradigms in Surgery Leading QuestionsParadigm examples Sports: Fosbury Flop high jump Popularized & perfected by American athlete Dick Fosbury 1968 Summer Olympics Mexico City won gold medal (world's attention). Over the next few years the flop became the dominant style and remains so today. Before Fosbury, most elite jumpers used Western Roll, Eastern cut-off or scissors jump to clear the bar.
17 Paradigms in Surgery Leading QuestionsParadigm Sports: Fosbury Flop high jump What was the paradigm paralysis? (the inability or refusal to see beyond the current models of thinking) The old cliche "If it ain't broke don't fix it“ “Change occurs when there is an issue with the result + in direct proportion to dissatisfaction” )
18 Paradigms in Surgery Leading QuestionsWhat is a Paradigm ? Medical Paradigm: Peptic Disease is a behavioral/dietary: Early 20th Century Ulcers are believed to be caused by stress and dietary factors. Treatment focuses on hospitalization, bed rest, and prescription of special bland foods. Later, gastric acid is blamed for ulcer disease. Antacids and medications that block acid production become the standard of therapy. Despite recurrence ulcers. 1982 Australian physicians Robin Warren and Barry Marshall first identify the link between Helicobacter pylori (H. pylori) and ulcers, concluding that the bacterium, not stress or diet, causes ulcers. The medical community is slow to accept their findings. Easter holiday, Petri dishes incubator for five days (recommended 2 for Campylobacter) 1994 (ulcers are curable? 1 day per week OR) A National Institutes of Health Consensus Development Conference concludes that there is a strong association between H. pylori and ulcer disease, 1997 FDA approves the first antibiotic (clarithromycin) peptic treatment
19 Paradigms in Surgery Leading QuestionsWhat was the paradigm paralysis? (the inability or refusal to see beyond the current models of thinking) Medical Paradigm: Helicobacter pylori The dictum of Karl Schwartz: “No acid - no ulcer” (1910, true but…) Schwartz provided framework for ulcer research Paradigm period: 2 Centuries or Paradigm paralysis: What do I believe is impossible to do in my field, but, if it could be done, would fundamentally change medicine/my business?
21 Paradigms in Surgery Leading QuestionsWhat was the paradigm paralysis? Reminder: Laparoscopic Operations are performed Far from their location Small incisions (usually 0.5–1.5 cm) elsewhere in the body Ego Paradigms 1).“Small cut, Small surgeon. Big cut, Big surgeon" (The Prof always used to say… in trauma this made sense….) 2). Surgeons must have “hands on”.. 3). The old cliche "If it ain't broke don't fix it" 4). Technophobia = Phobia/Fear of novel technology (going to Zero) Paradigm paralysis: s
22 Paradigms in Surgery Leading Questions Plastic Surgery Paradigm:Reduction Mammoplasty for Macromastia/Gigantomastia Inferior pedicle 1924: Hollander 1960: Strombeck, McKissock vertical bipedicle dermal Superior pedicle 1957, Arie first described superior pedicle mammoplasty 1967 Ivo Pitanguy 1973 Weiner in United States 1982 Daniel Marchac 1994, Madeleine Lejour popularized
24 Paradigms in Plastic Surgery
25 Paradigms in Surgery Leading QuestionsWhat is a Paradigm ? Plastic Surgery Paradigm: Surgical Ellipse Dimensions: length-to-width ratio of 3:1 – 4:1 AND 30º angle Remember you left me 20 years ago
26 Paradigms in Surgery Leading QuestionsWhat was the paradigm paralysis for surgical ellipse? (the inability or refusal to see beyond the current models of thinking) *** The Chief of the Department told (Apprenticeship Model) Written in Textbooks (EBM Model) Dog ear is hideous (no plastic surgeon should have such a result)
27 calculation of a fusiform ellipse vertex angles, expressed by the following formula (62):Paradigms in Surgery Is paradigm of surgical ellipse dimensions accurate? Method: - Ellipses published in the literature (57) - Ellipses excised at our outpatient clinic (83) - Comparison with mathematical formula
28 Paradigms in Surgery Results:None of the data matches the paradigm of a 30º angle for a length-width 3:1 – 4:1 (so what do we do with the dog ear?)
29 Paradigms in Surgery Case 1Leading Questions Paralysis Paradigm - No surgeon is thinking about the dimensions (conscious level) - How to close the lesion - Subconscious ratio 1: degrees Going to the next paradigm- if 50 degrees has a dog ear what to do?
30 Paradigms in Surgery The validity of paradigms in skin surgeryPlastic Surgery Paradigm: Direct Closure of Rounded lesions: Infeasible Feasible with price: - Dog Ear - Hypertrophic Scar
32 Paradigms in Surgery Is direct closure of circular defects feasible? (yes)
34 Paradigms in Surgery Case 2Leading Questions Paralysis Paradigm: dog ear (limited elasticity of the skin) Funny looking scar at the end of operation will redistribute
35 Paradigms in Plastic SurgeryThree paradigms were found incorrect Two new surgical techniques have been developed
36 Paradigms in Surgery Paradigm examples
37 Paradigms in Surgery New method of umbilical repositioning by incising the anterior rectus sheath and rectus abdominis muscle Cases of unilateral abdominal wall plication during the TRAM flap operation. Advantages: - Umbilicus stable and non stenotic Avoids hypertrophic scar Normal abdominal strength, - Performing abdominal strain and general exercise without areas of weakness in the abdominal wall. This method does not weaken the contralateral abdominal muscles, Fuente del Campo, A.*, Raveh, T.**, Gordon, C.B.***
38 Paradigms in Surgery Paradigm example: The case of Umbilical Transportation 3 Seniors in one room, 1 Patient-Surgeon relationship Who can change a paradigm? An outsider with ego free insider Magic moment = luck= knowledge meet “Luck is what happens when preparation meets opportunity.” Seneca Again, keep giving credit…
39 Paradigms Survival KitSurvival Kit (or how to thrive) for those who are in a “paradigm period”(residency, marriage, prison) 1. The benefit/cost of Paradigm Benefit-Cost analysis (decision making tool) Adding up the benefits/value of an undertaking course of action, and then comparing these with the costs associated with it). a resident helps you collect data for an article => Cost= his name on the paper not brushing teeth-> decay You noticed a mistake by the Prof (=saving him/her) => Cost= the Prof thinks you are “smartie pants” (BCA estimating the strengths and weaknesses of alternatives for example: you noticed and decide not to say anything, the Prof has no issue with you but the patient may be harmed…
40 Paradigms Survival Kit2. Three levels of knowledge in the medical field: Technician Learning foundations of a profession (Plastic) concentrating on the HOW Habit is preformed, make sure it is the right one Apprentenship Model Master (Teaching, routine => WHY) Master Technician, Master Artist Any master has a routine but with high standards Pioneer (outsider) How to be a paradigm pioneer What do I believe is impossible to do in my field, but, if it could be done, would fundamentally change medicine/business? Unsolved problem (skin graft.., diagnosis by saliva)
41 Discover your own paradigms
42 Paradigms in Surgery Questions?
43 Paradigms in Surgery April 30th, 2015Hospital General Dr. Manuel Gea González México City Tamara R. Tilleman, MD, PhD, MPA Dean of Clinical Medicine Professor of Surgery Medical University of the Americas SKYPE: DeanTilleman
44 Match 2015 Results IMG 2015 MATCH DATA FOR IMG STUDENTS:For the 13th consecutive year, the number of first-year (PGY-1) residency positions offered through the National Resident Matching Program® (NRMP®) Main Residency Match®increased. A total of 27,293 first-year positions were offered in the 2015 Match. This represents an increase of 615 positions compared to last year and an increase of more than 6,600 positions since Match 2015 Results IMG
45 Road Map to Residency Look around: 2 types of student graduating med school (physicians)…
47 Practicing Physician (NRMP)Match Pass= 192
48 Practicing Physician (NRMP)Interviews 210
49 Raise your standards, learn to compete with yourself/yourself only
50 Match 2015 Results IMG 2015 MATCH DATA FOR IMG STUDENTS:For the 13th consecutive year, the number of first-year (PGY-1) residency positions offered through the National Resident Matching Program® (NRMP®) Main Residency Match®increased. A total of 27,293 first-year positions were offered in the 2015 Match. This represents an increase of 615 positions compared to last year and an increase of more than 6,600 positions since Match 2015 Results IMG
51 Match 2015 Results IMG 2015 MATCH DATA FOR IMG STUDENTS:For the 13th consecutive year, the number of first-year (PGY-1) residency positions offered through the National Resident Matching Program® (NRMP®) Main Residency Match®increased. A total of 27,293 first-year positions were offered in the 2015 Match. This represents an increase of 615 positions compared to last year and an increase of more than 6,600 positions since Match 2015 Results IMG For the 13th consecutive year, the number of first-year (PGY-1) residency positions offered through the National Resident Matching Program® (NRMP®) Main Residency Match®increased. A total of 27,293 first-year positions were offered in the 2015 Match. This represents an increase of 615 positions compared to last year and an increase of more than 6,600 positions since 2002.
52 Match 2015 Results IMG 2015 MATCH DATA FOR IMG STUDENTS:For the 13th consecutive year, the number of first-year (PGY-1) residency positions offered through the National Resident Matching Program® (NRMP®) Main Residency Match®increased. A total of 27,293 first-year positions were offered in the 2015 Match. This represents an increase of 615 positions compared to last year and an increase of more than 6,600 positions since Match 2015 Results IMG
53 2017 Match – are you smarter than 90% of your classmates ??
54 Paradigms in Surgery May 30th, 2015Hospital General Dr. Manuel Gea González México City Tamara R. Tilleman, MD, PhD, MPA Dean of Clinical Medicine Professor of Surgery Medical University of the Americas SKYPE: DeanTilleman
55 Paradigms in Surgery Leading QuestionsDrawing essentially from pioneering work of Thomas Kuhn To begin of your own paradigm shift (1) What do I believe is impossible to do in my field, but, if it could be done, would fundamentally change my business? (2) Who, outside my field, might be interested in my unsolved problems? WHO: The "Paradigm Shifters" have the big idea, however, the "Paradigm Pioneers" are the individuals who have the courage, faith and "intuitive judgment" to ensure a successful paradigm shift. Segregated schools are simply not right, and as pioneers, integrating our school is a vision that is "not an act of the head, but an act of the heart." WHAT: What "set of rules or boundaries," or simply stated by Barker, paradigms, are in need of a facelift in your organization? Federal mandates stated that busing can no longer be the means of integration, however, our schools must reflect our world today; diverse. This mandated created a sense of urgency (Kotter) in the change process. WHERE: "To not quest for excellence might be considered sacrilege." Raising the expectation of what success is in your organization will inevitably create a need for a paradigm shift. Current enrollment is 92% African-American, 2% Hispanic, and 6% Caucasian. Yes, this is 130% better then years previous, yet it should not be considered as integrated. The where is most likely within your organization as well! WHEN: "Paradigm Paralysis" is what an organization will face if there is no "paradigm pioneer" to lead the conscious thought to real life. "A leader is a person you would follow to a place you wouldn't go yourself." WHY: In conclusion, if you read this review and are highly curious as to the paradigm shift that must take place to integrate the school that I work in, then Barker has definitely fulfilled his mission of taking an individual through the process of "Discovering the New Paradigms of Success."
56 Paradigms in Surgery Leading Questions(we can learn from this case when is a “paradigm shift” (unsatisfied results : cost/benefit=outcome) “Change occurs in direct proportion to dissatisfaction” – Douglas Horton, American clergyman, formula for change was created by David Gleicher D x V x F > R D = Dissatisfaction with how things are now;(Outcome) V = Vision of what is possible; (Scope) F = First, concrete steps that can be taken towards the vision;(Action) Change is possible if the product of these three factors is greater than R = Resistance