University of Illinois at Chicago
This program has flown by thus far and unfortunately we are already entering the last week of our second rotation. I have enjoyed my time in both the orthopedics and oncology departments and am looking forward to continuing in this final week. I think my group has been successful in our goal of assessing clinical needs and ultimately have found some issues that can we can work on in the months and years to come.
For my last week, I hope to spend some more time in the radiation oncology department to further observe any apparent clinical needs. I think that my interest in the field helps me be creative in my thinking and will allow me to be passionate as I move forward to tackle some of the problems I encounter. As of right now, I think the area of radiation oncology that I think can be improved most easily is the immobilization techniques for patient simulations and external beam therapies. When I discussed this issue with the residents of the department, they seemed to be under the impression that the casting system for abdominal and lung cases had “acceptable” outcomes so there was really no need for innovation especially given the low cost of production. To me, this response felt like it was a result of biases from being in the field for a long time. These immobilization devices have been in place for as long as the residents have been practicing so it may be difficult for them to imagine anything else being viable. I hope to continue discussing this issue with the staff next week because I personally am very excited about getting involved in this innovative space during my time as an IMED student.
Another area I hope to get more exposure to in the coming weeks is the various tools used for administering brachytherapy safely. We have only seen one brachytherapy procedure conducted for cervical cancer which involved some primitive tools such as stacked towels used to minimize radiation exposure to the patients’ legs. Similarly, we have seen a few patients with ocular melanoma which require brachytherapy administration via surgical implantation of a radioactive plaque directly onto the tumor of the retina. Unfortunately, we have never been able to actually watch that procedure in the OR so hopefully this week we will be able to get that experience. Ocular melanoma is an extremely rare condition but UIC/UChicago actually has a fair number of these patients given their experience in the treating the disease. I imagine that there may be a space for innovation in this space due to the required coordination between the radiation and surgical team. Furthermore, there are some fairly limiting side effects of treatment such as permanent vision loss and potential extreme eye pain that may lead to eventual removal of the eyeball itself. Any method to minimize undesired radiation exposure to peripheral tissues would certainly reduce these devastating effects.
While we unfortunately only have a few days left in the program, I am excited to continue my experience with radiation oncology and am hopeful for some interesting findings the days to come!
My second week in hematology/oncology was definitely a major shift from the first week spent solely in radiation oncology. On Monday we met with Dr. Rondelli who was extremely helpful in explaining the basic science of medical oncology and bone marrow transplants. This knowledge would prove to be very important as we continued throughout the week and observed in the clinical arena. He also discussed with us some of experiences of past students in the program and explained which areas he felt would be interesting to us from an innovation standpoint. Overall, I think our group was very thankful for this initial meeting because it laid a strong foundation for the rest of the week and helped us be more prepared as we observed.
On Tuesday we spent some time in the stem cell lab and blood bank to get some insight into how blood marrow transplants are prepared. This part of the immersion experience was particularly interesting to me due to my interest not only in the basic physiology of the immune system but also due to the level of complexity of preparation from an engineering perspective. Blood samples are processed in a very careful and reproducible way involving not only human handling but also complex machinery designed to extract particular blood components. One example which I thought was quite impressive is a machine designed to use monoclonal antibodies which bind CD34 (a cell surface receptor) to extract only stem cells from a patients blood sample.
Our next stop on the hematology/oncology rotation was with rounding with Dr. Quigley at the clinic. Personally, this part of the experience was not my favorite, mostly due to my own ignorance of the clinical scenarios playing out in front of me. I am not familiar with most medical protocols for treating cancers or hematological diseases so most of the discussions between Dr. Quigley and residents were over my head. Furthermore, with all 4 members of our team rounding, the rooms quickly became packed with residents and students so it was hard for us to observe most of the interaction. This is not the fault of the medical staff but was simply unfortunate for our team of students. Overall, I think it was definitely a valuable experience clinically but from an innovation standpoint it was quite difficult.
On Thursday, we spent the morning with Dr. Rondelli in his clinic and in the Infusion Area of the Outpatient Care Center. This experience was definitely good for clinical needs assessment because there were many patients and a vast number of blood pumps being used to administer chemotherapy. One issue that jumped out to us right away was the troublesome scheduling as we have seen in many departments throughout this experience. The charge nurse was responsible for manually assigning patients to rooms at times throughout the day, trying to accommodate for specific patient characteristics. For example, she tries to match male patients with other male patients in the same room and keep certain immunocompromised patients in their own rooms. At times theses accommodations make her job quite difficult as she must weigh certain preferences over others. Furthermore, the entire system is done by paper and pencil, with her copying information from the computer check-in and scribbling down names as the situation changes. At the end of the day, her schedule is marked with eraser shavings and red arrows indicating last minute changes to patient rooms. We imagine that this scheduling system could easily be improved and would drastically improve the efficiency of the clinic.
At the end of the week, we actually decided to spend more time back in the radiation oncology department because overall our team felt more productive in that space. The patient load is much lower so we have more time to discuss with residents and physicians the problems they see on a daily basis. I expect that we will continue to spend time in this clinic in the coming week and am excited to continue where we left off last time.
Unfortunately, our time scheduled in the radiation oncology department has come to a close and we are now beginning with a new experience in the hematology/oncology department. While I am extremely interested in the clinical and engineering problems of radiation, I am looking forward to beginning a new chapter this week. I expect that the pace of the clinics will be quite different from that of radiation and that the patient volume per day will be large. This should allow us to stay busy throughout the rest of the rotation and observe a large variety of patients and procedures.
Admittedly, I am quite ignorant about the details of hematology and medical oncology so I am glad to have a chance to work in this department. Hopefully the staff will have time and be receptive to questions about how hematologic disease and cancer are handled medically. I imagine that there are a huge variety of treatments available to tackle these devastating diseases and I hope that as a team we can begin to scratch the surface regarding any potentials spaces for innovation. As we have discussed in our open classes, I think that sometimes ignorance in a field can be very beneficial for the success of the team as we are not limited by biases of experience. We have not been trained to do things in a certain way so it may be easier for us as outsiders to recognize problems that may not be so easy for regular staff to appreciate. Taking advantage of this perspective should be beneficial for our group as we prepare observations and ultimately deliver assessments about possible inefficiencies in the clinic.
This week I am most looking forward to working with the medical oncology team since I have an interest in pursuing a career in oncology down the road. I am not only fascinated by the physiology of tumor dynamics but also recognize the clear importance of cancer management in our society today. There are huge efforts being made across the globe to create better cancer outcomes and perhaps we as a team can begin to contribute to the conversation. Given this knowledge it is important to have unrealistic expectations about our experience in the coming weeks. We almost certainly will not make a groundbreaking change in cancer care but that does not mean our efforts are not important. Rather, as long as we can keep the scope of our observations within reasonable limits, I am confident that we may indeed be able to make a positive impact on the delivery of care. I am looking forward to beginning that process tomorrow afternoon!
This week we were assigned different teams in a new department for a second 3 week rotation. Fortunately, I was matched into my top choice of hematology/oncology which is a field am interested in both clinically and academically. I envision myself pursing a career in radiation oncology and I hope that this program can give me a unique perspective about needs assessment and innovation in that workspace.
We have been working primarily with two attending physicians, Dr. Howard and Dr. Koshy, and their respective residents in the department. Every staff member has been very open to discussions with us and has provided insights about clinical knowledge and needs in the field. I am very grateful for the time and effort they have invested in our experience and I am confident that our team will continue to learn as the rotation continues.
Compared to my first rotation in orthopedics, this week has been much less hectic and has allowed for more time of reflection. I think this is simply a result of the nature of the specialty rather than a specific trait of UIC clinic in particular. Radiation Oncology has a significantly smaller overall patient volume and each case is quite complex taking longer time. Furthermore, every case is a collaboration between multiple oncological teams, including surgery, medicine, and radiation. Integration of these therapies is necessary for optimal outcomes for patients. However, this complexity also comes with a price. Communication becomes increasingly important as the level of integration increases so any errors in communication can be extremely detrimental to patients.
Throughout the week, the observations I was most excited about involved patient immobilization techniques during external beam therapy. In short, during therapy a patient must be in precisely the same position for the radiation beams to be accurately targeting the tumor and not normal tissue. Currently, there are a number of devices which are used to this end and at UIC I believe the most common method is a casting system. During the planning stage of treatment, the patients are asked to undergo a simulation, where they lay down on a casting material. The material expands and hardens over the course of about 10 minutes so that it creates a mold of the patients body. Thus, each time they come back they can lay down in that mold and reproduce the body position from the previous treatment. The casts are indeed quite cost efficient as they are made of relatively inexpensive materials. However, they do require storage in between uses and ultimately disposal at the conclusion of therapy. Furthermore, in pediatric cases, general anesthetic is used to prevent patient movement during the treatment. This seemed not only very expensive for the hospital given the cost of medications but also very extreme for the patients and parents. I imagine that most parents would not enjoying having their child receiving anesthetic on a consistent basis. I discussed this issue with one of the residents at length, and he ultimately had the view that this is the best solution to the problem, given other alternatives such as forced immobilization which would be traumatic for the child. At this point, I do not see a simple solution to maximizing efficiency of immobilization but I am excited to pursue these issues moving forward. Perhaps this area could be a longitudinal project for my career in medical school and beyond.
These last 3 weeks in the orthopedics department have flown by and unfortunately it is already time to shift gears. I am very thankful to the staff at UIC and IBJI for allowing us to spend time in the clinic and operating room. As a group, I think we learned a great deal not only about how orthopedic clinics are run but also about the process of thinking like an innovator. This experience has been invaluable to me as a student and I am confident that I am more prepared to approach problems in the future.
On Thursday of this week, we were fortunate enough to spend another day with Dr. Gonzalez in the OR. We watched a number of procedures and were able to discuss with the doctors potential issues during the procedures. Dr. Gonzalez was especially helpful in showing us the details of the surgeries and explaining the biomechanics involved in each step. One case which I found particularly interesting was the carpal tunnel procedure. Hand movements themselves are extremely complex given the large number of muscles and bones involved in coordinating precise actions. Carpal tunnel syndrome is associated with increased pressure in the tunnel connecting the wrist to the hand. In order to compensate, surgical cutting of the transverse carpal ligament can increase the area of the tunnel. This relieves the pressure on the contents of the tunnel, hopefully leading to resolution of symptoms.
Intuitively, I would imagine this procedure would cause major limitations in hand movements, especially when the wrist is flexed. However, based upon Dr. Gonzalez’s vast experience in the field, he rarely receives complaints by patients following carpal tunnel syndrome. There seems to have been little work done comparing grip strength in flexion following the surgery. Zaid and I discussed this issue and are hopeful to conduct some clinical outcomes or cadaver research in future to get a more precise picture of how carpal tunnel surgery affects hand function.
Overall, I was very pleased with my experience in the orthopedic department and am looking forward to starting in the oncology department for the remainder of the program.
Unfortunately, this is already the start of my final week with the orthopedics department and as expected the time has flown by. I still feel as though I am just getting acquainted with some of the staff members in the clinic and am very appreciative of the time I have had thus far. Nonetheless, I do have high hopes for the remaining days in this rotation and hope that we can continue working with Dr. Gonzalez to find real time problems in the clinic and operating room. I feel as though I have not only learned a great deal about the clinical aspects of orthopedics but have also grown significantly as a critical thinker and innovator. I have a newfound appreciation for the process of needs assessment and will carry this experience forward through my career.
Today, we worked with Dr. Gonzalez in the Illinois Bone and Joint Institute just as we did last Tuesday. Unfortunately, today had a slightly higher patient load compared to last week so we had more limited face-to-face time with the doctor throughout the day. I did, however, get the chance to discuss some of my ideas with Dr. Gonzalez about upcoming surgeries I will be observing on Thursday at UIH. In particular, I noticed Dr. Gonzalez would be performing a number of carpal tunnel procedures this week so I decided to do some journal reading regarding biomechanics of the carpal tunnel during this survey. I found a huge array of articles pertaining to this procedure and focused on a few which I thought were specific and targeted with the potential for innovative ideas.
In particular, I noticed that the current carpal tunnel release procedure results in complete destruction of the transverse carpal ligament which runs laterally across the wrist. The proposed physiological role of this ligament is to not only provide protection of nerves and tendons below, but also push the ligament closer to the bones of the fingers. In this way, it is acting as a pulley to prevent bowstringing of the tendons when the wrist is flexed. Intuitively, I imagined that cutting of this ligament during surgery would result in decreased range of motion at the wrist, so I asked Dr. Gonzalez about whether patients had complained of this problem after the procedure. Unfortunately, this never seems to be an issue for patients and studies on cadaver wrists have not shown significant changes in physiological range of motion. Zaid, another member of my team, asked other questions as well and Dr. Gonzalez was quick to respond with references to literature about what type of work had already been conducted which addressed our concerns.
It is very easy to view this experience as a letdown, as none of our ideas regarding the surgery seemed to be real problems in the clinical realm. However, I view it as a learning process and a chance to practice my abilities of questioning and maintaining a critical perspective during observation. I am confident that if I continue honing this skill, I will become more capable of making contributions in the future as a physician and innovator.
Unfortunately, this week has been quite busy so it has been awhile since my last post. However, my time in the orthopedics department, despite the long hours, was quite exciting. Our team spent most of the week with Dr. Gonzalez who is the head of the department here at UIC. I really enjoyed the longitudinal experience of working with the same attending throughout the week. Unlike the first week of the rotation where we worked with a different attending every day, our experience with Dr. Gonzalez provided much needed continuity for the rotation. We were able to get a better picture of what his life is like everyday and have more in-depth discussions about the types of obstacles he faces as an orthopedic surgeon.
Throughout the week we spent some time in the clinic with Dr. Gonzalez who is extremely efficient with patient flow. He sees upwards of 60 patients in a single day and, despite a few hiccups with scheduling, seems to maintain a steady pace throughout the session. Unlike Dr. Mejia who uses the magnet system for managing his schedule, Dr. Gonzalez relies solely on the traditional system to guide his progress. We spoke with a few attendings about the necessity of a new system (e.g. magnets, etc) to manage flow and received very different feedback. Some attendings do believe that formalized orders can increase efficiency but others feel comfortable without any external guidance. For me personally this was a bit disheartening because during our first week we spent so much of our efforts focusing on this issue as a potential space for innovation.
On Tuesday, we had quite a different experience because rather than going to the UIC clinic we spent the day with Dr. Gonzalez at the Illinois Bone and Joint Institute on Michigan Ave. This clinic time was so different than UIC mainly due to a huge decrease in patient volume. Dr. Gonzalez only saw a total of 15 patients throughout the day, which paled in comparison to his 60-70 at UIC. Since he was not as rushed with seeing patients, Dr. Gonzalez was able to not only spend more time with each patient but also spent time with us discussing our experience thus far. He comes from an engineering background himself so he was very excited to share his perspectives regarding the role of engineering in orthopedics. He showed us some of his own work in the field and discussed the possibility of innovation in that sector. Furthermore, he even described some of his own patents for medical devices that are useful in surgery. Overall, I was extremely pleased with my experience in the private clinic and am looking forward to spending more time at IBJI in the coming week.
The most exciting part of the week for me was Thursday where we spent all day in the OR observing as Dr. Gonzalez performed a number of operations. We were lucky enough to witness two total knee replacements and a total hip replacement which were extremely intriguing, especially since I may want to pursue orthopedics as a career choice down the line. Although I was quite ignorant as to the details of these procedures, I did try to maintain a critical eye throughout the day, focusing on details of the procedures which seemed inefficient. At the end of the day, we were able to discuss some of our ideas with Dr. Gonzalez, who was more than open to hearing our thoughts. We had written down a few ideas, such as concerns about guidance of drills through bones, and to each question Dr. Gonzalez was quick to respond with references to literature about how our questions had already been addressed professionally. This was not discouraging, however, because he seems to really support our enthusiasm in the OR and wants us to succeed as students. We have decided to do some academic reading before our next day in the OR so we can have a more educated perspective coming in. He will be performing a number of carpal tunnel surgeries so we will try to focus on this procedure in particular. Hopefully this will lead to further questions and we can start finding real issues to potentially address with the team. I definitely have high hopes for the week to come and think that our work with Dr. Gonzalez will certainly be beneficial.
Not much has changed since my last post so I will keep this one short. I begin the second week of rotation tomorrow after a morning meeting with my team and the rest of the immersion group in the innovation center. I am excited to share our first week experience with the other students and am eager to hear about their perspective as well. This formal meeting time should be very beneficial for our group as we not only get more time to discuss our goals for the rest of the rotation but also hear from Dr. Kotche about her advice moving forward.
The next two weeks of rotation in the orthopedics department should be very interesting, as we are formally assigned to work under Dr. Gonzalez who was out of the clinic last week. I think it will be very beneficial for our group to have consistency of attending physicians so that we can make longitudinal observations. Hopefully, Dr. Gonzalez will be as open to discussion as Dr. Mejia was last week so we can continue our conversations about work efficiency in the clinic.
Along those lines, I am perhaps most eager to continue our work with Dr. Mejia from last week. He seemed very excited to get involved with our program and recognized a major need for improvement in the process design of his clinic. We as a group have reached out to him this weekend with the hope of sitting down for a brief meeting outside of the clinic. A more formalized meeting with Dr. Mejia could lay a great foundation for our ideas moving forward. This week could prove to be very productive for our team and I look forward to getting started!
This is the very first week of the clinical immersion program and, to be honest, I was not quite sure what to expect from my first rotation in orthopedics. Overall, I have been quite pleased with the progress we have made as a group and I am excited to get more feedback from the UIC orthopedics staff moving forward. I believe we have found some interesting issues in the clinic that may very well lead to concrete projects in the future.
More specifically, our time spent in the first week has been almost entirely in the orthopedics clinic with various attending physicians and residents. In my first day of the rotation, I worked with staff under Dr. Matthew Marcus. My original focus as an immersion student with Dr. Marcus was to focus on procedural issues in the physician-patient interaction itself. I observed a few visits and unfortunately felt discouraged because most of the time spent in the visit was simply conducting a patient history. It felt like there was little room for innovative thinking in this space and I truthfully became a little discouraged by the end of the first day. I discussed this feeling with other members of my team and overall it seemed that this was a shared sentiment.
However, the second day in the clinic proved to be an entirely different situation, as we spent time with physician Dr. Mejia. Right away, I was very impressed with his demeanor and ability to concretely articulate ideas and communicate with residents and students alike. The day really became exciting when another member of my group, Zaid, noticed a small bag of magnetic characters (numbers and letters) that were sitting at the nurses station. He asked a nurse on staff what those magnets were used for and she explained that Dr. Meija had developed a system for himself to maximize efficiency of patient flow. He would use the magnets as signals to tell him which patients should be seen in which order and also provide basic information about that patient. For example, if the patient is second to be seen and needs an operation, Dr. Mejia places a magnetic “O” and “2” on the door of the room. He then has to manually update the system after each patient interaction by replacing all of the magnets on the doors.
Right away, the members of my group were intrigued by this system. The simple fact that a physician felt compelled enough to develop such a process indicated to us that there was likely an underlying process issue that needed to be addressed. We approached Dr. Mejia about his system and he was very receptive and excited to work with us and potentially find means of improvement. He shared with us briefly his thoughts about what flaws exist in the patient flow of the UIC clinic and encouraged us to think critically about how he can get involved.
At this point, we have only just begun our discussion with Dr. Mejia but we have planned to meet more in the future to discuss the possibility of more actively tacking this systemic problem. I personally am very excited by this prospect and feel as though my group could very well be on track to improve efficiency in that clinic.