
Maternal deaths; female neurosurgeons; car keys and the elderly: Upstate Medical University's HealthLink on Air for Sunday, Sept. 1, 2024
Obstetrician-gynecologist Rachael Sampson, MD, discusses the rising rate of maternal mortality in the United States. Larry Chin, MD, a neurosurgeon and the dean of Upstate's Norton College of Medicine, explores why female doctors might pursue careers in neurosurgery. And geriatrics chief Sharon Brangman, MD, talks about when it's time to take the car keys from an aging parent.
Transcript
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," an obstetrician reports on rising rates of maternal mortality in the United States.
Rachael Sampson, MD: ... 1,205 maternal deaths occurred in the United States, and that's that number that we see in the news, and that's the one where we all stepped back and said, "What is happening? What can we do better?" ...
Host Amber Smith: And the dean of Upstate's Norton College of Medicine discusses why women may feel comfortable training in neurosurgery and other specialties at Upstate.
Dean Larry Chin, MD: ... Upstate really has a tradition of being champions of equality. Upstate graduated the first woman who was granted an MD degree in the U.S., and that, of course, was Elizabeth Blackwell, and that was in 1849. So there's this great history. ...
Host Amber Smith: All that, some advice about taking the car keys from an aging parent, and a visit from The Healing Muse, right after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.
On this week's show, Upstate ranked nationally in a study of female neurosurgeons, and we'll hear from the dean of the Norton College of Medicine about the importance of producing a diverse pool of physicians. But first, most pregnancy related deaths are preventable. So why are the rates of maternal mortality rising?
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
The majority of pregnancy-related deaths in women are preventable. And today I am talking with a doctor about what can be done to help reduce the maternal mortality numbers. Dr. Rachael Sampson is at Upstate completing a fellowship (specialized training) in maternal fetal medicine.
Welcome to "HealthLink on Air," Dr. Sampson.
Rachael Sampson, MD: Thank you very much for having me.
Host Amber Smith: Can you define maternal mortality?
Rachael Sampson, MD: Maternal mortality refers to the death of a woman from complications of pregnancy or childbirth that occurred during the pregnancy or within six weeks after the pregnancy ends. So we're going to go through a lot of definitions here and a little bit of math because a lot of these definitions seem like the same thing. But there are nuances and are differences that really are driving our statistics and driving how we are trying to help patients and how we're trying to reduce these rates.
So it's one thing to talk about maternal mortality, but then another concept is, is it pregnancy related?
And I think that's something that patients often ask or that the public often asks me, because there is a difference between maternal mortality, pregnancy-related deaths and then pregnancy-associated deaths.
Host Amber Smith: But you said up to the time period six weeks after delivery?
Rachael Sampson, MD: That's when we talk about maternal mortality, and we can talk about maternal mortality rates in that context.
There's also a consideration to look at statistics based on pregnancy-related deaths. A pregnancy-related death is a death during pregnancy or within one year of the end of pregnancy from a pregnancy complication. So that chain of events -- and that ties into what we'll talk a little bit about later, maternal mortality review committees (MMRCs) -- was that chain of events related to pregnancy, or was it pregnancy associated? So a pregnancy-associated death, for instance, is a postpartum (after the baby is born) death from a car accident.
Host Amber Smith: I see. And this, just to be clear, has nothing to do with the baby, the infant, we're only talking about the mom?
Rachael Sampson, MD: It's a great question. So how do you tease the two out? And that's where a lot of these definitions and where a lot of the statistics become difficult. And I'm so thankful that we're on this podcast discussing these because traditionally these were things that nobody talked about. A lot of maternal health and women's health, we're realizing now, was really pushed down to the basement. Not great to talk about these topics. I don't know if I can use the term "sexy" -- it's not sexy to talk about these things, traditionally, is what we thought. And I just really want to thank you for talking about them and for making it accessible.
Host Amber Smith: Well, how common is maternal mortality, and also, how common is pregnancy-related death in America?
Rachael Sampson, MD: So I think the best thing to talk about, or what I'd like to focus on, is the maternal mortality, because that is, I don't want to say it's an easier concept to wrap your head around, but I like to compare apples to apples.
So when we talk about maternal mortality. This is where I get into the math. So we always base that on the number of maternal deaths per 100,000 live births. And that gets a little confusing because I'm not a math person, but if we look at every 100,000 live births in the United States, we look at the vital statistics, because this is where these numbers are coming from. We translate these definitions to: Looking at every 100,000 live births, how many moms died?
So a lot of what we hear in the news, and what's really concerning, is that in 1990 there were 10 maternal deaths per 100,000 live births. In 2021, there were 32, almost 33 -- 32.9 -- so there were 33 maternal deaths per 100,000 live births. So from a statistics point, that's a huge increase, to go from 10 to 33. And then when you translate that to how many actual moms have died, when we look at 2021, and this was a really big year, a really hallmark statistic, that I think obviously there are a lot of multifactorial reasons, but I think it really changed the momentum in this country, and I think it was really a call to action. Because in 2021, the data that came out, is that 1,205 maternal deaths occurred in the United States, and that's that number that we see in the news, and that's the one where we all stepped back and said, "What is happening? What can we do better?"
Host Amber Smith: Well, do we know why the numbers are going up in America?
Rachael Sampson, MD: So again, it's multifactorial. So I will take a step back and go back to statistics. And there are some parties that say, "Maybe we're better at reporting these. Maybe we're better at looking for them. Maybe we've come so far in the past 10 years, 20 years, 50 years -- right? -- 100 years. Maybe we're in such a better spot than our grandmothers and our great-grandmothers were that maybe we're just watching it better. We know what we're looking at, so we're reporting it. We used to call preeclampsia (a serious condition in a pregnancy) "toxemia of pregnancy." We literally thought there were toxins. There is some element of truth to that, but we know that there's much more to it, right?
Our science has become more refined. Our statistics have become more refined. So there is one party that says, "Well, maybe we're just doing better. And maybe that number is high because we've made that high by finding those." And I'm not discounting that, and I think that gives us hope, but the American College of Obstetricians and Gynecologists (ACOG) and the Safe Motherhood Initiative, which I'm a part of, and which Upstate is a part of, really made a conscious effort and really spoke and said that might be the case.
However, there are obvious disparities that are of critical importance in our country, and we want to make those continued calls to action and not just say, "We read the data wrong, and we overread it.
Host Amber Smith: Well, how does the data in America compare with other parts of the world?
Rachael Sampson, MD: So I'm going to go back to the numbers. When we look at that 100,000 live births, if we take globally, and we lump together a lot of high-income countries -- all comers, high income, you have a certain GDP (gross domestic product) -- these are what your rates were.
And again, these are compiled, once we become worldwide, we have the World Health Organization, the United Nations. The U.N. has different arms of it: There's UNICEF. There's the United Nations Population Fund. They say that there are 12 deaths per 100,000 live births for high-income countries.
So if you look back, we haven't been in that order since 1990, when we had 10. In 2021, we were at 32.9, and in 2020 and 2019 we were around 20, increasing every year, 20.1 and 23. So I look at it as, we went from 10 to 20, and then really quickly from 20, we went to 33, and other countries were reporting on the order of 12.
If you look at countries such as Australia, and these are publicly available data, Australia, Austria, Japan, Spain, high-income countries, very reportable, very transparent statistics, two deaths per 100,000 in 2020, three deaths for one of those countries. So obviously the United States is lagging behind our counterparts.
And then when you look at low-income countries, we're on the order of a hundred, so 430 per 100,000 live births. Huge.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Rachael Sampson. She's completing a fellowship in maternal fetal medicine at Upstate, and we're talking about maternal mortality rates.
You mentioned disparity. Is there a difference among different races of women or different ages of women when you look at maternal mortality?
Rachael Sampson, MD: Something that came from that 2021 data is that the death rate in black moms in that year, in that cohort, was more than 2.5 times that of white and Hispanic mothers.
So that greatest increase rose from 37 to 69.9, so 37 to almost 70 deaths per 100,000 live births in that 2021 cohort of data. That's looking at non-Hispanic white females, with a maternal mortality rate of 26.6, and then higher than Hispanic females, who had a maternal mortality rate of 28.
So that increase from 2015 to 2020 to 2021 really showed that there is a baseline jump, and I guess that's the question: What drove that? And we can get into that, if you're interested.
Host Amber Smith: Well, the pandemic happened during that time, right? At least part of that time. Did that influence the numbers, do you think? Did COVID play a role?
Rachael Sampson, MD: So a lot of interesting data supporting that, that yes, it did. As a physiologist, and as looking at physiology, normal physiology of pregnancy, the pathophysiology of COVID, when you mix those together, that's a perfect storm. Moms were sick. Moms died. And pregnancy, much like obesity, much like pre-existing hypertension, diabetes, is a huge risk factor for severe COVID and death from COVID. So I think COVID did affect that data, those numbers that we're seeing that are coming out from 2021.
We have provisional data from 2023. Again, this data is available, I'd say, on a rolling basis, but really it gets packaged and reviewed by, and again, we can talk about these MMRCs and the national committees.
So when we look at the 2023 data, when we look at that, it does seem like it came down a touch. And that, again, would contribute a little bit more to COVID, but again, we're still higher than other high-income nations. And although the 2023 data seems a little bit more in line with 2018, 2019, 2020, where I kind of said around 20 deaths per 100,000 live births, provisional data for 2023, we have about 19 deaths, maybe 20 deaths. Again, we'll see what the final is on that. I don't want to pinpoint solely COVID, and again, science is not perfect, and teasing that out is never going to be perfect. There are other things going on that are contributing to this.
Host Amber Smith: So what are the leading causes of maternal mortality?
Are all of these women dying in childbirth?
Rachael Sampson, MD: The most common, I will say, it's the postpartum period. And we have to look at it from different, I don't want to say perspectives, but different statistical methods.
So I think as a frontline clinician, as a clinician first, research scientist maybe second, to me, the postpartum period remains the scariest time. A lot of that, I think, comes from having been a general OB-GYN in the community for a long time. I think that patients, once they have the baby, and that's very common, I see that, I see that in my family -- you have the baby, you kind of think you're out of the woods. And I think that's something that OB-GYNs as a group are doing a lot better at: educating patients that the postpartum period is a really scary time.
Childbirth, in and of itself, yes, also a hugely scary time. A lot can go wrong, kind of gets into other things that there are different models for how to deliver, where to deliver. Do you feel comfortable delivering in a hospital? Some patients don't. Some patients prefer to deliver at a birthing center or at home. A lot of that has to be factored in to really get to "Where can we help most?" and "Where can we keep patients the safest?" Or give patients the tools so that if things don't go as planned or aren't safe, "How do we go to the next step?"
Host Amber Smith: The problems that you're talking about that might come up in the postpartum period, are these things unrelated to pregnancy, necessarily?
Are they things that develop during pregnancy?
Rachael Sampson, MD: So a lot of things that develop in pregnancy, a lot of them are related to preexisting conditions. Other times are solely pregnancy conditions.
So a perfect example that I like to use is diabetes in pregnancy. Some patients have an underlying glucose metabolism problem or an underlying metabolic syndrome. So that might affect them in a gynecologic visit. And then with counseling and appropriate intervention, that has been shown to decrease in incidents of gestational (during pregnancy) diabetes or maybe recurrent, preexisting diabetes in interval pregnancies.
So there are factors that are really tied into, again, postpartum diabetes, things like that. That's really not what the issue is, but that increases the risk of hypertension in pregnancy, and if hypertension does not become overt preeclampsia antenatally (before the birth), it's also important to highlight we see that all the time. That's a bread-and-butter to me, postpartum preeclampsia. And every day I diagnose patients with that. I admit them to the hospital, and they shake their head, and they say, "I never thought I could get that postpartum." And I think that's something that, we're working on, really highlighting that things can happen, but again, without scaring patients. And that's an important caveat of everything.
Host Amber Smith: So how many of these deaths do you think are preventable?
Rachael Sampson, MD: Eighty percent of these deaths are preventable, and the corollary of that is that 20%, only 20%, are truly not preventable.
So I think when we talk about preventability, that's something that is really looking at, was there at least some chance of the death being prevented by one or more reasonable changes to the patient, the family, the provider, the facility, the system or community factors?
And this is the definition that maternal mortality review committees use to determine if a death is preventable. So there's two questions. The first is, yes/no -- was this preventable? But the second is determining the chance to alter that outcome on a scale, no chance that this could have been altered, some chance or a good chance of changing that.
When we look at that 80% of 1,205 deaths, over 900 deaths that could have been preventable.
Host Amber Smith: Upstate's "HealthLink on Air" has to take a short break. Please stay tuned for more about maternal mortality rates.
Welcome back to Upstate's "HealthLink on Air." I'm your host, Amber Smith.
My guest is Dr. Rachael Sampson, who is completing a fellowship in maternal fetal medicine at Upstate, and she's been telling us about increasing rates of maternal mortality.
Host Amber Smith: So where are these maternal mortality review committees?
Rachael Sampson, MD: So these are state initiatives, or state led, and they are multidisciplinary. So what's wonderful about these is New York state, we have New Jersey, Pennsylvania, all places where I have practiced with ACOG.
And they're not just OB-GYNs. They're pathologists, because we're talking about autopsies. They are social workers. They are internal medicine doctors, cardiologists; they are community advocates. So it's really a multidisciplinary team that comes together in order to look at these causes in order to say, "Is there anything that could have prevented this?"
And/or "If the patient was not pregnant, would this have happened?"
And I think that's a really important clinical framework in order to frame it as an OB-GYN, because unfortunately in medicine, you can't control everything. And I think in obstetrics and gynecology, when you're dealing with two lives, and that perfect storm happens, that's really how you move it forward and how you make sure that you're doing right.
Host Amber Smith: The increase, these numbers that have gone up so much, it seems like really it's a crisis. What message do you have to health care providers? What do they need to know to catch these deaths and prevent them before they happen?
Rachael Sampson, MD: There's a lot. I think something that is kind of at the highlight of my list, just thinking offhand, is looking at implicit bias, looking at systemic and structural racism. I think that's a component that really has grown out of the past few years that I think was never part of our obstetric curriculum. That was never a consideration. I think that's something that, every day, physicians, not just OB-GYNs, but physicians, really need to look at when they are talking about mortality, morbidity (disease) and mortality, in medicine. So I really think that's a really important one that's always at the front of my team's thought process, that when we talk about these numbers, we keep in mind that disparity and that that disparity persists -- socioeconomic, education factors, so behind all of those, we still have that.
Another thing, you're individualizing it, which is so important, precision medicine and individualizing it, but also the use of a bundle (guidelines to improve patient care) and checklists. And I think that those have a place, and I definitely appreciate those, and I do believe that there's high-quality evidence that says the use of a patient safety checklist and the use of a bundle does promote better outcomes because you have everybody on the same page running through the same things, and things aren't going to get missed or lost. What I sometimes worry about with the use of that is, are we putting a blanket over all patients, and is there more trouble coming from that?
So it's such a tough yin-yang to, go back and forth on that, but I think that keeping those in mind, we have, a lot of resources in place for maternal hemorrhage. We have a lot of resources in place for maternal hypertensive crisis. We have a lot of resources in place for venous thromboembolism, and that's pulmonary embolism, clots, related to pregnancy, because pregnancy is a hypercoagulable state (where bloods tends to clot easily).
We're becoming better, and we're putting more resources together for maternal mental health, which has also skyrocketed. That's something I didn't touch upon as of yet, but, again, from a medical point of view, I think doctors are very good at seeing a high blood pressure and knowing what to do. It's a lot harder for us with those less tangible signs and symptoms. And maternal mental health has really exploded and is a crisis, and that the mortality rates from that, again, were we not reporting them before? Were we not cued into them? Have they always been there? I don't know.
But the very fact that we talk about them now, and we see how high they are and that they're higher than other groups, other categories of death. When you have a point where sepsis (serious condition in reaction to infection or injury), it used to be called sepsis of childbirth, sepsis is still a concern, but less than maternal mental health and death from that, in a lot of cohorts, a lot of studies, that's really concerning.
Host Amber Smith: Is there anything that pregnant women or new moms need to keep in mind?
Rachael Sampson, MD: I think, again, I never want to scare patients. That's definitely not where I'm coming from, but to advocate for yourself and to keep advocating and do what you have to do to be heard. And if you don't feel well, make that known.
And if you still don't feel well, make it known even more and just persist because you know your body, and you know your body best. I just always want that. I want every patient to be heard.
Host Amber Smith: I think, like you said before, though, the tendency is, once you have the baby, and you're bringing the baby home, you think that's over, like that's in the past, the risks associated with being pregnant and delivering are over. But if that's not the case, especially with new moms that maybe don't know what to expect, it's a huge change.
Rachael Sampson, MD: It's huge. I think another really important change, or practice pattern, in the past, I'd say 10 years, is bringing patients back sooner.
I remember 10 years ago, 15 years ago, in medical school or pre-med, and you had a baby, and I remember the doctor saying, "I'll see you in six weeks." Didn't matter if you had a C-section, didn't matter if you had a vaginal birth. You went home for six weeks, and then you didn't go back to the doctor for six weeks because the doctor told you, "I won't see you for six weeks. I don't have to see you for six weeks." And now, when I was in practice, it was, "I'll see you in two weeks. That was very, very routine, and again, every practitioner has their different style. I said, "I'll see you in a week," or "Come see me. You will leave the hospital on Monday, Tuesday; come see me before the weekend. Come see me Thursday, Friday."
And again, traditionally patients said, "Well, is there something wrong with me? What's not right?" Even that awareness, I think, is helpful.
And I think that, again, if it's making it safer for us to have babies than it was for our grandmothers, I think that's fantastic.
Host Amber Smith: So when a new mom gets home with the baby, family and friends love to come over and see the baby, but is there something those people can do to help the mom or to be more aware of what might be going on with her?
Rachael Sampson, MD: I love that question. I think that any family support, just being there listening, and then I think, again, I use this word "checklist," but the blood pressure is ubiquitous in my world, and technology and devices have become so amazing, we can send patients home with these small blood pressure cuffs and just take the blood pressure. So my mom comes over, first thing she does is take my blood pressure. Then she looks and says how cute the baby is. Little things like that, it's little anecdotes that really make kind of a family checklist that, of course, the baby's here, and this is amazing, but how's mom? Let's check in and make sure that's not lost.
Host Amber Smith: Well, Dr. Sampson, thank you so much for making time to talk to us about maternal mortality.
Rachael Sampson, MD: Thank you for having me.
Host Amber Smith: My guest has been Dr. Rachael Sampson. She's completing a fellowship in maternal fetal medicine at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
Upstate being the first co-ed medical school may attract women for training -- Next on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
More than half of medical students in the United States are female, which helps increase the number of female physicians practicing medicine. But the medical specialty where women remain significantly underrepresented is neurosurgery.
Today I'll be talking about the reasons for that, and the efforts that Upstate has made to improve that, with Dr. Larry Chin. He's a neurosurgeon and dean of the Norton College of Medicine at Upstate.
Welcome to "HealthLink on Air," Dr. Chin.
Dean Larry Chin, MD: Well, thank you for having me, Amber.
Host Amber Smith: Now, the neurosurgery program at Upstate comes out at the top of a survey of leading medical schools for female neurosurgeons, in a recent paper in the Journal of Neurosurgery. So I wanted to ask you about that. Can you describe what the authors of this paper looked at?
Dean Larry Chin, MD: Sure. So the paper that we're talking about was published in the Journal of Neurosurgery, and the title is "Leading Medical Schools for Female Neurosurgery Graduates," and it comes out of the University of Illinois at Chicago. And what the authors did was, they identified from a national physician database all of the practicing doctors who list neurosurgery as their specialty.
And then they looked at the education, the medical school education. So it's not actually looking at the residency training program, but the medical school from which they graduated, and then they looked at the schools and the total number of neurosurgeons and how many were male and how many were female.
And then they also looked at the proportion of the total number of neurosurgeons that they graduated and what percentage were women or men. And it was in this last category, the proportion of female neurosurgeons, where SUNY Upstate did quite well.
And specifically what we're looking at is the schools that had the highest proportion of female neurosurgery graduates, and there were two at the top, and that was at 25%. The two schools were University of California at San Diego, and the other school is State University of New York Upstate Medical University. And I'm quite proud of that.
Host Amber Smith: Well, let's talk about what a neurosurgery residency includes, because this happens after medical school, right?
Dean Larry Chin, MD: That's right. You graduate from medical school, and then the next step to becoming a practicing neurosurgeon is to do a residency. And residencies in the past have varied in number of years, but for the last 30, 40 years, it has been either six or seven years. And in the last 10 years or so, it's become standardized where it takes seven years of training after graduation from medical school. So we call it postgraduate training, or graduate medical education.
And that's a minimum of seven years, although many neurosurgery residents, after they graduate from residency, will do an additional fellowship that may last one to even up to three years. So you could conceivably be in training for nine or 10 years before you actually become a practicing neurosurgeon.
And just for context in the study, I should add that they identified a total of almost 3,500 neurosurgeons in this national physician database. And 91% were male, and 9% were female.
Host Amber Smith: So that's 3,500 practicing neurosurgeons in the United States. Is that enough, or do you think that we need more neurosurgeons?
Dean Larry Chin, MD: Well, like some specialties, some super-specialized areas of medicine, in addition to probably not enough specialists, there's also a geographic inequality. So, as you might expect, large urban areas certainly have enough, or maybe in some cases too many, neurosurgeons. And then you could go to vast areas of the country, and I would consider Central New York one of those areas, where there are very few neurosurgeons relative to the geographic area and also available for what amounts to a largely rural population. So the absolute number of neurosurgeons is probably not so far off, but the distribution is not even.
Now, neurosurgeons are very specialized. If you look at other fields, for instance, family medicine or pediatrics, there is just an absolute shortage.
So in general, there's a shortage of doctors available, but the greatest areas are the primary care specialties.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Larry Chin. He's dean of the Norton College of Medicine at Upstate and a professor of neurosurgery.
In the paper from the Journal of Neurosurgery, the raw numbers of female neurosurgeons are bigger from the bigger schools like Yale and Stanford, but if you look at the proportion of female to male neurosurgery graduates, like you said, Upstate and the University of California at San Diego come out at, like, 25%. So at Upstate, four of the 16 practicing neurosurgeons were women, and I believe you were the chair of the (neurosurgery) department at the time period they were looking at.
What was done at Upstate to attract women to neurosurgery?
Dean Larry Chin, MD: Well, I can't take all of the credit, that is for sure. I came to Upstate in 2011, and I was chair of neurosurgery until 2019. And the study actually stopped collecting data at ... I think the last year was 2014.
And there are some reasons, the main one being that it takes time to train. So if you started training in 2014, you might not be in practice yet. So they didn't collect data after 2014, so that that wasn't going to affect the numbers. But yeah, I think that it's fantastic that Upstate has this legacy of training, I guess you would say, a disproportionate share of women in neurosurgery.
What did we do different, or what has been done differently in the past? I think that Upstate really has a tradition of being champions of equality. Some of the listeners may know that Upstate graduated the first woman who was granted an MD degree in the U.S., and that, of course, was Elizabeth Blackwell, and that was in 1849.
We have a very long tradition of really paying attention to that. Sarah Loguen Fraser was one of the first black women educated and graduated as an MD in the U.S. So there's this great history.
We've had more recent role models and mentors: Dr. Pat Numann, who was head of the American College of Surgeons and one of the founders of Association of Women Surgeons, I think has been a great role model for women in surgery. And she continues to be affiliated with the medical school, and, I think, is just a wonderful person for really all students to look up to.
And I think that Upstate has been a place where paying attention to things like equality and having women have the access and the mentoring and the encouragement to go into specialties where traditionally they've been underrepresented, it's just something that we pay attention to.
Host Amber Smith: Is it true that more women than men apply to and are accepted into medical school these days?
Dean Larry Chin, MD: Oh, absolutely. If you look at our recent classes, anywhere from 55%, 56%, I think we've had a class as high as in the low 60% (range), are women. and that is a trend that exists across the country. And so, more women apply than men, and more women get accepted than men.
And so it's really changed, I think, how a lot of people perceive what a doctor is and what a doctor looks like. For me, there's nothing but good that comes from that.
Host Amber Smith: So what do you think it is about the specialty of neurosurgery that in general tends to attract more men than women?
Dean Larry Chin, MD: That is something that people have thought about and even written about. For the last 10, 15 years, we've been trying to understand that. And it's not just neurosurgery. So in fact, the specialty that has the lowest percentage of women is orthopedic surgery. If you look nationally, women, in terms of practicing orthopedic surgeons, probably a little over 5%.
For neurosurgeons, you'll see numbers that range from 7% to 9%, depending on the study that you look at. So orthopedic surgery, neurosurgery, another area is interventional radiology, also very low numbers of women. Interventional cardiology and many of the cardiac-related fields traditionally do not have a lot of women.
And so, what are the reasons? There are many. First of all, there is, I would say, this longstanding perception for certain fields, maybe it's a stereotype that has been wrongly passed down, but that the field is somehow more optimally suited for men. And I think that is a myth that has been long dispelled. But somehow, some things, the perceptions don't change. And that's why we see specialties like orthopedic surgery and neurosurgery not have enough women in the field.
But then there are more tangible reasons. I think that if you survey medical students, there are still people that would look at, "Well, what's the flexibility in this specialty, with regards to parental leave or the ability to have a family?" And that is something that weighs more on the minds of some women that are in medicine, and that has been cited as a reason.
I think that we have to be honest and still say that women still, even in this day and age, face, if not overt but subtle forms of harassment, especially in certain surgical fields. And I think that that is something that creates a negative environment for women.
There are issues related to salary inequality and other minor things that can influence how people feel about, "Do I feel welcome in this specialty group?" And then, traditionally, if there aren't as many women in a field, and there aren't as many role models and mentors, that will influence the numbers of students that would be interested and feel like, "Well, I can see myself being a neurosurgeon or an orthopedic surgeon."
Host Amber Smith: So there must be specialties that have more women in them.
Dean Larry Chin, MD: Oh, absolutely. Certainly the one that has the most women is OB-GYN (obstetrics and gynecology), where the vast majority -- I've seen one study that well over 80% of the specialists in that field are women, but certainly the pediatric specialties oftentimes are very much heavily weighted to more women in those fields.
Host Amber Smith: So let me ask you, is the profession of medicine striving to mirror the diversity of the population? Are you trying to have an equal number of women as men neurosurgeons and pediatricians or not?
Dean Larry Chin, MD: Well, I think in general, yes, we would love to see the proportions of medical students in general mirror the population. But I don't think that is everything. For instance, if you look at the numbers of black and brown physicians, if you just mirror the population, it would still take a long time for the practicing pool to catch up with what the population looks like.
Same thing with women. If we continue our trend, which is if you look at the number of residents, so the people in training who are women, it's much higher than the number that are in practice. So if, let's say the number is there are 9% practicing neurosurgeons are women. The number of neurosurgery residents who are in training that are women is much higher. It's almost 20%. But that gap is still going to take a long time to close if you want to have basically 50% of each, men and women, in neurosurgery. So it would take still a long time to catch up.
So I think that, while yes, we want to mirror the population, I think we also have to be mindful of the fact that there were many, many years of inequality, not only in neurosurgery, but other fields, and inequalities in terms of women and men, but also of other groups.
Host Amber Smith: As dean, how do you assess whether someone who applies to attend medical school will make a good doctor?
Dean Larry Chin, MD: We have a whole team that is specialized in doing that. As dean of the school, I actually do not directly get involved with the admissions process. We have a dean of admissions, Dean ( Robert) Ruiz, who does an outstanding job, and there is a committee dedicated to reviewing students and their applications, and they do a fantastic job. I think our medical school classes are not only diverse, but the students themselves are outstanding, and they're contributors to their community.
And so what I tell our admissions committee is, I want the best students because I think that our patients and our community deserve the best and the brightest taking care of them. But I want our students to be diverse because they can learn from each other, and the diversity makes the education better, and that helps everybody grow. And it improves our health care. And so, we really look at all factors. and I think that from that diversity, that's what helps the education to turn really these outstanding students into outstanding doctors.
Host Amber Smith: As a neurosurgeon yourself, is the field of neurosurgery today something that you would recommend a new doctor go into?
Dean Larry Chin, MD: Oh, absolutely. I think that it is not only extremely interesting and challenging, and if the technical aspects, and especially operating, appeal to a student, then for me, I can't think of a more rewarding field. Now, I think that every single field in medicine has all of those attributes, and there's the right student for each of those fields. And so I don't think that being a neurosurgeon is any more special than any other field, but for me personally, I love what I do. And the people that I see going to the specialty, they love it as well.
Host Amber Smith: Let me ask you, though: The seven-year residency -- why is it so long? Are they doing the same things over and over, or are they doing that many different things that it takes that long to fit it all in?
Dean Larry Chin, MD: Yeah, that's a great question, and actually, one of the things that is thought about in terms of, well, do you really need seven years to be a neurosurgeon? And with the shortages of various specialties, does it make sense to try to train people quicker and get them into practice sooner?
I think that if you look at the field, and you look at the very large variety of things that neurosurgeons do, I think the seven years is justified, because a neurosurgeon isn't just operating on the brain. You're also operating on the spine and also on everywhere the nerves go in your body. So it is a very large number of different kinds of operations, ranging from techniques where you're putting screws into the bones of the spine to doing delicate surgery on the brain under an operating microscope, and so just the tremendous variety of different types of surgery.
And then, you touched on it, there's a lot of practice involved, and I think that we want to make sure that we're training the best neurosurgeons and that when people go out, they're not only competent, but they're safe. And I think that that takes time. So while seven years or eight or nine seem like a lot, I think that it takes that long to properly train someone.
Host Amber Smith: Dr. Chin, thank you so much for taking time to tell us about this.
Dean Larry Chin, MD: Well, it's wonderful to be here, and thank you for inviting me.
Host Amber Smith: My guest has been Dr. Larry Chin, the dean of Upstate's Norton College of Medicine and a professor of neurosurgery at Upstate.
I'm Amber Smith for Upstate's "HealthLink on Air."
Here's some expert advice from Dr. Sharon Brangman, chief of geriatrics at Upstate Medical University. How do you advise adult children when it's time to take the car keys away from a parent?
Sharon Brangman, MD: Well, this is one of the toughest things that we deal with in geriatrics. There is no set age when somebody should stop driving. This is a very individual thing. We should not have a one-size-fits-all. The aging process, in and of itself, can make driving more risky. For example, someone could have arthritis in their neck, and they can't turn their head to look over their shoulder when they're changing lanes, or they may have a weakness in their legs that could keep them from pressing down hard on the brakes. There are also vision problems that occur, or hearing problems that can make it difficult to drive. And of course, if you have any kind of memory problem that impacts your ability to make decisions or have appropriate reactions when you're driving, that could be another red flag.
So what we usually tell adult children is that they have to have a plan. You can't just do this overnight. You have to look and see how you are going to supplement the driving needs of their parents, for example, when they have to stop driving. And we live in a society, and especially in our city, we don't have a very walkable city, and most of our services are out in the suburbs. So when you stop someone from driving, you can cut them off from everything from groceries to the pharmacy, to going to church and socializing. So you have to have a plan. You have to have a process so that you can figure out who's going to fill in those gaps. A lot of adult children feel ambivalent because they can't do it, but we now have lots of driving services, and there are actually people who do this now as a living, who can come and help drive. And yes, you may have to give up some of your spontaneous ability to come and go, but you can still be able to get the things you need appropriately, if you don't have a car yourself.
And we always want to stop before there's a terrible accident. And I don't have a crystal ball to predict when that might happen for any one person, but we don't want to wait for someone to get hurt before we make that decision. And that's the part that gets tricky because again, that's a very individual thing.
There are driving evaluation programs that can be helpful, where an older adult can go and get a driving test by someone objective to just see how they are behind the wheel, and if there's any adaptations that might be helpful or anything that can be done to help them stay on the road safely. We have some patients who stopped driving at night, or they don't drive during the busiest times of the day when the roads are quieter, and that's sometimes is an adaptation that works. But unfortunately, there does come a time when it is time to hang up the car keys to keep you safe and to keep others safe, as well.
Host Amber Smith: You've been listening to Dr. Sharon Brangman, chief of geriatrics at Upstate Medical University.
And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: Poets have a way of finding the truth of an experience, even in the seemingly quiet, undramatic moments of illness. Mary Beth O'Connor from Ithaca, New York, recalls the moments of sitting vigil with a friend who can no longer communicate in her beautiful poem "what is time to her?"
time that passes so slow
for us visitors
reading to her, holding
her hand, longing for her
to open her eyes,
to smile at us, trying
to coax her back ...
maybe all those months
seemingly sleeping, she's been
busy beyond interruption
weaving a shroud
like in the fairy tale
getting ready
the way creatures
know how to prepare
nests, store black walnuts
learn to fly ...
and we, so well-meaning
and bereft, cannot seem
to just let her
David Dixon is a physician and poet from North Carolina who describes the ache of sitting with a parent who is slowly dying, in his poem 'Still Life with Dad and Shade Tree."
After he's gone, what is it we keep?
What is it we scoop and carry like apples
in apron folds
clutched tightly to a chest?
And where would we even store
such a harvest? For surely
it's written somewhere that
both the plucked and the fallen
are gathered, one bushel at the time,
then taken to the same prepared places
of light and laughter. Sorted by size,
separate from the rotten fruit
so they don't spoil the lot,
hidden in cool cellars.
Such a tasty, sweet metaphor for memory,
is what I think,
even as there is still an answer on the phone,
still the welcome of your crooked hug
in the doorway,
still no idea what I'm missing:
no better than half-a-peck
of pretense,
trying to write this poem
as we sit here together.
Waiting.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.
Next week on "HealthLink on Air," all about rheumatoid arthritis.
If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.
Upstate's "HealthLink on Air"produced by Jim Howe, with sound engineering by Bill Broeckel.
This is your host, Amber Smith, thanking you for listening.