The Society of University Surgeons (SUS) has awarded Carla Pugh, MD, PhD, Thomas Krummel Professor of Surgery at Stanford Medicine and Director of the Technology Enabled Clinical Improvement (T.E.C.I.) Center, the 2023 SUS Trailblazer Award. Dr. Pugh will be presented with the Trailblazer Award by SUS President Dr. Timothy Donahue on Tuesday, February 6, 2024, at the 19th Annual Academic Surgical Congress (ASC) in Washington, DC.
The SUS created the Trailblazer Award in 2020. This award recognizes individuals who have developed a new area of academic pursuit or opened new avenues of investigation or academic thought that have the potential to be groundbreaking for years to come. The “trailblazing” contributions of the nominee are broadly interpreted and are not limited to traditional surgical science. Nominations should specify how this individual has created a new and sustained domain of scholarship or knowledge. The SUS seeks to honor and recognize these individuals because of their embodiment of the principles of the Society and to establish role models for future generations of surgeons to honor and emulate their contributions to the science of surgery. Past winners include George Yang, MD, PhD in 2020, Julie A. Freischlag, MD, FACS, FRCSEd (Hon), DFSVS in 2021, and Robert S.D. Higgins, MD, MSHA in 2022.
Dr. Pugh was nominated by her peers and selected as the recipient by the present and past leadership of the SUS. Her groundbreaking work on sensors, motion tracking, and simulation to quantify surgical performance aligns perfectly with the intent of the award. The SUS was also impressed with Dr. Pugh’s dedication to training learners at all levels, prioritization of health equity, and her prominent roles in several societies in academic surgery.
That Was Medicine
At age five, Dr. Pugh knew that she wanted to be a doctor. Both her mom and dad were born in the rural south. Dr. Pugh explained, “If you were born in the rural south 80 years ago the probability of being born at home by a midwife was 90-100%.” Her family would tell her stories of the amazing women, her mom’s aunt, and dad’s grandmother, who managed her parent’s deliveries at home. These two women were not only midwives but also veterinarians, who cared for all the farm animals.
As a child, Dr. Pugh believed these women were physicians, explaining, “I’m five and I’m hearing they both had lots of tools, and were not afraid of blood and I’m thinking, wow…that’s me! Every year I would hear amazing stories about them from both sides of my family. I was just enamored.” Her mom bought her a stethoscope when she was six years old, and the family lore is of Dr. Pugh listening to people’s ankles in the grocery store. She stated, “In my mind, that was medicine – helping everyone, everywhere. All my subsequent experiences just reinforced that interest.” By 9th grade, she decided she was going to be a surgeon, after taking an advanced science class and watching a documentary about Dr. Paul Tessier, commonly known as the father of craniofacial reconstructive surgery.
Dr. Pugh and her dad and mom at her graduation from the University of California Berkeley.
A Love Affair with Anatomy
By the time she got to her 2nd year of residency, she started to realize that she had a general love of human anatomy and the surgical treatment of organ-based disease. She realized that although she loved craniofacial anatomy and thought it was intriguing, if she became a craniofacial reconstructive surgeon, she would not operate in the abdomen or the chest. Dr. Pugh could not see herself never operating on the heart, liver, and intestines and this resulted in a painful breakup with her “love affair” of craniofacial anatomy and reconstructive surgery. She spoke to her mentors at the time who were plastic and reconstructive surgeons, and it was a difficult decision, but she said, “I am one of those surgeons who’s in it for the anatomy. I was fascinated by the human body then and I still am. It amazes me and it is super exciting. Ironically, when I was finishing my residency, general surgery was still a specialty. It was notable that every year an increasing number of chief residents were doing fellowships, but I trained under surgeons who were global oncologists, and one day they were doing an APR and the next day they were doing a parotid. There was no colorectal, there was no endocrine surgery, that didn’t exist when I was a resident. That’s when I veered towards staying in general surgery with a focus on education – my other passion.”
That Was the Moment for Me
Dr. Pugh is an internationally recognized expert in the use of simulation, advanced engineering technologies, and artificial intelligence to develop new approaches for assessing and defining mastery in clinical procedural skills. She is also a leading international expert on the use of sensors and motion tracking technologies for performance measurement.
Dr. Pugh was the first surgeon in the U.S. to get a PhD in education. This stemmed from her interest in anatomy. Once she became a resident, and even as a medical student, she looked at anatomy textbooks and wanted real time access to detailed information. When she was in medical school and residency, Google didn’t exist, it was just textbooks. Dr. Pugh would spend time in the library trying to get more detailed information about human anatomy and surgical tools and found it frustrating. She shared: “I didn’t realize until later that I was a visual learner. You could be reading a textbook about a specific surgical procedure, and they would name an instrument, but they didn’t show a picture of the instrument. That was unforgivable for me. I wanted all the information immediately available. When they had a pilot with a computer-based assessment with the National Board of Medical Examiners at our medical school, that was the moment of my first education-related epiphany. I was thinking, there it is, all the information in one place.” She further explained, “All of the information I was trying to find at 2AM in the library, looking through hordes and hordes of books to try and find a picture of something, all of this could and should be on the computer. This was my dream and vision, 30 years ago.”
Dr. Pugh would photocopy textbook images to make visual manuals of operations and anatomy, and everyone wanted them. She explained, “That gave me inspiration and encouragement that what I wanted, other people wanted. They would say, you just explained something that I never understood, and people wanted me to tutor them. They wanted to buy my notes, they wanted me to publish manuals. That gave me a sense that there was a need and that I had a purpose. This is when I knew that I wanted to be an academic surgeon. I also knew that there was going to be a second, complimentary component to my surgical career. This was a continuous conversation in my head. So, during the last two years of medical school through the first two years of residency, there was an intense focus on career planning, and exploration.” Dr. Pugh wondered if she needed additional training and if so, who should she partner with that had the same passion and desire. The Chair of Surgery for her residency program, Dr. LaSalle Leffall, told her to meet two people and he wrote letters to both of them. One was Dr. John Skandalakis at Emory, who was often referred to as the father of surgical anatomy. The other surgeon was Dr. Robert Chase at Stanford, who had an NIH grant and was building a library of 3-D surgical anatomy and putting it on computers. As Dr. Pugh was born and raised in California, when she came home from residency for the holidays, she would make time to meet with Dr. Bob Chase to strategize how to build the complimentary part of her surgical career that would focus on anatomy, computers and education.
Her residency program at Howard allowed Residents to take two years off for professional development or research so Dr. Pugh was initially planning to write grants with Dr. Chase to fund two years of research with him and then go back to Howard to finish residency. Just before they finalized the grant writing plan, Dr. Chase had a new revelation noting that what Dr. Pugh wanted to do was so unique and different that she needed “bigger” credentials. That was the moment they changed directions and Dr. Pugh started looking at PhD programs.
They initially investigated a PhD in computer science but as they looked at the classes, most were mathematics and didn’t quite fit what they were looking for. During one of the planning discussions, one of Dr. Chase’s colleagues commented, “what you are really interested in is education.” And that was it-that was the moment that began her journey to obtain a PhD in education.
Dr. Pugh’s foundational mentors in surgical education, anatomy and innovation: Dr. LaSalle Leffall, Dr. John Skandalakis, Dr. Robert Chase, and Dr. Thomas Krummel.
The Data Frenzy
In 1997, as part of a graduate school human computer interactions course, Dr. Pugh built her first sensor-enabled simulator. One year later, the simulator was implemented in the medical school curriculum at Stanford for first year students. She also used the simulator for her dissertation by collecting sensor data and comparing palpation forces used by medical students compared to practicing physicians during a simulated pelvic exam. The data frenzy and interest took off from there. Dr. Pugh stated, “Once people hear you are doing something interesting or getting data no one has seen before, they start to invite you to give talks. I became popular with the engineers and computer scientists, and with medical education groups.” Dr. Pugh explains that while she was taking a deep dive into the sensor data, she was also immersed in her graduate school courses, “In parallel to all of this, I was gaining foundational knowledge in pedagogy, learning theories and policy and it was both exciting and humbling to learn, at a systems level, that the major variables of importance (finances, policy and governance structure of the education system) for K-5 was similar for surgical education and training. I also learned classic education history. For example, I learned about The Committee of Ten, who decided what was in the curriculum, how to deliver content and education, how to train teachers, how to create and schedule the process of knowledge delivery. What this group did for high schools was somewhat parallel to what Halsted did for surgical training, transitioning from an unstructured apprenticeship model to a structured model of rotations, learning and assessment-that whole history was mind blowing.” Dr. Pugh learned from education professors at Stanford who were “ridiculously famous” people in education and she explained that it’s only now that she appreciates their impact in the field. Dr. Pugh found the doctoral experience amazing and life changing and was comforted to know that if she was going “off the beaten path” to do this, that she was happy in her choice. Both the educators and engineers validated her passion for surgical education and innovation and gave a unique perspective for understanding medical and surgical education research and innovation from a leadership and systems level. Dr. Pugh also felt that her entire doctoral experience gave her the tools of the trade and quantitative proof that there was something reoccurring and scientific about what surgeons do with their hands. The theoretical underpinnings in the school of education and the quantitative foundations in the school of engineering were highly complementary. Dr. Pugh stated, “it was just fascinating, and it was encouraging and foundational in terms of my knowledge and understanding of what could be with respect to surgical training and education.”
I Had a Village
Dr. Pugh completed medical school, surgery internship and residency at Howard University, and a PhD at Stanford University. When asked about her mentors, Dr. Pugh said, “I had a village. What I wanted to do was off the beaten path so there wasn’t just one person who had done it before and had all the answers. Most of my mentors were Society based.” Dr. Claude Organ became an early mentor through the Society of Black Academic Surgeons (SBAS) when she was a medical student. She stated, “It was especially meaningful that someone of his stature would take the time to mentor a student.” The annual SBAS meeting was full of highly visible senior mentors that were very hands-on including but not limited to Eddie Hoover, Rosalyn Scott, Haile Debas and LD Britt. Their mentorship and sponsorship provided a strong foundation for her career success. She also stated, “The peer mentors from this organization are an immeasurable source of strength and support. Their impact on my career and my personal growth as a leader, mentor and influencer is irreplicable and greatly appreciated. I cannot thank my SBAS colleagues enough.”
Dr. Pugh was inspired by Dr. Numann and her ingenuity and passion around forming the AWS and bringing women together. Other mentors and strong supporters in the AWS included but are not limited to Drs. Julie Freischlag, Diana Farmer, Leigh Neumayer and Nancy Gantt. Dr. Pugh was grateful: “Even though they were very visible and in high demand, they were all a phone call away.” She noted that they helped her multiple times along the way, in terms of questions she had about her career trajectory, career moves and advancement, and contract negotiations.
After beginning her PhD at Stanford, Dr. Thomas Krummel became a key mentor. He was the one who really gave her permission to have a career as a surgical innovator. He was holistic in his support of her career. He helped with presentations, technology demonstrations, abstracts and papers. Dr. Pugh is now the inaugural Thomas Krummel Professor of Surgery at Stanford.
On the grants and research side, Dr. Melina Kibbe was a critically important peer mentor. Dr. Pugh recalls her time at Northwestern, “Melina knew her way around the NIH and was very successful. Everything she learned she generously shared. When I think about my pathway to obtaining my first RO1, I have many memories of her feedback on how to write a perfect story, set up outside readers and address missing links in the impact and innovation sections.” Years later, similar to Dr. Kibbe, Dr. Pugh was awarded the Presidential Early Career Award for Scientists and Engineers (PECASE) award.
The Best Strategy is One That Comes From a Village of Mentors
For mid-career surgeons, a frequent topic of conversation is the benefit of staying at an institution and the complexities of deciding when to stay or leave. From Dr. Pugh’s perspective, she said that she looks at it as a decision tree. The first question to address is whether there are major deficiencies in leadership support relating to your specific idea of success. Faculty should only leave when there is major misalignment across multiple areas, she explained, “The reason I say this is because there is no perfect job. The main reason for you to take a job is to learn about yourself. In general, it is better to stay and work through whatever problem you have. Those problem-solving skills will benefit you throughout your career.” Dr. Pugh stated that her biggest epiphany when faced with leaving an institution, came while she was on the phone with a mentor who said, “There are two, very different scenarios here. For one of the packages, the school and institution have already decided your area of interest is a priority, there is a budget, there is a building or a center going up and now they are looking for someone to lead it. This is a very different opportunity than negotiating with the Chair of Surgery for something YOU want to build. There are pros and cons to both. In the end, you must clearly map out what you want, when you want it and why. Which of your career and relationship goals are not being met or can be greatly expanded?” Dr. Pugh argued that this is where society-based peer mentors come in. Because there are so many personal variables in these decisions, it is beneficial to discreetly ask more than one colleague for their take on the situation. Dr. Pugh felt it is best to have a holistic strategy around major career decisions, and the best strategy comes from a village of mentors.
Constantly Reinventing the Space
As the Vice Chair of Innovation and the Director of the Technology Enabled Clinical Improvement (T.E.C.I.) Center, Dr. Pugh has faced some unique challenges. Being in a space of innovation oftentimes means having a multi-disciplinary team. As the Vice Chair of Innovation, this means there are surgeons of all different specialties and different areas of innovation. Dr. Pugh stated that, “The unique challenge is to constantly foster and reinvent the collaboration workflow and the opportunity for innovation. Innovation happens on a platform that enables people to have permission to come up with their wildest ideas and not be judged. There must be a creative and safe place to cultivate new ideas. This is the same for my research team. I have computer scientists, electrical engineers, education specialists, people at various stages in their life and careers, with completely different professional backgrounds, so it’s about creating a safe space where everyone is valued, and they have the freedom and trust to bring up far reaching ideas and ask any questions.”
Understanding the Surgical Leadership and Networking Workflow
Dr. Pugh has served as the President of the Society of Black Academic Surgeons, Council Member of the ABS, AAS Liaison to the AWS, SUS AAMC-CFAS Liaison, ACS Recorder for the AEI Institutes, and SAGES Executive Board Member to name a few of the leadership positions she has held in professional associations and societies. It’s important to participate in societies because it is as the saying goes, birds of a feather flock together. If you want to be a leader in American Surgery, you must spend time with other leaders. Dr. Pugh said, “There are so many people I have met, admired, and learned from in society leadership. It is that group that provides peer mentoring and inspires you with their personal stories and leadership style.”
She recounted that Dr. L.D. Britt called her one day when she was an Assistant Professor at Northwestern and asked why she was not participating in the ASC meeting. She admitted she had not heard of the ASC. A week later, Dr. Kibbe asked her to be Northwestern’s institutional representative for AAS. Soon after, she co-chaired the AAS Education Committee and partnered with the SUS Education Chair on the Education Plenary session for ASC. That is how her relationship with AAS and SUS began. In looking back at the ASC, she recalled, “those were fun times. Networking, CV building, learning how to lead, run a meeting, get a session on the program, get buy in, and be flexible in your expectation or agenda so that you get to success. Amazing leaders have come through the SUS, there’s no question about it, and if you want to have top notch leadership skills in surgery, you miss out if you don’t sit in on the Executive Council meeting with SUS leaders. It’s been years since I sat in that room, but I remember several things that I’ve learned from key leaders in the SUS.”
The Tipping Point
It is said that many academic surgeons deal with a “mid-career” crisis, and Dr. Pugh was asked for her thoughts on this. She joked that she may have been watching too many mindfulness YouTube videos lately but that she felt that being mid-career was such a grounding, challenging and interesting place all at once, adding, “Mid-career surgeons have lots of experience on the CV building side, they have clinical experience, and are at this tipping point where they are switching from the pressure of being successful, to what legacy they want to leave and what’s the best platform for that legacy to grow.” She further explained that, “You may be in a place where you have found complete happiness in curing cancer one patient at a time, or you may be completely disrupted by a newfound expectation and goal that you want to achieve above and beyond what you are doing right now. This is the time to take a leadership course! There are a lot of leadership courses, some that can help you define and get to the next phase of your career, and there are some that are more holistic. One course that I recently took in the business school at Stanford was an Interpersonal Dynamics Course. I was blown away. The course focused on learning about your unique contributions in the interpersonal arena and how you can use your gifts to set others up for success. This course helped me to recognize that part of the mid-career crisis is realizing that your clinical acumen and research achievements are only part of your legacy, and the bigger part are pearls of wisdom, personal support and friendships you fostered during your career.”
AI Should Make This Easier
In addition to serving in various national and international leadership roles, Dr. Pugh has developed 17 curricula in simulation-based medical education for medical students, physician assistant students, and surgical interns. As part of the American College of Surgeons Post-graduate course series, she also developed a longstanding, simulation-based education course for contemporary laparoscopic hernia skills.
Dr. Pugh was asked to comment on why surgical education is important and her thoughts on Artificial Intelligence in the future of surgery and surgical education. Dr. Pugh felt that simulation-based assessment and training fits well into the new conversations that are happening with respect to precision education and artificial intelligence.
Discovering she was a visual learner and that this was the driving force for wanting pictures of everything that was talked about in surgical textbooks lead her to conclude that everyone should be tested early on and offered learning resources and curricula that fit their learning style. She stated, “AI should make this easy. I think AI supported precision education is the future. AI is exceptional with certain types of pattern recognition and tracking, but human beings are still better at non-linear patterns. We are still realizing how we can benefit each other as AI is still developing.” Dr. Pugh explained that there are a lot of opportunities for AI in terms of the surgical workflow in the OR and for learners. For example, she was looking for something online and came across a picture of surgical anatomy that was incorrect – the ureters were in the wrong place. She was upset because she was thinking if a medical student came across this picture, it would proliferate inaccurate information. AI should make sure that the picture never appeared on the internet in the first place or gets a label noting it has inaccurate content. Dr. Pugh stated, “There’s an unlimited number of places where AI can be used, and once we get over the hype that it’s going to do everything for us without us guiding and priming it, then we will start to partner and define where we want it to work for us. AI is an amazing tool, and it has progressed tremendously beyond what many thought it would in the past five years so it’s exciting.”
Own Your Passion
The Trailblazer Award recognizes new areas of academic pursuit, avenues of investigation and academic thought. Dr. Pugh had advice, especially for those that are innovators, as she feels that it can be destabilizing to have an extreme level of passion for something but not know how to foster that passion towards a successful deliverable.
She advised, “If you want to have high levels of impact in the medical field, don’t give up your clinical expertise. Stick with your clinical pursuit and add your passion on top of that. Sometimes medical students will come in and they see AI and computer science and they want to take years off to explore this area and this is okay. However, some leave medicine and become engineers, which is also a great path, however you now have to accept that you will be delegated to being a collaborator or an outsider to some of the inner circles in clinical medicine.”
In addition, she stated, “Your passion and your vision are your responsibility, and you must learn how to share your vision but also accept that not everyone will understand it.” Dr. Pugh recalls that there were many naysayers and people confused by what she wanted to do, and it was very frustrating. She described it as being a very lonely place at times because people didn’t understand. It took 20 years for some of them to understand her passion and why she went off the beaten path to pursue it. It’s a very rewarding feeling to have some of them come to you and say, “I get it now!” She stated, “In the early parts of your journey as an innovator you will want affirmation and you are not going to get it all the time. When you find a few people who get it, stick with them and magnify the positive feelings and affirmation they provide by 200% to make up for those who aren’t there yet.”
Layers and Textures
It is tradition to ask the SUS award winners if they have an interest/hobby that may surprise people. Dr. Pugh’s interests are in line with her being a visual person. She stated that she has a natural sense and ingenuity around home décor, work and living spaces. For her, it’s not just decorating but it’s a keen sense of lighting, visual-spatial workflows, and art. She also enjoys painting and noted, “I really enjoy playing with different types of paints. Acrylics are a lot of fun because you can layer it and create textures that rise off the canvas. I don’t think anybody knows that I enjoy going to arts and craft stores to look for new paintbrushes, colors and other materials that can be used to create something new.” That seems to be the most comfortable place for Dr. Pugh-creating something new.
The Society of University Surgeons is honored to present Dr. Carla Pugh with the 2023 Trailblazer Award at the Academic Surgical Congress on February 6, 2024, taking place in Washington, DC. She is the true embodiment of the type of individual that this award seeks to recognize.