Q & A with Sonia Ramamoorthy

Dr. Sonia Ramamoorthy is a nationally recognized colorectal surgeon who serves as the Chief of the Division of Colorectal Surgery and as Vice-Chair of the Department for Quality and Safety. In this interview, she talks about what brought her to surgery; the innovations coming out of the UC San Diego's Department of Surgery in quality of care, robotics, and minimally invasive surgery, and shares what she'd do if she weren't a surgeon.

May 26, 2017 | Interview by Lindsay Morgan

You graduated from Boston University Medical School in 1996. What interested you in medicine?

There was a moment when I was 16, my uncle, who was in his 40s, had a huge myocardial infarction, and my mom asked me to fly with her to see him. I remember getting to the hospital and seeing him in the ICU, so critically ill, and the doctors there, talking to my mom—and I was fascinated by everything. Everything they were doing to keep him alive; the cardiac monitor; all the care he was receiving; and the fact that they were able to save his life. It left a big impression on me. I loved science but I never imagined that I would apply it to medicine.

How did you end up in surgery?

I decided to do surgery as a first rotation in my 3 ^rd year of medical school, to get it out of the way, because I thought I was going to do medicine. But I actually really enjoyed surgery and felt an immediate chemistry with the people. I went on to do other rotations—I did ER, I even tried OB—but nothing made me feel the way I did during surgery and when I was interacting with surgeons. We were on the same wavelength.

What was it about surgery? What's this wavelength thing?

I think it's that it's a group of people who are fast thinkers, very smart, very hard working, and very passionate. I also liked the fact that, in surgery, you could impact patients very quickly for a moment in their life. I liked that episodic, radical, impactful care. And part of it was the discovery, the exploration, the intriguing thing of finding out what the problem is, what we would encounter, and how would we address it.

You went from Boston to UCSD, where you did your residency under Dr. A. R. Moosa followed by a fellowship in colorectal surgery at Washington University in St Louis, and subsequently, a faculty position at UCSF. The Department was then fortunate to bring you back to UCSD to lead its colorectal surgery program. Can you tell me about where this division fits within the landscape of CR surgery in our region? In what ways are we a leader in this space?

UCSD and the Department of Surgery has emerged in the last 15 years as an innovation hot spot for surgery, some of which stemmed from innovations in CR surgery that were being done here that weren't yet widely adopted by the rest of the country. So for example, robotics; single incision surgery; transanal techniques; 3D surgery; and natural orifice surgery, which was pioneered by Dr. Horgan, our Chief of Minimally Invasive Surgery.

I remember the first time robotic surgery was introduced at the CR Society in 2008. Myself and two other surgeons presented to 5,000 CR surgeons and it was the first time our society had really seen robotics applied to CR surgery. Up until then, everyone was doing everything laproscopically. I think that opened peoples' eyes to the possibility of robotic surgery for CR disease. And now it's almost become standard of care for rectal cancer surgery.

You pioneered robotic surgery for the CR division and were the first surgeon to use robotics for a CR procedure in San Diego. Can you talk to me about the benefits, and the potential drawbacks?

The drawbacks have always been financial and the learning curve. And the time it takes to do it. But the benefits are very clear for pelvic surgery—it's a very tight spot to access and robotics allows us to get into these small areas. It has allowed us tremendous visualization, tremendous access, with enhanced capabilities, all with a minimal invasive approach. And particularly for rectal cancer patients it can be the difference between a permanent colostomy bag, and preservation of bladder and sexual function.

You're the Vice-Chair of Quality and Safety for the department. How do you define and measure quality?

There are a hundred metrics you can use, but essentially, you want to deliver the best possible care, the most compassionate, the most up to date, and the most satisfying care for the patient and clinician. It's easy to say; it's not easy to do. Quality isn't determined by any one person's effort. It's an entire system effort.

And there's a constant need to go back. You see sky scrapers, where the window washers start at the first window and by the time they finish, they've got to go back down to the first window and start again. I see quality improvement that way. There are constantly areas that need attention, whether it's at the level of faculty, staffing, or the parking lot. It's a never-ending job.

What is UCSD doing to improve the quality of surgical care?

We have a quality council, in which all the surgical divisions are represented. We focus on everything from clinic to OR, OR to floor, and floor to recovery at home. Start to finish.

Our ability to measure quality has improved a lot. In the past, we had very little data that was marginally reliable, but now physicians can look at their own outcomes data and its pretty accurate. We can compare our outcomes locally, regionally (with other UCs) and nationally.

Being able to analyze this data is critically important. It allows us to figure out what we're doing right, what we're doing wrong, and to understand the reason things aren't working. If outcomes aren't good, why is that? Is it related to your patient population? Is it because there's something that could be improved in the process of care? Is it the data capture? Is it something that the system isn't doing well? Until you tease it all out, you don't really know.

How are we doing at UCSD?

From a quality standpoint, we are doing amazingly well. We are often judged as a hospital as a whole as opposed to individual departments, but when you break things down, the Department of Surgery does very well. Our mortality rates have always been some of the lowest in the country, which is amazing. That's people staying up all night, that's people looking at numbers, that's people managing minute to minute to save someone's life—it's not by accident and I don't take it for granted. There are areas for improvement and we're constantly working on those things, and trying to stay ahead of the pack. A couple areas we are especially focused on now are surgical site infection and readmissions. These two areas are problematic for the system as a whole but especially for patients.

How do you incentivize the additional effort that is required to deliver quality care in all its varying dimensions?

We always start with the question: what should we be doing and how can we do it? Some of what we should be doing is driven by the patients' response. Some of it is driven by the payers, and some of it is driven by what our physicians think. But I've found that physicians don't necessarily need any incentive other than to know what the right thing is. Everyone wants to improve, they just need the information, resources, and guidance.

I want to ask you about the concept of centers of excellence—an approach for directing care to high volume centers versus conducting elective, risky surgeries in low-volume facilities. The idea is, the more you do, the more experienced you are, the better your outcomes will be, and there is research to support this. What are some of the tradeoffs to consider in terms of developing UCSD 's specialties as centers of excellence.

I think we're moving away from the concept of Center of Excellence, and more towards validating centers. So in order to be a center that is "validated" for management of rectal cancer, say, and to be accredited by the American College of Surgeons Commission on Cancer, you'll need to show that you have the appropriate multidisciplinary team to take care of these patients. What high volume centers represent is a specialized infrastructure of nurses, doctors, allied providers and technology that is necessary to manage complicated cases. Volume matters, in that it's a "reporter" for all of these pieces. And as is true in almost all aspects of life, the more you do of something, the better you become at it. But the idea of validating centers is about surgeon competency more than just volume.

The field of surgery is moving more and more towards minimally invasive (MIS) approaches. Can you talk to me about this shift—why is it important, and what is the division of CR surgery doing?

MIS for CR surgery has demonstrated better outcomes across the board. Cancer patients get out of the hospital sooner, they have less pain, and they have less long-term morbidity. With these benefits, those who need additional therapies like chemotherapy are more likely to receive them in a timely manner. Not every case can be approached that way but you can want to make sure it is applied when possible.

The Department of Surgery recently welcomed Sir Murray Brennan (GNZM, MD), the Benno C. Schmidt Chair in Clinical Oncology and Vice President for International Programs at the Memorial Sloan Kettering Cancer Center, as a Grand Rounds guest lecturer. In his remarks, he sketched the evolution of the surgical treatment of cancer, and spoke about the problem of excessive and expensive treatments, many of which lead to only modest benefits.

How have you grappled with this issue in your practice?

It's true that many procedures are performed unnecessarily. In fact, "appropriateness of surgery" is a new metric of quality from CMS. Payers are asking us to clearly state why the surgery is appropriate for the patient, and our answers are going to be increasingly scrutinized. If you don't clearly define why you're doing something and why it's necessary, it's not necessarily going to be covered.

Making a decision about whether surgery is going to prolong life and/or prolong quality of life is always hard. A lot of patients are understandably scared to die. And many patients do not have advanced directives, which is a fault of our health system; and they will often come in never having thought that this could be a life-limiting or life-altering hospitalization. It's not unreasonable for the surgeon to say, I don't think this is going to help you so I'm not going to do it. So it's no longer on the table and it takes the burden off of the family and lets the process of palliation begin. We too often get caught in the "they want everything done" web which can mean unnecessary surgery and an awful, painful death. As our population ages, this scenario is only going to be more commonplace. Surgeons need to think carefully about the way we counsel patients and families—being open and honest is key.

What has been a challenging moment in your life as a surgeon, and how has it shaped you?

My husband was hit by a car in the Bay Area and eventually brought here to UCSD. He received great care and we are eternally grateful to the system and our colleagues, but, going through that, I realized how vulnerable you are as a patient, when something disastrous and catastrophic happens in your life. It's like you have no control and you really do put your life in the hands of other people. We [surgeons] get busy with our day to day stuff and sometimes don't realize what a patient is giving us. They're giving us their life. They're trusting us.

And last year, my dad passed away and he was here at UCSD as well. And again, we received really great care.

These experiences really changed me as a surgeon. How I approach families and how I treat them in that moment of need. I know how that feels like. It's such a gift, what we do, and I don't think you can ever be too frequently reminded of how important that human touch is.

And what's a particularly bright moment?

We operate on lots of young people with bad diseases, cancer or inflammatory bowel disease. And a lot of them go through really terrible therapies that sometimes prevent them living normal lives, getting married and having children. When I get pictures years later of them with their new babies, it makes me feel like a million bucks. In some small way, we did something to protect and preserve that ability for them for the future. I love it.

People are carrying so many hard things. I think of those encounters in the interview room: the surgeon walks in, it's the 4 ^th appointment of the day, say. The family is there. This is maybe one of the most difficult moments of their life. There's a huge incongruity in that encounter. Having gone through some darkness yourself, I imagine it brings a sense of trust.

And empathy. Understanding. There's one way I would be able to speak to patients before all of that happened to me, and there's another way I come to them after all this has happened in my life. And I think they get it.

One last question for you and it's a bit of a frivolous one. If you weren't a surgeon, what would you be doing?

Very easy. I'd be an exterminator. I hate bugs.

Not what I was expecting.

I really hate bugs!