Face Value: 3D Hollywood Animation Aids In Transplantation

The face is the only part of the human body that we cannot hide.  It reveals our innermost feelings; it communicates our deepest and darkest emotions; it is the index of our mind. It protects the organ which houses our special senses—our vision, our smell, our hearing, our taste, our speech. Put simply, the face is an integral part of our identity.

It stands to reason, then, that facial damage ends up damaging identity as well.

 

When the face has been destroyed through trauma or disease, surgeons must take into consideration both the form and function of the remaining tissue (lips, jaws, eyelids, nose, etc.). Of course, plenty of plastic and reconstructive surgical techniques are able to address any one of these facial components, but what happens if a patient is missing both a jaw and a nose? Or both lips and cheekbones?

 

In these instances, patients may be better off receiving transplanted tissue from a deceased donor. The world’s first partial face transplantation was performed in France in 2005 on a woman whose nose, lips, chin, and cheeks had been removed after she was bitten by her dog. The patient, Isabelle Dinoire, has made astronomical process since her surgery, and she reports being “very satisfied” with the results.

 

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Isabelle Dinoire, the world’s first facial transplantation patient, just after the operation and one year after.

Face transplantation became a reality in the United States in 2008, when surgeons at the Cleveland Clinic transplanted most of Connie Culp’s face after a gunshot wound from her husband left her without a nose, cheeks, eyes, and the roof of her mouth.

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Connie Culp, America’s first facial transplantation patient, just after the operation and one year  after. 

Although there is quite a bit of data to aid in reconstruction, it is fragmented and almost impossible to manipulate, according to Dr. Darren Smith at the University of Pittsburgh Medical Center. To help in planning surgery, plastic or plaster models are created for mock cadaveric dissections. But by combining medical imaging with the 3-D modeling software used to animated films, there is new hope for the field of reconstructive surgery.

 

Smith and Gorantla along with Dr. Joseph Losee have combined conventional medical imaging software with Maya, animation software used to create a 3-D model of patient’s head and neck anatomy. Due to this integration of softwares, researchers are able to better understand the damage to a patient’s craniofacial anatomy.

 

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The software provides detailed imagery of the patient’s bones, muscles, nerves, and vessels, and this ultimately allows physicians “to customize the procedure to the patient’s individual anatomy so that the donor tissue will fit like a puzzle piece onto the patient’s face.”

 

Exciting things are happening in the field of medical imaging, and it will be interesting to watch as various fields of medicine are impacted by developing technologies.

 

 

 

http://www.diagnosticimaging.com/articles/medical-imaging-and-3-d-hollywood-animation-combine-aid-face-transplants

 

When Social Media Promotes Self-Harm

In this digital age, more and more patients are utilizing social media to communicate and empathize with each other. Generally speaking, this is regarded as a healthy practice. It promotes patient autonomy; it empowers patients to take control of their disease; and it allows for collaborative exchange of coping strategies.

But what happens when this communication is counterproductive? What happens when collaborative online communication becomes a threat to patients’ health?

This question was left untouched until very recently, when word got out that pro-suicidal images are circulating through Instagram—the popular picture-based social media platform with over 80 million users. Although the founders of Instagram have taken a firm stance against the promotion and glorification of self-harm, a recent study uncovered heaps of images showing bleeding cuts, active cutting, pill overdose, and actual methods of suicide.

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More than a quarter of the images found in the study have a pro-self-harm theme, and none of these images mentions the use of any mental health resources. Furthermore, only 5% of the images demonstrate any glimmer of hope. The majority of the images are laden with depressive content, and virtually none of them promote psychiatric intervention.

These findings are alarming for a number of reasons, but chiefly because they contradict the goals of the e-patient movement. According to e-patients.net, participatory medicine is a “model of cooperative health care that seeks to achieve active involvement by patients, professionals, caregivers, and others across the continuum of care.” It is an ethical approach to care that also holds promise to improve outcomes, reduce medical error, and increase patient satisfaction.

Instagram, a platform that is frequently used by e-patients to promote healthy lifestyle choices, may actually be promoting content with suicidal themes. Whenever an Instagram user posts a photo with the hashtag “ #suicide,” a message appears on the screen that directs the user to various resources for suicide prevention. In theory, this is an excellent solution; but in practice, not so much.

One would imagine that the people posting images of their own suicide attempts are already in a very vulnerable place. When they are promoting content with hastags such as #iwanttodie and #lifeisover, the brief message on suicide prevention only serves to magnify their feelings of inadequacy and isolation.

Dr. Arshya Vahabzadeh, a resident physician in child and adolescent psychiatry at Massachusetts General Hospital, commented on the medical implications of his findings: “A lot of our patients engage with social media.,” he says, “and they often describe incidents of bullying or difficult interactions they’ve had with their peers.”

What a site like Instagram allows these patients to do, though, is validate their depressive feelings and suicidal thoughts by reaching out to other patients on the verge of suicide. The conversation that ensues is not one of encouragement and praise; it is one of injury and contempt.

This study shows us that, although social media can serve as a beneficial tool for patient-to patient communication, it can also endorse and even encourage harmful acts such such as self-mutilation. Moving forward, we must engage with social media platforms to ensure that issues such as these do not go unnoticed. It’s important to proceed with caution. We must use this as an opportunity to educate users of social media on the severity of suicidal content.

When Medical Education Fails: Reinventing Sex-Ed

When a baby is born intersex, many physicians find it appropriate to assign a sex through surgical intervention. Advocates of early genital surgery suggest that, if normalization surgery is done at birth or shortly thereafter, the intersexed child will be capable of developing a gender identity that echoes the surgically assigned gender, therefore decreasing psychological trauma in the patient. However, with the advent of marriage equality in many states, the intersex community has begun to develop a collective voice—a voice that is challenging the ethical permissibility of normalizing surgeries at birth and shedding light on its destructive potential.

It all comes down to the conception of normality: normal genitalia, normal sexual anatomy, normal sexual desire—these arbitrary expectations presume that there is a correct way to be male or female, and, on the flip side of the coin, that there is an incorrect way to be male or female. This notion of ‘normality’ complicates and obscures ethical boundaries—boundaries that are drawn by the scalpels of clinicians who have not received adequate education on the psychosocial implications of intersexuality.

Because physicians are not properly trained to treat intersexuals, there is no common understanding amongst health care providers of what exactly is meant by the word ‘intersex.’ Is there a point at which a male becomes a female, anatomically speaking?  If sexuality exists on a spectrum, how can we fairly decide the point at which genital ambiguity becomes too ambiguous?

What we see here is a sad truth: the terms ‘female’ and ‘male’ do not describe what is anatomical; rather, they describe that which is designated first by medical professionals, and second by the sociocultural forces that impress importance to a social fabrication which is viewed instead as a social authenticity. These forces serve only to alienate intersexed children and make them feel inadequate, undeserving, and monstrous.

It is for this reason that adult members of the intersex community have begun sharing their narratives. Adults living with intersex often assert that good intentions are inadequate reasons to maintain a practice that has shown itself unethical and unscientific. Many of these adults were not told of their normalizing surgeries, so they grew up feeling abandoned and alone. Others suffered severe psychological damage when they grew up to identify with the sex not assigned to them at birth. Good physicians take the whole patient into account when developing a treatment plan, but these narratives often mention a general lack of appreciation for the psychosocial implications of an intersex diagnosis. Many intersexed adults claim that physicians are insensitive, so—rather than providing families with resources and options—they encourage surgical normalization simply because it’s easier than dealing with a patient’s psychological trauma.

I believe that, with the proper educational tools, intersexed persons will receive healthcare that is ethically right and medically appropriate. As it stands, there are no guidelines to which physicians can refer when treating intersexed patients. There is no standard of care, and there certainly isn’t a course in medical school devoted to teaching future physicians how to empathize with an intersexed patient. Therefore, I propose six guidelines that—when incorporated into medical education—will give physicians the proper tools to engage in ethical, inclusive, non-discriminatory healthcare:

 

  1. Intersexed children should be treated in a supportive, honest, and shame-free manner. They should be awarded full disclosure of all medical information, even if the physician is afraid that it would harm the child.
  2. Psychological help should be readily available for intersexed children and the families of intersexed children. The obstetrician who delivers the intersexed child should refer the family to a psychologist who specializes in counseling LGBT youth.
  3. Care providers should connect intersexed children and adults to avenues of peer support outside of the clinical setting. These include, but are not limited to, parent support groups, intersex support groups, and organizations that advocate for intersex equality.
  4. Intersexed newborns should be given a gender assignment rather than a sex assignment.
  5. The only surgeries that should be performed at birth are those that are necessary to maintain the child’s physical health.

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The Gender Expansion Project is a non-profit advocacy group that works to promote gender inclusive education and awareness. http://genderexpansionproject.org/gep-history/ 

We are observing the birth of a global movement toward recognition of the ethical treatment of intersexed persons, but the fight for equality is far from over. For America to walk in stride with countries such as Switzerland, Australia, and Germany—all of which have passed laws to ensure the ethical treatment of intersexuals—we must address our semi-flawed system of medical education. Physicians have a responsibility to provide ethical treatment to all persons regardless of race, class, gender, and sex. Therefore, medical schools have a responsibility to better educate their future physicians so that the next generation of healthcare providers will be better equipped to face the challenges associated with the intersex community.

The Importance of Usability: Putting the Patient First

In addition to developing apps that allow patients to track their lifestyle habits—exercise, diet, sleep patterns, etc—mHealth is also promising in its potential to engage patients in their general health information. Specifically, in the information that is stored in hospital health records. A play on EHRs, Mana Health has developed “a patient portal solution that has been designed for today’s consumer.”

Mana Health is a New York startup that won the opportunity to design the patient portal for the New York eHealth Collaborative, a non-profit organization that works to improve health care for New Yorkers through the development and establishment of electronic health records. Mana Health recently designed an interface that facilitates the sharing of patient data around the state, not only between hospitals, but also from hospital-to-patient. The endeavor is unique because it is not contained in a single healthcare system, but rather will pull information from across the state and consolidate it in a user-friendly “patient portal” platform.

One of the best features of the program, at least in my opinion, is how user-friendly the interface appears to be. While existing electronic medical records (such as Epic) are filled with numbers and abbreviations, Mana Health’s platform is truly geared towards the patient and offers streamlined graphics that illustrate the patient’s relevant health information.

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Mana Health’s platform transforms the complex electronic health record into a personal health record that allows patients easy access to their information: “unlike the clunky PHRs of days past, they said they wanted something that a typical consumer would feel comfortable using.” Their concern for user-centered designs is something that all mHealth developers should strive to emulate. The liberal use of color-coded graphics is a simple way to increase the scope of users, especially to those who may have low health literacy and will serve to benefit from the image-based layout.

As mHealth advances, there are many issues that will continue to spring up. I have addressed several of these in past blog posts—addressing low health literacy, accessing hard-to-reach populations, funding mHealth endeavors—and the creation of user-friendly platforms is yet another point of serious consideration. mHealth is a direct product of creativity and innovation, and these driving forces should not stop at the development of the idea, but carry over into the details of its execution.

http://www.mhealthnews.com/news/new-patient-portals-bring-mobility-hix?page=0

http://mana-health.com

http://nyehealth.org/about-nyec/

So You Want to Start a Health-Startup: The Challenges That Lie Ahead

Now that our class is coming to a close, and given the amazing presentations and responses at our final critique last night, I thought this article in the Boston Globe was particularly appropriate.

Entrepreneural spirit just a start to “disrupt” health care – http://www.bostonglobe.com/business/2014/04/25/more-than-entrepreneurial-eagerness-needed-disrupt-health-care/POSS7fv6mBZQPGfhojuO7I/story.html

The article talks about the recent boom in hackathons, accelerators, and showcases specifically relating to health and medicine. There are tons of new startups and products that are coming out with the potential to change medicine, but they are all running into the same problem.

Once you’ve built an app, or built a device, in order to validate it you need to do some sort of pilot study. But it turns out, health startups are finding it extremely hard to find doctors and hospitals willing to work with them on a pilot-study.

The reason isn’t that doctors don’t want change, but it’s because they are already extremely busy people. In almost every field there are dozens of apps claiming and trying to do the same thing. So in an extremely limited time resources setting it becomes very hard for doctors to decide whose product they should pilot.

Not only that but hospital systems are extremely bureaucratic, institutional review board approvals can be hard to come by, and clinical trials can often costs startups easily between 50 – 100k!

All of that made me realize how lucky we are in our medicine in media class to have problem owners who are so invested in the products and teams. We don’t have to struggle to find a physician partner, because we already have an in-built one.

Creating a medical product is far from an easy pathway, but since all of us are lucky to have one of the biggest obstacles in our path cleared, I hope to see several of our innovations in the real world in the near future.

mHealth to Improve Health Outcomes: Paying the Bill

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As we continue to develop innovations in mobile health technology, one of the first questions that needs to be asked is “Who’s paying for this?” Effective mHealth campaigns should be tailored to their target audience, which requires preliminary research about the platform and its potential, conducting focus groups, and multiple rounds of pilot testing.This costs money, and most industries want to see profits in a timely manner. In answer to the growing interest in mobile health, the National Institutes of Health (NIH) has developed two grants to fund mobile health aspirations. Specifically, these grants are aimed at “utilizing mobile health tools aimed at the improvement of effective patient-provider communication, adherence to treatment and self-management of chronic diseases in underserved populations.”

The article I read, which outlined the NIH’s plans entitled “NIH grants to fuel adherence, patient-provider communication” initially caught my attention due to its direct alignment with the interests of my MMAL group: patient adherence and patient-doctor communication. In order for patients to adhere to their treatment plans, it is important for them to feel engaged in their health. The NIH notes the potential of mobile health to “educate patients about the importance of sticking with treatment regimens and changing behaviors,” a promising avenue to improving adherence.

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These grants simultaneously address the need for increasing mobile health use and the importance of patient-doctor communication to foster patient adherence and better health outcomes. However, what makes these grants stand out to me as relevant is their direct address of “underserved populations.” It is all too easy to overlook the destitute when visualizing shiny new mobile health technology innovations. However, these populations suffer the worst health disparities, especially for chronic health conditions and could stand to benefit (possibly the most) from mobile health innovations. In its quest to serve all populations, the NIH also addresses one way in which they plan to avoid using mHealth to marginalize other populations. Specifically, they hope “to transmit patient data digitally from remote areas to specialists in urban areas,” taking advantage of the growing wireless infrastructure available to the population.

Finally, the projects funded by these grants should be designed to last two years, with costs not exceeding $275,000.

It is my hope that medical professionals will take this opportunity to address health disparities in their communities in a creative and innovative way. mHealth holds a growing potential to improve health conditions among those populations most strife with health disparities. Increasing patient adherence by using technology to foster patient-doctor communication will certainly prove effective in the very near future.

Transparency Is Not a Complete Solution: What Data Doesn’t Always Tell You

As a pre-medical student and a future doctor I’m well aware of the fact that it will be a number of years before I become a practicing physician. I’m also very well aware of the fact that the medical environment and community that I will be practicing in could be very much different than the medical environment of today.

That’s neither a good thing nor a bad thing, hopefully it’s good, but for now it’s just a fact. So I always do my best to keep an eye out for information that could help me understand the direction medicine is going so I can envision what medicine will eventually look like.

One thing I hear a lot about is this effort to hold doctors accountable and to empower patients to use data to select the most appropriate healthcare. I think the goal behind that mission is absolutely wonderful. Doctors are supposed to first and foremost help their patients, and patients deserve the opportunity to be able to learn and decide for themselves where they want to obtain their care.

The only concern I have though, is that the metrics and data being provided to patients to make their decision are not always truly indicative of good care. For example, one thing I’ve heard about is both paying and judging surgeons based on their rates of complications. Seems like a decently fair strategy. But what happens if you’re an amazing surgeon, but you decided you wanted to help a lower income population. Isn’t very much possible that the environment your patients are in after they leave the surgery could affect the degree to which they have complications? That doesn’t necessarily make you a worse doctor does it?

Just the other day I came across a phenomenal article about this subject from Lisa Rosenbaum MD, from the New Yorker titled “What Big Data Can’t Tell Us About Healthcare”.  In this article she talks about a recent release of Medicare payments that was made available to the public. In this release anyone, including patients, can look up the amount doctors are billing and how they rank amongst their peers.

The basic idea is that transparency can help patients make informed decisions.  And the implied message is that doctors who are billing higher are misusing the system and ripping you off.

“The hope is that members of the public will be empowered by their access to payments data, and will use this information to identify doctors who are behaving badly, helping to end fraud and profit-driven overuse.”

But that’s extremely missing. Just knowing how many Medicare specific treatments your doctor does , how much he or she bills for them, and what their total overall billing is does not provide nearly the whole picture. You don’t know what the doctor’s costs are; maybe the area they are in requires higher costs? You don’t know the exact breakdown of the doctors billing system within their practice. Often times a single doctor bills the entire practice’s procedures.

And there is an overall dilemma between doctor judgement and what’s deemed as necessary that  this also highlights. Is a test unnecessary just because it doesn’t return positive results?

How do we define quality care and how do we provide patients with a data set that is truly reflective of that? That’s still a challenge that is yet to be answered.

http://www.newyorker.com/online/blogs/currency/2014/04/the-medicare-data-dump-and-the-cost-of-care.html

Has the Influence of Harry Potter Spread to Medical Education?

As the semester comes to a close, it’s not unusual to see clusters of seniors chatting eagerly about how they’re going to spend their last summer before starting medical school. According to a study done in 2006 by the Mayo clinic, students that enter medical school with mental health profiles similar to their college peers. Although they spend their next few years training and studying on how to improve the health of others, they tend to disregard their own in the process. Reports show decreased attention to getting adequate sleep, meals, recreation and show higher rates of mental distress as student’s progress through medical school.  Sadly, the same study has also shown that depressed students are less likely to reach out for help because of the stigma surrounding mental illness.

With the worrisome consequences of depression in medical students including possible burnout and increased rate of contemplated suicide, it is important to contemplate how a change in culture within the medical school environment can be brought about to tackle some of the stigma surrounding mental illness.

So, what can we do to bring about this change?

Lisolette Dyrbe, M.D., and the lead author of the Mayo study, has encouraged a lot of conversation about the issue.

“It’s certainly important for the student to learn the right coping strategies, time management skills, and stress reduction techniques. All of that is important, but it is not the entire answer. We also have to look at school-level initiatives. There needs to be organizational change.” 

So, how are institutions responding?

Including pass/fail options for courses, reducing volume of course material, and giving students more opportunities to work and teach outside the hospital are just some of the ways that universities are working to lessens the stressful burden on patients. Many programs also provide mandatory resilience and mindfulness courses that teach coping mechanisms and stress management techniques. In addition, other universities have incorporated confidential web sites and hot lines for counseling, hired mental health experts, and have developed elective courses in health and wellness.

But, is this really helping?

Recent studies have examined these changes and have identified an important problem: students aren’t participating. Despite the good intentions of the universities and resources provided to the students, only a few seem to be taking advantage of these opportunities and these, more than likely, aren’t the ones that are in real need of care.

One program, though, has been able to show some success.

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The Student Wellness Program at Vanderbilt medical school, which provides a variety of health and wellness activities, has been seen to improve the health of students by effectively partnering and empowering the medical students themselves into organizing and promoting their own health and interests. The program has allowed the students to be divided into four “colleges,” similar to the Hogwarts houses in Harry Potter, that allow the students to connect and organize activities that provide an outlet outside of the classroom. Dr. Scott Rodgers, the associate dean of medical student affairs describes the aim of the program perfectly and outlines the importance of health and happiness for these students.

“It’s a challenge for anyone to stay healthy and happy. But when doctors are able to stay healthy and happy, that means patients get physicians who are more compassionate and selfless. They end up with doctors who really have the energy to invest time in them.” 

As undergraduate students pursuing careers in medicine, this discussion brings up some interesting conversations. What can we do to better prepare ourselves for medical school going forward? Are there ways that we can contribute to not only helping ourselves and our peers reduce stigma surrounding mental illness but also to improve health within the medical community?

 

sources: https://www.aamc.org/newsroom/reporter/jan2013/325922/stress.html; http://well.blogs.nytimes.com/2011/12/22/a-medical-school-more-like-hogwarts/?_php=true&_type=blogs&_r=0

 

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ePatient Benefits for the Unconvinced Physician

When discussing ePatients, we’ve mostly talked about the patient perspective – how an individual can become more empowered, educated, electronics savvy, etc. – but what about the physicians?

Well, in interacting with ePatients, of course the physician themselves may also learn information they hadn’t known, learn to empathize more with the individuals, and even gain some tech skills in the process. These all sound great, but sometimes when a doctor is over worked and just plain tired from life, I’m sure the last thing they are thinking of is how to learn how to use a new app a patient has just brought in.

The culture of passive medicine is in part carried out by physicians’ attitudes towards such patients. Of course, if your patient is compliant to everything you say and doesn’t question any of your prescriptions or treatment notes – you’re life as a physician isn’t too difficult because everything is a one-way conversation. But with the incorporation of ePatients – the physician has to work to build that two-way relationship, which not all physicians are willing to do.

So for those physicians unconvinced by the new ePatient movement – how about a very concrete and quantifiable benefit? EPatients can help you make money.

Now this sounds a bit crude. Money should not be the core of medicine, but sometimes it is and to some people it is. And in this sense, ePatients can bring in money for physicians by increasing physician referrals.

It has been shown that referrals are most effective through word of mouth. If a previous patient likes the way you work, then you get a referral. It’s just that simple.

Now how do ePatients factor in? Well, if you think about the grand scheme of things, creating an ePatient means a closer relationship formed by the physician and patient by methods of direct and indirect communication. This communication should ideally make the patient feel more secure and welcome in the portion of the healthcare system you have introduced them to. So simply (and idealistically) speaking, you put in effort to be a more engaged doctor in the patient’s life and treatment plan, and eventually they will like you and get you referrals.

Now, all doctors should communicate with their patients because medicine is not just about the biological treatment, but the social and psychological treatment as well. Social aspects of physician-patient interactions can go a long way. But – if you are still not into this ePatient thing – then maybe take into account how the ePatient movement can factor into your business plan. Is it a little more appealing now?

Final Thoughts about the Medical Media Arts Lab

 

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Last night was our final critique of our semester in Medical Media Arts Lab. It’s been a incredible journey being able to see a simple idea turn into a feasible project in just a few short months!

Here have been my three biggest takeaways:

1. Having a passion is so important. Many times throughout the semester I would feel discouraged or unmotivated, especially in the beginning when we were trying to figure out what exactly was the question we were trying to answer. Were we trying to make an exhibit to educate people about artificial heart technology or to tell the untold story of Dr. Akers’ contribution? After the first critique many of the comments expressed the same. But as Mijin mentioned in our presentation, it was the passion and excitement of the audience members during our first presentation that made us realize we had something bigger on our hands than we expected and helped us go back to the drawing board and see our problem in a different light. It was also encouraging each time we conducted an oral history interview with the individuals involved in the artificial heart project in the 1960′s. They each were so willing to share their story and eager to see it come to life in the present day, and the energy was contagious. Without a passion and an intrinsic motivation to continue, this project wouldn’t be happening.

2. Teamwork is essential. Our prototype and ideas honestly wouldn’t have come this far without the team I was in. Emily is an amazing speaker and hard worker, Mijin has valuable resources and skills with capturing stories from the past, and I contribute with my skills in digital media. This can be applied beyond the scope of our project into the subject of healthcare as well. All semester we’ve been talking about how to improve the communication, through whatever medium, between physician and patient. We’ve been talking about changing the conversation of the physician-patient relationship from the patient being a passive follower to the patient having an active voice and contribution to the dialogue about their healthcare. This can only happen if both the patient and doctor see themselves as a team rather than two opposing sides of a problem.

3. Start with Why. This is technically taken from Simon Sinek’s TED talk, but it’s been a common critique through the design process and practicing our presentations as well. Each time we’ve come up with a cool idea for a display we wanted to include in the exhibit, we were always stopped and asked “Why?” Would implementing this idea bring us closer to our goal, or do we want to add it because it looks cool? I saw the same principle applied in the other projects as well as they gave their final critiques. Many of the other teams designed a mobile app as part of their solution to their problem, but I liked how the ICU team recognized that although using an iPad to display information about rounds would be cool and in line with the digital health literacy trends of today, the current limitations of technology suggest that using a more traditional medium like a giant display screen would suit their problem’s needs a lot better.

I’m so thankful to my team members, our amazing problem-owners Dr. Grande-Allen and Dr. Igo, Dr. Ostherr and the teaching team, and all the individuals who helped us get to where we are today. I’ll be graduating this semester and moving to a different city so my contribution to our Artificial Hearts Project has come to an end, but it’s been an honor to be a part of this amazing process, and I can’t wait to visit when the exhibition opens!

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