Global Engagement Spotlight: Dr. Carlie Arbaugh

By Mohammed Al Kadhim

Dr. Carlie Arbaugh is back in California after a month-long rotation in Anchorage, Alaska. She had so many interesting experiences and exciting stories to share with us.  

Intro: Dr. Carlie Arbaugh is a general surgery resident at Stanford. She just finished her third year and is starting her professional development time, up to two years to do research and other educational activities before returning to finish her last two clinical years of residency.  

Dr. Arbaugh was born and raised in a rural farming part of Pennsylvania. Her hometown has a population of about 1,000 people and is mostly working class and low-income. That background piqued her interest in health disparities and social justice in general and ultimately inspired her to pursue a healthcare career. Health disparities have continued to be a motivating factor in her medical training and have shaped her overall career goals.  

She moved to California to attend Stanford School of Medicine followed by Stanford General Surgery Residency. Prior to moving to the Bay Area, she attended Cornell University for her Bachelor of Science in Human Biology, Health, and Society within the Division of Nutritional Sciences; a year studying Human Sciences at the University of Oxford in the UK; and two years working in quality improvement at Boston Children’s Hospital.  

Tell us about the rotation, how did you find out about it and what motivated you to apply?  

Dr. Arbaugh: “The rotation was in Anchorage, Alaska and was one month long (from the end of May to the end of June). What motivated me to apply to this rotation is my passion for developing a skill set and a career working with underserved communities and addressing health disparities.” 

The Covid pandemic changed the plans: “I was originally hoping to go abroad for an elective rotation but because of Covid traveling out of the country was uncertain. Instead, I decided to pursue an in-country independent away rotation somewhere that would give me experience with patient populations different than those we typically care for at Stanford and the affiliate sites”.  

The connection: “I was connected with Dr. Reinou Groen, an OB/GYN physician at Southcentral Foundation and the Alaska Native Medical Center through Dr. Sherry Wren, surgery faculty at the Palo Alto VA and Stanford with extensive experience in global surgery. I have known Dr. Wren since I was a medical student, I volunteered in her Humanitarian Surgery Course, and have continued to work with her as a resident and through the Stanford Surgery JEDI Council”.  

Funding from the Stanford Center for Innovation in Global Health (CIGH): “I learned about funding opportunities through CIGH from Dr. Wren and Dr. Michelle Barry (Director of CIGH). CIGH has funding available for residents interested in pursuing independent away clinical rotations. I applied and was selected for a grant which I have been able to use to cover most of my travel and cost of living expenses for the month-long rotation. Personal travel and exploration are paid for out of pocket of course. The Stanford GME continued to pay my resident salary and covered malpractice insurance since the ANMC is considered part of the Indian Health Service (IHS) and non-profit. I am very grateful to both CIGH and Stanford GME for their support of this experience”.  

Alaska Native Medical Center: “The institution I rotated at is the Alaska Native Medical Center (ANMC) which is an alliance between South- Central Foundation (SCF) and Alaska Native Tribal Health Consortium (ANTHC) . The Alaska Native Medical Center is a comprehensive hospital with a robust General Surgery and Trauma Department. They also have specialties including Obstetrics and Gynecology, Pediatrics, Internal Medicine, Urology, ENT, Orthopedics, etc.”  

Why was ANMC a great learning environment? “ANMC is part of the Indian Health Service and serves the Alaska Native population. I have been very passionate about indigenous health for a while. Furthermore, although ANMC is not itself based in a rural setting (it’s based in the city of Anchorage), it is the main hospital for a very large catchment area in the state of Alaska and cares for patients across the state, including many rural villages.” 

Did you come across any challenging realities of healthcare in Alaska? “Alaska is the largest U.S. state by far and there are still many remote villages that do not have access to comprehensive healthcare. In some remote areas health centers don’t have the ability to provide 24/7 care. They may only have one or a few providers, not always a physician, and often not specialists. Providers may travel there daily, weekly, or monthly. For this reason, many trauma, surgical, OB/GYN and other types of patients are sent to ANMC for their care. It is not uncommon for patients to be transported hours by vehicle or plane to get to ANMC. The village health centers referring patients to ANMC are frequently not as well equipped in terms of resources. Because the health centers are sometimes limited in their capability patients receive variable levels of care before they are transported hours to higher level care at ANMC. Sometimes patients arrive having undergone diagnostics like imaging and sometimes not. Trauma patients may receive initial care to stabilize like an IV, fluids, and antibiotics or a tetanus shot (as indicated). However, the health center often doesn’t have the resources to provide additional needed procedures or operations (hence the transfer) and in combination with the long transfer times across a large state this effectively can result in delayed presentation, escalation, and ultimately time to treatment.” 

“Gestational age and NICU resources are other factors that play a role in decision making in OB/GYN at ANMC. For example, for pregnant women presenting at less than 26 weeks gestation with the need for an emergency C-section, once delivered the pre-mature infant would often need to be sent to another hospital. This would result in the mother and baby being physically separated, making mother-baby bonding challenging.” 

Time spent with the General Surgery team: “At ANMC I covered a 24-hour shift once a week on the General Surgery team. My role on that 24 was similar to a General Surgery call shift at Stanford or one of the affiliate sites. I saw new patient consults in the Emergency Department, on the floor, and in the ICU, assisted with add on operations, responded to nursing pages, and rounded on admitted patients pre and post call. The General Surgery team at ANMC has regular General Surgery residents from Banner in Arizona that rotate with them for two months at a time in their second, third, and fourth years as core rotations in their training. It was truly wonderful meeting and making friends with the three Banner residents that were rotating at the same time as me – Maryam, Michael, and Luc. All were very kind and helped to orient me to the hospital and workflow. Besides the 24-hour call shifts on General Surgery I spent the majority of my time with the OB/GYN team and a few days with the Orthopedics team. This provided a diverse experience and learning opportunities that are not typical of General Surgery training but important for my interests, goals, and career path”.  

Trauma looks a little different in Alaska: “The mechanisms of trauma in Alaska are different than what we are exposed to at Stanford and the affiliate sites. For example, ATV related injuries are not uncommon as well as trauma mechanisms related to the population living in an environment where interactions with wildlife (hiking, hunting, fishing) are prevalent. These activities are a big part of the economy, identity, and culture of Alaska.” 

Any other prevalent conditions in the area? “Several of the general surgeons shared with me that H. pylori and gastric cancer are more common in Alaska than in other parts of the U.S., and that gastric cancer tends to present in younger patients.” 

Why should a General Surgeon have exposure and training experiences in Obstetrics and Gynecology? “I am interested in practicing in low resource settings and in such settings, there may not always be an OB/GYN or other surgical subspecialists available. In these sorts of settings and situations the General Surgeon needs to be equipped to perform Cesarean sections, manage ectopic pregnancies, provide abortion care, and treat other Obstetric and Gynecological emergencies and complications. These are the patient care experiences I aimed to get exposure to at ANMC. I also assisted with non-surgical OB/GYN patient care including vaginal deliveries and education and counseling around contraceptive methods and breastfeeding.” 

Working with the Alaska Native and other indigenous populations: “When working with native populations in the U.S. there are some similar considerations as when working with other under-represented populations. For example, native populations can sometimes have mistrust of the healthcare system especially when it comes to interventions or research. This is rooted in a long history of being repeatedly discriminated against and taken advantage of without acknowledgement, apology, or appropriate reparations in many circumstances.” 

“ANMC is part of the Indian Health Service (IHS). Numerous patients and family members expressed feeling more comfortable receiving their care at ANMC than elsewhere for cultural reasons. ANMC really integrates Alaska Native culture, history, art, and symbolism into the aesthetics of the hospital. There are pieces of Alaska Native art like paintings, baskets, traditional clothing, etc. throughout the hospital displayed in window boxes and hanging on hallway walls. It’s meaningful that patients can come to a place where their culture is visibly displayed and celebrated.” 

“The wings of the hospital are named after natural elements like the “water region” and the “mountain region”. This extends to the outdoor surroundings of the hospital as well. Despite being in the urban setting of Anchorage, ANMC sits on a campus surrounded by natural beauty with wooded trails, views of snow-capped mountains, and not infrequent animal sightings. These references and close contact to nature have special meaning as nature and wildlife are such a key part of Alaska state identity and are also a common theme in native culture – a deep respect, harmony, and reciprocal relationship with the natural environment. There is a lot to be learned from native culture especially as we face challenges of global warming, loss of biodiversity, and other environmental issues.”   

“There is also attention given to cultural perspectives in the way medical care is delivered. For example, ANMC offers a traditional healing clinic where traditional Alaska Native approaches to health are combined with modern medicine. Services include traditional counseling, healing hands/touch, healing circles, talking circles, and a traditional healing garden with plants native to Alaska. Some of the food options in the cafeteria also reflect what is culturally relevant in Alaska and to the native population, like fry bread and reindeer chili or sausage. As with many hospitals in the U.S. (not unique to ANMC) the challenge is that cafeteria food options are not always healthy options.” 

 Were there any language barriers? “The majority of the Alaskan population (native and non-native) that I interacted with in Anchorage spoke English. I imagine that in some of the remote villages one might encounter more Alaskan natives who speak a native language. Unfortunately, for many indigenous populations in the U.S. the history of oppression and racism has resulted in many native languages being learned and spoken much less and some native languages being lost altogether. Often there are elders who speak the native language but far fewer native people in younger generations who do. There have been efforts in some native communities to reclaim their native language. For example, when I was a medical student, I did some work with the Lakota population in South Dakota and there were examples of preschools where elders were teaching children Lakota language and also examples of high schools on the reservations offering native language classes.”  

Domestic violence awareness and resources: “Unfortunately, indigenous populations are at higher risk of domestic and sexual violence, mental health issues, and suicide. At ANMC there is a lot being done to bring awareness to these issues, educate, provide resources, and heal. During my time at ANMC I noticed numerous informational posters and pamphlets about domestic and sexual violence awareness and resources such as hotlines and healing circles posted in restrooms and waiting areas. These were made to be culturally appropriate. The same was true of pregnancy and breastfeeding informational resources in the OB/GYN department.”  

Women’s reproductive rights and care in the current political and social climate: “Although it was not planned, the timing of this rotation was very pertinent to recent events in the political and social climate with the reversal of Roe v. Wade in June. I already knew I wanted more exposure and training in women’s healthcare. There has always been a tremendous need and that need will increase drastically as women in many states are denied their reproductive rights, decisions about their bodies, safe abortion care, and life-saving treatment. Unfortunately, similar to many other social justice issues, the denial of this fundamental right will disproportionately affect women of color and women with few resources, including the indigenous population. The opportunity to learn from the OB/GYN team as a non-OB/GYN trainee is even more meaningful to me and has shaped my goals and plans for supplemental training and involvement in education/awareness and advocacy in these areas”.  

Expectation vs. actual experience: “The experience was even better than I was hoping. The clinical experience was very diverse including both pediatric and adult patients and a combination of general surgery, OB/GYN, and some Orthopedics. The setting was also incredible. I had a feeling I would like Alaska because I love being outdoors in nature. The wildlife in Alaska far exceeded any expectation. On my days off I explored Anchorage and went on day trips. I hiked, saw glaciers, went to a reindeer farm, played with sled dogs and learned about the Iditarod, and saw Denali.  

Outcome and next steps: “This opportunity reaffirmed for me that I love working in the community and in particular working with underserved populations. I definitely still have a long way to go to complete my training, but this experience was reassuring for me that my knowledge and skill set are growing and can be applied towards the passions and goals I have. And there are many of these skills that are transferrable. For example, the skills I have gained from laparoscopic surgery in my first three years of General Surgery residency can be applied in OB/GYN. I was able to contribute to OB/GYN procedures (e.g. laparoscopic salpingectomies and laparoscopic management of ectopic pregnancies) in a meaningful way even though I am not an OB/GYN provider. Being able to bring that skill to the team results in trust which leads to better teamwork, collaboration, and learning opportunities for everyone involved, and ultimately better patient care. I want to continue to build on this. I am already brainstorming other places to go and experiences to have to continue developing my skillset for working effectively in lower resource areas and to support other interested trainees to be empowered to do the same.”  

A special thank you: “I want to thank all of the healthcare providers in General Surgery, OB/GYN, and Orthopedics, the support staff, and especially the patients that I had the opportunity to work with at ANMC. I also want to take the opportunity to recognize and give a special thanks to Dr. Reinou Groen, my main mentor for the rotation. I am so grateful for Dr. Groen’s support for months leading up to the rotation and truly touched by the kindness and warmth she displayed throughout my rotation and stay. She and her family invited me to their home several times for homecooked dinners, provided career mentorship, and gave me recommendations of things to do during my time in Alaska. Dr. Groen always introduced me to her colleagues and advocated for me to get the best possible clinical experiences to achieve my educational goals. The feedback I received on this independent rotation was very positive. The General Surgery and OB/GYN teams both expressed being open and interested in having more visiting residents. For those interested I would definitely recommend the opportunity and would be happy to connect and help support that.”