Graduate students complete a six-week immersion term at Weill cornell Medical college to get a first-hand look from a medical perspective at the challenges and opportunities in biomedical engineering.

By Jay Wrolstad

Monday: I reported to the OR at HSS at 8:30 to shadow Dr. Bostrom. While with Dr. Bostrom I was able to observe two total knee replacements, two total hip replacements, and finally a total knee revision…. I could see just exactly how each tool was attached to the knee to provide aid in making precise cuts when shaving off the femoral condyles and the tibial plateu. My final experience on Monday, Dr. Bostrom allowed me to scrub in and view a total knee revision up close.—Blog entry by Jeff Ballyns

Standing at the elbow of a surgeon in the operating room isn’t something most engineering students expect to do as part of their coursework. But there are substantial benefits for both doctor and observer in such situations that help develop and put to use new technologies that improve treatments in a broad array of medical specialties. A handful of Biomedical Engineering (BME) students discovered those benefits for themselves last summer while spending six weeks in New York City working with physicians at the Weill Medical College of Cornell University and its affiliate, the Hospital for Special Surgery (HSS). It was, by all accounts, an eye-opening experience for the graduate students, who now have a much better appreciation of the applications for their research.The program’s inception dates to 1999, when Cornell professor Donald Bartel, who has collaborated on various projects with the Hospital for Special Surgery for some 30 years, first conceived the idea of an immersion term.

"We initially offered a program in orthopedic biomechanics at HSS, which is the orthopedic affiliate of the medical college," says Bartel, who holds a joint appointment as the Willis H. Carrier Professor of Engineering in the Sibley School of Mechanical and Aerospace Engineering and a senior scientist in the Department of Biomechanics at HSS.

Bartel’s prototype immersion program was developed with backing from a Whitaker Foundation grant to build bridges between the Ithaca campus and the medical college. "That program focused almost exclusively on orthopedics at HSS, whereas the present program has a broader focus that includes a variety of medical specialties," Bartel says.

"We felt the students needed exposure to the clinical environment and to research that can’t be done on the Ithaca campus," he says. "Those in the biomedical engineering field need experience collaborating with medical practitioners. They need to understand how institutions like the HSS and the medical school operate."

While the focus of the summer immersion course is an introduction to the clinical environment, students also receive formal instruction in medical ethics in a course developed by Betsy Myers, associate professor at Weill Cornell and associate scientist at the HSS, and Timothy Wright, professor of applied biomechanics in orthopedic surgery at Weill and associate engineer at HSS. Participants spend much of their time in operating rooms and clinics at the two facilities, each of them shadowing a designated physician mentor and learning first-hand how patients are diagnosed and treated. They also pursue an independent study project.

The immersion term, a requirement for all BME Ph.D. students, offers exposure to a range of medical imaging technologies used in routine clinical diagnosis. Participants observe surgical procedures such as replacing a broken hip, repairing a severely damaged knee, or removing a cancerous prostate.

The students focus on five primary medical concentrations: neurology, cardiology, radiology, orthopedics, and neo-natal pediatrics—fields in which there is a predisposition for the kinds of technology engineers can deliver.

"A lot of the BME research can be done here on the Ithaca campus—working with animals at what is one of the best veterinary hospitals in the country—but we also want our students to have an appreciation of what it’s like to work in the human clinical environment," says Michael Shuler, the Samuel B. Eckert Professor of Engineering and the James and Marsha McCormick Chair of the BME department.

Students making medical devices have to understand the physicians’ needs, he explains, and they should be exposed to medical research as well as the ethics associated with human research, all of which are part of the immersion program. "But the most unique part is the chance to have first-hand experience being in the operating room," Shuler says.

Yi Wang, Faculty Distinguished Professor of Radiology at Weill, offers a similar take. "The clinical exposure lets students see how technology is being used in practice," he said. "There is an immediate return for the engineering students, who gain specific and valuable medical knowledge first hand in addition to getting academic credit. This specific knowledge may be called on for guidance in their current and future engineering work. And they learn how to collaborate with physicians on projects. Such experience in interacting with medical people will be important later on in their careers when they work with practitioners. So there is a long-term benefit."

Wang, who helped develop and administer the immersion program, says the physicians, as a whole, were open to working with the BME students. "The Weill mission is to focus on medical research and treating patients as well as educating medical students, and this program is another aspect of that mission," he said. "On the other hand, the participating physician mentors also benefit directly from the summer immersion, because our technology-savvy engineering students participate in and contribute to their mentors’ research projects."

Shuler notes that the clinicians appreciate the skills and training that BME students bring to the table. "Medicine has become dependent on technology of different types. Doctors want to involve students who have an understanding of the technology that is complementary to their specialties," he says. That means explaining not just the use of current technologies, but also the shortcomings of those technologies in clinical practice.

"Many physicians are naturally inventors and they often relate well to engineers," says Shuler. In fact, he adds, during the immersion program clinicians presented some problems to students that will turn into continuing research projects.

The surgery gave me a feel of the kind of user interface the surgeons are familiar/comfortable with. I have learnt one thing that I will always remember when I design instruments/devices in the future: keep everything simple and ready to use. It’s not that the surgeons don’t understand how it works but it’s the simple fact that in the OR there is no time.—Blog entry by Abhishek Ramkumar

One promising project was conducted by BME student Hui Xu, who developed an inflatable cuff to enhance peripheral magnetic resonance imaging while working with Dr. Martin Prince, a professor of radiology at Weill Cornell.

"I’m interested in this technology because it’s a very powerful medical tool," Xu says. In measuring data obtained through MR imaging, the contrast agent is injected into the arterial vessels, so maintaining a constant blood pressure level is critical to get a clear image, she explains. "Most blood-pressure devices are hand-inflated, but they can leak, affecting the image, so I worked on a pressure regulator unit that was used successfully on some volunteer patients. It was exciting to see that my design did work, and it did improve the quality of the MR image by reducing the venous contamination."

Diego Rey also was able to experience the sense of accomplishment from seeing his research applied successfully in the clinical setting. In collaboration with Dr. Alexis Te in the urology department at Weill Cornell, Rey successfully tested a device to treat symptoms of an enlarged prostate.

"Currently, it’s common to treat the condition using a catheter with a microwave antenna that is inserted in the body and uses radiation to kill prostate tissue and open the urethra," he says. "The idea is to heat the targeted area without affecting external tissue."

But no tests had been done on the effectiveness of different types of devices used in the procedure and the heating levels they produce. "Our experiment was designed to test all the devices for their efficacy. This involved using a jelly-type material, with properties similar to prostate tissue, and observing how it reacts to microwave radiation."

He completed a proposal for such testing and the experiment has been passed on to master of engineering students (M.Eng.) to take to the next level. A paper based on the proposal was submitted to the American Urological Association. "It’s satisfying to know they were able to use the work I did," says Rey.

Ph.D. candidates in the biomedical engineering program include (front row, from left) Jeff Ballyns, Omotunde Babalola, Hui Xu, (back row, from left) Abhishek Ramkumar, Clarissa Lui, Satish Degala, and Diego Rey. Degala was unable to participate in the immersion term due to an injury.

Jeff Ballyns conducted experiments in cartilage and tissue engineering while working with Dr. Hollis Potter, who runs a clinical MR unit at HSS, observing knee surgeries and methods of creating new tissue that replicates the functions in the body.

"MRI imaging is the basis for understanding the geometry of the meniscus tissue in the knee and for making a mold to create a replica," he says. "Seeing how the hospital facilities work, how efficiently the surgeries are performed, and the tools available to surgeons, was very educational. I also discovered the vast amount of research being done in hospitals. The surgeons were very open to talking with engineers and explaining their work and having us get some first-hand experience."

Two teams of surgeons were working on her for this replacement. The first team was a group of orthopedic surgeons, performing the total knee revision. But working right next to them, on her torso, were a group of plastic surgeons from NYP-Weill, working on harvesting some muscle tissues from the left side of her ribcage.... I had never seen a plastic surgery, so this proved to be a very exciting and educational case...even the orthopedic surgeons were very impressed.—Blog entry by Tunde Babalola

Clarissa Lui, who focused on vascular surgery during the immersion program, evaluated the prospects for new technologies in surgical procedures. "Treatment for an abdominal aortic aneurysm, for example, is now being done with less invasive procedures," she says. Instead of opening up the abdomen, a catheter is inserted in the femoral artery to position a device that can fix the dilation of the blood vessel.

This stent-type device could be improved using new materials and designs. It may be possible to include microfabricated sensors to monitor the blood pressure in the affected area of the body, rather than relying on a CT scan, Lui says.

"I learned the clinical side of how technology is applied, and I went on rounds to visit patients with the doctor as he explained the surgery, which gave me a much better idea of how disease is treated," she says.

For Omotunde Babalola, the immersion program marked a return to familiar turf, as she had worked at the Hospital for Special Surgery, doing research in biomechanical implant testing, before enrolling in the BME program at Cornell.

At that time she served as a research engineer focusing on osteoporosis and fracture healing models, including hip and knee implants. "What was great about the immersion program is that I was exposed to a number of other medical disciplines outside of implant research, such as imaging technologies and tissue engineering and regeneration, and was able to observe the actual replacement surgeries," says Babalola.

Instruction in medical research ethics and statistics provided insight into additional areas of interest for biomedical engineers, she added. "I discovered potential applications of my work that I was previously unaware of. It’s easy to work in the lab, but observing surgery and the process of putting an implant into a body will help me create better tissue designs because I have a much better idea of what the surgeons need."

Babalola supports the immersion program as a BME requirement, noting that it fosters collaboration between students and the medical school. "Now I know people there who can help me with my research and can assist with evaluating my work," she says.

Abhishek Ramkumar, a student who worked on a computational model for an infant lung while in the immersion program, says the opportunity provided a glimpse of what to expect in his future interactions with doctors.

"Everyone in BME needs to do this; to see that doctors and engineers don’t think alike, which is something I did not understand before," he says. "We learned what types of technology doctors need, and that’s an important consideration when designing a product. Collaborating with doctors is critical in developing any detection tool or technology, because it helps eliminate assumptions about the design of a device."

Rey notes that in encouraging engineering students to join them in the operating room, the clinicians wanted not only to demonstrate the procedures and tools being used, but also to ask for the students’ input.

Adds Xu, "Our goal is applicable for clinical diagnoses, and it’s good to know what is available to doctors now, and improve those tools or build new ones. I enjoyed observing the interaction between doctors and their patients. And it was helpful to see how technology is applied to research."

Participants in the immersion program, who lived in a dormitory at the medical college, provided periodic progress reports on a web log (blog) site set up by Diego Rey, met weekly with Wang, and at the end of six weeks, wrote term papers and delivered 30-minute presentations on the experience.

Shuler says that beginning this year, an orientation session for the immersion program will be held in the spring and students will be debriefed in fall semester. "We are looking to send a much larger group this year, about 14 students, compared to six in 2005, and we are fortunate that there is a reservoir of doctors in New York City willing to participate," he says. Lawrence Bonassar, associate professor in the Sibley School of Mechanical and Aerospace Engineering and the Department of Biomedical Engineering, will be the Ithaca coordinator for this year’s term, working with Wang, his counterpart at Weill.

Scrubbing in was quite an experience seeing just how careful one has to be once washing your hands and putting the headgear on along with the smock and gloves. Seeing the operation up close is quite a different sensation with all the new smells and seeing all the debris that is removed when changing the implant.—blog entry by Jeff Ballyns

Among the collaborators is Timothy Wright, an immersion program coordinator and professor of applied biomechanics in orthopedic surgery at Weill Cornell. "The program reinforces the strong connection between engineering and medicine," he says. At the HSS, says Wright, the idea is to offer a broad experience, with some formal training, including lectures on responsible conduct in surgery and experimental design.

In the labs the students were shown technologies not available in Ithaca that will help them with their research, says Wright, adding that the engineers benefited from comparing notes with students at the medical school.

Exit interviews reveal that, beyond a doubt, observing in the OR is the most exciting experience," says Wright. "We are a teaching hospital, and the surgeons want to describe what they do to the engineers, who were able to observe joint replacement surgery, for example, and get a look at the actual cartilage tissue and the restrictions faced by surgeons doing replacements."

Potter, the attending radiologist, notes that the students were enthusiastic about learning in the hospital setting, inquiring about the work of clinicians and thinking about how to model their projects to meet physicians’ needs.

"This is an opportunity for students to see how technology is implemented, at the bedside, and how it is applied to patients," she says. Potter points out that while Ballyns was able to conduct experiments in cartilage and tissue engineering, he also examined research data and talked to a GE scientist who was at the hospital at the time, providing him with an industrial perspective on medicine.

"There are many ways to apply BME," Potter says. "Engineers can work in research, or a hospital. The students here learn that they don’t work in a vacuum. They get to see how their work interacts with that of the doctors, and they learn that they have to balance feasibility with science."

Surgeons benefit from the program as well, says Dr. Tom Sculco of HSS, learning from teaching students who come from different, but related disciplines. "The immersion term fits well with our educational efforts at HSS," he says, pointing out that the hospital has a long history of participation with Cornell biomechanics students interested in orthopedic surgery as motivation for their thesis research. "It’s gratifying to see the program expand to the rest of BME and Weill Medical College."

Cornell’s interest in interdisciplinary endeavors like the BME immersion program is based on the principle that each party can benefit from the knowledge and experience of the other. The program has recently been awarded one of 12 seed grants, funded jointly by the Office of the Provost at each campus. The one-year, $50,000 grants are designed to encourage cross-campus interactions between researchers at Cornell’s Ithaca campus and at Weill Cornell.

"Certainly in this program there are complementary strengths on the two campuses," says Shuler. And with an increasing number of graduate BME students choosing faculty members at Weill as their research project advisers, Shuler says, a long-range goal is to create a seamless connection between the two campuses as well as the disciplines. The immersion program is a strong first step in that direction.