Surgeon Steps Outside Operating Room to Find Solutions to Pedestrian Injuries in the Elderly

    • December 16, 2013

As a young surgeon in a busy Miami hospital, Carl Schulman, MD, MSPH, noticed a disturbing pattern.

Elderly pedestrians were rushed into the operating room with injuries sustained from being hit by vehicles. Unlike young people who usually survive such accidents, many elders died from complications of their injuries.

Schulman was frustrated.

His abilities as a trauma and burn surgeon could only go so far in helping these patients. He wanted to learn more about why so many older people were getting injured—and what could be done to prevent it. But as a newly minted surgeon, he spent most of his time in the operating room, as expected, and not puzzling over a medical issue involving just one group of patients.

For Schulman, help came from the Robert Wood Johnson Foundation Physician Faculty Scholars program. As part of the three-year career development award, beginning in 2006, he received the salary support and time he needed to research the largely unexplored problem of pedestrian injuries in the elderly.

RWJF Physician Faculty Scholars, which ran from 2006 through November 2012, sought to strengthen junior medical faculty’s leadership skills and academic productivity. Scholars received funds for a three-year research project, along with mentoring, networking, and other supports. Read the Program Results Report for more information.

“The gap the Physician Faculty Scholars program filled for me was to have protected time,” said Schulman, associate professor of surgery, University of Miami Miller School of Medicine. “A surgeon makes his worth by being in the operating room and generating revenue for the institution. A lot of surgeons don’t get time off to do research.”

“Traditionally, if you are an academic surgeon, and you have no funding, 100 percent of your time is surgery,” he said. “If you get a traditional research grant, you can protect a small amount of time—maybe 10 to 20 percent. In this program, my institution had to make a clear commitment to protect at least half of my time. It forces the institution to do something that it wouldn’t do otherwise.”

A fivefold chance of being in a pedestrian crash. During his time as a scholar, Schulman conducted a study to learn more about the causes of the often-fatal pedestrian accidents involving older people. In part, he wanted to learn whether prevailing wisdom about educational interventions for older people was true—that they are so set in their ways that such interventions are not worthwhile.

Schulman’s research revealed that there was a fivefold increase in the odds of being in a pedestrian crash when someone didn’t obey the pedestrian signal. In addition, the odds of being in a crash increased fivefold when pedestrians did not use the crosswalk.

According to Schulman, this finding had never been shown in previous studies.

“That [finding] might seem like a ‘duh’ moment, but it was not known before,” Schulman said. “It suggests that a behavioral intervention would be successful.”

Specifically, a safety program incorporating proper crossing techniques—similar to that for younger age groups—may reduce the risk of elderly pedestrian injury. Based on the strength of his findings, Schulman received funding from the Florida Department of Transportation to carry out an elderly pedestrian safety program called “Safe Crossings.” The program targeted older people in Miami-Dade County.

In the program, a coordinator traveled to senior centers and activity clubs to give a short presentation with a question-and-answer period about pedestrian safety. The program also set up a “mock” street where seniors could practice safe crossing behaviors and handed out brochures, reflective bands, and flashlights to help them cross streets in their own neighborhoods.

In all, more than 700 older people participated in the program. Some 93 percent said they had learned something beneficial from the presentation, according to follow-up surveys.

Learning a new research approach. Through his work on the pedestrian crash study, Schulman also learned about an epidemiological research approach that he had never heard about before. Called “case-crossover,” it is an alternative to the more expensive and time-consuming case-control study. In case-control studies, researchers need to find people with the disease or injury they want to study, and then compare them with people who have similar characteristics who don’t have that disease or injury.

But in the case-crossover approach, Schulman could use people who had received injuries in a crosswalk as both the case and the control. He did that by asking them what was happening at the time of the crash (e.g., did they obey the stop light, were they wearing their glasses, was it day or nighttime, etc.), and then by asking them what they were doing at an earlier period when they had crossed the street without incident.

“You look for discordancy in those interviews,” Schulman noted. “It’s very cost-effective and solves the problem of matching the controls,” Schulman noted.

Starting to see himself as a policy leader. One of the goals of RWJF Physician Faculty Scholars was to help the scholars begin to see themselves as health policy leaders. To help facilitate that shift in perception, the RWJF national program office continually sent scholars invitations to attend RWJF-related meetings. Schulman, who had received his master’s degree in public health, attended a meeting in Washington about the Robert Wood Johnson Foundation Health Policy Fellows program.

The meeting was “invigorating,” Schulman said. He recalled hearing two participants who are physicians tell stories about how they made a difference in health policy. “They were often the one physician voice in a room otherwise devoid of physicians, yet people were making health policy that would affect physicians,” Schulman said. “And their voice actually changed legislation that was going to be enacted.”

“It reminded me that one voice was critical,” he said. “I serve on several state committees on trauma. I used to have a fatalist approach that no matter what I said, it wouldn’t make a difference. But you can make a difference.”

“By trying to promote future leaders in health care and health policy, RWJF gives people the opportunity to really make a difference. Even though I’m a single voice, I do feel empowered to try and make that difference.”

New role as research director. Since the end of his RWJF fellowship, Schulman has taken on increasing research responsibilities. In May 2012, he became director of the William Lehman Injury Research Center at the University of Miami, which works to improve the treatment, prevention, and rehabilitation of traumatic injuries resulting from blunt trauma. Schulman doubts that he would have been named to that position without his RWJF experience.

“The RWJF program was the best research, real-world experience that I’ve gotten so far,” Schulman said. “If I didn’t have this program, I would not have learned enough to continue to be successful in doing research.”

RWJF perspective. Because many scholars are still early in their careers, it may be too soon to judge the real impact of RWJF Physician Faculty Scholars. However, several scholars currently hold leadership positions in academic medical centers and in local, state, and federal government, and conduct innovative research projects with the potential to affect health and health care.

“The Physician Faculty Scholars program developed a cadre of physicians—65 in total—who will or who have become productive, creative, and influential physician-researchers and leaders,” said RWJF Senior Program Officer David M. Krol, MD, MPH. “It also filled a niche for some physicians who wanted to pursue research that would likely not have been funded by other sources.”

Carl Schulman, MD, MSPH

Carl Schulman, MD, MSPH
RWJF Physician Faculty Scholar

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What a Miami surgeon learned about how to prevent elderly pedestrian injuries.