“No Words Can Describe this Experience”

From the 11/13/2020 newsletter

Perspective

  

Michelle Minikel, MD – Bellin Health

  

“No Words Can Describe this Experience”

 

Dr. Michelle Minikel works as a primary care physician in Green Bay, WI, a COVID-19 hotbed. In this essay, she shares some of what she has experienced over the past nine months …

  

Over the past few months I’ve been asked to be interviewed and to serve on a panel discussion and to give a lecture and to write a piece about what it was like to care for a “disadvantaged” population during a major COVID outbreak in Green Bay.   I want to say “yes,” but it’s hard.  I don’t usually feel up for the task.  I don’t know if I can really put to words what this pandemic has been like. 

 

How can I convey the frustration…

Of seeing the first positive SARS-CoV-2 test result of a patient of mine who works at the JBS meat-packing plant?  The very same patient who had asked me a couple of weeks prior for an excusal from work, due to her high-risk conditions? She later informed me she was denied.  Having toured the plant and seen the working environment, how can I ever describe what it was like to know, just know, that COVID was going to tear through that plant like a tornado?  It wasn’t a surprise; we had already seen it happen in multiple plants.  But the public health department was powerless to close the plant.  I will never know if there is more that I could have done to close it, even if for just a couple of weeks.  A couple of weeks that could have perhaps saved a couple of lives. 
 

 How can I convey the heart ache…

Of what it was like to see a once hospitalized COVID-survivor, back to see me in the clinic, whos husband didn’t make it, who didn’t survive the infection she brought home from work?  

Or to see the patient who also blew whistles at her meat packing plant in early March and whose requests to wear a mask were denied?  “We matter less to them than the cows,” she told me.  

 Or what it was like to see two of my pediatric patients in clinic and finally meet their premature newborn baby sister, taken from her mom’s womb as she died at age 30 of COVID?  
 

 How can I convey the anger…

That the meat packing plants wouldn’t close down and instead let the fire rage for days, stoked with bonuses for the employees who did not miss work?  Are our hamburgers really that essential? 

 Or of hearing people decry the springtime Green Bay outbreak as stemming from a lack of education among the Hispanics?  Day after day in clinic, I heard about their fears of continuing to work and the sacrifices they were making to protect themselves, and answered their questions about how to best prevent the virus.  All while watching hydroxychloroquine be given to them in the hospital, in many cases, even weeks after the CDC stopped recommending it. 

 Or of watching people in Green Bay, even now, shop without masks and continue go out to restaurants and bars, while our children aren’t able to attend school?
 No words can describe this experience. 
 

 

 

Michelle Minikel, MD is board-certified in Family Medicine and practices through Bellin Health in Green Bay WI. She leads the Clínica Hispana.

 

Opinion: Trump's baseless claim that doctors are profiting from coronavirus has consequences

From the 11/2/2020 Milwaukee Journal Sentinel 

Faculty Op/Ed essay 

Opinion: Trump's baseless claim that doctors are profiting from coronavirus has consequences

Jayshil (Jay) Patel, MD - Pulmonary and Critical Care physician

As the COVID-19 pandemic rages in Wisconsin, doctors stand on the front lines, caring for critically ill patients infected by the coronavirus.

But, according to President Donald Trump, doctors are inflating the death toll for financial gain.

Just like veterans shouldn’t have to defend serving their country, I never thought I’d have to defend doctors caring for sick patients, especially after hundreds have died fighting the battle. But here I am.

Doctors must provide clear documentation when billing for their care. Misreporting medical conditions is a crime and violates ethical principles our profession considers sacrosanct. No financial incentive replaces lost family time and the compounded threat to our well-being.

The truth is, health care workers have taken pay cuts while continuing to care for the sick. Hospitals and outpatient clinics have closed, resulting in the loss of an estimated $200 billion and communities losing access to care.

When the president points his finger, there are consequences.

Last March, he pointed to the calendar and said the virus would go away by Easter. It didn’t, and 230,000 have died.

Then, he turned his criticism toward our nation's leading infectious disease expert, Anthony Fauci. Chants to "Fire Fauci" echoed across his rallies as if he were a contestant on "The Apprentice," the reality TV show Trump once hosted.

Now, while doctors stand on the front lines, a line the president has never walked let alone seen, his hot finger points at us. Despite the scorching light cast on us, we will continue to do our job, even if the president doesn't do his.




Jayshil (Jay) Patel, MD, is an Associate Professor of Medicine (Pulmonary & Critical Care Medicine) at MCW. He is a member of the Curriculum Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.



Link to the essay: 
https://www.jsonline.com/story/news/solutions/2020/11/02/trump-claim-doctors-profit-coronavirus-baseless-hurtful/6131051002/

The Emotional Toll of Being a Health Care Provider During a Global Pandemic

 From the 10/16/2020 newsletter

Kern Grand Rounds Preview

The Emotional Toll of Being a Health Care Provider During a Global Pandemic

Paul A. Bergl, MD - Pulmonary, Critical Care, and Sleep Medicine

Dr. Bergl will be part of a Grand Rounds panel discussion sponsored by the Kern Institute during MCW’s Professionalism Week. The presentation will be held virtually on Thursday, October 22nd from 9:00 - 10:00am CT. To register, click here.

When I was asked to contribute a written reflection on the emotional toll that COVID-19 has had on healthcare workers, my first reaction was - and still is - genuine fear. Fear that any public emoting would come off as disingenuous or hyperbolized for rhetorical effect. Fear that I would come off as whiny, as weak, as lacking resilience. Fear that I had little to offer and nothing particularly novel to say about a pandemic that has been covered from every last angle. Most importantly, fear that, as a gainfully employed and financially comfortable white man, I might leave others wondering, “He thinks he has a reason to feel burned out?”

In this loosely chronological reflection, I do not assume that I have captured the sentiments of many of my colleagues; instead, I only offer my own. And I hope that I have made evident my sincere sympathy for those suffering greatly from the fallout of COVID-19 and my perpetual gratitude for those working even harder than I.

The "early" days

February. I remember my first reaction to COVID-19 was blithe naivete. Skeptical of media hysteria, I encouraged friends and families to keep on with their daily lives. “You are far more likely to die from a bolt of lightning than a novel virus spreading overseas.”

After coming to my senses as SARS-CoV-2 spread among our neighbors, I next experienced exhilaration. Here was my moment to fulfill the great dreams I had as a twenty-something applying to medical school... To save lives! To be part of living history! To serve on the frontlines of a crisis! Rapidly elevated to hero status, I dutifully reported to my clinical roles and spent most waking hours helping my colleagues prepare for Armageddon. We developed protocols; we debated how we would allocate scarce resources. We strategized about how to save our medical students’ education. Despite long hours in the ICU and countless email exchanges and Zoom meetings outside of my clinical work, I was indefatigable.

The pandemic continues

Of course, incredible sorrow interspersed these periods of elation. I witnessed patients succumbing to COVID-19 in an airtight room, devoid of any symbol that they indeed were a person. No family. No photos of loved ones. No spiritual guides. No favorite sweatshirt. Who wouldn’t cry after holding the phone to a dying octogenarian’s ear while her family pleaded with an unyielding fate?

Soon, guilt settled in. Guilt that I had regular opportunities to see real actual live people while millions of lonely people huddle indoors, comforted at best by faces on LCD screens and at worst, discomforted by total solitude. I reported dutifully to a job in which solidarity was high... A shared sense of purpose in a fight against a new enemy. Why should I have any sense of grief when so many collected unemployment? Or experienced the exasperation of witnessing racial injustices on two fronts? Or suffered through the grief of losing a loved one to a crisis partly of our own making?

Then came a rising and ultimately unmitigated anger. My fellow citizens began flouting social distancing. My leaders began politicizing every part of the fight. Millions assumed that because most cases were mild that the entire thing had been blown out of proportion. These attitudes depreciated not only the work my colleagues and I were doing in the ICU every day, but also the efforts of our greater scientific, medical, and public health communities. Yes, I am still pretty pissed off.

My own experience as a COVID-19 patient

In August, I suffered the profound malaise of two weeks of a so-called “mild case” of COVID-19 that sapped not only my energy and sense of smell but my optimism that we were turning the corner on a crisis. To add insult to injury, I believe I contracted the virus while performing a bedside procedure that conflicted with my own values... but a procedure that I was ethically obligated to provide nonetheless, at least within the framework of how we provide healthcare in America.

Where we are now

Now, as cases surge to their highest levels, I can see the lassitude that heralds burnout on my own face and those around me. I try to remind myself every day that I am privileged. And I am. I try to ignore the outside noise when I am at the bedside. “Remember Paul, your obligations are to this patient, this human being, and you need to be the best damn doctor you can be right now.” Sadly, there are few outlets to recharge from exhaustion these days. And after all, depersonalization is probably adaptive, right?

Paul A. Bergl, MD, is an Assistant Professor of Medicine in Pulmonary, Critical Care, and Sleep Medicine at the Medical College of Wisconsin. He will be part of a Grand Rounds panel discussion sponsored by the Kern Institute on Thursday, October 22, 2020 from 9:00 – 10:00am CT. To register, click here.

Why We Need More Black Male Physicians

From the 8/7/2020 newsletter

Resident Reflection 

Why We Need More Black Male Physicians

Victor Redmon, MD - MCW Med-Peds resident 

Dr. Redmon shares some of his experiences as both a medical student and a resident physician, followed by his reflections regarding the encounters…

My name is Victor Redmon. I was born and raised in Florida – and although I was well-traveled, I had never lived outside of the state until I came to MCW for medical school in 2013. I stayed here for internal medicine-pediatrics (Med-Peds) residency, for which I am now in my fourth and final year. I will be serving as chief resident of MCW’s Med-Peds program for the academic year of 2021-22.

 June 2016 – A Black Patient and His Family 

I am at the end of my third year in medical school and one week into my acting internship in the VA ICU. The ICU fellow receives a call to transfer a patient from the acute care floor to the ICU due to concerns for sepsis in a cancer patient. As the “intern” on the team, I eagerly accept the responsibility of taking the admission. I do a brief chart review and go to meet the patient and to gather more history. He is a Black male veteran, early 50s, frail and cachectic (characterized by physical wasting with loss of weight and muscle mass due to disease). 

I introduce myself to him. “Hello, I am Victor Redmon and I will be part of the ICU team caring for you downstairs.” He looks me up and down. 

He responds, “You mean I’ll actually have a Black doctor taking care of me? Well that’s all right,” he says with a smile. 

I meet various members of his family over the ensuing weeks, most of whom shared the pride and adoration that they had a Black male caring for their loved one. I continue to take care of this patient for the remainder of the month. He had a long and complicated ICU course, as he was dying and at the end stage of his cancer course. 

We conduct several family meetings to discuss goals of care and code status. The ICU attendings and fellows did an excellent job facilitating the meetings and the family felt well informed. I was called to his bedside after one of these meetings. “I was told you had some questions for me,” I said as I entered the room. “Hi! We just wanted your medical opinion on what we discussed during the family meeting. What do you think we should do?” 

Being a medical student at the time, I was completely caught off guard with such a heavy question. I responded with the same answers my attending and fellow provided earlier. 

The family says, “Okay, thank you, doctor. We just wanted to hear it from you because you are one of us.” The patient passed away on my last day of the rotation. 

April 2020 – A Black Hospital Employee and His Words 

I am now a third-year resident serving as a senior resident for one of the inpatient pediatric teams. Like most days in the hospital, it has been very busy with admissions and duties on the medical floor. I had also not eaten breakfast or lunch and was starving by midday. I informed my interns that I was headed to the cafeteria for lunch and would be back soon. I head to the elevator and notice an environmental services worker waiting as well. He was a Black man, likely early to mid-20s. The elevator arrives and I gesture for the worker to get on first, since he had equipment to haul around. He says, “Thank you, doc” and gets on the elevator. 

I notice him staring at me and decide to make some small talk. I ask, “So how is the day going for you so far?” 

He responds, “Not too bad, just another day. Are they treating you well here?” 

I respond, “My work is busy, but all things considered I am very happy here.” 

He says, “Good, I am glad to hear it. Do you know how rare it is to see a Black male doctor?” The elevator dings and the worker says to me as he exits, “I’ll see you around, doc. Keep up the good work. I am proud of you, I really am.” 

I respond, “Thank you, brother. I’ll keep doing the best I can.” The elevator doors close. I am alone. 

July 2020 – A Reflection on What Needs to Change 

 I have had numerous interactions similar to what I’ve described above, but these two encounters I remember very vividly. As a medical student, I viewed these interactions as a source of pride and empowerment. My Black patients truly trusted me and related to me in a different way than they could with my non-Black colleagues. I have come to recognize the position I am in. No longer am I just any medical student and no longer am I just another resident or trainee. I represent a source of pride and encouragement for the Black community. Truly, this is humbling. However, as I matriculate through my training, I ask myself more and more, “How and why?” Although I still feel a sense of pride and encouragement, I also have feelings of disappointment, sorrow and isolation. 

Through my experiences in training, I have become increasingly aware of the impact of underrepresented in medicine (URM) physicians when taking care of their representative patient population. Of course, this is not a new concept. Many medical schools and graduate medical education programs, including MCW and Medical College of Wisconsin Affiliated Hospitals (MCWAH), have initiatives and policies in place that are centered around diversity. Yet, I believe that largely there has been little to no progress. 

There have been many published studies that reflect the lack of progress with diversifying the racial-ethnic population of the medical schools and academic medical centers since the 1990s. Similarly, there are well-published studies illustrating the positive impact URM physicians can have with both the underserved population and their representative population. URM physicians play a pivotal role in providing care where it is needed the most, which has been well documented and proven in several landmark studies. I believe there is a general intent to diversify our medical student and GME population in order to be more representative of the population we are serving. Yet, I consistently see that diversity takes a clear back seat to academic achievement, which is defined by grades and standardized test scores. 

My sentiments are not universal. There are many nonminority physicians who work extremely hard to provide excellent care to minority populations and underserved areas. There are even more people who work tirelessly on diversity and do not view diversity as an “extra” – but rather as “necessary.” I applaud and congratulate these people. I am blessed that I have been surrounded by individuals, many of whom are my colleagues and close friends, who truly feel that this is a critical area in medicine we need to improve upon. 

I chose this topic to provide clarity and shed light on how URM physicians may feel from day to day. Of course, I am not the sole voice for URM physicians – just a part of it – but I am not alone in my thoughts and experiences. I do not have a solution to the diversity dilemma, nor am I trying to give one. This is part of a larger socioeconomic discussion, which I believe traces back to our primary education system. As Americans, we are at a truly unique and critical point in our history. We are in the middle of a global pandemic that has caused a significant economic and social strain on our society. Our society as whole is in the middle of political strife with the Presidential election looming. We are in a unique era of social justice and potential social reform. I must say that I am worried about how racial relations may change as a result of what is currently happening in our country. I am proud of the principles that my parents have taught and instilled in me. I am proud to be a Black American. 

I am proud to be a husband and father. I am proud of, and grateful for, the training I have received and the relationships I have built here at MCW and MCWAH. I am hopeful for the future. 

Victor Redmon, MD is a fourth-year resident in the MCW combined medicine and pediatrics residency program. This essay was originally published on 8/3/2020 as part of an MCW “Monday Morning Coffee.”

“First Night-onCall” 2020: Preparing for Internship in the Face of a Pandemic

From the 8/7/2020 newsletter

Invited Commentary

 

 “First Night-onCall” 2020: Preparing for Internship in the Face of a Pandemic

 

Sondra Zabar, MD and Kinga Eliasz, PhD MS – New York University Grossman School of Medicine

 

Drs. Zabar and Eliasz are on the team that instituted the “First Night-OnCall” (FNOC) experience for trainees. In this essay, they describe the experience of modifying FNOC and running “FNOC 2020” in the pandemic era…

 

The transition from medical student to resident is difficult and dicey for patient safety in the best of times. In the US, virtually all recently-graduated medical students begin their residency training as interns on or about July 1. It has been reported that, in some academic settings, hospital-based risk-adjusted mortality rate goes up 4-8% in the first two months of a new residency year. While the cause of this bump in mortality is contested, we take seriously our responsibility to ensure all new house officers are as prepared as possible for unfamiliar clinical settings and dramatic increase in patient care responsibilities.

In COVID-19 times, everyone is looking at this transition through a new lens. Last spring, almost all near-graduate medical students across the country were pulled off their final clinical rotations. At the same time, these medical students needed to be ready to join the pandemic front lines on July 1 as interns. Special attention was needed for the safety of our patients, learners, staff, and faculty. We needed to design effective instruction to empower communities of learners with both the core values and outstanding diagnostic and communication skills that would be needed during a pandemic.

We knew that evidence-based orientation-to-residency strategies based on experiential learning and performance-based assessment are the most efficient and effective approaches to set expectations and build a resilient, unified workforce in this new era of practice.

How would we do this?

 

Adapting and Implementing First Night-onCall (FNOC) to the COVID-19 Era

We first created and implemented First Night-onCall (FNOC) at NYU Grossman School of Medicine (NYUGSOM) in 2017, a large-scale, authentic, immersive simulation developed to support incoming interns, address the hospital’s need to improve early escalation of seriously ill hospitalized patients, and cultivate our medical center’s culture of safety from Day One of residency. FNOC provided a collaborative, immersive “on call” simulation experience for all incoming interns across many of our largest residency programs. The program was so well-received by interns, faculty, and leadership, that it is now a core component of the residency orientation experience.

This year, FNOC – developed in collaboration with our simulation center (NYSIM) and core GME faculty – was adapted to the COVID-19 pandemic with the following goals:

1. Demonstrate the institution’s commitment to supporting both intern and patient safety.
2. Solidify each intern’s core knowledge base using WISE-onCall (WOC) Modules, a transition-to-residency curriculum on common safety issues which is part of the Aquifer collection of online clinical learning tools.
3. Reinforce the importance to patient safety of checking two patient identifiers and the appropriate escalation of urgent care.
4. Ensure each intern could properly “don and doff” Personal Protective Equipment (PPE).
5. Address interns’ concerns and comfort with caring for COVID-19 patients.
6. Provide a forum for interns to meet their peers and leaders, voice their concerns, and understand resources available to them.

To accomplish these goals, “FNOC 2020 COVID Edition” orientation included the following features:

1. Priming pre-work:  Incoming interns were asked to complete at least five out of the available twelve WISE-onCall online modules.
2. Shortened, in-person three-hour immersive simulations: New interns, in small groups, were challenged to:

o   Don/doff PPE and engage in a mannequin-based team simulation.

o   Evaluate a decompensating, hypotensive patient and activate a rapid response team (escalation) using remote standardized patient and nurse interactions, where learners were assessed using behaviorally-anchored checklists.

o   Recognize a mislabeled blood culture bottle.

o   Conduct an effective patient handoff.

o   Engage in a faculty facilitated debriefing of the entire experience emphasizing COVID-19 specific concerns.

 

Assessing Interns’ Concerns Prior to FNOC 2020

At the start of FNOC, interns reported being concerned about having adequate access to appropriate PPE. They worried about virus exposure despite the use of PPE. They felt unprepared, uncomfortable, intimidated, and anxious. They recognized they needed additional PPE don/doffing training and ventilator management. Despite their concerns and skills deficits, they were committed to caring for COVID-19 patients and were eager to learn current care protocols, and care for patients. 

Prior to FNOC 2020 COVID Edition, only 13% of the 215 participating interns from twenty-two residency programs reported having had seen, and only 19% felt comfortable with, providing care for a COVID-19 patient. Although 42% of the brand-new interns reported having ever witnessed a medical error, only 26% reported any formal patient safety training, and only 2% had any experience reporting a medical error.

 

FNOC 2020 was successful

Assessing and addressing our new interns’ knowledge and attitude regarding caring for COVID-19 patients was critical.

The impact of the session was reassuring for our institution.  80% of the interns reported greater comfort caring for a COVID-19 patient. This year, for the first time, 94% of entering interns completed more than the required number of WISE-onCall modules and over 90% agreed that the modules increased readiness-for-internship by providing a framework to organize clinical information. Almost all interns endorsed that FNOC 2020 was an effective, fun, and engaging way to learn patient safety, and 100% felt that it was an overall good approach to improve readiness-for-internship.

Patient safety awareness was also improved. They were reminded of the importance of checking two patient identifiers, and properly donning/doffing PPE. After FNOC 2020, 91% of interns reported that they were more comfortable speaking to a supervisor, to escalate an urgent situation and report a medical error.

 

As medical educators we must challenge ourselves to create engaging, immersive, innovative, and flexible simulation group experiences such as FNOC that can be rapidly adapted to the educational needs of any level of learners. In our experience, a deliberately-designed experiential orientation reduces the variability seen in entering interns, builds community and instills aspirational institutional norms – generating a culture of safety for patients.

 

 

Sondra Zabar, MD is a Professor of Medicine and Director of the Division of General Internal Medicine at the NYU Grossman School of Medicine, and Affiliate Professor of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. She is a national award-winning medical education researcher with expertise in performance-based assessment of clinical competence.

Kinga Eliasz, PhD MS is a Postdoctoral Research Scientist and Assessment and Evaluation Analyst in the Research on Medical Education and Outcomes (ROMEO) Unit of the Program for Medical Education Innovation and Research (PrMEIR), Division of General Internal Medicine and Clinical Innovation, NYU Grossman School of Medicine. She is also a Deputy Editor of Teaching and Learning in Medicine: An International Journal.

A View from Internship

From the 7/31/2020 newsletter

A View from Internship

Kim Tyler, MD, MS

Dr. Tyler, who recently graduated from medical school, shares her thoughts on developing a professional identity even as medicine goes through the upheaval of a pandemic …

Starting my intern year during a pandemic is not what I had in mind a year ago when I was preparing residency applications. I could never have anticipated what this first month of internal medicine residency would be like. I find myself thinking multiple times each day, “I should not be allowed to do this.” “Who decided that I was qualified to do this?!” “It is wild that they let me do this.” There is a constant tension between what I feel is expected of me and what I feel is within my abilities. I wrestle with “Impostor Syndrome.”

The first time a patient called me their “doctor,” for example, I nearly fell over. The first time I was summoned to pronounce a patient’s time of death, I stared at my pager wondering if they’d contacted the wrong person. A few weeks out of medical school, “doctor” is an identity I have not yet learned to accept.

As I move through my days, I experience twinges of incompetence. I fear that a patient might call me out. Of course, this is a familiar theme for many during the pandemic. None of us has the faintest idea where this is headed, and uncertainty lingers over all of healthcare. When the ICU fellow is questioned by a family member about treatment options for a COVID patient, does she feel the same doubt that I feel? Do even the most confident attendings have moments of distress? Perhaps some who have made careers out of medicine are being reminded of how they felt when they first started—now challenged by an illness in whose face previous medical knowledge seems inadequate. Is there, in this moment, an opportunity for all of us to acknowledge our hidden feelings of inadequacy and hesitation?

Sensing what it means to be a physician

Even though I am new to this, I believe I am starting to sense what it means to be a physician. In the quiet moments after a patient has confided a fear, a hidden addiction, or a smothering depression, I realize I am accompanying them on their journey. Even as I struggle to enter home healthcare orders, sort out conflicting lab results, or work through admission orders, there are times when I allow myself to just stop and be present in the spaces I inhabit with my patients. The specter of this pandemic highlights the importance of sitting with suffering even when we cannot relieve it.

Even in this time of great uncertainty – and in the midst of my first weeks as a doctor – I can see the beauty in simply and generously being present.

Kim Tyler, MD MS is graduate of the Medical College of Wisconsin Class of 2020. She is currently a PGY1 in the MCW Internal Medicine residency program.

Reflections on Courage

From the 6/5/2020 newsletter



Reflections on Courage


Meghan Nothem, DO - Internal Medicine resident


The COVID-19 pandemic has been a disheartening and unsettling time. I have experienced shock, dismay and frustration to a level at which I could never have anticipated prior to beginning my post-graduate training. I have witnessed healthcare providers display both courage and fear in the face of a virulent disease with sparse and often inadequate personal protective equipment. There have been moments which have terrified me to the core but fortunately, these are overshadowed by the selflessness of my peers and the positivity they have shown during this truly terrifying time.


Courage can be defined as "stepping up to the plate" when few others will. It means showing up to care for critically ill patients and maintaining positivity for those who will benefit from hiding personal fear. It means acting as a connection between patients and families when they are separated by a screen. It means acting as a leader for those who need a strong voice to carry them through. It means telling your family that you are not worried, so that they may rest easy. It means telling your civilian friends that the situation is under control but that they should continue to stay home for their own protection and for the safety of others. It means isolating yourself in an already emotionally challenging profession. It means putting your own feelings, worries, pain and sleeplessness aside and fighting another day. Thank you to all of the co-residents, medical professionals and staff who have helped me to help others during this era of unforeseeable challenge.

Meghan Nothem, DO is a second-year internal medicine resident at MCW

The Power of a Letter on Memorial Day Weekend, 2020

From the 5/29/2020 newsletter



The Power of a Letter on Memorial Day Weekend, 2020



Adrienne Klement, MD - Hospital and Palliative Care Medicine




Hours to days. This is the prognosis required to allow a patient up to two visitors in the VA hospital.


It was a Memorial Day to remember. The Wood National Cemetery looked bare without flags marking each tombstone. Instead, a wreath ceremony took place. Celebrations were virtual and the day subdued.


For our veterans and their families, Memorial Day is for celebration and mourning to honor fallen brothers and sisters, family members, and loved ones in service. It is a day to reflect on the price and sacrifice of military duty.


For many of our patients, celebrations took a backseat to the longing for everyday living. For veterans facing difficult decisions ahead, those recovering from a long battle with the coronavirus, those at end-of-life, those living with dementia, or those with hidden injuries like post-traumatic stress disorder, the lack of usual (and necessary) sensory inputs – the warmth of sunlight hitting a cheek, the sound of birds chirping on a spring morning, the sound of a familiar voice, or the touch and scent of a familiar hand – was missed more than ever.


Similarly, the toll on their families and the hospital staff did not go unrecognized. Many found innovative ways to cope and adapt.


Some patients and families bring prior experiences and learned coping skills from their military mindset. Skills – such as managing uncertainty in uncontrollable situations, sending mail to reduce feelings of isolation during wartime, and handling multiple crises at once – seem all too familiar. On the other hand, memories of confinement, past trauma, and lost freedoms resurface, too.


Hours to days. The pressure for prognostic precision feels immense.


The power to grant meaningful touch and physical presence at the expense of fending off the enemy virus feels costly and unnatural. For patients on our palliative care unit at the VA and for veterans admitted whose care needs exceed their caregiver’s abilities at home, bridging the separation with video chats and phone calls feels inadequate during a very vulnerable time. For those with hearing and vision impairments, this medium is exceptionally difficult.


So, on Memorial Day weekend, sparked by memories of our past and past traditions, we asked families and friends to write letters to help bring coveted familiarity to the bedside. Through the extra efforts of our social workers, nursing assistants, nurses, recreational therapists, and restorative aides, we received and delivered more than 25 letters (and counting).


The letters had an impact - not only on the writers and the patients – but also on the staff members who were fortunate to read them. One patient’s wife wrote, “I pray that the Lord will allow me to kiss those lips, hold your hands, and our eyes lock on each other one more time. If He does allow it, I will be happy, if He doesn’t, I will save my kisses for when we meet again this time in heaven.”


On this Memorial Day, as these letters are read, I sit outside counting my blessings. I hug and kiss my husband and kids. As I do so, my mind wanders to all of the families remembering their fallen soldiers and to the families longing to embrace their soldiers confined to the hospital. Some of them have only hours to days before they, too, will be remembered on Memorial Day.



Adrienne Klement, MD is an Assistant Professor in the Department of Medicine (Hospice and Palliative Medicine, Inpatient General Medicine) at MCW. She practices at the Zablocki Veterans Affairs Medical Center.

Make it to the Mat

From the 5/29/2020 newsletter

Make it to the Mat


Katie Recka, MD - Palliative Care Medicine



It was March 31, 2020. I was happily isolated in my VA office, attending a WebEx meeting. My phone vibrated. It was Mom. Probably a misdial. She only calls in emergencies. Couldn’t she just
text?


I was already grabbing my coat and keys before the voicemail was done. Something was wrong. It was Dad. Stomach pain, coded in the emergency room, now in the ICU. Or was it surgery?


That night we huddled together in my childhood home, just two blocks from Bellin Hospital in Green Bay. We were so close to him, but we may as well have all been in Texas for the good it did us. All we could do was stare at the pictures flashing by on the television and wait for the calls. It was Netflix, and the show was an episode of the docuseries, Cheer, and my father was dying.


He’s out of surgery.He’s on three pressors.This doesn’t look good.We have certain visitor exceptions; would one of you like to visit?


All the with the sunny inanity of the television in the background, its face-to- face intensity now archaic. There are no masks in the cheerleader pyramid, no social distancing.


Now I was the one who was spinning and disoriented. My father didn’t have COVID-19, but the presence of the virus in the community would keep all of us out of the hospital, my second home. Now I was (gasp-double flip-will she make it?) a patient’s family member, not a doctor. I wasn’t an insider. I was a helpless daughter, the annoying daughter who kept calling, the daughter born forty years ago in the same building where Dad was intubated, sedated, alone.


We build our own pyramids within our health systems, vibrant and wholesome when they work well, but precarious when they don’t. The days ticked by. At first, Dad was too delirious to use the phone in the ICU, he didn’t remember why he was there, but he was desperate to get out. Then he was in acute care, and he was terrified knowing he might never get back to his family and to his home that were so close, we were almost visible from the window of his room. Finally, he was in sub-acute rehab that we promised would be better but wasn’t. Each step was filled with well-meaning experts who couldn’t accommodate the one thing my father needed, the reassuring voice of a loved one unfiltered by electronics.


We built layers of help. Homecare promised light and fresh air, but with facemasks and eye shields, would we even recognize his home nurse if we saw him in the grocery store? The gear protected everyone from an invisible virus but isolated us. How do you bond with the strangers in your own home when they are faceless?


The whole goal in Cheer is to “make it to the mat.” The athletes practice until they collapse. They run, jump, and flip to the finals despite both physical and spiritual injuries. We watched Dad move painfully from bed to chair. Then he could walk, then take on stairs. A high-five from everyone when he ate at the kitchen table and support when he kept his game face on during the complicated reality of closing the law office he had opened ten years before I was born.


I can and will slip back into my comfortable role, but what do I do now as an insider? The provider with a new normal? We keep going until we get it right.


Our well-trodden path to the conference room is now the well-worn keyboard on our computer. It’s WebEx, Zoom, Skype, FaceTime, Facebook, Instagram, text, and phone. We attack this new normal like athletes do. We need to do it again, and do it again, and do it again so that constantly making connections becomes our normal. We nail that mental backflip until we believe that sheltering apart is sheltering together. If we don’t believe that masks and eye shields and gloves facilitate contact instead of separate, what patient is going to believe us when we look through a layer of scratched Lexan and say things we don’t believe ourselves?


Keep going. Do it again. Make it to the finals. Somewhere, there is another father coding and another family out there spinning and disoriented. We need to be there to catch them. We need to stick this landing hard and leave it all on the mat.



Katherine A. Recka, MD is an Assistant Professor of Medicine in the Division of Hematology and Oncology - Medicine at MCW. Her practice focuses on Palliative Care.

Where is My Toolbelt?

From the 5/15/2020 newsletter


Where is My Toolbelt?


Wendy Peltier, MD - Section Head of the Palliative Care Center


In normal times, palliative care team members work up-close with patients and families, offering clinical expertise, goal discernment, and support at a patient’s most challenging life transition. Our “tools” include our hands-on clinical expertise where we touch and listen to our patients as we diagnose and treat symptoms, while focusing intently on empathic communication – both verbal and non-verbal – to provide support and to encourage understanding.

We sit together with families to link them to nursing, spiritual, community, and child life support services. We share long intervals of silence in close proximity, permitting time for everyone to process difficult news while allowing for deep- seated emotions to emerge. We gather weekly for our interdisciplinary team (IDT) conferences to debrief cases and develop care strategies as a group.

Our toolbelts includes an abundance of team approaches to manage conflict, coping strategies, corridor conversations, group meetings, and hugs. It is how we work.


Isolation has a Profound Impact on End-of-Life Care and Planning

As the risks of COVID-19 became evident, our hospital changed overnight. Patients facing this frightening, new disease with uncertain outcomes needed more support than ever, but the dangers of viral infection forced us to prohibit our dying patients from having visitors. We limited our own contact with patients to conserve personal protective equipment and held our IDT meetings by conference call. Dynamic changes evolved, such that we wore masks and eye protection even for patients without the virus. We sought ways to link to families remotely for goal setting. Our team, like so many others, worked in scrubs that we removed and washed as soon as we got home. Any time we spent working from home was filled with virtual meetings, and constant worry of what was to come. This was a time to pull out ALL our tools, but our toolbelts were out of reach.


Things Have Evolved

As our hospital activated video visits and encouraged connecting patients to their families via iPads, we learned the power of these connections, although we also witnessed the shock families experienced when finally seeing a sick loved one for the first time in days or weeks. Emotions ran very high, as we wished we could place a hand on a shoulder or even assure families that the visiting rules would soon be lifted.

Our team at Froedtert & MCW is not alone. We are partnering with other palliative care providers locally and nationally to develop and implement new strategies. It has been daunting, yet inspiring. Everyone misses the close contact upon which we depend. We partnered with hospital administration and nursing leadership to develop visitation protocols that accommodated end oflife visitors, albeit far from our ‘normal’.


End-of-Life Care is Best When it is “Low-Tech” and “High-Touch”

Everything came into focus for me recently when the mother of one of my colleagues was admitted to our unit nearing the end of her life. Caring for the relative of one of our own, amplified our desire to make the patient’s and family’s last moments as fulfilling as possible.

Despite the limitations, we created meaningful experiences. Since my colleague’s loved one did not have the virus, she was able to spend time with her mother – a gift that our other patients do not share. She had the technology resources and creativity to connect her mother with all of her grandchildren via Facetime. A few cherished items from home warmed the room. Relatives were able to safely travel from out of state for support. As I sat in her room, hearing stories of her mother and family in happier times, I felt a sense of grace and peace despite my mask and goggles. I realized how much I have missed these bedside conversations and long for the day when the COVID-19 danger has passed.

We who practice palliative care and hospice are commonly asked, “How can you do this work, day in and day out, and stay afloat?” My response is often that I can’t imagine NOT doing this job and have always viewed it a special privilege to provide guidance and comfort at such a sacred time. Although we often deal with intense emotions, we also witness true love within families, facilitate ways to stay in the moment, and celebrate life even as death approaches. This present challenge has only intensified the value and richness of what we do.

Practicing in the COVID pandemic has included new work rules, PPE, computer meetings, and a longing for the day when thing approach normal again. We have developed a new appreciation for our old high-touch, up-close, sitting- together toolbelts. The day we get to strap them on again can’t come soon enough.


Wendy Peltier, MD is an Associate Professor of Medicine and Section Head of the Palliative Care Center in the Division of Hematology and Oncology at MCW. She is a member of the Faculty Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

Social Narrowing

From the 5/1/2020 newsletter


Social Narrowing


by Laura Mark, PA-C, MPH


Social distancing. Two words that have become universally used (although somewhat less universally practiced). We cover our faces and our hands, we pretend to know exactly how far six feet is, and we Zoom like there’s no tomorrow. We – the people on the streets and in the grocery stores and on video chats – are the socially distanced. And there are very real mental, emotional, and physical consequences to social distancing, some of which we likely won’t recognize until long after the practice ends.

But one group has remained quiet in the dialogue of distancing: patients within the walls of our hospitals. The day that visitation was temporarily suspended was filled with frantic phone calls, goodbyes, and pleas to reconsider. Our patients, particularly those with prolonged admissions, provide the ultimate example of what it means to be socially distanced. And I’d argue that theirdistancing predates this pandemic. Hospital admission removes patients from their contexts – their homes, health, jobs, and social networks. Then, patients must not only cope with the unknown but do so without their normal tools and support systems.

Under normal conditions, patients can hold on to some level of normalcy through their visitors. Studies increasingly recognize the positive influence of family presence on patient outcomes. It takes only minutes at the bedside to see why. Family members become therapy aides, cheerleaders, advocates, and even physical voices for patients. If you are a patient, your loved ones push the wheelchair behind you as you take your first steps. They ask questions so that you don’t have to, and they hold your hand as you listen to answers you may not want to hear.

When the ban on bedside visitors went into effect, a patient’s spouse – who had been at his bedside for months – sobbed that she feared her husband would “give up” without her physical presence. A small part of me wondered the same.

The patient didn’t “give up” in the way that his partner had worried. But the distancing patients face has grown. Patients assigned to certain rooms can look out their windows at miniature family members waving from three floors below. Others rely exclusively on virtual contact – no time like the present to become tech-savvy! Others are limited to listening through a phone held to their ear by a masked caregiver, their breathing tube preventing any verbal response.

Clinicians and staff fill whatever gaps they can in an endeavor I’d best describe as social narrowing. And that narrowing deserves to be celebrated. Even before SARS-CoV-2 crossed the species line, medical teams were addressing the social distancing of their patients. Despite a tremendous work burden, nurses make time to play cards with their patients (and no, this does not corroborate a certain senator’s claim of underworked, poker-playing RNs). Between assisting with intubations and running to codes, respiratory therapists listen to stories and share their own. Technicians learn what meals, music, and bed positioning a patient prefers. There are haircuts and pedicures and birthday parties and trips outside, even while on life support. This – this – is the revolutionary work of social narrowing.

The distance that remains is filled by yet another group: the patients themselves. When faced with unimaginable challenges, patients continue onward. They stand, even if they need three sets of hands to lift them. They practice breathing exercises, even if no one is watching. They wake up every day and find ways to hope.

The burdens of social distancing that non-patients carry are both real and serious. But let us not forget those who will remain distanced long after the curve has flattened. They deserve to be honored, along with those doing the daily work of social narrowing.


Laura Mark, PA-C, MPH is a Physician Assistant in Critical Care Anesthesia at the Medical College of Wisconsin. She works in the Froedtert Hospital Cardiovascular Intensive Care Unit.