Preview of presentation by Adam Hill, MD - Author of Long Walk Out of the Woods: A Physician’s Story of Addiction, Depression, Hope, and Recovery

From the 7/31/2020 newsletter

Three Questions for Adam Hill, MD 

Dr. Hill is Chief of Pediatric Palliative Care at Indiana University’s Riley Hospital for Children and author of Long Walk Out of the Woods ~ A Physician’s Story of Addiction, Depression, Hope, and Recovery

He will deliver Kern Institute's Grand Rounds on 8/6/2020 - 9:00 - 10:00 a.m. CDT

REGISTER HERE

  

TRANSFORMATIONAL TIMES: Dr. Hill, you developed and direct a program at Riley Hospital for Children called an "Compassion Rounds." What led you to develop the program and what impact do you see it having?

ADAM HILL, MD: We wanted to create a safe space for human storytelling, where individuals from all walks of life could come, share their experiences in a brave yet vulnerable way and know that they are being loved and supported for their authentic truth. We wanted to cultivate compassion, empathy, understanding and in doing so, breed a culture of human connection within our hospital walls. We intentionally open this space to all people, from EVS workers, cafeteria colleagues, to teachers, therapists, nurses and docs. We don’t focus at all onclinical medical decisions or even clinical encounters but instead about our own human experiences and how those experiences make us who we are today. In doing so, we create connections, friendships, perspectives and pathways for support. So that if an individual is struggling in their own story, they know that they are not alone and have cultivated their own silos and spaces now to reach out for help.

Over and over again we see these connections flourish outside of the meeting spaces. Sparks that turn into brushfires and true connections that develop when we take off our own blindfolds and realize that we are all in the same room together. Walking around with our own insecurities, fears, and anxieties in the same way. And we don’t shy away from the harder conversations like ourmental health, personal trauma, abuse, race, addiction, work trauma, grief/loss, etc.

TT: How do you use empathy to explore the emotions and needs of your patients?

DR. HILL: Having my own story of health conditions allows me to challenge myself to constantly stay open-minded and open-hearted. That we all have our own stories that are deeper than any stereotype or superficial assumptions assigned. That I hope people will get to know me as Adam, a man/husband/father/dog-lover/physician and not merely as someone with a history of addiction or depression. I hope to give my patients and their families the same dignity, a respect of listening to their story with a willingness to be changed.

From my own experience, I know that personal truth is layered under levels of denial, self-preservation, anger, projection, shame, guilt and the external pressures of having to portray some semblance of perfection or a stereotyped ideal of how to live your own life. Getting to the truth of someone’s experience requires patience, presence, trust, respect and a safe enough space where this truth can be explored. I hope to show up in this way for my patients, to build this trust and know that I can’t ever know what their story, life or lived experiences is like – but that I am willing to listen to find out.

 

TT: As a palliative care specialist, how do you manage your own mental well-being while caring for patients, especially during the pandemic or any other crisis?

DR. HILL: Without pretense. Without any expectation of perfection or that I have everything figured out. I am a work in progress and I strive not for perfection but for progress every single day. That I can show up, do my best and provide space for grace that I am a human being in the midst of difficult times and I can only control what I can control. Over almost a decade of recovery, I have learned my own triggers, my own needs, my own limits and where I need to set boundaries in my own life. I’ve developed skills and techniques, and I rely on ongoing counseling to continue to move forward in my own processing of the complexity of the daily work. I’ve learned how to communicate those needs to my family and my colleagues in a way that allows me to continue to do the intimate work every single day.

I also find deep meaning and purpose in the work that I do. Although difficult work, I see this as an incredible opportunity to make a difference in someone’s life during the hardest days of their lives. That I didn’t cause the pain, suffering, sadness or grief. I am not in control of what happens in the world all around, but I do have a role to play in showing up, doing my best and bringing intention into the work. And then, on the back-end, finding healthy ways to integrate that work into the story of my life in a way that allows me to be a father/husband/son as the top priority of my life.

Dr. Adam B. Hill is the division chief of pediatric palliative care at Riley Hospital for Children at Indiana University Health. His work in palliative care is focused on allowing patients to live the best quality of life possible, in the midst of chronic, life-limiting and/or life-threatening medical conditions. Dr. Hill is passionate about physician wellness and self-care in the context of changing the culture of medicine surrounding mental health conditions and addiction. In 2017, Dr. Hill published a groundbreaking New England Journal of Medicine articled titled “Breaking the Stigma: A Physician’s Perspective on Self- Care and Recovery.” In this article Dr. Hill shares his own story of personal recovery from depression and substance use. As a result, Dr. Hill has become a nationally recognized lecturer on the topic and has also authored a book entitled “Long Walk Out of the Woods: A Physician’s Story of Addiction, Depression, Hope and Recovery”

Excerpt from: Long Walk Out of the Woods ~ A Physician’s Story of Addiction, Depression, Hope, and Recovery

“...Worldwide, evidence continues to show that worsening mental health is an occupational work hazard in the medical field. I know firsthand how one’s mental health can deteriorate during medical training. Studies have shown that 27 percent of medical students are depressed, a rate three times higher than an aged-matched cohort of their peers. The numbers don’t get any better after graduation either as depression rates among medical residents are an estimated 29 percent. In medical schools in the United Kingdom, a multi-school study found 52 percent of medical students reported substantial levels of anxiety. While another study found the proportion of medical interns meeting criteria for depression increased from a baseline of 3.9 percent prior to medical training to a staggering 25.7 percent during medical internship. In the group of individuals reporting their mental health conditions, more than 80 percent did not feel adequately supported in their disclosure.”

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.

A Letter to our 2020 Interns

From the 7/31/2020 newsletter

A Letter to our 2020 Interns

Wendy Peltier, MD
Froedtert & MCW Palliative Care Section

Dr. Peltier, who graduated from medical school in 1991, shares her perspectives with our newest graduates on how the uncertainty of treating COVID-19 reminds her of her days caring for patients with HIV/AIDS …

Dear friends going through your internship,

Congratulations on becoming PGY1s! Truthfully, most memories of the times around my internship at Rush Medical College in 1991 are a blur. For example, I cannot recall the popular songs, who won the Super Bowl, or even the model of car I drove. However, as clear and crisp as if it was yesterday, I remember the faces and stories of many of the patients and families for whom I cared.

1991 was near the peak of the HIV/AIDS epidemic. Young, talented, previously healthy homosexual men were hospitalized in droves with frightening, rare conditions including Kaposi’s sarcoma, PCP pneumonia, CNS lymphoma, and terrifying degrees of cachexia. Each diagnosis was a death sentence and most HIV/AIDS patients knew they were dying. Their families were afraid to walk into their rooms or to touch them. Many patients disclosed their sexuality to loved ones for the first time at the same time they learned they had a terminal diagnosis. I sensed everyone’s fear and anxiety. I saw first-hand the stigma and bias the patients and families endured.

As health professionals, we were considered at high risk, as well. There were no effective treatments. Needle sticks and fluid splashes might kill us, and it took weeks to get test results back after an exposure. We wore double gloves and goggles. We adopted increased vigilance when performing procedures and interacting with potentially infected patients. It was scary.

Uncertainty and fear

There was much uncertainty, fear, and misinformation about the HIV virus. At the same time, as interns, we were directly responsible for hands-on aspects of hospital care in ways that would be unthinkable now. Even after being up all night on call, we stayed until late the following evening until the work was done. We often went thirty-six hours without sleep, went home for a few hours, and then went back in for more. There was no such thing as a “weekend.” We placed IVs and central lines, drew blood, inserted catheters, and – often – transported patients for after-hours testing in Radiology. Our scut lists were long.

Years later, I can see how working with patients with HIV/AIDS and my internship experiences laid the foundation for the doctor I am today.

Internship has always been – and continues to be – a time of transition, excitement, and anxiety. Despite the stress, we considered our intern years both a “rite of passage” and an honor. We were gratified to be trusted with the care of our patients and were uplifted by their moments of grace. We were frequently exhausted but did not see it as abuse. And, besides, our chiefs and faculty constantly told us how much worse they had had it.

A steep learning curve

The intensity quickly imprints memories that will last through your career. Every intern likely remembers the first patient they admitted, the mystery case where they nailed a diagnosis, and the first central line they placed. They remember the first time one of their patients died. You will likely carry similar memories with you.

It is also a time when relationships with colleagues take on new meanings. You learn about functional and dysfunctional teams. You develop your own habits of caring for patients while you explore disciplines and seek out role models that can show you how you might want to build your career.

Some things have changed and some have not

In the years since my internship, much changed. Scientific discoveries led to transformative medical treatments for HIV/AIDS and, by the early 2000s, contracting the virus was no longer a death sentence. The LGBTQ community and its allies tirelessly fought the bias and stigma surrounding the diagnosis.

As part of my practice as a neuromuscular neurologist, I saw patients in clinic with longstanding HIV/AIDS and neuropathy. I always asked them to share their stories. This led to meaningful conversations, reaching far beyond their neurologic symptoms. After my internship where essentially, every HIV/AIDS patient died, I was amazed to meet individuals living full and active lives fifteen years after infection. I suspect you will see patients experiencing post-COVID effects many years from now, as well.

My friends, there are parallels between my internship and yours. Just as with HIV/AIDS, previously healthy people, young and old, become suddenly and critically ill. They are isolated from their families. Patients are victims of bias, guilt, and isolation. Medical professionals fear for their own health. There is uncertainty and misinformation. There are more questions than answers. Just as in 1991, politics intrudes on patient care.

Here are my wishes 

As a long-ago intern, here are my wishes for you:

May you be in the moment, and stay close to the patient and family experiences amidst the COVID-19 pandemic, with keen attention to empathy and advocacy.

May you keep your faith in Medicine and vigor for Science, even when you feel tired and overwhelmed.

May you take time to regularly reach out to support and encourage your colleagues and team members with patience and kindness.

May you look back on this time with pride and wonder.

 

I know you feel overwhelmed by the challenges and opportunities you face. I encourage you to honor and share stories of your experiences with colleagues and friends. Reach out to faculty like me, who have been through crises for support and perspective. You are not alone. We will get through this together.

In gratitude for all you are doing, 

Wendy

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.

"Black Swans": Bad Doctors Reveal our Vulnerabilities and Opportunities in Medical Education

From the 7/31/2020 newsletter

Director's Corner

Bad Doctors, Rare but Devastating, Reveal our Vulnerabilities and Opportunities to Create Robust Character and Professionalism in Medical Education

Adina Kalet, MD, MPH

In this week’s Directors Corner, Dr. Kalet highlights what “black swans” or “bad apples” reveal about our vulnerabilities in medical education and what we need to do to ensure the public’s trust …

My heart sinks every time. In an era when trust in medicine and science is put to the test every single day, we do not need another “bad doctor” story. But there it is in the New York Times. Dr. Sapan Desai, who founded a company named Surgisphere while he was a surgery resident at Duke, provided aggregated, unverifiable – and likely falsified – data for two COVID-19 hydroxychloroquine studies published by Harvard Medical School researchers in Lancet and the New England Journal of Medicine. Dr. Desai refused to release the raw data when scientists around the world questioned the veracity of the studies. Both papers were rapidly retracted.

This type of “fake science” does immeasurable harm. It creates confusion. Critical public health messaging is interrupted, making the dissemination of actual findings more difficult. It threatens public confidence in much needed, ongoing clinical trials. It ruins trust in the medical profession. But while we would like to demonize this one “bad apple,” he is not the only one to blame. We must examine the system that enabled him to thrive.

Black Swans in Medicine

Misconduct by scientists and physicians is thought to be rare (although emerging evidence suggests otherwise). For the sake of argument, let’s say bad doctors are as rare as black swans. In the “black swan theory,” seemingly unpredictable events – like a physician willing to lie, falsify data, and harm patients – will have major negative effects. Institutional responses to individual bad actors are often weak and inadequate because of their supposed rarity. However, as philosopher Nassim Nicholas Taleb points out in two best-selling books (The Black Swan: The Impact of the Highly Improbable and Antifragile: Things that Gain from Disorder), systems should not dismiss the existence of black swans as rare, unpreventable aberrations but, rather, build robust systems that rise up and do not fail in the face of the unexpected or unimaginable. Creating such a system is healthy, lifesaving, and trust enhancing.

In the New York Times article, journalists Ellen Gabler and Roni Caryn Rabin interviewed dozens of people who either worked with or supervised Dr. Desai at different points in his pre-medical, medical, and surgical education (he is now a practicing fellowship-trained vascular surgeon). They described him as “a man in a hurry, a former whiz kid willing to cut corners, misrepresent information or embellish his credentials as he pursued his ambitions.” Nurses and fellow residents reported their concerns to leadership about Dr. Desai’s untrustworthiness and his routine dishonesty about everything from patient care to his whereabouts. He once lied that he didn’t answer pages because he had been performing a rare surgical procedure. Why wasn’t he stopped from progressing through training? Why would a residency, and then a fellowship, allow such a physician to graduate, effectively recommending him to the world for a lifetime of medical practice? What possible justification exists?

It Gets Worse

Dr. Desai did come close to being expelled from his vascular surgery fellowship at the University of Texas Health Science Center. His career was saved when a faculty member with whom he was doing research argued that the frequent complaints were a result of “personality differences and professional jealousy, not substantive deficiencies in surgical skill or patient care.” Unfortunately, this defense that others are merely envious is typical for “black swan” physicians and would have been a tip-off for anyone familiar with dealing with certain types of personality disorders.

He was given the opportunity to remediate his communication skills and went on to finish the program and enter practice. Not surprisingly, Dr. Desai soon had three malpractice claims against him at the community hospital in Illinois where he worked as a vascular surgeon before he left “for personal reasons.”

Remediation Works for Some, but Not All

As an expert in medical professionalism remediation, I have met many students, residents and colleagues who behaved in ways that “hit the radar” at least once. They have cheated on exams, plagiarized patient write-ups, had another student sign them into required sessions, or been disrespectful to members of the staff or of the faculty. I have even met a student or two who falsified scientific data; it is rare, but it happens. When confronted, the vast majority of these trainees show insight, are remorseful, remediate, and sincerely apologize to whomever they hurt including – and especially – their peers. In my experience, these are good prognostic signs. These students learn from remediation and never demonstrate egregious behavior again. Talk to me about the strategies that work.

However, some trainees – the superficially charming black swans – are exceedingly arrogant, disrespectful, and dismissive. They lack empathy for others and fiercely resist feedback. Occasionally, I have met a trainee who is unwilling to engage in any meaningful discussion about their behavior. As was apparently the case with Dr. Desai, if the person is especially brilliant or “awe- inspiring,” they are given second, third, and fourth passes even when their behavior imperils patient safety. Even though their behavior patterns satisfy diagnostic criteria for serious, difficult to treat personality disorders, their supervisors make excuses and justify choices by believing themselves compassionate.

Of course, we want all of our students to succeed, but truly bad behavior is corrosive. When a medical education program tolerates borderline clinical competence and unprofessional behavior, the community of peers notices. A lack of action is toxic to the educational and patient care environments. We run the risk of losing the trust of our other trainees and our communities if we fail to respond to lapses in professional behavior.

This Must Change. It is an Issue of Character.

Medical educators must face up to the challenge and work to ensure that consistent standards of competence, character, and caring are met by our trainees and ourselves. I believe educators in general do not openly address these issues because we feel we have neither the effective low-stakes, formative strategies nor the institutional support to tackle them when they arise. These barriers contribute to the “hidden curriculum” which tolerates a range of unprofessional behaviors.

Evidence to support remediation practices is mounting rapidly. In a recent review of the evidence, we and a group of international colleagues summarized what we do and don’t know about remediation. We concluded that well-run, effective remediation programs are reassuring to both the students who need them and to those who don’t. This takes some investment, but it is critical.

Our Obligation to the Future

Everyone’s professional judgement can lapse from time-to-time, especially when under unprecedented stress. There is, however, a very big difference between someone who lapses occasionally and someone with long-term patterns of unacceptable behavior.

One other thing: We need longitudinal data if we are to spot patterns. How do we know if there are ongoing concerns if we don’t “feed forward” professional behavior information about individual students and trainees? Only half of US medical schools have policies that support feeding forward while the other half feel strongly that to do so violates educational privacy. It is rare that a medical school provides honest information to residency training programs about lapses in professionalism or that these programs provide detailed information to future employers.

The best way to build robust, non-fragile systems is to take the assessment of professionalism and character development as seriously as we take the assessment of knowledge. Once we do this, we can build hardy, rigorous, and effective remediation programs for those who don’t meet the standards.

It should go without saying that not every medical student should become a physician, particularly when they exhibit patterns of egregious, life-threatening behavior. We must create systems that consistently harness judgment and courage to identify and confront the black swans. Those who lack the character strengths to be a physician should be dismissed.

I know that this is an exceedingly complicated issue, but I also know that this is one way we meet our societal obligation to care for the next generation by transforming medical education. Future patients, the integrity of science, and society will all suffer if we fail to act.

Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.