We have both a duty-to-care and a responsibility to care: what does that look like?

 From the 12/11/2020 newsletter

Director’s Corner

We have both a duty-to-care and a responsibility to care: what does that look like?

 

Adina Kalet, MD MPH

 

This week Dr. Kalet considers how today’s physicians, facing unacceptable fragmentation of care, need to recommit to an Ethics of Care for, with, and about the individual patient. Our Tripe Aim is Character, Care, and Competence.

 

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A good friend of mine is suffering. She recently underwent what was expected to be a relatively straightforward surgical procedure both she and her physician expected would correct a disabling problem and improve her quality of life. Instead, she developed a rare, perplexing, painful complication that significantly limits her mobility, interferes with getting a night’s sleep, and has not responded well to treatments. And she essentially has been abandoned by the surgeon who performed the procedure.

 When, months later, it became clear that she was not going to recover as expected, the surgeon did not make referrals to a pain specialist, and only referred her to physical therapy on the patient’s request. He does see her in “follow-up,” but focuses only on the immediate post-operative issues, not the new condition. When my friend reaches out to inform him of her progress and asks clarifying questions or for advice, the registered nurse on his team responds to her messages in a curt “just the facts,” perfunctory manner. Although the surgeon’s office has reached out to inquire about her progress through an impersonal “app,” no one has expressed care or concern that her pain continues. In my book, this is abandonment and, therefore, unethical. 

 As physicians, we have both an obligation and responsibility to care for, with, and about our patients. Like other service providers, we have a “duty of care,” which is a legal obligation requiring us to adhere to “standards of reasonable care while performing any acts that could foreseeably harm others.” From this perspective, strictly speaking, my friend’s surgeon did his duty. And given the current fragmentation of health care into sub-specialties, he can argue that by ensuring post-operative wound healing, he is discharging his obligations.  But this is not caring.  

The Ethics of Care, developed by feminist scholars including Carol Gilligan and Joan Tronto among many others, holds that moral action goes beyond meeting standards – being objective and justice orientated – but centers on the relationships and connection with others, especially when they are vulnerable and require expertise. The Ethics of Care emphasizes the importance of attentiveness and responsiveness to the individual and acknowledges the complexity of care taking. Rather than taking a narrow view on the obligation to refer my friend to a competent expert, I believe this physician had a responsibility to do the complex, skilled work of caring for her. He demonstrated no intention to do anything beyond his narrowly focused area of expertise.

When I told my friend’s story to a mentor who is an experienced surgeon, he said, “These are the patients you hold close, you give them your personal cell phone number, you respond and see them often until there is some resolution or even if there isn’t one. You are in this relationship for the long haul.” The wise and ethical physician makes the referrals, ensures the patient understands what needs to be done, has the difficult conversations, and “quarterbacks” the game until there is a resolution.  

By any measure, my friend is a “good” patient. She takes medication as prescribed, engages in physical therapy with enthusiasm and commitment (she is a “weekend warrior,” after all), listens carefully to the recommendations and advice of her physician, engages actively in decision making, and is extremely well informed. Luckily, she has caring pain management specialist and access to friends and relatives who are in health care. I have advised her to move on and consider the surgeon who operated on her as she would any high paid tradesman rather than as her physician. This is terribly disappointing, but common.

To be clear, while this isn’t likely “malpractice” it is, in my view, clinical incompetence. My friend’s current predicament was not likely due to a mistake in judgement or poor surgical technique, but her physician did not take responsibility to relieve her suffering by actively, assertively, compassionately, and competently caring for her. To do this well, he would need a mature, internalized professional identity to help him make morally informed choices in a therapeutic and caring relationship, especially when things got frustrating or went wrong. It would enable him to spend the time and make the effort to communicate with this patient directly, guide her to effective symptom relief, and sincerely empathize with her situation. This is not easy; sophisticated clinical communication skills are required. These include being capable of actively listening, while accurately identifying and appropriately responding to emotions, all while conducting clinical reasoning and creative problem solving. These are learnable skills, but require both a desire and practice to master. This physician is not trying hard enough. 

All physicians need to take responsibility for caring for patients, especially when the going gets tough, vexing, perplexing, and challenging, like when a patient, who should have recovered, does not. In one way or another, managing chronic pain is the responsibility of all physicians. Central to effective pain control from the patient’s point of view is being taken seriously, remaining hopeful and realistic, being listened to, and experiencing authentic empathy from a trustworthy physician or other health care professional. Anyone who has gone through childbirth understands that extreme pain – as long as it is going to be time-limited and will end with the birth of a healthy infant – can be “suffered” without medication, be well-tolerated, and can even be experienced as joyful when surrounded by trustworthy, caring, and competent health professionals. On the flip side, even mild to moderate pain can be unbearable when “suffered” alone or is a sign of loss of bodily integrity, increasing disability, or a terminal diagnosis. A mature and skillful physician has the potential to relieve suffering simply by staying in relationship with a patient. 

Modern medicine takes place within complex institutions and, even with the best intentions, the incentives can be perverse. If care and caring must happen within trustworthy relationships, then health care systems that divide the labor so that everyone works at the “top of their license,” are dividing the patient. I worry that as a side effect of “team care,” health care professionals are being encouraged, incentivized, or forced to destroy therapeutic relationships.  This is why physicians must have a strong character and a moral compass-sense of agency, and masterful communication skills to remain “the patient’s doctor” when there is rough going; staying put when it would be more comfortable to leave or send in someone else.

I have spent much of my career learning, teaching, and studying patient-physician communications. To motivate others to take this very seriously, I often point out that patients are more likely to sue a physician for “abandonment” of the type described here than for actual malpractice. I interpret this to mean that people will forgive mistakes, but not lack of care.

 

 

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.

Loving Each Other Through the Darkness

From the 12/11/2020 newsletter

Perspective

 

 

“Loving Each Other Through the Darkness”

 

 

Alicia Pilarski, DO & Cassie Ferguson, MD

 

 

“My patient was talking with me a few minutes ago and then he just coded…we tried everything we could. Breaking the news to his family over the phone was awful.”

 

“I just can’t unsee what happened to my patient. She was so badly abused and injured and I can’t imagine what she went through…”

 

“I made a mistake. I thought our patient was suffering from congestive heart failure, but it was sepsis. I never gave antibiotics and caused further damage from giving diuretics. I’m not sure how I can go back to work tomorrow.”

 

As physicians and learners, we see people suffer with protracted and difficult illnesses. We see lives instantly devastated by a new diagnosis or injury. We are asked to bear witness to the death of patients too sick to be surrounded by their own family. And then we kneel alone, face in our hands, before rising quickly to take care of the next patient. We are not taught or given the space to process these tragedies aloud.

Death, loss, and errors are inherent to the practice of medicine, yet a false sense of separation keeps us from reaching out to one another when their impact becomes too much to struggle with on our own. This sense of separation exists for many reasons, but is certainly driven by the isolating medical hierarchy, our unforgiving culture of blame and shame, and our own sense of exceptionalism; this erroneous belief that we are inherently different from one another, that we are the only one that has struggled in this way, that others have somehow handled it by themselves. Our current social situation exacerbates these issues, offering less opportunity to be physically present with our work family and making resources harder to recognize.

These obstacles to connection fuel our unwellness. They prevent us from seeing that our suffering is not exceptional; it is universal. We hope you know that we see you behind that mask and know that patient’s death made you think of your own mortality and wonder if someone in your family is next. We see you on that Zoom call stretching every ounce of your energy and patience in order to be a mom, a teacher, a researcher, a physician. And we see you sitting six feet away from us in the break room struggling with that last case that shook you to your core.

 

We see you. We are you.

 

We also know that connection is a remarkable force and have witnessed its power in our own lives. Talking openly about our struggles with one another reminds us of our humanity and wakes us up to the reality that we are not so different from one another. It is also a powerful force for healing; sharing our anxiety, grief, anger, and fear with someone who will listen empathically strips these emotions of the shame and paralysis that are often attached. And in turn, your story of how you overcame what you experienced can become “someone else’s survival guide.” (Brené Brown).

We encourage you to ask how you might tap into and add to the incredible power of our community and draw on the collective compassion of your colleagues. We want to be your first line of defense when what you’ve seen saturates your coping mechanisms. We want to be there for you like someone was there for us.

Dr. Rana Awdish phrased it most beautifully in her book, In Shock:

 

“How we care for each other during life is the true restoration—the definition of agency…Our ability to be present with each other through our suffering is what we are meant to do. It is what feeds us when the darkness inevitably looms. We cannot avoid the darkness, just as we cannot evade suffering. Loving each other through the darkness is the thing to look for and to mark. It’s there, in the shadows, where we find meaning and purpose.”

 

Resources for providers, trainees, learners, and staff:

 

·   Our institution has several resources and opportunities to reach out for support, both for peer support and more advanced support.

 

• For a list of the current Froedtert & MCW Supporting our Staff (SOS) Peer Support team, please visit our website: https://infoscope.mcw.edu/MCP-Medical-College-Physicians/Practice-Initiatives/Peer-Support-Program.htm
• If you need immediate support, please page the SOS Team (414-314-1763) or email Dr. Alicia Pilarski (apilarski@mcw.edu) or Dr. Timothy Klatt (tklatt@mcw.edu).

 

 

Alicia Pilarski, DO is a Associate Professor in the Department of Emergency Medicine at MCW. She serves as the Graduate Medical Education Patient Safety and Quality Officer. She is the Associate Chief Medical Officer at Froedtert Hospital. She is actively involved in Wellness in the Kern Institute, MCWAH, MCW, and the hospitals.

 

Cassie Ferguson, MD is an Associate Professor of Pediatrics (Emergency Medicine) at MCW. She leads the MCW M1 and M2 REACH curriculum focused on promoting wellness. She is the director of the Student Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

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Global Engagement Elicits the 3Cs

From the 12/4/2020 newsletter
 

Perspective 
 
 
Global Engagement Elicits the 3Cs
 
 
Stephen Hargarten, MD, MPH and Tifany Frazer, MPH – MCW Office of Global Health
 
 

In this essay, Dr. Hargarten and Ms. Frazer share how the missions of MCW, the Kern Institute, and the Office of Global Health overlap, and celebrate how students – taken outside of their normal cultural contexts to experience medical care in low- and middle-income countries – return with new appreciations for the value of competence, character, and caring in medicine …  
 
 
A MCW medical student recently reflected on a positive experience with a mentor: 
 

“We can easily forget we are treating a person and not just the disease. Despite feeling like we know best, we sometimes forget to include patients in the decision-making process. The doctor and patient collaborated to help develop their own healing systems outside from dependency on medications. Medications for chronic pain were replaced with relationships.”

As we celebrate MCW’s 10^th Annual Global Health Week, we are reminded that global engagement opportunities expose our students to new healthcare practices, build their character by challenging their personal beliefs, and stimulates the development of innovative solutions for patient care. As one trainee reflected, after observing that access to technology is restricted in low resourced settings, “You have to use and rely on your clinical skills and judgment. You likely become a better steward of resources, and arguably a better clinician.”
 
A report by the Lancet Global Independent Commission on “The Education of Health Professionals for the 21st Century” asked academic institutions to rethink professional education reforms in our century. It stated “the extraordinary pace of global change is stretching the knowledge, skills, and values of all health professionals.” The Commission called for “more agile and rapid adaptation of core competencies based on transnational, multi-professional perspectives to serve the needs of individuals and populations” and sought transformative education to develop leaders for the 21st century. 
 
The transformational gift of Robert D. and Patricia E. Kern validates the belief that the healthcare environment of the 21^st century is a global one, encompassing everything from engaging with researchers worldwide to providing clinical care in culturally diverse local communities. MCW trainees’ reflections following their global health research and clinical rotations are reviewed and demonstrate the following themes: perspective, awareness, ambivalence, and practice. A trainee reflected: 
 

"The list of health disparities I witnessed ultimately would take me hours to describe. As a physician, this experience forced me to alter my expectations and become more flexible in regards to medication compliance, progression of disease processes, and utilization of diagnostics and treatments given these limitations in resources." 

This student experience parallels the Kern Institute’s national movement and vision to transform medical education along the continuum. Engagement with diverse communities, whether local or international, reflects the current and future common realities of healthcare and humanity and what type of doctor is needed for the future. Another trainee reflected, 

 
“I am certain I have been impacted in more ways than I can truly describe. I know that as a physician and even more so as a human being I have been undeniably transformed."

 
Similar to the Kern Institute’s advancement of the Triple Aim of Health Care through its “Triple Aim for Medical Education,” faculty and staff active in global health efforts facilitate stronger connections to become caring, competent, and compassionate physician leaders committed to improving population health and enhancing patient outcomes, locally and globally. Our trainees benefit from experiences in low, middle, and high resourced settings, that compare and contrast health and health care in a variety of complex socioeconomic, political, and cultural environments. As the Kern Institute seeks to develop innovative models to optimize health system performance, physicians who are more comfortable “using a truly globalized approach (integrating therapies and treatment from a variety of resourced settings and cultures)” are more likely to improve health through enhanced care at a better value. 
 
Immersion in clinically and culturally diverse settings allows medical students and faculty to examine their preconceived notions of medicine and their roles as healers. The AAMC posted a story on their website indicating that “global health curriculum and electives provide lessons in patient advocacy, health equity, and humility.” A medical student quoted in the article reflected on a global health rotation in a low resource environment, “Working in this environment requires self-awareness, strength, and humility to accept and then overcome challenges to one’s way of being, thinking, and perceiving the world.” This parallels the Kern Institute’s expected outcome to cultivate physicians with the attributes of “fairness, honesty, kindness, leadership, and teamwork.”  
 
Most of the institutions collaborating in the Kern Institute are, with MCW, fellow members in the Consortium of Universities for Global Health (CUGH) including UW-Madison, Mayo, UCSF, Vanderbilt, and Dartmouth. Our connections to these institutions through CUGH would provide a ready-made platform for us to broaden the reach of Kern innovations, testing our ability to sustain and replicate these initiatives through a global health lens. 
 
As a medical student stated,
 

“As a future provider, this experience has expanded my character and ability to care for diverse patients in several ways. Foremost, it re-enforced that the basic principles of medical care are present across all cultures and peoples. Physicians have a responsibility to help alleviate physical and emotion suffering in all those that seek our care, and to do this, we must establish trust, and show empathy."

As the Kern Institute’s leadership continues to seek broad input on what this transformational gift can impact, we know that continued investment in global health-focused educational offerings is necessary for creating compassionate, caring, competent physician leaders with strong resilient character for the 21^st century.
  

Stephen Hargarten, MD MPH is a Professor of Emergency Medicine, Founding Director of the Comprehensive Injury Center, and Associate Dean of Global Health at MCW. 

 
Tifany Frazer, MPH is the Program Manager of the MCW Office of Global Health. 

Words for these times, a pandemic

From the 12/4/2020 issue


Poetry

Words for these times, a pandemic 

Julie Arthur



Could I write words for these times?
Arrange letters in some fashion
To make the distance bridged.
Writing is a powerful weapon, I am humanity’s soldier,
Words are an offering, a salve.


But nothing I write can unbreak my son’s literal broken heart.
Nothing I can write can sooth the figuratively shattered hearts I see on the floor all around me.


We are masked these days whether
we wear them or not,
and those masks hide the smiles
as well as the frowns, the fear
-that doesn’t just emote from the eyes you know-
and the recognition that these days, which are not for always, are at least for now.


I am not young nor old
And feel I should have wisdom to not feel so breathlessly scared every moment.
Steadfastness escapes me at every turn, I’m left chasing it, just as all are chasing answers
As to how things will end, how we’ll all get out
Of this ok.


These times are not for always.


Something I repeat as a hymn or a hum underneath the terror of the currents of my day.
An oar on this lonely lifeboat to white knuckle
And never let go of.
I wish I could give so many things to others,
Hope, or inspiration, or kindnesses,
Things to pack for the singular journeys we seem to all be on together.


Perhaps these words, these letters, can be
The salve then, used when the wounds are fresh,
When it’s night and things overwhelm,
To read and reread and in the silence to know:
I am there with you too.




Julie Arthur is an Education Program Coordinator II at MCW. “I have worked for MCW for almost 12 years, and have been writing poetry and fiction since first grade! I believe as much as medicine heals, words do too.”