“Proceduralists” Do Care!

From the 6/4/2021 newsletter

Perspective/Opinion

“Proceduralists” Do Care!

Harvey Woehlck, MD - Professor, Department of Anesthesiology

Dr. Woehlck reminds us that doctors whose main task is to perform procedures can break from their molds and have fulfilling roles as caring physicians, as well …

What does a caring academic proceduralist look like in today’s modern medical environment?  

We can imagine that the modern proceduralist descended from the surgeon of ancient times.  In the second century, the expression of “laudable pus” was a common procedure which, of course, required incision.  [Excuse the digression, but laudable pus was staph-related and often survivable with incision and drainage as the only treatment, as opposed to what we now call necrotizing fasciitis, which was uniformly fatal at the time.]  Amputations were described a century earlier, where lack of anesthetics required the proceduralist to be as fast as possible. 

in that era, caring may not have been a meaningful virtue; completing the amputation – and allowing the patient to survive – was meaningful.  Unfortunately, this may have selected for what we could today call a psychopathic trait in proceduralists of the preanesthetic era.  Just how could you have empathy when the goal was to amputate as quickly as possible?  

Nitrous oxide was synthesized in 1772, but was mostly used as a party curiosity, not for procedural pain relief.  Anesthetics like ether gradually increased in use from the 1840s to the present day, but “modern” pain relief is something we would recognize only in the twentieth century.  Prior to the era of anesthetics, lay literature, newspaper accounts, and battlefront stories from numerous wars and conflicts described eager but cruel doctors sliding down the slippery slope of brutality themselves, amputating, when possible, on the most minor of injuries as if to draw the biggest possible crowd as part of a spectacle. 

Flash forward to the present.  With a history like that, what does a caring academic proceduralist look like in today’s modern medical environment?  

High-tech procedural platforms require numerous people for support.  Housekeeping, instrument processing, lab services, anesthesia services, proceduralists and assistants, nurses, technicians, and more are part of the team.  Let’s not kid ourselves. All of these people and resources need to work together. They are expensive to operate and maintain.  We need to be mindful of RVUs created, payer mix, and the effect on dollars generated, turnaround times, expense units utilized (which includes choice of drugs and equipment). You wind up with a dizzying array of competing factors.  Add to that teaching of students, residents, fellows, and it’s amazing that we’re not reduced to robotic, unemotional, protocolized efficient machines in an environment devoid of empathy focusing on getting patients in and out faster and cheaper. Without efficiency, modern infrastructure could not exist.

And then, there’s caring and the patient’s best interests.  

Many people equate a caring physician with a good bedside manner. While that is important, some might argue that caring is secondary if the patient is asleep or sedated for the most critical part of one’s procedural interaction. As an anesthesiologist, the life-or-death part of most interactions with a patient occur when the patient is unaware. Stolid efficiency might be supportive of the infrastructure that allows us to provide an optimal level of care by today’s standards, but it doesn’t end there.  

The epitome of proceduralism transcends efficiency and a low complication rate. But it differs for patients receiving their definitive procedure versus those at the beginning of their diagnostic journey.  

What about the lost patient, trying to find the mountain pass to Erewhon?  I’d argue many nontraditional opportunities exist for caring, some of which could be hard to explain.  And notice that I used the word “argue” in there.  People who know me personally know that I am frequently contrary and argue a lot.  I pride myself on being one of those “competing factors.”  

Let me exemplify:

As a proceduralist – an anesthesiologist – I recently had a patient with a mundane problem having a common procedure, and I was part of the anesthesia team.  This is what Kikuko Tsumura might call an “easy job” for me.  Or what I imagine the late economic anthropologist David Graeber might have berated as a job where any interchangeable person with minimal competence sufficed.  

But I noticed the patient had multiple co-morbidities that didn’t substantially alter anesthetic care. Those anomalies happened to fit a pattern for a diagnosis that was neither listed nor treated by any of the dozen qualified healthcare providers he had seen in the prior six months. In addition to performing the dull, boring anesthetic, I took it upon myself to arrange some screening tests for this potential undiagnosed problem that would tie together the co-morbidities into a single diagnosis and change treatment 180 degrees.  

The test came back positive for what the textbooks call a “rare disease.”  After a referral and more procedures, the patient thanked me for figuring out, and finally solving, the underlying issue that caused years of suffering and, untreated, would have taken decades off of his life.

Why didn’t others find the problem?  Did we unknowingly allow ourselves to wear the mask of tunnel vision and be compartmentalized into that mechanical state of efficiency?  Was it production pressure?  Protocols?  A nebulous bureaucratic expectation that we maintain our defined roles?  

Many opportunities existed to look the other way and perform only up to minimum acceptable standards.  Breaking from this mold is what I call caring.  I am sure nobody would have noticed the difference had I only done the minimum.  For some, caring could mean providing emotional comfort, but for others, it may mean taking the extra time to solve a problem, even if it opens the uncomfortable door of crossing boundaries of specialties or roles, or advocating for the rare and unpopular.  

Tsumura might summarize this approach by arguing that caring encompasses the dignity of work.  Or becoming more invested and engaged as the job becomes increasingly routine or trivial, extracting from context nuances that defy description.

For me, in my procedural world of the unaware, caring transcends the routine and encompasses the intangible.

For further reading:

Kikuko Tsumura. There’s No Such Thing as an Easy Job. Bloomsburg Publishing, 2020.   ISBN: 9781526622242 To find the book, click this link.

David Graeber. Bullshit Jobs: A Theory. Simon & Schuster. 2018. ISBN: 9781501143342 To find the book, click this link. 

Harvey Woehlck, MD is a Professor of in the Department of Anesthesiology at MCW. In addition to multiple educational, clinical, and administrative responsibilities, Dr. Woehlck is an accomplished concert pianist. 

Poppies on the Grave – Symbolism and Memorial Day

 From the 5/28/2021 - Memorial Day - newsletter

Perspective

Poppies on the Grave – Symbolism and Memorial Day

By Capt. Tej Ishaan Mehta MD - United States Air Force Medical Corps and Internal Medicine Resident Physician

Dr. Mehta reminds us why Memorial Day is such a unique holiday and how commemorating all fallen military personnel can bring us together as one nation…

One-million, three-hundred and four thousand, six hundred and eighty-four. At the time of writing, that is how many United States military personnel have perished in in the line of duty. How many mothers have wept at the sight of Death Notifiers walking to their door? How many fathers have broken down upon receiving that terrible phone call? How many lives have been ruined by the loss of a loved one in service to our country? How many lives have been saved? This Memorial Day, I urge you to consider these questions.

Memorial Day is unique amongst American holidays. All other major American holidays are marked by celebration, but Memorial Day is marked by mourning, by remembering the fallen. Memorial Day honors and mourns the United States military personnel who died in the performance of their duties. The establishment of Memorial Day is complex and uncertain, but general trends are clear. After the end of the Civil War, citizens across the United States recognized the importance of honoring those who had fallen in combat. With the death of Abraham Lincoln in 1865, commemorations were widespread. The National Cemetery System was established for casualties of war and the practice of Memorial Day became common. Across the North and the South, the fallen from both sides of the war were honored, respected, and remembered, continuing their service even in death by helping to reunite the country.

At any National Cemetery today blooms of scarlet are seen. Red poppy flowers are placed on the graves of many war dead, a tradition that dates to World War One. In 1915, after the Second Battle of Ypres, red poppies grew over the graves of some 120,000 casualties. A sea of red, to cover the blood that had been shed. The poem, “In Flanders Fields” by John McCrae, was written about the battle describing the flowers growing on graves. With it, the practice of placing red poppies on the graves of the fallen became common. The practice holds in many other countries as well, serving as an international symbol to honor the fallen.

During the Vietnam War, another somber Memorial Day tradition developed. To recognize those soldiers who were missing in action or had become prisoners of war, military dining facilities set a Missing Man table. The table is usually set for one, to symbolize their isolation. A slice of lemon is placed on the plate, to represent their bitter fates. Salt is sprinkled on the plate to represent the tears of their families. The drinking glass is inverted, to represent that they cannot partake in the meal. The chair is empty to represent their absence. Lastly, a single candle is lit to represent hope and illuminate their way home. This tradition reminds us that while we may enjoy the freedoms in our lives, those freedoms are earned by the protection and sacrifice of others.

One-million, three-hundred and four thousand, six hundred and eighty-four. As I sit here, tallying the scores of fallen soldiers I am reminded of an apocryphal quote from Josef Stalin, “The death of one man is a tragedy. The death of millions is a statistic.” The point of Memorial Day is to stand in stark contrast to that statement; to make the deaths of millions into one tragedy at a time. Memorial Day has helped mend the wounds of the Civil War, of World War One, of the Vietnam War and of countless other conflicts by bringing disparate sides together in their common loss. This Memorial Day, let us remember the good that so many sacrificed for and in so doing find that which brings us together.

Tej Ishaan Mehta, MD, is an Internal Medicine Resident at MCW and a Captain in the United States Air Force Medical Corps.

Rituals Stir our Memories and Push us toward Transformation

 From the 5/28/2021 - Memorial Day - newsletter

Director’s Corner

Rituals Stir our Memories and Push us toward Transformation 

Adina Kalet, MD MPH

In this week’s Director’s Corner, Dr. Kalet asks us to both attend to our need for commemoration of the very difficult time with rest and reconnection while we also work to sustain hard won transformative gains …

Memorial Day weekend is especially poignant this year. As a nation, we are exhausted. We have collectively experienced fourteen months of a frightening, isolating, unpredictable pandemic, an eye-opening year since the murder of George Floyd, widespread calls for social justice, and a nail-biting presidential election. We have been irrevocably changed and are emerging - in fits and starts - into a new post pandemic reality. Now that many of us have been vaccinated against SARS-CoV-2, we are eager for the summer season to kick off.

In many ways, the past months have forced us to innovate, create, and find new ways to conduct our lives. It is not yet clear which of these changes are good or sustainable, but we are different now than we were then.

Rituals and gratitude are important as we honor those who have served

In this Transformational Times issue, Capt. Tej Ishaan Mehta MD, who is an Internal Medicine resident at MCW, movingly recounts how Memorial Day came to be after the Civil War, when our deeply divided nation emerged from that awful, bloody conflict. He writes, “Across the North and the South, the fallen from both sides of the war were honored, respected, and remembered, continuing their service even in death by helping to reunite the country.”  He reminds us that ritual and symbolism have the power to bridge our gaping chasms and heal our festering wounds. 

This issue also features a fascinating excerpt from Richard N. Katchske’s new book, Knowledge Changing Life: A History of the Medical College of Wisconsin, 1893-2019. Mr. Katschke, MCW’s Chief Historian, describes our medical school’s mobilization during World War II.  Our faculty and students served the nation by embracing a dramatically accelerated curriculum to ensure a supply of physicians prepared to go to war. And go to war they did. Many served with great distinction, and one made the ultimate sacrifice. I plan to read Katschke’s entire book (I will share some highlights) and recommit to a favorite pastime of studying the class portraits that line the hallways on the main floor of the medical school building. I will inspect the faces and uniforms, knowing that many served overseas or at home in a war effort. How many were impacted by WWI, WWII, Korea, Vietnam, Iraq, and Afghanistan? Who went on to have careers touched by the influenza pandemic of 1918, by HIV/AIDS, or by other national challenges?  I will wonder. 

On this day, we honor the individual soldiers who made the ultimate sacrifice to protect and defend our many precious freedoms.  It is important to commemorate them, and we must support their grieving families and the loved ones who were left behind. It is a somber but awesome opportunity to take time to honor their losses, recognize their sacrifices, consider what they have taught us, and pledge to make a difference in the world they shaped. 

An evening ritual in New York and beyond

The response to COVID-19 inspired its own rituals. Starting mid-March 2020, at 7:00 p.m., everyone on my block in Brooklyn, NY came out on their stoops to make “noise” (some had musical instruments) for a good twenty minutes to celebrate the health care and essential workers who went to work every day at the hospital around the corner. This nightly ritual, which was occurring at 7:00 p.m. all over the globe, continued daily for many months, and evolved into a means for neighbors to check in with each other and socialize. It was so joyous and silly, that I found that I missed it when it petered out. 

Although not a part of our national Memorial Day commemoration, those of us in health care, and those whose families have been touched, also remember relatives and friends who died from COVID-19. The rituals to honor front line health care workers and first responders remind us that, as a society, we must address the unconscionable health disparities and social ills that put so many, particularly our Black and Brown citizens, at outsized risk.  As of yesterday, an estimated 3,511,748 worldwide have died of COVID-19, and it isn’t over yet. In many parts of the world, hospitals resources are overwhelmed, oxygen is not available, and vaccine supplies and infrastructure are inadequate. Despite the circumstances and at enormous personal risk, our international health care colleagues face the pandemic and do their duty with character and compassion. Heroes are everywhere. Perhaps someday soon, there will be a COVID-19 Remembrance Day.

Medical Education will continue to transform 

How will we remember these pandemic times? Will they change our work when things return to something resembling “normal”? I suspect that there will be many tell-tale signs stamped on our educational practices. We have new levels of savvy with technology-enabled education, admissions processes, international conferences, and performance-based assessments. We have narrowed the “digital divide” between us and our applicants and students to address issues of equitable access. Even if a significant proportion of medical education remains remote, we will be better at enhancing face-to-face sessions with meaningful, integrative faculty-led small group experiences. While fancy equipment and simulators might be irreplaceable for some types of teaching, expanded use of low-cost virtual reality devices and mobile apps offer areas of untapped potential. As we harness new educational practices, what we discover will become endlessly scalable. 

Emerging from the pandemic will also help us re-commit to preparing our trainees to practice in, and influence, health care systems. How do we help our students and trainees see the “big picture” of medicine in society? How do we enable our trainees to provide outstanding, equitable health care to the marginalized? How do we prepare for future pandemic and health crises? Can we embrace technology, yet keep medicine humane? We will need to integrate the transformational goals of the Kern Institute into a constantly evolving medical education landscape.

Wars and pandemics have lead to unspeakable, senseless horror. Both, however, have also resulted in opportunities for innovation. Battlefield medicine during WWII led to life-saving civilian improvements in trauma care, limb salvage, reconstruction, and antibiotic use. The pandemic offers opportunities, as well and, as we commemorate the many losses of the past year, we will fiercely embrace the future. 

Too many have died both in battle and from preventable, treatable disease. We insist that they did not die in vain, and pledge to learn something good and important in their honor. 

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.

Stand Up for What You Believe In

From the 5/28/2021 - Memorial Day - newsletter

Perspective/Opinion

Stand Up for What You Believe In

Chad Kessler, MD

Dr. Kessler is the National Program Director, Emergency Medicine, Department of Veterans Affairs.  He is also a professor at Duke University and a staff physician at the Durham VAMC. He is the epitome of charismatic and inspiring VA leadership.  Here is an essay that he generously let us share from one of his twice weekly newsletters ...

So, I was sweating through my Thomas Pink button down shirt this late Friday afternoon and eon or two ago.  I was still in the hospital at 6:00 that day, stewing in this tiny, windowless room…not only because of the jungle like temperature, but the unfamiliar and frankly unnerving environment. As a young chief, this was all very new to me, and having to sit with these top leaders was terrifying, and only intensified by the news I had to share. We were short on coverage, I felt that we were teetering on unsafe care in our Emergency Department, and I needed to advocate for staff in a miserable budget year.  That word…I didn’t realize how much power was in that single word.  I literally remember the second when the Boss stopped the meeting in mid-sentence, and said, “Kessler, did you say we have an ‘unsafe’ environment?” Like I had uttered a profanity in Temple or put ketchup on a hot dog.  I looked around, realized everyone was staring at me, and said prophetically, in my best Homer Simpson voice, “uh…yes.”  I’ll be honest, I don’t remember much after that, except feeling like I said or did something wrong (even though I knew I wasn’t wrong), that people were mad at me, and that I truly may get fired…but I got home, gave my wife a hug, the kiddos jumped into my arms, grabbed myself a two liter chai and thought in my head, I did the right thing, right?     

 

Here’s the moral of my tale…Stand up for what you believe in, even if you’re standing alone! It may be pressure from your boss to not open your mouth, it may be your team telling you everything is fine or it may be that little voice (you know, the easier wrong voice) whispering to you how much you really like your job...and don’t really feel like updating your CV.  But whatever it is, make sure you’re doing what is right in your mind.  It’s your name on that memo, on that patient chart, it’s your voice they will hear, and it’s your conscious you will live with for years to come.  So, make sure you do the right thing, take the harder right, and stand up for what you believe in…even if you’re standing alone.

 

Just for closure sake, we did end up getting that additional coverage for the ED, and I did not get fired.  In fact, I specifically remember one of the senior leaders coming up to me later that week, telling me how brave that was…and was indeed the right thing for patient care. If only he was standing with me during that meeting…but nonetheless, alone or together, we need to stand strong for what we believe in.

Dr. Kessler curates an amazing series called “C20” or Covid in 20, which currently has over 100 informative episodes on a variety of topics from “COVID and the law (Episode 63) to COVID and delirium (Episode 28).  Some are VA specific, but many are not.  Click here to check them out.