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General Medicine

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Finding a Mentor: The Complete Examination of an Online Academic 
   Matchmaking Tool for Physician-Faculty
Make Your Own Mistakes
Professionalism: Capacity, Empathy, Humility and Overall Attitude
Professionalism: Secondary Goals 
Professionalism: Definition and Qualities
Professionalism: Introduction
The Unfulfilled Promise of the Quality Movement
A Comparison Between Hospital Rankings and Outcomes Data
Profiles in Medical Courage: John Snow and the Courage of
   Conviction
Comparisons between Medicare Mortality, Readmission and 
  Complications
In Vitro Versus In Vivo Culture Sensitivities:
   An Unchecked Assumption?
Profiles in Medical Courage: Thomas Kummet and the Courage to
   Fight Bureaucracy
Profiles in Medical Courage: The Courage to Serve
   and Jamie Garcia
Profiles in Medical Courage: Women’s Rights and Sima Samar
Profiles in Medical Courage: Causation and Austin Bradford Hill
Profiles in Medical Courage: Evidence-Based 
   Medicine and Archie Cochrane
Profiles of Medical Courage: The Courage to Experiment and 
   Barry Marshall
Profiles in Medical Courage: Joseph Goldberger,
   the Sharecropper’s Plague, Science and Prejudice
Profiles in Medical Courage: Peter Wilmshurst,
   the Physician Fugitive
Correlation between Patient Outcomes and Clinical Costs
   in the VA Healthcare System
Profiles in Medical Courage: Of Mice, Maggots 
   and Steve Klotz
Profiles in Medical Courage: Michael Wilkins
   and the Willowbrook School
Relationship Between The Veterans Healthcare Administration
   Hospital Performance Measures And Outcomes 

 

Although the Southwest Journal of Pulmonary and Critical Care was started as a pulmonary/critical care/sleep journal, we have received and continue to receive submissions that are of general medical interest. For this reason, a new section entitled General Medicine was created on 3/14/12. Some articles were moved from pulmonary to this new section since it was felt they fit better into this category.

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Monday
Dec082014

Finding a Mentor: The Complete Examination of an Online Academic Matchmaking Tool for Physician-Faculty

Guadalupe F. Martinez, PhD1

Jeffery Lisse, MD1

Karen Spear-Ellinwood, PhD, JD2

Mindy Fain, MD1

Tejo Vemulapalli, MD1

Harold Szerlip, MD3

Kenneth S. Knox, MD1

 

1Departments of Medicine and 2Obstetrics and Gynecology, University of Arizona, Tucson, AZ

3Department of Medicine, University of North Texas Health Science Center Department of Medicine, Fort Worth, TX

 

Abstract

Background: To have a successful career in academic medicine, finding a mentor is critical for physician-faculty. However, finding the most appropriate mentor can be challenging for junior faculty. As identifying a mentor pool and improving the search process are paramount to both a mentoring program’s success, and the academic medical community, innovative methods that optimize mentees’ searches are needed. This cross-sectional study examines the search and match process for just over 60 junior physician-faculty mentees participating in a department-based junior faculty mentoring program. To extend beyond traditional approaches to connect new faculty with mentors, we implement and examine an online matchmaking technology that aids their search and match process.

Methods: We describe the software used and events leading to implementation. A concurrent mixed method design was applied wherein quantitative and qualitative data, collected via e-surveys, provide a comprehensive analysis of primary usage patterns, decision making, and participants’ satisfaction with the approach.

Results: Mentees reported using the software to primarily search for potential mentors in and out of their department, followed by negotiating their primary mentor selection with their division chief’s recommendations with those of the software, and finally, using online recommendations for self-matching as appropriate. Mentees found the online service to be user-friendly while allowing for a non-threatening introduction to busy senior mentors.

Conclusions: Our approach is a step toward examining the use of technology in the search and match process for junior physician-faculty. Findings underscore the complexity of the search and match process.

Introduction

Across the spectrum of disciplines within the academy, it is well documented that mentorship is key to career advancement and satisfaction among faculty (1). For physician-faculty, mentoring is “considered to be a core component of the faculty duties…to fulfill…th(e) academic medicine mission” (2). Although important, structural barriers to mentorship still exist (2,3). Finding an appropriate mentor is critical not only in establishing a productive and engaging mentorship, but in having a successful career in academic medicine (4). However, scholars note that finding the most appropriate person is not without its challenges: especially for junior faculty (3-7,9). Some studies find that junior faculty (and faculty new to institutions) depict the search process as the most difficult step in establishing a mentorship (3,7,9,10). In these studies, mentees recommend a match process that begins with a comprehensive list of potential mentors that includes contact information (3,7). Although noteworthy, this recommendation fails to elaborate on the extent to which a mere list could improve the search and match process. How such lists are implemented or if supplemental mechanisms were used to connect unfamiliar faculty is unclear.

Prior literature stresses the importance of “effort and persistence” when embarking on a search (3,4,9). Through this seemingly daunting process, scholars specifically advise mentees to ask colleagues to connect them to others with similar interests, and invest time into researching the backgrounds of potential mentors to determine their suitability. However, there are inherent challenges to this approach. First, the time spent investigating mentor backgrounds may vary greatly depending on the number and quality of resources available to conduct such an investigation. Second, mentees new to an institution could find it difficult and/or unproductive to ask new colleagues to connect them to potential mentors as colleagues may not be able to make an appropriate connection if they are unfamiliar with the mentor pool. Although this could point mentees in the right direction, they could spend an inordinate amount of time meeting with numerous contacts only to find academic and clinical interests to be unrelated or tangentially related to theirs. Previous studies found that mentees who self-match with a mentor, are more likely to be satisfied with their mentorship experience (3,4,7,8). Yet, if the institutional mentoring culture functions as described above, mentees would have to rely solely on their division chief or department chair for an assigned mentor. This could be problematic if the chief or chair is unfamiliar with the strengths of the mentor pool.

In hallmark studies by Williams et al. (7), and Straus et al. (3), they highlight perceived barriers to mentorship from the mentee perspective, and find those to be: a) a lack of local and adequate mentor selection, b) time constraints for the mentors, c) inadequate access, and d) a lack of formal programs and mechanisms to connect faculty. Straus et al.’s (3) study also sheds light on mentees desire to choose a mentor instead of being assigned. They find that mentees perceive assigned partnerships as superficial, but that assigned matches are sometimes useful because the search process is challenging for those new to an institution. Given the conflicting perceptions, these authors call for additional strategies to improve the search and match process as well as an examination of those strategies. Methods to optimize mentees’ time and diversify searches have yet to be delineated. More importantly, the role technology could play in mentoring remains understudied. As identifying the mentor pool and improving the search process are paramount to both, a mentoring program’s success, and the academic medical community, innovative approaches are needed.

We build on the work of Straus et al. (3), and Sambunjak et al. (10) by examining the search and match process for physician-faculty mentees participating in our department-based mentoring program. In our cross-sectional study we seek to better understand internal matching behaviors and the role technology could play. We detail and explore technology aimed at improving the search and match process for our mentees. This “matching” tool further advances our knowledge about the role technology could (or could not) play in addressing the challenges associated with the search and match process. Our research questions ask: If a “matching” tool is implemented, what would the matching behavior be within the department? What are the primary usage patterns among mentees? How receptive have mentees been in adopting this mechanism to aid their search and matching efforts?

Methods

The University of Arizona’s Department of Medicine developed a department-based faculty mentoring program in March 2011 during which a needs assessment was conducted on junior physician-faculty. First, like Straus et al.’s (3) findings, mentees partaking in our needs assessment desired assistance with the search and match process. Mentees reported a lack of knowledge about available mentors, their areas of expertise, and difficulty establishing contact with senior faculty.  The committee concluded experimenting with a computer program that functioned much like an online matchmaking service would improve the process; extending matching beyond the common strategies of contact list distribution, top down assignments, and informal social forums. The committee then customized an online matchmaking program, Mentor Match© (Intrafinity Inc., Ontario), to create a “virtual space” for mentor and mentee use. The committee crafted a “one-stop shop” where faculty accessed mentor/ mentee profiles containing academic interests, department mentoring events, and mentorship contract templates (Figure 1).

Figure 1. University of Arizona department of medicine opening user console view.

It was suspected that our faculty demographics included an overrepresentation of junior faculty (assistant professor rank) as compared with the number of senior faculty (associate and full professor rank) (11,12).  Also evident was that commitments to medical students and trainees prevented senior faculty from being able to devote sufficient time to mentor junior faculty. As such, the committee piloted an interdisciplinary approach and included mentors outside the department and College of Medicine to compensate for the low number of available mentors in Medicine (e.g. Public Health).

Methodology

A concurrent mixed method design was applied. We triangulated quantitative (numerical) and qualitative (descriptive) data to provide a comprehensive analysis of the primary usage patterns related to search and match behavior, and understand satisfaction with the online tool (13). We generalized results to our sample and then explored nuances based on narrative feedback.

Implementation

With the official launch of the mentoring program in January 2012, Mentor Match© went live to connect over 100 physician-faculty and faculty-researchers. At this time, the Department of Medicine had 65 junior faculty in search of mentors. A combined total of 54 mentors (N=32 full professors; N=22 associate professors) from the Department of Medicine, Department of Emergency Medicine, and College of Public Health served as mentors for this group.

Faculty profiles include email addresses and detailed background information about each faculty member (e.g. academic track, age range, overall years teaching) (Figures 2 and 3).

Figure 2. University of Arizona department of medicine mentor/mentee profile and skills inventory.

Figure 3. University of Arizona department of medicine mentor/mentee profile and skills inventory.

Once faculty data is entered, Mentor Match© produces a complete listing of top recommended mentors based on similarities between mentees and mentors. One-on-one demonstration of how Mentor Match© works occurs during new faculty orientation. Current CVs are uploaded and available for in depth review of publication record, training history and current funding. Junior faculty can also access other junior faculty profiles in the department to form peer mentoring groups.

Participants, data, and analysis

Voluntary mid-year and annual assessments are components of the mentoring program. IRB approved questionnaires developed by the committee were disseminated to program participants as part of a broader study and program quality control. For ongoing program evaluation and to inform the committee, we collected data from five sources: a) committee meeting minutes, b) observation notes, c) human resources faculty rosters from 2011-2012; 2012-2013, d) 2011 junior faculty needs assessment report, and e) voluntary end-of-the-year questionnaires.

Study participants included only mentee MD’s, DO’s, PhD’s, MD/PhD’s, and MD/MPH’s with the rank of Assistant Professor, Lecturer or Research Scholar in the Department of Medicine on one of three faculty tracks: clinical-educator, clinical, and research.  

Cross tabulations formulated in SPSSv21 were used as part of survey analysis to compare categorical data from faculty rosters and questionnaires relevant to matching behavior and usage patterns. Qualitatively, document analysis using thematic coding for trend identification was conducted using Nvivo 10 to analyze narrative comments. Similarly, document analysis and thematic coding was implemented on committee meeting minutes, observation notes, and faculty roster to report the events and decision making process involved in the implementation of the program and matching tool (Figures 4 and 5).

Figure 4. Mentor match questionnaire (end-of-year).

 

Figure 5. Analysis coding scheme for setting description in methods and results.

 

Results

The program began with 65 mentees in January 2012. After annual faculty attrition, 72% of mentees (44/61) reported using the software and completed the voluntary end-of-year questionnaire in January 2013.

Selection patterns

Mentees were asked to report their primary use of Mentor Match©. Three usage patterns were apparent (Appendix D, Table 1.0a). Over half of mentees reported primarily using the software to search for potential mentors both in and out of the department. Almost a third of mentees reported mainly using the software to search for potential mentors within the department only. Just under 10% (4/44) of mentees reported primary usage of the software to expand their professional peer network. Slightly over half of males utilized the software to search for potential mentors both in and out of the department. However, among females, this latter usage pattern was even more prevalent (17/25; 68%). Among those reporting primary usage to search for professional network expansion, males reported this practice at a disproportionately higher rate (3/19; 15%) than that of their female counterparts (1/25; 4%).

While mentees considered the recommended list of potential mentors from Mentor Match© in their match decision, just over half reported negotiating their primary mentor selection with their division chief’s recommendations (25/44; 57%). This means that mentees discussed their search results and interests with their chief to come to an agreement about who would serve as their mentor (Tables 1-3).

Table 1. Questionnaire results: gender.

 

Table 2. Questionnaire results: Search and matching behavior after Mentor Match© implementation in the department primary use and gender cross tabulation.

 

Table 3. Match results and gender cross tabulation.

 

In this “negotiation” the mentee and chief come to a consensus instead of the chief assigning a partnership with no input from the mentee, a relatively common practice prior to this mentoring initiative. For the mentee, there is a sense of self-matching with guidance from the chief. This match pattern occurred proportionate to the respective totals of male and female mentees. An extremely small minority of junior faculty, all males, did not have mentors at the time of data collection (2/19; 10.5%). Finally, the next most common match patterns were the forced assignment (9/44; 20%) followed by the self-matched (8/44; 18%). At almost an even rate, female (5/25; 20%) and male (4/19; 21%) mentees reported considering the software’s top recommended mentors, but were ultimately assigned a mentor by their division chief. Remaining mentees (4/25; 16% females and 4/19; 21% males) reported considering the software’s recommendations, but eventually self-matched to a mentor of their choice.

Mentee feedback

The vast majority of mentees (40/44; 91%) found the software user-friendly, reporting that they would use the software for ongoing searches (Table 4). Questionnaire comments included positive feedback. Mentees’ appreciated the: a) non-threatening forum enabling access to detailed information about potential mentors, b) forum’s convenience, and c) functionality allowing access to research scholars outside the department. Finally, recommended improvements called for introductory training on website navigation, and viewing access to junior peer profiles.

Table 4. Mentee feedback.

 

Discussion

Building on Zerzan et al.’s (9) guide, we provide a robust description of implementing a software-based mentoring program. This software serves as a faculty directory and matching tool to facilitate mentors-mentee relationships in a large clinical department. Our systematic approach toward matching is a first step toward examining the use of technology to ease the search and match process for junior physician-faculty. We discovered that a “negotiated approach”, where junior faculty Mentor Match© selections were then explicitly discussed with division chiefs and department heads, was highly used and valued. Our data suggest that knowledge of local organizational culture or other information that can only be imparted through discussions with their chiefs and colleagues, are also highly valued.

Sambunjak et al.’s (10) qualitative study highlights the complexity of navigating partnerships. Our findings extend these observations to the search and match process, which is just as complex. More in-depth examination of the decision making process for those using software based matching or self-matching is needed to better understand what leads to junior faculty securing successful mentoring relationships. The shortage of mentors found in our needs assessment mirrored findings from national studies,11,12 implying that mentoring junior faculty is a challenge or not a priority compared to students, residents, and fellows. Given today’s heavy emphasis on clinical productivity and formal responsibilities teaching \ trainees at all levels, inspiring senior faculty to mentor junior faculty could be particularly difficult (5,15).  Departmental leaders and program administrators must realize mentor shortages will impact the search experience regardless of methodology employed. The consequences of not addressing barriers in mentorship may include frustration with the search process, junior faculty turnover, and erosion of an important part of the academic culture. In addition to heeding recommendations by Straus et al. (3) of providing protected time and formal recognition for mentoring, departments should foster interdisciplinary networks inside and outside of the medical discipline, leverage the emeritus professor workforce, and embrace mentor panels. Technology based mentor searches could facilitate implementation of such initiatives with the goal of improving professional satisfaction among mentees.

Limitations

Our study examines the usage patterns of and feedback on Mentor Match© from the junior faculty mentee perspective, but there are limitations. First, we have not assessed whether and how mentors use Mentor Match© to research mentees who have reached out to them. Knowing if immediate access to mentees’ backgrounds and skills assists mentors in deciding whether to accept a mentorship or refer them to a colleague could inform us about the potential benefits of this software tool for mentors. This study also draws on a small mentee self-reporting sample in one department with just over half of all junior faculty participating. Although the sample is small, particularly regarding software feedback, findings provide a starting point to learn the technological needs of faculty related to the search and match challenge. Such data helps us tailor online profiles and site navigation. Finally, we also do not know whether there is a significant advantage to “negotiated” mentorships as compared with those established solely by using Mentor Match©.

Despite these limitations our study is the first to assess the role technology could play in the search and match process for physician-faculty. Casting the online matchmaking net more broadly to include other colleges and including trainees could add another dimension toward understanding how to improve the search and matching process in academic medicine.  

Conclusion

Our study details Mentor Match© implementation and illustrates that software driven approaches can assist physician-faculty in establishing mentoring relationships. This approach may complement other search and matching efforts ongoing in departments and may be used to connect faculty across disciplines. In general, this tool continues to have a positive impact in our department, helping to achieve our goal of facilitating and expanding the mentee’s professional networks.

Acknowledgments

Role of each author in manuscript preparation:

  • Dr. Martinez is the lead author of this paper. Participation included mentoring program committee membership, IRB documentation, data collection, study design, analysis, initial manuscript draft, revision implementation, approve final version.
  • Dr. Lisse’s participation included mentoring program committee membership, questionnaire design, manuscript review/editing, approve final version.
  • Dr. Spear-Ellinwood’s participation included data member checking, manuscript review/editing, approve final version.
  • Dr. Fain’s participation included mentoring program committee membership, questionnaire design, study design, manuscript review, approve final version.
  • Dr. Vemulapalli’s participation included mentoring program committee membership, questionnaire design, study design, approve final version.
  • Dr. Szerlip’s participation included chairing the mentoring program committee, manuscript review/editing, approve final version.
  • Dr. Knox is the senior mentor on this paper. Participation included mentoring program committee membership, IRB documentation review, study design, questionnaire design, manuscript review/editing, approve final version.

Funding:

This study was partially funded by an internal educational research award by the University of Arizona College of Medicine Academy of Medical Education Scholars in November 2012 and the Department of Medicine Administration.

Secondary Publication Notice:

This descriptive article is an unabridged report. A 500 word version of the full length manuscript is under review for primary publication in Medical Education’s Really Good Stuff section. This section presents short reports that illustrate general lessons learned from innovation in medical education, and include very little data and description.

References

  1. Savage HE, Karp RS, Logue R. Faculty mentorship at colleges and universities. College Teaching. 2004;52(1):21-4. [CrossRef]
  2. Sambunjak D, Straus SE, Marusie, A. Mentoring in academic medicine: A systematic review. JAMA. 2006;6(9):1103-15. [CrossRef] [PubMed]
  3. Straus SE, Chatur F, Taylor M. Issues in the mentor-mentee relationship in academic medicine: A qualitative study. Acad Med. 2009;84(1):135-9. [CrossRef] [PubMed]
  4. Jackson VA, Palepu A, Szalacha L, Caswell C, Carr PL, Inui T. Having the right chemistry: A qualitative study of mentoring in academic medicine. Acad Med. 2003;78(3):328-34. [CrossRef] [PubMed]
  5. Pololi L, Knight S. Mentoring faculty in academic medicine: A new paradigm? J Gen Intern Med. 2005;20(9):866-70. [CrossRef] [PubMed]
  6. Benson CA, Morahan PS, Sachdeva AK, Richman RC. Effective faculty preceptoring and mentoring during reorganization of an academic medical center. Med Teach. 2002; 24:550-7. [CrossRef] [PubMed]
  7. Williams LL, Levine JB, Malhotra S, Holtzheimer P. The good-enough mentoring relationship. Acad Psychiatry. 2004;28:111–5. [CrossRef] [PubMed]
  8. Yamada K, Slantez PJ, Boiselle PM. Perceived benefits of a radiology resident mentoring program: Comparison of residents with self-selected vs assigned mentors. Can Assoc Radiol J. 2014;65(2):186-91. [CrossRef] [PubMed]
  9. Zerzan JT, Hess R, Schur E, Phillips, RS, and Rigotti, N. Making the most of mentors: A guide for mentees. Acad Med. 2009;84(1):140-4. [CrossRef] [PubMed]
  10. Sambunjak D, Straus SE, Marusic A. A systematic review of qualitative research on the meaning and characteristics of mentoring in academic medicine. J Gen Intern Med. 2010;25(1):72-78. [CrossRef] [PubMed]
  11. Data and Analysis: Faculty roster. Distribution of full-time faculty by department, rank, and gender. 2012. Available at:  https://www.aamc.org/download/305522/data/2012_table3.pdf (accessed 12/8/14).
  12. Stacy J, Williams LP, Blair-Loy M. Medical professions: The status of women and men Center for Research on Gender in the Professions University of California- San Diego; 2013. Available at: http://crgp.ucsd.edu (accessed 12/8/14).
  13. Creswell JW. Research design: qualitative, quantitative, and mixed methods approaches 3rd edition. Thousand Oaks: Sage Publications, Inc.; 2009.
  14. DeCastro R, Sambuco D, Ubel PA, Stewart A, Jagsi R. Mentor networks in academic medicine: moving beyond a dyadic conception of mentoring for junior faculty researchers. Acad Med. 2013;88(4):488-96. [CrossRef] [PubMed]
  15. Berger TJ, Ander DS, Terrell ML, Berle DC. The impact of the demand for clinical productivity on student teaching in academic emergency departments. Acad Emerg Med. 2004;11:1364-7. [CrossRef] [PubMed]

Reference as: Martinez GF, Lisse J, Spear-Ellinwood K, Fain M, Vemulapalli T, Szerlip H, Knox KS. Finding a mentor: the complete examination of an online academic matchmaking tool for physician-faculty. Southwest J Pulm Crit Care. 2014;9(6):320-32. doi: http://dx.doi.org/10.13175/swjpcc138-14 PDF

Friday
Aug292014

Make Your Own Mistakes

Michael S. Chesser,  MD

 

Department of Medicine

Phoenix VA Medical Center

650 E. Indian School Road

Phoenix, AZ 85012-1892

 

One of the many adages that we collectively pass on to our medical students and residents is the concept of “making your own mistakes.” In other words, one should not compound the mistakes of others by failing to make one’s own assessments and treatment decisions. I frequently recount certain stories to my house-staff in order to illustrate how easily even conscientious doctors can violate this rule! Here is one such story.

Between the autumn of 2008 through the spring of 2009 I was assigned to Joint Base Balad in Iraq, flying Critical Care Air Transport (CCATT) with the U.S. Air Force. I was the physician on a 3 person team with the task of providing en route critical care for ICU/Trauma patients during our standard air evacuation flights on cargo aircraft. Our transcontinental flights were on the C-17, an enormous aircraft designed to transport large cargo like main battle tanks--not the critically wounded! Our patients were often on ventilators with every imaginable tube emanating from them. The typical patient was intubated and possessed many of the following: chest tubes, a suction tube coming from their still-open and packed abdomen, a ventriculostomy, external fixators on shattered limbs, or outright missing limbs. As we were often charged with flying more than one of these complex patients we had to rapidly assess them and ensure they were adequately stabilized and try to predict any of the things that could go wrong with them in flight. Once we were airborne and on our way to Germany, we were essentially on our own! Anything we failed to anticipate and have a response for could prove catastrophic as we only had the ability to run a few basic labs on a portable i-STAT device. With the noise of the aircraft I could not even use my stethoscope to any effect. We were always pressed for time as the air crew was always determined to takeoff well before the sun came up. The reason for this being that large cargo planes parked on airfields in locations where insurgents are looking to shoot anything they can at you are ripe for disaster. We typically flew these missions at night to improve our odds of reaching a safe altitude before anyone could try something nefarious. Our equipment allowance and procedures allowed for us to care for up to 6 patients at a time with up to three on ventilators.  It was quite common to have last minute patient's added on—“as we were going anyway” and “had space.” These continual changes added to the chaos, but I had at least learned to always expect my eventual patient mix to look nothing like the initial briefing that we would receive after first being alerted. 

It was in this milieu where my nurse, who I might add is a veritable icon of clinical virtue, prevented me from egregiously violating the aforementioned rule. It was shortly before midnight local time when we entered our ICU in order to get our allotment of patients ready for transport to the flight line and situated on the aircraft. This particular mission was atypical as we only had two patients assigned and neither was on a ventilator. While I was still reviewing the first patient’s chart, one of the ICU nurses made a point to approach me and tell me that our other patient was being “nasty” and “drug seeking.” I made a mental note of this and took a quick glance at him across the small ICU bay. I could tell he at least looked stable and apparently had a broken leg. My nurse was at his bedside talking to him. At this point, I diverted my attention back to what I was initially doing. It was mere moments after this that one of the ICU doctors came over to complain to me about what a “jerk” (he used much stronger language) this patient was being! The doctor was describing the patient as disoriented and abusive. Of course, the first thoughts that came into my mind were along the lines of “I so don’t have time for any nonsense from this guy…” and “just my luck to have to deal with a disruptive and difficult patient.”   

Now that the figurative poison was starting to diffuse in my mind, I felt myself start to get indignant. I was telling myself that I was in no hurry to go over and assess the second patient. Fortunately, a few moments later my nurse was next to me wearing one of her expressions I knew so well. I was immediately relieved to realize I was not the object of her frustration (this time.) I had flown with her long enough to have a few of her annoyed looks cataloged.  It was apparent that our colleagues were greatly failing to meet her expectations! In no uncertain terms, she informs me that this unfortunate soldier had a substantial hip fracture and was in immense pain. Furthermore, he was sorely under medicated. Of course, he was agitated and not on his best behavior! My sense of indignation rapidly gave way to pangs of guilt as I realized I was on the crux of perpetuating this mistake! My pen flew from my flight suit pocket to the order sheet she held to correct this omission. This “difficult” patient’s demeanor and mental status improved dramatically once we started to get better control of his pain. During the bumpy ambulance bus ride to the flight line my team and I wedged our thighs underneath his stretcher to try to lessen the bouncing and improve his comfort. He was remarkably patient with us considering how much the extra bouncing hurt him.

Over the next several hours, on the flight from Iraq to Germany, I learned more of his story. He was a middle-aged soldier who had fallen approximately 30 feet from a Blackhawk helicopter landing on unforgiving concrete below. In addition to the physical trauma, he had been subjected to the added mental torment of not being able to get into this helicopter as it was taking off. He found himself clinging frantically to the wheel, reportedly unseen by the pilot, until he could maintain his grip no longer and fell. With that mechanism of injury it was amazing that the only thing broken was his hip and a few ribs and that he was still alive! In addition, the CT scans revealed he had a relatively small amount of intracranial bleeding and some parenchymal contusion of his lung. Despite significant continued pain--especially associated with all the bumps involved in transferring someone from one continent to another using an array of stretchers, ambulance busses and military cargo planes--the patient was in pretty good spirits by the time we arrived at the ICU in Germany the following morning. He was now a huge fan of my nurse and rightfully so! A couple of days later, when we were back in Iraq my nurse presented me with a challenge coin, a small coin bearing his unit's insignia, from his assault helicopter battalion. He had called a friend in his unit expressing immense gratitude for my team and asked his friend to convey these coins to us. Anyone who has served in the military will tell you that these seemingly small trinkets are often used to mark highly meaningful events. It was at this point that I finally reflected on my own thought processes that cold desert night and heard the voice of one of my attendings from twenty-plus years ago –“Chesser, make your own mistakes.”

Reference as: Chesser MS. Make your own mistakes. Southwest J Pulm Crit Care. 2014;9(2):142-4. doi: http://dx.doi.org/10.13175/swjpcc113-14 PDF

Thursday
Aug072014

Professionalism: Capacity, Empathy, Humility and Overall Attitude

Robert A. Raschke, MD

 

Banner Good Samaritan Medical Center

Phoenix, AZ

 

Recall we have previously defined professionalism and agreed on our primary goal as physicians, and reviewed competing goals that sometimes threaten to distract us. Recall that the Oath of Maimonides brought to mind a few attributes of the good physician that we discuss next. This list is not complete, but a good start. (If you think of others, please comment – I am trying to learn this topic myself in more depth, and would appreciate your thoughts).

Capacity

You have to be cognitively, psychologically and physically healthy to do your best work, but we all have natural tendencies that might need to be overcome in order to optimize our capacity. For instance, I am fundamentally very lazy intellectually (and otherwise). I found I had trouble keeping current with medical literature once I finished fellowship training and went into practice, since I no longer had to worry about being periodically formally tested. But my career choice in medical education helped counteract my laziness. I started a monthly Critical Care journal club within our fellowship, which conveniently fulfills my job duties, but has the personal benefit of forcing me to keep up to date, practice formal rules of critical appraisal, and come to firm conclusions about whether and how each article should impact my patient care. I strongly recommend considering a career in a teaching program as an aspect of your personal professionalism. I’m not implying that doctors in non-teaching positions can’t be highly professional – this clearly isn’t true. But a teaching job emphasizes maintenance of your cognitive capacity and other aspects of professionalism as specific job duties, and protects time for you to work on them.

Teaching also multiplies our ability to bring wellbeing to our patients, through the professional actions of those who have learned from us. I seldom thought about this until just recently – but now it strikes me that we might do more good through the hands of our pupils than through our own.

I have had an interest in hemophagocytic lymphohistiocytosis for about 15 years, and have been made fun-of over the years by some of my partners because of my Don Quixote-like pursuit of that esoteric diagnosis. Persistence paid off though, and I was partially vindicated when I was able to publish a paper describing our experience with HLH in the adult ICU. I also presented our findings in relation to HLH many times to our residents in morning report and Grand rounds.

About a year ago, I received a phone call from one of our graduate residents, who had gone on to open practice in Flagstaff AZ – about a 2-hour car ride north of Phoenix. He was cross-covering a hospital service, and had picked up the care of a hospitalized 21-year old girl with fever of unknown origin, that reminded him of a patient with HLH that I had previously presented in morning report. He correctly diagnosed her with HLH, and was calling to arrange transfer down to Phoenix so that we could take her treatment forward. None of his partners had ever heard of HLH before and therefore had no chance of diagnosing it, and the patient having developed shock and multisystem organ failure would almost certainly have died without specific therapy. After a prolonged ICU stay she survived. Eventually she rehabilitated and returned to finish her college education at Northern Arizona University. My academic interest in HLH, and my role in teaching residents about it, had amplified my professional capacity in a way that I hadn’t expected.  

Happiness in your personal life will reflect on your professional capacity. This can be a very difficult balance, but your job as a physician should not endanger your primary personal relationships. If it does, you might want to look for a different practice, or different specialty within medicine. Enlist your spouse or partner in your work struggles. My wife (of 30 years) Carolyn has been a wonderful blessing to me in this regard. Carolyn is a teacher, but she knows a lot of medicine. She learned it by listening to me vent my work-related frustrations over the past many years. I sometimes bounce cases off her just to ask her what she thinks, having found that her intelligence and keen deductive powers often lead her to the proper course of action, even if she doesn’t know right medical semantics. At times, I feel like I can withstand almost anything that happens in the ICU because I know that Carolyn will be waiting to give me a hug when I get home. Do not sacrifice this blessing for your job, instead make it part of why you are a good doctor.

Physical health will also reflect on your professional capacity. Exercise regularly. Your routine workload ought not to prevent you from working out. If it does, I would recommend you figure out a way to remedy that, because you and your patients will ultimately suffer if your work hours are unhealthy for you. But I think this is rarely the case if you nurture good personal exercise habits. Figure out the physical activities that you enjoy, and make time for them. You ought to be able to get some exercise even during your busiest work weeks. Even a 15-minute work out is better than none at all, especially if you make it habitual over the long course of your life. Whether you enjoy walking your dog, running, yoga, weight-lifting or kayaking, your capacity to do good word will benefit from regular physical activity outside the hospital.

One last thought about capacity: Don’t take a job that would exceed anybody’s capacity to provide good care. I have seen hospitalists with a work list of 40-50 patients for their weekend rounds. No matter how efficient you are, no one can reliably do a good job with that magnitude of workload. As professionals we should set limits on how far we let business people direct our practice of medicine. 

Empathy

I once overheard an intern handing off the care of a patient to another intern, mention that he had ordered the nurse to “throw a Foley in” the patient. I may have been unfair in my quick judgment of the intern’s apparent lack of empathy, but the way he made this statement struck me as nonchalant, with an attitude that the insertion of a Foley catheter was of little consequence one way or another. I had not experienced having a Foley myself at that tender point in my life, but it did strike me that I wouldn’t want one unless absolutely necessary (in fact, it gave me the heeby-geebies just thinking about it).  I have wondered if we should all have to have IVs and Foley’s put in us during medical school, just to help us understand that procedures that seem trivial to doctors can be very stressful to a patient, and should not be undertaken without careful deliberation.

Many physicians relate experiences of personal illnesses to the growth of their own empathy towards their patients. I’ve noticed that as I get older, more and more of my patients are about the same age as my children. It helps me to see my son or daughter in these young patient’s eyes, and helps me appreciate how scared they might be.  But we can’t wait to have children, or to get sick in order to develop empathy. The best I have been able to do is to actively seek empathy at the bedside of my patients. The more you know about your patient, the more likely you are to feel it.  If you don’t particularly feel it, you can at least practice the actions of empathy.  It’s difficult to imagine a physician without empathy attending properly to all aspects of the pain and suffering of their patients.

Depending where you work, the proportion of patients who end up in the unit because of self-destructive behavior can sometimes get overwhelming. There are times when I have estimated that fully two-thirds of the patients on my service were there because of alcohol and drug abuse. It can be challenging to empathize with patients who are morbidly obese, or who are narcotic-seeking.  We have recently seen epidemic proportions of both in our unit. Recently, I was asked to consult on a 45-year-old woman with cellulitis. She had ceased walking 18 months ago because of progressive morbid obesity. She had severe emphysema related to a long history of smoking, and severe obstructive sleep apnea, but refused to use oxygen and BiPAP breathing-assist device that were prescribed by her physician. She had several doubtful unconfirmed diagnoses such as fibromyalgia for which she was addicted to narcotics. The reason I was consulted is that she was having progressive difficulty breathing. But the cause of this seemed pretty obvious to me – she had smoked 3 packs a day for 25 years, and she weighed almost 450 lbs. She was so fat it was amazing she could breathe at all.

She was at rest as I entered her room, but when she awoke to my presence, she suddenly appeared in painful distress. It looked to me like she was faking it. I couldn't get her to give me any useful history. All she wanted to talk about was how much pain she was in - when was her next dose of narcotics due? On examination, she was extremely poorly-kept, smelled bad, and had an abdominal pannus that literally hung down to her knees even while she was laying flat on he back. The chaffed skin underneath was where her cellulitis had blossomed. I have to say in all truthfulness that I was disgusted by her physical appearance, and I judged that her illness was 100% self-inflicted.

I think she might have sensed my unkind thoughts, because I could tell she didn’t like me much. She became very upset with my decision to withhold additional narcotics because they might worsen her breathing. I was relieved when I left her room, but we were clearly adversaries.

Before I came back to see her the next day, I thought about Maimonides prayer – “May I never see in the patient anything but a fellow creature in pain”.  How could I bring myself to sincerely look at this lady as a fellow human being in pain when I had such a judgmental attitude about her? I pondered this as I entered her room to look in on her.  I noted that she had required intubation overnight as I expected she might, but she was not heavily sedated, - in fact, she was actually more alert than she had been on the previous day. Although awake, she couldn’t speak because of the endotracheal tube – this was probably helpful, because it prevented her from riling me by asking for more narcotics. No one else was in the room.

I didn’t have a good plan for how to proceed, but I knew I wanted to make an effort to nurture some empathy for her. Without thinking too much about what I was doing, I took her hand and told her that I knew that everything that had been happening to her over the past few years had been very tough for her, and that I knew she was suffering. I said that she had a tough road ahead as well, but that we had some ideas that could help her (tracheostomy), and that I was going to do my best to get her better so that she could return home as soon as possible. I could feel these words become sincere as I said them. At one point I referred to her as “sister” – not as slang term - but as a way to express to her that I cared about her as a person. This wasn’t a technique – it came out of my mouth in response to kind feelings that I was beginning to have towards her. She listened attentively, and her eyes even got teary. When I was done, she wouldn’t let go of my hand for awhile. I didn’t know what else to say, so I just stood there holding her hand until it seemed like it would be OK to let go.

Another patient who taught me about empathy was a Native American woman who was admitted for an infected stage IV sacral decubitus ulcer. She was in her early-sixties, but she was a wreck. She had a history of noncompliance and had suffered severe sequelae of diabetes, with advanced ischemic heart disease, dialysis-requiring renal failure, blindness, and bilateral above-knee amputations. I remember that when I first heard about her, a very unkind thought entered my mind. Before I ever even met her, I questioned whether it was worth to exert the effort to get her over her acute illness. Her body was so ravaged that I felt that her life wasn’t worth the extensive effort it was going to take to prolong it.

I realized this was a very bad way to think of a patient, so when I met her, I asked her some questions unrelated to her medical history, for the sole purpose of learning more about her – in a search for empathy – in an attempt to understand the value of her life. I asked about her kids, and she told me a story about her youngest son that stuck in my mind. She said she was driving with her husband down a lonely unpaved road on the Indian reservation one day, about ten years previously, when they saw a boy about 12 years old walking off on the dusty shoulder ahead of them – miles from the closest building. She said she knew that boy – had seen him wandering around the reservation - knew he didn’t have parents that cared about him. She said “I wanted that boy”. She told her husband to pull over. Simple as that. The boy got in the car and went home with them.  She raised him as though he was her own son without ever officially adopting him as far as I could tell. He had grown up to be a fine man, and became a teacher. She told me that she had 8 children. Four by birth and four by “adoption”. All of her adult children worked serving others –as teachers, nurses, one as a physical therapist. This information vastly corrected my deficient empathy in the care of this patient. Most patients can provide you with something you can use to connect with them if you seek it out.

I have prejudices that I will probably never overcome. The only advice I can give is to be aware of your prejudices and do your best to find some way to love each of your patients.  You cannot be a good doctor for your patients unless you care about them and are committed to helping reduce their suffering, whether their illness is their fault or not.

Humility

Humility is a characteristic that hangs in the balance with our pride, waxing and waning over the course of our career. We all try to achieve the self-confidence we need to make big decisions under stress, but maintain the humility to recognize and correct our mistakes and accept the help of others. I learned an important lesson about my own pride and lack of humility by observing pride get the best of one of mentors.

When I was a resident in the ICU in the mid 1980s, I was on call under the supervision of my mentor and hero who had been an attending for about 3 years at that time. We got called to the bedside of a patient on mechanical ventilation who was suffering acute shock. We both stood by the bedside trying to figure out what was going on as the nurses got IV fluids and pressors started. The patient continued to deteriorate, and my attending called for a chest X-ray to rule out pneumothorax. As we waited for the radiology tech to arrive, the patient rapidly deteriorated. I suggested that we put a chest tube in without waiting for the x-ray, but my attending said no – we should wait. We waited. The patient continued in a downhill spiral, and coded about 10 minutes later, just after the X-ray finally was taken. He did not survive the code. The CXR showed a pneumothorax.

I don’t know what thoughts are in other’s minds, and I sometimes unfairly project my own tendencies onto others.  But I have interpreted this experience based on my own struggle with pride. I have an immediate tendency to say “No” to any suggestion made by an intern or resident in regards to patient care. I think this tendency comes from an unhealthy pride and desire to always be the one to come up with the smart idea. It’s a little bit humiliating as an attending to have someone in training beat you to the punch. It typically goes like this: intern makes reasonable suggestion; 2) I reject it and verbalize every reason I can think of why it’s a bad idea, (as though I had already considered and discounted it); 3) then I walk off by myself, realize the idea was a good one, and figure out a way to implement it without losing too much face. This last part is usually easier than I think it’s going to be, since the environment in which I work is mostly about doing the right thing for the patient rather than who gets credit. Even though this whole process probably seems ridiculous, it has helped me take advantage of the good advice of others many times over the years.  

The nurses have been a HUGE source of good decision-support for me. But their good advice can only be effectively sought and put to advantage with the proper humility. I once witnessed two attending physicians enter a patient’s room, one right after the other. The first was called to the bedside by a veteran ICU nurse with 25 years of experience because she felt the patient “just didn’t look right”. Objectively though, nothing much seemed to be going on – the patient’s vitals hadn’t changed much, and his morning labs and CXR looked OK. The first attending, a pulmonary critical care specialist, pointed this out, and left the patient’s bedside just as the second attending arrived. Although the second physician shared uncertainty about what was going on, they felt uneasy about leaving the bedside when the nurse felt something bad was brewing. They examined the patient carefully, noting that the legs had mottled. The second physician reordered labs and the CXR, which revealed a tension pneumothorax.  A chest tube was placed, and the patient recovered. Over the years, the nurses have covered for my shortcomings and given me invaluable advice many times. I have also probably missed many opportunities in situations in which nurses didn’t think I would listen to them, and therefore kept their good ideas to themselves. I try to teach my fellows that one of the most important parts of being a good ICU doctor is to treat the nurses with respect and get them in the habit of expressing their opinion by asking for it often. Doesn’t mean you always have to take their advice, but it’s a serious handicap to not at least hear it.  

Overall Attitude

Probably the most important aspect of professionalism is the attitude you take to the patient’s bedside. If you're in Critical Care, or in almost any other field of Medicine, you have potentially the most privileged and fulfilling professions in the world. The most frustrating, user-unfriendly EMR in the world doesn’t change that. So don’t let anyone tell you otherwise. Patients, families, nurses in the hospital want to be able to look up to you. They want you to be the one who can make things better. Can you think of any other profession with more chances to be an angel to someone who is facing one of the toughest days in their lives?

The care you give a patient or their family are likely to be remembered by them for a long time to come. You have incredible leverage to benefit them and a unique opportunity to have a lasting positive effect on their lives. Whether you treat them well or poorly may affect them profoundly, maybe for the rest of their life. I don’t think it’s going too far to think that it even may affect how they treat others, because when people perceive the world as a kind place, it often becomes easier for them to act in kindness to others.

This is the attitude I think we should bring to each workday. 

In any situation that we are faced with, there is good that can be done.

Our job is to find it, and make it happen.

Recently, I’ve seen doctors do a number of things that “weren’t in their job description” – these are the things patients and their families will remember long after they’ve forgotten strictly “medical” aspects of their care. One of my partners took a patient on life support out of the hospital into our lobby courtyard at night to see the stars. Another invited a recovered patient to come with her and give a talk about the importance of nurses to her son’s third grade class. One physician arranged to have a dying patient’s dog snuck-in for a visit, obviously against hospital rules. Another went out to a camper in our parking lot, in which one of our patients wife and daughter were staying, to fix a plumbing leak. Consider yourself as the good guy or gal – this will enrich everyone’s life, starting with your own. One of my mentors keeps a picture of batman in his office to remind him of this.

One more memory about attitude:

Five years ago, I received a call from our transfer coordinator.  I was being asked to assume the care of a patient in transfer who was in a very dismal situation. She was 36 years old, married, the mother of four boys. She was pregnant with a 22-week baby - too young to survive birth. She had recurrent breast cancer with metastases to her lungs and brain. She had lapsed into a coma and was intubated on mechanical ventilation, as edema around her brain tumor increased. 

I covered my face in my hands as I took in this information, and I remember thinking how much I hated certain aspects of my job. There didn't seem to be any reasonable chance for this transfer to turn out anyway but terrible. I resented being put in the position in which I would have to shoulder the emotional burden of bringing her family through their bereavement. If the patient’s family had known what was on my mind, there’s no way they would have allowed me to take care of her.

I went through the motions when the patient arrived, gleaned some more history. Her name was Samantha. Her cancer had recurred at 10 weeks pregnancy. Her oncologist had offered her chemotherapy and hormonal therapy, but warned her that these treatments were risky for the baby. Samantha decided to sacrifice her own treatment for the welfare of her baby. She had been hoping for a girl.

On the fifth hospital day Samantha suffered brain death secondary to cerebral edema, related to her brain metastasis. Her baby was only 23 weeks old – a gestational age with only a 40% survival rate. After consultation with her husband, we carried forth a plan to keep Veronica’s heart beating as long as possible, until her baby could mature enough to survive. Over the next 7 weeks, we maintained Samantha’s blood pressure, gas exchange and temperature. We replaced hormones made by the hypothalamus of the brain and pituitary gland. Fifty days after her mother Samantha's death, healthy baby Samantha was born.

I feel rotten about my initial bad attitude looking back over this case – which turned out to be one of the most fulfilling of my career. That’s one of the great things about critical care. Sometimes the most discouraging beginnings can entail unforeseen potential for you to accomplish good as a physician.  When you have experiences such as this, hang on to the memories (this is one of my selfish reasons for writing this series). Remembering miracles that you are witness to will help you fight discouragement which is the enemy of the proper professional attitude as an intensivist.

Reference as: Raschke RA. Professionalism: capacity, empathy, humility and overall attitude. Southwest J Pulm Crit Care. 2014;9(2):104-14. doi: http://dx.doi.org/10.13175/swjpcc105-14 PDF

Friday
Jun202014

Professionalism: Secondary Goals 

Robert A. Raschke, MD

Banner Good Samaritan Medical Center

Phoenix, AZ

Please recall my lengthy disclaimer from Part 1 of this series.

In part two, we reviewed the Oath of Maimonides. We considered our profession as a sacred vocation. We defined professionalism: A good doctor can be trusted to always place his/her individual patient’s best interest first, with ability, good judgment, and a caring attitude. We determined that we should be willing to make sacrifices in our commitment to our primary goal (as critical care physicians) – getting our patients and their families through their illness with as little disability and suffering as possible.

Now, my second disclaimer – I am going to express my opinions from atop my Ivory Tower – as I am not in private practice, and protected a bit from the harsh reality of the business world. I am going to express my possibly somewhat naive perspective on secondary goals related to our profession. These are not necessarily bad, but they may distract from our primary goal. I personally feel that I have to de-prioritize these goals in order to do what’s best for my patients.

It is not your primary goal to run your business.  I’m employed in a teaching hospital - so I can speak to this issue without having to "pay the overhead". However this was a personal choice I made early in my career, at a time when it was an unpopular and poorly-paid career path. I was able to afford it because my wife and I kept modest personal finances. The small home we raised our children in for 20 years cost less than twice my starting salary of $65,000. We have been blessed by not having to worry much about money along the way.  

The good salary we make as doctors ought to be used to achieve financial security in a modest lifestyle, so that we are less vulnerable to financial incentives. Remember, we did NOT go into medicine for the money. I’ve observed that some of my colleagues who spend a lot of money in their personal lives get caught-up in business practices that are not the best for their patients. I’ve also observed that some of the highest-earning physicians are most likely to suffer financial anxiety or even personal bankruptcy. Separate physician and business duties as much as possible .  Don’t hang out with or take gifts from medical salespeople that you would be at-all ashamed to tell your patients about. If you find your actions as a doctor are being unduly influenced by financial incentives, consider whether you can simplify your personal finances.

It is not your primary goal to have your patients or colleagues like you, as long as you are acting with good judgment and good attitude, in the patient’s best interest. One of my partners recently had a very frank discussion with a patient who was strongly suspected of Munchausen’s disease. Her self-destructive behavior had resulted in numerous ICU admissions and over 20 unnecessary endotracheal intubations. It was crucial to the care of this patient that this diagnosis was confronted, to avoid other unnecessary and dangerous interventions, and so that the underlying psychiatric disease could be treated. But this confrontation prompted an angry response. The patient filed an official complaint. This complaint came at a very bad time for my partner, and actually threatened costing him his job – although thankfully this did not come to pass. I hope he is able to do the right thing again next time, but it can be hard in a system where incentives for universal patient satisfaction are strong.

Another of my partners recently expressed exasperation with the more common difficulty of properly communicating poor prognosis to overly-optimistic family members who are praying for a miracle. We agreed that we have an obligation to express the truth – withholding poor prognostic information is essentially a lie of omission. Sometimes family members misinterpret this as a pessimistic attitude rather than plain old-fashioned honesty, no matter how much compassion we bring to the topic.    

I have injured my friendship and working relationship with several of my colleagues over the years because of disagreements over what was best for the patient. Conversely, some of my most shameful actions as a doctor were committed in an attempt “smooth things over” with colleagues that appeared to be trying to achieve the impossible, usually in relation to what I perceived to be futile care.

Several years ago, I was called to the bone marrow transplant unit to intubate a young woman with recurrent acute leukemia. She had previously failed two allogeneic bone marrow transplants, and had just failed an investigational chemotherapy protocol. She was in blast crisis, and rapidly developing multisystem organ failure. Worst of all, she had grade IV graft-vs-host disease and suffered florid gastrointestinal symptoms and was covered in skin lesions. She was non-communicative due to multifactorial delirium. Her family trusted the transplant hematologist, having known him for years, and they believed him when he told them that he could still save her.  

The transplant hematologist and I had had many disagreements in the past in situations in which I felt that patients and their families had been subjected to unnecessary suffering in futile situations, but up to this point, we had always been able to find at least an uneasy alliance. This time though, I flat out refused perform the requested intubation, and instead strongly recommended comfort care. I explained by rational to the patient’s family, who reacted with anger.  The transplant hematologist consulted a critical care physician from another group who came and inbutated the patient. The patient died several days later, during infusion of stem cells as part of a third transplant attempt.

This conflict damaged the working relationship between our groups, and hurt everyone’s job satisfaction, because we all enjoyed supporting the good work done in our bone marrow unit. It also hurt our group’s billings. But as best I can tell, my partners understood and supported my decision.   

It is not your primary goal to avoid a lawsuit. It is an incredible blessing not to get sued in the course of your career. Besides the obvious drawbacks, the stress of a lawsuit can seriously degrade your capacity to concentrate on taking care of patients, and even lead to physical illness. A lawsuit may even be career-ending – several very good clinicians that I know have made drastic career changes as a result of lawsuits. One perinatologist became an acupuncturist after a lawsuit involving an unpredictable complication of a blood transfusion. Others dropped out of critical care to practice office medicine or take administrative jobs.

But our primary goal takes precedence over medical-legal concerns. The practice of defensive medicine often leads patients to suffer complications of medically unnecessary procedures. Honesty in disclosure of errors is an ethical facet of our profession that often conflicts with the desire to avoid lawsuits. I once disclosed a major error in anticoagulation therapy that led to potentially disfiguring complications of cosmetic facial surgery to a young woman and her husband – this motivated them to send a letter to the CEO of our hospital at the time (the guy who signs my paycheck). Another time, I disclosed to a family that a patient’s previously unexplained in-hospital mortality had been determined to be caused by a transfusion-related West Nile Virus infection. I had exerted a major effort to make this obscure post-mortem diagnosis, the discovery and disclosure of which led to a request for records from a law-firm retained by the family.

I very much appreciate the help of the lawyers and paralegal staff of our risk management department, but I purposely avoid asking them for advice in situations when I already know the right thing to do for the patient. 

It is not your primary goal to achieve external measures of “quality” or utilization. Recently, the idea of physician “report cards” has been popularly embraced, and many employed physicians now have financial incentives based on surrogate measures of quality-of-care. Unfortunately many of the pooled outcomes used to define quality are difficult to interpret in the care of an individual patient. Recall the story of the liver transplant patient who received prolonged futile care (related in part 2 of this series). Note that the initial, poorly-focused care of this patient benefitted the 12-month mortality statistic for the transplant program, while appropriate comfort-focused care of the patient worsened the ICU mortality statistic. This example shows how statistics that sound like very valid measures of quality can be very misleading.  

Other surrogate markers of “quality” are initially supported by what seems like high-level experimental evidence, but are later found to lack benefit, or in some cases even cause harm. Recent examples in our specialty include early goal-directed therapy for severe sepsis, tight glucose control and the use of drotrecogan-alpha (Xigris®).

Even valid surrogate measures of quality are likely to greatly oversimplify what it means to be a good doctor, focusing excessively on a few particular elements of care, and distracting from aspects that might be more important to an individual patient.

I resist being incentivized to achieve any measure that may conflict with my primary goal, but also think we ought to analyze our “quality data” with open and self-critical minds. I do my best to use it to learn to how to make myself a better doctor, rather than concentrating solely on making my statistics improve. I think it is best to simply do the best job you can for each individual patient, prioritizing the things that are most important to that person, and let specific individual data points that others use to define quality fall where they may.

I don’t like being on committees, but I force myself to be involved in the process by which quality measures are chosen. I bring skepticism to the meetings, even in regards to practices that are currently “evidence-based” – because history proves that many of these will eventually be found to be erroneous. I try to champion quality improvement processes that make the most sense, such as hand-washing, and getting unnecessary invasive hardware (such as unneeded Foley catheters, and IV lines) out as soon as possible.

Unfortunately, the un-professional behavior of a few among us has damaged the trust that most people have for their doctors, providing a rationale for monitoring and incentivizing our behavior. But real professionals don’t need to be financially incentivized to do what’s right. It is my opinion that the people who most want to incentivize us (politicians and administrators) do not have the wisdom to pick the right actions to incentivize, and may not always have the individual patient’s best interests at heart.

Capacity: You have to be cognitively, psychologically and physically healthy to do your best work as a doctor. I studied medicine pretty hard during my training, but I am fundamentally intellectually (and all-around) lazy. Once I went into practice, I found I had trouble keeping current with medical literature, no longer having to worry about board exams. Trying to force myself to read worked about as well as most diets. Eventually the problem was solved when I started a monthly Critical Care journal club with our fellows. This forced me to review the current literature each month, and actually read the articles carefully. We each have our own ways to stay current, but having a teaching job is a big advantage. It justifies study as a job duty, and protects some time for you to work on it.

Happiness in your personal life will reflect on your ability to survive stress and maintain the right attitude at work. My wife Carolyn has been a wonderful blessing to me in this regard, and has helped me be a better doctor. Back in the days before we took night call, whenever my pager went off at night, it woke us both up. I would call in and try to figure out over the phone whether the patient was sick enough to warrant getting out of bed and driving in to the hospital in the middle of the night. It was pretty obvious to Carolyn that my ability to make good decisions when awoken from delta waves at 3 AM was questionable at best.  She suggested that I should just go in and see every ICU admit no matter how things sounded over the phone.  “You don’t do anything but toss and turn in bed anyway worrying that you should have gone in”.

This was a little extreme at the time for a teaching program, because we already had interns and residents in house all night. But it was endorsed by my wife, and it helped improve our patient care. The system was adopted by our entire group and practiced until we switched to 24-hour in-house coverage.  My happy marriage and supportive home life are an important counterbalance to the disappointments I often face in the ICU.      

Exercise regularly – you ought to be able to get some exercise even during your busiest work weeks. Whether you like running, yoga, weight-lifting or playing with your dog, your physical capacity and ability to concentrate will benefit from regular physical activity outside the hospital. I try to do some form of exercise at least twice a week, no matter how late I get home, even if it’s only for ten minutes.

Don’t take a job that will exceed your capacity to provide good care. I have seen hospitalists with a work list exceeding 50 patients for weekend rounds. No matter how efficient you are, no one can reliably do a good job with that magnitude of work load.

Feel free to comment if you disagree with part or all of the above. They are just the personal opinions of a confessed ex-altar-boy and boy scout!

END OF PART THREE  (next: part 4: “Attitude”)   

Reference as: Raschke RA. Professionalism: secondary goals. Southwest J Pulm Crit Care. 2014;8(6):349-53. doi: http://dx.doi.org/10.13175/swjpcc081-14 PDF

Thursday
May292014

Professionalism: Definition and Qualities

Robert A. Raschke, MD

Banner Good Samaritan Medical Center

Phoenix, AZ

 

[Please recall my lengthy disclaimer from Part 1 of this series.]

Moses Maimonides (1135-1206 AD) was a Jewish rabbi, philosopher and physician who studied and practiced in northern Africa. The Oath of Maimonides expresses his attitude towards our shared profession, that is still applicable to the bedside in a modern ICU:

"The eternal providence has appointed me to watch over the life and health of Thy creatures.

May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.

May I never see in the patient anything but a fellow creature in pain.

Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements. Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today.

Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling."

I want to try to define professionalism, then call-out distinct qualities required to do the job right, as enumerated by Maimonides.

Definition of professionalism for a doctor: A good doctor can be trusted to always place his/her individual patient’s best interest first, with ability, good judgment, and a caring attitude.

Maimonides points out, first and last, that it is a privilege to be a doctor –not just a career (the word career implies that our main purpose is to make a living for ourselves).  Being a doctor is a sacred vocation. Our profession is first and foremost one of being a servant to others, not to ourselves. I personally can’t reliably maintain this attitude every minute of the day, but I try to remember it as often as I can. In addition to this proper attitude, Maimonides describes commitment, capacity, compassion and humility, which we will discuss shortly. But let’s start with “attitude” - just as Maimonides did.

I once very briefly took care of a 57 year old woman with a past medical history of short bowel syndrome, dependent on intravenous feeding. She had acutely developed Klebsiella pneumoniae sepsis of unclear origin and acute renal failure. She was receiving antibiotics, stress-dose steroids and dialysis. During her hospital course, she developed belly pain, and a CT showed pneumatosis intestinalis. The surgeon initially recommended conservative medical care, but after 72 hours, her condition deteriorated and he decided to operate. I saw her in the early afternoon on that day, just before the operating room technicians arrived to take her down to the OR. By this point, the proper course of action was already decided, and nothing I was likely to find on physical examination was likely to change it. So I looked her over briefly - put my stethoscope on her chest without listening very carefully - already thinking of the list of other patients I had left to see that afternoon. But as I straightened and prepared to leave her room, she told me that she was scared she was going to die.

Fortunately for me, I wasn’t terribly inpatient that day. My work list wasn’t too long.  I decided to mentally put my work aside*, and spend a little time with her [in retrospect, this thought that it was not “my work” to spend some time talking with this patient was obviously incorrect]. I brought a chair into the room and sat at her bedside. She told me some things about her life that I previously had no idea about – personal goals that her illness had prevented her from fulfilling. Now she felt she might never have another chance. I actually believed that she would come through the surgery OK.  I listened, and was able to comfort her a little. We ended up holding hands and saying a prayer together. The transport personal showed up to take her to the OR, interrupting us a little, but we had had a nice quiet moment together. I told her I would check in on her after her surgery. But she developed intraoperative complications and died in the OR, never again regaining consciousness.

This surprised and deflated me when I was notified shortly thereafter. Then it struck me more deeply that I was the last person on earth to talk with her before she died - perhaps with the exception of the anesthesiologist asking her to count backwards from 100. What would this patient’s sister, or best friend have given to trade places with me in that quiet moment we had together? The privilege that this represents is astounding. Whether you believe in God or providence, there was a reason that we are given such opportunities that goes way beyond simply making a living. The great opportunities we share demand our commitment.

Commitment: being willing to make sacrifices in an unswerving effort to achieve a single goal. Our primary goal, as taught to me by my friend and mentor, Tom Bajo, is to get the patient and their family through their illness with as little disability and suffering as possible. This sounds very straightforward on paper, but it can be hard to keep your eye on the ball in complicated clinical situations.

Consider the following story:

A 54-year-old patient who was admitted to the hospital with a chief complaint of “I feel terrible”. He underwent a liver transplant 12 months before, but was suffering transplant rejection despite treatment with tacrolimus and rapammune - drugs that had inflicted significant side effects. Over these past 2 months he suffered progressive severe liver failure, and had been turned-down for a salvage transplant. He had suffered recurrent episodes of acute renal failure, severe nosebleeds, unremitting diarrhea, encephalopathy, and depression.

In his admission history, his symptoms included nausea, anorexia, muscle pain, headaches, weakness, belly ache, recurrent nose bleeds, general debilitation and vomiting-up bile and all his medications. He had been admitted 3 times in the prior 2 months for similar complaints, only going home for a few days in between admissions.

At the time of his physical examination it was noted that he was cachectic, somnolent and deeply jaundiced. When the nurses tried to place a Foley catheter, the patient refused – the nurse quoted him in the chart as despairing: “I’ve been through so much.”

The patient expressed his wish to be made DNR to multiple physicians, and an order to that effect was written. But he was incredibly debilitated, and his ability to defend his decision was weak. A few hours later, a specialist spoke with him and rescinded the DNR order.

The primary managing physicians made the following assessment of the patient:

  1. pancytopenia secondary to liver failure
  2. volume depletion causing acute renal failure
  3. hypercalcemia partially related to immobility
  4. rhinorrhea, possibly secondary to CSF leak

(this later diagnosis seems odd, but was influenced by the patient’s complaint of a persistent runny nose after treatment of the patient by an ENT doc who was consulted to treat his nosebleeds – it was hypothesized that the treatment might have been complicated by a fracture of the patient’s cribiform plate, resulting in a cerebral spinal fluid leak)

I want to pause the story here for a moment to consider this assessment. It strikes me that it is almost unrecognizable in relation to the patient lying in the hospital bed. The assessment that lays more closely to the truth, and that would have better guided appropriate therapy is:

  1. the patient is dying.
  2. the patient is suffering.

The following management was ordered:

CT scan of brain and sinuses, spinal tap, neurosurgery consultation, ENT consultation, cefepime and vancomycin antibiotics, lab tests including TSH, free T4, iPTH, 1-25 vitamin D, 25-hydroxy vitamin D, SPEP, UPEP, Beta-2 transferrin of nasal secretions, Fe, TIBC, ferritin, methylmalonic acid level, homocystiene and fractionated bilirubin (looking for hemolysis).

I can’t say what thoughts were in other people’s minds, but their actions speak about the goals they were committed to achieving. Some appeared to be committed to merely keeping the patient alive. Some appeared to be committed to making obscure diagnoses that were highly unlikely to bring any relief to the patient. Some who privately felt the reversal of the DNR was wrong, seemed committed to preserving their working relationship with the specialist, who is a highly respected physician. Many doctors felt that what the patient really needed was comfort care, but nobody committed to that as their primary goal.

The patient suddenly lost consciousness, was found to have suffered a massive intracranial hemorrhage, and was transferred to the ICU – astoundingly for "a higher level of care”! By this, they meant more intervention – possibly endotracheal intubation. But now, my partner Jennie assumed authority for his care, and she immediately re-established DNR status and initiated comfort care.

If you are going to commit yourself to a single goal, pick the one that is achievable and most important to your patient, then chase it to the best of your ability with a caring attitude.

There are many false primary goals in medicine – not necessarily bad goals, but distractions from the best goal. We all need to de-prioritize these in order to be better doctors. In part 3 of this series, I will review some of these (likely getting myself in further trouble).

Reference as: Raschke RA. Professionalism: definition and qualities. Southwest J Pulm Crit Care. 2014;8(5):291-6. doi: http://dx.doi.org/10.13175/swjpcc071-14 PDF