A Qualitative Systematic Review of the Professionalization of the Vice Chair for Education

Guadalupe F. Martinez, PhD 

Kenneth S. Knox, MD

Department of Medicine

University of Arizona

Tucson, Arizona. USA

Abstract

Background

Pulmonary/Critical Care physician-faculty are often in academic leadership positions, such as a department chair. As chairs are responsible for the success of their education programs, and given the increased complexity involved in evaluating learners and faculty increases, chairs are turning to colleagues with expertise in education for assistance. As such, vice chairs for education (VCE) are being introduced into the mix of academic executives to respond to the demands for accountability, training requirements, and professional development in a rapidly changing medical education climate. This review synthesizes the published literature around the VCE position.

Methods

An advanced electronic database and academic journal search was performed specific to the medical, medical education, and education disciplines. “Vice Chair for Education, Educational Leadership, (specialty) Residency Program Director” terms were used in these search processes. We conducted a qualitative systematic review of VCE literature in the English language published from January 1, 2005 to April 1, 2016.

Results

From the 6 studies screened, 4 were excluded and 2 full-text articles were eligible and retained for review. Both studies were cross-sectional and published between March and August of 2012 with response rates above 70%. Each employed quantitative and qualitative methods. The studies report important demographics and job duties of the vice chair.

Conclusion

The vice chair for education in academic medical departments has emerged as an important position and is undergoing professionalization.

Abbreviation List

AAIM-Alliance for Academic Internal Medicine

PRISMA-Preferred Reporting Items for Systematic Reviews and Meta-Analyses

VCE-Vice Chair for Education

Introduction

Schuster and Pangaro (1) introduced the pyramid of educators concept in their book chapter, Understanding Systems of Education in 2010. They designate the top of the pyramid as the institutional leaders or “academic executives” of the medical education system. These leaders include positions such as department chairs, deans, and CEOs. Pulmonary/Critical Care physician-faculty are often in leadership positions such as these. Locally, at our southwest institution and affiliate training hospital, the senior vice president for health sciences, chief medical officer, internal medicine department chair, vice chair for education, vice chair for quality and safety, internal medicine residency director, and one of the three associate residency directors are all pulmonary/critical care physician-faculty. Nationally, according to the Alliance for Academic Internal Medicine (P. Ballou, AAIM email communication, May 2016), 12% (20/172) Internal Medicine department chairs are pulmonary/critical care/allergy physician-faculty belonging to the association to date. As chairs are responsible for the educational success of their programs, and given the complexity involved in evaluating learners and faculty, department chairs are turning to colleagues with interest and expertise in education for assistance. Vice chairs for education (VCE) are now being introduced into the mix of academic executives. Although the VCE role may vary by institution, VCEs are likely to respond to the demands for accountability, training requirements, and professional development in a rapidly changing medical education climate.

According to sociologists DiMaggio and Powell (2), one way to respond to external pressures is to create and legitimize new positions intended to better manage changes and demands. They go on to define this process as a professionalization of a position. Despite the emergence of the prominent and potentially pivotal position of the VCE, the formal recognition of this position and clarity of its purview over the educational mission remains obscure. In addition to synthesizing the published literature around the VCE position, we sought to determine two points that could best inform the medical education community about this position and future directions for educational leadership. First, is the role of department VCE defined in the academic literature? Second, what evidence exists that the position has professionalized in academic medicine?

Methods

In adherence with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (3) guidelines, we conducted a qualitative systematic review of VCE literature in the English language published from January 1, 2005 to April 1, 2016. The authors adapted the Cochrane Collaboration and developed and followed a specific search protocol a priori (4-5). The protocol is summarized below and detailed in Table 1. Institutional Review Board approval is not necessary for literature reviews.

Table 1. Search protocol in adherence to the Cochrane Collaboration

1. Text of the review	a. Background: As department chairs are responsible for the educational success of their learners and faculty in academic medical centers, changes in how they delegate and manage the educational mission are evident. VCEs are now being introduced into the mix of academic executives to respond to the demands for accountability, expertise and leadership from changing medical education climate. Despite this important role, the formal recognition of this position and clarity of their purview over the educational mission has remained obscure. b. Objectives of the study are to: i) review how well-defined the role of the department vice chair for education is medicine education institutions, and ii) understand to what extent the position is professionalizing and becoming institutionalized. iii) gain insight into the above via synthesis and appraisal of relevant literature.
2. Criteria for selected studies for review	Exclusion Non-English works Commentaries Perspectives Newsletters Lone job descriptions Unpublished under-review research reports	Inclusion English language works Peer-reviewed published or in press qualitative, quantitative mix-methods original research reports, or articles with a research component Book chapters dedicated to the role solely Written between: January 1, 2005*-April 1, 2016 *Average of Brownfield (9) and Sanfey (5y) mean years since the establishment of the position as reported in 2012 publication (12y; 8y)
3. Search strategy	a. Email outreach to national VCE- Internal Medicine and Emergency Medicine interest group and listserv for the purposes of: i) triangulation ii) accessing submitted, in press, and unpublished work iii) accessing grey literature such as white papers and institutional reports. b. Electronic search consisting of the following relevant journals: Academic Medicine American Journal of Medicine Medical Education Journal of American Medical Association American Educational Research Association Journal of Surgical Education Medical Teacher The American Journal of Surgery e. Ancestry search of inclusive study references for snowball e-searches. f. Relevant database search of the following: Cochrane Database of Systematic Reviews ERIC MEDLINE PubMed Research Gate Science Direct Zotero f. Search engines: Google Google scholar g. Conference proceedings for specialty educational associations (Internal Medicine; Anesthesia, Surgery, Emergency Medicine, Pediatrics, Dermatology, Family Medicine, Psychiatry) h. Word search: Vice Chair for Education, Educational Leadership, (Specialty) Program Director

Search protocol

The first author completed an advanced electronic database and academic journal search that included those terms specific to the medical, medical education, and education disciplines. “Vice Chair for Education, Educational Leadership, (specialty) residency program director” terms were used in these search processes as well as the search engine examination. The first author also conducted an ancestry search of the references listed in the screened literary pieces. The authors reached out to a national interest group made up of primarily VCEs in Internal Medicine via a national VCE email distribution list to combat publication and database bias, and gain knowledge about any existing grey literature, conference proceedings, unpublished or recently submitted works. Hand searches were not conducted as the ancestry search found the earliest relevant and indexed piece to be in 2012. Additionally, most journals have moved historic volumes as of 2005 to an online interface.

Inclusion and exclusion criteria

Authors set inclusion criteria to be qualitative, quantitative mix-methods original research reports or articles with a research component. Reports were to be full-text peer-reviewed works published or “in press.” Additionally, book chapters dedicated solely to the VCE role were considered.

Excluded were commentaries, perspectives, newsletters, pure job description documents, unpublished research reports or articles and those in “under review” status.

Data appraisal and extraction

Framework analysis (6), citations and full-text articles were charted, indexed, identified for themes, and finally, mapped and interpreted to collect and examine text for review. Appraisal of methodological soundness, reporting, and contribution to knowledge was conducted once full-text articles were identified for review. Validated quality assessment tools for quantitative and qualitative works were implemented and are discussed later in this review.

During the ancestry search, citations were imported into Endnote. Full study documents were imported into QSR Nvivo 10 software for analysis. Data categories and coding were developed via consensus building between the authors as part of the analytical framework Figure 1.

Figure 1. Thematic coding and concept mapping. As a method of mapping methods for qualitative data structuring, this concept map illustrates themes that emerged from data. Concepts are linked to demonstrate the relationships between them. Similarities, differences, strengths, and weaknesses were identified and threaded throughout each domain-or branch of the map that focuses on a particular aspect.

The first author began the initial coding process and queries followed by member checking by the senior author to improve categorization credibility. No initial categorization discrepancies between the authors occurred.

Results

Search results

From the 6 screened studies, 4 were excluded and only 2 full-text articles were eligible for review. See Figure 2 for detailed PRISMA flow diagram.

Figure 2. PRISMA 2009 Flow Diagram. The diagram depicts the flow of information throughout the systematic review. Mapped are the number of records identified, included and excluded.

Study characteristics

Both studies were cross-sectional and published between March and August of 2012 with response rates above 70%. Each employed quantitative and qualitative methods, but each favored one method Table 2.

Table 2 List of relevant, but excluded literature and justification

Author	Month/Year Published	Literary Type/Topic	Focus/Justification for final exclusion
Sanfey et al.14	March web content and July 2012	Web-based and article based Review/VCE scope of duties and qualifications	Brief website review of the authors’ previous work that delineates VCE qualifications for MDs and PhD educators, career development opportunities, and job description with specific workloads for each mission. The authors offer sections on career advice specific to time management, acquiring a national reputation, funding for educational research activities, and resource sites to find a VCE position. Excluded as this is a review and career offerings are opinion-based. Via a surgical organization task force, the online material underwent a slight title modification. This online review of the original research was subsequently published in print with the American Journal of Surgery.
Pangaro15	August/2012	Commentary/VCE and direction for future educational leadership	Highlight gaps in nation’s overall approach to medical education. Offers a paradigm shift calling for medical education to use evidence-based data, and educational theory to inform future directions and departmental leadership. Innovation and creativity is stressed. In this spirit, there is a call for a specific leadership style (collaborative) on the side of the Chair that could likely empower the VCE role. Insightful and relevant for future directions, but excluded as the commentary is opinion-based.
Wolfsthal et al.16		Book Chapter/Internal Medicine Program Residency Director Job Description	Seven page chapter in the internal Medicine association’s textbook for medicine education programs. This chapter outlines the job description of Internal Medicine program directors. One paragraph with 5 bullet points articulates that the VCE role may be combined with that of the Internal Medicine Residency Program Director role. This chapter does serve as additional evidence of dual leadership roles that appear as a trend among the VCE and internal medicine departments. However, excluded as chapter is not dedicated solely to the VCE position and integrated, in-depth, with the PD position.

Sanfey et al. (7) is a quantitative work that provides basic descriptives with means. A job description with specific categories is the qualitative element presented. Participants were 20 MD surgeons and 4 PhD educators serving as VCEs in departments of surgery. One data collection instrument was used and consisted of an online survey with Likert scales and open-ended questions with comment sections to gather short narrative responses.

Though Brownfield et al. (8) employed both quantitative and qualitative methods, the study was dominated by an inductive qualitative approach. Participants included 59 MDs serving as VCEs in departments of internal medicine. The primary source of data was VCE responses to an online survey comprised of open-ended questions to collect narratives.

Appraisal of studies

Each report was appraised by the authors. We applied Spencer et al.’s (9) appraisal of qualitative work, the National Collaborating Center for Methods and Tools (10), and Jack et al.’s (11) quality appraisal tools for basic descriptive statistics. Post scoring and deliberation, studies were categorized into either: low, moderate, good, or high quality studies. This process helped us make an informed decision regarding the quality of the research reports. The qualitative assessment tool was applied to Brownfield et al. (8). Scores between the authors ranged from 35 to 44 (maximum score of 72) and a mean score of 39.5 (8). Sanfey et al.’s (7) qualitative scores ranged from 30 to 41 and a mean score of 35.5; quantitative scores ranged from 14-15 (maximum score of 18) and a mean score of 14.5 (7). In all, both reports were of good quality (scale consists of low-good-high categories), methodological rigor, reporting, and knowledge contribution.  Studies note sufficient and important limitations regarding relatively small sample sizes, non-responder bias potential, and limitations to just two fields: surgery and medicine.

Synthesis of study findings

Although both research reports were related to the VCE role, there was substantial heterogeneity in their study aims that allowed for a broad conceptualization of the role. One study was largely to create a career development path for VCEs on a national level, while the other sought to establish, in detail, the roles and responsibilities of VCEs.

Similarities. Both studies had VCEs as the primary data source with the Brownfield et al. (8) work implementing follow up member checking with a group of VCEs at a national conference. Both also refer to the elevated expectations from institutions and accreditation agencies for evidence driven education and administrative practices as an external force that has led department chairs to create the VCE role. However, these studies noted that the clerkship and residency director roles have job descriptions and recommended protected time established by national accreditation bodies. Notably absent is a formal job description for the VCE role. As such, informed by their data, these studies set precedent by establishing a job description by providing lists of expected duties and activities. These duties not only centered on program and director oversight, but reflected a value system that appreciated autonomy, educational expertise, promotion of educational scholarship and investment in the further development of leadership skills.

In terms of demographics, both studies found that VCEs were more likely male, senior MD professors with additional training in education. Formal establishment and recognition of the position is difficult to deduce from the studies. Each study identified the position as “relatively new.” They both cite this as a reason to explain why participants reported uncertainty in their responsibilities and the lack of a formal job description. VCEs in both studies served in the position for a widely variable number of years ranging from 6 months to 25 years. Distribution of protected time for the role was addressed. However, Sanfey et al. (7) provide a snap shot of participants’ work load distributions with ascribed percentages to each of the institutional missions. In terms of preparation for the role, they went into greater detail about expectations. The investigators note a national increase in educational graduate programs in academic medicine and suggest chairs seek VCEs with backgrounds in graduate medical education in order to meet the demands and expectations of the position.

Differences. Sanfey et al. (7) reviewed the academic preparation for the VCE position, terms of employment, expected scholarly productivity, and took inventory of participants’ job satisfaction as well as specific leadership skills they desired to acquire and improve upon. In this study there was comparison between MD and PhD educators’ time allocations, and demographics. Closing their report, Sanfey et al. (7) discussed recruitment strategies for the hiring of VCEs, and stressed the importance of education portfolios and educational research productivity among potential candidates. Furthermore, they provided recommendations to those in hiring positions to strongly consider PhD educators for the role given PhDs scholarly productivity outpaced those of their surgeon peers who often have time consuming clinical demands.

Methodologically, Brownfield et al. (8) state they ask for job descriptions in their data collection, but do not note actually triangulating these documents with survey responses. From survey responses and an in-person group follow-up meeting, Brownfield and colleagues (8) noted in-depth, dominant themes that emerged from those surveyed.  Unlike Sanfey, they include how participants experienced the role, and if metrics for assessing their success were clearly established at their institutions. Despite a relatively robust set of reported responsibilities, most striking was the theme of reported uncertainty about the role among their participants. This was as a result from vague expectations or ill-defined purview. Brownfield and colleagues (8) provided a set of guidelines for current and prospective VCEs to consider that could potentially mitigate such an experience. A few include: the importance of transparency with the Chair about expectations, delegation, priority setting, and establishing an appropriate infrastructure of support.

Two themes that answer our research questions. Both studies a) formally identified and defined VCE duties, and b) documented the establishment and professionalization of the VCE position in departments of surgery and internal medicine in the U.S. Analysis indicated a theme wherein VCE roles and duties were defined in both works. However, the purview was dauntingly broad. As expected, multiple indicators of the professionalization, as defined by DiMaggio and Powell (2), of the VCE role in academic medicine exist within these two published studies. Both studies were published in quality journals (Academic Medicine (Impact Factor 3.292 at the time their study was published) and the Journal of Surgical Education (Impact Factor 1.634 at the time their study was published) (12-13). Moreover, data in these studies contributed to a formalized job description that set a vast scope of duties, broad oversight purview, working conditions, and career development needs of this group at a national level.

Discussion

The VCE role is designed to help the department navigate an ever changing, complex and diverse academic environment in medical education. Because these studies included only two disciplines, we believe the position remains ambiguous and not well-defined. It is clear the responsibilities of the position need refinement to maximize its impact within the department.

Both studies provide specific examples of the VCE responsibilities and roles with attention to how VCEs are expected to oversee educational programs. Brownfield et al. list position expectations that include: educational program oversight, promote scholarship and serve in leadership activities. Sanfey et al. (14) provided examples by subcategorizing responsibilities by i). administration, ii). teaching, and iii) research responsibilities. Both studies defined oversight as: setting the philosophical tone and course to move programs toward institutional and/or departmental vision; defining priorities; creating initiatives that would aid in program advancement; play a key role in redesigning evaluation technologies and methods; developing faculty reward systems; designing faculty development curriculum; consultant to all the educational directors in the department; advising the chair in faculty recruitment; chairing educational committees; training education staff regarding accreditation and strategic initiatives, and identifying and securing resources. Though broad, this collective list outlines responsibilities that are different than those presented in Wolfsthal et al. (16) job description of Internal Medicine residency directors and Foster and Clive’s (17) chapter on the Program Director as Manager. Unlike the VCE oversight examples that are illustrative of executive leadership, the current program director literature offers examples of managerial responsibilities to a single program. Responsibilities include: implementing policy and initiatives; setting agendas for meetings; budgeting basics; delegating authority; office personnel management, and time management. This distinguishes the VCE role from that of other departmental education positions such as the residency director. From the reviewed studies, VCE responsibilities are more vision-driven rather than managerial in nature (18).

Finally, it was unclear if the VCE position should be bundled with other administrative leadership roles. According to Brownfield et al. (8), this was pervasive in internal medicine as well. While we do not believe this is unique to one specialty, Sanfey et al.’s (7) work did not report dual leadership in surgery perhaps because the survey question was not asked. Regardless, the complexity in the Sanfey et al. (7) article was not as rich or apparent as Brownfield et al.’s study.

Given the emerging importance of this influential leadership role, we were surprised by the lack of a VCE recruitment strategy. In fact, both studies touch on the fact that the majority of participants were thrust into the VCE role with a small minority being promoted into the position internally. Neither study solicited the perspectives of department chairs, what they expect of the VCE and why they were chosen for the role. This practice is in stark contrast to the guidance provided by the articles where they provide discussion points and items to negotiate prior to accepting the VCE position. The data suggest a formal recruitment process with negotiation for educational resources is needed for the VCE position to realize its potential.

Yielding 2 full-text studies this review is not robust and thus, limits recommendations. Other medical disciplines may have similar roles, but no data has been published. Never-the-less the information in this review is educationally significant. This review serves as a critical starting point from which to gain knowledge about more nuanced educational leadership positions and their mobilization towards legitimacy, formal recognition, and time allocations in clinical departments. This review documents the professionalization of the VCE role in the academic community in its infancy.

As many pulmonary/critical care physician-faculty make up the top administrative and educational leadership roles at our institution, we speculate that pulmonary/critical care and practice lends itself to leadership in academics. Building relationships with multidisciplinary ICU teams is much like building academic leadership teams. The skills necessary to articulate sensitive information to family members of critically ill patients provides a foundation for dealing with the most challenging aspects of administrative leadership discussions that are inherent to academe. Defining successful leaders and studying the personality traits of those from medical specialties would provide further insight and are ongoing.

Scholars are encouraged to consider research pertaining to the VCE role and to move beyond the job description to study the value the position brings to the department. Studies should include department chair perceptions of the position in the changing education and healthcare landscape, and whether these types of roles are more appropriately suited for particular medical disciplines over others. Examining the academic culture of departments to inform the desirable dynamic for the VCE is important. A starting approach can tease out how this role is impacted by departmental relationship dynamics, behaviors, and values. Finally, future studies that include robust examination of the VCE relationship with the chair would triangulate the existing body of work, and could validate what we know about educational leadership and academic executives.

Acknowledgements

The authors thank Carole Howe, MD, MLS of the Arizona Health Sciences Library for her guidance regarding database searches, and the University of Arizona College of Medicine Department of Medicine for allowing research time to conduct this review.

Authors also thank Ms. Sarah Almodovar for her time preparing and reviewing this work.

Finally, the authors thank those on the Vice Chairs for Education in Internal Medicine national interest group distribution list for responding to inquiry for grey literature knowledge, clarification questions, works in press, and unpublished works. We thank the National network of VCE responding to inquiry for grey literature knowledge, clarification questions, and unpublished works: Drs. Michael Frank, Stephanie Call, Erica Brownfield, Alan Harris, John Mastronarde, Bradley Allen, Ellis Levin, Lisa Bellini, Gerald Donowitz, Joel Thorp Katz, and Susan Wolfsthal.

References

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Cite as: Martinez GF, Knox KS. A qualitative systematic review of the professionalization of the vice chair for education. Southwest J Pulm Crit Care. 2016;12(6):240-52. doi: http://dx.doi.org/10.13175/swjpcc044-16

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

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

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

Professionalism: Introduction

Robert A. Raschke, MD

Banner Good Samaritan Medical Center

Phoenix, AZ

Editor's note: This is the first of a multi-part series on professionalism. The remaining parts will be posted over the next few weeks.

An important event in my career occurred about 20 years ago, late on a Friday afternoon. I was scheduled on call in the ICU for the entire 72-hour weekend, and even though I was just getting started, I was already tired and in a lousy mood. At 5 PM, I got a consult to see a patient in the neuro ICU. He was a 34-year-old man who had attempted suicide by drinking ethylene glycol antifreeze after an argument with his girlfriend. He had initially stabilized from a medical standpoint, but then developed delayed-onset cerebral edema. The team that was taking care of him had unsuccessfully pursued all treatment options. After 8 days of effort, he remained in a deep coma, near brain death. Now, with nothing left to try, and no hope left for a good outcome, they were dumping responsibility onto me just in time for the weekend.

I considered this unhappily as I began to page through his thick chart, trying to suppress my frustration so that I could concentrate, but I was interrupted by the patient's nurse – Terry - before I could get very far. She told me that the patient's mom had just stormed into the unit, and was demanding to talk with her son’s doctor - which as of the last 10 minutes was now me.  She warned me that the patient’s mother was inpatient, accusatory and totally unrealistic about her son's prognosis, but despite all this, Terry acted somewhat relieved that I was there. The impression that she was somehow happy about the situation made me even more angry than I already was. 

I had had enough. I really gave Terry an earful– outlining all my suspicions about the bad motivations of the referring team and concluding with my refusal to do their dirty work. Somehow, in my self-centeredness, I expected her to empathize with me. But she didn't. Instead, she appeared to be somewhat shocked and deflated. She listened silently to my rant, then turned and walked away without saying anything.

It took me a few minutes to realize that she had a higher opinion of me than I had of myself. She had thought I was a good doctor– strong enough to shoulder a tough situation– compassionate and empathic for a bereaved mother - ready to take on this challenge and make a bad situation a little better. I had proved her wrong.

I always thought of myself as a good doctor, but I realized then that I really wasn't all that good. I composed myself and tried to reset my thinking. I introduced myself to the patient’s mother briefly after explaining that I hadn't had time to review all the records– later, we would sit down and really talk. She actually wasn’t as unreasonable as I imagined she might be. It turned out I did have an important job to do in this case– to help a grieving mother come to terms with the death of her beloved son. The next day I apologized to Terry– this turned out to be a good long-term investment, since we continue to work together to this day.

This was an experience that got me thinking about how I could try to become a better doctor. Not by studying in order to get smarter, but by having the proper goals and attitude– the things this series is about.  Recounting this story also gives me the opportunity to admit that I claim no special personal legitimacy to write a series for SWJPCC on professionalism. I am pretty lazy at times. I have a temper when I’m under pressure. I can sometimes be hurtful to nurses and residents. There are even a few people who would consider it the height of hypocrisy for me to come off like I know anything about being good.  During the week in which I first began writing this section, I did a bunch of very unprofessional things– things I was ashamed of them even as I was proceeding forward with them:

1. I got a page about a patient that was deteriorating just as I sat down to a very nice lunch. The patient was a young, otherwise– healthy alcoholic. I decided to relax and finish my lunch before heading up to see him. By time I finished dessert, he had deteriorated and was extremely unstable. 
2. I had misgivings about a patient’s DNR status. I thought the family might rescind the DNR order if they fully understood the clinical situation. But I didn’t want them to rescind DNR status, so I purposely avoided talking to them. 
3. I missed the essential (and not obscure) physical finding of abdominal pain in a patient with septic shock on steroids– a clinical mistake that I’ve repeatedly lectured others about during Mortality and Morbidity conference. This error delayed diagnosis of a life-threatening bowel perforation.
4. I declined a personal invitation to attend the memorial service of a patient that I felt very close to– who had in fact asked me for a hug the last time I had seen her before she died. Instead, I sat at home and watched TV.

So no, I am not an expert at professionalism. But I do care about it. So I am not going to write about the doctor I am, but about the doctor I want to be. Please look at this series in that spirit and do not allow my personal shortcomings to undermine our consideration of this topic.

Why discuss professionalism in medicine? I've considered the possibility that the age of professionalism is over– that talking about it is like trying to get your kids interested in playing the board-game Monopoly. Technology is the thing nowadays. It’s incredibly satisfying to help save a patient’s life with ECMO in the ICU. Yet some technological advances increasingly distance us from our patients.     

I have heard that when Laennec invented the stethoscope in 1816, there was widespread concern about the negative effect it might have on the doctor-patient relationship. Prior to the invention of the stethoscope, doctors placed their ear directly upon the patient's chest to listen to the heart and lungs. At this point in history, the stethoscope actually came between the doctor and patient– a barrier to the intimacy of the physical examination.

In a modern ICU, all patients are under "standard precautions" for infectious disease control– this means doctors and nurses are supposed to wear gloves when we shake their hand. Other infection control precautions require that masks, eye-shields and gowns be worn inside patient rooms. When we employ a proning bed, the patient is totally cocooned– it’s is difficult to even see a patient inside a prone bed, much less touch them.

Telemedicine is increasingly incorporated into patient care– this allows a physician anywhere in the world to take care of patients in our hospital remotely, utilizing video cameras. Mobile devices– almost like robots– with a face display video screen for a head, can be wheeled into a patient’s room to facilitate electronic interactions between doctors and patients.

The advent of the hospitalist has all but destroyed the traditional continuity of the doctor patient relationship. Patients who are sick enough to land in the hospital are rarely seen by their family doctor. Within the hospital, many doctors (including myself) work shifts– taking care of individual patients only within the time slots of their work schedule. Technically, my responsibility for my patients ends at "quitting time”.

More physicians are employed by healthcare systems than ever before. The choices that patients and doctors once made together are thereby increasingly influenced by non-physician administrators. Politicians have increasingly attempted to create financial incentives for doctors to behave as they think we should behave. The very semantics of related constructs such as the “physician report card” diminishes us as a profession, turning us back to a time before we could be trusted to know and do what was best for our patients.

I think it's fair to say that the risk that might lose our professionalism, our humanism, has never been greater than it is at this point in the history of medicine. So there has probably never been a better time to reconsider professionalism as an essential part of being a doctor.

Many of us were taught in medical school about how to “act professional” – maintaining a detached demeanor, not allowing yourself to get emotionally-involved, appearing confident in all situations, etc. That’s not the kind of professionalism I’m going to talk about. Sir William Osler once said “the secret to the care of the patient is in caring for the patient” I think that’s a much better place to start our consideration of professionalism.

In the next installment we will consider the Oath of Maimonides and how it applies to the practice of medicine 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."

Reference as: Raschke RA. Professionaism: introduction. Southwest J Pulm Crit Care. 2014;8(5):284-7. doi: http://dx.doi.org/10.13175/swjpcc067-14 PDF