With 'Horrendous' Decisions Afoot in COVID-19, Teams Are Key

; Abraham Verghese, MD; Tait D. Shanafelt, MD

Disclosures

April 24, 2020

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This transcript has been edited for clarity.

Abraham Verghese, MD: Tait, it's such a great pleasure to have you with us when I know you are incredibly busy at the hospital. You're in a unique position: In addition to being a hematologist, you pioneered the whole concept of physician wellness through a series of wonderful studies and papers when you were at Mayo. We were really privileged to hire you [at Stanford] as the first physician chief wellness officer anywhere in the country, and you've done some remarkable things with your WellMD Center. But I don't know that you ever anticipated the need for the kind of wellness program that we're requiring right now. Before we get into that, how are you coping personally? How is life? How are you managing to stay sane in the midst of all you're doing?

Tait D. Shanafelt, MD: It's great to be with you, Abraham. Thank you for asking that. With the increased demands and challenges we're all trying to respond to so rapidly, it's taken deliberate focus to recognize that this isn't going to be a 1-week sprint and to make sure that I'm taking care of my own health and wellness enough so that I'll be able to help support our colleagues in the organization throughout this pandemic.

Personally, that, in part, really centers on making sure I'm getting enough sleep. For the past several weeks, I was way behind. I finally had a day off and I both slept in and took a nap to try to refill the bank a little bit. I try to make sure that when I get home each night—even though it's much later than typical—I unplug for a half an hour or so and check in with my wife and kids.

One of our colleagues in the psychology department chaired a webinar earlier this week and said something that really resonated for me, which was titrating how much of the news I'm engaging with, whether it be television or in print. So much is going on. We're seeing it firsthand for ourselves each day at the hospital and we don't need to tie into that broader froth. When we're not at work we need to allow ourselves some time to fully disconnect from what's going on with this pandemic so that we have some time to recharge.

Helping an Institution Cope

Verghese: That's wonderful and it's helpful for us to hear that from you. You began your wellness career—this invention of a whole new program in medicine—because of the burnout that is so prevalent in medical circles. You really did a lot to codify that and to bring about solutions. Now you're suddenly faced with this unfamiliar, new kind of very real threat. How has your thinking evolved and how have you helped an institution cope with this and delineate lines of action and response?

Shanafelt: As you suggest, I think this is different from anything we've dealt with before. Rather than simply pull traditional tools out of our toolbox and try to apply them to this situation, we need to approach it with humility and be completely open-minded about what the needs are right now. And that begins with really listening to the healthcare professionals on the frontlines and asking them what they need, what their concerns are. That requires very visible leadership. We've been holding regular listening sessions over the past several weeks with nurses, physicians, advanced practice providers, residents, and fellows. We ask, What are the circumstances now? What is worrying them most? What do they need that they don't have? What can leadership be doing? What information would be helpful for them? We've learned a great deal that has, I believe, helped us be more effective in trying to have clarity in what supports we're setting up for our team members here at Stanford. But things are so dynamic, we need to have these types of conversations, forums, and channels for feedback with our colleagues regularly if we're going to continue to be effective in the way we support them. We think it's important to use fresh eyes right now.

Strong Sense of Duty

Eric J. Topol, MD: Going into the new year, it seemed like we were still at the nadir of morale-busting burnout. And then, of course, this all happened. I was reading an interesting piece by Lisa Rosenbaum in the New England Journal of Medicine that came out yesterday. It gave me another thought about this; I'm curious to hear yours. There were many quotes from the folks in Seattle who were the first wave to confront patients in the crisis. Douglas Leedy, a University of Washington Medicine chief resident, said, "A lot of us healthcare workers go into medicine for moments like this." It is interesting to see accounts like this, just as there are ones about lack of personal protective equipment (PPE) and all sorts of nightmarish situations of the healthcare workforce being put into war without ammunition. There's a coming together. Can you give us a sense of where all that is?

Shanafelt: That is a great observation. We all are dealing with this, but our spirit is with our colleagues in New York City and Seattle at the frontline. I did my training at the University of Washington, and every time I read reports about those hospitals, it just takes me vividly back to my residency days. I couldn't agree more with the sentiment that this is part of our purpose as healthcare professionals, certainly as physicians, to confront disease, to confront fear, to support our communities. Even as we're trying to develop treatments and vaccines, [it is part of our purpose] to be with those who are facing this illness right now, and [share] the anxiety they experience, even when we're largely providing supportive measures for them. Every day I'm dealing with a workload that's the most I've had in many years. But I point the car toward work with a tremendous sense of purpose, knowing that everything we do today is going to matter. There is a strong sense of that.

I signed up for this as a physician, but my children didn't.

Yet you touched on another dimension to it, that we also want to know that our organizations, our leaders are protecting us to the extent possible, providing the right supports so that even as we put ourselves potentially in harm's way, that we're not unduly risking our own health, particularly for our colleagues who have their own health conditions or who are older and at higher risk of severe infection. Also a strong concern is that I signed up for this as a physician, but my children didn't. Wanting to make certain that we're not a portal of transmission to our family and that our own dedication/altruism/commitment is not putting our family at risk is a common concern. I think that is partly why there are so many dimensions to this challenge.

Fundamentally, the core platform of well-being initiatives right now is about PPE. That is the fundamental well-being concern of today's healthcare professional. That is different from what we would have been talking about 3 months ago or a year ago. There is both a sense that we became physicians to serve in times like this, but there's fear and anxiety and concern for ourselves or our families as well.

Effective Strategies

Verghese: I've been so impressed with something that the dean said when we interviewed him on this program, about the necessity for clarity, open communication, and feedback. You've done a marvelous job in the succession of videos that you sent out to make us aware of all the resources that are out there. You've also done a lot of feedback sessions with some of our frontline people and with all kinds of people. What are some of the lessons and principles that are emerging and evolving from such conversations?

Shanafelt: Our colleagues really need visible leadership right now from all of us who are either leaders just because we're more experienced colleagues who others look up to, or because we have formal leadership roles. I would suggest that all of us as physicians really set the tone for the tenor of the care team. So, first, there is a real need for being willing to visit the wards, visit our teammates, and ask them what they need. I know that's sometimes frightening because right now we may not be able to provide everything that is asked for. But people understand that and they appreciate that we're humbly asking for that feedback and trying to address what we can. Because again, they need to know that their concerns are heard and recognized. That is a first step.

Protection is...bigger than just PPE

Protection is a second step and it is bigger than just PPE. People want to have very clear guidance of what they can do at the end of their shift to make sure they don't take this infection home. They need to know that they have access to testing if they develop symptoms.

They also want to know that we will prepare them to be effective and provide good medical care if they have to be redeployed. This is a dimension that we don't always appreciate. Most physicians are willing to step forward and help wherever is needed right now, even if it's far afield from their daily work area of expertise. But they take great pride in their work, and none of us wants to provide medical care that we feel is substandard because we have a knowledge deficit. Our people are telling us, "When you deploy me to where you need me, please make sure that you provide the right backup to experts, the right tutorials to help me come up to speed, because I need to know that I'm a good physician, even when I'm not in my area of expertise." This sentiment has been expressed.

And then there's the whole dimension around human limitations. We're working longer hours, have rapid-cycle shifts, and have a lot of exposure to human suffering. There are limitations of resources that we've traditionally not dealt with in the US healthcare delivery system and most Western healthcare delivery systems. We're dealing with moral and ethical challenges. And we're providing support for our tangible needs, be that basic needs such as food or occasionally more convenient lodging if we're going to be back in a short period of time or don't feel comfortable going home to our family. There is [need for] psychological and emotional support so that we can continue to come back day after day. There are some very tangible concerns or needs that people are asking of their organizations in this time.

There's also a dimension that people need to know that if they do acquire the infection, that the organizations that they work for will take care of them and their family—that although we're putting ourselves in harm's way, we will be looked after should we acquire the infection.

Those are some strong sentiments that have come through in these sessions as we've engaged our teams. The last one I'll mention is that transparency of information is also really important. We're experts in the field of medicine; we understand data and numbers and what they mean. I think to the extent that we don't transparently share information, people tend to fear the worst. Being transparent and authentic with our team members about where we stand as an organization and what we're dealing with actually tends to alleviate fear and bring a sense of calm.

Facing Ethical Decisions

Topol: The antithesis of calm is deciding who to put on a ventilator. This is becoming a big issue in New York City at the moment. It is certainly likely that it will be similar in many other hotspots around the country. It's kind of a whole new chapter in biomedical ethics, because people on the frontlines are making extraordinary decisions that otherwise might have been done with a lot more time in academic centers, perhaps with the input of bioethicists. And now we're talking about the harrowing experience where physicians in the trenches—sleepless or sleep deprived—are having to make some extraordinarily difficult choices. Can you discuss that?

It's critical in this time that we don't feel that we have to make difficult decisions alone.

Shanafelt: You said it well, Eric. I don't know that there are any simple answers. Obviously these are choices that we've never faced previously in the United States. It's critical in this time that we don't feel that we have to make difficult decisions alone. There are just so many difficult choices right now. We tend to be a self-sufficient, self-reliant group as physicians. Traditionally, we're not always willing to ask for help or we have to be in extreme circumstances to be asking for help. This is a time when we're all facing some of these particularly challenging decisions each day and we need to have a low threshold to rely on colleagues. Don't feel that you're making any difficult decisions alone. The type of dilemmas that you're surfacing are horrendous. To the extent that we do have some guidelines and approaches, developed with the input of our ethicists and our ICU experts and many others, it can help us feel that we at least have some guidelines by which we're making these decisions, horrendous they may be. There has been a lot of thought and input from many voices about how we approach them so that they're not mercurial and we don't have to feel that someone else would make a different decision in the same circumstance.

But at the end of the day, that doesn't make the choices any easier. In the first several weeks of this challenge, we leaned on the expertise of our infectious disease colleagues, our ICU colleagues, our emergency room colleagues. I think we're entering this chapter where the expertise of our psychiatrists and psychologists is going to become one of our most important resources to both support our patients and communities but also our healthcare workers who are having to make these types of choices, which are really a "Sophie's Choice."

Topol: I really like your point about having collective minds to help make decisions to provide some level of comfort. Bringing it back to the Medicine and the Machine theme, algorithms are starting to crop up to predict who you should put on a ventilator or not. To me, that seems to be potentially a serious flaw, because those algorithms are not going to capture the human element. But it could give someone comfort also, because the algorithm says, "I shouldn't intubate this person." But I can't imagine that that's going to substitute for human judgment.

Shanafelt: That's well said and I couldn't agree more. It's helpful for us to have some guidelines and principles to help us think clearly and in a consistent way. So I would be a strong advocate for principled approaches and team-based decision-making for these types of choices. But I completely agree with your sentiment also that this cannot be a cookbook. When we're making these incredibly difficult choices that are life and death, choices when a patient that we're caring for is at the other end of that decision, it just can't be an algorithm. We have to have a principled approach and a group to help us make these decisions so no one is making them on their own.

Topol: To compound what we're talking about, there could be three patients simultaneously who have gotten to the point of intubation and there's just one ventilator. So it's not just a one-on-one decision; it's multiple patients, multiple families, multiple circumstances. This is already starting to happen. And even more strange, what I would have considered unheard of is the idea of sharing ventilators between patients. The way it's projected, we will be seeing a lot of this, not just in New York City.

Importance of Support

Verghese: Both Eric and I are fortunate to work at large institutions with relatively good support, but we've been hearing from a lot of our listeners and colleagues in far-flung places who often are very much alone with a small ICU. Could you give two levels of advice for what an institution might do in the absence of a wellness officer and the well-oiled machine that you have? And secondly, what are some simple recommendations you have for our listeners as individuals to survive this marathon? Because that is what it's going to be.

Shanafelt: Not all institutions have unlimited resources to bring for support. But, again, I think leadership is our most important tool right now. Leaders being visible, being transparent, being honest, listening, asking questions, and doing what they can is the first thing. Related to that is showing honor to our colleagues for the work that they are doing. The importance of this cannot be overstated. People are making heroic sacrifices right now and recognizing that, acknowledging it, and affirming it—even if we can't always meet all of the needs that we would like to meet—is critical. Those are two things that all organizations can be doing and should be doing.

Again, to the greatest extent possible, [organizations should] provide protection and reassurance to people. We can only do so much with respect to PPE, but they can be clear on what steps people can take to make sure that they're not taking the virus home at the end of their shift. All of our organizations can provide information and guidance on this. They can help reframe things from a sense of being powerless, of "there's nothing we can do to help us understand," to "there are things that we can do to try to reduce risk to the extent we are able." They should provide moral, ethical, spiritual supports to people in these challenging times.

No matter how large or small, almost all of our hospitals have social workers, chaplains, and mental health professionals whose wisdom and expertise we can draw on to provide support. Identify resources that you do have that you can mobilize to support people. Reframe them because these are unprecedented times. We are facing great uncertainty. None of us will have all the answers. We need to rely on our colleagues. And we need to support one another.

We need to attend to rest and sleep—short breaks and respite can be important—and it's important to find ways to do that. Titrate the news down, and make sure you identify some small moment each day for yourself and for your own needs, even if it's just a call to your partner or your children.

Many have, in some form or another, expressed the sentiment that we're not just fighting a virus right now; we're fighting fear. We as physicians can really either amp up that fear in the team through our own behaviors and interactions or we can be the catalyst, the agent who brings a sense of compassion, support, caring, honor to our colleagues and our team in this unprecedented time. If we can all reframe ourselves and make sure we take those moments for ourselves so we center and be able to bring that calm to our teams, I think that that is part of our charge, our role, our mission as physicians—to bring that to our team, our hospitals, our patients, and our society in this unprecedented time.

Verghese: Tait, that is beautifully said and we couldn't end on a better note. We want to thank you so much for your time.

Shanafelt: Thanks so much. It was great to visit with you.

Eric J. Topol, MD, is one of the top 10 most cited researchers in medicine and frequently writes about technology in healthcare, including in his latest book, Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again.

Abraham Verghese, MD, is a critically acclaimed best-selling author and a physician with an international reputation for his focus on healing in an era when technology often overwhelms the human side of medicine.

Tait D. Shanafelt, MD, is one of the nation's leading voices in physician wellness, advocating for system changes rather than focusing on individual resilience. Board certified in hematology, his clinical practice is focused on chronic lymphocytic leukemia.

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