Your Life Your Doctor – On the effective habits to help your medical caregivers

PREFACE

Are you ready? Asked the young man to his father, helping him close the protective coveralls they had to use to enter the room of a Covid-19 patient. Their eyes met through the face shields, and the smile of their gladness was perceivable despite the mandatory face masks. If it had not been for the virus, Frédéric Schlunke and his father Stephan, a consultant at the Moncucco clinic in Lugano (a non-profit organization[1] in south Switzerland), would never have had the opportunity to work together! The former is an economics and business student at Bocconi University in Milan and his father is a general and vascular surgeon, active for over 25 years in the field with over 15000 surgical procedures performed since the end of his internship in 1998.

The two entered room number 110 together. Because the Swiss Army had drafted Frédéric to support staff work on hospital wards in the Moncucco clinic of Lugano, where the Covid-19 infected people would be sent, both were called to act on the same patients. Lugano is the most populated town of Ticino, Switzerland’s Italian-speaking area, which is only 70 km North of Milan - Bergamo, one of the largest Italian centers of the viral outbreak in spring 2020.

The compassion encountered in the relationship between nurses, medical staff, administrative employees and this extemporaneous flood[2] of patients was eye-opening, and it partly “caused” the genesis of this book.

The peculiar state of isolation of the patients—no relative, if not in exceptional situations, was allowed near them—and the “substitute family” that the care team compassionately offered them was extremely touching. It led medicine to win its primary goal back: making people feel better, even in the face of ineluctability.

This book originates from the wish to ease the relationship between patients and physicians, helping both worlds unite in thriving for the best potential outcome. Via an excursus about the formation of the human ego-system and the importance of touch during our growth, we will discover how the patient and their relatives can help doctors avoid cognitive errors—our ego being a leading generator of such errors and a bias to our perception of reality.

A possible solution could already be provided by the aviation industry. Forty years ago, pilots found themselves in a similar situation: the heroic times of pilot idolization were fading away, carrying with them their ego as well. Today, pilots and crew members have learned the power of thanking those who draw attention to an error or mistake, an attitude that the medical field would undoubtedly benefit from. In this scenario, the patient and their family could represent the physicians' co-pilots, and the operating team should act as the surgeon’s co-pilot in the operating theater. The essential premise for this scheme to work, though, is that physicians accept patients and the operating-team as their peers, their equals. Just like aviation implemented Crew Resource Management (CRM) and crew selection procedures to achieve a change of behavior in cockpits, the author will suggest pre-med-schools, specialist selection tools and checklists with questions that the patients and their relatives can use to help physicians think—think and act correctly.

At the beginning of the pandemic, the Moncucco Clinic did not yet have dedicated iPads or tablets to help patients communicate with their families. Therefore, nurses and doctors would frequently lend their private cellphones to bridge the gap between elderly patients and, let’s say, their grandchildren. This same staff would then have to stay on one side of the border, sleeping in hotel rooms—organized by the Clinic—for several weeks, without seeing their own families and children on the other side, if not through the same (sanitized) cellphones. A surreal situation that saw light because many Swiss hospitals on the border cities (Basel, Geneva, Lugano, etc.) often rely on the convenient working force from “the other side”.

Many physicians and other health care workers know from childhood on what their fate and life goal will be: to become a doctor, a nurse, a psychologist. Some follow that path because a family member has been an example for them, some others do it after personal experience or even after a personally experienced illness in their family or on their own skin. However, most health care providers chose this path be-cause of a need for compassion, and because of the unique emotion of satisfaction that altruism pays us back.

And so it was for the author. He did not have family members active in the hospital field (three generations of chemists preceded him). However, he experienced some relevant events in his childhood… although not more relevant than those each of us has had to endure! As we will see later on, in a chapter dedicated primarily to surgeon’s EGO, our childhood experiences are of most considerable importance to determine the formation of our character. Schlunke had the opportunity to attend several workshops and retreats of the LEO-institute, which changed his way of looking at events forever! [3]

Since the very first years in the surgical field, he started noticing the disparities between colleagues and their different behaviors in the operating theatre, with patients and with other physicians or nurses. The dream to become a surgeon overwhelmed him at a very young age and he quickly encountered mentors who made him say: «One day I will be and behave like them. Namely, I want to thank Dr. Guido Von Allmen and Dr. Diego Donati. »

I want to learn to fix people - I want to become a surgeon, a passionate surgeon.

His elementary school teachers remember him saying this since age 8. He grew up in French-speaking Switzerland, but being a German native speaker and initially, until his 12th birthday, also a German citizen, he soon began being bullied by his fellow first graders: “you are an SS!” Which ironically corresponds to his initials... It was not until German history and World War II became a school topic that he started understanding the abhorrent behavior of the Nazi regime. Slowly, but steadily, the conviction grew in his child’s Weltbild: “I have to do something to make up for the atrocities that my ancestors did to humanity. I want to learn how to fix people...I want to become a surgeon, a passionate surgeon!”

A well-known novel by Samuel Shem: The House of God, published in 1978, describes the first internship year of young doctors and medical interns in a fictionalized—but probably personally experienced—New York hospital in the early 1970s. Even then, the depersonalization and psychological harm endured by the majority of residents seemed the only way to obtain a passport to the world of “medical freedom”—meaning to become an independent specialist:

« The House of God had been founded in 1913 … had broken down into many hierarchies, at the bottom of which lay the very people for whom it had been constructed, the House Staff. Consistently, at the bottom of the House Staff lay an intern. »[4]

During his career to become a surgeon, Schlunke made the conscious decision of never to bully any of his fellow assistants; but he created instead opportunities and conditions for the younger colleagues to learn and evolve in a peaceful and sustaining ambiance. During several years as vice-chair for surgery in the hospital of Locarno, Switzerland, he started managing the surgical ward together with his former superiors, Dr. Paul Biegger and Dr. Diego Donati, achieving a familiar and stimulating atmosphere for the entire team.

Hospital La Carità was found to be the best Swiss hospital in its class in a study commissioned by the Swiss consumer association about patient satisfaction in 2007.[5] In 2008, Locarno La Carità became the first Swiss hospital[6] to get full accreditation by the Joint Commission International (JCI). On this occasion, Schlunke had the privilege to contribute firsthand to implementing the "time out" procedure in the OR[7]; furthermore, he had the chance to directly address the surgeons' disruptive attitude by demonstrating in an ironic video how this type of behavior could lead to severe medical errors. (The footage obtained the first prize at the European vascular surgery convention in Athens, 2011).

The “Speak up” campaign by the JCI (2002 and 2018) and Schweizer Stiftung für Patientensicherheit (2015)[8] would validate the efforts made through those years. In the JCI[9]certification process, some evidence became noticeably clear to the whole staff: allowing people to speak up and even encouraging a critical incident reporting system (CIRS) is of immense value when aiming for the quality elite. However, the system only works when every single person, from the ground up participates, encouraging them to speak their minds. Therefore, just a fear-free environment allows real qualitative growth. [10]

One of the slides used in Schlunke’s motivational talks quotes: “Good surgery is made where a scrub nurse can stop a surgeon!” Your hospital is excellent if your nurses are free to stop a doctor or a surgery administrator! In Schlunke’s own ironic words: “At home, my scrub nurse—my wife—stops me whenever she feels like it! Just with a snap of her fingers!”

Good surgery is made where a scrub nurse can stop a surgeon.

After having experienced the results and the well-being of health-care workers, administrators and patients in a hierarchically flat system, Schlunke’s additional objective was to get the best working conditions for “the folks at the bottom”: the gratification of working in such a flat organization is immense and therefore leads to better results.[11]

Most of the time, simple steps lead to great outcomes: in the Checklist Manifesto, Atul Gawande[12] could seamlessly demonstrate how a simple surgical checklist can dramatically diminish complications and provide an exponential gain in quality. This change was observed not only in the facilities located in developing countries, where everybody expected to notice its major impact; it also proved to be effective in institutes like the Massachusetts General Hospital. The same has happened in Locarno’s Hospital La Carità, where the checklists have also been implemented. At the same time, only a stone’s throw away, medical residents are still bullied today.

The medical world has yet to learn!

One of this essay's objectives is to elaborate useful and straightforward tools, bringing a renewed awareness to patients and colleagues; not to blame them, but with the intent to co-create a better medical world. Therefore, we will explore what to expect and eventually how to choose, with a reproducible approach, the ideal physician for your specific condition.

When facing the urgent need to find the best solution to a personal health problem, the quest for many of us is to locate the adequate specialist capable of solving our condition, or at least able to help us cope with it.

How can I find the competent and compassionate professional for my health problem?

What are the most pressing issues patients deal with when having to undergo surgical treatment? Most of the time, the patient turns to their family doctor, friends, and relatives asking: “do you know a good surgeon?” or “how can I find the competent (and compassionate) professional for me?”

Some people, like our writer’s wife actually, have a strong opinion on such an emotional subject. In her own words, she “does not care if the surgeon is a nice person.” She needs “two skillful hands and a proficient perception! If you have two left hands with five thumbs, you should not touch patients..." However, being a former scrub nurse, she knows how to evaluate the expertise of a physician!

At the end of this book, you will find suggestions and questions you can ask your surgeon or physician, to help you understand and help them think... the right way.

In the medical environment, ego-driven and insecure colleagues are continuing to exploit, harness and take advantage of the delicate condition of young learners. To get their residency training, surgical operations, or any other mandatory step to obtain their license, junior doctors are therefore forced to accept the tyranny of those who should be their mentors.[13] By reading books[14] that deal with doctors' education, we can gain insight into the so-called “soft skills” a physician should learn. Luckily, other colleagues have been able to demonstrate with scientifically recognized methods (Mazzarelli & Trzeciak)[15] that "compassion matters" and that it is not only an "added value" to technical skills, or a quality which is just “nice to have”

Compassion matters!

But how can young doctors, nurses and future hospital managers understand how necessary these "soft skills" are?[16]

One goal of this publication lies at the root of the hope that future generations will do this job better than us—or should we say, better than how we have been taught.

How many of us—from the highest ranked to the less rewarded paramedic—have already paid the heavy price? The risk of caregiver burnout and the repercussion on their families is a real problem. And burnout starts early: trainees are equally at risk. A study of the University of Pennsylvania that followed physicians over their intern year (i.e., the first year of residency, out of medical school), showed that one-third of the students experienced a sharp increase in depression.[17] Depersonalization rose over time among the participating students, as did emotional exhaustion. As one might expect considering these developments, researchers found that these students also showed a reduction in empathy towards patients.[18] This same study was built upon research published in the Journal of the American Medical Association (JAMA), that demonstrated how empathic concern decreased over the first year out of medical school for junior doctors.

And without empathic concern (the feeling component), there can be no treatment with compassion (the action component).[15]

INTRODUCTION

Surgeons never cry

“I have seen things you people wouldn’t believe. Attack ships on fire off the shoulder of Orion. I watched C-beams glitter in the dark near the Tannhäuser Gate. All those moments will be lost in time, like tears in rain”

Rutger Hauer. Blade Runner, 1982

On the third morning of the retreat that had been organized by the Locarno Hospital and the LEO-Institute[3] in May 2008, the surgeon amidst the group—myself—with tears rolling down his cheeks requested to speak: "You are completely crazy… all of you! How the hell do you think that I can go back to my normal activity, with all these overwhelming feelings pouring out of me, and convince people that I will open them up and cure them? Hey?!"

In that peculiar period of my life, I had built for myself a very well-functioning personality of a sunny surgeon: "no problems—only solutions!", which was mostly well received by staff and patients. Patients love to hear that there will be no problems! Not that I did not care about patients who could encounter complications—no, the whole surgical team of Locarno was keen on treating in a comprehensive and emotionally understanding way the (few) complications they would encounter. So, like many of my fellow surgeons and clinic staff, I had built a fairly thick shell to protect my inner feelings from the harsh exposure to the cruel destinies of others. This carapace would also help me keep calm when put under pressure—at least this is what I told myself. The idea of crying, especially in public, was inconceivable for a surgeon who strived for an image of reliability, robustness, and self-assurance! The last time I had cried it had been more than ten years earlier, as a young intern in a urology ward. I was sitting in an intensive care unit with the husband of a 26-year-old Turkish woman who had died—abruptly, from a not soon enough diagnosed urosepsis—leaving two small children and her spouse.

The above-mentioned seminar had, however, a broad objective: leading the staff towards a more conscious and compassionate lifestyle, thus delivering, in the end, better care to patients. The journey would bring the team to deal with their personal emotions, exploring everyone's survival mechanism, that automatically triggers when we are judging, prejudging or every time we get "pinched" in our images of ourselves (the image we hope other people see when looking at us). Hence, this path would bring us to deal with the mask we wear to fend off every blow aimed at our image... I bet this sound familiar to some of you!

One of the workshop's principles and techniques was to express publicly—at least to the group gathered in the room—our feelings and experiences. Especially those that had not generated such good results, or the ones associated with psychologically painful situations.

That morning one of the participants had just opened up, stating how difficult it was for him to feel appreciated by others, as in his life since childhood he had been trying to make his mother happy, at all costs. He began to describe in detail how he had built a mask to keep up appearances during his entire life, becoming a financial accountant while his innermost desire was to be a nurse or a doctor. He had chosen the "easier" way to make sure he would not disappoint his mother's expectations. By doing so, he lost all his joy, even in his job, which, from his perspective, had to be his life-filling accomplishment. The whole group was abashed, and sincere sympathy began to flow in the room. Every single person realized how everyone's mask was preventing us from exposing our "selves" to the world, not wanting to risk "losing face" but also never knowing for sure if the compliments received were addressed to the mask or to our "true self"...

We deeply link the fear of abandonment to being forced to wear a mask, hoping to get away with it. Our brain is constantly evaluating our different coping systems and the potential effects of our actions in all organizations, not only in hospitals. We are thus creating insecurity in our teams. One way out of this spiral is to create fearless organizations: to permit learning, innovation, and compassion.[19] The profound experiences of this seminar liberated an unprecedented energy throughout the whole hospital, uncovering the power of sharing emotions and of subjugating fear at the same time. Being reassured by the team retreat, the now sensitive surgeon and the entire crew would become an even more joyful unit, which cared and would take care of the surgical and the emotional needs of their patients and teammates!

To be clear, it was not like the complete universe had turned out to be peaches and cream! However, a world full of possibilities had opened up to us.[20]

We all learned that it is possible and not really dangerous—unlike our primitive survival brain keeps telling us with its inner voice—to open up to others about our fears and puzzles, without being hit on the spot by misjudging, as one would expect!

It is possible to get rid of fear instead, and this is a priceless value to add to any relationship!

Let me now share with you a communication technique. Try beginning a conversation with patients or teammates by stating the fears (the personal fear) connected to the topic. Immediately after having stated the fear, express the aim of the discussion (possibly a goal that leads to a joint result, not to the individual domination of an idea or a person).

E.g., "Boss, we want to find a suitable solution for the patient, working together on this difficult fracture. I do fear, though, that you do not take my opinion about these new surgical techniques seriously and will decide for a conventional treatment which could affect the patient's health."

That was actually half of the job because the real fear expressed here should be, "I fear you will not accept my opinion on these new techniques and will therefore dismiss my proposal, hurting my feelings. I also fear that, as you do not support me, other people will think that I am not a trustworthy surgeon..."

How do you think your boss will react the next time you start a conversation in this manner?

It is likely that the comfort zone of the participants will be seriously tested, but here is the recipe—in this precise order—to a perfect statement. Show:

• Vulnerability (I fear that …)
• Empathy (I feel that you …)
• Direction (What do I want)
• Exploring (Can we explore this together?)
• Caring (I do care about you and your feelings)

Now, how do you think a surgeon will react the next time you consult them before your planned surgery or for a second opinion?

Once you discover the power of such a valorous, fearless world, you will never want to look back!

The essential and "sine qua non" condition for this system to work is that it must reflect the speaker's true inner conviction—not that of the mask! Otherwise the listener will almost immediately sense this as manipulation and not as a request for empowerment!

Consider that the simple act of speaking about one’s fear inexplicably makes it disappear... well, until our little inner voice suggests a new, fearful thought and therefore a negative emotion. However, note that fear is a necessary feeling for the evolution of species and the survival of individuals. It should just not constitute the main point of inter-human communication!

Discussions with patients are notoriously more comfortable to empower because the common goal is easier to find and clear to both parts! Moreover, fears can also be understood more readily: they only need to be expressed! Until this type of inter-personal experiment became routine in our hospital, it was customary to let the patient be the fearful speaker, leaving to the doctor the reassuring, knowledgeable role. This "automatic" mode of relationship, with its manifest “biased” knowledge system, puts the two speakers on different levels.

Most doctors and other professionals will object that it is precisely because of this knowledge gap that we cannot put patients and doctors on the same level.

However, what I mean is that we should put them on the same emotional level, leaving knowledge aside. We both are humans with very similar prejudices, fears, masks and desires. But there is one thing that physicians can do. We can let go of our superhero-surgeon cape, giving our patients a glimpse of our true self! By embracing our fears and those of the patient, and at the same time by expressing our total commitment to the procedure, we will be on the same emotional, human, level.

This feeling generated in our minds, that of the patient and mine, will connect us more profoundly than any other professional relationship. It will not hinder complications, but the acceptance of them potentially occurring will be easier to face—on both sides.

Quite often surgeons experience complications as a personal failure. Therefore, every time "the case" is mentioned in conversation, or the patient walks into the office, the wound in our ego reopens. The management of surgical complications is discussed in numerous other publications, which are already very useful to doctors and patients. For this reason, this topic will not be further developed here.

Getting back to our five-step method: by discussing with our patients—or the patient discussing with their surgeon—we can level our emotions and our “selves”. We can empower the relationship—we can empower the patient!

YES, WE CAN EMPOWER THE PATIENT!!!

[1] https://moncucco.ch Accessed April 10, 2021

[2] https://www.bfs.admin.ch/bfs/en/home.assetdetail.12847991.html (deaths by canton statistics) Accessed April 10, 2021

[3] Leo Institute. Accessed April 10, 2021. https://leo.institute Accessed April 10, 2021

[4] The House of God - Samuel Shem, MD - 1978 - Dell publishing.

[5] https://www.google.ch/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKEwi014nYrKzpAhXF0qYKHRMfBmEQFjAAegQIBBAB&url=https%3A%2F%2Fwww.comparis.ch%2F%2Fmedia%2Ffiles%2Fmediencorner%2Fstudies%2F2007%2Fkrankenkassen%2Fstudie%2520patientenzufriedenheit%25202007_de.pdf&usg=AOvVaw1La6wJEyGhB6uvhUA94aZv Accessed June 10, 2020

[6] https://www.eoc.ch/Ospedali-e-Istituti/Ospedale-Regionale-di-Locarno/Qualita.html Accessed April 10, 2021

[7] https://www.eoc.ch/dam/Publication/Atti20del20convegno20JCI2028per20pubblicazione29pdf.pdf Accessed April 10, 2021

[8] Gehring, Dr. Katrin, and Prof. Dr. David Schwappach. Speak Up - Wenn Schweigen Gefährlich Ist. Speak Up Für Mehr Sicherheit in Der Patientenversorgung. Patientensicherheit schweiz. https://www.patientensicherheit.ch/fileadmin/user_upload/2_Forschung_und_Entwicklung/Speak_Up/Schriftenreihe_08_DE_Speak_Up.pdf Accessed April 10, 2021

[9] https://www.jointcommission.org

[10] Garvin, David A., Amy C. Edmonson, and Francesca Gino. Is Yours a Learn- ing Organization? https://hbr.org/2008/03/is-yours-a-learning-organization Accessed April 21, 2021

[11] Craig, William. The Nature Of Leadership In A Flat Organization, 2018. Accessed April 10, 2021 https://www.forbes.com/sites/williamcraig/2018/10/23/the-nature-of-leadership-in-a-flat-organization/#279f69995fe1 Accessed April 17, 2021

[12] Gawande Atul - The Checklist Manifesto, how to get things right - 2009 Metropolitan Books of Henry Holt & Company LLC; 2010 Profile Books Ltd, London.

[13] Jauhar Sandeep - Intern, a doctor's initiation - 2008 Farrar, Straus and Giroux, New York.

[14] Gawande Atul - Complications, a Surgeon's Notes o an Imperfect Science - 2002 Picador

[15] Trzeciak Stephen & Mazzarelli Anthony - Compassionomics, the revolutionary scientific evidence that caring makes a difference - 2019 Studer Group

[16] Vikis EA, Mihalynuk TV, Pratt DD, Sidhu RS. Teaching and learning in the operating room is a two-way street: resident perceptions. Am J Surg. 2008 May;195(5):594-8; discussion 598. doi: 10.1016/j.amjsurg.2008.01.004. PMID: 18367140.

[17] Rosen, Ilene M., Phyllis A. Gimotty, Judy A. Shea, and Lisa M. Bellini. "Evolution of Sleep Quantity, Sleep Deprivation, Mood Disturbances, Empathy, and Burnout among Interns." Academic Medicine 81, no. 1 (January, 2006): 82-5. doi: 10.1097/00001888-200601000-00020. PMID: 16377826.

[18] Bellini, Lisa M., Michael Baime, and Judy A. Shea. "Variation of Mood and Empathy During Internship." JAMA 287, no. 23 (June 19, 2002): 3143-6. doi: 10.1001/jama.287.23.3143. PMID: 12069680.

[19] Edmondson Amy C. - The fearless Organization, Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth - 2019 Harvard Business School - John Wiley & Sons, Inc., Hoboken, New Jersey.

[20] Stone Zander Rosamund & Benjamin Zander -The Art of Possibility - 2000 Harvard Business School Press & 2002 Penguin Books