Editor’s note: The Young Fellows Association (YFA) of the American College of Surgeons (ACS) Communications Committee recently held an essay contest. Young surgeons were challenged to write an essay on the theme For Our Patients and the winning essay was written by Emmanuel M. Gabriel, MD, PhD.
As tired and simplistic as leadership clichés may be, I believe that many hold truth, such as “There is no ‘I’ in team,” and “Lead by example.” These adages find their way into everyday medical practice. Equally trite are medical clichés—“Treat the patient as you would want to be treated or how you would want a loved one treated.” I, myself, am guilty of using these phrases often in practice when educating residents and medical students in an attempt to have them take ownership of the patient and become effective leaders to ensure the best health care outcomes for our patients. Yet even in my early career, I have the sense that the underlying meaning behind these common phrases is all too often lost not only on my trainees, but also on myself. The daily demands of complex multidisciplinary treatment, research, education, and administrative duties routinely dilute the energy we dedicate to serving as leaders on behalf of our patients.
A recent experience has reinvigorated my understanding of what it means to be a leader for the patient. Allow me to first preface this story by saying that this personal experience is very complex and that the health care professionals involved are all hardworking, intelligent, and dedicated to achieving the best possible result as it pertains to their area of expertise. In addition, as a surgical oncologist, I understand the current atmosphere and limitations of health care that all physicians face. It is within this challenging context that leadership for the patients must be performed and improved.
Shifting from health care professional to patient advocate
This story is about my mom, who was recently diagnosed with an aggressive form of leukemia. After three days of waiting for transfer from a small community hospital ill-equipped to deal with her condition, she was admitted to a large academic center. To the credit of all of her physicians, she recovered from a multitude of acute, life-threatening conditions and was able to start novel chemotherapy, giving us cautious optimism and hope that she would survive her latest disease process.
However, her battle was not without its bumps, which I witnessed firsthand staying with her 20 to 24 hours each day. For example, she went into flash pulmonary edema following a red blood cell transfusion, which is not unexpected given her previous resuscitation and petite stature. However, the next day, it was thought that she was still intravascularly depleted and was challenged with a crystalloid infusion at 150 milliliters per hour, again resulting in flash pulmonary edema. During her three-week hospital course, the changing nurses, sometimes on different units, would try fluid boluses, at which point I had to intervene and suggest gentler rates of infusion.
Another example of my mom’s battle occurred when she received an appetite stimulant one night. The stimulant’s side effects caused acute delirium, resulting in her removing her high-flow nasal cannula, rotating 180 degrees in bed, and desaturating to the 60s. I recognized the problem in the middle of the night, and the nursing staff promptly responded after I alerted them. However, that medication remained on her order list and was again offered to her the following two nights, which I promptly refused.
My mom was being followed by multiple teams, with hematology/oncology as the primary team. At times, communication between the teams was suboptimal. Morning recommendations would not be followed-up on or the recommended orders would be entered the following day when the tests were not entirely relevant anymore. There was uncertainty as to when and who was placing these orders. This miscommunication is a source of frustration that patients know all too well and is a common complaint my own patients have expressed.
These are a few of the challenges that we encountered during my mom’s hospital stay. Whether these events would have affected her overall outcome is debatable. In no way do I feel that these issues arose intentionally. Having trained at major academic centers, I have witnessed similar events firsthand and received similar complaints myself. It is all too easy to become complacent and accept these occurrences as the best that we can do. This experience was profoundly enlightening to me as a health care professional, but also as my mom’s advocate.
It’s a team effort
In our story, leadership for the patient, my mom, really equated to an unyielding vigilance and thoughtful coordination of a complex health care plan to optimize not only the oncologic outcome, but also the overall patient experience and her mental and emotional well-being. I provided that vigilance in anticipation of events that could cause harm, trying to minimize potential problems as best I could. I also acted to coordinate my mom’s care among her different teams, keeping a detailed log of her vitals, labs, diagnostic studies, and daily recommendations, and questioning plans of care when they did not seem to conform with our understanding of the recommendations or were not fully coordinated.
Physicians are well-trained to raise these issues, but many of our patients do not have medical expertise or family members with medical backgrounds to advocate on their behalf. Hence, it naturally falls to us on the physician side to maintain this level of vigilance and care coordination on behalf of our patients. In other words, it is up to us to be leaders for our patients, whether we are on the primary care team or a consulting team and whether the patient is a family member or a complete stranger.
I liken this experience to watching a 100-meter sprint, where each care team represented a runner in his or her own lane. Each runner crosses the finish line, but is separate from the other competitors. Leadership for the patient should look more like a crew team rowing a race. There is a designated captain of the boat, but all members work in harmony to reach the finish as effectively as possible. In this way, we can truly be leaders for our patients and obtain not only positive outcomes, but also enrich patient well-being and satisfaction, as well as emulate some of the truths in those leadership and medical clichés.
This essay is dedicated to Dr. Gabriel’s mom.