A great big thank you for years of ethics support in the hospital AND for a great Grand Rounds on How to Mitigate Moral Distress among Providers by our very own Sutter Senior Bioethicist, Dr.Shilpa Shashidhara. 

A recording of her presentation is available HERE. Please watch it if you can!

And here are my notes:

What is moral distress? 

Moral Distress was first defined by Dr. Andrew Jameton (1984) as a natural response to violation of one's core values. In healthcare, it is a feeling of uncomfortableness that arise when providers are unable to do the thing they believe is the "right" thing to do. It is an inability to act within our individual and/or professional values. 

These are ethically challenging situations, where providers feel powerless. 

Moral Distress can lead to disengagement and burnout, can have negative impact on patient care. Prevalent in high stress environments (e.g. ICU: critically ill patients, family members in distress, etc). Has been magnified by the pandemic: challenging clinical situations, managing really ill patients, not having PPE, concerns about allocating resources in stressed healthcare system

• "I don't know if this is the right thing to do"
• "I feel stuck"
• "Both options are equally bad"
• "I feel like I am causing harm to someone"

If not addressed, moral distress takes toll on personal and professional well-being

3 areas that cause moral distress

• clinical situations (e.g. non-beneficial treatments that family is requesting, sense false hope with discordant prognosis by different providers, unrepresented patients that cannot make decisions for self and we don't know their values and acceptable quality of life)
• internal constraints (e.g. fear of speaking up, self doubt, anxiety, wish to not cause conflict, lack of confidence, feeling "stuck" in the middle)
• external constraints (e.g. power imbalance: RN vs. MD, resident vs. attending; fear of legal action,  poor communication)

Moral distress is a root cause of burnout. 

• 42% physicians experience burnout (long hours, overwhelming workload, lack of support)
• 54% of nurses experience moderate burnout with emotional exhaustion,28% high burnout
• significant role of burnout in organizational turnover

How do we mitigate moral distress to best support providers to reduce burnout?

Identify the problem--> Express a concern

Use debriefing sessions, specifically interdisciplinary debriefing sessions

• mitigate negative effects
• normalize and validate experience of negative emotions
• supports providers
• uncovers gaps
• promotes team cohesion
• opportunity to explore systemic problems

Debriefing sessions: goal is NOT just venting session, but also action planning. Both together are more effective

Part 1: Preparatory: identify needs of healthcare provider, gather relevant information, set goals, plan logistics

Part 2: Implemental: 8 step method

4 As to Rise Above Moral Distress (Developed by the American Academy of Critical Care Nurses)

Can be done as individual or ina group

What else can we do?

Targeted education training for providers, promoting provider ethical decision-making. What is appropriate in a complex situation?

Communication skills and practice

Don't forget to take concerns to hospital/clinic administration to be sure they understand what is happening and look at systems-based solutions

                

Serious Illness Communication (Sanders, 6/2/2021)

Many thanks to Dr. Justin Sanders for a really important Grand Rounds presentation this week on Serious Illness Communication. Dr. Sanders is a family physician, a palliative care specialist and a researcher in Dr. Atul Gawande's think tank, Ariadne Labs. He has a particular interest in disparities and inequities in end of life care.

A recording of his Grand Rounds can be found HERE.

What is serious illness communication, you ask? 

Serious Illness Communication is a framework for how health care providers can engage with patients with advanced illness to elicit their goals and values, share their prognosis, and explore key topics for their end of life care-- all essential components of advanced care planning as well as the physician-patient relationship. 

Dr. Sanders (and the serious illness care model) ask us to proactively identify patients with severe illness so that we can prioritize and systematize important conversations. The goal?  Improved communication with our patients and "goal-concordant care"-- that is, to be sure that the care a patient receives at the end of their life is concordant with the life they want to live.

Take a moment to consider your patient panel, or if that feels overwhelming, take a look at your patient schedule for today and ask yourself this question: which of my patients would I not be surprised if they died in the next year? 

This is called "the surprise question" and has been validated in palliative care studies. Maybe you are thinking about a patient with chronic heart disease, lung disease, cancer, or  maybe one who has been hospitalized several times in the last year; perhaps it's someone with decreasing mobility, or even one that you hear a lot from their caretaker. It may be helpful to extend that time to 1-2 years so you capture as many patients is possible.

Now, the next question: is there a way your system can help plan the time, space, and opportunity to have these important conversations? Maybe an EHR prompt? An extended visit? A dedicated visit?

Once the space is set, the serious illness communication can begin-- guided by the serious illness communication guide (SICG) cut and paste below. 

The work is big: Have you asked them who their surrogate decision-maker should be in their stead? Do they have an Advanced Care Plan? Do they have a POLST? But perhaps more importantly:

 Here are the key SICG questions:

• What are YOUR goals?
• What are YOUR fears and worries if your health deteriorates or your illness progresses?
• What are your strengths?
• What abilities are important for you in your life?
• What might you be willing to go through for the sake of more time?

These are such a powerful set of questions-- of course, the very questions I would want someone to ask me if my time was short-- and turns out the very questions patients want to be asked. 

He also spent some time talking about framing prognosis and encouraged us to use a framework for how we present this information. An original viewpoint co-authored in JAMA by Dr. Sanders and colleagues is linked here for your own reading.

The short take is this: prognosis communication is super challenging, many of us struggle with how to provide this type of information in a useful way that doesn't allow for hope. The article argues that prognosis may be communicated in three different approaches: time-based, function-based, and reasonable-uncertainty based. Exploring with a patient for his/her preferences to guide the discussion will help providers give the patient the most useful information.

Time: how much time do you think I Have

Function: what will my function look like

Reasonable uncertainty: remember our goal is not to be right; it's to help patients have the information they need to reach their goals.

And then, finally Dr. Sanders said, you (the provider) should take the information gleaned from this rich conversation with your patient, apply the prognosis information you have, and make a recommendation (patients want a recommendation from you!), using language like this: "I have heard you say_________________and based on what you said, I am going to recommend ________________________."

Voila. Hard stuff. Thanks for the work you do.

AI in Radiology (Rael, 5/19/21)

Thanks to SMGR Radiologist, Dr. Jesse Rael, for a thought-provoking Grand Rounds titled AI in Radiology this week. Super interesting. 

The recording is available HERE for your viewing pleasure. 

Here are my thoughts on Dr. Rael's presentation: 

facial recognition at airport (cnn.com)

Artificial intelligence is the the theory and development of computer systems able to perform tasks that normally require human intelligence, such as visual perception, speech recognition, decision-making, and translation between languages.

AI is present in many aspects of modern life, including facial ID, social media platforms, google search, digital voice assistants (siri and alexa), smart home devices, amazon recommendations, and more.

The topic of AI feels very far from where we are in the world of safety net primary care-- where literally just getting a patient a follow up appointment with a PCP feels like moving a mountain. But I am not sure my sense is actually accurate. In fact, Dr. Manny Mendoza gave a Grand Rounds just a few months ago on AI in Primary Care. The link to that GR summary and recording is here. And the truth is, AI is already making changes in primary care: decision-making tools, benign vs. malignant lesions in dermatology, chronic disease management and more.

With regards to radiology, AI means a computer that is trained to interpret images to either rule in/out a radiographic diagnosis. This could include a wide range of diagnoses, from fractures to pulmonary emboli to cancer, and beyond.

Proponents of AI in radiology argue that radiologists are expensive, there is increasing expectations of productivity, that imaging is getting more complex, numbers of images per study are increasing, and that AI could streamline and improve that work. 

Dr. Rael doesn't think that computers are going to replace radiologists, BUT, he believes, radiologists who don't adopt the evolving technology will likely be replaced. In his words, AI could be considered equivalent to autopilot in a jet engine cabin-- the pilot is absolutely needed, particularly for complex situations, and the autopilot function is there to help him do his job better. 

Dr. Rael's hope is that AI will help radiologists to become more productive, enhance protocols, be available where radiologists are not, and more. And, as he points out, radiologists do much more than interpret images-- they are involved in clinician-to-clinician and clinician-to-patient communication, QA, education, policy making, hands on scanning, biopsies, etc.

Dr. Rael spent some time helping us to understand the concept of "deep learning" currently being used in image interpretation. He showed us how a computer can "see" images (e.g. a kidney or a brain lesion) on a screen.

There are many different current AI projects around the world: identification of pulmonary edema on CXR, white matter abnormalities in very preterm infants, PE recognition, benign vs. malignant breast lesions, abnormalities in knee MRI, and automatic scan range delimitation in Chest CT. The possibilities are endless! Dr. Rael himself is involved in a neuroradiologic project looking at image analysis for different brain lesions-- what does a glioblastoma look like? How can a computer recognize it?

And what about global health implications for providers working in places where there are not only no radiologists, but no machines to image (e.g. butterfly ultrasound with images being interpreted by offsite AI)? 

What do you think about AI in radiology and AI in general in medicine? Deeply interesting, kind of scary, and definitely cool.

My advice for this week: if you have a question about a radiographic finding, don't forget to call your friendly local radiologist-- I always feel like I understand more about a complex impression, after I have spoken to a real live human radiologist. Will that always be so?

What a Pain! Tales of Adult Arthritides (Ramirez, 3/31/2021)

Thank you to Dr. Vanessa Ramirez for her review of two very important inflammatory arthritides at Grand Rounds this week: psoriatic arthritis and gout.  I gleaned so many important pearls from her presentation. For those of you interested in seeing the full recording, it is available here. My summary notes are below:

Inflammatory arthritides

• infectious (septic)
• crystal induced (gout, pseudogout)
• immune related (RA, SLE, psoriatic arthritis, dermatomyositis, Sjogren's)
• reactive

Psoriatic arthritis (PsA) 

• PsA affects about 20% of people with psoriasis 
• skin changes can precede arthritis sx for years-- even up to 12 years
• skin changes and PsA flares are not necessarily temporally related, nor is disease severity necessarily correlated
• typically asymmetric arthritis (in one, several or multiple joints), sacroiliitis (30-78%) 
• historic definition of PsA: serological negative (i.e. negative rheumatoid factor) polyarticular arthritis in someone with psoriasis skin manifestations
• classification Criteria for Psoriatic Arthritis (CASPAR) (2006) may be helpful in making this clinical diagnosis (see image below)
• early identification and treatment prevents joint destruction
• anti-CCP may be elevated (usually mild) in 12% of patients with PsA
• more likely in higher numbers of involved joints
• Risk factors for PsA
• scalp psoriasis 4x risk, intergluteal/perianal 2.3x risk, nail involvement
• earlier age at dx with psoriasis, >3 body sites affected, family hx of PsA (first degree)
• ESR is superior to CRP as a marker of damage progression and mortality
• Treatment for PSA includes lifestyle modification (diet, smoking cessation, exercise), followed by symptomatic treatments (NSAID, steroids, injections) and then TNF alphas
• see images below from the 2018 ACR Guidelines
• also see AAFP image, which includes cost of these treatments

2018 ACR Guidelines for Treatment of PsA

https://www.rheumatology.org/Portals/0/Files/PsA-Guideline-2018.pdf

https://www.rheumatology.org/Portals/0/Files/PsA-Guideline-2018.pdf

AAFP Psoriasis (Am Family Physician 2013)

https://www.aafp.org/afp/2013/0501/p626.html

Gout 

• Gout is caused by deposition of monosodium urate crystals in the joint space, periarticular structures and soft tissues
• associated with obesity, htn, hyperlipidemia, DM, CKD, heart failure, thiazide diuretic 
• ACR online tool Clinical prediction (see image)

• 

  https://www.aafp.org/afp/2020/1101/p533.html

  
  
  
• Treatment Acute
• 2020 ACR Guidelines for Treatment of Gout Flare
• Naproxen 500 mg BID OR indomethacin 50 mg TID, ibuprofen 800mg TID
• Colchicine (low dose) 1.2mg PO, then 0.6mg 1 hour later, then BID until flare resolves
• Oral prednisone 0.5mg/kg (5-10 days full dose then stop OR 2-5 days full dose and then taper over 7-10 days)
• Treatment Chronic
• all patients with tophi, radiographic evidence or damage or 2+ flares/year
• goal is symptom relief AND maintenance of urate levels (<6)
• we should be titrating allopurinol based on checking uric acid levels
• Allopurinol is treatment of choice, lower doses preferred to start
• if on thiazide for BP, switch to losartan

Augmented Intelligence in Primary Care (Mendoza 1/6/2021)

Many thanks to Dr. Emmanuel Mendoza for his Grand Rounds tour of the current state of technology in primary care and the emerging role of artificial intelligence (or as he reframed as "augmented intelligence") in primary care.

Dr. Mendoza reminded us that the transition in medicine to electronic medical records (EMR) has happened intensively and quickly over the last decade, leading to a great change in how we deliver healthcare and affecting our experience as clinicians caring for patients. Dr. Mendoza recommends three books on this transition for your pleasure reading: Deep Medicine, The Patient Will See You Now, and The Digital Doctor (see image below).

While the transition to the  EMR was touted as something that would be helpful and advantageous to physicians and healthcare delivery, many providers have felt professionally burdened and by the EMR. 

• 70% of clinicians report that the EMR increases their work hours
• 70% of clinicians believe that the EMR is contributing to burn out
• 70% of clinicians say that the EMR takes time away from patients

Are machines going to replace doctors?

Dr. Mendoza thinks not. He thinks, in fact, that computers and AI and machines should be thought of as tools that are designed to enable us to practice better medicine. Physicians are still needed because medicine is not just a set of algorithms. This includes a wide range of evolving AI technologies:

• Image processing

e.g. benign vs. malignant lesions

e.g. radiology (cxr reading)

e.g. diabetic retinopathy

• Patient engagement

via APPS

via Health trackers

via E-health programs

Dr. Mendoza covered a long list of different technologies and AI programs, and he reminded us that many of these technologies are works in progress; some will be raging successes and are more effective and more applicable than others. In fact, many will ultimately fail. Be aware of where the product is in its natural evolution (see image below).

Dr. Mendoza encouraged us to engage with the technology and explore them as they are being developed. Here are a few programs/apps/ideas for you to try in your spare time:

Technology you should play round with!

1. Patient symptom checker:  Symptomate: https://symptomate.com/

2. Preventive health via Facebook Preventive health: https://preventivehealth.facebook.com/

3. Chronic disease management via Omada: https://www.omadahealth.com/

4. Clinical Decision support: https://www.ibm.com/products/micromedex-with-watson

5. Medical education: FOAM: https://litfl.com/foam-free-open-access-medical-education/

6. Diagnosis: Human Diagnosis project: https://www.humandx.org/

7. EMR Voice Assistant: https://www.epic.com/epic/post/hey-epic-tell-voice-assistant-clinicians

8. Digital assistant for physicians: https://www.suki.ai/

Finally, Dr. Mendoza encouraged us to check out the AAFP innovation lab, where you can sign up to trial many of these technologies and give direct feedback.

https://www.aafp.org/family-physician/practice-and-career/managing-your-practice/health-it/innovation-lab.html