Dr. Matt Siuba is critical care physician from the Cleveland Clinic in Ohio and is the leading thinker of the zentensivist philosophy. On this episode we dive into the various ways in which we can put zentensivism into practice in the NICU. Matt Siuba can be found on twitter @msiuba ... Enjoy!
As always, feel free to send us questions, comments or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through instagram or twitter, @nicupodcast. Or contact Ben and Daphna directly via their twitter profiles: @drnicu and @doctordaphnamd.
As always, feel free to send us questions, comments, or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through Instagram or Twitter, @nicupodcast. Or contact Ben and Daphna directly via their Twitter profiles: @drnicu and @doctordaphnamd. The papers discussed in today's episode are listed and timestamped on the webpage linked below.
Enjoy!
Dr. Matt Siuba is critical care physician from the Cleveland Clinic in Ohio and is the leading thinker of the zentensivist philosophy. On this episode we dive into the various ways in which we can put zentensivism into practice in the NICU. Matt Siuba can be found on twitter @msiuba ... Enjoy!
As always, feel free to send us questions, comments or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through instagram or twitter, @nicupodcast. Or contact Ben and Daphna directly via their twitter profiles: @drnicu and @doctordaphnamd.
As always, feel free to send us questions, comments, or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through Instagram or Twitter, @nicupodcast. Or contact Ben and Daphna directly via their Twitter profiles: @drnicu and @doctordaphnamd. The papers discussed in today's episode are listed and timestamped on the webpage linked below.
Enjoy!
Okay, welcome everybody Daphna. How are you today?
Daphna:I'm doing great POST call but other than
Ben:how was that call?
Daphna:Not too bad. Not too bad.
Ben:You practice intensive ism tenants in during that call. Were you able to?
Daphna:You know, I really try one of my favorite things to do on tucking rounds is see what labs we can cancel for the, for the morning. So at the very least, I got that done last night.
Ben:Beautiful. Okay, so we have the pleasure of having on the show today, Dr. Matt Siuba. Matt is an adult critical care physician from Cleveland, Ohio. He is an associate professor of medicine at the Cleveland Clinic Lerner College of Medicine. He is also the Associate Program Director for Research and Critical Care fellowship at the Cleveland Clinic. He is the founder and main contributor of the blogs intensivist.com. And hosts does intensivist podcasts that you can find on all major podcast platform. Matt, thank you for being with us.
Matt Siuba:Thanks to you both for having me here. I'm really excited.
Ben:Now No, thank you. And I guess for for the listeners who I mean, I made this very conscious choice of inviting you on the show, because one of the main reason is that your Z intensivist manifesto came out in an adult intensive care sort of journal. And I was puzzled whether or not neonatologist had the chance to read it. And I think we would all benefit from from reading it. And I was fortunate to come across your paper, thanks to I think a mutual friend of ours, Avi Cooper, who retweeted it. And so again, the the benefits of the Twitter platforms are showing they're showing how how productive this can be.
Unknown:Absolutely, yeah, I think this is an exciting area to consider implementing is intensive ism. And obviously, there's a lot of applications. The the idea of it has really taken hold pretty well in the pediatric ICU community. So I guess this is the next logical step in the processes.
Ben:And and so for the for the people listening to the podcast, who are not familiar with Zen tensive ism, can you give us a brief overview to bring everybody up to speed?
Unknown:Sure. So intensive ism, the best definition for it is minimally invasive, maximally attentive critical care. So it starts from this foundation, where we're trying to be as minimalist as possible, within reason, considering we're taking care of the sickest patients in the hospital. But it's the foundations of it that that allow someone to become as intensive as no matter what setting you're in, no matter what what type of ICU or acute care setting you're in, is, it's really sort of a three fold idea of the things that constitutes intensive ism, you have to be a clinical master in your domain to be able to understand when it's possible to kind of pull back and do less, so you can't come straight out of the gate out of training and immediately know how to do these things. You have to learn how to tolerate risk in a way that is probably different than what is normal for the average. And especially I would say, from my experience in residency, definitely risk tolerance is a harder thing to do in pediatrics and neonatology than it probably even as an adult medicine. And then finally, the goal of all this minimalism and risk tolerance and clinical mastery is is to elevate humanism in any way possible. And that still applies to a 26 week old who, you know, barely is just becoming a human, but still, anything we can do to sort of liberate them from from things that we're doing reflexively would be potentially to their benefit.
Ben:And, and for the people who may not be familiar with your background, I think it is important for us to know that you did a med peds residency, is that correct?
Unknown:Yeah, that's right. So I was really excited to get to talk a little bit about pediatric stuff with you too. I did a pediatric and med peds residency. And I do I have had before there was ever a term for intensive ism. These are ideas that I always had in my mind and and honestly a lot of the lessons that I learned on how to be minimalist came from working in pediatrics. Because, you know, if you're a mid if you've admitted a child to the, to the inpatient unit, very different experience and admitting an adult inpatient unit. First and foremost, you sort of agonized over whether you're going to obtain labs, how frequently you're going to get labs, and you're, it's really sort of done because you're nobody wants to poke the child, which I think which we treat it, I wish we treated adults like that. Because a lot of people that are getting labs every 246 hours probably don't need those. And if you don't have some sort of line that can be drawn from that means that person is getting poked every time sometimes in the middle of the night. So I started to develop a taste for some of these ideas from from that experience. And working in peds helped me be a better minimalist when I went to the adult my adult rotations, but also just seeing how there's also a lessons from adult medicine and how to better tolerate risk because I think we have this impression in children that if you if you miss anything even one time, then this is going to be terrible, the parents are going to be very upset that your child might come to harm. But the reality is we do so many exhaustive workups on on younger people and you know, find false positives or end up introducing harm by doing tests the patient may not have needed and so I think there's lessons to be learned from both sides, which I think was the unique part of my training. And I really did value the neonatology part of my training, even though I ended up going the opposite the extreme opposite side. Exactly, exactly. I remember when I was in the NICU. You know, a patient that had been there for about six months was essentially a geriatric patient and neonatal or else. But some really interesting lessons there. I mean, it's very, very hard to tell, sometimes very hard to predict deterioration, sometimes at least in my experience as a resident and neonatology. And that makes this risk calculation a little bit different than I think it does in the adult population, which is really interesting.
Daphna:You know, it's, it's interesting that sometimes they think even in neonatology, we get out of the pediatric mindset. So, you know, we were doing things to these preterm babies that we wouldn't do to, you know, a toddler. And so I think this is especially important for for neonatal colleagues. I like what you said, and that there's risk to everything, including doing the workup, right? There's risk to doing the workup, there's risk to the fallout of excessive testing or intervention, and maybe you can give us some, some examples of how that has, kind of, in your experience worked for you.
Unknown:Yeah, so I think the first thing to think of is, if you if you just take a moment and consider. And this is like one of the hardest things about becoming an attending, consider the why for every single thing that you do in June, when you interact with a patient, when you're entering orders in the computer, you start to realize, maybe there's not necessarily a firm rationale for the, you know, the sort of orders that we sort of clicked on the page and sort of add to the patient's chart. In my setting, like every patient that gets admitted to the ICU gets a troponin drawn, I have no idea whether that's something that's helpful or not. But these are the kinds of the things that we that are done reflexively, because this is the way that we do them. And that I think those are the the biggest opportunities to say, I'm not going to look for every disease and every patient, because that really betrays the whole idea of, you know, pretest probability of disease and base rates of disease and things like that. So I think that's the first opportunity to say, Okay, I'm not gonna go crazy with this workup. Because, you know, in our setting my setting in in your setting, we're like, Okay, the first, the most important things are, I need to make sure that there's something that's not imminently life threatening going on. And that doesn't mean that I have to rule out every single life threatening disease in every patient, you still have to sort of weigh the risks and the benefits of the workup. Depending on the depending on the particulars of the patient, what kind of presentation they have, you know, and in your setting, as well as mine, you know, sending somebody to a scanner is a big risk, there's a lot of you know, sending somebody for a transport is a big risk. So really just have to make sure that we're you know, sort of appropriately titrated in terms of how risk tolerant we are and how aggressive we want to investigate things. I think the best way to think about the initial stages of workup is it's probably okay to be a little bit more aggressive to establish the primary diagnosis, but I don't need to do exhaustive workups on all the different ancillary diagnoses if they, you know, don't have I don't think they fit the main part of the picture. An example for my setting is if somebody has mild hyponatremia that probably has nothing to do with what's killing them. But it's it's something that often gets a you know, a three to $500 workup of additional labs that probably doesn't really make much of a difference. So those are the kinds of things that take your focus off, the main things are going on with the patient. And if you spend time trying to figure out what's the cause of the hyponatremia, is, you take your mind off of the organ failures a little bit, you take your mind off of the person in the bed a little bit. And so that's that's the way that I think about. So intensive ism is not so much about doing the very, very least at all possible times, it's more just about appropriate titration of care.
Daphna:Yeah, I think that was such a good, that's such an important point for people who are going to try to slowly incorporate this into their practice, is that, that there's that risk to of taking, taking your eye off of the maybe the most important problem at stake. And I love how you're also able to really include humanism, and in medicine, and I think our listeners would like to hear a little bit more about that there must be something in your history, your upbringing, your past that makes you as humanistic as you are?
Unknown:You know, that's a really good question. Honestly, no one's asked me that to this point. Think about that a little bit. You know, I think there's a couple of things that come to mind, I think everybody comes to medicine, because they want to help people, right? That's like in everybody's, you know, boilerplate statement. For since the beginning of time, I think it's just a matter of trying to in our settings, especially where you have somebody that can just become sort of a wash of tubes and lines and monitors, and you start to lose the picture that there's a patient there. And I would think some ways that would be harder, and you're setting because this person is now doing this, this baby hasn't even developed the personality yet. And we haven't started of seeing those dimensions. And a lot of times, I never get to see those dimensions of the people that I meet at the time that they that they come to me because they may already come, you know, in an advanced state of illness and already on life support. So I think the I don't I don't know that I have a specific, you know, background story or anything like that. It's just, I've seen moments throughout my training that where I noticed that people are sort of dehumanized, either passively or actively. And I just think about any of us or any of our families being in that position. And it's, you know, it really feels morally reprehensible not to be focused on those things. I think that's the that's the most, I think there's nothing else that it comes down to, except for sort of ethics and morals for the reason that I feel that way. When we think about adding treatments to patients and adding invasive interventions, those are opportunities to take away some of that humanity and some of that normalcy. So in my setting, if you don't feel quite comfortable with this patient not being intubated, but they're they don't necessarily have a hard indication to be intubated, you put them on a ventilator to make yourself feel better. Well, I took away some of that person's consciousness, their ability to interact with their environment and things like, and if I can avoid that, I probably should. And I think that's really what it comes down to the evidence for all the things we do in adult critical care is, the effect sizes for the things that we do are pretty small. So we really have to think we really have to bear in mind. How beneficial do I think this is for this individual patient, because I'm going to I'm taking something away every time I had an intervention. And you know, in an ideal world, everyone would be on, you know, peripheral vasopressors. And on high flow nasal cannula and setting up with your family at the bedside and in sort of engaging with us as much as possible. That's not always possible. But there's those margin cases that we're probably a little bit too aggressive with, where we have opportunities to allow people to be a little bit more awake and alert and participate in our environment.
Ben:I'm gonna jump in and try to be a little bit of the devil's advocate here because I think I am so in sync with that mentality of de escalating care in the intensive Indian in the ICU as much as possible. But I can I can hear the naysayers saying, Well, you know, you're bordering on negligence if you're not checking on certain things. And to go back to your manifesto, and where you talk about something specific, where you mentioned abiding abnormality. And you say, you discuss avoiding the normalization heuristics, where you say we should distinguish between adaptive responses which should be left alone from maladaptive, which needs correction? I think this is all well and good. But it seems so hard to tow this line between being attentive and not being negligent. How can we convince the naysayers that it is not negligence and that and that there is there is room for a paradigm shift and intensive care?
Unknown:Yeah, I think the way that I would approach that is to kind of flip it on its head a little bit and to say, Can you prove to me that monitoring that thing more frequently is actually beneficial? Because most of the time you can't. There's certain things we have to watch really closely. To go back to the hyponatremia example, if you're trying to correct it, we have to make sure it's not moving to, to briskly things like that. But there's a lot of labs that get cycled. And just to just to say, Hey, I watched that thing go down to normal. So I'm better doctor. Now, it doesn't really work that way. And again, not knowing how effective any of these monitoring interventions are, I think the burden is on the people who would like to do additional testing to prove that that's something that's beneficial. Because otherwise, you're just adding, adding intensity of care without any clear benefit to it, as a way that we can help people do this better would be as if we could understand what it means to stretch normal a little bit. So there are some things that I know and if correct me if I'm wrong, hopefully I remember this correctly. This correctly from NICU. But I think I think in the NICU, you're also kind of okay with permissive hypercapnia. And respiratory failure. Same is true for us. So if that's something that we learned through, you know, evidence over time, that that was something that was at least permissible, if not beneficial. And I think we just need just find out what happens when we stretch, stretch the boundaries of what we consider to be acceptably abnormal, because there are some things that are abnormal in a way that it's so so far from baseline or so far from the normal ranges, that that is something that is potentially harmful. Okay, sodium, a 105. That's bad for everybody. But at the sodium a 128, has me doing something about that really going to help anybody in the ICU when they're in multi organ failure? No, probably I need to focus on the multi organ failure and not worry about just checking up on these little things, just in case, just in case mentality. While it sounds good. And it sounds prudent, I think is is the root of a lot of the excessive interventions that we, you know, take on in my setting, if we ever admit someone who's at the ICU with respiratory failure, residents will also will often list pulmonary embolism and the differential diagnosis list. And, you know, I can't prove that every patient that comes to the ICU doesn't have a pulmonary embolism, I would send everybody with a CAT scanner, I guess I'm not sure what the benefit would be. But we can consider the individual characteristics of that patient, their hemodynamics their oxygenation their ventilation, and say does that make does it make sense to pursue this and this particular patient, thinking about that in that deeper, deeper way, is being maximally attentive without necessarily getting extra tests. And I think that's where things kind of fall apart, we think if we think about something, we must investigate it. And that's where things go wrong, because I can think about all kinds of horrible things that could potentially go wrong when somebody and if I investigated all of them, I'm gonna find a lot of false positives. And I'm going to do harm because I'm gonna introduce treatments, or testing or invasiveness that that otherwise wouldn't be pursued.
Ben:In one of your presentations on Zen and Zen tensive ism, you have a slide that states that doing less requires more effort. Can you elaborate on that a little bit?
Unknown:Yes, I think doing less is the hardest thing to do. And it's not just the psychological strain of of sitting back and saying, Okay, I have to trust my judgment and trust my experience, and what I know about this patient what I know about similar patients in this situation, that's one level of difficulty, the higher level of difficulty is sharing that perspective and a world that does not necessarily abide by those practices. So if the nurse comes to me and wants me to replace the potassium, because it's mildly low, and I declined to do that, because I don't think it's necessary, it's going to take me more time to go through and explain why it's not, that's not something I'm going to pursue right now. Rather than just turning to the computer and putting the order in. In the long run, you could say if people get to know you that, that that that upfront work may pay off, because then they know, that's not something that I'm going to overreact to. But in general, when you're trying to cope with expectations by other people, nurses, respiratory therapists, families, patients, consultants, it takes the extra time to explain why I'm not going to do that. And it's worthwhile to me because again, I think this is a morally imperative thing to do otherwise, you know, you could say, well, why am I going to go through the effort, I could just replace this potassium, I could get this scan, I could let them go for this procedure. It takes time and effort and energy to advocate for those things. Sometimes the best way to get through it is just to do metacognition, explain your thought process that people, it works really well, for allied health professionals that works really well for family members. I usually will say if the family member wants to pursue something that I don't think is necessarily appropriate, but I could see other people in that situation would would do you know, other people in my shoes would do it. I just say, you know, I think the odds of this helping are less than the odds of it being harmful. And usually people accept that. That's not something that people want to necessarily push through. They just want to know that you're thinking carefully about the situation. You care about them or their family member. It doesn't mean you innocence. I have to do everything
Ben:Daphna, if this is okay with you. I can can ask one more follow up to that. As as the intensive care unit has become really regulated by shiftwork, and a lot of handoffs, between colleagues, how do you manage this style of practice, when you're handing off patients or receiving patients from colleagues who are on the opposite side of the spectrum? We've all had colleagues who are extremely conservative. So how do you navigate this this? How do you how do you maintain some harmony in the in the ICU? Considering considering intensive ism?
Unknown:Yeah, that's a that's a challenge. And it's a bigger challenge for me, because my primary role right now is as a Nocturnus. So I primarily work at night, and I'm providing care for essentially night shift coverage for usually a few days at a time. So that that can become an issue if the daytime attending and I have very different levels of risk tolerance for different practice styles. I think in some way we all practice variability, to some extent is probably okay and acceptable. So some of this comes down to this communication of metacognition that I that I discussed before, so I those same conversations I would have with the nurse or the respiratory therapist, I'd have with a colleague saying, Hey, I, I understand in this situation, you would often do this, you would have intubated this patient, this is somebody I opted to leave on high flow nasal cannula because of XY and Z. And then ultimately, I know they're going to do what they're gonna do. And, you know, it's like, sometimes it'll sometimes sometimes you'll persuade, and sometimes you won't, I do think momentum is a powerful force. So if they say, Oh, this patient's already on this path, they may be a little bit more willing to, to maintain that path. And I think that's just a psychological bias. It's not like a superpower or of setting somebody on that on a course or anything like that. The The other thing is, how do I receive a patient that I think is, you know, that carries a lot more aggressive than when I'd be comfortable with that's a little bit more challenging, especially again, if I'm, I'm trying not to disrupt the necessarily the harmony of what the plan is, unless I think it's directly harmful? At some point, you know, it's, it comes down to humility. From my standpoint, as well, I have to realize that the things that I do, I think are right, but there's, there's a range of what's, you know, medically reasonable things to do. And I think as long as we're operating in that range, that's okay. If we're not, then I think, you know, it's gonna be a much larger, deeper discussion with that person about how to get on the same page. Fortunately, that does not need to happen most of the time. That's good.
Daphna:I, you know, the term itself has been in it, right. So it feels like something that's very peaceful. And over time, I think it is a more peaceful way to practice for the patients. But you definitely alluded to, you know, the mental burden as a clinician, that you do have to check on that patient more often. You do have to think, you know, maybe I didn't get all those tests, maybe I am missing something. So I wonder how you kind of personally balance that and when, you know, physician burnout is so much at the forefront of of, you know, the media, in terms of physicians, especially given the last, you know, year and a half. I you know, any tips for how to kind of balance that, especially for those of us who are, you know, still pretty early in our careers.
Unknown:Yeah, that's a great point. My perspective is the the maximally attentive, attentive part of this paradigm is what makes it really, really rewarding and beneficial to me. I love to go to the bedside. So if you have an excuse for me to go back to the bedside and check on a patient, then that's that's a bonus for me. So this is a
Ben:speaking darkness. Language right now.
Unknown:So this process is it feeds it's, it feeds itself. So if I say I need to go check on a patient in an hour, I'm gonna go check on that patient and our, if the patient sometimes I'll pull up a chair, and I'll sit in the room for a little bit and just kind of take everything in, look at how see how they look, if it's somebody that's on life support, or, you know, look at the vent, look at the you know, hemodynamic parameters, make, you know, see if minor adjustments are helpful. And then I'll just kind of sit there and watch and think and think about if I need to do anything differently, you know, if the trajectory is positive, meaning that the illness is improving or stabilizing, then I don't necessarily feel obligated to think deeply about Oh, should I have looked for this, that or the other thing, take the positive trajectory for what it is if things are not going the way you think, then you'd have to go further. Or, you know, as a point that I really, you know, I already sort of made but I'll emphasize again, because I think it's so important. If I don't know what the primary diagnosis is, I need to go further. And that means I'm going to do more invasive things and people will be like, can you really do that if you're calling yourself sometimes? Yes, of course. You know, critical care is a Is Critical Care and they're you know, there's very few aspects of critical care, you can say should never be done, a lot of things just have a very, very narrow indication. And if you need to pursue something more invasive to find out what's wrong with the patient, then you do that. But otherwise, if you're just trying to make sure that things are gently moving in the right direction, then you just watch but but again, that gives me opportunities to go check in with the patient, see what see how their sort of statistics and things look and make decisions about what to do next, or to continue to watch.
Daphna:Yeah, I wonder if you're, you know, your commitment to pull up a chair and sit in the room, I think that's how you get the the buy in from from the rest of the staff. I wonder you're no stranger to working with learners. And so what is the best way other than, you know, modeling, but to get buy in from the learner to, you know, may have seen the, the opposite? The day before the week before?
Unknown:Yeah, so I think the most important thing is what you already mentioned, which is the modeling and and the metacognition, those are the things that open the door for, for learners to, to take on some of these principles. And also, maybe, hopefully, to be inspired by them. I think it's good for trainees to see a wide range of, of styles. So they can see what makes sense for them, based on their personal disposition, and also kind of what kind of outcomes they see. And, you know, that that is, I think, something that's beneficial, because you you learn as much from people you don't want to model, you know, you don't want to be a role model as those that you do. So I think it's good for people to have a wide range of experience to say I don't intubate that patient, but the next physician who comes on into a patient, they can see sort of the different rationale for pursuing one path or the other. And over time, they're accumulating those experiences and seeing kind of what makes sense for them. I, it's, it's hard for me to think that everybody, including myself, couldn't benefit from being a little bit more minimalist from time to time. So I think just giving them that opportunity of the contrast, even if they've only worked with people who are very risk intolerant, is beneficial.
Ben:Can you elaborate a little bit on specifically that last point, the risk tolerance? It sounds it's such a scary term. But I think when you put it in the context of of Bayesian sort of modeling, it makes a bit more sense. But but can you for the listeners who may have that question, what is risk tolerance? And what are its limits?
Unknown:So the way that I think about clinical risk tolerance is how much are you willing to abide in terms of mild abnormalities or in terms of not having answers in order to take care of the patient? And that is something that is, I think, in some ways, part of our personality, and the way sort of that we're wired is still whether or not you think this, you know, it's, it makes sense to, to, to tolerate higher level of risk or not? Yeah, so So some of the to some extent, this comes down to understanding the sort of the behavioral economics of things, which is to say, How much does, how much do does mean, adding something to the to the care of a patient actually make a difference? That part is much more difficult, because people, we most of us come with a commission bias. So if I did something, at least I did something. And if the patient got worse, hey, I did everything I could, though, the problem with that mentality is you start to remove yourself from the, the part of responsibility, we say, I added something, and that may have been harmful. And that's something that's a little bit harder for people to to, to consider. But I still think a lot of people would rather have tried something that was harmful than not try something and the patient gets worse anyway. A good example of this is sort of rescue therapies for septic shock and adult patients. So people like to give methylene blue or actually cobalamin or things like this to see, okay, this person is on three vasopressors. And they're still worsening, I better just do this to say that I did it. And I think we probably there's things like not necessarily those specific medicines, but things like that, where we do them or say, hey, this patient is sick, it could be might as well try it. And I think that's an a lot of ways the wrong mentality. Because you don't know that you're necessarily going to you're you don't know that you're adding an intervention that's positive. You just know that I'm doing something. And that's the part of risk tolerance where I think the conservative mindset falls apart. Because if you think if you just commit more to this pic took care of this patient, they're going to make them better. I think that really misunderstands how powerful they are interventions we have are there they can be. I think they have measured ability to be powerful in the positive direction and the ways that they could be negatively power before, sometimes we can't even conceive or we can't even see. And I think that's the part that that's that's the reason why low risk tolerance and higher interventionism persist, because people don't see what they don't see.
Ben:And I think there may be even a bias of people assigning the deterioration after an intervention is implemented to the patient and not the intervention say, Well, you know, I did my thing, and he or she got worse. She kept getting worse.
Unknown:Yep, they it's never end, you know, the, the idea of luck never enters into it. Sometimes people get better, despite what I do. And sometimes I sometimes I do the right thing, and people get worse. And I think that's one of that's one of the hardest things to, you know, cope with as a physician, I think is realizing those those issues. But anytime you anytime a patient, if you add something, anytime a patient gets worse, it's a patient factor, or it's bad luck. And anytime they get better after you add something, it's because of what I did. Absolutely, absolutely. And I'm not gonna pretend like I'm immune to that, but it's, I'm very mindful of it.
Ben:It is it is a cognitive bias for sure. Do you think that this can can be sort of this, this philosophy can be ingrained better in our in our residents and our med students. By emphasizing the study of biostatistics more heavily past medical school, I feel like we need to understand pretest and post test probability better in order to make better, more informed decision.
Unknown:If we can enter a world where we talk less about the Krebs cycle and more about clinical decision making, in medical school, and beyond, I think we'd be a lot better off. If you think about it, we spend almost no time thinking about how we make decisions, or why we make decisions or whether this is a reasonable thing to do or not. Because again, otherwise, if you can't think about these things systematically, and consider what the risks of for this particular patient are, then everybody should get a CT scan for pulmonary embolism. If it is like, so then anytime you're in, that sounds absurd. But that is the way that a lot of people practice, because they don't necessarily take into consideration the base base rates and sort of those particulars of the patient condition that would make it would make a diagnosis more or less likely. But it's because we spend a lot of time learning about how to conceptualize disease and how to treat disease, but not necessarily how to make decisions.
Ben:Yeah, I was reading recently, Daniel Kahneman Thinking Fast and Slow. And where he talks about all these different biases, these heuristics and the concept of loss aversion, which I was like, oh, man, I wish they taught us that in medical school, because you just fall prey so easily to all these different biases and heuristics.
Unknown:Yeah, absolutely, if I remember correctly, because that was a part of the book that really stuck with me, too, is, you know, in terms of magnitude, people would accept, you know, half as much of a loss as they would, you know, they want to gain double compared to how much they'd be willing to lose. So like, people are really, really risk averse. And and I understand it, but it's also misunder, again, misunderstands what the power of our interventions are.
Daphna:When you talk about clinical kind of decision making, I think that's particularly salient in how we've tackled the COVID pandemic, certainly more in your domain than in ours. And you've written on this a few times in the last year. And so how has that changed your practice? Or have you been able to recruit more people to your practice after, you know, dealing with, with really the chaos of the last year?
Unknown:I think this was everything about this last year, obviously, all the challenges and sort of all the all the all the strife that we all encountered, it was a really, really good lesson. And sometimes it isn't, to be honest with you. We the first, you know, commentary that we wrote about it back in April, when the pandemic started, was, you know, a few weeks into us encountering illness here in the United States. And we set thing you know, there was a lot of people that came out with similar commentaries at the same time that we're very mindful of being cautious of adopting new therapies and things like that. And just focus on best best practice evidence based care for ARDS and septic shock and things like that. And we wrote in our paper that it was going to be very unlikely that we're going to find new pharmacologic interventions that were going to be beneficial. And this was at a time that people were using hydroxy, Chloroquine plasma ritonavir. Org kinds of different therapies which the plausibility of them working was really, really low in the first place. And then just to think about broadly applying therapies to patients that were not tested in randomized clinical trials? What is mind boggling? I understand that desperate putting
Ben:all the therapies together as if you're gonna be synergistic.
Unknown:Right? Yeah, exactly. So like, you know, all these, you know, monoclonal antibodies and all these different therapies, and we're just kind of throwing things at the wall and seeing what sticks, knowing very well, like we all sit, like we all just said, We have no idea what we do works or not, you know, we just hope that we point this individual patient in the right direction. And if it's temporarily related to what we did, we think it was something that we did. But in the case of just broadly, I mean, I was aghast to see these therapies that every patient was getting hydroxychloroquine ASA through Meissen, based on really, really, you know, sort of flimsy preliminary information. So it wasn't hard for us to come out and say, the likelihood that any of this stuff is going to be helpful is very low. It wasn't like we had to be, we didn't have to have a crystal ball to figure that out. Because we have 30 years of critical care evidence that says pharmacologic interventions, and critically ill patients in the adult side anyway, almost never have a mortality benefit. So the odds that these things you're going to have make make big waves, there's going to be really, really low. The other aspect of of intensive ism that I think was given a space and the pandemic was trying to understand how minimalist we could be with respiratory support, because we had such a large swath of patients get developed severe arity, or develop different manifestations of hypoxemic, respiratory failure and ARDS. And initially, it started with people being really aggressively intubated on very low levels of oxygen, things we would have never done to a patient before for a variety of reasons. Some of that, again, based on sort of hearsay on what had happened in other places, and then the pendulum kind of swung in the opposite direction. And we have to start asking ourselves, are we waiting too late with some patients, but it really has given us an opportunity to see sort of a full spectrum of hypoxemic, respiratory failure with or without invasive support to see what those you know what the power of those interventions are, I wish we would have seen more of them and trials rather than just observational series. But it's it's really interesting to see how far we can stretch human physiology will in the process, I hope we learn what's acceptable and what's not acceptable in terms of stretching it.
Daphna:Well, it was certainly difficult for us to navigate, you know, family members call me doctor in the family and and I didn't know what to tell them. So I you know, it's been a hard year for everybody, but certainly you for you and your colleagues. So thank you for everything you're doing. And I think having a really a platform for, for your theory, I think really shine through and in this last year. I do have one additional question not related to COVID. But are you a minimalist in the rest of your life?
Unknown:Wow, that's a really good question. You know, I don't know that I would, I don't know that I would necessarily qualify as one. I mean, I tried. I tried to be mentally uncluttered and keep my spaces uncluttered. I do have an affinity for technology, I'll be honest with you. So I definitely can't pretend like I'm not like sitting in an open room with a meditation cushion or something. So. So I would say in some ways, yes. And other ways know, that sort of Zen intensivist demeanor that I consider to be an important part of the practice. It's kind of just I would swam, wired. So I'm kind of this kind of who I am no matter what. So I guess that part follows me outside of work as well. But I do think a lot about some of these, you know, behavioral decisions about how we think about how we tolerate risk outside of work, too, because I mean, there's a lot of decisions we make every day in our lives about how to approach different problems.
Daphna:Go, ya know, it's funny that you said about, it's how you're wired. Right? So we're not all wired that way. Right? And what do you think is the best way to combat? You know, what, what sort of behavioral training do we have to do? For those of us that are that are not wired.
Unknown:So I think in the first place, the intention has to be there. So you have to see that this is something that is potentially beneficial, if you can't, or if you're skeptical, and it's going to be a hard road for you. The second thing is to start to think about cognitive, you know, aspects of decision making and risk tolerance. Like if you've sort of read in on some of these things, or think about them a little bit, that is a way to start to develop the right mindset to think this way. The other thing that's helpful and this is, again, I think, to some extent, how you're wired or not, but I think there's a lot of ways that we can improve upon this. And a lot of these ways we probably have drought throughout training is just having a consistent calming presence. So that's something I think you can actively try to try to cultivate. Whether you're just using mindfulness technique aches or are just kind of trying to have a good internal barometer on how you're feeling at a given time and how to sort of maintain composure one's there stressful situations. Because obviously we're that's kind of our normal at work on for all of us we're steeped in stressful situations. So you get inoculated to it to some extent, it can definitely not go as well as you might like if you're not intentional about it, and really trying to maintain mindfulness and difficult moments. So I think that's probably the heaven developing that calming presence part is probably the most important. And I think, if you have good humility about how much we really have to offer people, then I think that makes it a little bit easier. Because if everything every decision I made was a truly a life or death decision, this would be a really, really anxiety provoking way to practice. If everything if whether I'm going to check this BMP or not, is going to decide whether the patient lives right, if things actually work that way, this would be an incredibly stressful profession. But sometimes we'll have some people have some some aspect of that mentality, even maybe just internalized. And I think that's a you can see that in trainees especially they're terrified, they're making a mistake, I'm glad that they're tariff, I'm glad to some extent that they're terrified, I want them to be careful. I want them to be careful about what they're doing. But I don't want them to be terrified in a way that every every tiny little minut thing matters. And because then you you lose focus on the big picture. And that makes it hard to maintain any sort of composure.
Ben:I think what we discussed a little bit earlier about conservatism in in medicine, where we do a lot of the things on to the patients to to make ourselves feel better, can be mirrored sometimes to families that would step into the ICU and, and demand that all the tests are being done and that all the interventions are being done so that for their own peace of mind, they feel like at least we've done everything that we were supposed to how do you navigate this? And how do you steer families into this sort of humble and more humane sort of roads that we've been talking about as well.
Unknown:The first thing I tried to emphasize, as I previously mentioned, was, I really make it clear to people I'm only interested, I am deeply invested in what happens to their family member. I know I've never, you know, I usually say some some variety of Sorry, I had the sound of my headphones, I usually have, again, some variety of you know, I know we haven't met before, it's really, really important to me that we get whatever's the best outcome. That's, that's possible for your family member, based on their severity of illness and their underlying comorbidities, comorbidities, frailty age, there may be limitations to what's achievable. But I want to sort of incorporate what I think is medically possible with what do you think are reasonable goals for your family. So that's the starting place that I try to work from. And from there when I get requests, so that's kind of how I start the relationship, I usually start to relationship saying some version of I'm worried about them, I'm worried about this person, I'm worried about you. And then more that establishes that we're on the same page, or our goals, or our goals are in the big way aligned, when we start to talk about specific requests for different things, tests, cones, consultants, procedures, things like that. I, the metacognition that I described, usually goes a long way and and towards pointing people in the direction that the, towards what I think is appropriate. If if I feel like there's still some resistance, sometimes I'll say this is the criteria that we would reach for me to consider that decision. I will call this consultant once we reach this situation, that's kind of the way that I look at that. So that's that's the first step. Usually, that's enough, if we get into a point where it's really a high point of contention, and I don't think it's medically inappropriate. And I think it's possibly in the realm of reasonable, then I will sometimes make concessions, but that's really a rare situation that it has to get to that point. And if there's a question, go ahead.
Ben:No, I was saying this could also be a way to build trust with the families by doing that one intervention that you're not completely opposed to, that might actually foster a relationship that you can be trusted even when you decide to withhold the other interventions.
Unknown:Yeah, and some of that, I think, comes down to that humility piece. Like I have to realize some of the things that I don't do is because that's my style of practice. And if it's not an imprudent thing to do, or it's not a you know, something that's going to be harmful, then yeah, those are the times where I want to make it clear to people I'm not trying to be against I'm not just trying to have it my way. This is this is the way that I practice because I think it's the best for your family member but if you know I, the thing that always sticks in my head and I've heard it from from people at different points, family members, or you know, my family members or other people on public is whenever people feel like they weren't listened to, and then something bad happens. That's always the worst case scenario, whether it was preventable or not, the doctor didn't listen to me. And then things got worse, that I always try to avoid that situation, whatever, you know, whenever possible, because I never want to make somebody feel like I invalidated them in a way that made their family member get hurt, or they made them get hurt. And that's something that's really challenging, but I'm very mindful of that. And so that's why I try not to take too hard of a line on some things as long as I don't think it's harmful.
Ben:For the, for the listeners who may be interested, I mean, I have enjoyed reading a lot about Zen philosophy as well. And there's a big advocacy within Zen philosophy for repetition routines, and just sticking to repeating the same steps over and over again, do you have a specific routine in the ICU, when when you take call that a few things that you do always the same way? And that you would want to that you could share with us?
Unknown:Yeah, I think the things that I generally do, so I work in a couple of different settings, with different level of support and resources. So there's some variation based on that, which I'll talk about in a second. But in general, what I tried to do is I try to walk the unit fairly regularly, just to be abreast of what's going on. Because when I'm working at our main hospital, I'm usually covering 60 to 80 patients, but I have, you know, a few residents, a couple of fellows. And so there's a lot of help. But some sometimes things don't necessarily rise to me as quickly as I would like them to if there's an issue. And I'm fortunate to practice in a place where I trained so the I have some built in trust from nursing and respiratory therapy. So I like to just kind of keep keep pace of the unit and have a good feel for what's going on and how to, you know, sort of anticipate things before things start going truly wrong. That's that's something that I think is my strongest routine. And this is one of the regional hospitals I work in I do formally round at night, just an abbreviated fashion to actually see all the patients because I don't have quite as many. So just something to touch base, establish rapport, and then sort of set set my expectations for how I think the night should go for this patient. And if things don't go this way, this is these are sort of the interventions that will take on so then everyone started has a mental plan. I think as you as you both probably know, sometimes the first thing that the nurse will ask you is what's the plan for this patient? What are we doing for this patient, which is just totally appropriate, but like I've tried to set that, set that up ahead of time, so that there's not sort of that feeling of uncertainty, something I started doing recently, which I think is really interesting. And depending on the setting you work in, this may not be an issue, but sometimes that when I'm admitting a patient, the resident, and or fellow will present to me Well, we won't necessarily be immediately at that site, depending on what else is going on. So you know, might be in another unit or something like that. So generally, what I've been trying to do, at least for the last couple of months, is go to the bedside, talk to the nurse and say, give me this patient's here. And can we talk about sort of some of the specifics about you know, what the plan is for the patient. It's, it's an eye opener, if you haven't done I mean, again, depending on your setting, you might not have to that it's an eye opening experience, to find out how poorly we communicate what our expectations and our goals are. And I think that that creates in the in the long run, not only is that create uncertainty for the nurse, and maybe uncertainty for the family, but that creates a lot of extra work for us because they don't know what to focus on. And then they're paging out for small things. And you know, again, we're not staying focused on on what the the key issue is here. I think those are the most I think those are my most consistent sort of practices that I think are beneficial. The one other thing I'll say whether you know, the the the occasions where I round on day shift, or I'm actually primary on the patients, or when I'm seeing somebody at night, before I get presented by the trainee or an advanced practice provider, I always review the chart fully and I want to know everything before they start talking to me just so I can. I only want them to focus on telling me what's important. I don't want to hear details that are extraneous, I want them I want it to be more of a conversation. So we can sort of talk about the right plan for the patient rather than a formal, you know, soap presentation, like we learned in medical school or whatever. And just, that's something that I found helpful so that I make sure I haven't missed anything going into it but also allows us to have a little bit more of a constructive conversation rather than just somebody regurgitating data to me.
Ben:I think I think this is sort of indicative for medicine in general. Because we as you mentioned, in the manifesto, we've we've moved away from the bedside, and we're talking about all these different biases and all these different issues that we think we're going to solve by having objective information from the EMR. And in truth, you're better off going back to the bedside, even if you're Eyes can be biased sometimes. But this repetition and those feedback loops are what is going to get you to get the proper gestalt of the patient and the proper direction. So that's, I think this is very cool.
Daphna:Don't get me started on the EMR. And then as n tends to vism is really, you know, kind of, really a less is more kind of philosophy. But I wonder, what are the things that you know, you can you feel like we can have no shortage of or the you know, that you can always add to the care.
Unknown:I think one thing that is very important is just sorry to say this for probably the third or fourth time now is under truly understanding what's the primary diagnosis. And I think that's something that it's, we should we should go to a great extent to, to get to that point, because how are you going to reverse all these organ failures, if you don't even know what you're treating? In my setting, there's a big issue where if somebody comes in and is hypotensive, requiring vasopressors, the assumption is that that person has septic shock, because I work in a medical ICU. So So or if they have respiratory failure, it's, it's either a pulmonary edema or it's ARDS, and then it's just kind of accepted based on their past medical history. What's important to me is, is to go the extra mile in terms of making the primary diagnosis. A lot of the times this can be done non invasively. This could be point of care ultrasound, if you can get if you have the skills and the equipment, and you can get adequate images to make a clinical decision. All you've done is done an enhanced physical exam, and now you can make a decision about what to do with this patient. But if that these kinds of things are not enough, or if non invasive monitors are not enough, then I think you have to become a more invasive and establish the primary diagnosis. Think it's good.
Ben:It's interesting, because we spoke about this with Daphna on our last episode reviewing a journal article, where in our case in the NICU, there's a tendency to feel like, oh, the underlying diagnosis is prematurity. And we're and we're shifting more and more way from it's the prematurity to why was the baby premature? And then this article that we discussed, describe these different federal phenotypes, saying, well, there's different reasons why you would born be born prematurely. And all these different reasons have their own implications for the baby in terms of growth in terms of mortality, morbidity. So it does, it does still very much apply to the NICU, despite the fact that we might be tempted to think it's all pre news, you know.
Unknown:Now, that's a great point. And that there's two things about that I want to highlight and connect to my setting. Number one is, yeah, what is the right deck? I mean, prematurity is like almost a symptom rather than a diagnosis. And there's a lot of things that I get that are like that, too. Why is this electrolyte this way? Why is the heart rate so high? Why is it so low? We just kind of get focused on okay, there's an abnormal number, and I'm going to fix it. But not what would lead to that to that effect. In my setting, that's usually rapid ventricular rate with atrial fibrillation, always assume that the rate is the problem will treat the rate and everything will be better without any thought to what caused the underlying the second thing that you think that AI to better answer deafness question about, what do we need more of is we do need to have a better description for what our diseases are, whether that's phenotypes of phenotypes, something, something else to say, you know, everything that I treat, almost in my setting is a syndrome. And then a lot of different patients get lumped into those groups. So we need to start to be able to tease those people out to hopefully find therapies that are going to be a little bit more effective when they're given an undirected fashion, rather than an all comers fashion.
Ben:We're coming close to an hour already. And I have so many more questions. But I wanted to talk a little bit about the about the blog about z intensivist.com. And I wanted to give you the opportunity to share with our listeners a little bit as to what you're trying to achieve with that blog and the different articles that you have over there. I know you have a few categories, but I'm going to I'm going to let you go over that.
Unknown:Sure. I appreciate that. So I have been mulling the idea of doing some sort of written work on this topic, in addition to the sentences manifesto for a while and I just kind of wanted to have a place to more or less download my thoughts. So about two months ago, now I started sentence service.com with the idea of it being a place to share these kinds of ideas, maybe in a little bit more of a granular way. So not just talking about you know, the the first art the the manifesto talks about sort of broad concepts. It gives a couple of concrete examples, but it's mostly just sort of conceptual. And the goal with the blog is to delve into things a little bit more deeply talk about specific scenario specific diseases, and in some ways, actually specific cases. And I've started to add some cases to the to the series. So the three main sections of the site and again, it's it's still kind of in its infancy. The first section which is sort The main section is called art of medicine. And that really addresses a lot of these issues. How do you address this situation? How you address this case? Or how do you think about these kinds of situations and apply these principles to them, whether it's cognitive, or, or otherwise. The second section is called Deadspace, which has, obviously is a physiologic analogy there. But it talks about ways things that we do that are probably unnecessary, this would be analogous to like things we do for no reason which the journal for hospital medicine puts out. So just picking up things that we do all the time, it's not really clear why probably doesn't add value may hurt. So that's the idea for that the third section is a little bit more amorphous. And that's sort of the education section, I have a lot of educational material I've produced, particularly on like shock and mechanical ventilation. So the some sort of that stuff hides there. The big goal going forward is to get more guest writers from different different areas of the world, different disciplines, to give their take on on these ideas in their setting. So this would be a perfect place for a neonatologist to write a post, or many posts. So just as a plug to you both and your listeners, that would be something that I would be very interested in, is just exploring these ideas in different spaces, I really want to keep everything sort of within the realm of acute care, I don't want to talk about like health screening or stuff like that. But things that apply to patients that are hospitalized, no matter how big or small they are, and then see how these, these ideas apply in different parts of the world with different resources, it's easier for me to talk about doing less when I work in a place where I have everything available to me. But interestingly, a lot this, this idea has really taken a foothold in Latin America as well, and in low and middle income countries. And that's something that I think is really inspiring and, and really speaks to the universality of some of the the messages that we tried to share in original paper. So and then, you know, the podcast is really just kind of like the audio Digest version of the site at this point. But I do also want to start to develop that into a conversational format, where we talk about different issues, kind of like we're doing today.
Ben:Yeah, I mean, I've been, I've been a big fan of the vent rounds, I thought the vent rounds are awesome. And you post them on Instagram, and I really enjoy just like even taking screenshots and trying to work through the case, looking at the graphs and, and the flow volume loops and stuff. So yeah, no, thank you for that. And no, I think there's, I think there's, there's room especially for neonatologist to apply this. I mean, I was I mean maybe I'll maybe I'll read the contribution. I mean, we do have so many cases where we sort of let the babies grow and just back off, and they do better. And I think it's important to highlight those stories. Definitely go ahead.
Daphna:No, I I'm just so grateful. You know, this is something that I feel in my bones when I walked through the unit and, and I'm not wired like you, but I, I am I really empathize with my families and with babies and I so I feel like it's the right thing to do. Even though it is admittedly sometimes a struggle for me to make the that cognitive move and say I don't I don't need to do that, I want to do that. But I don't need to do that. And so I really, I appreciate you putting it out there giving it a name. And, you know, I think the more we can talk about it, the more that you know, we can agree upon, you know, some of our protocols and guidelines, and can be more about the monitoring and back to the physical exam versus sending this you know, onslaught of repetitive labs and things like that. So, I hope you get lots of contributions because I think it's important work. Thank you.
Ben:Okay, I'm gonna finish up with a difficult question to you because you're you're a very judicious man. And but you've made a terrible decision in your life already. You moved away from pediatrics, and you went into adult critical care. Now that you've sort of taken this this path, is there anything that you regret or miss from pediatrics now that you're seasoned sort of adult intensivist?
Unknown:That's such a good question. You know, it is, it is it is very difficult. It was that I struggled and nobody knows better than my wife because I put her through many agonizing conversations about what to do about my future. But it was really you know, being in med peds is very challenging. Obviously, I broadly interested in everything I want to learn as much as I can about different different things. I entered into med peds residency thinking I would do either or adult or pediatric critical care or perhaps both. It's in the end, it didn't really feel like it was going to be feasible for me to have a acceptable lifestyle and doing both. Also, I would still be in fellowship. So that's, that's another consideration. Yeah, the thing is that now and I will say interestingly, and I'm not just saying this because I'm here. I think in the end, if I had done a pediatric critical care, I would have thought hard about doing neonatology. Obviously, I think there's a lot of similarities in the physiology of the patients I take care of now. I'm in terms of, you know, respiratory distress and, and things. There you go. Yeah, so I and I, honestly, I really liked my NICU experience. i Okay, like my peds ICU experience, I didn't like it as much as I liked adult ICU. And then the the thing that I really, there's two things that I miss. Now I don't miss working in a clinic but I miss seeing cute kids in clinic like that was a lot of fun. So so that I do miss and then the other thing is I really did like congenital heart disease a lot. So anytime I get an adult with congenital heart disease now I get very excited because I I try to keep up on the physiology as much as I can. Now that I work in the setting that I work in, but that's something and because I was I was really debating whether to do like peds cardiac critical care for a while so. So I think I miss I do miss babies. I miss the NICU. I miss cute kids in the office, I miss congenital heart disease. I do think I'm better offer my training that I that I that I that I did Pete's because I learned I learned about how to be a minimalist and I learned about diseases that that children grow up into adulthood with now and now they're in my Ico so whether it's cystic fibrosis or sickle cell or adults with congenital heart disease, so so I'm I'm glad for the training. And I'm a little bit sad that I'm it's not something I'm doing every day. In the end, though, I think I felt like I had to choose because it's really hard to be good at even one thing, let alone more than one thing. Yeah, well,
Daphna:it's never too late, you know?
Ben:Yeah, we have a spot for you. To talk to me. But I mean, it's true. I mean, I always wonder when we use these little micro containers to draw a CBC on a baby and it requires half a milliliters. I always wonder why are we not using this on everybody? Why are we drawing three CC's on an adult? I know it's maybe negligible. But But why? So
Unknown:I agree. I mean, we have good data in the adult ICU that says we we trans we transfuse and we fill up automize peep everyone to have a hemoglobin of about nine by the time they leave the unit. So that's like, it's not great.
Ben:Well, Matt, thank you so much. This was a lot of fun. And we'd love to have you back in the future to discuss the progress of the intensivist that come, please, everybody listening, go check out intensivist.com Check out the podcasts and your contributions. And let's, let's allow the movement to grow. Matt, thank you so much.
Unknown:Thank you both appreciate you.
Ben:Take care. Thank you for listening to this week's episode of the incubator. If you liked this episode, please leave us a review on Apple podcast or the Apple podcast website. You can find other episodes of the show on Apple podcasts, Spotify, Google podcasts, or the podcast app of your choice. We would love to hear from you. So feel free to send us questions, comments or suggestions to our email address NICU podcast@gmail.com. You can also message the show on Instagram or Twitter at NICU podcast. Personally, I am on Twitter at Dr. Nikki spelled Dr. NICU. And Daphna is at Dr. Dafna MD. Thanks again for listening and see you next time. This podcast is intended to be purely for entertainment and informational purposes and should not be construed as medical advice. If you have any medical concerns, please see your primary care practitioner. Thank you