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Practicing Respect in the ICU
7 Plays4 years ago
This is a previously released episode that I thought would be of great interest to our listeners. As we move forward post 24 months of COVID-19 reconnecting with our purpose and core values is more important than ever. In this episode, we discuss the practice of respect in the intensive care unit. Our guest is Samuel M. Brown, MD, MS, a practicing intensivist and Director of the Center for Humanizing Critical Care, at Intermountain Medical Center in Murray, Utah. Dr. Brown holds an academic appointment as Associate Professor of Medicine at the University Of Utah School Of Medicine, Murray UT. He is a prolific investigator and author with a wide range of interests including complexity in critical illness, echocardiography, and ethics. Our conversation covers topics such as dignity, respect, compassion, and burnout. Join us in a fascinating discussion with a thought leader in bringing humanism to critical care.
Additional Resources:
Recent article co-authored by Dr. Brown and colleagues reviewing important aspects of the practice of respect in critical care medicine: https://bit.ly/3uFLou8
The Center for Humanizing Critical Care works with researchers and clinicians with the goal of helping patients and family members make it through critical illness with their humanity intact: https://bit.ly/3JTxfjp
Speak, Memory: An autobiography revisited. By Vladimir Nabokov: https://amzn.to/3iKaXVc
Recommended
Transcript
Introduction to Intensive Care Medicine
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
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Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
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To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
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And now your host, Dr. Sergio Zanotti.
00:00:32
Speaker
Welcome to another episode of Critical Matters.
00:00:35
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Today we'll be discussing the practice of respect in the ICU.
00:00:39
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It is a great honor and pleasure to have Dr. Samuel Brown as our guest.
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Dr. Brown is the director at the Center for Humanizing Critical Care and Intermountain Medical Center.
00:00:49
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He's a practicing intensivist and holds an appointment as associate professor of medicine at the University of Utah School of Medicine in Murray, Utah.
00:00:57
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Dr. Brown is an NIH-funded researcher with an interest in the body's response to critical illness, non-linear hemodynamics, and echocardiography.
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He has published extensively in these topics and also in the intersection of critical care, ethics, and history.
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Dr. Brown is also a respected medical humanist and ethicist with a special interest in embodiment, sickness, and the end of life.
00:01:21
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Dr. Brown has authored a book entitled Through the Valley of Shadows, which covers many of these topics.
Respect and Dignity in ICU Practices
00:01:27
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He is the lead author in a recently published paper in the Blue Journal, The Practice of Respect in the Intensive Care Unit.
00:01:33
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Dr. Brown, welcome to Critical Matters.
00:01:36
Speaker
Thanks so much, Sergio.
00:01:37
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It's a pleasure to be with you.
00:01:39
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I think it would be great to just acknowledge that respect and dignity are values that intuitively we would accept as important and necessary in our critical care practices.
00:01:50
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However, I feel and suspect many of our listeners would agree that these values may be actually lacking in the ICU today.
00:01:58
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So why don't we start by defining these terms?
00:02:00
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How do you think about respect and dignity?
00:02:02
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That's a great question.
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You know, we had a much longer version of the
00:02:09
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of the perspective piece originally where we walked through the origin of these terms and a lot of the professional readers, the reviewers felt like we went into too much detail, but I think they're interesting stories.
00:02:26
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The basic notion behind dignity is that dignity historically meant a special kind of human being.
00:02:32
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It meant the aristocracy, the queens and the kings and the ruling class
00:02:37
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And dignity was a mark of superiority of particular individuals.
00:02:42
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And then in the 18th century, you know, it starts a little earlier and then extends dramatically along over the next two centuries.
00:02:50
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There's this notion that maybe dignity belongs to every human being.
00:02:56
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Maybe we've misunderstood that.
00:02:58
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And the part that makes you worthy, you know, dignity comes from
00:03:03
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being dignified, it comes from being worthy of something, meriting something.
00:03:08
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Maybe you get there just by token of being a human being.
00:03:10
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Maybe you don't actually have to be the king to be dignified or worthy of some response.
00:03:18
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And we made the argument that respect, and this is an argument that comes out of the quality and safety group at Beth Israel Deaconess, who have been real pioneers here and are part of this overall project,
00:03:29
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they said, you know, at a practical level, why don't we say that respect, which comes from an old root that means to look again, what if respect really refers to the practices or behaviors that acknowledge the inherent dignity of other human beings?
00:03:42
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And so for us, this really became a story of respect and dignity as interrelated terms, but dignity is something that every human has just by token of being a human and respect to the practices and behaviors that honor it.
00:03:56
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And one way to think about the etymologies is to think that
00:04:00
Speaker
Respect and dignity are fundamentally about acknowledging that people are worth seeing Respect to look again dignity having merit or worth so we think of it as people are worth seeing in the ICU That's that's how I think about those two terms and I think that it's a it's a great it's a great definition explanation because they are different concepts but
00:04:24
Speaker
They go hip by hip together and they can't probably coexist one without the other one, especially in the world of critical care.
00:04:31
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One of the things that I think makes me think about this concept, Sam, is Henry Thoreau said that every man is my master, alluding that every human being we meet knows something that we don't know or can teach us something we don't know.
00:04:47
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And from that perspective, everybody we meet, whether it be a patient or a
00:04:52
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another provider in the ICU can teach us something and definitely deserve all our respect from that perspective.
00:05:01
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John Thoreau and the other transcendentalists were a big part of that movement I was talking about to say that dignity is not just for the queens, kings, and presidents.
00:05:09
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So it's an inherent condition to being human.
Compassion and Emotional Sustainability
00:05:13
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And I think that that's something that we often forget in the ICU, not only with our patients, but with our coworkers.
00:05:19
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And we'll get to that, I think, a little bit later.
00:05:21
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Let me ask you, how does compassion fit into this?
00:05:26
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Could you be compassionate and be without having respect for your patients or vice versa?
00:05:34
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Yeah, we had a big expert convening meeting that was the genesis for this piece we did for the Blue Journal.
00:05:41
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And as we got together, we started running through the list of the kinds of positive adjectives you might apply to a person that seems...
00:05:50
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deeply humane or aware of the big issues.
00:05:55
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And one by one, if you didn't attend very closely, they all sort of started to run together.
00:06:02
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So compassion, as we think about it, is the capacity or desire or manifestation of a
00:06:17
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a sense of shared identity that tinges oneself with sadness when another person is sad.
00:06:25
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And in that respect, it's not so different from empathy.
00:06:29
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And I think we get at the, we're getting at the same thing.
00:06:33
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We're getting at a notion that when we encounter another human being, we make ourselves open to the miraculous beauty of humanity as manifested through this
00:06:45
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specific individual.
00:06:47
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And I think compassion, if you have true compassion, I think you are likely to be respectful.
00:06:54
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That said, I think there are times that you can practice respect and not be overwhelmed by compassion.
00:07:02
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There are plenty of casual encounters that we have with people that don't require a deep emotional resonance, but nevertheless do require a respectful
00:07:12
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behavior.
00:07:13
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So one of the reasons in our practical work we've been focusing more on respect and dignity is that those are a kind of baseline behavior set that can be done regardless of the emotional state of the given clinician and that don't require the kind of intense, continual emotional investment in patients that so rapidly can lead to compassion fatigue.
00:07:40
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You know, we
00:07:41
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We in the ICU and our colleagues in oncology and advanced heart failure and other domains who care for people at high risk for death, we have to have a capacity to continue to care for these people both medically and humanly.
00:07:57
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And if we had perfect, infinite, exquisite compassion such that every death of every patient we encountered affected us the same way that the death of an intimate
00:08:10
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relative would affect us, we'd all lose our capacity to come to work.
00:08:15
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We'd be so hopelessly bereaved we couldn't get out of bed in the morning.
00:08:19
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So what we're trying to get at with respect and dignity is a notion that we can honor and acknowledge the marvelous beauty and power of every human being in our encounters with them in a way that on average is
00:08:35
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possible for clinicians who care for patients at high risk for pain and death.
00:08:42
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And I'm a strong believer in compassion.
00:08:45
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And I think even as we're navigating the stresses of caring for patients who are at high risk for death, we don't want to cut ourselves off from compassion, even as we want to be careful and aware that we ourselves only have a certain amount of emotional
00:09:03
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resources.
00:09:04
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That's sort of a long answer to the question.
00:09:05
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But when we talk about respect and dignity, not uncommonly we do hear from clinicians who are really worried about their discapacity to go about their lives if every death of every patient is experienced as the kind of tragedy that it truly is to the person and the people that love them most.
00:09:28
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So we're trying to help people understand that what we're after is a balance
00:09:31
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and an awareness of the intrinsic dignity of every person and a greater sort of pushing the needle as we say in the modern jargon a little bit closer or maybe quite a bit closer to that model where we are respectful of each other in a way that encourage all of us to flourish as human beings.
00:09:56
Speaker
And I think that that I mean that's a great way of looking at it because
00:10:01
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In lay language, when we talk about this, I think without a lot of thought,
00:10:07
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terms seem to be used interchangeable and people refer to the same concept.
00:10:12
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I think, like you said, there are different layers and have different implications also for the provider.
Practical Examples of Respectful Actions
00:10:17
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So I think that really thinking of dignity and respect as the building stones to really a more humane practice for our patients, but also for the providers.
00:10:27
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One of the things that I really liked from the Blue Journal paper was one of the tables that talked about a
00:10:34
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Specific examples of respectful and disrespectful behavior because I think at the end of the day defining terms talking about what it means is only important to the extent that we can recognize that
00:10:47
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how we're doing it or when it happens around us.
00:10:50
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Do you mind, Sam, if we just go through some of these common encounters that occur in the ICU on a daily basis, and you can maybe show us or comment on a disrespectful approach that is probably very common and how you would think would be a more respectful approach to take it.
00:11:06
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So I guess the first thing that happens every day when I walk into the ICU and start seeing my patients is I approach a patient's bed or enter a patient's room.
00:11:16
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Yeah, I think the thing that, you know, these patient family advisory councils that are showing up at more and more hospitals, and I think should, they're a marvelous thing.
00:11:25
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We've run one for several years, and the group at Beth Israel Deaconess, which again is a pioneering group here, have one for, I think, a decade now.
00:11:34
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You really, you sort of sit down together as peers and you think through that process of the encounters and the experience.
00:11:42
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and you learn some dramatic things.
00:11:44
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And one thing that I learned from a patient family advisor as we were talking about this question of entering a room was that when you're a patient in the ICU, that room is your home.
00:11:57
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More to the point, that room is really your bedroom.
00:12:01
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And it's experienced as a private place.
00:12:06
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Now, we
00:12:06
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Clinicians don't think that way.
00:12:08
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We clinicians just see it as the place where the current patient is being housed.
00:12:12
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Their home is off in another city somewhere, and we would never go into that home uninvited.
00:12:18
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But when we come to the room, we clinicians think of ourselves as owning the room and almost as if the patient is squatting there in our home.
00:12:29
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The reality is the patient experiences it as their bedroom.
00:12:32
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And I think once I understood that, I thought, oh, crap.
00:12:35
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because we all do things that are less than what we wish we were doing, and that's true of all of us, even those of us that are agitating for change.
00:12:44
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I realized, oh man, I wouldn't walk into a person's home without knocking on the door.
00:12:50
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I mean, so why am I doing it routinely in the ICU?
00:12:55
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And so after that, patient family advisor revealed, the story was that she was asleep in bed
00:13:03
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and somebody walked silently into a room and touched her.
00:13:07
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And everybody thinks it was probably a phlebotomist drawing morning labs and tried to sneak into the room unannounced so as to let her sleep, maybe draw the blood off the art line and she'd sleep through the whole thing.
00:13:21
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But she woke with a start in her own bed to a stranger standing over her.
00:13:27
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And that image just haunted me.
00:13:30
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I thought, oh,
00:13:31
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You know, think about us at home in our own bed awake suddenly to a stranger staring at us.
00:13:37
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That was very unsettling to me.
00:13:38
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So ever since then, I knock.
00:13:40
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When I go to a room, I just knock.
00:13:43
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And, you know, 10% of the time, 10% of the time, the, sorry, can you pause the recording?
00:13:55
Speaker
Is that okay?
00:13:56
Speaker
Yeah.
00:13:57
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Time when I knock, it's actually not an opportune moment.
00:14:00
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They're in the course of being bathed, or they're on the toilet, or there's some other reason that they don't want a visitor.
00:14:06
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And so that's helpful information to me.
00:14:08
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I knock, they say not ready, and I step back and I go to another room, and then I circle back.
00:14:14
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And that's another component of dignity.
00:14:17
Speaker
If we believe a person has dignity, then that has to involve some sense of privacy and or control over their body, admitting that in the ICU commonly the normal
00:14:28
Speaker
modes of interacting around bodies are affected in some important ways.
00:14:34
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And some are necessary, right?
00:14:36
Speaker
I mean, all of the life support stuff that we do violates the integrity of a body.
00:14:42
Speaker
So it's not as simple as just the normal social encounters we'd have.
00:14:46
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But even within the strange setting of the ICU, I think, as you've indicated, there are still gentle things we can do.
00:14:53
Speaker
And so for me, I don't enter rooms in the ICU anymore without knocking.
00:14:57
Speaker
It takes...
00:14:58
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second and clearly communicates respect.
00:15:02
Speaker
And I think that the way you framed it is very powerful, but I also think another way of thinking about this is that we talk a lot about patient-centered care, yet everything we do centers around our needs and our convenience.
00:15:16
Speaker
When we see the patients, how we round, how we organize this, how we organize that, and I think that
00:15:22
Speaker
moving forward that definitely needs to change.
00:15:25
Speaker
So one of the things that we, of course, very commonly in the ICU is that our patients are intubated, sedated, hopefully less and less, but really, or might be unconscious.
00:15:34
Speaker
How about when we approach that patient and start to examine them?
00:15:39
Speaker
Could you talk about respectful, disrespectful behaviors in that action?
00:15:44
Speaker
Yeah, this observation came up when we were doing a project here at Intermountain trying to understand what made a great nurse from a patient's perspective.
00:15:53
Speaker
And so we went through the unsolicited feedback cards that came in, and we found that essentially every patient praise for a nurse, you know, the spontaneous praise that comes from the families written to the nurse manager or the hospital CEO, essentially every one of the nurses identified in that way.
00:16:14
Speaker
the family said, he spoke to my loved one or she spoke to my loved one even when they were asleep as if they could hear or as if they were a person.
00:16:24
Speaker
And that was sort of disconcerting to me because I'd never done that.
00:16:28
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I just assumed if you're unconscious, whatever you're unconscious, I don't need to talk to you other than to say, open your eyes to see whether you're in a coma.
00:16:35
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But realizing that the families experienced it that way made me pause a little bit and wonder what I was doing.
00:16:41
Speaker
And then the other observation is
00:16:44
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this growing awareness of two phenomena.
00:16:47
Speaker
One is that patients in this state are integrating stimuli from the environment into delusions, nightmares, and dreams that they're having.
00:16:58
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And so there's some sense in which our interactions with apparently comatose individuals are remembered in distorted ways.
00:17:05
Speaker
So it's important to make them as much as we can within medical necessity, non-toxic,
00:17:12
Speaker
And then the second piece is increasingly realizing that some people actually can hear, and we don't know precisely when they recover the ability to hear clearly.
00:17:23
Speaker
And so in those circumstances, it's important to talk.
00:17:26
Speaker
So the way we do it now, or the way that I do it and that we recommend and recommend in the paper is with a comatose individual, you address them and you tell them you're about to touch their body.
00:17:38
Speaker
Just, you know, we use a thing, I can't remember whether we called it that in the Blue Journal thing,
00:17:43
Speaker
we use a thing we call the dinner party rule.
00:17:46
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And basically the dinner party rule says imagine that you've been invited to a dinner party by a host that you respect.
00:17:52
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Now ask yourself when you're about to do a behavior in the intensive care unit is this something I would do to the host of a dinner party?
00:18:01
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You wouldn't enter the house without knocking, you would address them by their preferred name, not by some name that you found off a birth certificate or some official registration document, and you would
00:18:13
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give them some indication, ideally asking permission, before you touch their body in any way.
00:18:20
Speaker
That's just a normal part of the way human beings interact.
00:18:24
Speaker
So the way we recommend interacting with comatose individuals is just to say, hi, use the preferred name that you've identified from the family, or if not that, then you know it's Ms.
00:18:35
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Jones.
00:18:36
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I'm Dr. Brown.
00:18:37
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I'm the supervisor for the doctors.
00:18:39
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I'll be examining you now.
00:18:42
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I need to examine your leg or I need to examine your genitalia or whatever it is.
00:18:46
Speaker
Just giving them some sense if they're listening and in any case reminding yourself that this is a human being and the way you interact with human beings follows more or less that dinner party rule that I talked about.
00:18:59
Speaker
You indicate before you touch.
00:19:00
Speaker
And that notion of touching also was triggered for me by this.
00:19:07
Speaker
I was rounding
00:19:09
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At night, I was covering for night, wasn't the day attending.
00:19:12
Speaker
And we came to a patient, diabetic in septic shock.
00:19:15
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The team told me they didn't know the cause.
00:19:17
Speaker
And I said, well, have you thought about Fournier's?
00:19:20
Speaker
And immediately, the resident, without drawing the drapes closed, without telling the patient, without any other indication of what was going on, had grabbed the man by the scrotum and elevated his genitalia.
00:19:37
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And it just, that image just struck me so vividly that this man had noiselessly with no introduction or warning and no privacy in full display to everyone in the ICU grabbed another man by the testicles.
00:19:54
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And that struck me as wrong.
00:19:56
Speaker
And so that's when we have to examine now, even if they're comatose, we say, hi, I'm sorry, I need to examine your genitalia.
00:20:03
Speaker
And I think that's a good practice to remind
00:20:06
Speaker
people of respectful behaviors toward the body of another person.
00:20:11
Speaker
And I think that those are all great points.
00:20:15
Speaker
and I'm actually very happy that there's some validation to something I've been doing for a long time, but without thinking about it in these terms, when families would ask about comatose patients, should we talk to them?
00:20:26
Speaker
I've always said, well, you should talk to them assuming that they can hear you.
00:20:30
Speaker
It's important for them probably to know that you're here.
00:20:32
Speaker
But even though I think we're good at giving people advice, we're not as good as following that advice ourselves.
00:20:38
Speaker
And maybe I've examined that patient that morning without talking to them and letting them know what I was going to do.
00:20:43
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So I think a very powerful
00:20:44
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lesson for everybody.
00:20:46
Speaker
What about rounds?
00:20:47
Speaker
Rounds are an intricate part of the ICU.
00:20:49
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I think it's one of the things that defines us, our multidisciplinary approach.
00:20:53
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More and more at our ICUs and sound critical care, we are really trying to make a deliberate effort and design to include families.
00:21:01
Speaker
How do you view the presence of families or patients in rounds?
Family Involvement in ICU Rounds and CPR
00:21:07
Speaker
I think that, to be honest, we can no longer provide any credible rationale for excluding families from rounds.
00:21:19
Speaker
We started this in earnest probably four years ago, and now it's a routine open invitation.
00:21:28
Speaker
Families are always invited to rounds.
00:21:32
Speaker
And when we first started doing it, it was a little bit, we had to kind of figure out, work out the kinks, just how precisely do you interact with the family members during rounds.
00:21:42
Speaker
And for us, the family members are invited to all of rounds, not just at the end to say, hey, this is what we decided, what are you thinking?
00:21:51
Speaker
We bring them into rounds.
00:21:54
Speaker
Now, it's been our experience that probably only about 30% of families actually want and are able to be on rounds.
00:22:01
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But what's crucial is the open invitation, because when you invite them to participate, they know that you actually honor them as members of the team.
00:22:12
Speaker
So my usual statement to people is, you're as much a member of the team as we are.
00:22:17
Speaker
I mean, we need you as much as you need us.
00:22:20
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So they come.
00:22:21
Speaker
And it's been our experience that 90 plus percent are just glad to be a part of it.
00:22:26
Speaker
The first several times they go, they don't understand a word anybody's saying.
00:22:31
Speaker
And then they start to get a little more confident and then they'll ask a little question.
00:22:35
Speaker
I find very commonly that they know more about the patient's course than the current bedside nurse, definitely more about the patient's course than the house staff.
00:22:45
Speaker
And so it's very common that we actually get a net benefit purely on a medical clinical side from having the family members in rounds.
00:22:53
Speaker
And then, of course, the human side is substantial.
00:22:58
Speaker
You know, I found back
00:23:00
Speaker
before we used to have families on rounds and present during procedures and total elimination of visiting hours, I found that as an attending, you know, it seemed like 30% of my job was what I called apology rounds, where I would just go around from like four o'clock until six o'clock PM, apologizing to families that they didn't feel like they'd had enough attention through the day.
00:23:24
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They didn't feel like they understood what was going on.
00:23:26
Speaker
They didn't feel like they were getting the, the, the,
00:23:31
Speaker
focus of resources that they felt they deserved and commonly had no idea that we had spent 45 sustained minutes deliberating carefully about how we were going to proceed and what needed to happen, etc.
00:23:44
Speaker
All they knew was that they'd seen us for 60 seconds and had some quality time with the nurse.
00:23:50
Speaker
So what I found now that we've more fully integrated family members into the flow is that I don't have to do apology rounds.
00:23:58
Speaker
upset families have become the exception rather than, you know, sort of the norm because they're with us when we're doing this stuff.
00:24:05
Speaker
I've even started when I got to do some follow up on the labs.
00:24:08
Speaker
I just wander into the patient's room and check the labs there.
00:24:11
Speaker
I got to check the labs anyway.
00:24:13
Speaker
Why shouldn't I do it in the presence of the patient and family?
00:24:16
Speaker
And then they can see that we're doing it and I'll, you know, let them look over my shoulder as we look at the labs.
00:24:21
Speaker
And it's been really a good
00:24:24
Speaker
I think when we first started, we were a little bit worried about the time commitments and whether there would be weird dynamics.
00:24:32
Speaker
And occasionally you do have to, if you've got an intern that's especially eager to talk about end of life, but they haven't figured out how to communicate with the family, you have to sort of teach them in the presence of the families.
00:24:45
Speaker
You don't say your weird, categorical, harsh statements about life and death issues.
00:24:53
Speaker
But that doesn't mean that you can't have these important conversations even in rounds.
00:24:57
Speaker
You learn a more respectful language to do it.
00:24:59
Speaker
So we're huge fans at Intermountain of family-based rounding.
00:25:05
Speaker
The thing to note about us is that we, because we were one of the early places to be computerized back in the 70s and did a lot of physiology and information systems and have large multidisciplinary, we actually have a rounds room where we do the rounds.
00:25:21
Speaker
So the family member comes with the nurse when the nurse comes to rounds.
00:25:25
Speaker
In institutions where rounding is true bedside rounding, that's even easier to get the families involved.
00:25:33
Speaker
They just step out the door to the team that's standing in the hallway and participate.
00:25:38
Speaker
So both of those models have been able to work in our experience.
00:25:42
Speaker
And in most of our programs, we don't have trainees and some we do, but most we don't.
00:25:47
Speaker
So we usually do bedside rounds and the families are part of it.
00:25:50
Speaker
And we have also found that it's transformational in terms of, like you said, saving time for us later, but also in terms of how they feel integrated.
00:25:59
Speaker
And they are also experts.
00:26:00
Speaker
They're experts in the human beings in that bed.
00:26:02
Speaker
And they have that expertise that we don't have.
00:26:05
Speaker
And I think it adds a lot.
00:26:07
Speaker
what about I call them the world experts in the humanity of the patient exactly are and they are they know things that we would never know and
00:26:15
Speaker
What about highly charged situations like a cardiac arrest?
00:26:19
Speaker
I think that when I was a trainee, it was like an absolute no, no family members during a cardiac arrest and probably because we know how we behave during these situations.
00:26:30
Speaker
But now it's changed.
00:26:32
Speaker
And as we try to do this better, what would be examples of disrespectful and respectful behaviors in that situation, Dr. Brown?
00:26:41
Speaker
I think that's a great point.
00:26:41
Speaker
There are a couple of RCTs.
00:26:43
Speaker
I know some people like to argue about the outcome of the RCTs, but I think, just being totally honest, there are reasonable RCTs and the reasonable inference from those RCTs is that families should be invited to be present for CPR.
00:26:56
Speaker
And to be honest, we've extended that well beyond CPR and in the White Journal Annals of ATS maybe two years ago now.
00:27:05
Speaker
A junior faculty who's great, Sarah Beasley, and is really a rising star in this area, led an effort to describe our experience of family procedural presence for all of the procedures that we do in the ICU.
00:27:20
Speaker
And again, it takes a little bit of training.
00:27:22
Speaker
You get a little bit used to it.
00:27:24
Speaker
I found that it's much easier to do procedures in the presence of families, to learn that skill.
00:27:30
Speaker
than it is to learn how to train an NP or an intern or a resident doing the procedures.
00:27:38
Speaker
So after just a few procedures, you get pretty accustomed to doing the procedures with the families right there.
00:27:44
Speaker
You screen them for fainting risk, and you make sure if they're intoxicated or wild, they're not allowed to stay.
00:27:51
Speaker
I mean, safety first, absolutely.
00:27:53
Speaker
But then you find that it's very easy to integrate them in, and that humanizes in a couple of ways.
00:28:00
Speaker
It's just, it's, you know, nothing about me without me.
00:28:02
Speaker
That's the classic disability rights phrase, and I think it applies in the ICU.
00:28:06
Speaker
If something's happening to their loved one, they want to be there.
00:28:10
Speaker
Why would they be exiled from the side of their beloved at their time of greatest need?
00:28:14
Speaker
It just makes no sense at all.
00:28:17
Speaker
The second thing that I find is that, like you said, we behave a little better.
00:28:22
Speaker
We're less disrespectful.
00:28:23
Speaker
I think particularly when we get tired, we can do things that frankly would embarrass us if we could see them when we were
00:28:29
Speaker
well rested and looking in from the outside.
00:28:33
Speaker
And so having the family members there I think helps us to do healthier and more respectful ways of dealing with the stress.
00:28:42
Speaker
And again, I think it's just part of this broader sense of teamwork that we have together.
00:28:47
Speaker
So when I run a code and family members there, I'll usually bring the family member to my side.
00:28:53
Speaker
I'll put my arm around their shoulder.
00:28:55
Speaker
I'll have the family member put their hand on the foot of the patient so that there's some skin contact.
00:29:01
Speaker
That keeps us out of the way of the people doing the CPR and the other procedures, allows us to see what's going on, and then I'll run the code with them right there.
00:29:09
Speaker
And if they, it's been my experience that just having me right next to them, knowing that they're with the person that's in charge is enough, and we have not had difficulties with them
00:29:22
Speaker
the worry is always, oh, they're gonna interfere with the CPR, they're not gonna make it work, et cetera.
00:29:26
Speaker
But they've been great about it.
00:29:29
Speaker
And I think it also can be, when it's appropriate, a natural way to make the transition to recognizing that the CPR didn't work.
00:29:43
Speaker
And then, a lot of what happens when a death, an undesired death happens
00:29:49
Speaker
is the grief, and there's no way around the grief.
00:29:51
Speaker
It's just sad when people die.
00:29:53
Speaker
It just is.
00:29:55
Speaker
But there's also a component of wanting to make sure that death has been resisted in a meaningful way, that there's been no abandonment, that then there's been no hunger for the person to be dead, and often allowing people to be present for the CPR takes care of that component of the grief.
00:30:12
Speaker
They know that we really did try.
00:30:14
Speaker
They saw us trying to circulate the blood with our own hands.
00:30:18
Speaker
in the patient's body.
00:30:19
Speaker
And I've found that in my personal experience, the somewhat tentative observations from the randomized control trials suggest that, in fact, they do better knowing that this has been attempted.
00:30:34
Speaker
It's the closure.
00:30:35
Speaker
I mean, understanding, and I think it's also, this is also true for rounds in terms of understanding how many
00:30:42
Speaker
different disciplines and how many people are interested in their loved one getting home.
00:30:47
Speaker
There's nurses, there's respiratory therapists, there's nutrition, there's chaplains.
00:30:50
Speaker
And I think that when they see that, regardless of the outcome, I think that they feel a lot better about what has been done for their loved ones.
00:30:57
Speaker
So these are all very, very important lessons.
00:31:00
Speaker
The last behavior that I think is very relevant for our audience since I presume we have a lot of young listeners has to do with attention.
00:31:09
Speaker
our attention during any encounter with families and patients.
00:31:12
Speaker
And this is something that I'm sure a lot of us struggle with socially as well when we're out to dinner with friends, when we're at home.
00:31:20
Speaker
But you want to maybe talk about this a little bit?
00:31:25
Speaker
Yeah, we all struggle with this now.
00:31:28
Speaker
We've become addicted to the virtual encounter with the world.
00:31:37
Speaker
people can tell when you're paying attention to them.
00:31:40
Speaker
And they can tell in a high-stakes moment, if you're disengaged, that you don't respect them.
00:31:48
Speaker
So when you're at the bedside, you really ought to have your attention with them at the bedside.
00:31:55
Speaker
And if there's an occasional moment where you cannot for a compelling clinical reason, you identify that fact explicitly.
00:32:05
Speaker
You just say,
00:32:06
Speaker
I'm sorry, there's an emergency I need to address, or I'm sorry, I need to see what this page says.
00:32:12
Speaker
Because when you indicate it, and when you indicate it with an apology that indicates that it's a deviation from what's expected, you do them the respect of anticipating that they have some claim on your attention.
00:32:24
Speaker
When you just do it, when you just divert your attention without signaling that you're doing it explicitly, you're telling them that they're not even worth the
00:32:35
Speaker
updating to know that something has happened.
00:32:38
Speaker
And often you do have to look at a computer during an encounter with a patient.
00:32:42
Speaker
And my goal with that has been to show them what you're looking at so that your attention can be shared with this other thing.
00:32:51
Speaker
But I think, you know, it's hard to be a clinician these days.
00:32:54
Speaker
It's exhausting and stretching.
00:32:56
Speaker
And there's a strong temptation to divert yourself to other attentional tasks while a patient or family is
00:33:05
Speaker
telling a story that's not immediately relevant to the medical aspects of their care.
00:33:12
Speaker
But I think we have to acknowledge that it's disrespectful and it makes us mad when our teenagers do it to us as parents and our patients and families have every right to be upset if we're allowing ourselves to be distracted during our encounter with them.
00:33:27
Speaker
And I think it's one of those things that we just have to recognize and make a deliberate effort.
00:33:31
Speaker
And it's really about becoming better listeners, right?
00:33:34
Speaker
And if we just learn to listen, to truly listen, I think a lot of this would be taken care of.
00:33:42
Speaker
Do you think of disrespect to a patient in the ICU as causing a harm to that patient?
00:33:48
Speaker
And how do you think about that?
00:33:51
Speaker
We debated that question for a long time, both in the expert consensus conference and in the writing of that piece for Blue Journal.
00:34:01
Speaker
Historically, we've tended to say if something causes a quote unquote objective harm, then we care about it.
00:34:09
Speaker
If it led to an adverse drug event, if it led to a hospital fall with a broken hip, if it led to a readmission, then something is bad.
00:34:19
Speaker
And we've been very much driven by the secondary effects of certain kinds of behaviors.
00:34:27
Speaker
And at some level, we need to be mindful of the secondary effects of the things that we do.
00:34:33
Speaker
We weren't advocating that you ignore secondary effects, but we wondered together whether disrespect itself, particularly when it was in a severe kind of mode,
00:34:49
Speaker
was sufficient to represent a harm in and of itself.
00:34:55
Speaker
In other words, even if there were no other secondary harm related to it, it could be considered a harm in its own right.
00:35:03
Speaker
And that basically is saying that disrespect is intrinsically bad.
00:35:09
Speaker
Now, as it turns out, it turns out that there's some interesting evidence, mostly from simulation studies, but not exclusively from that,
00:35:16
Speaker
that certain models of disrespect palpably lead to what we've traditionally called objective harms.
00:35:24
Speaker
And so there's also that reason that we should be attending to it.
00:35:27
Speaker
But we've argued that profound, profound disrespect really ought to be considered a harm in and of itself.
00:35:36
Speaker
And again, that group at Beth Israel Deaconess in Boston have already integrated into their
00:35:42
Speaker
quality and safety work a disrespect dashboard, and that disrespect dashboard treats them the way any other adverse event was, is treated.
00:35:53
Speaker
Now, that's not, they don't investigate every single time someone forgets to knock before they enter a room, but for example, when the hospital lost the body of a patient, that was a grave disrespect.
00:36:07
Speaker
You know, nobody died early as a result of it.
00:36:09
Speaker
There were no, I mean, the patient was already dead.
00:36:12
Speaker
but losing the body through a miscommunication in the morgue and the funeral home, that's profoundly disrespectful.
00:36:18
Speaker
So they investigated it with a root cause analysis as an adverse event in its own right.
00:36:26
Speaker
And I think that the direction that BI Deaconess people have taken in that regard is in fact, it's right headed.
00:36:34
Speaker
Clearly not every disrespectful event will need
00:36:38
Speaker
25 people to spend 25 hours doing a full root cause analysis just like not every drug event requires that but it ought to be present in our thinking as we think about what it means to be a high quality system that healthcare system it ought to include our management of disrespect and our solutions to decrease the amount of disrespect
00:37:06
Speaker
And I guess two points to those comments, Sam.
00:37:08
Speaker
On one hand, when I was reading about this and thinking about it, I also kind of was thinking along the terms of a dose response.
00:37:16
Speaker
So one very large dose can be very harmful, but small doses repeated enough times can probably cause as much harm to a patient.
00:37:25
Speaker
And I think those are things that we need to think about as well.
00:37:29
Speaker
That's a great point.
00:37:30
Speaker
And the second thing is that when we really think about creating value for our patients, it's really about improving patient outcomes and their experiences at the same time that we lower cost.
00:37:43
Speaker
And I think that part of the patient experience has had a bad name for a lot of physicians because all they think about is Prescani scores.
00:37:51
Speaker
But respect in that area is probably something where we have tremendous opportunity to make a difference.
00:37:59
Speaker
Yeah, I personally tend to think of those HCAP scores that get administered by Prescani and other corporations as a mostly statistically meaningless number that goads us to try to do the right thing.
00:38:17
Speaker
So I have kind of a mixed relationship to them.
00:38:20
Speaker
I don't for a moment believe that the HCAP scores accurately represent what people think they're accurately representing in most circumstances.
00:38:28
Speaker
And at the same time, I think they bring to our attention and the attention of administrators the absolute importance of humanizing the encounters that we have with people, not because CMS is going to get mad at us if we don't do it, but because it's the right thing to do.
00:38:47
Speaker
We are human beings.
00:38:49
Speaker
These are our peers.
00:38:51
Speaker
They deserve that respect.
00:38:54
Speaker
And I think that the unintended consequence of treating your patients with respect, from my perspective, would be that your self-respect will increase.
00:39:04
Speaker
And I think that is very important in terms of burnout, which is very prevalent, and we'll get to that in a second.
00:39:10
Speaker
But also, I would imagine that the more you treat your patients with respect, the more likely you are to treat your colleagues and the rest of the team with respect.
00:39:18
Speaker
And overall, it has to be a contagious effect.
00:39:21
Speaker
kind of environment that really changes the way that ICU feels.
00:39:26
Speaker
Yeah, I agree.
00:39:27
Speaker
I'm a scientist, so I always want to pause and think what the data are.
00:39:30
Speaker
The data are that disrespect is contagious.
00:39:32
Speaker
There's pretty good data for that, actually.
00:39:35
Speaker
Whether respect is contagious, we think so.
00:39:37
Speaker
The research has not been well done yet.
00:39:39
Speaker
But if disrespect is contagious, it stands to reason that the elimination of disrespect will interrupt the contagion of disrespect.
00:39:48
Speaker
So at some level, I think we already know the answer.
00:39:50
Speaker
The other thing I would say that we need to call out is that administrators are culpable in the disrespect of patients when they create work environments that are highly toxic to the clinicians.
00:40:08
Speaker
So I don't want the clinicians to think, oh, my boss is a jerk, so he's the reason that I'm causing all this trouble for patients.
00:40:14
Speaker
That's not the right answer.
00:40:16
Speaker
It's also not the right answer to say it's all about the clinicians.
00:40:20
Speaker
And the thing that worries me as we become much more MBA-driven in medicine is that people tend to think that if they're just running human resources and strategy and the patient ratios and RVU targets and all that kind of stuff that the MBA crowd feel is their bailiwick, it can't possibly be my problem if my clinicians aren't treating people well.
00:40:47
Speaker
It's certainly not my
Role of Administration in Fostering Respectful Environments
00:40:48
Speaker
fault.
00:40:48
Speaker
But the reality is that when administrators treat their clinicians disrespectfully, that disrespect is contagious.
00:40:57
Speaker
And I think we need to get more and more of the administrative people mindful of that, that when you treat your clinicians disrespectfully, you increase the chance that they in turn will treat others disrespectfully.
00:41:13
Speaker
And I think that that really rides right into what I wanted to ask you next, which is also the system's responsibility in creating environments that lead to burnout.
00:41:22
Speaker
I mean, there's definitely a lot of factors internally, but in terms of barriers to the practice of respecting the ICU, do you want to comment on empathy fatigue and a little bit on burnout?
00:41:35
Speaker
Yeah, that's the concern.
00:41:37
Speaker
Again, like we talked about earlier, if people get too invested in compassion, they can be exhausted.
00:41:42
Speaker
None of us can tolerate the death of multiple intimate friends over the course of a month.
00:41:48
Speaker
It's just too much.
00:41:49
Speaker
So if we're not careful, we can run out of empathy.
00:41:54
Speaker
And that's something we have to manage.
00:41:55
Speaker
Sometimes when you think, I've got to start behaving more respectfully, we think, oh, I've got to have an intimate emotional bond with every person that I treat.
00:42:04
Speaker
And that's actually not
00:42:06
Speaker
true and may not be the right target for us because we have to have the capacity to care for the people that continue to come into our care.
00:42:17
Speaker
So there are risks and there are data that suggest that if you identify too powerfully with too great an emotional resonance with patients and families that you will develop empathy fatigue and
00:42:35
Speaker
are at risk for burnout.
00:42:36
Speaker
Now, burnout's an interesting question, needs more research, because there is some evidence that if you humanize carefully, avoiding excesses of empathy that will overwhelm the clinician's psyche to the extent that the clinician can no longer function correctly, then humanization, respect, can actually decrease burnout.
00:43:00
Speaker
People can feel connected again to the things that called them into medicine in the first place.
00:43:05
Speaker
So we're really in a Goldilocks kind of place, or if you're a classic philosopher, you're looking for that Aristotelian mean.
00:43:14
Speaker
What you're after is the sweet spot.
00:43:18
Speaker
Practicing respect without becoming so emotionally overloaded that you have no capacity to continue to care for additional patients.
00:43:27
Speaker
And so one of the reasons that we call for research in that perspective piece in Blue Journal
00:43:32
Speaker
is precisely because we need to find that Goldilocks spot where the porridge is not too hot and not too cold and the chair is not too big and not too small.
00:43:41
Speaker
And looking for that sweet spot is the work of good research, good collaboration with patient advisory councils and with the patient advocacy groups, thinking together, how do we find the sweet spot?
00:43:55
Speaker
Because I think that we will have that capacity.
00:43:58
Speaker
And the sweet spot may vary slightly based on the
00:44:02
Speaker
the location and structure of the hospital, it may, or the, you know, the locus of healthcare being provided, whether that's a hospital or a clinic.
00:44:13
Speaker
It may also depend on the cultural background of the patients and the cultural background of the doctors.
00:44:18
Speaker
There will be this ongoing, there will be this ongoing navigation and discussion that comes to something like that sweet spot.
00:44:28
Speaker
What we've really been advocating, in addition to the research, is a model that says that we are partnering in this.
00:44:35
Speaker
We are teams, and those teams include clinicians and patients and families.
00:44:40
Speaker
It includes the whole crowd.
00:44:44
Speaker
And by creating that capacity to have functional teams, we make ourselves capable of developing in useful and important directions.
00:44:57
Speaker
that will allow us to accommodate shifts or local variations, et cetera.
00:45:02
Speaker
And I think that the first step, obviously, is recognizing we have a problem.
00:45:09
Speaker
Yeah.
00:45:09
Speaker
The second question, I mean, is like you said, is finding through science, what is that sweet spot, which I think is true because we think of everything being a linear relationship, more is better, but probably for most things in life and definitely in the ICU, they're nonlinear relationships and there might be more like you's that there's a sweet spot and then you get in trouble.
00:45:30
Speaker
But I also, I think you're right.
00:45:31
Speaker
And the other thing that I always think about, Sam, is how do you model, how do you teach people to be respectful?
00:45:38
Speaker
Obviously, as a parent, I've always grappled with this in one way as example, but how do you model these behaviors?
00:45:44
Speaker
And I think the examples you gave are very specific examples that we can teach people to think about, but I'm sure that this would also be the topic of future research with your group.
00:45:57
Speaker
You're absolutely correct that we need more research to understand how to model it.
00:46:02
Speaker
My sense has been that it's important to see it executed well.
00:46:07
Speaker
So I try to make sure that I draw attention to people who do it well and encourage people to spend a little bit of time in the presence of people who do it well.
00:46:17
Speaker
I think that's important.
00:46:18
Speaker
I think for, I mean, essentially every person I know wants to do good and be good.
00:46:25
Speaker
Now we have blind spots, we have things that pull us in the wrong direction, we have exhaustion, we have things that get in the way of our wanting to do good and be good.
00:46:35
Speaker
Most commonly, I think it's failures of vision and failures of consistency.
00:46:41
Speaker
And for failures of vision, I've found personally, and I think others have as well, that actually getting advice and collaborative input from the other participants is huge for changing your vision.
00:46:57
Speaker
So I strongly recommend that ICUs, even if they can't pull off a full patient family advisory council,
00:47:06
Speaker
that they, a couple times a year, identify some graduate from their ICU, whether it's a patient or a family member or both, and then invite them back for a debrief.
00:47:20
Speaker
And have the debrief be with the unit management and with one or two of the clinicians that are really invested and with the clinicians that cared for them.
00:47:32
Speaker
And then just talk it through, just say,
00:47:35
Speaker
We're so glad to see you again and we want to know what we did well and what we could have done better and tell us about your experience of it.
00:47:46
Speaker
What were the things that really worked?
00:47:47
Speaker
What were the things that we could work on to improve?
00:47:50
Speaker
Now you have to be thoughtful that some people will decline the invitation because of PTSD or not feeling ready to discuss things.
00:48:01
Speaker
You can sometimes meet with them off the unit to lessen the risk of
00:48:06
Speaker
PTSD in my experience even though PTSD probably affects somewhere between 15 and 35 percent of ICU graduates only a minority of those with measurable PTSD symptoms are unable to interact with the healthcare team afterwards especially in a neutral location and then through that process you learn a little bit more you get a little bit more understanding and then you are going to find people who don't have the PTSD so they're able to come back to the ICU environment who are
00:48:36
Speaker
pretty good at communicating and who have some memorable stories and then you bring those people to your nursing in services or to your division meetings for the docs and you have them present you have them talk about it and it's been our experience that having those actual graduates of the experience describe what it was like that's been most useful for training and
00:49:04
Speaker
transforming around the vision in this respect.
00:49:09
Speaker
For continuity, for follow through, that's a little harder.
00:49:13
Speaker
We as human beings notoriously do worse than we intend in part because we sort of forget.
00:49:19
Speaker
And I think having periodic recharges can be helpful.
00:49:26
Speaker
And recharges that indicate that the administrators who manage the system
00:49:33
Speaker
and the colleagues care about it.
00:49:35
Speaker
So we've tried periodically to have, even though we've really tried to train up this group really well, to periodically have refresher in-services or refresher division meetings where we have lectures from, or brief talks or question-and-answer periods from patients and families that have come out the other side.
00:49:56
Speaker
It does take a champion, as I think we've all known.
00:49:59
Speaker
You can't make something happen
00:50:01
Speaker
without either some sort of regulatory oversight that's sort of exhausting and soul-crushing or with some local champion.
00:50:10
Speaker
But it's been my experience with local champion and reasonably clear-seeing administrators that even relatively informal mechanisms can make it possible.
00:50:21
Speaker
People want to be good.
00:50:22
Speaker
They just sometimes don't see clearly and sometimes are exhausted or in
00:50:29
Speaker
systems that interfere with their capacity to be as good as they'd like.
00:50:33
Speaker
Yeah, and I think that it's a common theme in life that we focus on the differences we have with other people, yet at the core, we are very much alike and want the same things.
00:50:44
Speaker
We actually, as Sam and several of our programs, have done something we call the celebration of life, where we invite graduates of the ICU or families of patients who died for a day where we meet with the staff, talk about different topics.
00:51:00
Speaker
Don't do it maybe such as...
00:51:03
Speaker
systematic debriefing but what we have found is not only it's very powerful for the patients and their families but it's extremely powerful for the staff in creating that common sense of purpose which I think is probably one of the most important antidotes to burnout and I think that it has so many benefits yeah that's great
00:51:23
Speaker
So this has been, I think, a fascinating discussion.
00:51:26
Speaker
I think that a lot of topics that are extremely relevant to where we are today in critical care, I'm sure we could go on for a long time, but I want to be obviously very respectful of your time.
00:51:38
Speaker
And what we'd like to do, Sam, at the end of every Critical Matters episode is just ask our guests a couple of general questions just to tap into their wisdom of life in general outside of the fast lane.
00:51:50
Speaker
Would that be okay?
00:51:52
Speaker
Sure.
00:51:53
Speaker
So the first question relates to books and what book or books have influenced you the most or what book have you gifted most often to others?
00:52:04
Speaker
I have to say my favorite book for a very long time is Speak Memory by Vladimir Nabokov or Nabokov some people will say.
00:52:14
Speaker
It's his memoir and it's this sort of
00:52:18
Speaker
It's this celebration of the power of language and perception.
00:52:22
Speaker
And I love it.
00:52:23
Speaker
I read it.
00:52:25
Speaker
I read it probably every other year still.
00:52:27
Speaker
Just this sense of being alive to awareness and alive to language, the power of language.
00:52:36
Speaker
Not everybody likes Nabokov, but I think his love of language is really quite illuminating.
00:52:45
Speaker
And I think very timely for where we are today in education where it seems like everybody is learning from tweets or from PowerPoint slides.
00:52:53
Speaker
And I always worry how that affects the way we think about problems in terms of the ability to really articulate an idea and think about it through language, which I think is very powerful.
00:53:05
Speaker
I have not read this book, but definitely will get it and try to explore Nabokov a little bit more.
00:53:13
Speaker
The second question... I try to read about a book a week.
00:53:18
Speaker
I just feel like that's part of how you stay alive.
00:53:22
Speaker
I'm with you.
00:53:23
Speaker
I think it's sad that we seem to be separating ourselves from books because I think there's so much to learn from them.
00:53:31
Speaker
Well, and I think that it really speaks also to what we're talking about at the beginning with dignity and respect is that the true questions of humanity remain the same over the centuries.
00:53:42
Speaker
And people have explored these questions a long time ago where you're reading the Stoics or reading Thoreau.
00:53:48
Speaker
I mean, these are all questions that are still 100 percent relevant to our lives today.
00:53:52
Speaker
And I think that through reading, you can really learn a lot about yourself.
00:53:59
Speaker
Yeah, I agree.
00:54:00
Speaker
The second question is, what do you believe to be true in medicine or in life that most other people don't believe?
00:54:10
Speaker
I think it's always hard to know what other people do or don't believe.
00:54:15
Speaker
I'll confess that I am practicing Mormon, which is an odd American religious tradition, which I love a great deal.
00:54:24
Speaker
And I think as I've pondered more and more in the ICU, in my scientific work, in my intellectual work, I have this sense
00:54:36
Speaker
That this is not all there is.
00:54:38
Speaker
I'm not trying to go ultra mystical I'm not trying to make any big sweeping religious statements, but I just have this sense that The mere everyday the mere physicality is not all there is and and that sense that there is more to us than just our flesh and our bones is deeply meaningful to me and and I think motivates a lot of this and
00:55:05
Speaker
work that I'm doing to try to understand how we identify, treasure, and preserve that which is marvelous in all of us.
00:55:16
Speaker
And I think, I mean, it speaks very powerfully to the fact that sometimes it's not having the right answers, but having the right questions that are important.
00:55:27
Speaker
And really thinking about those big questions, I think, can guide everything we do, whether professionally or just in our life.
00:55:33
Speaker
Yeah.
00:55:35
Speaker
And the last closing question is, what would you want every sound critical care and every intensivist that listens to this podcast to know?
00:55:49
Speaker
To this question of respect and dignity, I think we ought to know something human about every patient we treat.
00:55:59
Speaker
At a minimum, their preferred name, but ideally, some story, some story.
00:56:04
Speaker
fact or reality about them that makes them just a little more vivid for us as human beings.
00:56:12
Speaker
That's what I really try.
00:56:14
Speaker
Everybody I meet in the ICU to know just a little bit more about them than their physiology.
00:56:22
Speaker
And I've been really nourished and enriched both humanly and spiritually and intellectually and even scientifically
00:56:31
Speaker
by being open to those little glimmers of distinctive illumination that come from the individuals I meet.
00:56:39
Speaker
Absolutely.
00:56:39
Speaker
And I would push it one step forward and say that probably applies to everybody you work with.
00:56:45
Speaker
Learning things about the people around you that make them human definitely makes the connections a lot stronger and makes difficult times easier to deal with.
00:56:55
Speaker
Yeah, you're right.
00:56:56
Speaker
You're absolutely correct.
00:56:58
Speaker
Well, I really want to thank you for your time.
00:57:00
Speaker
This was a fantastic conversation.
00:57:02
Speaker
I look forward to reading the books you recommended.
00:57:07
Speaker
I also look forward to seeing some of the research that your group will put out in this topic and hope to have you back on Critical Matters as a guest again.
00:57:15
Speaker
Okay.
00:57:15
Speaker
Thank you so much, Sergio.
00:57:16
Speaker
It was great fun.
00:57:19
Speaker
Thank you for listening to Critical Matters, a sound podcast.
00:57:22
Speaker
Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
00:57:28
Speaker
Sound's transforming the way critical care is provided in hospitals across the country.
00:57:33
Speaker
To learn more, visit www.soundphysicians.com.