Central Line

Episode Number: 146

Episode Title: Inside the Monitor: When Bad Things Happen to Good Anesthesiologists

Recorded: November 2024

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Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. ZACH DEUTCH:

Hey, welcome back everyone. This is the Central Line podcast, and I'm your guest host for today's episode, Dr. Zach Deutch. Today we have the guest editor of December's ASA Monitor, Dr. Muhammed Rafique. The topic of that issue is when bad things happen to good anesthesiologists. Obviously an enormously important topic which is touched probably everyone in our profession. So we're very delighted to have Dr. Rafique with us.

Dr. Rafique, you have been on the Central Line podcast before. We're very happy to have you back. I'm looking forward to speaking with you. To start off, I want to just explore how you got involved with this issue, which really has to do with navigating personal and professional crises. Can you talk about that and what this topic means to you personally?

DR. MUHAMMAD RAFIQUE:

Thank you very much, Dr. Deutch. It is a pleasure to be here again. Yes, this topic is broad and when I saw that ASA Monitor will have an issue dedicated to this topic, I felt like I needed to volunteer for that. Despite being so specialized professionals, we are all very vulnerable to face adversities of professional and personal life. At work, the most feared challenge can be loss of a patient or any debilitating complications for the patient under our care, extra burden of work which all can lead to burnout and of course job loss is always a possibility. In personal life, illness is in the family, domestic problems or financial burdens and loss of a loved one are personal health difficulties could be things which affect us like all other humans.

DR. DEUTCH:

Okay, so we know that life is a long process with its ups and downs, and you've alluded to that already. And becoming an anesthesiologist is a long road, and it can even be longer for people that may have started their training overseas. So I think many of us would like to believe, or did believe at one time, that once we get to our goal of finishing our professional training and becoming an anesthesiologist, it's not downhill from there, pretty much. But that isn't necessarily true for all of us. So could you talk about some of the challenges and unforeseen problems that we face in our professional lives?

DR. RAFIQUE:

A very good question, Dr. Deutch. Becoming a physician and specializing in anesthesiology is a long journey, and this journey is not accomplished by a single person. Everyone who is on this path, people around them including parents, siblings, spouses, significant others, children and friends, and other people around us are part of the journey and all these people around us help and support us in this journey and possibly make sacrifices in this process. As an example, if you have school going children, you may not be able to be present at all the school activities like games or musical recitals or other things, and it is your spouse and significant other who may be doing all this heavy lifting. All this can add up and may lead to stress. So if an anesthesiologist, after all these sacrifices, has either a personal health issue or any other reason which makes them unable to continue as an anesthesiologist, it could be a dissatisfier for all those around us who supported us in our journey. After becoming a physician anesthesiologist, it is not a downhill journey in my opinion. Rather, it is a celebration of achievement and commitment of service which will bring personal and professional joy to us. It is time to reap the fruits of hard work and commitment, benefit the patient population as well as the society at large by all the good work which we can do as anesthesiologists.

DR. DEUTCH:

So we know that there are unforeseen hardships and challenges. What would you say to people that are uncomfortable with talking about those type of things that would rather just push past them, sweep them under the rug, and sort of just move on without any contemplation?

DR. RAFIQUE:

I think I disagree with you on that. These vulnerabilities are part of being a human. So one cannot just sit idle and say, oh, if I'm so vulnerable, maybe we should not talk about these things, or I should not work this hard and strive to achieve any big goals. I would rather say that these realities give us the opportunity to reflect and maybe give more value to the achievements we get through hard work and dedication. And if things like this come in our way, face them the best we can and find a solution which will be a good solution. And whoever faces those adversities, they usually come out stronger and are able to be a better self and be a better professional and be a better human and serve their purpose of life in a much better way.

DR. DEUTCH:

Okay, so talking about these issues we’re, you know, you make an argument, a very reasonable argument that we're going to delve into these. So one of the most challenging and heartbreaking adversities that we might face would be the loss of a patient, whether intraoperatively or in a critical care setting, in any setting where we're involved as as part of a clinical team. In addition, death of patients can lead to litigation, um, other types of recrimination, which is really exacerbating that pain and is essentially an insult on top of injury phenomenon. This takes a huge emotional toll. We know this. What can we be doing to prepare for these type of events, and what things can we do on an organizational level to not just have the individual prepare, but the organization to support the individual in these times of difficult crisis?

DR. RAFIQUE:

Well, that is a very good question. Um, we all value and care about human life and want to make it better for our patients through our hard work and good anesthesia. And we are passionate about doing what we do every day. So if there is a negative outcome in patient care, it is really hard for the physician. It brings feelings of helplessness and sorrow. It makes us sad. It causes stress and can lead to burnout and depression. It is very important that if there is a bad outcome, which can be a complication or loss of life, the department or group and the institution should provide support and help the physician to find peace, get relaxed and be able to recover from the emotional trauma and so that they can find their groove back. This is at the emotional level.

So far as the legal process is concerned, every institution, every hospital usually has a legal department, and whenever something like this happens, the legal department should proactively meet the physician and help them to understand the process so that whatever may be the cause and whatever may be the legal process, look like they should prepare the physician to be able to face it. They should provide all kinds of legal support so that they are not worried about--because most of the times, physicians may not face any kind of legal action all their life, all their career, or maybe once or twice. So they never very familiar with the process, and they're never very good at the process, and they don't know what they are getting into. So if the institution provides them a framework which will help them to navigate the legal process that really can help and the physicians in the process, as well as give them peace of mind and keep them focused on their clinical work and other good things they do in life. And actually, there is an article in our, uh, ASA Monitor this month which actually breaks down the legal process, how things proceed or how things work, and gives us a kind of, uh, framework for a layman that what to expect, what to do, and what not to do whenever there is a legal case against a physician for malpractice. And it is a very good read. I think everybody should read that article when they get a chance.

DR. DEUTCH:

So just out of curiosity, have you in your current position or prior positions, either participated in or witnessed an organizational departmental initiative to support someone in a time of crisis like this?

DR. RAFIQUE:

Um, yes. I'm very lucky so far that I never had a situation where I faced a lawsuit personally, but a colleague of mine had actually a lawsuit against her in a cardiac case, and she was, uh, wrongly kind of included in that lawsuit. And the university hospital we worked for, uh, they supported her in every which way. They provided her, uh, initial framework. Then they provided her institutional attorneys who were very good. And, um, they worked with the physician, prepared her to be able to face the court proceedings. And it all worked out really well for her. And and there was no implications to her. So I have been lucky that I wherever I worked, there was a legal department in the hospital who were supportive.

DR. DEUTCH:

For that specific case that you described. What about colleagues helping with the emotional fallout and self-recrimination that may result?

DR. RAFIQUE:

Definitely. We kind of had a very close group in that department. It was 7 or 8 pediatric anesthesiologists, and we all are very commonly, very often hang out together in a break room. And we used to talk about it. And so everybody talked to her and supported her and told her that it was not something which she had done in any manner. And she was a very good physician. Everybody, as everybody would tell that, okay, if my kid was getting surgery, then I would be asking for you to do it. So don't feel any lesser than anybody else. It is just that you were part of the case, and the complication was actually through the heart lung machine, and there was some air embolism and she had no role in it. But because she was part of the case, she was named in the legal case.

DR. DEUTCH:

And, you know, you make me think of the fact that when bad things happen to good anesthesiologists and all of, as you've mentioned, and we all kind of recognize on an innate level, life is sacred. But somehow when bad things happen to children, this is especially heartbreaking. I am not a pediatric specialist, but I can only imagine how much more difficult it is in that situation. So having a support network would be extremely important. And it sounds like that tight knit group was was very, very useful in that situation.

So we're going to shift just a little bit. We're going to talk about burnout. Now this has been covered at least a couple of times by our Central Line podcast series. I hesitate to say this is somewhat of a buzzword that implies that it's an issue without substance. I think we all know that buzzword really means it's on everyone's mind, because it is very pertinent and does have a lot of substance. Um, can you give me your take on this issue, what you think the current state of, you know, our profession is vis a vis the mental health of our physicians and the strategies that people might employ to keep them in their right place.

DR. RAFIQUE:

Yes, definitely. Very good question. I agree, burnout and physician burnout has rightly received a lot of attention in recent times, which has helped us to be able to talk about it openly and find strategies and find help, um, which could be needed at times whenever somebody is experiencing it, um, or even to avoid it. There is actually a very beautiful article written by Dr. Gustin, which is part of this month's ASA Monitor, and he talks about the strategies which he finds are very helpful, and they are supported by the literature, which can help to avoid, or even if you are already experiencing it to conquer it. Also, another article by Dr. Hartwig is a personal story. It is a heartfelt story where he talks about what were the things which pushed him into burnout and what was his path, and how he gained his groove back, how he recovered from it, and what were the things which worked for him? And then he he actually almost quit the profession. And then what helped him to come back and find the joy in doing the thing which he always wanted to do to be an anesthesiologist and has successfully, uh, navigated it since then.

My personal strategy is to avoid burnout include I find joy in my work. I discuss stresses of work with my colleagues at work. We have a break room, which we call our bubble. Everyone comes there and shares their challenges, which helps everyone to deflate. It is like a talk therapy chamber. And in addition, I spend time with my wife and kids and when I get home, I try not to think about work. When I'm at home, I have a very rudimentary small gym at home for exercise. All these things collectively help me to stay sane and avoid burnout.

DR. DEUTCH:

And this article that you described, as well as the kind of communal space where you can share freely that sense of honest self-disclosure is hard, but I think is very useful for other colleagues, because we may have had some of the same thoughts, fears, challenges, and we were hesitant to voice them for a variety of reasons, and to have somebody else kind of put that in a talk or speak in front of you or in an article says, you know, you're not the only one, and there's others out there. And I think that's very valuable. And I'm looking forward to reading that piece that you mentioned.

DR. RAFIQUE:

I agree, it is a beautiful read.

DR. DEUTCH:

So talking about strategies, stress management is key. You've you've alluded to it in your own personal life. What can people do in our profession and certainly translatable to other professions as well before tragic challenging events to ensure that as people we are more resilient. So what can we do for ourselves? What can we do for our peers at that time and after something might go wrong? Do you have any tips or strategies for our listeners?

DR. RAFIQUE:

Yeah, that is a great question. I think this should be part of the residency curriculum, and trainees can be trained on this via simulation lab where these situations can be replicated, and then techniques and strategies which can help in this regard can be discussed, which will prepare the trainees to, um, be able to face these situations in a better way. Same is true for us. One, we all are part of a bigger practices or groups, and wherever we can find friends, where we can honestly and freely discuss things which kind of work as a talk therapy could be very helpful. Also, um, simulation scenarios which deal with these things for even the anesthesiologists who are already done with the training, can be helpful for them to understand and be able to learn how to navigate these things. Simulation, day and day, is getting better, and that can help us to learn how to deal with these situations and how to manage that stress. In addition, things in personal life, which include spending time with your loved ones and exercise and other things which keep us healthy both physically and mentally, that could be helpful to manage the stress and be able to navigate a situation like that and prepare us to be able to deal with these things if they come to us.

DR. DEUTCH:

Now. While we've been discussing these issues, I've been thinking about something and I'm going to get a little bit personal. Um, Mohammed, where were you originally trained and where are you from originally?

DR. RAFIQUE:

So I was born in Pakistan and that is where I did all my schooling. After I finished medical school, um, I spent only about a year and a half an internship there, and then I came to US. So I did all my training here in the US. Actually, I did my internship in Rochester, Minnesota, and then residency at Tufts University in Boston.

DR. DEUTCH:

Okay. So the reason that I ask is I'm just curious and I don't know, you know, having done almost everything professional in this country, you may not be able to give a really comprehensive answer. But I'm curious if there are cultural differences in the way that physicians in other countries would approach the issues we're talking about, which would be either coming to terms with the negative event, disclosing a negative event to peers, and how a peer network might support or not support them in a different type of culture. If you're able to comment on that, I'd love to hear your thoughts.

DR. RAFIQUE:

Uh, that is a very good question. Yes. You're right. Um, although I am from a different culture originally, but I didn't practice medicine there for very long. But I know these things do come up these days. If I think of it, 20 years ago, when I was, uh, finishing the training, nobody talked about burnout or stress or negative outcomes. Everybody would be trying to kind of push it under the rug. But now more and more communication has become very easy. People see that bad outcomes happen everywhere. Stress is everywhere. Burnout is everywhere. So people are realizing, okay, these things which we are experiencing. Maybe it was burnout or if there are bad outcomes, like it doesn't make you a necessarily a bad doctor. And people talk more freely about these things these days. But still, it is to some extent a taboo for people to admit that they have stress or burnout. In Pakistan at least, where I have a lot of friends who were my classmates and still it is a little difficult conversation sometimes.

DR. DEUTCH:

That's helpful for understanding, and it's always great to think of ourselves as part of an international community, because there are certainly lessons to be learned for us across oceans and things that we can teach others as well. So I always try to keep cognizant of those things. Is there stuff that I can learn that can make me a better professional or a better person? Um, because the way we do things sometimes is right, and sometimes it isn't necessarily the best way.

So we are coming to the end here. I have one more question for you, and it's been great talking with you. As the guest editor of December's ASA Monitor, share with us kind of some highlights of that. Anything unexpected you might have learned from working with the contributors, and it sounds like you had some wonderful contributions. And on top of that, anything specific that you're hoping that readers of this issue are going to get from delving in there and just flipping through it?

DR. RAFIQUE:

Yes. The most important thing which I want to highlight is I realize that these things are very personal. Either a bad outcome or a litigious experience, and people may not feel very comfortable to talk about a bad outcome or a lawsuit, even if they were not guilty or responsible. And a good amount of time has passed, and I felt that sometimes asking them can induce a PTSD, and they may feel the same stress again by talking about it. So what I learned from this whole exercise was that even if time has passed, and if someone is uh, not very open about talking about a bad outcome or a, uh, an experience they had in a situation like that. It may not be very wise to try to invoke or try to ask them again and again. And I think the articles in this month's Monitor are going to be very thought provoking for people to see that all these things are possible. All these things can happen to any anesthesiologist, and there are strategies out there to be able to manage the stress and be able to feel and get better. If you have stress or burnout. And, uh, we have a very big and large community, and most of the times the institutional support is instrumental and is always there to help you in case of a difficult time.

DR. DEUTCH:

Mohamed, thank you so much for joining us. And, um, I think that the membership, our readers will really be thankful to you for putting together a wonderful issue as guest editor for readers and listeners, please pick up that December issue and you can always look for more information on the web at samaritans.org. We'll see you next time.

DR. RAFIQUE:

Thank you very much.

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