Service Fanatics

by James Merlino

  Chapter 1

  Transformed by he Patient Experience

  In 2004, I was a colorectal fellow at Cleveland Clinic, in my final year of medical training. The institution had one of the preeminent colorectal programs in the world—and still does. It had among the highest case volumes in the world, as well as several leading colorectal surgeons, including department chairman Victor W. Fazio, a world-renowned, pioneering colorectal surgeon considered by many to be one of the grand masters in the field. Training under Fazio would not only mold me into a great surgeon; it would virtually guarantee an exceptional career. The day I was accepted into the fellowship program, I was ecstatic, knowing that I was joining one of the best programs in the world, if not the best. All of my hard work and sacrifice from years of training had paid off.

  Six months into my fellowship, my 77-year-old father noticed blood in his urine. He was quite healthy, save for minor high blood pressure. He had an office cystoscopy, which confirmed multiple lesions in his bladder. At first, Dad did not want to come to Cleveland Clinic, preferring to be treated at a community hospital closer to home. I was insistent that he be treated at Cleveland Clinic, for several reasons. We had a world reputation as a top hospital and had the number two–ranked U.S. urology program. More important, consistent with Cleveland Clinic’s reputation for clinical innovation, we were providing minimally invasive urological surgery, clearly preferable for a 77-year-old.

  Dad was admitted to the hospital on December 15 for a biopsy, to be discharged later the same day. His biopsy evolved into the removal of the lesions, as they were thought to be superficial—good news, because this would prevent a more invasive bladder resection. The procedure generally went as planned; however, Dad’s abdomen was distended afterward, necessitating a small incision in it to ensure that his bladder had not been perforated. This complication required him to stay in the hospital for observation. I went to the postanesthesia care unit shortly after his surgery. He was still not quite recovered, but he opened his eyes when I touched him. He was having some difficulty breathing and still had an oxygen mask on his face. He pulled the mask down, and I reassured him that everything was OK. He looked at me and asked, “Am I going to die?”

  My father’s stay in the hospital was rocky. He was admitted to one of the surgery floors and suffered continuous respiratory problems, requiring supplemental oxygen and respiratory treatments. He developed an ileus, where his bowels were not functioning, and required a nasogastric tube, which is placed through the nose into the stomach to decompress air and remove fluid. I walked into my father’s room as one of the staff colorectal surgeons was placing the nasogastric tube. I had performed this procedure hundreds of times on patients, but I had never seen it done from the perspective of a family member. It was difficult. Dad was clearly distressed, and I could see desperation on his face. He looked over at me, and I had to leave the room, unable to bear seeing him in pain. I was traumatized. My father, whom I viewed as a man of strength and determination, had been reduced to his most vulnerable state, and I had no idea how to help him. I wanted to cry.

  What was supposed to be an ambulatory procedure evolved into a several-day stay that ended the night of December 22 with him arresting in his hospital room and dying. The complications that caused him to be admitted or that took his life were no one’s fault in particular. While an autopsy was not performed, Dad likely succumbed to either a heart attack or a pulmonary embolism. His last days in the hospital, however, were wrenching, both for him and for our family. I am certain Dad died believing that Cleveland Clinic was the worst healthcare institution in the world. I know my family would not disagree.

  His experience during those seven days was a test case for how not to manage a patient’s experience. It’s ironic now, because we didn’t use the words patient experience back in 2004, but when you dissect his hospital stay, you can absolutely overlay a template of the factors that today we consider important to patients. Dad complained about pushing the call button and the nurses responding slowly or not at all. When he was finally able to eat, he ordered menu items that did not appear on his food tray. He wanted to go for walks, but there was no one to help him. Physical therapists were supposed to see him every day but did not. Probably most difficult for me, the physician covering his stay did not round on him every day. His care was managed primarily by the urology house staff.

  I vividly remember the night Dad died, a memory indelibly seared into my mind. It was three days before Christmas, and I had come home late after shopping and gone to bed. I heard the phone ringing but tried to ignore it because I was exhausted and thought it probably wasn’t important. I finally answered the call. A urologist colleague and friend of mine who had helped take care of Dad was calling from Florida. Away for the holidays, he had been alerted to the situation by the house staff. Because of our friendship, he wanted to be the one to break the news: “Jim, I’m really sorry, but they lost him.” He told me that Dad had arrested and they were unable to bring him back. My friend didn’t know what had happened. If you’ve never experienced such a call, there is nothing I can say that will describe it.

  My brother picked me up, and along with my mother and sister, we drove to the hospital around midnight in one of the worst snowstorms in years. Dad was the closest family member I’ve ever lost, and the drive was surreal. What actually happened had not sunk in. I think we believed that we would get to the hospital and learn this was a terrible misunderstanding. But it wasn’t.

  When we arrived at the hospital, we were taken to his room. His body lay on the bed. Everything else had been removed, and the nurses had covered him up. They spoke with us briefly. A resident from the primary service, who looked very tired, was on call and answered questions as best he could. We believed we were a pretty strong family that could cope with anything, not realizing how much of a fallacy that was at a time like that. The nurses tried their best, but they just could not supply the medical information we sought: Why? What went wrong? Wasn’t he getting better?

  Someone from mortuary services was available and delivered a very mechanical recitation of our next steps, including inquiring whether we wanted an autopsy and who should be contacted about the final arrangements. It seemed highly impersonal that we were being asked who would take care of the arrangements just after we’d been informed, in the middle of the night, that Dad had unexpectedly died. Arrangements? Seriously?

  Finding There Was an Other Side to Healthcare

  This experience with my father was the first time someone very close to me became ill with a serious disease. Even though I was a physician and a current trainee of the organization, I found myself grappling with emotions and beliefs that I had not previously felt because never before had I sat on the “other side” of healthcare. Of course, I had seen my share of serious illness and witnessed many people die. I’d had that conversation with a lot of family members, but I’d never taken much time to consider what it was like to be on the receiving end of such heartbreaking news. This painful personal experience made me realize that patients and families deserve much more compassion and humanism than the healthcare workforce appeared to be capable of delivering at such a difficult time. And if Cleveland Clinic wasn’t able to adequately and consistently “check the box” on delivery of compassion and empathy when someone died, when were we doing it?

  As a member of that healthcare workforce—a doctor—my entire education on how to treat patients thus far had been based on observation. It was essentially on-the-job skills training, observing the caregivers who taught me. That must be the way patients should be treated. After all, I was taught by some of the best in the world! Many cautioned about getting too close to patients, advising me, “Don’t get emotionally attached, as it will cloud your objectivity.” I was taught to be a consummate professional: objective, detached, thoughtful. In medical school, we were told that touching the patient was an important sign that you cared. But some physicians cringed when patients or their families re
ached out to hug them. A faculty member said that if a family member touched your arm, “Stare at her and stop talking until she removes her hand.” Physicians like Fazio and Remzi (introduced in the Preface) touched and hugged patients all the time—it was part of their magnetism. I suspect that many trainees mimic the behaviors of the people with whom they most closely identify.

  Healthcare is not always humanistic; caregivers are not always compassionate; we don’t always display empathy. Just as patients should expect to have consistent and standard-of-care reproducible medical care, they deserve and should demand a consistent approach, but medical training is often contradictory.

  A diligent trainee, I had planned to model the behaviors of my teachers. But after my father’s experience, I knew that the way we had been taught was wrong. There was something missing. I decided I would be different—I had to be. While I had not yet started to practice medicine independently and could probably not articulate how I should practice, I knew that this experience would forever steer me going forward. I would take much more time to focus on the humanity of the patient and the environment in which I practiced.

  Dad’s death was a wake-up call, reminding me why I had gone into medicine in the first place. Medicine is not about treating patients. It’s about taking care of people—people who have lives and loved ones, with unique identities, hobbies, passions, successes, and failures—with a history. Patients are not objects, numbers, or diseases. Patients are people we encounter in what is frequently the most challenging and difficult time in their lives. And everyone employed in healthcare delivery should not have to go through an experience like mine to understand why patient-centeredness is important.

  Determining to Leave Cleveland Clinic

  The month before my dad died, I was offered a coveted staff position in Cleveland Clinic’s colorectal surgery department. This was an exceptional opportunity. Fazio informed me that in his 35-year tenure as department head, he had offered staff positions to only two fellows right out of training, and I was one. Having set my heart on staying in Cleveland, I was fortunate to have also been offered positions at two competing local healthcare organizations. When the official offer from Cleveland Clinic arrived on my desk, there was little question where I would practice. I could barely contain my excitement. But after my experience on the other side of patient care, I was thinking very differently about my decision and career plans. I wanted to practice with a strong focus on establishing relationships with patients and their families. My father’s experience greatly changed my perception of Cleveland Clinic and whether I could achieve such a practice in this environment.

  The first months after his death were very hard for me for a couple of reasons. First, I felt like I had failed my father in some way, that if I had paid closer attention to his care, perhaps I could have altered the outcome somehow. My guilt was overwhelming. I was the physician son who should have done more. Second, I started 2005 on a new service within our department, paired with a physician who had a notorious reputation for bullying house staff. I thought that my strong work ethic, aptitude for building relationships, and ability to get along with people would carry me through the two months on his service. I was wrong. The inappropriate treatment, which consisted of very personal bullying and insults about my professional competence, began on day one.

  Driving to work every day, I was sick with fear that I’d be fired for being incompetent and that my career would be over. Intellectually, I knew this was not true and that I was experiencing some departmental rite of passage. But emotionally, I was eviscerated by the constant, capricious bullying. What made it worse was that everyone knew it was going on, that it had happened to many others before me, and no one did anything to stop it. A culture of fear permeated the department around this individual, and the commonly held belief was that you just had to grin and bear it. While I had witnessed bullying behavior in my residency, this was the first time it had been directed at me. It was very personal. The experience was degrading and emotionally draining. I transitioned off the service with my confidence as a surgeon shattered.

  The fellow who followed me experienced the same oppression to the point that she broke down in the operating room, scrubbed out of the surgery, and went to the chairman’s office to tender her resignation. She was a top surgeon who had come from Great Britain to do a yearlong training at one of the best programs in the world, but flabbergasted by the treatment she received, she threatened to quit and return home. She was removed from the surgeon’s service, but there was no formal action against the surgeon.

  My bullying experience was the second strike against Cleveland Clinic. My father’s death had reawakened the empathy in me, and I was shocked by his poor experience in the organization. Now I had been terribly bullied as a member of the house staff. There was no way I would practice medicine like this. There must be a better way to treat patients and each other. I informed Fazio that I would not be accepting his offer and would join MetroHealth Medical Center instead. I believed that Cleveland Clinic was an evil place that treated patients poorly and fostered an environment in which people did not work together or support one another. I could not wait to walk out the door on June 30, 2005. When my fellowship concluded, I left Cleveland Clinic what I thought was for good.

  You Stop Seeing Patients as People in Medical School

  I was no stranger to choosing the unexpected path. I did not follow the traditional track of high school, college, and medical school. I was what’s known as a “bent arrow” going into medical school, not taking the straight route. While I had always wanted to be a doctor, my original undergraduate degree was in business administration. From my high school days, I had worked in public service and had been involved with political campaigns, which influenced my initial educational choice.

  Enthralled by government service and administrative management, I found public advocacy and political campaigns intoxicating. But there was a downside to politics. I never quite felt that I was doing anything to benefit people or that I was making a meaningful contribution to humanity. After five years, I reevaluated my career trajectory and ultimately decided to pursue my dream of being a physician.

  I had to go back to school to take science prerequisites before applying to medical school. I was accepted into Case Western Reserve University (CWRU) School of Medicine. It was my first choice, because I wanted to stay in my hometown of Cleveland, but also because the school had a unique curriculum. CWRU pioneered early patient exposure: new first-year students were required to follow a pregnant or geriatric patient. This was believed to make medical education more patient-centered.

  I remember my nervousness and apprehension the first day I met my patient: young, single, and pregnant. I followed her through prenatal care and was with her the night she delivered. At the hospital, she was not progressing and the fetus began to exhibit signs of distress. She was rushed for an emergency C-section. Fortunately, both the baby and mother did fine. When I visited them the next day, she thanked me for being there for her. I was the only person she knew during her delivery, and I had seen her through the entire event. She admitted that she had been terrified and that it meant a lot to her that I was present. It was a moment that confirmed my calling for me: I was here to help people.

  During my first two years of medical school, most students spent just a few days learning how to interview patients, chiefly how to take comprehensive medical histories. I was fortunate to be one of six students selected for a special program sponsored by Drs. Susan and James Carter. Susan was an oncologist, and James was an internist and former chairman of medicine at MetroHealth Medical Center. They felt that in-depth exposure to patients early in training would strengthen students’ compassion and empathy. Once a week for two years, we trucked over to Metro and spent time with the Carters, discussing physical diagnosis skills, practicing taking histories, and examining actual patients.

  During the final two years of medical school, the clinical years, there was litt
le time to cover compassionate care delivery, empathy, or much of the human side of medicine. The work and pace ramped up, and like all medical students, we were thrown into the rat race of hospital floors. We were eager to see patients and act like real doctors. Subjects such as empathy and humanism were the furthest things from our minds, displaced by checking labs, running around for reports, and getting “scut,” or daily tasks, done for the house staff.

  I ultimately chose general surgery for my residency. I was captivated by the ability to “fix” problems for people. Surgeons can make a patient better. They do not manage chronic disease, from which patients are never quite cured. This aspect was very appealing.

  I trained in surgical residency when there were few of the regulations that are in effect today. There were no work hour restrictions, and residents would spend up to 20 hours a day in the hospital, often on call multiple days in a row. We became experts at getting things done. We came in early in the morning, rounded on 20 patients as fast and efficiently as we could, checked labs, put in orders, and reported to the OR by 7:15 a.m. We operated all day and rounded on the same 20 patients, plus a few more, before we went home. We would eat, sleep, wake up the next morning, and do it all over again. We were lucky if we were off one Sunday a month. We were there to take care of patients, assist with surgery, and try to learn as much as possible. It was exhausting, often dehumanizing work.

  While the program I trained in was benign relative to other surgical training programs, there still were some attending surgeons who were oppressive and just outright mean and nasty to virtually everybody, especially the house staff. This behavior surprised and shocked me. Coming from the world of public and business administration, I had never before witnessed such childish and narcissistic behavior. These doctors who were supposedly focused on care were driven by ego. What kind of world had I entered? I thought we were supposed to take care of people.