Name:
RTL- Ep 75- Careers in Pulmonary and Critical Care Medicine
Description:
RTL- Ep 75- Careers in Pulmonary and Critical Care Medicine
Thumbnail URL:
/images/podcast-microphone-banner.jpg
Duration:
T00H30M54S
Embed URL:
https://stream.cadmore.media/player/4b806429-89b6-4458-8f40-5b5924a4acaf
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/4b806429-89b6-4458-8f40-5b5924a4acaf/RTL- Ep 75- Careers in Pulmary and Critical Care Medicine.mp3?sv=2019-02-02&sr=c&sig=NpKY%2BeiJnTeITZJf9pa1NhslCAxMIASY1HD4J5uvP%2BY%3D&st=2024-05-02T16%3A04%3A42Z&se=2024-05-02T18%3A09%3A42Z&sp=r
Upload Date:
2022-09-15T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[Dr. Smith] Welcome back to Run the List, a medical education podcast in partnership with McGraw Hill Medical. Our hosts are Dr. Navin Kumar, Dr. Walker Redd, Dr. Emily Gutowski, Dr. Joyce Zhou and myself, Blake Smith. As a quick disclaimer, this podcast is meant for informational and educational purposes only, and should not be understood as medical advice under any circumstances.
[intro music] [intro music] [intro music] [Dr. Smith] Today, I'm really excited to be talking with Dr. Daniela Lamas, an instructor of medicine at Harvard Medical School and attending physician in pulmonary and critical care at Brigham and Women's Hospital in Boston and an associate faculty at Ariadne Labs, a center for health systems innovation founded by Atul Gawande, where she works with the Serious Illness Care Program.
She's also written for the New York Times, The New Yorker, The Atlantic, and published her first book in 2018 called, "You Can Stop Humming Now A Doctor's Stories of Life, Death, and in Between." And she's a staff writer for the medical TV drama, The Resident. We're really quite lucky to be talking to her today about a career in pulmonology and critical care medicine.
So thank you so much, Dr. Lamas for joining us on Run the List. So could you begin by telling us a little bit about yourself and where you did your training? [Dr. Lamas] So pulmonary and critical care fellowship offers a huge range of career paths. If you're interested in outpatient pulmonary, seeing patients with your bread and butter COPD, asthma, you can do that.
You can do that, and that can be your main career. Also, some people choose to spend some time in the intensive care unit or all their time in the intensive care unit, as an ICU, as a critical care attending, which is what I sort of found myself more drawn to. There's also all sorts of more niches within pulmonary critical care that people find, taking care of patients with diseases like cystic fibrosis, also in pulmonary and critical care.
You can find your field in lung transplant, obviously the medical side of lung transplant, because you're not a surgeon, but not to diminish the work of surgeons, but the before and the after of lung transplant is really where some of the work that allows the patients to get home takes place. And obviously people work closely with the surgeons, so that's a really cool field as well, it's an area that I had considered.
There's other things that you just don't even sort of know how interesting they are until you're in fellowship. Interstitial lung diseases, like weird diseases that overlap with a lot of rheumatologic stuff. That's a way that people can go and become specialists in that, and those patients often go to transplants, so there's ways to sort of find yourself in multiple worlds. So a wide breadth, you go into it thinking, "Yeah, I kind of like the ICU," but people end up with all sorts of variable careers from this one fellowship training.
[Dr. Smith] Yeah, that makes a lot of sense, and in the first two years of medical school, when you hear about diseases that manifest in the lungs, but also in other systemic organs, for me, it was kind of confusing at which point certain physicians may see those patients, as you mentioned, CF but also rheumatologic conditions, so it sounds like there are ways in which as a pulmonary doctor, you could kind of be a part of or leading that patient's care, depending on what point in time you see the patient in their disease course.
[Dr. Lamas] Yes, definitely. - Definitely. - [Dr. Smith] Yeah. So it's March 2021 when we're recording this episode, and I'd be remiss while we have you here on the pod to not ask you about this, but what has your role as an ICU physician been like throughout this past pandemic in this last year? [Dr. Lamas] So as I think we started to understand, as we began to anticipate the pandemic and saw footage from Italy and then New York, the critical care, ICUs were really where, as we all know, the sickest coronavirus patients went, and these were medical intensive care units.
And so there was really this growing realization that our training to manage ventilators, to be able to communicate with families about things that are awful and scary and try to find some way to give them an idea of what might be ahead despite the great amount of uncertainty, that those skills that we had trained for, that those skills were what was going to become the most important or not the most important, it's not some sort of competition, but that we were going to become essential in the setting of this pandemic.
And I think so often the parts of medicine that people focus on are these huge moments of sort of catastrophe and resuscitation, the big surgery, the massive transfusion protocol, racing a patient down a hallway, that's not the way it was with coronavirus. And really looking at these patients who did well, who we thought might not have, became so evident that particularly early, where we didn't- Before we had Decadron, before we even were regularly using Remdesivir outside of a trial, what seemed to make the difference for people was meticulous critical care, and by that, I mean, daily, not just daily, moment to moment titration of the ventilator, making sure that we manage volume status, that nurse outside and inside the room, making sure to suction secretions, these questions about when we start paralytic, when we start proning and then when we start taking off those things, so that patients don't linger in these sort of delirious comas longer than they have to.
[Dr. Smith] Right. [Dr. Lamas] That excellence, that level of critical care, even now where we're seeing all these patients who've cleared virus, but oh my gosh, they're delirious, they're slowly clearing sedation, they're slowly vent weaning, all of these things that we're trained to do, that's what we were doing for those patients in the pandemic. And of course, we were doing it under the shadow of this sort of awful circumstance, under a great degree of fear to which we were unaccustomed, really unaccustomed.
I've never- We generally take care of patients with cancer and I stand outside the room and I say, how sad and I mean it obviously, but I have never thought that what that patient has could be a risk to me, and so that was a unique feeling. But I think it was and remains a great honor, one obviously that we would've preferred not to have, but a great honor to care for these patients and to be critical care doctors at this time, and to have people know what critical care doctors do, for whatever that's worth, too.
[Dr. Smith] Yeah, definitely. I think it's amazing, kind of the perception of critical care doctors from the outside at this point in time. And everyone in the public is now a coronavirus expert. [Dr. Lamas chuckles] Yes. [Dr. Smith chuckles] And so they've peered into the ICUs on the news and they've kind of seen physicians like you really tending to patients and also their families.
Before recording with you, I read your piece that you wrote about a year ago in March 2020 in The New York Times, and we'll link it with this episode after, but it's been pretty amazing to hear stories of physicians having to talk with families who otherwise can't be at the bedside of their loved ones in the ICU as they would be in any other year. And you mentioning kind of that the families carry with them these invisible scars and that we're going to have a fleet of wounded patients, I think was the words you used.
Could you talk about what dealing with these families and speaking with them probably on a daily basis was like early in the pandemic and maybe even now? [Dr. Lamas] Sure. It's so interesting to hear those words and think, like I remember thinking that I was going to write that piece at this moment when the Brigham was for the first time limiting their visitors, and we had to tell somebody who was a visitor for somebody who did not have coronavirus, who had had a lung transplant, I think actually, and a really protracted recovery that he couldn't come back to see her the next day.
And I remember thinking like, ah, this can't last that long, like, I can't believe this. And yet we still are struggling to get people in, who should be able to come in, although the rules have been lifted significantly. But you know, it was a huge shift, I mean, it was from one day to the next. The ICU is so much, as you said, is so much about families.
We used to, before COVID, we used to actually have family members present on the rounds for their loved one. - [Dr. Smith] Oh, wow. - [Dr. Lamas] Yeah, yeah. We didn't do it in my residency. I think it's sort of more of an understanding now. And also, maybe it's more hospital specific, I'm not really certain about that, but at least at the Brigham and Mass General and Beth Israel, where I trained in all three and now at the Brigham, we would be able to have a family member, even two family members join us and listen to us reviewing the data, look at the chest X-ray with us if they wanted to, and you set ground rules, like they're not actually a member of- They are a member of the team actually, but they're not the same as the rest of the members - of the team- - [Dr. Smith] Right, right.
[Dr. Lamas] -but it works. It really allows them to know that we're trying, right? And they can see how the tone shifts, they can see as things aren't getting better, they see it more than they do over the phone, where we just give these weird, oh, they're stable updates. God, what does stable mean if you're in the ICU? You know, that can be so misleading. And so I think we struggled with a lot of that language.
We struggled with keeping people apprised when things were not getting better and making sure that they weren't just blindsided when they finally got that call, oh my gosh, we're worried that they're going to die, you can come in now. And so I think that that was hard. I think that was really hard on our interns and residents, particularly who were often the ones who were making a lot of these calls.
[Dr. Smith] Yeah, I mean, that's such a unique perspective, and to think that, as you said, these are kinds of the components of critical care medicine that you were well versed in while trained in, but this was a new virus in March 2020 and so much was unknown and so much is still unknown- - [Dr. Lamas] Yes. - [Dr. Smith] -in March 2021, but also to have to learn how to manage family concerns from a distance was probably new for you, and you were kind of training almost in lockstep with the growing caseload in your hospital and the pandemic globally.
So I would imagine each day was probably quite heavy and a lot of learning in a way. [Dr. Lamas] It was. And yeah, just so much fear. I mean, sometimes it would strike you on the phone with somebody or when somebody was so sick, we started to allow a family member, two at the most, to come in to be there at the bedside and we would have them put on their gown and mask and shield, and they were just so scared.
I mean, everybody was so scared and I think that that fear, like this person who is afraid that they will get sick from the person that they love and yet they want to be there. I mean, it's just a horrible combination of factors. And you made the point that I had written that there would be this sort of fleet of wounded survivors or whatever I had said, and that the families would carry all these scars, and I think that's true, and I'm sure, they're out there, and I think we don't even yet know even a year later, the sort of magnitude of that burden, what is it for this mother whose adult son died I think the day after Mother's Day, because she asked for him not to die on Mother's Day and she had never seen him while he was in the hospital because she was just too scared to see him, what is life like for her now?
And we follow, the patients who survive get followed in some way, but the families of the patients who don't survive, I mean, how do we make sure they're okay? We don't have a mechanism to make sure of that. So it's definitely in our minds. [Dr. Smith] Yeah. Yeah, I know that in their Year In Review, The New York Times just had kind of a whole series on these stories and each story is so deeply personal and especially these families - where many individuals- - [Dr. Lamas] Yeah.
[Dr. Smith] -in the family of varied ages were kind of wiped out by the virus. And yeah, I agree with you, I mean, reading your piece earlier today, a year after you wrote it, I mean it was like prophetic in some ways and deeply poignant in the time and just brought me, it hearkened me back to where I was as a med student, but also as a citizen at that time.
So yeah, I mean, thank you for writing it and like I said, we'll include it in the show notes for this episode, but that was only in the last year of your career. So how has your career changed over time since residency? [Dr. Lamas] I went into residency entirely uncertain what I wanted to do. I knew that I wanted to do internal medicine because decisions we make are sort of so, I mean, for some people they're not random, but there's so much randomness to them.
I really liked my resident on internal medicine when I was a med student. She made me feel like part of the team. And that I think was mostly all it took. Also, I liked medicine, I really enjoyed surgery, but when I left that rotation, I realized that if I never returned to an OR, I wouldn't miss it, so felt like I didn't like it enough. But yeah, medicine, I liked, because I think I just liked my resident, my intern was really nice and just like, yeah.
When he ordered cupcakes for the team, he got one for me, that's like a specific thing I remember, and medical school was a while ago. So I didn't know what I was going to do. My father's a cardiologist, I thought probably I should be a cardiologist. So I tried to, I did some research with some cardiologists. That was fine, but I don't know, I think probably because my father loves cardiology so much, I found it sort of intimidating, worried about the ability to read echoes and found myself overwhelmed as an intern by EKGs, and so I thought, I don't know about this.
Loved the ICU and I loved it because it was teamwork. I loved it because these were the sickest patients because you were there making these acute decisions and because of the families, because you were really in it with people in these horrible moments and what you said and the way you said it mattered, you could do good even if the patient wasn't going to be okay. And so I chose, I had no real knowledge of pulmonary other than sometimes patients cough, - sometimes they have asthma- - [Dr. Smith chuckles] [Dr. Lamas] -sometimes weird things happen to their lungs that I can't fully understand, but ultimately because I liked critical care and was going to internal medicine, the pathway is to do a pulmonary and critical care fellowship, which I did, and found that pulmonary is really interesting.
[siren wailing in the background] I just wait for it, somebody is going to the hospital. [Dr. Smith] I know, I am so sorry. [Dr. Lamas] Oh no! [Dr. Smith] There have been so many sirens, I'm not even near a hospital right now. I guess across the river- [Dr. Lamas] They're just hearing our conversation. They're like, yeah- [chuckles] [Dr. Smith] Must disrupt.
[Dr. Lamas] Yes, exactly. No, they just want to give like some mood sounds, we're talking about sickness, like yeah. [Dr. Smith chuckles] Anyone who listens to our podcast is very familiar with the background noise. [Dr. Lamas chuckles] Right. So yeah, so in fellowship I became really interested as well in pulmonary diseases, interstitial lung disease is interesting, but I like the idea that my time off is my time off.
And so haven't been drawn too much to doing a lot of pulmonary clinic. Really, was drawn particularly to the intensive care unit as I sort of suspected. And so that's been what the clinical part of my career has looked like since then. [Dr. Smith] Yeah. That's really great. And maybe you could more explicitly mention your time breakdown between any academic activities, the clinical practice you just mentioned, any medical education or teaching you do and your writing?
[Dr. Lamas] Sure, I'm glad to. So I am overall 80%, which, what does that really mean? So I am overall 80%, which, what does that really mean? I just essentially, I mean, the way it works in academic institutions is that you pay for your time essentially. So after they've stopped paying for you, you do a certain amount of clinical time that pays a certain amount, and then you get grants to pay for the rest of the time.
And so I do 14 weeks of clinical time, ten of those are in the ICU, four of those are in sort of vent rehab unit essentially, which is kind of interesting in a way that allows you to follow some of these ICU patients afterwards. And then I do have a grant that supports some work in building structure of support for ICU survivors and then also have a post intensive care unit clinic and then have some administrative roles in my institution.
I think the goal often in people's time breakdowns is sort of not having anybody paying for them. And that's a goal that I still have not fully met, but I think that ultimately as hopefully writing but I think that ultimately as hopefully writing will continue to be something that I do in a structured fashion, that can kind of build up some of that time. [Dr. Smith] Yeah, definitely.
Can we talk more about your kind of really admirable and impressive program that you've been involved with for a while to follow ICU survivors and provide longitudinal care to these patients? How easy or difficult has it been to try and integrate this work into your current critical care practice? [Dr. Lamas] So I became interested in fellowship and the fact that, you know, we see patients in the ICU and then they leave and we kind of wave and are happy that they made it, but what does that making it actually look like?
And I became aware of the fact that there's this huge range of survivorship after critical care from people who are still on a ventilator unable to go home to people who actually look great, like these are the saves, young person comes in, like profound septic shock, ARDS, then they get better. So I was interested though in what does that better look like, and how can we help them not just survive, but sort of thrive after the ICU, and sort of started a clinic for ICU survivors where they will be screened for issues like anxiety, depression, post-traumatic stress, we had a social worker and psychiatrist working with us.
Medication reconciliation, people get stuck on all sorts of meds they don't necessarily need. Physical therapy, sort of really making sure that all of these dangling things that last after the ICU are not all left to a primary care provider, which doesn't seem fair. And also we are the people who took care of these patients in the unit, we should follow them afterwards, even for a visit.
It makes sense, a lot of institutions do it, turns out it's actually hard to do. There's a lot of post-traumatic stress, people don't necessarily want to come back to the hospital where all of this happened, maybe they live far away. Also, we care for a lot of cancer patients and patients with sort of advanced malignancy, giving them an extra appointment is not necessarily a fair thing to do, so we haven't been targeting that population.
With telemedicine, with COVID increasing the understanding that surviving isn't the same as really being okay, I think it will be easier and has become a busier clinic, but it definitely makes sense, the sort of basis for it makes sense, but it's something that is hard to actualize for sure. [Dr. Smith] Yeah, thanks for the really kind of honest and nuanced answer.
I mean, I think it's really wonderful and it's something that I hadn't necessarily heard of. So the fact that not only is it something that you're thinking about, but actualizing even in any form is amazing. So, and kind of on top of that, you also do some writing. As I mentioned in the beginning, you wrote a book that was published in 2018, you've written articles in prominent newspapers and also a TV show.
So how do you manage to continue to do this during your clinical work and how has writing influenced you as a physician? [Dr. Lamas] Yes. I think that writing has been really essential for me I think that writing has been really essential for me as a physician, particularly in the intensive care unit, which the people are great, we laugh often, not in an inappropriate fashion, but- - [Dr. Smith] Right. - [Dr. Lamas] -it's dark.
The ICU can be really sad. The ICU at the Brigham, even before COVID, particularly before COVID, when we had so many Dana-Farber patients, there is a lot of death. And so for me, writing has been, writing and not having 100% clinical time have been the antidotes to the burnout that is so rampant among critical care physicians. And so that's been essential to me, it's a way to process my own thoughts, and it's a way to combat that frustration of feeling like you're screaming into a void, when you see something that you feel like is wrong.
There's the ability to tell a story and to have it read more broadly. Does it turn into change? Not necessarily, but it's a first step. And so that's been important for me. And also, sometimes I write sort of briefer memoir type of pieces, but sometimes, and hopefully increasingly I feel like drawn to doing this again, have done some more freelance reporting, and then it's just this cool passport to follow up with people you saw in the hospital, to talk to doctors that you know who are doing cool stuff.
It's just a way to be in it and to learn and to sort of connect with the world, but in this very defined way, which is how I like things. And so that's been really, really valuable for me. And to have some more contributions in a broader way, in addition to the extraordinarily valuable one-on-one patient interactions. [Dr. Smith] Yeah, certainly. I really like the way you put that as kind of a passport or almost like a conduit throughout the hospital to talk to patients and other physicians in different ways.
There are physician writers and we've had some on the podcast, but it's definitely a rare breed, if you will. And I think it's amazing to read some of the pieces from writers like you, not even just physician writers, but I would say true writers- [Dr. Lamas] Thank you. [Dfr. Smith] -and for the lay public to just kind of read about what's going on in the hospital or about just real human connection with some of your patients is wonderful.
[Dr. Lamas] Thank you. The fact that you said writer, I mean- I feel like, I don't know, maybe people in med school often deal with this, I think this idea of like how many identities, - like what it takes- - [Dr. Smith] Right. [Dr. Lamas] -to claim an identity is hard. And I definitely- People say things like, oh, you write, or something, I'll be like, yeah, yeah, I like to write.
I mean, I don't claim that identity. I feel like it's really easy to claim the identity, like I'm the med student and then you're the resident and then you're the attending or the fellow, but to say like, oh, there is this other thing that I do and I do it enough and I think it's real enough that it's something I do, is hard. Anyway, so I appreciated that. [Dr. Smith] No, definitely.
I mean, I think it's always funny when there's the physician hyphen, like physician X, physician Y. So I think you could take claim kind of being a writer. You've written widely enough that it's certainly more than most people like me. [Dr. Lamas chuckles] [Dr. Smith] -but, right. So why don't we round out the conversation and just finish talking about what you really enjoy about pulmonary and critical care medicine as a field and maybe what you don't love as much?
[Dr. Lamas] Sure. So I just finished a stretch on service and whenever I finish, I'm relieved to be able to wake up later and not have the stress of having to go in the hospital, these infinite rounds that we do, and yet, oh my gosh, I miss it. It's like I had this little world and suddenly I'm not part of that little world anymore.
And I look up my patients on Epic and I, of course, have that internal monologue, oh, what did the next attending find? What did I do wrong? Thank God they have somebody else now, but also you just miss it. And I miss the teamwork, the residents, I like it. I mean, they're often the nurses, they're all just great. And so a lot of what drew me to critical care to begin with as a resident, this team that you're a part of in this really intense time where you're all there together, trying to make things the best they can be and trying to be honest when they can't be, okay?
These moments and the procedures, all of that, all of that that drew me as a resident was real. I mean, a lot of things, when you get down to it, they feel a little anticlimactic or different than the way you thought, and this wasn't, I think what I have found that I think people recognize perhaps more than I did, as a resident, I feel like I didn't understand how sad the ICU was. I actually liked codes.
And as a fellow, it was hard for me to- At first, when I had a little more time, wasn't just always filling out sort of list on a scut list. I realized like, oh my gosh these families are suffering, these patients are suffering, and even the ones who survive might not be okay. And so it took me a while to sort of come to terms with that. And I think seeing people after the ICU was really part of that.
So I think the amount of palliative care, the amount of tough family conversations in the ICU was more than I knew as a med student and resident, and yet also makes the field so much more valuable. So it's granted a lot more depth than I even appreciated when I chose to go into it. [Dr. Smith] Yeah, I see what you mean that it's kind of both a really, not a negative, but kind of just something that you have to really keep in mind when deciding, but also in some ways, a positive about the field.
[Dr. Lamas] True, true. [Dr. Smith] For a lot of our are listeners who have yet to make a career choice, how do you see this field changing? Obviously, it's a very broad field, but how do you see pulmonary and critical care medicine changing in the future? [Dr. Lamas] Oh, that's interesting. I think there's some sort of structural stuff that changes that sounds small, but matters for quality of life.
There's been a really big emphasis to have people, attendings also in the ICU overnight, which is a hassle for being overnight, but means that when you're on, you're not on for like a seven day stretch where you're on call day and night, which is good for quality of life. So those are sort of small structural changes. I think in a big picture way, I think COVID has really made us aware of how we use has really made us aware of how we use a lot of these sort of broader life support technologies, not just vents, but things like ECMO, this lung bypass machine.
I think thinking about how we use these technologies, thinking about how we use the ICU. There's a lot of worries that we often use the ICU as a place where people come for their goals of care to shift, or we do sort of intensive comfort measures, is that the best use of an ICU bed? So, I think questions about what is the role of an ICU and how best we use our resources are things that we will continue thinking about, and that perhaps will change over time from the perspective of people who don't do ICU.
Look, I think in the coming years, we're going to see a lot of pulmonary disease that is a sort of sequela of COVID potentially. And so that's something that sort of more specifically is going to be interesting. [Dr. Smith] Yeah. That's a super kind of interesting take. [Dr. Lamas] Yeah. [Dr. Smith] Yeah, thanks for spelling that out. So our very last question in these careers episodes is always any general advice you'd provide to current medical students at any stage in their training of the four years and what they could be or should be thinking about when choosing a specialty?
[Dr. Lamas] Sure. So to med students, I mean, you guys know this, but med school is hard. It's like being a med student, I think is one of the worst roles in the hospital. I mean, we had a med student on in the ICU with us who's really smart, he was great. And yet just because he was a med student, like when he was around, something would fall or like something would fall out of his pocket while on rounds and we'd all turn around.
It's really, really hard to be a medical student and it gets, not to co-opt or phrase from something else, but it gets so much better. I mean, being an intern is hard, but being an intern is so much better than being a med student. Finally, you're the intern. It's great. So regardless of what you choose, it'll be awesome. And it will definitely be better than medical school. In terms of thinking about career choice, I mean, I guess to not try to find, I mean, I got really hung up trying to figure out what was the right thing for me to do?
Like what would be the thing that would allow it to be sort of the most awesome, like, I didn't want to make a mistake. Thing is, you're going to choose something and you're going to choose somewhere to go to train in that, and you're never probably going to have an experiment where you did another path and you're going to find things in your path that you love.
You know, like would I have been happy ultimately if I'd done, say cardiology? I'm sure I would have. It would've looked different, but it would've been okay. And so I think just being aware of the fact that making decisions based on factors that might not seem like the right factors, like, should you really make a decision about a career because you loved your resident or because somebody gave you a cupcake?
Probably not, but you know what? Also that's okay. You're going to find something that you love. And so I think not getting- I mean, it's obviously important to do what you want to do, to make the right choice for yourself, but not getting too hung up on why you're making the decisions that you are and know that whatever you find in medicine, medicine's an amazing career, like whatever you choose, you have probably the coolest job that somebody can have and you'll find something in it that you love.
[Dr. Smith] I really love that answer. And now I want a cupcake, so- - So yeah, this has been - [Dr. Lamas] Ditto. [Dr. Smith] -such a fun conversation and so helpful to learn from you and your journey to become a pulmonary and critical care physician. In addition to the amazing work you're doing with health systems innovation and being an accomplished writer.
So everyone go check out her writing, which we'll include in the show notes in addition to her book. And thank you so much for joining us on this episode of Run the List. [Dr. Lamas] Thank you for having me. [outro music] [outro music]