General surgery, palliative care and the new meaning of the phrase, “going viral”  [PODCAST]

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“Today and for the foreseeable future, COVID-19 is a serious threat, virulent and contagious, not only leading to an impressive display of human vulnerability and arrogance, but also demonstrating how innovative and creative humans can be during a time of crisis.

On a daily basis, I am inspired by the outpouring of courage, empathy, and compassion, as well as the injection of original and mutated ideas that will govern the blueprint of our destiny.  The truth is that the coronavirus has gone viral and, in so doing, opened the door to other remarkable evolutionary adaptations.  Adaptations that will both thwart its virility and enhance our society’s immunity, resilience, and long-term survivability.’

Pringl Miller is a general surgeon.

She shares her story and discusses her KevinMD article, “The new meaning of the phrase, ‘going viral’.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Pringl Miller. She’s a general surgeon, and she wrote the KevinMD article “The new meaning of the phrase, ‘going viral.'” Pringl, welcome to the show.

Pringl Miller: Thank you, Kevin.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Pringl Miller: Sure. It’s been exciting, and it’s been filled with a lot of obstacles. I’m a mid-career general surgeon who actually represents one of the 0.7 percent of general surgeons in academic surgery, so you can imagine how it’s an interesting journey, being somebody who is so underrepresented.

I’ve had an unconventional career in that I also decided to do a hospice and palliative medicine fellowship about 12 years into my general surgery clinical experience, and I’m one of 80 surgeons in the United States who have become board-certified in hospice and palliative medicine. While a lot of people think that there’s really no synchrony between general surgery and hospice and palliative medicine, there is a lot of synchrony. And so it’s been interesting to embark on a hybrid practice that isn’t well known or well understood. I’m one of those innovative people who have been trying to integrate a hospice and palliative medicine mindset into the care of seriously ill surgical patients.

Kevin Pho: So tell me, what are the factors in the decision-making process in pursuing a palliative care fellowship while also being a general surgeon?

Pringl Miller: Well, that’s a great question. One of the factors was, you know, how can I improve my communication skills? I was thinking more globally: How could I be a better surgeon? As a surgical trainee in the late ’90s and early 2000s, palliative wasn’t really on the map yet, so we weren’t really learning a lot of communication skills.

And so my thought process was that in acute care surgery practice, which my surgical practice had evolved into, I was seeing so many more older, sicker folks, and even younger, sicker folks, and I felt like I needed better skills to be able to navigate with them what the right decision was for them, in terms of having an operation that may end their life or change their quality of life. But it’s a force field, because general surgeons, as I pointed out earlier, don’t really embark on palliative care. So being able to balance bringing that to surgery has not been easy.

Kevin Pho: So what’s an example of using some of those communication skills that you learned in your palliative care training, incorporated into your general surgery practice? Can you give a specific story or an example?

Pringl Miller: Sure. I think in a general way, the idea is to assess what the patient’s goals and values are. In a traditional way, a surgeon will know what the diagnostic issue is and have a surgical recommendation, but there isn’t a conversation about whether embarking on that recommendation is actually going to lead to the person’s or the patient’s goals and values. And so the paradigm is to assess the patient: what their expectations are, what their quality of life looks like, what they want out of their care. And then you form your treatment recommendation to what it is that is important to them, instead of what it is that we can do.

There have been a lot of, you know, historical writings about surgeons making decisions that are acceptable from a clinical indication perspective, but the outcomes aren’t good. And there’s still a lot of momentum for surgeons to do the things that they can do, without respect to how that leaves the patient on the other end of their operative intervention. So it’s a patient-centered approach, instead of a “what can I do for you from a technical perspective”-centered approach.

Kevin Pho: Now, for those general surgeons, or general surgeons in training, who may be listening to this and want to improve their communication skills short of doing another fellowship, what are some tips and advice that you have for them?

Pringl Miller: There are certificate programs, and more and more in academic medical centers there are palliative care services. So even just rotating with palliative medicine physicians, to just absorb some of the language skills. There’s also a very popular program called VitalTalk, which is geared toward helping clinicians relate to patients on their level, and how to give bad news and how to assess goals of care. That’s like a two-day course, so there are shorter-length academic or educational initiatives that surgeons can participate in. The American College of Surgeons, every year at their annual conference, has some courses and/or lectures that pertain to palliative medicine.

And there’s a group of us that are hoping to establish a more competency-based fellowship, so that surgeons don’t have to rotate out of their clinical practice for a year to do a time-based fellowship, which is obviously pretty difficult for a surgeon to do. So maybe in time, surgeons who want to get board-certified can do it in a more prolonged, competency-based format.

Kevin Pho: All right, so let’s transition into the KevinMD article that you wrote, “The new meaning of the phrase, ‘going viral.'” Now, for those who haven’t read the article, can you just walk my audience through it and share the story of why you decided to write it?

Pringl Miller: Yeah, I went back to see, and it was published in April, so I wrote it in the April time frame, a couple of months, three months, after we started understanding that our country and the world were being burdened by this coronavirus and the pandemic. I was thinking about viruses, and thinking about the phrase “going viral” being more of a social media explosion, something positive, the spread of ideas. And given that our trajectory was such that we weren’t really getting a handle on the virus, we were going to have a different association with the term “going viral.” So that’s where the title came from.

And then in the several months from when we started having people infected in the United States until when I wrote the article, I think there was a very interesting dichotomy between people and leadership not taking it as seriously as I felt the virus needed to be taken care of to get control over it, and then some really remarkable people doing amazing things from a humanitarian-type standpoint. I think we see this often, where there’s a crisis and you can go in two directions. You can either avoid it and not believe it, or you can engage with it and really try to do something about it.

And so some of the messaging really had to do with that dichotomy: averting responsibility, not taking things seriously, but also people, you know, understanding how serious this could be and trying to do something about it. And how are we going to recover as a human race at the end of this? You know, what will we have learned by how this has impacted our society?

Kevin Pho: So you wrote this article, like you said, back in April, and we’re speaking in the last week of December now. Could you have imagined that we are where we are today?

Pringl Miller: I think that’s part of the reason why I wrote this: I wasn’t feeling, even at that time, that the level of concentration and organization around how to get control of this was going in the right trajectory. I was thinking about my surgical training with disaster and trauma. You know, we’re very trained to anticipate the worst-case scenario, and so my mind was going toward, you know, what is the worst-case scenario, and are we really containing this to prevent the worst-case scenario? So I don’t think I would have ever imagined we would be where we are, but I felt like we weren’t where we needed to be at the time.

Kevin Pho: Currently there are two approved vaccines, and there’s a third one, the AstraZeneca one, coming soon. So within the next few months there could be three approved vaccines coming out. What’s your assessment of where we are now in terms of the leadership, and your prediction in terms of what the next few months are going to bring?

Pringl Miller: I think we’re in a better place than we were several weeks ago. I guess it’s more than several weeks ago, but for the election. I think that the new administration at the executive level is taking this problem more seriously. The vaccines obviously are going to confer a certain amount of immunity if people are willing to get vaccinated, if it becomes not for emergency use authorization only. So I’m not really sure exactly how that’s going to roll out for the general population.

I’m not actually sure that behavioral patterns have shifted much as it relates to the physical distancing and mask wearing and all the things that the CDC is recommending in terms of travel and sheltering in place. So I think that it’s true that the immunity is really going to be more the ticket, and not just the prevention of not exposing other people.

Kevin Pho: We’re talking to Pringl Miller. She’s a general surgeon, and she wrote the KevinMD article “The new meaning of the phrase, ‘going viral.'” Like I said before, we’re speaking a few days before New Year’s. From a general surgery standpoint, can you describe some things that you’re seeing on the front lines of the pandemic?

Pringl Miller: Yeah, I just came back from a small valley town in Southern California. I had been reading a lot about what my colleagues were experiencing, and now I’ve seen it firsthand. This is a particularly hard-hit community, and their occupancy in the hospital has exhausted the number of beds, so they’ve erected multiple tents. All of the beds in the hospital are pretty much occupied by COVID-positive patients. There are ICU patients all over the hospital, in units that used to be designated for other purposes.

It was quite profound to be a general surgeon covering during the Christmas holiday, seeing the level of illness and the frequency of deaths that were happening, and talking to my hospitalist and intensivist colleagues. I was in my own little surgery bubble, and nobody who was sick on the ventilator was having an operation, but it was just intense. It felt very much like a MASH unit: the COVID-negative tent, the COVID-positive tent. The tents are stacked like train cars, and people are just doing the best they can.

In this particular hospital, they’re doing all that they can for the community, but there aren’t enough staff. There were actually FEMA staff there, and there were National Guard staff there, just trying to pitch in and lend a hand to the travelers and the permanent staff that were there. So it was a really remarkable effort, but even in this effort, people are dying frequently, and who knows how they’re going to recover ultimately. So I was really pretty devastated by seeing what I saw, with such a high number of COVID-positive cases.

Kevin Pho: How’s that affecting your general surgery cases, and how’s that affecting your practice?

Pringl Miller: So I’m not doing elective general surgery. Elective general surgery is shut down in a lot of places, from what I hear from my colleagues and what I read, which is totally understandable, because there isn’t the bandwidth with the staff and the beds to accommodate inpatients that are, you know, healthy, and it wouldn’t be good for them anyway, for the exposure. So I think for general surgeons, or surgeons that do elective work, their work has been really derailed by this pandemic, and I don’t know when that’s going to change.

I think that people are learning a lot about how to communicate in different ways because of the PPE and the masks and the face shields, and also because of surrogates not being present at the bedside and having to communicate on the phone. So I think in some respects, as horrible as this is, we may be learning some things that we can utilize at the other end of this. But certainly surgical practices have really changed, because hospitals are focusing on taking care of the people that have COVID, and when they need an operation, you know, I imagine it happens, but very carefully.

Kevin Pho: And if there’s something that you know now that you wish you knew back before the pandemic started, what would that be?

Pringl Miller: My thought about that is, just like so many others, I wish that we had done a better job early on to contain it, because it’s really sad to know that there are so many people who probably didn’t need to die.

Kevin Pho: And my final question, Pringl: What’s your take-home message that you want to share with the KevinMD audience?

Pringl Miller: I’d like people to just protect themselves and to recognize that we’re all in this together. I don’t think that we’re going to be successful in getting to the other end of this if we don’t all do our part. And you know, that can be as simple as doing the face mask and trying to not be in communication with other people directly. Everybody can do something to try to help us survive this and get on the other end of this.

Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.

Pringl Miller: Thank you for inviting me.

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