EP. 41: LOVE AND MERCY IN THE ICU
WITH WES ELY, MD, MPH
An ICU physician and writer shares his fight to restore humanity in the ICU by “finding the person in the patient, using touch first and technology second.”
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Episode Summary
The ICU can be a traumatizing place for patients, who are frequently heavily sedated, rendered unable to speak by breathing tubes, isolated by family visit limitations, and sometimes even physically restrained. In fact, a significant proportion of patients discharged from the ICU later develop persistent cognitive impairments and physical disabilities. Over the past two decades, Dr. Wes Ely has worked to improve the care of patients in the ICU, leading landmark studies resulting in the development of delirium prevention protocols that are now adopted in ICU everywhere. Today, Dr. Ely co-directs the Critical Illness, Bran Dysfunction, and Survivorship (CIBS) Center at Vanderbilt University Medical Center. In this episode, Dr. Ely joins us to share his career-long fight to reform ICU medicine and to recount poignant stories that illuminate and elevate the humanity of patients amid the chaos of the ICU — and in the process discusses themes that seldom appear in contemporary medical discourse, such as love, beauty, and mercy.
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Wes Ely, MD, MPH, the Grant W. Liddle Chair in Medicine, is a sub-specialist in Pulmonary and Critical Care Medicine who conducts patient-oriented health services research as a Professor of Medicine in the Division of Allergy, Pulmonary, and Critical Care Medicine at Vanderbilt University Medical Center. He is also a practicing intensivist with a focus on Geriatric ICU Care, as the Associate Director for Research for the VA Tennessee Valley Geriatric Research and Education Clinical Center.
Dr. Ely’s research has focused on improving the care and outcomes of critically ill patients with ICU-acquired brain disease (manifested acutely as delirium and chronically as long-term cognitive impairment). He is co-director, along with Dr. Pratik Pandharipande, of the Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, which consists of over 90 investigators from Departments of Medicine, Surgery, Neurology, Anesthesia, and Psychiatry.
The CIBS Center has amassed thousands of patients into cohort studies and randomized controlled trials, who together built the methodology for ICU acquired brain disease research and newly adopted treatment paradigms including the ABCDEF Bundle. His team developed the primary tool (CAM-ICU, translated into 35 languages) by which delirium is measured in ICU-based trials and clinically at the bedside in ICUs worldwide. He has over 500 peer-reviewed publications.
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In this episode, you will hear about:
• How Dr. Ely discovered medicine as a calling while growing up in rural Louisiana - 2:33
• How a fascination with cardiopulmonary physiology, combined with an interest in patient relationships, led Dr. Ely to critical care medicine - 4:27
• A discussion of how patients in ICUs can often be “de-humanized” - 6:31
• A story from early in Dr. Ely’s career that illustrates “malignant normality” — when treatment norms led to patient harm - 10:40
• A discussion of physician burnout and how the dehumanization of patients contributes to it - 13:27
• What Dr. Ely and his colleagues have learned through years of research about the harmful standard practices of ICU care - 18:53
• An explanation of the ABCDEF treatment bundle designed by Dr. Ely and his collaborators to improve outcomes of patients in the ICU patients - 24:04
• How Dr. Ely processes the guilt and shame he feels from the harm he inadvertently caused to patients early in his career - 29:37
• Reflections on how eye contact, physical touch, and openness of the heart are essential to good medicine - 36:03
• A discussion on how Dr. Ely’s spirituality has influenced his approach to patient care - 44:51
• What it means to provide healing when patients are facing serious illness, even at the end of life - 50:45
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Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:03] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to the Doctors Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions. We meet with deep thinkers, working across health care, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] It wasn't long after Dr. Wes Ely became an intensive care physician that he discovered just how traumatizing of a place the ICU can be. Patients are frequently sedated, drifting in and out of consciousness. They often have breathing tubes inserted down their airways, rendering them unable to speak. Family visitation can be limited, leading to a profound sense of isolation. On top of all this, patients can sometimes even be physically restrained. It's perhaps not entirely surprising that a significant proportion of patients discharged from the ICU later develop post-traumatic stress disorder with additional symptoms of dementia and persistent physical disabilities. Over the past decades, Dr. Ely has worked to improve the care of patients in the ICU. Leading landmark studies, resulting in the development of delirium prevention protocols adopted in ICU everywhere today. He details his fight to reform ICU medicine in his 2021 book, Every Deep-Drawn Breath. In this episode, Dr. Ely joins us to share how he connects with patients, recounting touching stories that illuminate and elevate the humanity amidst the chaos of the ICU. We discuss themes seldom mentioned in medical discourse, including love, mercy and spirituality. Wes, thank you so much for taking the time to join us today and welcome to the show.
Wes Ely: [00:02:26] It's my privilege. Henry, I appreciate you having me on. And you, too, Tyler.
Tyler Johnson: [00:02:31] Thanks for being here.
Henry Bair: [00:02:33] You have had such an incredible career revolutionizing ICU medicine. But before we get to all of that, can you take us to the start and tell us how you first discovered a calling in medicine?
Wes Ely: [00:02:45] Thanks for asking that. I am so thankful just to be on this podcast, because when we talk about the doctor's art, I think I got into it for the right reasons for me anyway, personally, which was that my father had left us when I was little. I was being raised by my mother in the hot and dusty fields of Louisiana. I was I had to be a farmer because we had no money. And I was trying to earn some money for our family. And I was around these amazing people in the fields. We had huge fields of 6000 tomato plants and purple peas and watermelons and all this stuff. And all day long we would either plant in the spring, harvest this produce. And I got to know these men and women that we picked with all day long. And at first I thought I belonged with them. But I realized over time that they would not have really a way out from this area. They were going to be migrant workers. And that was their. That was their choice. But they also didn't really have much of an option out. And they would little things in their life medically would become big things. You know, cuts would become big abscesses and they'd lose teeth. And so I said, you know, maybe what if I was lucky enough to study science and medicine and I could be with these people as they were suffering and and be present with them at the bedside, holding their hand, helping them through harder days. And that's why I got into medicine. That was it. I wanted to serve these people and have a role in in our relationship that I could be of service.
Tyler Johnson: [00:04:27] You know, that calls to mind this kind of ideal of I'm not saying that you even knew what it was at the time or that you necessarily planned to go into it. But that calls to mind this sort of ideal of the country family doctor, right? Who's there for every stage of life to take care of the baby when they're born, and the old man or woman when when he or she dies. And yet you ended up going into critical care medicine, which in some ways you could argue is pretty far on the other side of the spectrum from the sort of country family doctor. So how how did that shift come about? How did you end up going into critical care?
Wes Ely: [00:05:03] Yeah, along the way, I was actually going to be a family practice doctor and envisioned myself carrying a leather bag to their homes and such. What happened was I was working at UVA with this family practitioner named Louis Barnard. He was actually the first endowed chair of family practice in the country. And we would sit in his study at night and he would talk about his life in this field. And I kept telling him how fascinating was about cardiopulmonary physiology. I just absolutely fell in love with Guyton's textbook of heart and lung physiology, and that it just it got me so excited about the science of the way that the body worked. And when I started going into the ICU at Charity Hospital in New Orleans, I not only loved the physiology, but I saw that these people were extremely scared. They were on death's door having this unexpected circumstance in their life. And I thought, well, maybe if I both love the physiology of what we're doing in the ICU and I can establish relationships with these people at this very, very vulnerable time in their life, that could be a melding of these two things. And I'll stop just by saying that in the next five years, what I learned was unexpected, was that the field was going into a direction that would prevent me from the very thing that I loved, which was prevent me from looking people in the eyes, talking to them, having a relationship with them because the field was in the direction of deep sedation, in a coma, immobilized on a ventilator. But I didn't know that at first.
Tyler Johnson: [00:06:31] Yeah. I'm glad you brought that up. You sort of beat me to the punch because I was going to say that I remember, you know, as a medical student, I didn't have a whole lot of experience in the ICU, just the way our rotations work. So it wasn't really until residency. But as an internal medicine resident along with you, I was fascinated by the V=IR and all of the cardiopulmonary equations and the figuring out how "pressers" work and all that kind of stuff I just thought was so fascinating. And so when I got on to my initial ICU and CCU rotations, I just was over the moon about thinking about it, right? Like the intellectual puzzle and the processing of all of the information was just so exciting to me, and I found it to be enormously satisfying. And yet. As I got a little bit deeper into those rotations to the point that you were just making, I realized that most of what I was doing, whatever it was, whatever it felt like, the thing it did not feel like was taking care of a person. Because most of the people were unconscious. Many of them had to between their vocal cords and couldn't make any sounds. It was as if they had ceased being people and had started being these super complicated, really interesting, fascinating machines that involved a whole bunch of really cool, complex intellectual puzzles, but no human connection because it was almost like the human had ceased to be there. And I know this gets to later sort of what would become your life's work, but can you talk to us a little bit more about that tension in the ICU, about how it often does seem hard to remember that the person is a person and instead they they often seem to come to be a machine and sort of how your career has reacted against that inclination.
Wes Ely: [00:08:28] Yeah, I love the fact that you brought this up, Tyler. Your humanistic heart made it so that you were unsatisfied by your experiences as a resident when these people were essentially put through a dehumanization chamber of sorts and made from colors and their favorite music. And the four questions I always asked my patients or the loved ones around them are what's their favorite music, food, pets, names and hobbies. And once I know those things about somebody, it forces me to think of them as a person. But that came with gray hair. At the beginning. I was just thinking, What central line do I put in? What ventilator settings do I use, etc.. I'm just going to read you this one paragraph from the author Note in every deep, drawn breath. And what I wrote was I was trying to contrast benevolence and beneficence. Know benevolence is the desire to do good, but you can do harm even though you desire to do good. And that's what I was doing. Beneficence is actually doing good. And what I wrote here is.
Wes Ely: [00:09:24] "As a young ICU doctor, I went to extreme lengths in my sole focus on saving lives. In so doing, I sometimes sacrificed patient dignity and caused harm. This happened when I traded the priceless gift of eye contact and conversation for medically induced unconsciousness and many hundreds of hours of deep sedation that I thought were required. One by one, patients and their loved ones began to reveal to me the error in my thinking. I had broken our covenant by taking away the patient's voice in his own medical narrative, which is to say his life. The journey back to my original oath first Do no harm, brought me to this work."
Wes Ely: [00:10:07] So that's what it was. I had this control freak. Attitude that I thought I could control all the aspects of this patient's life. But what I was doing was I was only dealing with physical and I was ignoring completely the mental and the spiritual aspects of who these people were. And it was to my detriment and their detriment, because what they were getting was an automaton and not a healer. And my own journey as a physician was dealing with the guilt and the shame of who I had become.
Henry Bair: [00:10:40] We thank you for for opening up about that and being vulnerable with us. I'm wondering if there is a patient story or an experience you can share that illustrates how you came to see that what you thought was doing good for the patient actually ended up being not so.
Wes Ely: [00:11:00] Yeah, I'd love to start off with Theresa Martin. This is a woman who was in her mid twenties and she came to me after an aspiration event. She developed bad bilateral pneumonia and aspiration-related ARDS. And I was her doctor and I thought, "oh my gosh, I'm I'm the greatest doctor. Now I can do all these procedures." And day after day, I kept her paralyzed and sedated. And once it was clear she was going to survive, I just was patting myself on the back thinking, you know, "I've come of age. Here I am. I'm I'm God's gift to critical care." But I had her come back to see me months later. It was my first post-ICU clinic, essentially. And her mother, instead of them walking in, wheeled her in and a wheelchair. This woman in her twenties and she couldn't talk well. She couldn't remember those names. She couldn't go back to work. She couldn't bathe herself or walk easily. She had actually she had calcium built up because I X-rayed her arms and legs because her mother said to me, why can't she moves her her shoulders or her elbows or her knees. She had built up calcium like rocks in her joints, heterotrophic ossification because of the prolonged immobilization, and writing every deep down breath, I actually was able to get her medical records 25-30 years later. I won't keep reading a ton from the book, but I'll just read this to you because I when you said that, Tyler, about what we were doing, it brought up this term that I now call "malignant normality."
Wes Ely: [00:12:35] So I got her chart. I was reading what I had written with my own hands after she was surviving. And I wrote, "However, amazingly enough," and this is my own writing on her transfer note, "'However, amazingly enough, the patient still manifests only single organ -lung- with good renal g.i and cardiovascular function.' How naive I was and how far from the truth as I would see in a few weeks when Teresa returned to me with her body and brain irretrievably broken. As physicians, we generally think we are most likely to harm our patients with an errant scalpel, a central line placement gone awry or a medication error. But sometimes we cause more harm by blindly accepting usual practice as best practice when familiarity breeds complacency. And that's what I call malignant normality."
Tyler Johnson: [00:13:27] Yeah. You know, I have to say that Henry and I set off on the journey of making this podcast. Now, I don't know, nine months ago or something, with the idea being that everybody is familiar with the epidemic of burnout, right? If you've been in health care for 3 seconds, you've heard the term "epidemic of burnout" and you can pull up 9 million articles on Google with all kinds of scary statistics about how many people are leaving medicine, how many people who are still in it are disillusioned with it, how what the burnout statistics are. I think every major academic institution now has a yearly survey to try to measure this. Stanford even has a Chief Wellness Officer now alongside the CEO and the CFO and the C-whatever-else-O, they have a CWO. So this is a big deal, right? And there's all kinds of hypotheses about what's causing this, and to be clear, as we've acknowledged many times on the podcast, a lot of it is systemic stuff and the bureaucratization of medicine and the business of medicine and yada-yada. But Henry and I also had this barely-formed hypothesis that part of the reason for the epidemic of burnout is because doctors have lost touch with what makes medicine meaningful, what brought us here in the first place. And as I just intimated, I think when we set off on the journey of making this podcast, we sort of knew there was something there and we felt like it was worth talking to a lot of people for a lot of hours to try to figure out what it was, but had a pretty poor idea of exactly what that meant.
Tyler Johnson: [00:14:55] But as we have gone through these conversations with many doctors, I have become convinced that what you're describing in the ICU is a highly concentrated distillation of a broader fundamental problem in medicine, which is that we have reduced people to machines and we try to view, not try. But to your point about malignant normality, we have defaulted into viewing the sacred act of caring for another human into something that is more akin to adjusting dials to try to get, as you say, renal physiology better. Right? And so then that allows the young version of you to write a note that pretends that everything is okay because the creatinine is fine and the bilirubin is fine and whatever, when in fact the person is broken. But the reason you can write the note is because you're not seeing the person anymore, right? You're seeing a bunch of numbers and a bunch of you're seeing a machine readout. And all of which is to say that I feel like one of the most important things that you're writing and your work does is to try to help us culturally to battle against what I think is robbing medicine of both its meaning and its magic.
Wes Ely: [00:16:24] Yeah. And let's get this very clear for your listeners: When a physician or a nurse or some other person who's in the health care profession is with a patient at the bedside, this is holy ground. And I'm not talking about religion. I'm talking about the intimate relationship between two human beings that get to meet one another at a vulnerable time and both people under vulnerable situation because the medical professional is there as a vulnerable human being who can make mistakes, who can do things to the other person that can hurt them, and the person whose health is endangered at that moment is on the receiving end and at the mercy of the person who's providing the care. And so if I am to do my job and to actually become a healer, it's got to go way beyond scientific knowledge and data and facts, Because what is mercy? My definition of mercy, my working definition of mercy is that I want it's to the extent that I will do for the patient what they need is the extent to which I'm willing to dive in to the chaos of what they are experiencing and provide them lifting and healing. And what I did early on as a physician was that I dove into their chaos, but I did not provide lifting and healing.
Wes Ely: [00:17:47] And so what I was doing all those years was providing false mercy. I made myself feel good. People around me thought that I was doing medicine well, but instead I was creating a burnout factory. Because to get back to your your notion of the burnout, why was it a burnout factory? Because none of the sweetness, none of the beauty, none of the intimacy was there anymore. I extracted all of that out of the medical interchange between me and my patient, and that is where I was left bereft of of any of the goodness of medicine. And that's what creates burnout. So I actually think that what I'm talking about in EDDB, Every Deep-Drawn Breath, is actually a burnout solution, which is to see the person as an entire human being and provide the love and the mercy that they deserve to raise them up. Their human dignity remain intact. And to me, that's why I'm not burned out to this day. I love being in the vocation of medicine, and I don't get tired of it because I can see the person again. But it was a long journey to get here.
Henry Bair: [00:18:53] Wes, in the brief amount of time we've talked so far, you've touched on the many ways that patient care in the ICU leaves much to be desired. And throughout your work and writings, you have addressed this problem from two angles: the humanistic and the scientific. From the humanistic side, you point out a problem with medical culture in dehumanizing patients and seeing them as a collection of quasi-mechanical parts to be repaired. The scientific problems with the practices of ICU medicine concern what you were actually doing to patients, which in the story you shared earlier, left your patient with persistent cognitive and physical disabilities. To give our listeners some context, can you share with us what some of the major problems with ICU practices you saw were and how did you try to reform them?
Wes Ely: [00:19:45] Sure. The end of the story is that what we did over the last 20 years was generate dozens and dozens of New England Journal / JAMA / Lancet papers, you know, hard core randomized controlled trials, cohort studies funded by the NIH, the VA, et cetera. And we've run over 30,000 patients through these clinical trials because I knew that at the end of the day, it would be science that would change people's mind, not a conversation about warm and fuzzy. And so we took the technology and the science and we we put questions to the patients that, you know, is there a better way to do this? So what we were doing wrong was that we thought that our job was just to keep them alive on life support, on a ventilator or get them out of shock with suppressors. And we once they were on the life support in the of we got them completely out of the realm of who are you? They were unconscious. They were on a ventilator, they were immobilized. And what we had to prove was that they were developing a new disease and the new disease they were developing is referred to now as PICS - Post-Intensive-Care Syndrome picks. And this PICS, it's kind of a forerunner to long-covid, if you will. If you want to connect the two things right now, a lot of people with COVID, 100 million people around the world are experiencing different vagaries of severity of long-covid, some of whom have listened to this list: an acquired dementia, post-traumatic stress disorder, depression, physical disability of muscles and nerves, cardiovascular problems. Guess what? PICS patients have: acquired dementia, PTSD, depression, physical disabilities and cardiovascular difficulties, mitochondrial disease. So what we were doing for the past 25 years is studying a rapidly acquired disease that occurred in the ICU, that what we were doing iatrogenically to the patients was actually begetting this disease and making it worse. And our research had to investigate piece by piece how do we undo this and redirect our therapy so that the patients won't end up with such profound physical, cognitive and mental disabilities?
Henry Bair: [00:22:01] And what was actually happening to patients? Was there a link to specific interventions you we re providing that were resulting in some sort of physiologic change that were then manifesting in the cognitive decline, the PTSD and all the other changes?
Wes Ely: [00:22:20] By the way, for the listener, where this is going is that we created a six step bundle called the A to F bundle or A, B, C, D, F bundle. And if you just break down the bundle, basically what we're saying is: what we were doing then versus what we do now. What we were doing then was too much sedation, benzodiazepine drips. Those drugs are neurotoxic when patients have a non intact blood brain barrier. The Gabaergic drugs are going across the blood brain barrier and creating neuronal apoptosis. We don't actually have proven cause and effect there, but we have strong predictive and associative data to say that those drugs, whether they were directly neurotoxic or indirectly neurotoxic, what was happening was that the patient, as they were mobilized, was developing what essentially became an acquired dementia. And we published this in the New England Journal of Medicine. It's it was called "The Long-term Cognitive Impairment After Critical Illness" And the the degree of cognitive dysfunction that they had looked like Alzheimer's disease and traumatic brain injury. So these patients have a neurocognitive deficit that is on par with AD and TBI, and it doesn't go away necessarily. About a third of them get better, but about two thirds of them don't or get worse. And they get a they get atrophy on their CT's and MRIs and they can't go back to work, just like I saw in Teresa Martin, my first patient, although I didn't know it at the time. And they get about a third get profound major depression, about 20% get profound PTSD and about 60% are physically disabled for years. So that's what we learned and that's what was happening. And then we had to figure out how do we undo this?
Tyler Johnson: [00:24:04] So can you can you talk a little bit about the bundle? What what is it? What are its constituents? How does it work? Why is it effective?
Wes Ely: [00:24:10] So what happened was, as a chief resident in 1996, I decided that first thing I had to do was get people off the ventilator faster. So I came up with this idea working, building on the work of other people like Andres Esteban in Spain and Martin Tobin in Chicago of doing what's called Spontaneous Breathing Trials. And so every day in the ICU, we subjected the patient to a test where we would just turn the ventilator off and see if they could come off the ventilator. And it sounds kind of silly now because it's usual care, but back then we thought that would cause a heart attack. So I was actually scared that I was going to hurt people when we did this randomized controlled trial. But instead it got in the New England Journal because it shaved two days off the ventilator time. It cut complications in half, and it saved about $5000 per patient. The next step was, well, if the ventilator getting turned off helps, what about just turning off sedation? And that's now called an SAT - Spontaneous Awakening Trial, followed by the CBT step B, Spontaneous Breathing Trial. And you might think, well, why would you not turn off sedation every day? Well, back then we thought that that would create PTSD. It would make them aware of what was going on. It might worsen them. But what we learned and we found we published this in Lancet was if we turned off the sedation every day and paired this SAT and SBT -spontaneous awakening and then breathing trial- that it actually saved lives.
Wes Ely: [00:25:31] One in every seven people that got this protocol called the ABC Protocol was alive at the end of one year who would not have been alive otherwise. So we were this is a very low number needed to treat. It was actually a 30-35% increase in the reduction in the hazard of dying. So then by about 2007-2008, we we knew that delirium was causing big time increases in mortality. We knew that stopping the drug and stopping the ventilator would save lives. Then we had to switch the drug. So we started studying drugs other than gabaergic drugs like Propofol and benzos. And over the years, we've proven that if you can avoid the gabaergic drugs, you can increase the brain function, increased survival, etc.. So now what the bundle essentially is, is A analgesia take care of their pain. B both turn off the drug, turn off the vent. C Choose a drug other than a benzo. D take care of their delirium and then E is early mobility and F is family at the bedside. And that simple thing actually we've shown in over 30,000 people has a dose response to increase survival, decreased length of stay, less nursing home transfers, less ICU bounce backs, and better brain function.
Tyler Johnson: [00:26:55] One thing I just want to remark on in passing for, especially for our younger listeners, is that if you go to any large academic medical center where you're thinking about doing residency, one of the things they will always talk about is bench to bedside medicine, right? Which is this idea that you come up with something in the lab and then you are able to do the translational research that carries it all the way through to where it benefits patients. And then the idea is supposed to be that you're supposed to have this virtuous cycle, right, where you do that, and then you see the further problems the patient have and that sends you back to the bench and then that gives you more innovations or whatever. I'm not exactly sure the analogous title to give this, but I just want to point out that this is that same cycle at play, only at a sort of human functioning level rather than the molecular or the genetic or the biochemical level. Right. This is seeing a problem that's in the ICU and thinking, well, gosh, why are we leaving these people intubated and sedated for arbitrary numbers of days instead of just figuring out when they need and are ready to wake up and then waking them up and taking them off the vent, then and then doing that. And all of which is just to say that this kind of research loop can be just as virtuous a cycle as the bench to bedside one, right? And can have just as big an impact on the on the lives of our patients, which I think is an important thing for people to think about as they're going into their clinical training, that this is something that can also make a difference, even if you don't have a PhD in biochemistry or what have you.
Wes Ely: [00:28:27] And Tyler, you're a lot younger than I am. I've got all this gray hair. But but you will know and you could share with the others, too, how people, when we're young, can tell us what they think is right or wrong for us. And when I was young and not gray haired, lots of professors called me in the office and said this was a bad idea. Don't do it. You won't get any grant funding. It will kill your academic career in critical care. We don't care about the brain so much. We're just caring about the lungs and the heart. And the only reason that I kept going was that I could not deny that every time I saw a patient back in the clinic after the ICU, their truth was that their life had been irrevocably changed. And the more I looked at the patients, I realized I had to acknowledge what was going on in their lives and figure out a way to change it. Because I couldn't live with myself as a clinician if I let that keep going. So I just had to work with other people to say, Look, eventually we'll get grants, eventually we'll do the right studies. And but at first we were met with a lot of rejection, a lot of rejection. And over time, though, we built this research operation, which hopefully has helped people.
Henry Bair: [00:29:37] So I'd like to, you know, bring it back to a personal point that you mentioned earlier, which was you had to deal with a lot of guilt and shame as you reflect on the earlier parts of your career when you were, in effect, doing things that were harming the patient. Can you tell us more about how you have been able to manage those emotions?
Wes Ely: [00:30:02] You know, I mentioned earlier that when my that my father left us when I was little and I kind of became a surrogate dad for my siblings. And and I'm going back to that because I had to figure out how to control things that were hard as a as a young boy. And I brought that asset into medicine with me that I'm good at controlling things, I'm good at fixing things. And maybe that's part of why I went into critical care. What I did, though, with medicine for the patients was that I created that asset into a liability. And in other words, the desire to control every medical circumstance. I overdid it. And when I remember when I was a second year medical student at Tulane, my mother gave me Osler's book, Equanimitas, and his his 1890 address to the University of Pennsylvania students about equanimity or even coldness. And Osler was trying to make a point for us that if we can keep an even keel in medicine, we'll think clearly. What I did was I took his good advice and I grossly overextended it so that I pulled back from my patients in this desire to have equanimity or equanimity.
Wes Ely: [00:31:11] I pulled back so far that I didn't allow myself to enter into their life story in their chaos. And so I was not doing a very good job as a physician. I wasn't really paying attention to who they were, and they were on the receiving end of a doctor who wasn't really responsive to what they actually needed. I thought I knew what they needed, but I wasn't listening, etc. So to me, only after I started realizing that I was doing this harm to them, did I start to question what have I become as a physician and had to face the the answer and do the work to kind of dig deep inside of me to realize that I was guilty of something that I never wanted to become, which was an insensitive, technology-driven scientific robot who was not actually being a caring and loving person at the bedside. And that was hard but important. And what it did was it made me determined to go back to why I went into medicine in the first place and see the whole person. Is that help?
Tyler Johnson: [00:32:29] Yeah. You know, I think especially for people who are in their training, hearing you talk about this reminds me of a quote that's been variously attributed most often to Oliver Wendell Holmes, although as best I've been able to source it, it nobody actually knows who first said it. But the quote says, "I wouldn't give a fig for the simplicity on this side of complexity, but I would give everything I own for the simplicity on the far side of complexity." And the reason that I bring that up here is because I think most people, when they're bright-eyed, bushy-tailed medical students, have this idea that, oh, it's all just about caring for the patient and I just need to care for the patient. Right? And I just and as if humanism were the entirety of medicine. And then when you get into the rigors of your intern year and then you're a supervising resident or you're a fellow in the MICU, it becomes very clear that humanistic medicine or humanism is not going to carry the entire day, right? You have to know about vent settings and you have to know about presser dosing, and you have to know about antibiotic selection. And you have to understand V=IR and cardiopulmonary physiology and all the rest of it.
Tyler Johnson: [00:33:34] But the issue is that what so what I see in that Oliver Wendell Holmes quote is this progression of naive simplicity to understanding complexity, to understanding simplicity. And I think that what happens with many doctors is that we get stuck in the complexity part and we forget to come back to the deeper simplicity that's on the far side, which is to say that we have to develop the intellectual rigor, and that's absolutely necessary and fundamental to everything else that we do. But if you stay there, you become a robot. And if you become a robot, then you become burnt out. Is I am becoming more and more convinced. The more people we talk to, the more I become convinced that one of the foundational problems in medicine is that we get stuck in the complexity phase. And it's just it just gnaws you down to the bone. It just leaves not it hollows out medicine, it leaves it without a heart. And so what you have to do is get to the complexity and then add the humanism back so that you have the deeper simplicity on the other side.
Wes Ely: [00:34:37] I love that. And I think what you're kind of getting at is you're moving from one strength curve to another. Arthur Brooks has a great book out now called Strength to Strength, and I'm not here to plug his book, but what he's talking about is moving from one strength, which is this early on fluid intelligence that we've got and moving then forward towards more of a crystallized intelligence. Because, Tyler, after we start to get that fund of knowledge of antibiotic choices and how to do the procedures physically with our hands and and making decisions about how to interpret cardiac arrhythmias, et cetera. That's kind of more of a fluid intelligence that's data driven. But if you don't come back onto that second curve and crystallize all that down so you can take care of the person again, you're going to miss completely out on it and it'll be a been there, done that thing. You're going to burn out not like what you're doing anymore and go into business or something. I really I mean, I really think that the love of a human being might draw us in. Then we have to tell the young people who are coming in, you've got to work really hard to get to learn your trade, to read a lot. I tell people, read, read, read to your sick, to your stomach, read to you, puke, and then start reading. That's how much you have to read to to stay up with your knowledge gap. But then you've got to get all that and it becomes muscle memory, how to do that. Then you come back to your heart and you connect your brain to your heart. And now the patient has a physician.
Henry Bair: [00:36:03] So in your book, you talk often of seeing the patient, both literally, you talk about making eye contact with the patient, but also metaphorically seeing the patient as a whole. Can you tell us what that actually looks like in the ICU and how that makes you a better doctor?
Wes Ely: [00:36:23] Yeah. I have a list of do's and don'ts in the ICU. Do's and don'ts for physicians. And one of my dos is take a knee. And what I mean by that is that I regularly, whether you physically do this or not, I don't care. But my point is that when I take a knee, I'm actually kneeling down at the bedside with my patient so that I level with that person. I'm not standing above them and I'm holding their hand and I put my right hand in their right hand and my left hand on their shoulder. And then I have both of my hands on that patient. Focusing on loving them, focusing them. Understanding who they are. Looking them straight in the eyes and saying, You know what, Mr. Smith? I am here for you and I don't want to tell you what's the matter with you. I want to ask you what matters to you. And I call this switching the preposition. So going from this is what's the matter with you to let me understand what matters to you and when I can place my hands on them, look them in the eyes and ask them what matters to them, then I can understand what is my job for this particular person. And it's different for every for every individual person. Because I have a phrase in the book. I call it Spanish quarter persona as mundo. Each person is a world. And what I'm trying to do is find out who is this world that's in front of me and how can I love them?
Tyler Johnson: [00:37:54] That's so interesting. I mean, I just have to remark in passing, you are the only other person I have ever heard talk about taking a knee at a patient's bedside. But soon after I became an attending, you can ask the folks who are on my service, my inpatient oncology service that almost every time we see a patient together, I kneel at the patient's bedside to the point that my knees are tired at the end of rounds from kneeling on the floor all the time. But it's exactly for the reason that you say, because it's a it is a categorically different experience. The towering over the patient and looking down on them like you're looking into a well versus the being down with them and looking them in the eyes. It's just a complete like the relationship is completely different in those two things. And it and it recasts the entire nature of the encounter. Right. Because it does I've never thought about it in these terms, but when you're standing above the patient, looking down into the well of the bed, it feels like, oh, I mean, I hate to be so blunt, but it sort of feels like, Oh, hey, there's a thing we need to fix, right? Like, this is the car we're working on is sort of like the kind of the sense, but it's very difficult to maintain that kind of relational aspect to the patient if you're sitting there inches away from their face and looking them in the eyes.
Wes Ely: [00:39:14] I'll tell you, I love what you just said and I love that we both do that. And so next time I'm going to be thinking about you as I'm taking the knee. Two things. One is I am a spiritual person. I believe in a higher power. And one of the math phrases that I carry around in my head is V=v, and it's a capital V equals a little v, and V is voluntas, which is Latin for 'will.' And what I'm saying is that I want to adapt my little v will to the will of my higher power, which is a capital V, And so with me being a little v, when I'm kneeling down at the patient's bedside, I'm making myself smaller and I'm doing that on purpose. I'm trying to make myself smaller and make the patient larger. So I'm looking at them as the big V and me is a little bit. I'm saying I hope the listener here can realize this could apply to you whether you're atheist, agnostic, Jewish, Buddhist, Hindu, Christian, whatever you might be. This is a way of allowing the patient to be large and me to be small because I'm there to serve them, not the other way around. And that's just a position that I want to take at the bedside. And if I can bring my science as a physician scientist and that humanistic attitude to the bedside, now I'm combining the touch and the technology, which is what I think is required to truly love this person and provide them the best care. They don't just want love. They want great decisions. They need both.
Tyler Johnson: [00:40:43] Yeah, it's it's so funny. I remember when when I first got into the ICU as a resident, I just remember thinking, this is impossible. No human can process this amount of information about all of these other humans in anything like real time and then make decisions, right. Because it's all of these huge lists of drugs and all of their doses and then dynamic dosing of pressers and dynamic vent settings and dynamic vital signs and all of the new medical problems and all of the organs like it was just this flood of information. Right? That was the signal was indistinguishable from the noise. But I remember as a third year resident then sitting down to pre round during my last ICU rotation and having this like momentary out-of-body experience like, oh my gosh, I have become a a brain that can process all of this information. Like I can take all of this stuff about all of these people and know if they're doing better or worse and what we should change to help them get better. And I mean, like it was just this totally, almost like out-of-body experience, which is just to say that when you reach that state of sort of flow, intellectual flow that you're talking about, and then you can join that with bringing back the humanistic heart, I really feel you sort of alluded to this briefly before, but that's where you sort of feel like, okay, this is what it means to really be a doctor, right? Like, this is what it means to be a physician is to be able to join that kind of intellectual development with still having the heart at the center of things.
Wes Ely: [00:42:22] I love what you just said about what it means to become a real a physician, and I'd like to tell a story if I can. You know, we talked about a lot about burnout, and there's not been a more egregious set of burnout in my career than happened during COVID, when the nurses were all leaving in droves and the doctors were up there in the COVID unit. I was in the COVID unit at Vanderbilt, and then it happened, the Anti-vaxxer situation and the patients were coming in yelling at us and blah, blah, blah. And so one day I was in the unit and this woman came in and this kind of embodies what we're talking about here. She was she was getting more and more hypoglycemic. She was more and more sichypnic. And it was clear that she was heading toward a ventilator. And she said to me through tears. "Dr. West, do you want me to tell you why I didn't get Vaxxed?" And I said, Well, Miss Smith making up the name here, and I have permission to tell her story. By the way, written permission. I'm very careful about written permission for all of my patient stories. And by the way, in Every Deep-Drawn Breath, every patient's a real patient, a real name. All direct quotes. I record them with these digital devices and get them transcribed. So it's all nothing, no names or anything or changed.
Wes Ely: [00:43:31] But in her circumstance, she said. "I didn't get vaccinated because the man on the TV said that they were trying to depopulate society of people like me." And I was kneeling down at her bedside, like I said, I was holding her hand and she was crying. And that was her story. And I think because I was making myself small on purpose, because I was at her eye level. Nothing entered my brain like, "oh, my gosh, there's another anti-vaxxer" or "I'm so mad with all these anti-vaxxers and I'm burned out" Instead it was "I see her as a victim of misinformation" and I want to make absolutely certain that the one thing that I commute to her, that I transmit to her with words and actions is I will not leave you. I am here with you. I am devoted to you. And we will get through this wherever is happening to you. Our team will be present with you. And that was the message. And I think that that's an anti burnout message. That's medicine. And that's why I did not get burned out during COVID. And I'm not saying I have all the answers, but what if we could adapt our structure and medicine to to combine the science and the humanism like that? That's kind of what I'm getting at.
Henry Bair: [00:44:51] Wes, that is such a powerful story. Hearing the outpouring of love you show for your patients really brings tears to my eyes. I'd like to touch on something you mentioned earlier, which was your spirituality. Now, it's certainly not something often discussed openly during our daily clinical practice, but two things. First, as it turns out, spirituality is something that is important for many of our patients. Second, over the course of our conversations on this podcast, it's become apparent that spirituality is something that is important for many of our clinician guests. It's not something we plan to ask about. But when exploring why medicine is meaningful and the nuances of patient relationships, a spiritual or at least metaphysical dimension, will often reveal itself. Can you tell us more about if and how your spiritual beliefs impact your patient care?
Wes Ely: [00:45:55] Yeah. I'll use a couple of stories and you can ask me more questions about that. And one of my patients came in from an outlying city town. Acute abdomen. She needed to go down to the OR. They opened her up. She was completely full of peritoneal metastases. Sent her back up to me. She was in a lot of pain. And we knew that she was going to die quickly. She made it very clear to me early on that she was atheist. And she said to me, without me even saying anything about my own beliefs, she said, I know we're different in that regard and that's okay. And she said, There's something I want to do with my family. And I wrote this in Every Deep-Down Breath. There's a I didn't write all of it, but I wrote part of the story in there is that she she was a biochemist, hard core scientist, professor. And she said to each person in there in the room, "Do you love me?" And the person would come to her at the bedside holding her hand, her her sister, her mother. Yes. You know, I love you. And then she would ask them again, But do you love me? You know I love you. I'll be here with you. Do you love me? A third time? She asked every one of them three times. Do you love me? And then they would commit to be present with her during this process. And then she turned to me and asked me the same thing. So here was this atheist-Christian intersection because she I'm Catholic, actually.
Wes Ely: [00:47:15] And she didn't care. And I didn't care. And it didn't matter. It didn't matter that we were of different belief systems. What mattered was we were two human beings finding our way in this this cycle of her dying process so that I could be there for her and she could allow me to help her and be in there together with each other. And I tell other stories I needed to be about being with Dr. Gira Soul, who is a Buddhist dying. And I had got his Buddhist monks at the bedside so they could be with him. And there's a picture. All these patients pictures are online in a photo gallery on our website at ICUDelirium.org, by the way. But I don't care if my patient's Buddhist or Hindu or Jewish, whatever their faith system is. And as I said in this atheist situation, I just want to honor what their spirituality is. And I never will be proselytizing my spirituality on top of theirs. That would be an abuse of power, and that's not my role. So instead, my job is to say to them, Do you have any spiritual beliefs that you want me to know and honor? And I ask them that one by one every time, and I let them be the driver of that conversation. And then I try to make sure that I serve them in whatever their spiritual beliefs are. And that's the way that I have found is right for me to practice medicine.
Tyler Johnson: [00:48:36] I think just to draw two themes out there for our listeners that, as Henry is mentioning, I have become increasingly convinced are really important here. One is that I think the palliative care doctors are way ahead of the rest of us in that they have spiritual care as one of their stated domains. Right? Like, that's part of what they do is care for the person spiritually, which virtually no other doctor at least systematically does that. So one thing is just the idea that an ICU doctor thinks about that and asks about that and considers that part of their care just as much as renal physiology or whatever else I think is important. And the other thing is that I. I'm becoming increasingly convinced that medicine is a fundamentally spiritual pursuit. That doesn't necessarily mean that all doctors need to be religious per se. And I think that there is a I don't know if you want to call it a spirituality for atheists, but whatever, a metaphysics or an ethical dimension or something, but whatever you believe in about God or whether you believe in God, I believe that I have I am coming to conclude by virtue of the interviews that we are doing that the spiritual aspect of medicine matters not just in honoring the humanity of the patient, but also in honoring our own humanity. And we have and we as doctors, as you mentioned, about the mutually vulnerable interchange between a doctor and a patient earlier, We have to honor that spiritual, metaphysical, whatever you want to call it, element as we go into the doctor patient encounter to allow the encounter to maintain its full, its full value and its full meaning.
Wes Ely: [00:50:14] And I love that. And Henry, you mentioned earlier, but it is very evidence based to make sure your listeners know that the majority of your patients will have spiritual beliefs in a higher power. You can look all through the literature that's clear and the patients actually consider it an affront to who they are when they don't get asked. So the reason that I ask, do you have any spiritual values that you want me to know and honor is because the literature supports that. I'm very much driven by the science, and that's what's in the literature.
Henry Bair: [00:50:45] I'd love to close our time together with the same topic with which you closed your book, and that's end of life care. It's interesting that during a conversation we had with an intensivist a while back, Episode eight, I believe, when we asked her to share a meaningful moment in the ICU, she talked about a time when she was able to shepherd a patient to the end of life in a way that was transformative for both the patient and for the intensivist herself. And I think that's an important point. You're not going to be able to save the lives of all of your patients. So when that happens, when the medical options for prolonging life runs out, what else can you do for your patients?
Wes Ely: [00:51:31] Sure. I'm going to close with a story and a comment about what you're asking about. I mentioned earlier that kind persona as in Mundo, and I wrote in the book, I've come a long way since I viewed my patient as a lung to be fixed. And I find it almost unbelievable now to look back at the other me with a laser beam focused on a patient's collapsing organs. With scientific precision, I used to home in on the problem, seeing my patient through the lens of a CT scan or an x ray reduced a purely physical depiction of self. I thought I was cutting through the noise. Now I know the noise matters. And when somebody is dying and we know that we can no longer save them or we feel like we can't save them with technology, what we're essentially doing in the palliative care doctors, we'll talk about this a lot is shifting the ladder from cure, the wall of cure to the ladder of comfort that is no less important than curing. And what we have to do is resign ourselves to the fact that we are there to to to create a healing environment. But healing can happen even when somebody is dying. So my role shifts from healing related to cure to healing related to love and mercy. When I shift that that ladder over to the wall of comfort, and I am no less hopeful about my role as a physician when I'm ushering in a good death, then I am when I'm trying to save a person's life.
Wes Ely: [00:52:55] So to be clear. When it is. The situation that I have. For example, in the book, I've got two couples, both of them married over 50 years. Both all four of them have COVID. It was the Stephens's and the Hills. And these four people, a man and woman, man and woman came into our hospital and they were they had COVID and they were dying and they were separated. Initially, we were focusing on the science and it was all wrong. It was anti medicine. The man is asking for his wife saying, Where's Virginia? Where's Virginia? The wife of the other couple was saying, I've got to be with Henry. And what we realized is the only thing that matters at this time is to have these people in the same room, two beds put together in there in one hospital room that's meant for one person so they can hold hands, touch their faces to one another, if you will, and be present with one another as they're dying. And that's what happened. And the wife's talking to the husband and the husband is talking to the wife in two separate rooms. And those COVID patients are our human beings. Living out this holy moment in their life with all of the focus on the humanity of what they're going through and no longer worried about whether or not they're getting baricitinib and steroids or their oxygenation, etc.. And that is absolutely the fullness of medicine in the ICU and had nothing to do with saving their lives.
Henry Bair: [00:54:30] Thank you so much for closing our conversation with that beautiful story. I have to say, anyone working in health care, not just in the ICU, can learn so much about the heart and soul of medicine from the stories and insights you've shared with us today. Thank you again for taking the time to join us.
Wes Ely: [00:54:49] And just make sure your listeners know every penny from this book goes back to patients and survivors. I don't deserve to make any money off this book. So if you ever get to every deep run breath, you're paying it forward to them. And thank you so much for your time today. Tyler and Henry, it's been a great privilege to be with you. I've learned a lot.
Tyler Johnson: [00:55:05] Thanks so much, Wes.
Henry Bair: [00:55:09] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program, notes and transcripts of all episodes at the Doctors Art. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
Tyler Johnson: [00:55:27] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show. Feel free to leave a suggestion in the comments.
Henry Bair: [00:55:41] I'm Henry Bair.
Tyler Johnson: [00:55:42] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.
2023 Webby Award Honoree for Best Health and Wellness Podcast Episode
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LINKS
Dr. Wes Ely is the author of Every Deep-Drawn Breath, a chronicle of his experiences caring for ICU patients.
You can find out more about his work at ICUDelirium.org
Follow Dr. Ely on Twitter @WesElyMD
