14 minute read
Breaking Bad News
St Louis, Missouri
Dr Maria B. Majella Doyle
“I was in my fourth year of training,” Majella remembers, “and I was attending a meeting of the IHPBA Association. Gerry McEntee bumped into Professor Will Chapman; they had trained together in liver surgery, at King’s College London. Will had just moved to Washington University, and they were looking for a fellow, and I was looking for a fellowship. It’s so random the way things happen sometimes! I didn’t know anything about St Louis, and the only thing I knew about WashU was the manual I and everybody else used to carry in our pockets when we were trainees.”
Majella completed her surgical training at Tallaght University Hospital and embarked on a Clinical Fellowship in Abdominal Organ Transplant and HPB surgery at Washington University School of Medicine in St Louis, Missouri, in 2005.
“I only planned to come for a year to do some training in transplant, as this training gives you a lot of skills that you don’t necessarily get from doing just HPB,” she explains. “I intended to go back to Kings College in London and then return to Ireland. But there were no jobs in Ireland at the time and I was getting on well, so I stayed for a second year to complete the transplant fellowship. And then Professor Tim Eberlein, the Chair of Surgery at Washington University, Will Chapman and another surgeon, David Linehan, recruited me to join the department as a member of the Abdominal Organ Transplant and Hepatobiliary Surgery team. It’s been incredible; I’ve been so lucky.”
Majella started as an assistant professor and has since progressed to full professorship. She started out performing adult liver, kidney, and pancreas transplants along with liver and pancreas cancer resections before undertaking paediatric liver transplants. Subsequently, she became the Surgical Director of the Paediatric Liver Transplant Programme at St Louis Children’s Hospital in 2015. Somewhere along the way, she also found time to do an MBA.
“I decided that if I was going to stay in the US, I needed a better understanding of the business side of healthcare,” says Majella. “And so I completed an MBA at Washington University in 2012. It took 20 months and was a big commitment. Some of the responsibilities given to me in the department such as the role of Vice Chair for Clinical A airs are as a result of this experience.”
Majella focuses her clinical research interests on clinical outcomes, hepatocellular carcinoma, liver transplantation, and donor management. She is proud to be the current president of the Americas Hepato-Pancreato-Biliary Association and Councilor of the American Society of Transplant Surgeons.
“A typical week includes elective surgeries on Mondays and Fridays and a clinic on Wednesdays,” she says, “and then sometimes I do surgeries on Tuesdays and ursdays for living donors. But when you’re on call you just don’t know what’s going to happen. So you live a life of uncertainty. I came back from a holiday on two occasions to transplant sick babies … it’s sort of a crazy life really.”
Surgery call for adult liver, kidney, and pancreas transplants is shared between a team of six, but the paediatric transplant call is shared between just two.
“Dr Khan and I do all the paediatric liver transplants. is year already [early November] we have transplanted 21 livers, which may not seem like a lot when there are 52 weeks in the year, but each one is a big time commitment. We do at least ten days of call a month between kidneys, donors and transplants.”
When Majella arrived in St Louis rst, she lived in an apartment in the Central West End, a vibrant area close to the hospital, which she describes as being “a little bit rundown, but sort of up and coming” at the time. She stayed there until she met her now husband, Bob Roth, (‘he’s amazing!,’” she says) who works in biotech, and they moved to the suburbs when they married in 2014. “Now we live in a house with a garden and a swimming pool,” she says. “When I rst arrived in St Louis it was 105 degrees. Being Irish, I didn’t even know how I was going to be able to breathe! So the pool is great in summer. e winters are cold – not Boston or Chicago cold with big snowdri s, but we do get a few ice storms – and we get four proper seasons, and spring and autumn are beautiful.”
Majella says St Louis is a very liveable city.
“St Louis is nice and small, with a population of 2.8 million. It’s easy to get around. My commute is only 20 minutes in tra c and ten minutes if there’s no tra c. ere are big parks and it’s very geared towards families, with great museums and a wonderful zoo.”
Majella and Bob’s son, Rory, is six – “he keeps us all entertained” – while Bob’s two older children, Ryan and Amanda, are both away at college. Ryan, on an athletic scholarship as an ice hockey player, is completing his business degree, and Amanda is interested in attending medical school a er completing her undergraduate studies. e entire family loves to ski and goes to Colorado as o en as they can get away together; Rory has already decided he wants to be an Olympic skier. “Either that or an artist,” says Majella.
When she can, she gets out on the golf course, but claims not to be very good. “My husband is a much better golfer than I am,” she says. “So he’s always giving me tips.”
And she rides a friend’s horses when she gets the chance, having initially tried to learn polo. “ at’s what they do here,” she says, “but that proved to be quite di cult, so now I just go for a ride.”
Majella makes the trip back to Ireland several times a year to visit her parents, who still live in Wicklow and her sister, Sarah, who is also a doctor and lives in Greystones. Her brother lives in France.
“I’m very much a home bird so I love going back to Ireland,” she says. “We don’t really take vacations anywhere else, other than to ski.” ■
No Time to Eat
IT HAS BEEN SAID THAT HEALTHCARE PROFESSIONALS DO NOT EAT AT WORK, THEY FORAGE. BUT EVIDENCE SHOWS THAT ESTABLISHING A POSITIVE FOOD CULTURE IS VITAL NOURISHMENT FOR BODY AND SOUL
f the consequences of surgeons and other healthcare professionals neglecting their own diet and nutritional wellbeing weren’t so potentially serious, their poor eating habits might be seen as laughable. But as a factor contributing to burnout – the topic on everyone’s minds – it’s something to which more attention needs to be paid. Of course, not all surgeons conform to the stereotype, reliant on co ee, energy bars and high sugar drinks to keep them going. Dr Jamal Saleh FRCSI (1989) is a Consultant Orthopaedic Surgeon and Chairman of the Board of Directors at Alsalam Specialist Hospital, Bahrain. As well as his clinical work, Dr Saleh undertakes committee work for e National Health Regulatory Authority, is Governor of the Bahrain Chapter of the American College of Surgeons, President of Bahrain Sports Medicine and Sports Science Society, and chairs the Bahrain Mountain Biking committee. He directs and teaches Advanced Trauma Life Support and recently completed a masters degree in Healthcare Law and Ethics at RCSI. He says a disciplined approach to diet and lifestyle enables him to stay on top of this heavy workload.
“To stay healthy, I wake up early every day, even on weekends,” he says. “I alternate between going to the gym for resistance exercises and cycling as a cardio sport. I nd this combination suitable for my age and well being. At the age of 63, I weigh 73 kg, which is right for my height of 179 cm. I keep my weight down by weighing myself daily. My diet is healthy; I take fruit and water rather than a high-protein, high- bre breakfast before morning exercise. Other meals are low-fat and rich in white proteins and greens. I don’t rely on co ee to keep me stimulated, as I have an abundance of self-motivation and a busy schedule to keep me alert.”
Dr Saleh is blessed with excellent health and professional ful lment, but believes his healthy lifestyle coupled with diverse professional and extracurricular interests have protected him from burnout.
Professor Peter Brennan FRCSI (1997) is a consultant maxillofacial surgeon at the Queen Alexandra Hospital in Portsmouth specialising in head and neck cancers. He is an expert on how human factors such as fatigue, stress and emotions as well as nutrition and hydration, impact on patient safety and says there is an increased likelihood of human error if medical professionals are not properly fed and hydrated.
“It’s easy to forget to look a er ourselves at work,” according to Professor Brennan. “We know that taking breaks and eating and drinking regularly is a critical component of being ‘optimised’, helping to sustain our energy, concentration, and performance, and reduce the risk of human error. Yet … the realities of working in busy, modern hospitals get in the way.’
“Medicine is a demanding profession, with days o en starting early and nishing late, and many fall into the habit of forgetting to take regular breaks, not drinking enough uids, or missing meals. If we want to improve sta wellbeing and reduce the risk of errors, we need to change this.”
Professor Brennan says poor nutrition and dehydration signi cantly impact on performance in a demanding operating room setting, with even modest levels of dehydration shown to impair cognitive function and performance. Meals containing protein, carbohydrates and fats such as those derived from olive oil, sh and avocado as well as certain nuts have been shown to provide optimal nutrition, while simple sugars (such as chocolate bars) and processed food do not support long-term concentration and endurance.
Professor Brennan recommends taking a short break of 10–15 minutes every 2–3 hours when at work, especially if performing complex tasks or surgery. e procedure can continue if there is suitable expertise within the team, but each team member should plan to take a regular break, which can be staggered.
Dr Jamal Saleh, FRCSI (1989) Mr Niall Downey, FRCSI (1997) Professor Peter Brennan, FRCSI (1997)
Taking regular breaks in a long case leads to improved outcomes and shortens overall operating time.
“Even a short time spent away from operating can help provide a fresh outlook, improve morale, and enable a toilet and food/water break,” writes Professor Brennan. “Recovery is aided through regular sleep, which is positively linked to healthy eating and drinking.”
Mr Niall Downey was a Cardio- oracic Surgery trainee in Belfast and Dublin during the 1990s, receiving his FRCSI in 1997. In 1999, faced with a shortage of SpR Training Posts he “reluctantly jumped ship” and retrained as an airline pilot with Aer Lingus. He is currently a captain on the A320 and A321 eet ying on the airline’s European and Trans-Atlantic routes.
Downey set up Framework Health to share the aviation industry’s successful Safety Management System modi ed speci cally for healthcare.
“Human factors including nutrition and rest are a critical part of how other safety-critical industries structure their workload, an approach noticeably absent in healthcare,” he explains.
“Adverse Events are usually caused by systemic faults but o en blamed on the last individual to have touched the ball. We encourage healthcare to adopt a Just Culture, and embed a systemic Human Factors approach.”
For Downey, a useful acronym is HALT: “If I’m hungry, angry, late or tired I’m signi cantly more likely to make an error.”
“Hunger has been shown to contribute to reduced concentration and poor decision making as does dehydration,” he explains. “As little as a 2% drop in hydration has a signi cant e ect on performance, but is quickly reversed once uids are drunk. Seventeen hours without sleep causes impairment equivalent to a Blood Alcohol Concentration (BAC) of 0.05%, the drink-drive limit in Ireland, while 24 hours without sleep doubles this to 0.1%. All of this can be easily addressed by treating sta as the valuable resource they are, not as the cost they are sometimes perceived.”
As a pilot, Downey’s hours are limited to reduce risk, with a maximum of 15 hours on duty when there are two pilots. He also has access to regular food and drinks, and an approved hotel on the far side.
“My job o en involves getting up at 3am or earlier to drive to work several days in a row or arriving home at that time,” he says. “Disneyland it isn’t but it’s a vast improvement on conditions in my previous life as a surgeon! Another issue is that anger is a side e ect of all of the above and, unchecked can lead to bullying and incivility in the workplace.”
Elizabeth Bleed MD MA and Catherine Humikowski MD of the Critical Care Department at the Ann and Robert H Lurie Children’s Hospital of Chicago note in their article ‘Lunchtime Revolution’, published in the Journal of the American Medical Association in August 2022, that many doctors “ … have a pitiful relationship with food. Healthcare professionals do not eat at work, they forage. e act of eating is typically quick, e cient and solitary. Emails and patient charts dominate lunchtime … It is strange … that a profession devoted to preserving life holds the act of eating in such low regard.”
Bleed and Humikowski set up a weekly lunchroom in a conference room adjacent to the PICU in which they work, and invited their colleagues to join them. ere was no agenda for the gathering other than the simple act of eating together on ursdays at noon. e pair did not track “the bene ts of [their] wellness intervention”, but they hope that the initiative “becomes part of a broader culture shi among physicians around how we treat our bodies and each other. We hope students and trainees take note: eating is not a shameful act of self-indulgence. It is a biological, social and spiritual necessity. For a profession that lectures patients and families about nutrition … medicine is shockingly bad at nourishing itself. If basic human needs are not met, all other e orts to mitigate burnout, compassion fatigue and attrition will fail. Like building a house with no foundation, expensive structural investment in workforce integrity will collapse if everyone is hungry.” ere’s plenty of evidence to support Bleed and Humikowski’s belief that the act of eating is as nourishing as the food itself. ey cite a cross-sectional study of re ghters showing that communal eating correlated with improved performance; a survey of adults in the UK which found that participants who shared mealtimes reported increased happiness, life satisfaction, and community engagement; and research showing that strangers who eat the same food score higher on the measures of trust, con ict resolution and cooperative behaviour.
“Add these bene ts to increased e ciency and job satisfaction associated with lunch breaks at work,” they write, “and it almost seems like medicine is unking on purpose … [perhaps] the low-hanging fruit in the ght against burnout might be actual fruit. Establishing a food culture in medicine … requires a collective respect for the bene ts of shared meals and an acceptance that food is necessary for life and community is necessary for living.”
Bleed and Humikowksi conclude by exhorting clinicians, if their clinical practice is truly incompatible with a midday meal, to “revolt by eating lunch and expecting those around you to do the same”. is may be easier said than done. As Niall Downey says, “without buy-in from government and senior management we may have a long road ahead of us.” ■
Breaking Bad News
LEARNING HOW TO COMMUNICATE BAD NEWS IS ONE OF THE SKILLS TAUGHT IN THE HUMAN FACTORS IN PATIENT SAFETY PROGRAMMES AT RCSI
here is emerging evidence that the quality of the relationship between the clinician and the patient predicts objective improvements to the patient’s outcome.
It has been known since the 1960s that a supportive conversation with an anaesthesiologist directly prior to a surgical procedure results in a reduced requirement for pre-operative sedation and post-operative prescriptive pain relief. Other patient outcomes include, improvements in control of blood pressure, pain (including headache), weight and blood sugars, improved adherence to treatment recommendations, shorter time spent in hospital, and reductions in return visits to the out-patient clinic. is is the evidence which guides the training delivered to surgeons and healthcare professionals as part of the Human Factors in Patient Safety programmes at RCSI. e programmes are led by Professor Eva Doherty, Director of Human Factors in Patient Safety and faculty in the Department of Surgical A airs, and are delivered to the surgical, emergency medicine
