Search for tag: "u0539798"

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Dr. Harriet Hopf: I'm Harriet Hopf, professor of anesthesiology at the University of Utah. I'm talking today with Gretchen Case. Dr. Case is an assistant professor at the University of Utah in the division of medical ethics and humanities. She received her PhD in performance studies from UC Berkeley. I asked Dr. Case to sit down with me today to talk about medical humanities and why it is important for educating our future healthcare providers. But first I have to ask: how does someone with a PhD in performance studies come to be on the faculty of a medical school?

Dr. Gretchen Case: Probably most of the listeners don't know what performance studies is. Let me just tell you briefly that you can think of it as a blend between anthropology, theater, literature, and a bunch of other things, but what performance studies does as a field is look at all human endeavors as performance. So we do perform on stage but also perform in everyday life. One of the things that I've been particularly interested in is how people perform in a medical setting. How do doctors know what it means to behave as a doctor? How do patients know what it means to behave as a patient?
To say that someone is performing is not to say that they're faking it or that they're acting in the sense of acting that we think of someone taking on another character, but performing means to make something happen. How are they making something happen, responding to particular cultural scripts of this is the way it should be? If you think about it, doctors even have costumes, right? They put on their coat, their stethoscope, and suddenly they are a doctor. So there are lots of ways that looking at medicine through a lens of performance is really useful.

Dr. Harriet Hopf: Actually, you just made me think about how important our white coat ceremony is every August. Our first-year medical students get sort of inducted into being doctors by being given a white coat and a stethoscope.

Dr. Gretchen Case: Right. That's a very performative moment in that that makes it so, right? It makes something happen. They are given a coat and they are kind of inducted into this group. They are now, if not doctors, they are physicians in training.

Dr. Harriet Hopf: So what is the value of theaters and stories in medical education?

Dr. Gretchen Case: Humans are storytelling creatures. We use story and narrative to make sense of everything in our lives. Using theatrical approaches, using dramatic approaches, techniques to teach communication, for example, can be really, really valuable. The Mayo Clinic, Northwestern University, they both teach improv in their medical schools. Improvisational theater says you have to be in this moment listening to the other person or people and you have to respond in the moment. The first rule of improv is always, always, "Yes, and..." right? That's what you have to do in a clinic or in a hospital setting, is meet the person where they are, listen to them, and react in the moment and not be working from some script that is kind of preset or not be waiting for your turn to talk.

Dr. Harriet Hopf: How is the University of Utah using stories and theater in medical education?

Dr. Gretchen Case: I recently brought a panel together of, I think, six people who are in various ways using theatrical approaches in medical education or in medical practice. Some of them are using the idea that patients tell stories and how do we change stories that are not helpful? Or how do we adjust our stories as caregivers? Some of them are bringing in actors to play important roles. This becomes especially important when you're doing something like learning how to give bad news, learning how to disclose an error. That's the kind of thing you want to rehearse and practice when the stakes aren't as high. So if you can bring in a well-trained actor who can play that person in distress, that patient who's about to get the bad news, that's a much better way of rehearsing and practicing that.
Then others are using an approach called forum theater which is an interactive kind of theater which means that you present a problem and the audience helps solve it. So it's a way of getting a whole healthcare team together and saying we seem to have a problem at this point in the care. Can we think together about what the problems are? You get a much better idea of problems and how the solve them than either a bottom-up or a top-down kind of approach to that.

Dr. Harriet Hopf: A typical medical student in our program, do they get a chance to practice giving bad news through theater?

Dr. Gretchen Case: A typical student in our program, possibly, depending on electives they take, depending on what tract they are in. I believe that going forward all of them will be doing the inter professional experience, the IPE. That uses actors. The summer session that they do in IPE is about disclosing an error, so they will all get the experience of disclosing an error to an actor who is playing someone who is in great distress.

Dr. Harriet Hopf: How can physicians interpret patient stories effectively? How can we do a better job of providing information so that we get stories back that make sense to us as well as to the patient? How can we somehow use these stories that seem incorrect to us to improve how we communicate with our patients?

Dr. Gretchen Case: It's so often not about facts. It's about truth. Those are different things, right? The patient who is telling you a story that sounds untrue may be telling you a story that is factually wrong but to them is true. Stories aren't static. That's the other thing. You might hear a story from a patient, you might be able to add to it to change it, to give a prologue, to give an alternate ending.
People usually don't cling so tightly to their stories that they wrote. They are ready to hear more, to add more to it. So I think that's actually one thing that's really important for clinicians to know is: how can you be a co-narrator? How can you be a part of this story? How can you go back to that improvisational, "Yes, and.." "Okay. That's the story you're telling me. Let me add to it," and not, "but..." Not, "Yes, but..." and not, "No," but, "Yes, and..."

Dr. Harriet Hopf: I just got a great insight from this conversation because I'm an anesthesiologist and so I meet patients all the time for five minutes before they go off to have an operation and I usually don't have complete information. They often tell me something that makes completely no sense to me and I have to decide if gets in the way of going to the operating room? Does it get in the way of their being comfortable with having care?
What I hadn't thought about before was the stories physicians tell and how they're not always accurate either. I think we like to pride ourselves on our accuracy but part of the problem is what people hear and how they construct it into their own story, but part of the problem is what we say and whether it's accurate or not. That's actually something I'm going to take with me the next time I'm meeting a patient who tells me a story that makes no sense. I'm going to say, "Yes, and..." and try to figure it out, but I'm also going to think about the stories I'm telling that might be making no sense whatsoever to the patient.

Dr. Gretchen Case: Sometimes those stories that don't make sense are due to uncertainty, right? There's uncertainty in medicine. As much as we don't want there to be, there's a lot of uncertainty, and sometimes that's due to something like jargon, that what you think you're saying is very clear and it sounds very different to the patient. It could be a word that you don't even think of as jargon but it is to the patient. Even saying a word like obese, that's a medical term. If you say "obese" to a patient you may have just deeply insulted them and changed the entire nature of your relationship or what the story is.

Dr. Harriet Hopf: What I'd like to know is what's important about using theater in medical education? What's the ultimate outcome? What is it we're trying to achieve?

Dr. Gretchen Case: So much of what people are talking about when they raise concerns about things like bed side manner is how the physician presents him or herself and how they communicate. That's what theater and performance are about, is how do you present yourself to the world? How do you communicate to the world? So if we can take some of those lessons, some of those techniques that are kind of native to performance and theater and transfer them over to medicine so that every clinician, every researcher is thinking, "How am I presenting myself? How am I communicating?" What an amazing difference that would make in the way that we provide care and the way that patients receive that care and kind of understand why and how we want to help them and care for them.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope. University of Utah Health Sciences Radio.

Announcer: Medical news and research from University Utah physicians and specialists you can use for a happier and healthier life. You're listening to the Scope.

Interviewer: What does it mean to say a surgery went well? Well, one of the big variables in the equation is a controlled surgical site infection. Dr. Harriett Hoff from the University of Utah Medical Center. Her passion is preventing surgical site wound infections, so the first question is in the site of all the things that happens in surgery, how important is that component?

Dr. Harriet Hopf: Hugely important. Surgical site infection is one of the common complications after surgery. It delays the healing time, and it means a longer time in the hospital. It means maybe having more doctor visits. It takes a longer time to get back to work. So if you get a surgical site infection, it's often a devastating complication.

Interviewer: Not only for patients is it bad news but for hospitals it is too, because you've got patients that stay there longer. They don't have as good of outcomes. What are some of the other implications?

Dr. Harriet Hopf: Surgical site infection is actually one of the first things that the centers for Medicaid and Medicare services went after for paper performance metrics. So we are judged on not only our rate of surgical site infection but how well we do all of the things that we do to prevent them. Interestingly enough, the biggest thing that we can do is hand hygiene. So washing your hands is using soap and water, and we do some of that, but we don't have a sink in the room. But the other thing is to use the alcohol gel to clean your hands. So when you touch the patient, you get their bacteria on you. If you alcohol gel your hands immediately, then you're not going to spread that around the room.

Interviewer: So its touch, not necessarily airborne germs in those situations?

Dr. Harriet Hopf: In general, the germs that are being transferred are being transferred by touch. There is potentially some in the air, but that's much less of a problem. The operation room has negative pressure to take the bacteria away from the patient.

Interviewer: What does that mean, negative pressure?

Dr. Harriet Hopf: There is airflow in the operating room that works to sort of pull the bacteria away from the patient and keep stuff from outside the operating room from entering the operating room. So you can feel when you open the door to an operating room, there's a change in pressure when you open the door to an operating room and that helps to keep airborne particles from getting onto the patient.

Interviewer: So I was doing some due diligence before our conversation, and I found it interesting, you just said a lot of it's through hand washing, because that's what I gathered. And that kind of blows me away a little that in today's technologically advanced age, that's kind of the big thing, isn't it? Are there other considerations that are nearly as important?

Dr. Harriet Hopf: There are lots of other considerations. I spend a lot of time on hand hygiene because surprisingly enough people don't wash their hands enough. But other things include, for example, giving antibiotics within an hour before the incision helps to reduce infections by reducing the number of bacteria that is on the skin and in the incision that could cause an infection. Keeping the patient warm turns out to be very important. Operating Rooms are cold. They're cold because the surgeons wear a lot of clothes, and they need to be comfortable to operate. Under anesthesia patients don't manage their temperature very well. Among other things we make them naked. So that they're in a cold environment and they're not necessary naked, but, so there are things that anesthesiologists can do to keep the patient warm.

Interviewer: So what's going on there? Why does keeping them warm versus cold help?

Dr. Harriet Hopf: There's a couple of reasons. Your white cells work better when they're warm. They kill bacteria better. The other thing is when you're cold, it reduces blood flow to your skin to help maintain your core body temperature. And when you reduce blood flow to your skin, you reduce the oxygen level in your skin and you're white cells use oxygen to kill bacteria.

Interviewer: Interesting.

Dr. Harriet Hopf: So when they're cold, they don't get enough oxygen to kill the bacteria. So the things that we do to make sure our patients stay warm in the face of anesthesia and a cold environment, we actually put a blanket on that blows hot air on the patients in the pre-op area. It's actually a great way to warm them up.

Interviewer: Kind of pre-warm them.

Dr. Harriet Hopf: We pre-warm patients, because if you're cold when you go in the operating room, it turns out it get you colder. So we pre-warm patients so that they're warm when they get into that cold environment and they're okay. And then we actually use those blankets during the operation on the part of their body that's not being operated on to keep their body temperature up by adding heat to their system. One more thing that actually works really well, it's not clear exactly who the right patients are to get it, but just giving your patient a higher inspire level of oxygen decreases their risk of surgical infection after a particularly high-risk surgery.
So if you have a high risk, it's easier to fix it, so patients who are cold in the surgery, the best studied, if they get 80% oxygen instead of 30% oxygen, have a reduce risk of infection. So that's a pretty easy thing to do, low risk.

Interviewer: Interesting.

Dr. Harriet Hopf: Everyone is trying to find out now what's the right amount of oxygen, who should get it...

Interviewer: Kind of fine tuning it.

Dr. Harriet Hopf: Fine turning. There's a lot of interest in dressings that can kill the bacteria so that you don't have ongoing bacteria. We give antibiotics. Antibiotics are a double-edged sword. They cause problems. Can we come up with ways to reduce the bacterial load on your skin without causing clostridium difficile colon infections and resistant organisms.

Interviewer: Like it can be great to get rid of the antibiotics entirely if you could.

Dr. Harriet Hopf: It would be lovely. So there is a lot of interest in what kinds of things you could put in the wound that would help kill bacteria. I know a lot of places are now using silver-impregnated dressing. Silver turns out to kill...

Interviewer: The metal silver.

Dr. Harriet Hopf: The metal silver. It's a special kind of the metal silver, but it's pretty good at killing bacteria, so there's a lot of interest in using silver-impregnated dressings on surgical wounds. When I think about how do you get infected, part of it is their bacterial load getting into the wound during the operation. But you always have bacteria on your skin. And you wash them of the surface, but then they come up from the deep levels. So if you put silver on them, then you can keep that level of bacteria down for several days, that can make a big difference.

Interviewer: Interesting. Briefly you had mentioned more risky surgeries. Are there some surgeries that are more likely to develop site infections that others?

Dr. Harriet Hopf: There are. So the higher risk surgeries include, if it's in a contaminated area. So the colon is a great example of, it's got a lot of bacteria in it. They do a lot of things to clean it out. Operations on the face almost never get infected, because there's a great blood supply. We worry about diabetic patients. When their blood sugar is not well controlled, their white cells don't work as well so they're at a higher risk. We worry about patients who have arterial occlusive disease, so if they are having an operation on their leg, and it's not great blood flow to their leg, they don't get as much oxygen. They're at a much higher risk for an infection.
There are some surgeries that have a lower risk of infection, but we spend a lot of time on, so joint replacement, usually hip and knee replacements. They usually have an infection risk of about one percent, between 1% and 5% variable, but...

Interviewer: Pretty good.

Dr. Harriet Hopf: Pretty low rate; however, if you get an infection after you get a metal prosthesis put in your knee, it's devastating. They usually have to take it out, because metal does not resist infection well. So it's a prolonged rehabilitation after that. So there's a lot of interest in getting the surgical site infection rate after knee surgery to zero, or after hip surgery to zero, because it's such a devastating complication. On the other hand, there are some surgeries where yes, you might get an infection, but it's not as devastating. You may have to do some wound care for a few weeks and then it gets better.
So I sort of look at it as there's the high risk, and I'm going to look at things that I can do in the high-risk patients, and I'm going to do it for all of those patients, because it has a big impact, because there are so many patients at risk. And then the low risk patients, where when they get an infection, it just is devastating.

Interviewer: Understood. So we talked a lot about what happens in the operating room, things that you are doing. But patients can actually do things themselves to help prevent these as well. What are some of those things?

Dr. Harriet Hopf: There is some idea that maybe your diet can be helpful. Let's say people who eat a lot of yogurt. There are countries where people eat a lot of yogurt and they have lower risk of surgical site infection, and there is an idea that that might help your personal flora. No studies showing that, but on the other hand, yogurt is not a bad thing to eat. It won't guarantee anything, but... People taking deep breaths after surgery make a big difference. So maintaining your oxygen level in your blood stream is really important.

Interviewer: Breathe from the stomach.

Dr. Harriet Hopf: Right.

Interviewer: What about smoking?

Dr. Harriet Hopf: Smoking is really bad. Smoking acutely, if you smoke a couple of cigarettes, it reduces the oxygen level in your skin by about 40% for an hour. So if you think of a pack a day smoker, their oxygen level in their skin is down 40% all of the time except maybe when they're sleeping. It probably comes back up to normal, so that's a big problem. And we know smokers don't heal well. And a lot of plastic surgeons won't do elective cosmetic surgery on smokers, because they know it's likely to fail.

Interviewer: So if a smoker knew that they had to get surgery, if they stopped smoking just a couple of days before, would that make a difference?

Dr. Harriet Hopf: That's an interesting question. So the answer is no, probably not. It makes probably some difference. But it turns out that there's a lot of affects of smoking that lasts for months after you quit. So you should quit now, just in case you have surgery in the future. There is some benefit of quitting right before surgery that you raise your oxygen levels, but your white cells still aren't working very well. Smoking is one of the biggest risk factors for surgical site infection that we know.

Interviewer: What else? Is there anything else that people should be aware of that they can actually do to help their doctor guarantee that they have a better outcome?

Dr. Harriet Hopf: If they have diabetes, controlling their diabetes is a really important thing. And that's one of the things that we look at. On the day of surgery, not letting themselves get cold before they get there would be helpful. Fluids are another important thing. Drinking enough fluids is really important for getting your blood supply to the wound and helping your body fight infection. A lot of patients now come in on the day of surgery. The anesthesiologist will make you not have anything to eat or drink overnight for safety so we don't want anything in your stomach when you become unconscious.
A lot of patients go home the same day of surgery and may not want to drink that much, but actually drinking fluids, keeping hydrated makes a difference. So that's something that patients can do particularly after surgery. Moving around is really important, kind of getting your blood flowing, but not, if it's particularly abdominal surgery lifting heavy things and stressing the wound, but a little bit of motion really helps with the whole healing process.

Interviewer: So it sounds like a good idea if you're going to be going in for surgery that you can actually as a patient do things. And just ask your doctor a lot of questions I think beforehand.

Dr. Harriet Hopf: Asking questions is always a great idea and finding out what is the risk of your surgery and are there particular things that you can do. And most surgeons can probably tell you things that you can do.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope. The University of Utah Health Sciences Radio.

My personal passion is: How do we figure out a way to value and measure the variety of indispensable contributions that our faculty make to schools of medicine? I'm working on how do we revise our retention, promotion, and tenure guidelines to reflect the diversity of things that faculty do that make medical schools fantastic.

My problem is: How do you capture excellence? How do you measure that your faculty member is excellent?

I think part of the barrier is we have a model, that everyone is comfortable in, that doesn't really work, which says there's only one way to demonstrate excellence and that is having NIH grants and publishing and discovery science.

I think the big challenge is to change the culture so that not that we say, "Educational scholarship isn't as good," rather that we say, "Wow, there are faculty doing amazing things that aren't related to NIH and discovery science." They're doing other kinds of scholarships, and we've known for 20 years that we should be counting those other kind of scholarship, and now we're going to change our culture so people say, "That's a really valuable activity."

What I see is that we now encourage people to follow their passion, which then transforms how patients get their care, which then transforms how healthy our population is. I think it's an opportunity to really take us back home and change fundamentally how we deliver health care, because I think everyone would agree it's not yet perfect.

For our leadership to be looking for members of our faculty who may not have leadership positions but who have innovative ideas and will be people who can change how we view our institution is really important.