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Group Approach with Physicians Working in a Medical Intensive Care Unit in a Public Hospital

A Group Approach with Physicians Working in a Medical Intensive Care Unit in a Public Hospital

by Aaron Beckerman, Ph.D. and Martin Doerfler, M.D.

 

A) The Humanistic Medicine Program

In the fall of 1979, under the leadership of Jerome Lowenstein, M.D., a Humanistic Medicine program was initiated at New York University Medical School. The purpose of the program was to provide medical students and physicians an opportunity to discuss and examine the non-medical aspects of medical education, i.e., self-expectations and expectations of others; making critical decisions in the face of uncertainty; the caring-curing paradigms; dealing with the hierarchy of authority in medical education; the nature of interactions between medical personnel and patients and families; the power and limits of technological medicine; the tensions between law and medicine; death and (prolonged ?) dying ; working with non-physician personnel-nurses, technicians etc.

The first Humanistic Medicine group rotated on the Medicine Units at Bellevue Hospital, a public New York City Hospital. We ran one group each quarter. The group was composed of a team, which included 3rd and 4th year medical students, a resident, and on occasion, the attending physician who was the head of the team. Over the years the Humanistic Medicine program has continued to grow. By September 1986, all of the six groups which rotated through the Department of Medicine every 10 weeks were involved in the Humanistic Medicine program. The seminar leaders of the six groups included three social workers, two psychiatrists, and one primary care physician. In January 1991, a Humanistic Medicine group was organized for Medical Intensive Care Unit (MICU) physicians.

1. Dr. Lowenstein is a senior administrator, faculty member and practicing physician at New York University Medical Center.
2. One MICU resident referred to the Medical Intensive Care Unit as the mechanical graveyard.
3. In the summer of 1991, a Humanistic Medicine group was established on the AIDS unit.

B) The Setting: Bellevue Hospital

Bellevue is a 1232 bed general municipal teaching hospital in New York City affiliated with New York University Medical Center. All of the faculty and house staff in the Department of Medicine at Bellevue is New York University Medical Center staff members. The patient population of Bellevue is a racially and ethnically diverse group of primarily lower socio-economic status individuals. Afro-Americans, Hispanics and Asians are highly represented in the Bellevue population. A large proportion of substance abusing patients are admitted to the hospital. English is a second language to many Bellevue patients, and not spoken at all by a sizable minority.

II. The MICU (Medical Intensive Care Unit)

The MICU at Bellevue Hospital has twelve beds and is staffed by a team of physicians, nurses, and social work respiratory therapy, and nutrition personnel. Only the physicians and the nurses are full time on the Medical Intensive Care Unit.

The medical staff includes two attending physician (one from the division of Pulmonary/Critical Care Medicine, and one from the division of Infectious Diseases), a Pulmonary/Critical Care fellow, three third year medical residents and four interns (one from the Emergency Room program, and three from the medical residency program).

The interns and residents rotate on the MICU for one month.

The patients in the unit have serious medical problems requiring advanced medical and nursing care. Emergency room (ER) patients requiring Intensive Care Services for less than two days are likely to be admitted to the ER Intensive Care Unit. Most patients transferred from the Emergency room to the MICU are likely to remain in the MICU for 10-14 days or more. This results in a very ill population with relatively long stays in the unit, and over time, a high mortality. Fifty to 75% of MICU patients are either comatose or heavily sedated at any one time.

On the average 4-6 patients die in the MICU each month. A large percentage leave with major disabilities that severely limit their ability to lead an independent life. An unknown but not insignificant number of MICU patients transferred to other units in the hospital are likely to remain and die in the hospital.
The major types of services offered in the MICU include constant physician and nursing attention, the use of mechanical ventilation (respirators), invasive cardiac monitoring, blood pressure monitoring, and emergency haemodialysis. Most patients have a multitude of tubes, catheters, and wires inserted into their body. Given that approximately 90% of MICU patients at some point are intubated, (i.e. are on a breathing machine), verbal communication between patient and doctor can be limited, or in some cases, essentially non-existent. As will be noted below, this is frustrating for the physician as well as the patient.
The MICU is the primary training unit for the education of medical and emergency room house staff in the care of these types of patients, and the use of these advanced technologies. This is a required medical education assignment for all interns and residents. Most interns and residents approach the MICU rotation with considerable apprehension. In the MICU, a wrong decision, or a delayed decision can result in irreversible damage, and even death. The Intensive Care Unit is intensive for the physicians as well as the patients.

The MICU culture is different than other hospital units. Whereas in most units of the hospital, the focus is on saving lives, and restoring patients to pre-morbid function, with a significant proportion of MICU patient, the issue is extending dying and delaying death.

III. THE HUMANISTIC MEDICINE PROGRAM: RECURRENT THEMES

Note: The group meets once a week for an hour at lunchtime. A physician and I are co-leaders. Pizza and soda are provided by the hospital.

In the remainder of the paper we identify some of the recurrent themes that have emerged during the past 20 months, and discuss our approach in addressing these issues. We conclude with a brief comment on our co-leadership experience.

4. The AIDS unit is an exception, but even in this unit, the likelihood of an AIDS patient leaving the hospital and returning home, even for a brief period of time, is excellent.
5. The co-leader physician is the administrator of the MICU at Bellevue Hospital. I have an affiliation with the Humanistic Medicine program but not with the hospital.

A) Working With The Family

With the high percentage of MICU patients who are intubated at any one time, the comatose patients, and those who either speak little or no English, verbal communication is more likely to be between the doctor and the family member, than between the doctor and the patient.
Taking care of the unresponsive patient is upsetting to many MICU physicians. Some MICU physicians say that working with non-responsive patients makes them as doctors feel less human.
Some of the more experienced residents have found a rationale, (or is it a rationalization?), to ease the stress on the MICU. They regard the rotation as a learning experience and take the position that what is learned will help them to be better doctors.

The group experience legitimizes the ambivalence and tension of working with so many end-stage patients. Once acknowledged, rather than an idiosyncratic problem, it becomes a common issue shared by all members of the group. A second consequence of working with these very ill and unresponsive patients is the reality that the relative is quite often the exclusive “live” contact for the doctor. One of the experienced attendings takes the position that the family is the patient.

We have identified a series of common scenarios that take place between doctors and relatives. For some physicians — this might be thought of as the rational mode physician — the objective is to provide information in such a manner that the relative will have a realistic understanding of the health problems of the patient. Doctors who believe in the explanatory power of information per se, without the attending emotions, are often frustrated when dealing with relatives, especially when dealing with highly educated relatives who are unable to understand or accept the health condition of their loved ones.

6. We are using the term family, relatives, lovers, friends as interchangeable (i.e., whoever is involved with the MICU patient.)

7. Under these circumstances we have used at least two approaches:

One examines the role of emotion in language, particularly in those situations that have the potential of a major change in the relationship between patient and relative, including death of the patient. In the group, we reach for what the relative may be feeling as well as thinking at the time. The skill of listening to emotions as well as to words are examined. The concept of process, i.e. where the relative is in relationship to perception – as well as “reality” – are explored.

Doctors are not counselors. They are very busy and their interpersonal skills are idiosyncratic. The function of the group is to help the unit physicians reach for a fuller understanding of the meaning of the illness of the patient to the relative.

A second approach is role-playing. The social worker, a non-medical person, may take the role of the family member. The role of the “simulated relative” always includes at least three elements: 1) The hope – often times unrealistic-that the patient will improve; 2) How certain is the doctor about the diagnosis, and especially the prognosis; and 3) The direct question: Is X (e.g., my wife!) going to live or die, and if the latter, when?

B) Caring For The Dying Patient With Little Or No Hope For Recovery

The situation is fraught with complications. What is the quality of life of the patient, and who decides when treatment should be terminated- Patient? Family? Physician? State? In a large proportion of MICU cases the patient comes into the unit heavily sedated, often intubated, sometimes comatose. In some cases, the patient informed a relative or a hospital staff, that they wanted to be kept alive under all circumstances.

The law in New York State is clear. Unless there is conclusive evidence that the patient, or the surrogate requested some limitation in the treatment, they will receive treatment as long as there is a positive response to the treatment, even if the positive response is temporary. This can sometimes lead to prolonged treatment with no hope of permanent recovery.

Physicians are often frustrated in working with the dying patient. The financial expense of keeping end-stage dying patients alive for days, weeks, and sometimes months is regarded as irrational by some physicians. The problem becomes increasingly complex if the patient has asked to be kept alive as long as possible, and there is no relative or surrogate who can intervene.

A recent incident captures the sense of outrage and frustration experienced on the unit. An intern was drawing blood from a comatose AIDS patient with little or no hope of recovery. The intern stuck herself with the needle. At the group meeting, which occurred two days after the incident, the group vented their anger at what they regard as the irrationality of keeping the patient alive. The intern, who had been stuck, gave us permission to discuss the issue but said that she was too upset to participate in the discussion.

One of the co-leaders took the role of a lawyer and explained that the choice of life or death was not up to the physicians except in those cases in which the treatment was “futile”, i.e. there would be no medical results from the treatment. This was an opportunity for the group to express their feelings, and perhaps even more important, to begin to recognize and come to grips with the role of law and how it intersects with and constrains the options of the medical profession.

The premise of the law was identified, i.e., society expects doctors to keep patients alive and does not trust physicians to make life and death decisions. This did not go down easily among some of the group members, especially the interns.

The session ended with one of the interns talking about his grandmother becoming critically ill, and the problems he had in deciding when to let her die. On a more personal level, the group began to explore what might be involved in making the decision to stop treatment for a loved one.

C) RELATING TO MICU PATIENTS

On occasion, patients who are of similar age and social status to the MICU staff are admitted to the unit. If the patient is able to communicate, the likelihood of a relationship between the physician and patient increases significantly.

Ms. Jones, age 26, was admitted to a ward unit by Dr. Brown, an intern. Her medical condition at the time of admission was not considered serious. Dr. Brown went out of his way to make life a little easier for the patient, i.e., he made sure that she had her dinner; kept a rather close watch over her treatment; found time to occasionally sit and visit with the patient. Ms. Jones became increasingly ill. She was admitted to the MICU. Dr. Brown rotating on the MICU encountered Ms. Jones who by this time was unable to verbally communicate. Dr. Brown and Ms. Jones exchanged notes. When Dr. Brown came around, Ms. Jones would reach out for his hand, and they would hold hands for a minute of two. As her condition worsened, Dr. Brown would try to reassure the patient that she would get better and leave the hospital. She died in the MICU.

The group spent a meeting on this event. One physician took the position that he would always keep some distance from his patients and never, in his words get “over involved.” A hot and heavy discussion followed, with most of the MICU physicians taking the position that relating to patients is an important component of being a doctor. Different physicians told of a special relationship with a patient, how hard it had been, and how valuable. Dr. Brown, visibly upset, had the last word at the meeting. He said that it has been and still was extremely upsetting but that given the opportunity, he would do it over again.
“Desensitization” in its various forms is frequently raised in the group meetings. Sometimes it comes from the interns who are being exposed to MICU patients for the first time. To the intern, the resident can appear detached and emotionally uninvolved when performing a procedure that is obviously painful to the patient.

Residents are appropriately sensitive to being labeled “desensitized,” and yet there is some truth to the claim. In the group meetings, we have an opportunity to explore the dimensions of a relationship between doctor and patient that includes treating the patient, caring for the patient, and simultaneously protecting the physician from the ongoing experience of working with dying patients. In the group, we seek to explore this necessary doctor-patient dilemma, within the context of specific cases. It is essential that the term “desensitized” not be used as a pejorative medical generalization.

D) INTERACTION WITH COLLEAGUES

The stress on the unit sometimes generates tensions between MICU team members. Medical education, it should be noted, is hierarchical with a specific set of rights and responsibilities determined by rank, i.e., medical student (1st, 2nd, 3rd or 4th), intern, and resident (1st, 2nd or 3rd), fellowship, attending, etc. Under tension, utilizing their status and authority, residents sometimes dominate the group meeting, leaving little or no opportunity for the interns to participate in the meeting, or to express difference with the residents.

The highest authority in the group meeting is the physician co-leader. If need be, he is able to be an advocate for the interns, at least to the point of permitting the interns to participate in the meetings, and to have the opportunity to express their own point of view. (7)

MICU patients are referred to by some physicians as “interesting cases.” This usually means that the patient has a set of complex medical problems that are not amenable to a clear and definitive diagnosis, and are not responsive to treatment. Other hospital departments, such as surgery, pulmonary medicine, cardiology etc., which originally transferred the patient to the MICU, sometime follow the patient in the MICU. In consultation, the outside department consultants may seek to control the treatment offered to the patient. Interdisciplinary issues raised in the group meetings are sometimes brought to an interdisciplinary hospital-wide medical team on which the co-leader physician sits. On other occasions, the incidents suggest a less than clear message from the MICU staff to the consultant.

Attendings also rotate through the MICU on a monthly basis. They make rounds with MICU staff and in the main, have an educational function. The group provides an opportunity for the group members to examine the “fit” between the attending and the specific MICU monthly team. (8)

MICU staff often deal with situations that require the assistance of non-ICU nurses, technicians, transport personnel etc. (9). Comments are sometimes made about how hard the MICU doctors work compared to other hospital personnel.

7. The co-leaders usually meet at the end of each meeting to compare impressions. Domination by one or more group members is quickly identified and addressed, either prior to, or at the next meeting. For further discussion of co-leadership, see Co-leadership below.
8. Attendings do not usually attend the group meetings.
9. Since the MICU Humanistic Medicine program began in January 1991, there has not been a single negative statement about ICU nurses. If discussed, comments about ICU nurses have always been positive.

The opportunity to ventilate is sometimes helpful. On other occasions, one of the co-leaders may take the position, for example, of the non-ICU nurse and discuss her working conditions, nursing shortage, and responsibilities. This becomes an opportunity in which one of the co-leaders seeks to provide information and a perspective that will contribute to a fuller understanding of the issues confronted by other hospital personnel. This is an example of one of the objectives of the Humanistic Medicine program: reaching for a fuller understanding and appreciation of the other actors in the hospital drama

E) CO-LEADERSHIP

The MICU physician co-leader and the social worker have been working together for over 20 months. We have learned a few things about each other. Whereas the social worker is comfortable with silence, and in some cases seeks to promote silence, the physician co-leader tends to avoid silence.

At times, the social worker becomes emotionally involved in pursuing an idea, a feeling, or some partially articulated value, and is given a signal by the co-leader that someone else in the group wants to talk.
At some level, the social worker is the “inquiring outsider” i.e., what does that medical term mean? How do you know that the patient can’t hear you? Please talk to me as if I was the relative? Why should doctors be able to make decisions as to who should live and who should die?” etc., etc. This is a role that only the social worker can play and in this role the social worker is fully supported by his co-leader.

In addition to his role as administrator, the physician co-leader is regarded by medical colleagues as an outstanding physician. Among other things, he is one of the experts on advanced medical technology in the hospital. If left on their own, the MICU staff is likely to direct their comments in the group to the physician administrator co-leader.

They are not left on their own. The social worker is a respected leader in the group. Perhaps by design, the social worker always sits at the head of the table. In almost all cases, the social worker begins and ends the meeting. The mutual respect between the co-leaders sets the tone for the meeting.

The physician co-leader is a member of the ethics committee at the Hospital. He is extremely knowledgeable about State Law and the rights and responsibilities of patients, relatives and physicians. The social worker, while acknowledging the law, sometimes seeks to go beyond the law, and examine the value premise of the law, and most importantly, the value position of the group members.
As co-leaders, we have an honest, open and supportive relationship that allows us to be critical of our work. In reality, it seems as if we spend a considerable amount of time recognizing the contribution that we each make to the program.

F) CONCLUSION

The young doctors in the MICU spend their days and nights among critically ill patients and grieving families. The Humanistic Medicine program provides them with an opportunity for much needed reflection, emotional catharsis, mutual understanding and support. The weekly Humanistic Medicine group meetings might be thought of as a “safe harbor.” The combination of a physician and social worker as co-leaders promotes and supports these endeavors.

How to Cite this Article (APA Format): Beckerman, A. & Doerfler, M. (1992). A group approach with physicians working in a medical intensive care unit in a public hospital. Symposium of the American Association of Social Work with Groups, Atlanta, Georgia. Retrieved [date accessed] from /recollections/a-group-approach-with-physicians-working-in-a-medical-intensive-care-unit-in-a-public-hospital/.

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