Dr. Robert Milch: Surgical Palliative Care Pioneer

#002 - Join host Dr. Red Hoffman as she interviews Dr. Robert Milch, one of the pioneers of the Surgical Palliative Care movement.  Bob discusses the early days of the American College of Surgeon's Surgical Palliative Care Task Force, his career with Hospice Buffalo and what he learned through helping to set up hospice programs throughout the world.  He also shares how some of the giants of surgery, including Dr. Olga Johannson and Dr. James Cameron, were early supporters of the surgical palliative care movement.  Finally, he reminds us of the importance of taking the time to both read and reflect as we work with critically ill and dying patients. 

Books mentioned in this episode:
Mortal Lessons: Notes on the Art of Surgery by Richard Selzer, MD
How We Die: Reflections on Life's Final Chapter by Sherwin Nuland, MD
Intoxicated by My Illness and Other Writings on Life and Death by Anatole Broyard

To learn more about the surgical palliative care community, visit us on twitter @surgpallcare.

Transcript

spk_0:   0:13
surgical. Palliative care may seem counterintuitive, but surgeons have a rich history of pallid both their patients and their families. I am Red Hoffman in acute care surgeon in Asheville, North Carolina, and one of 79 surgeons currently board certified in hospice and palliative medicine. Join me as I interviewed the founders and the leaders of the Surgical Palliative care Movement, a diverse group of surgeons dedicated to providing a high quality palliative medicine to all surgical and trauma patients. Welcome to the surgical palliative care podcast. We heal with more than steel. Hi, everyone. This is Red Hoffman. Thank you so much for joining me for another episode of the surgical palliative care podcast today. I'm so excited to be interviewing Dr Robert Milch. Bob, as he likes to be called, is a general and vascular surgeon who has been involved in hospice and palliative medicine since 1978 and is considered one of the founders of the surgical palliative care movement. Bob, thank you so much for joining me today.

spk_1:   1:39
That's my pleasure. Thank you.

spk_0:   1:42
You're welcome, Bob. As we're getting started, can you please share a little bit about yourself with myself and our listeners? basically where you grew up, where you trained and why you chose to pursue a career in surgery. I

spk_1:   1:57
grew up in Buffalo, New York, trained here in general vascular surgery of the university program. After a brief stint in the service went into practice at the Buffalo Medical Group, we had a very active program. University affiliated hospital. Somewhere two or three years into practice became involved in a fledgling program related to the development and evolution of hospice service is that became formalized in 1978. We were the 11th Hospice program in the country, and while it was perhaps somewhat unusual to have a surgeon as the medical director, it it felt very comfortable to May. I think a lot of that goes to a couple of things, not the least of which Waas my family. My dad was a surgeon. He came up through the Depression and the Second World War and always conveyed into all of us the sense that what went on in the operating room waas A. At the end of the day, a small part of the totality of the care of the patient. I think he had been sensitized certainly the son of immigrants, having had to earn his stripes a time when, uh, there was bias in admission to schools and to hospital staffs for Jewish practitioners. And as I've reflected on the many things he taught often bye aphorism always by example. I think that sensitized me too, the desirability of taking a holistic, if you will view of the practice of medicine and of surgery in particular. He taught us that every surgeon should have three things. He's a sense of humor.

spk_0:   4:37
E I got that,

spk_1:   4:40
a sense of humility and an incision because then you could really understand the experience off illness on the role of the surgeon, meeting the needs of the patient and the family.

spk_0:   4:57
Thank you so much for sharing that. That's pretty profound. So it sounds like the seeds were planted for you to be this holistic practitioner by your father. But looking back where there any experiences or patients at the beginning of your career, that kind of lead you into wanting to pursue a career in hospice. There

spk_1:   5:20
were there were several red one. I never for gotten Waas a patient and he now being gone. I can I can share his name by the name of Tom Kericho. He had a complicated bile duct injury, and he lingered in critical care for a month before he died. And for all my earnestness, I was unable to certainly to cure him, but also felt chagrined that I wasn't adequate to relieving the distress that he was in, whether it was physical or psychological or existential. I was always acutely aware of my shortcomings in rendering care. I think some of it also I was an English major. And so I think I was receptive to some of the insights and philosophies, teachings and writings of physicians such as, uh, Anton Chekhov, for example. And then, as we moved into, huh, more recent authors reading What Cicely Saunders and bound Mt. And the early pioneer Sim, the evolution off palliative care at that time, primarily hospice care and what they contribute, what their insights were, and then to be able to appreciate the writing's off the Richard sells Er's and with Czech, Newlands and the other surgeons who contributed so much to the insights and if you will, The poetry of what we do is physicians and especially surgeons. Uh, that's a fertile ground with me. And then then I must confess, I, uh I like the challenge of formulating a hospice program, preaching, if you will, and bringing that kind of insight into the practice of First Hospice and then in his broader context, really care. Finding marvelous colleagues with him too Insult Tyra Biotic and Jeff Dunn and a whole slew of others. They coming to realize that we weren't alone and what we were trying to accomplish.

spk_0:   8:17
So I know you got started doing this work back in the seventies. At that time, did you have any other surgeons as part of your community, or were you finding support amongst medical doctors? Or were you finding no support at

spk_1:   8:33
all? Most of the support we found initially but was in the public. There was certainly demonstrably ll need for the practice of the tenants of palliative care, family of medicine and its embodiment in a comprehensive, interdisciplinary approach which Hospice offered. Like perhaps most surgeons, he appreciate the challenge off overcoming resistance. Perhaps on of promulgating a philosophy which inherently resonated with not only why we become physicians, but why we become surgeons.

spk_0:   9:22
Hey, how do you think you're early hospice work changed you and your practice as a surgeon.

spk_1:   9:30
It changes you slowly that once we come to the realization that so much of what we do eyes ultimately palliative, that leads us to being able to redefine a good outcome. And if you're only acceptable, outcome is cure. We are destined to be broken hearted and so redefining what we can bring to the bedside as a presence as a facilitator of patients and families. Continued growth at the end of life when you're is no longer a reasonable expectation that is fulfilling. And certainly that kind of professional fulfillment is what we all crave.

spk_0:   10:29
I'd agree with you there. I know some of my, um, most memorable experiences in the past year to have been those patients that I cared for first as a surgeon or in thesis Tickle intensive care unit, and then got to see them and care for them again as a hospice, attending and feeling that full circle and knowing that in the end I was still able to provide care even though I wasn't able to cure them. I think really brings a lot to the families, but really brings a lot to me as a physician, as an as a surgeon as well.

spk_1:   11:07
I would agree with you. It's ah, it provides a continuity and Carrie and that all too often we lose, I think, also, considering my own case, one of the things that took me to eventually leave surgery onto do palliative care hospice work full time was an increasing frustration with the way surgical practice and teaching was being carried out. We would assemble in the holding area with House officers and students who had not participated in the preoperative evaluation of patients. Uh, we're not going to participate meaningfully in the vast majority of cases post operatively. And while we were training technically competent young surgeons, in reality they had very little idea of what the experience of illness was all about. And that denigrates, I think, with a demonstration of the notion that while we deal with organs and diseases which occur in organs, illnesses, of course, occur in people. And it was almost to my thinking, a conspiracy against allowing young surgeons, surgeons and training to grow into this role. Not just a doctor, a surgeon, but surgeon s physician.

spk_0:   12:51
It's interesting. I hear you bring up those two words a lot, that idea of a physician and a surgeon, and I try for my self and for my trainees to remind ourselves that we are physicians. First, we all become physicians first, and then we become surgeons. And sometimes I feel like in that becoming, we lose part of what it means to be a true physician, a true healer, because we're focused so much on technical excellence, and we forget that truly, a lot of that healing does occur at the bedside. Um, maybe late at night, after all the work is done and you're going back to sit with the patients and the families again, it's it is easy to forget that, especially during training when we are so busy and tasked with learning so much

spk_1:   13:41
and just trying to get through the day. Yes, you know, becomes the challenge. My father had, uh, different ways of expressing that if you'll forgive the vulgarity used to say, you have to let the patient know that you care whether he should, sir goes blind. Hey, he had a very plain spoken way about him many times.

spk_0:   14:05
I love it. I love it. So I have a question. I feel like nowadays when I'm Consul Ting palliative care for some of my patients. I feel like I spend a lot of time educating patients, families and oftentimes other providers in the hospital about the differences between hospice and palliative medicine. And I'm wondering, when you first started this work back in the seventies, was that discussion going on? Or we're both of these disciplines hospice and palliative medicines so new that there wasn't so much work to kind of differentiate between the two?

spk_1:   14:46
That's a terrific question. We were so engaged involved in gaining a toehold for hospice that the notion of palliative care, if you, if you will, was almost secondary. We participated in Hospice Buffalo. We were one of, ah, few demonstration programs, starting in 1978 for the federal government that looked over a period of three years. They tried to figure out what this new horse in the race was all about. The Medicare aggregated data from I believe it was 12 national programs over a period of three years because there was no reimbursement for anything we did. I was a volunteer, but most of the staff. Was volunteers there being no reimbursement? We would check the obituaries frequently. Just if any grateful families had left the quest. For example, tow this buffalo because it was very much a hand to mouth organization the and program. After three years, they took this aggregated data to David Stockman, who was President Reagan's director of the Office of Management and Budget. And they said, All right, well, if you had X number of patients theoretically eligible for these service's thes comprehensive certain and why amount of money allocated for that, how long could you afford to pay for those? Service is, and Mr Stockman said, six months or less

spk_0:   16:40
is that where the six months came from,

spk_1:   16:42
And that is where our definition of terminal illness came through.

spk_0:   16:48
That's fascinating. I never knew that story

spk_1:   16:51
so, but that was a lifeline at the time because there was no reimbursement from the third party payers, a TTE that dad ploy from that, though it became possible once we'd earned our stripes and were able to demonstrate the appropriateness of what we were doing, the efficacy of it, then we could start to broaden the application of the principles of paillade of medicine. The phrase now is moving upstream so that rendering end of life care did not necessarily have to be a prognostic lee driven undertaking. We saw that the principles of payload of medicine were applicant ble along the course of illness and becoming Fassel competent. And it's rendering. We were able to make the case to those who might prove receptive to what? That we have a lot to offer, whether or not a patient happened to be dying.

spk_0:   18:01
Can you speak a little, too? How the American College of Surgeons first began considering the issues of death and dying. My understanding was that the initial conversations were really focused through the ethical lens of physician assisted suicide and kind of moved on from there. But please correct me if I'm wrong.

spk_1:   18:22
No, uh, that's absolutely correct. And there were a number of very engaged presentations at the college on among, particularly among surgeons, which began with medical aid in what we now call including referred to his medical aid in dying physician assisted suicide. I had the exquisitely good fortune to have been introduced to Dr Jeffrey Dunn, a surgeon in Erie, Pennsylvania, introduced by IRA by hockey. Who said there seemed to be two surgeons because you're interested in this? Jeff and I wrote an editorial for the bulletin of the college on Dhe from that found that there was a con GRE ho surgeons who, uh, were not only interested in end of life care and roll of surgery and end of life care. But we're passionate about it from that, with the good graces and encouragement of the college, developed a task force of like minded souls and developed a number of different programs undertaking which has just muscled ah, subsequent way.

spk_0:   19:54
How did you feel that this group was received by surgeons in general? Did you find when you went and spoke with people that surgeons were open to these ideas of surgical palliative care that you were proposing or were you met with? Skepticism

spk_1:   20:13
is certainly some skepticism, but I think perplexity but was it was probably the most common initial reaction tease. You know, surgeons interested in this touchy feely kind of stuff. But once we could dialogue with her with our colleagues pointing out what were generally acknowledged deficiencies in many of the aspects of care which we could render that our dependency on so many of our colleagues in internal medicine. Ah, that these were not antithetical to the history of surgery. Surgeons respond to the need to relieve suffering and expanding the receptivity, the acknowledgement and recognition of suffering in Beijing's, whether they be dying or not, and recognizing the contributions that surgery can offer. This is part of our history. This is on dhe. It's, uh, perhaps the proudest part of what we surgeons can can bring to the to the bedside as well as to the operating table.

spk_0:   21:41
I know that the surgical palliative care work group formed really 20 years ago now, and I'm wondering, Looking back, what do you see as the greatest accomplishments of this work group?

spk_1:   21:53
The greatest accomplishment, I think, is the recruitment of young surgeons to giving them a format in which to address everything from the mastery of you will of the more technical aspects of palliative care medicine to recognition of the role that Palin if Garrett medicine lays in everything from surgical bioethics to the training of young surgeons to development of cure Killa, so that some aspects of Bailey to fair are now incorporated in the vast majority of teaching and training programs. Younger surgeons such as yourself who have taken up this mantle. It was interesting, in retrospect, to see how so much of this evolve by enticing colleagues and palliative care medicine who were non surgeons into the notion of teaching program. I think particularly of great teachers like Tim Quill, David Weisman, who were wonderful educators and finding a way to melt their efforts with those of the college. And as the college became more receptive to, uh, if you will, welcoming outsiders such as David Weissman developing those comprehensive teaching programs which have now given 1,000,000,000 of care medicine in surgery such a strong foundation and foot hole we had we had a number of interesting encounters, particularly Jeff Dunn and I along the way. One waas introducing David Weissman to Dr Olga Jonas. Um,

spk_0:   24:01
can you tell for the audience, please who Olga Jonasson is?

spk_1:   24:05
Dr. Jonasson was the president of the American College of Surgeons at the time on Dr Weissman, professor of internal medicine palliative care at Wisconsin, who had developed a teaching program for non surgeons but bringing the two of them together. Now Dr Jonasson was about 61 As I recall, Dr Weissman's about 57 eyes go, bringing the two of them together with Dr Jonas UN's healthy skepticism off anything non surgical and Dr Weissman's passion for teaching and seeing his role as the camel's nose in the tent working together with her support, furthering the work of the of the Billions care work group, the other WAAS bringing a recognition to surgeons off everything they had to contribute. It was arranged for Jeff and me to meet with Dr Camera at Hopkins to see if we could interest him in furthering some of the work of the group. Certainly the imprimatur of Johns Hopkins and John Cameron could only be helpful at the appointed time. Jeff and I walked down the hall weeks of Hopkins to Dr Cameron's office. In that hallway has the pictures of every chief resident who's ever trained at Hopkins near as I can Tell, and into Dr Cameron's office, which I believe was also Dr Halstead's office. The tradition oozes from the walls, and Dr Cameron came into the meeting having just left the operating room. I'll never forget how starched and white his lab coat waas and with a little bit of skepticism, said, Well, what do you think you can teach me about palliative care? I just left the operating room of a patient who has cancer of the pancreas, with which we thought we could resect and which it turns out we couldn't. What can you teach me about palliative care medicine? After the bypass, we did. And after Jeff and I, uh, we're through tightening our swingers. We said, with all the respect that we could muster, Dr Cameron, you just went to talk with the family and broke the bad news of what the findings were in surgery. Was your chief resident are junior resident with you to see how you did that and to his everlasting credit? Dr. Cameron sat down, and we had a very engaging conversation over about 1/2 hour. And Dr Cameron then made it possible to have a conference at Hopkins about surgical palliative care.

spk_0:   27:21
I think about that a lot that the majority of surgeons, especially and especially ah, surgical trainees are not going to go on to pursue a fellowship in hospice and palliative medicine, and how so much of primary palliative care can really be learned by watching others who are slow skilled. And I'll often tell people who are asking, How do I learn this? And you know, if you have a good palliative care team at your hospital just going and observing some family meetings, you can pick up so many good tips that can really serve you and your patients so

spk_1:   28:01
well. You're absolutely right. And it's the question of exposure way. All learn. We are all mentored by example. We learn from watching other surgeons. We can take the teachings beyond what we need to cut in. So precisely, and just by participating, watching, learning, incorporate those lessons in tow, our own behaviors and our own practice patterns.

spk_0:   28:32
I also tell people that I find that patients and families are so forgiving and that if they realize that you're trying your best and coming from a place of love and really just speaking from your heart that you know, if you say the quote unquote wrong thing that they really will understand that they can see that you're really just trying to care for them on another level and that it's it is okay to practice. In some ways it's it's the patient room is a safer place to practice because you're not going to cut the wrong thing or inadvertently hurt someone. If you're coming from ah, place of love and support for the patient and their family, I really think you can't do any

spk_1:   29:14
wrong. It's demonstrating that you care. And that, too you will not abandon them. You will stay engaged, and you will provide all the assistance you can as a caring, human being as well as a surgeon and a physician.

spk_0:   29:33
So, Bob, I'm going to switch gears a little bit because you've done so much in your life. I wanted to ask you some other questions. I know that you worked as a member of the Palliative Care Concensus Guidelines panel of the National Cancer Center's network, and I'm wondering if you could tell us a little bit about that experience. And I'm also wondering if you were the only surgeon on that panel and what you felt you brought to it.

spk_1:   29:59
My recollection is that I was initially the only one, or if there were others, I'm sorry I didn't spend more time with him at the bar. There were. There were others Eventually. The major thrust there, though, came from the specialties from physicians like Susan Bloch. Thinking about it now read. Dr Steven Edge, a on ecological surgeon here in Buffalo, was also part of that program. But working through it, I became aware of my own inadequacies. A Ziff. I needed a reminder. But these are educators. I was always primarily a clinical practitioner, but I was no little bit in awe of watching them as they discerned goals, objectives and the practicalities off what needed to be set as benchmarks for all of medicine to practice, to be aware off what it was needed and to have to be able to construct ladders to reach those heights. It was, ah, formative experience for me, but I'm not certain that it was so much the role of surgery as it was in the there explication of what excellent, comprehensive care of the cancer patient rot.

spk_0:   31:51
Yeah, the guy those guidelines air just an excellent resource. I feel so I know that you've also served as a consultant for multiple countries as they've started their national hospice programs, and I'm wondering if you can talk to us a little bit about that. I'm particularly curious about, um the role of various cultures and how their views about life and death ultimately affected how they're hospice programs. Functioned.

spk_1:   32:23
Ah Ah, wonderful question. Particularly in 1995 we were asked by the government of Hungary to assist them as they went to establish a national hospice program. This was another learning experience for me because by then we were pretty full of ourselves in terms of what we had been able to do to demonstrate the efficacy of the interdisciplinary team. So when we went, we produce some very learned presentations, lectures, workshops, and it was then that I fully appreciated that we were on A M and they were on FM because we were in a country dealing with a society where we I really did not grasp their priorities, which were How do we get through the night? The notion off sustained release opiates, for example, who is that really understood in a country where if you wanted to get a patient at whole adequate pain relief, you had to make an appointment for a nurse to go out and give an injection we had with us as part of our team, a community pharmacist with whom we had worked extensively. Man, my name is Greg Pulliam. We really didn't have standardized pharmacologic solutions, for example, for aural medications or liquids. And what great Polian would do is he would take morphine powder and mix it with Kalua. Whatever the APA chief of choice was for the patient, and that became our liquid morphine. And the audience was more interested in what the community pharmacists had to offer, then what the learned practitioners could tell them about around the clock dozing of opiates and other medications. The lesson learned Waas to understand what the audiences priorities might be. And if you're going to meet their needs, you've got to understand their needs and the cultural gap. We subsequently worked lessons learned in Slovenia, Croatia on, and I'd like to think that we we made a contribution there as well. But as you know, there are great difficulties in the dispensing, the supplying off adequate, certainly opiates in countries including our own. On Dhe. That continues to be a problem, but it was lesson learned.

spk_0:   35:49
Sounds like it. Speaking of lessons learned, do you have any advice for young surgeons Or maybe not even so, young surgeons who are interested in integrating more palliative medicine into their practice.

spk_1:   36:07
You know, my first impulse Red is with confidence and faith in the intentions. Off practitioners today, especially surgeons, is too read and to read what other surgeons have written. Because I have found that that is what expands the appreciation of the experience of illness and how we can best meet the needs of those whose situations clamor for palliative care. One of my favorites is from Richard Selzer, who writes about a patient of his one of his old professors, who we operated for a perforated ulcer, and his His prose is like poetry, But he writes about the relationship between the nurse in the I. C. U. Hu is tending his patient, who is proceeding to die and how tenderly and lovingly they establish the relationship by a caregiving. And the last words in that that, he writes, are one never knows whose hands will stroke from his lips, the last bubbles of his breath. That alone should make one kinder to strangers.

spk_0:   37:45
Oh, that's lovely.

spk_1:   37:47
There are insights from the literature from Selzer and Newland and Anatole Broyard who wrote a wonderful tome, Intoxicated by My Illness, that harken to the humanity that we all share and which are best days, we're able to bring either to the Operating Theatre into the bedside.

spk_0:   38:12
Well, we'll be short list those books in the show notes so that during our free time we can actually do some reading that will inspire us. Thank you for that. I think it speaks also to the connection between narrative medicine and palliative care and that, um, rich history of taking the time to really write down kind of our thoughts and our feelings and our experiences so that we can really learn from them. And I know a surgeon's We don't always really have the time or or take the time to reflect, but I think it speaks to like this kind of end of light this palliative care and then end of life work really requires us to do some reflection at the end of the day,

spk_1:   39:08
agreed. And I think that's very perceptive on your part and and to realize how constrained we are for time, which is to the detriment of our care. Robert Penn Warren wrote that the secret of every story is time, but you must never speak its name to understand, you know, to appreciate that and the necessity of making time. This has got to be one of our drivers as well as to excel in all the other aspects of our care

spk_0:   39:48
has we're wrapping up. We'll fast forward time a little bit, and I'm going to ask you looking forward to the next 20 years. What do you think are the most important goals for the field of surgical palliative care?

spk_1:   40:03
I think that the goal needs be to incorporate the exposure of young surgeons to the competent, practice off palliative medicine that is going to involve, as you intimated, earlier exposure to what has become acknowledged as the state of the art. In they leave care practice, that means spending time. There's the word but spending time with the Pilate of care teams, recognizing that that the mandate for competent palliative care arrests not just on one practitioners so shoulders. Neither is it possible for one practitioner to render comprehensive palliative care. But that one practitioner also needs to be the night ISS of the principles of caring for the patient and about the patient, but then operational izing it care delivery through the use of our colleagues and the interdisciplinary team, which has become evident. That was the lesson from hospice. What is that? It's It's more than one person responsibility, but it is our duty.

spk_0:   41:41
Mmm. Thank you so much, Bob. One for joining me on this episode of the surgical palliative care podcast. But two for your work, your vision, your enthusiasm and your dedication to making certain that surgical patients receive the high quality palliative care that they deserve. It was so great speaking to you and so exciting to hear some of our history. I just love all these stories and so I'm really grateful for your time. Well,

spk_1:   42:13
that's very gracious of you, right. Thank you. Thank you for what you're doing. I think it's a really contribution, and I am most appreciative of the opportunity to be

spk_0:   42:24
part Thanks. Thank you for joining us for another episode of the surgical palliative care podcast. Be sure to subscribe to stay up to date on the latest episodes toe Learn more about the surgical palliative care community. Follow us on Twitter at Serge pal care if you'd like to get more involved with the surgical, palliative care social media team, please reach out on Twitter or via email at surgical palliative care at gmail dot com. Lastly, take good care of yourselves and take good care of each other.