Dr. Sharmila Dissanaike: Wellness and Ethics in Surgery

#008 - Join host Dr. Red Hoffman and co-host Dr. Mackenzie Cook as they interview Dr. Sharmila Dissanaike, professor and Peter C. Canizaro chair of surgery at Texas Tech University Health Sciences Center.   They have a wide-ranging discussion about leadership, wellness, disaster ethics and the role of social media in academic medicine.  Sharmila shares some of her journey to becoming a chair of surgery, discusses the importance of maintaining a growth mindset and emphasizes the need for all of us to maintain an interest in the nuance of our current situation, rather than on searching for black and white answers.  Once again, we also talk about the benefit of being a "spork" (neither a spoon nor a fork!). Join us for a great conversation!

Resources discussed in the episode:
Ethical Framework for the Allocation of Resources in the Event of Shortages by the American College of Surgeons Committee on Ethics

Ethics of PPE Allocation by the American College of Surgeons Committee on Ethics

ACS-MacLean Center Surgical Ethics Fellowship

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

Transcript

Red Hoffman:   0:13
Surgical Palliative Care may seem counterintuitive, but surgeons have a rich history of palliating both their patients and their families. I am Red Hoffman, an acute care surgeon in Asheville, North Carolina, and one of 79 surgeons currently board certified in hospice and palliative medicine. Join me as I interview the founders and the leaders of the Surgical Palliative care movement, a diverse group of surgeons dedicated to providing  high quality palliative medicine to all surgical and trauma patients. Welcome to the surgical palliative care podcast. We heal with more than steel.

Red Hoffman:   1:08
Hi, everyone. This is Red Hoffman. Welcome to another episode of The Surgical Palliative Care Podcast. Today I'm joined by my favorite co host, Dr McKenzie. Cook. Mac is an assistant professor in the Department of surgery at OhSU in Portland, Oregon. Hi, Mac. Thanks for being with me.  

Mackenzie Cook:   1:28
Oh, thank you for having me. It's a blast.  

Red Hoffman:   1:31
And today Mac and I are so excited to be talking to Dr Sharmila Dissanaike.  Sharmila is a professor of surgery and the chairwoman of surgery at Texas Tech University Health Sciences Center. She serves on the Ethics Committee of the American College of Surgeons and is the former chair of the Ethics committee for the American Burn Association. Sharmila, Thanks so much for taking time out of your busy day to be with us.

Sharmila Dissanaike:   1:58
Thank you very much for having me. I've been looking forward to this.  

Red Hoffman:   2:01
So, Sharmila, as we're getting started, can you share a little bit about yourself? Where you grew up, where you trained, why you decided to pursue a degree in surgery and how you became a chairwoman of surgery.

Sharmila Dissanaike:   2:15
Okay, how much time have you guys? But,  all right. So let's see. I think one of the characteristics, and I learned this more and more as I grow older, is that I have always been a perennial outsider. And there's some interesting literature in the sociology world, actually on how that influences how you look at things. And so when I was a child, Sri Lankan proudly by birth and my parents moved. When I was two years old, we went to Zambia, and then we went to Antigua in the West Indies. Then we came back to Sri Lanka mostly because they wanted me to be educated there at home. And after that I got a scholarship to go to Australia, finished medical school there and worked in Scotland for six months before coming to the US for surgical training. So, you know, I've been an itinerant wanderer my whole life, and I think that actually does influence a lot of how I look at things. Because I can watch people interact and do things from a certain perspective while gaining some ideas of how they're shaped by their place, time and culture. And I think that has a lot to do with how I later evolved an interest in ethics and palliative care. I actually went into medical school wanting to be a psychiatrist. I've been fascinated with how the brain works and how we think and why people function.  And so that was my area of interest. And then I got into med school and psychiatry clinical practice was not what I had envisioned it to me. It definitely would not have been a good idea that I pursued that, and instead I found surgery to be appealing because the other trait I have is I am incredibly impatient, and I like that If something could be done, just get it done and move on. Quick fixes and surgery was very elegant in its ability to diagnose a problem and have a solution and if not cure at least we'll significantly the vast majority of patients that we saw and that was incredibly appealing. And it clearly was the right decision, which is why, when I speak to young people today training who want to know what to do, I really do suggest that they look at where the personality traits lie and use that as a guide, because I think I would have been really not a very good psychiatrist at all and clearly surgery, has worked well for me and hopefully for the people that I've operated on,  

Red Hoffman:   4:38
You're not the first surgeon I've heard who said they also considered a career in psychiatry. So that's kind of interesting. How did you end up becoming a chairwoman of surgery because obviously there are very few of you in the country?

Sharmila Dissanaike:   4:53
I think that is a long and complex question and I don't know that anyone can actually answer that because there's always so many factors outside your control that lied to us. The reason I ended up in Lubbock, Texas was because my husband was from this region and this was the closest training program. So that's pure happenstance that the, you know it's not something I had control over necessarily. I chose to make a move to keep a relationship, and that's how I ended up here. However, by doing so, I think I ended up in an environment for someone who was very ambitious and hard working at baseline and who tended to take every opportunity to thrive versus maybe some other places where there is a more rigid, hierarchical structure and there are so many people competing for the same resource so maybe I wouldn't have done so well. I think location definitely had something to do with it. And so- Bloom, where you're planted is something I tell young people all the time because I do think that you have to capitalize on the traits of where you're at. I tend to be broad rather than narrowly focused. I'm a bit of anomaly. As an academic, I think everyone says focus.  I've spent my whole life doing things that interested me. Which means I did a bit of burn.   Oh, hey, this is interesting. This is an interesting academic aerial play here a while. And then ethics was interesting to me. And mindfulness was interesting and burn.  It was interesting and this was interesting.  And I just kept working on things that I found interesting. Breast cancer and economic disparities were interesting. So I did that. And so I've always done what interested me and really didn't say no to any opportunity offered. And when I am given an opportunity, I took care to do it well and I'm very organized. I inherited that from my mother. I can't take credit for it. She would have run our lives by excel if that had been available when we were growing up. So I am very organized. Helps me get things done. If I commit to something, I always deliver. I'm not one of those people that senior author has to harass with manuscripts 10 times. I was never that person. And so you know you just do a lot of hard work and eventually you get noticed is a leader.  And I've also never been afraid to speak my mind. I think that that part's fairly clearly established by this point. So, um, I think those traits just led me to being considered  to help lead the department.  Normally this is not an internal promotion, I believe right now I am the only chair a Texas tech who was an internal promotion at the main campus. And so it's not the way it's normally done. But I was asked to lead this department and I said Yes, and I think it's an unusual path. But it's important that people understand that everyone does not have to go through the same lab years and you do this and you do that and you do this step and you become the division chief and then you do this. A lot of people do the traditional path, but it's not the only path. And I think that if the open toe opportunity, some surprising things can happen even if you choose to go slightly unconventional road

Red Hoffman:   7:48
Mac and I just interviewed Dr Karen Brasel, and you sounded so much like her. She described herself as a spork neither of a spoon or a fork when she was talking about her research and academic interests.

Sharmila Dissanaike:   8:05
I suspect there are more of us. I think that the traditional model is just what everyone sees. And thanks to people like you doing podcasts like this, I think. And, you know, social media people trying to hear the stories of the sparks. I love that. I think I'm going to add that one. People who did things a little differently, I will tell you. Across the country, if you look at chairs and women chairs in particular, there does seem to be a tendency for the trauma surgeons to actually display this model. I think there's something about trauma that attracts people and fosters people, who are very much not niche explorers. We like to be broad. That's why you become a trauma surgeon, right? None of us went into it because we'd like to do the same thing all the time. Those of us that select trauma do it because we like to have surprises. We want a bit of chaos that we could bring order to.  Turns out to be a fundamental leadership skill.  And so I think there are reasons behind all this that we could do a whole podcast dissecting just by itself. But it's not a coincidence.  I could name a few others, but there are women trauma chairs who all I think have somewhat of the same characteristics.

Mackenzie Cook:   9:14
It's hard as a young surgeon to have a chair on the line and not ask this question, which is, when thinking about professional development, what is the biggest mistake people make in your experience? 

Sharmila Dissanaike:   9:26
They closed the door too quickly. They say no, because of ill guided advice to be careful what you say yes to you. Don't take that stupid committee meeting. No, no, no. You must focus on your r 01 grant and get your own thing and do this and do that. And some say no to all these other things. And there is interest to that. Now you can't overextend. You can't say yes to things absolutely. But the reality is for me personally, and that's the only framework I can really speak to, I would not have received opportunities I had if I wasn't willing to at least consider most opportunities that came my way. Now there are some things that are dead ends. There are some committees that you're not contributing much and you're not getting much, and I think it's okay to give it a try, go a few times and then gracefully resign and suggest someone else, because there are times that you need to say no. But I do think a lot of junior surgeons say no way too fast. They don't even give it a try. They're too busy with their big Project X and then not noticing small project Y when small project Y may actually be the one that gives them their foot up. So there's two things that really help you get to leadership. One is your credentials, your abilities. There's no short circuiting that, you have to have that, that's not optional, but the other is how many people know you and think well off you. That is actually the magic potion. It's not how many people you know. It's not actually what you know. It's how many people know you well and think well off you. And the only way to get to that number is for more people to interact with you and see the world you do. And that means being on committee, contributing to textbooks that aren't going to buff your CV very much, but help you get known. And I think that's what most people need.  That's because we're busy and we have to prioritize. But you know what? Everyone doesn't have to be a leader either, and that's okay, you know. But if that's the road you're aiming for, then you have to extend and spend your time doing those things.

Mackenzie Cook:   11:29
If only there was some way to be a spork and a knife at the same time.

Sharmila Dissanaike:   11:35
Some people do that, But yeah, it's difficult. Most of us fall into one of the two buckets.  

Mackenzie Cook:   11:40
Sharmila, you've been very outspoken about the need for surgeons to focus on their own health and wellness. Can you speak about why you think this is such a key issue for us as a profession, particularly right now.

Sharmila Dissanaike:   11:54
So again, a big topic to unpack. But let me start with the basic premise. We need to be well for ourselves, Just as human beings. And we need to be well for those that interact with us. I have seen and know so very many surgeons who do not do that. And then they burn out. And the problem beyond just that fact is that often when they burn out, they don't realize that maybe they had a piece to contribute to that.  They'll usually blame exclusively the outside situation because we're human, right? So it's not that I had to quit my job because I wasn't able to function in that system and should have looked for a better spot. It's always well, that person was horrible and these people are all a bunch of Blankety Blankety blanks. And I'm just gonna go away and go do wound care and never operate again. And it'll be low stress and no call, and I'll be happy and I see that so much, and it breaks my heart because these are people that we have invested a huge amount in training.  And I mean we obviously means the global we have of society, of  the surgical community, and I think that once they leave, they tend not to come back and we can't afford to lose that. And the more that people can be healthy and well early on, the benefit them.  Also, I think, it helps that if you're in a healthy state, you can recognize that sometimes it is entirely the place you're in, the people you're working with that are not a good match. You need to leave, and that's just fine. I have no problem with that. You know, I get a lot of people come up and talk to me after meetings and they'll say, What should I do? And that could be the story, and I just look at them and say, Well, clearly you need to leave right?  Like you get it, You can't fix this and they just look at me stunned because they expect me to tell them to, I don't know, meditate their way out of it or something. But the answer is you have to leave, and but you have to be healthy to know that, because if you're a mess. You don't even know if it's you or them because everything is such a mess. And so it starts with us being healthy. And then with us being healthy, we can make the right decisions about whether we're doing what we need to do. And if we're in the place, we need to be at the time that we need to be it because that will level for us to our careers as well. So I think that's why it's a fundamentally important aspect.

Mackenzie Cook:   14:10
Would you be able to talk a little bit about how you teach wellness or mindfulness either to your trainees or to your faculty or your partners?  How is something that you can teach people about,

Sharmila Dissanaike:   14:24
So I actually choose not to do that very formally because you can imagine that, you know, even though I teach it in a completely sectarian way, there are obviously religious basis things for it, and most people do know that for me personally comes from my Buddhist tradition.  I've been meditating since  I was 11 years old and so, you know, I'm careful not to make it  one more thing people have to suffer through. I mean, there's nothing worse than having mandatory wellness modules shoved up your throat to make you feel better. It  just doesn't work, so I do not do anything  mandatory. Number one right now through the Covid crisis, I have started a meditation group. We're doing it by Zoom, but it's open, it's open to the entire department as much as possible. I make everything we offer open to everyone, which means faculty, residents and staff. I think staff are often forgotten but they're front line, just like the rest of us. And so, whether you're a front office clerk , a telephone person or the division chief, you know it's open to everyone. And so we do a weekly session. We'll see how that goes. And if that's helpful to people on, I do it where we talk a little bit about stressors and ways to cope because really mindful must needs to be integrated. You can't just, you know, go nuts for 24 hours a day and then take five minutes to meditate. It's not gonna do anything, and so I do try to teach everything in a somewhat holistic context where you talk about how to frame stress and and how to do a little bit of cognitive work around that. And then you've got the deep breathing techniques.  Give yourself a time out and then, you know, I always say 2 to 5 minutes of some very basic mindfulness meditation is helpful, and I will teach that. So that's the model that I use. Mostly, I got into teaching it for burnout, and I no longer do that because I really do believe we've learned burnout is a structural problem. It's more to do with how we do it for health care than anything else, and so I will not use it in that context. However, I think any life tool that helps us just a little bit more during these crazy times is helpful. And so I teach it to anyone who asks. Basically, I'll be doing a webinar with ACS next week on this very topic, because a few people reached out. I did one for the thing was the YFA association now about 7-8 years ago, and a few people dredged that up and were talking about doing an updated version and so I'm doing that next week, so I'll teach it freely to anyone who's interested. But I am very careful not to formalize it to where it's viewed as a burden or something that someone needs to do. 

Mackenzie Cook:   16:45
It raises an interesting question, which is - I don't have data for this, but I suppose that the people who could, perhaps maximally, benefit from mindfulness, the strategies, are also people who would be least likely to block off the time or have the insight to attend there. But you have said making it mandatory is terrible idea. How do you approach that problem?

Sharmila Dissanaike:   17:09
So it's very difficult, and this is where I'm gonna give you my Chamberlin rule, and it's based on the former U. K P M. And I live by this. It actually draws from a lot of other religious traditions, too, but here's what he said. So a reporter asked him about the Middle East problem, and he said, What Middle East problem?  And the reporter just looked at him- What are you talking about? And he smiled and said, "For something to be a problem there has to be a solution. If there's no solution, it is not a problem."  And I live by that. And you are absolutely correct that the people who need it most probably are the least likely to want it. And I can't fix that. And so that's not a problem. My own religious tradition- the Buddle taught that there are people with lots of thick layers of dust in their eyes and people with only a little dust in the eyes. And he specifically said his teaching was aimed at those who only had a teeny bit of dustin their eyes. He freely said most people aren't gonna get it, and that's just how it is. And so that sort of pragmatism very much informs everything I do. My goal is not to reach everybody and their neighbor. It's to reach those who have that spark already in them, and maybe I can help fan it into a small little flame. That's the goal. And so it's going to be people who are already interested in their own well being.    

Red Hoffman:   0:00
Thank you for that. Such a good reminder to focus on what is in our control or somewhat in our control and let the rest go. So, as chairwoman of surgery, you've certainly supported the wellness of your department by moving towards more of a shift based model. And I'm wondering, what sort of pushed back did you receive when you were in the mist of changing into the shift work And how did you counter it?  

Sharmila Dissanaike:   0:00
So here's what's very interesting about that. It was really a very interesting journey. I did it for multiple reasons. Not because I thought patient can't would be better because the data suggested it was gonna be equivalent. But really like you attributed, I think it was better for the surgeons. And it was just a more fair, equitable way to do it. There's really no reason we should all do a day job and then a night job on top of the day job. So I approached it that way. And here's the interesting thing. I got zero pushback from administration. They were the ones who have to pay more and You know, we quibble to negotiate and, you know, I mean, yes, we had to go through the usual rigmarole, but really, there was no pushback. Nobody. Really? Nobody did. The pushback came from surgeons, So not my own surgeons in this team, but surgeons in general. And it was really difficult for many surgeons to concede that you could do when they have been trained to do as a shift worker. It just was going to something deep in their identities that really bothered them. And so all the push back came from surgeons, Really? Not from any Admins, there was no administrator in the the world that wants to work 24 hours, and so they had no issue with that. They completely got it. It was surgeons. And I think it has to do with that identity. And I think if you've been raised to think that you're 100% commitment to your patient is your defining feature than it is hard. But the point I make for that is Okay, So do you never sleep? Do you stay in the hospital until the patient is discharged? No, of course not. Right. You go home. and yes, you may be available. And, yes, you may around every single day, but someone is going to be responsible when you leave town for the weekend to go to your conference. We do that in house all the time, and you can't tell me that if it's okay for you to do when you go to a big conference every year that it can't be done in a way that it's okay the rest of the time. Because if it was so bad, then you shouldn't operate for two weeks before your big conference. If handovers and sign outs was such a terrible thing, then no one's doing that. So I think it's just that mindset that  when doing handoffs no matter what, and it's okay for that. To be part of a routine now doesn't mean we have to make the system better. Do we have to try to make errors less that get dropped in the mix? Absolutely. And I will tell you there are more errors. There's no doubt that when you have a shift system in any field, there will be more errors and we saw that, but we keep trying day after day to make things better, and we're not there yet. It's not perfect. I don't know if anyone has a perfect system in the country or the world, but it is getting better. But I needed to make it clear that this was the only way forward. We cannot just work surgeons harder as the solution. That's not okay. And at a busy level one center like ours, with huge volumes, there was no way to continue the way we've always done it. It needed to change. It will have problems, we'll figure it out. And I think that growth mindset that anything new is going to have mistakes and problems, and we'll just figure those out is crucial for any surgery department or any surgery group to ever get better, because I do worry that sometimes people have the first round of problems and then they want to go see told you it would work. You've got to get your people on board to understand that, Yes, we're gonna have mistakes we didn't foresee. It's okay, we'll figure them out and as always, you have a team that can have that mindset. You can really explore and come up with the best possible solutions.  

Mackenzie Cook:   22:21
I think that's really it's fascinating to hear that because the I'm a millennial, you know, three or four years into practice and a lot of times from our more senior surgeons,  we hear that mindset that you heard pushback on, which is that, you know, signing out is unacceptable, that if you ever go home, you're failing your patients. And I mean, it's sometimes feels like we're framed as a taking care of ourselves, taking care of the rest of our lives is in opposition to taking care of our patients, which it is clearly not.  We do a shift model, too. And it's really wonderful to hear that. Thank you. 

Sharmila Dissanaike:   22:59
Thank you. And you're right. I think the key, Mackenzie, and for everyone is to bear that in mind that there is no perfect model. I think that's what we have to keep. Going back to the old model wasn't perfect either. Yes. Now we've traded one set of problems for another. Okay, we'll keep working on it, and I do not think any of those problems are insurmountable.

Mackenzie Cook:   23:19
So we're gonna shift gears just a little bit. So you're very vocal on Twitter about the importance of providing primary palliative care to your patients, including discussions about goals of care and code status. And I'm wondering if you could talk to us a little bit more about primary palliative care and why you view it as such an important skill for surgeons.

Sharmila Dissanaike:   23:41
So again, this is one of those things I accidentally fell into. But as an acute care surgeon, there is no doubt that we get consulted on a lot of patients who are, at that point off needing a good discussion on goals of care. And it's because we get the consults for a feeding tube in the cancer patient. That's probably the number one trigger for this type of conversation. But we also see the trauma patient who comes in after their hip fracture, and we also see the person with the bowel obstruction and their liver failure, the cirrhosis. And so we're seeing people who have major underlying chronic health conditions who now have an acute surgical problem, and I don't think you can be in the field of what you care surgery for sure, and a lot of surgery without, to some extent, incorporating the primary palliative care focus. I don't think we do our patients a favor when we leave that out. And so, yes, that's one reason why I am such a strong advocate. The other reason is that I think it increases our satisfaction with our jobs. I really believe that. I know that. You know, like I alluded to earlier, I'm a big fan of, you know, do what you can and leave the rest be well. Part of it is that in the patients that we cannot cure with the knife, it is incredibly rewarding to allow them to have symptom control and relief in a good death. I find that every bit as rewarding. Okay, maybe, maybe not exactly. It is rewarding  saving a life, but it's close, you know, it's still very rewarding. And so I think that we need to remember that that that is incredibly rewarding to help a patient and a family through their final years. I'll tell you that the number of notes and letters I get from families is greater for those who might help as best I could to a good death who, you know, knew that I was with them the whole way and we were supporting. You know, one of my pet peeves is I run around, tell them to stop using the phrase withdrawal of care , drives me up a wall, like nails on a chalkboard for me because we never stopped caring , we're always there, we're always treating and caring, we're just doing it differently. And when you do that, you really give a huge gift, that patient and family know the surgeon's right there, you don't need necessarily to have another doctor do that, although very often I do include palliative care colleagues in this process, mainly because they can follow up at home. I mean, my goal for any patient who goes on the palliative care route is to get them home, and they will often carry this on at Home Hospice. And that's the piece that I'm not part off. So that's primarily my reason. If we're doing everything within the hospital, I'll often lead this myself. And, I find it rewarding as a person and as a trauma surgeon. Sometimes I don't get a very long term relationship with patients, but with these patients, Giving them that ability is is absolutely worthwhile. And again, I think just simply bringing it up and talking to them in honest, compassionate manner is another gift. I get so much feedback from patients and families, and that's what they appreciate it. You know, they say, no one's really put it that way for us before. And, you know, doctors have talked to them. I mean, they're,  no one is out there trying to hurt these patients. But if you don't frame it in a certain way that they understand, then you know you're still not there.

Mackenzie Cook:   26:50
Primary palliative care is  hopefully becoming more and more part of training, But I suspect that it hasn't been that way in the past. So is your goal in training a surgical resident? How did you develop these skills? Who were your mentors early on? And how did you test and grow as a primary palliative care provider?

Sharmila Dissanaike:   27:11
So one of my traits and again, like I said, is bloom where you're planted. I have had wonderful senior colleagues, there's no doubt, but I did not get direct mentorship in this. It just wasn't a thing. And so trial and error and just figuring it out myself. And you know what this love to be said for that, right? Most great inventions came from someone just tinkering and experimenting. And so it's kind of the same thing. You learn what works, you learn what doesn't. And I am honest to a fault. And so I never let that piece go. And then I finally found that, Hey, patients, actually kind of like this. They kind of like that. I'm straight with them and you just develop these techniques and you also educate yourself. So there are resources available that were there even then, you know,  when I trained. And, um, you know, there's podcasts like yours. There's books, there's webinars. There's all sorts of resource- the textbook that American College of Surgeons puts out, there are palliative care sessions at ACS. And so, you know, I just found this to be an interest, and so I connected with other people who were interested with it. Probably one reason I'm here right now, and you just kind of grow your own education. You read articles about this. You know, none of us can read every article, the journals we subscribe to. You just can't. But I found myself reading more articles about this, and so I honed my skills as this went on. And I will tell you, I do sessions with my residents on this because I do think this is something that is a mandatory part of trading. I have no qualms about having them make sure that they know how to do good palliative care. But I will tell you what they'll often tell me is that where they really learn it is when they're sitting with me in the room watching me have the discussion. Doesn't matter how many formal didactic education sessions I do. What is actually teaching them is going through it with me and watching me have that discussion, and they'll actually use some of the models that use, like, you know, the training, even the station, and then ending up going to different destinations. Gonna have some tried and tested analogies that I use with patients, and they will use those same things. And so a lot of this is still good old fashioned apprenticeship learning in our residencies. Despite all the tools we have available

Mackenzie Cook:   29:14
Through my residency and fellowship, it was the same thing, finding people who really were interested in it and learning it. And I think that toolbox of words and models, which Red, has really been a leader in distributing is very, very helpful for people to be able to use. And then I'll often just tell my medical students and residents if you consult the palliative care team, it's great if you could just join them in the family meetings. 

Sharmila Dissanaike:   29:42
I agree with that. I will say it goes both ways. I mean, I've had them say, Oh, I really like how you did this and what you said about this. And then I learned from what they do and how they say So you know, this really does need to be a two way street. I do think there are people, Gretchen Schwarze, who's done a fabulous work from Wisconsin on, you know, the best case, worst case scenario, and so there are tools out there now that are published. They definitely help, you know, provide a framework for this conversation. But again, much like we talked about mindfulness, people who are specifically interested in this will find those tools and adopted. I think our jobs is to give our residents this toolbox as best we can, and then some people will use it more than others. I mean, I will tell you there are people who still aren't quite comfortable with it and may never be. And that's okay. You know, everyone doesn't have to be a superstar and everything, but I do think that if we can at least provide our trainees coming out now with a few tools and at least remind them that this is something they need to consider. They can't just defer it to somebody else. That for me will be a win. The thing I would hate to see is for a generation of surgeons just go out and stick the feeding tube on the patient without going any further than that, you know, to just be a technician. Now there are times when a surgeon does have to just be a technician for various reasons, but I don't think this is one of them. And if we can simply move that mindset to where people are having this thought in the discussion. That alone, I think, will be a big, positive step.

Red Hoffman:   31:05
Sharmila, you obviously have a great interest in ethics as well. Can you tell us how this interest got started for you?

Sharmila Dissanaike:   31:14
I'll tell you that. A lot of my formal relationship started through the American College of Surgeons. And so it was some years back, and I was a member of the Young Fellows Association and they put out an email. So another good tip for career leadership- Read your emails. They put out an email about there was an opportunity for a representative on the ethics committee, had to write an essay. And I just you know, I had literally no background, no training, but yeah, I mean, you know, I'll answer anything practically at least now I don't. But I used to. And so I, um, typed out an essay, and my essay was actually about how there was so much stress on the patient part of the patient physician relationship. I felt there was not enough the other way. It was that the answer lay in the middle. Not really all focused on the patient because I felt that that time surgical ethics was excessively tilted a little toward patient autonomy and ensuring beneficence and not enough toward that interaction into sections. So I just wrote a one page essay and submitted it, and I later found out that was one if I guess, 32 essays, and I guess they like it. So they picked me, and all I can say is I wouldn't get in now because people apply for those positions now have, like an armload off experience in things and they've published papers and I'm like, Oh, my God! So I got into the right time. But it was that essay that, yes, they picked it. And so and obviously, no, I had some other stuff on my CD by that point too But anyway, so I got into their records. This ethics committee and I got to work with people who actually had training, which is fabulous.  By the way the training matters, I would strongly recommend anyone who is interested in this field to do the MacLean Ethics Fellowship.  ACS sponsors a certain number of those positions every year. I strongly encourage it. If it's feasible, it's a fabulous program. And so it's been really great over the years to watch it become more formalized. But I truly don't have that background. I mean, I'm a total impostor in that realm, but luckily an impostor that learns fast and can actually absorb wisdom and interact. And so I think I bring a different perspective from being very much a frontline worker as well as a leader in a rural area. I think that's one aspect I bring that is not necessarily common is that I serve a West Texas rural community, and that has a lot of challenges that I think are not recognized by people in large coastal cities. The way the hospital systems work, the way we work in regionalized distribution, the way we deal with 16% uninsured rate in the state that did not do Medicaid expansion. There's a lot of issues there, and I think allowing the two worlds to collide is probably the space I feel there is that I can take the learning from people who really have spent a lot more time and energy in the effort being educated on this and blended with the realities on the ground and hopefully come up with something useful in that mixing is where I see myself at that intersection.

Red Hoffman:   33:59
So I recently read your chapter in the Ethical Issues in Surgical Care text book that was published by the American College of Surgeons a few years ago. And I was particularly drawn to the section entitled Self Preservation is Not Self Interest and you write that carin for oneself as both a surgeon and a human being expands a surgeon's capacity to extend compassionate care to patients. Can you speak about how we should think about this in terms of the current pandemic? And how should we be balancing our moral obligation to care for patients with our obligation to preserve our own health and well being?

Sharmila Dissanaike:   34:40
So that's another story.  This question that's got a lot of pieces to it. I am gonna make a small plug as to the same ACS committee that wrote that textbook is going to have another webinar type session for Q and A maybe next week or the week after, so I would strongly encourage it. You'll probably get a lot better answer to that question then, because there'll be more people, smarter people than I am on it.  So a lot of this goes back to what we started this conversation with right? The mindfulness and the self wellness and things like that. So that's part of it. But the tricky question which I think is what you're really asking about is COVID. What is the balancing our personal health with the risks due to the lack of PPE, due to lack of adequate preparation at all levels stemming from the top on this crisis. So it is difficult. And so there are so many pieces to take out of this. So clearly nobody on the ground level dealing with this can be held at fault for the situation. right?  Not the patient, not the surgeon or anyone else involved. And yet here we are and and what do we do? And it's a very unique position. I don't know that many American physicians have had to deal with this before. I certainly never imagined having to deal with it in the richest country in the world. That was not something I saw coming. So I think we do hav to weight checks and balances, and I think it has to be dynamic. So I think that those who want a hard and fast rule, I think that may not be the best approach. And you may have noticed you mentioned Twitter earlier. I have been tweeting about disaster ethics, been amplifying the messages coming out of ACS. And I'm doing that to try to make it clear to everyone that we cannot hold to our usual business as usual plan. We just cannot. And that goes for ethics, just like everything else. It is not an immutable set of rules in golden tablets that we follow the same way. No matter what. I think it's really important. I think it's important for our training is never want to hear that because I do think that when you are training, there is this feeling that you know, if it's in the textbook, it must be right.  I don't know why this stupid attending is doing something different, because look, it's it's published and saying to do it that way, you know, we see that and it's because it was written down somewhere prestigious and unfortunately I think both young and old people are taking the standard rules we live by and trying to hold them in a pandemic. And you just can't do that because you're not helping people. So we have to adjust. Okay, so we have to adjust. How do we adjust now? Obviously, this has clear implications for scarce resource allocation ventilators, among other things. And then we might maybe we won't talk about that. But I'm gonna go back to your peopIe question, so that's a scarce resource. So clearly it makes sense to allocate to the highest risk people in the highest risk activities, right? That's where we're at. And we shouldn't have to. But we do. And until we get adequate PPE, we will ration.  And let's just be honest about it. I think one of the things that I've tried to do this whole time, it's just be honest about what we're facing and not try to sugar cooked it. So if we're rationing, then who should get it? Well, people treating known positive covid patients should get it. People doing intubations  should get it. People doing chest tubes and lines, you know who are getting up close and personal to that patients or a fabrics should get it. And after that, we need to decide. At what point does a medical condition have low enough severity? That may be the surgeon doesn't need to go and deal with it right now. Maybe the gall bladder doesn't get addressed. Maybe that chronic wound could wait a few more weeks until the person recovers. And then we'll address this. And so I think all of those things have to come into play. We have to make flexible, fluid decisions based on solid ethical principles. But we cannot come out and right out,  We cannot come out and say that, you know, absolutely not. Under no circumstance would we treat a Covid patient without a full and 95 face.  And so I think every institution, every person, to some extent has to understand that there will be a line. But that line will be different, and you do have to weigh the situation differently. So, for example, a patient with G I symptoms we know is not as infective as one with respiratory symptoms, right? We know that from the recent Nature article. That's a very important article that I'm a bit concerned, got overlooked a little bit because it speaks to infectivity, and that's what we're concerned about.  And so the more we can get to the nuance and then I think that we can balance our allocation of resources better. And I think we have to go to nuance.  Humans don't like nuance.  T

Red Hoffman:   39:52
It's challenging in this day and age, where things are a little bite size pieces for the media, nuance is hard to come by.

Sharmila Dissanaike:   40:01
We saw this with the malaria drugs, right? Nuance went out the window, and suddenly everyone should take Hydroxychroloquine.  And is it happened? And it's just it's a bit of a mess, and so we desperately need leaders who could work in the nuance. And I will tell you I think one of the reasons Dr Fauci is so well respected is because he has been willing to keep the nuance in the discussion. And he's trying desperately to do that. But we have to keep nuance in it. It's worse when we  vascilate madly from one extreme to another. As we get new information, that's worse. If we can keep nuance, we can at least keep some semblance of the thought process in what we're doing. And it's just killing me a little bit that the last two months I'm sorry it's been vascilations from 0 to 100 in every direction and driving me crazy, and I'm not even in the front line in New York, so I can't even imagine. And I just think that as leaders, the more we can explained the facts and describe the nuance and that's what I personally tried to do with my department. I think they're getting tired of my e mails, but I do send them frequently because things change. And I've been saying from the beginning this will change. What I say today is good for today, and in two days we'll change. You know, we had to shut down, completely because of a lack of supplies, then we opened it back up. And it's disconcerting for people in the Texas government. Governor came out with rules that you can't do elective surgery. Yes, not everything is elected, but some things are urgent. But you've got to go into those weeds and you've got to explain to people the rational and when people understand what the rational is, now they can take a given situation and make a sensible decision. Like today, one of my surgeons asked me about a patient to a Stones in the CBD. What do we do it? We worked through it and we decided that patient's risk of cholangitis was high enough that we needed to fix it before our covert surge. It that's the kind of nuance we need. A blanket rule that you will do no biliary surgery for three months is not going to help, because if that patient gets the air in the middle of a co dependent me, it is not in anyone's best interest. And so you really need the nuance. And I don't think as a country that we're doing that as well. In most places, I'm sure a lot of places are, but in a lot of places, it's not enough. 

Mackenzie Cook:   42:10
Im thinking a little bit about the covid pandemic and the publication from the Ethics Committee, the framework for allocation of resources in the event of shortages and your discussion about nuance. How do you go about writing an ethical framework for the country that both takes into account the nuance of Texas in North Carolina and Oregon in New York, and also the dynamic changes of peopIe availability, the surge, the effects of physical distancing? I actually found the guidelines to be very, very helpful. So clearly this was a success. How did that process unfold?

Sharmila Dissanaike:   42:46
So I'm thank you. It's a great question. I'm very proud of that. The current committee chair is on Henri Ford out of Miami and he's done a great job. There are several other members. I'm not gonna list them all by name only because I'll leave one person out and then will feel terrible about it ever after. But a bunch of incredibly dedicated, very well versed, really, in some cases professional ethicists.  What we do is by email. Surprisingly so. You know, the questions come up and we all took on issues kind of near and dear to our hearts. So I draft the PPE because as most people on social media, no, that topic was very near and dear to my heart, and some of the others drafted the others. And then we all review. We all do a little bit of tweaking here and there. We give input and we'll actually do it in a day and then release it because we understand it's time sensitive. And that's the beauty of getting a bunch of surgeons together who understand time sensitivity. It's fabulous. I mean, really, all of those were put out in such short notice by very busy people, and it's a phenomenal effort. It's a completely volunteer effort. So, yes, I really thank you for giving me the option and give them a shout out because I think they really did a great job. So how do we do it? You could drown in the literature that's out there. And so each of us took the piece that we're most interested or passionate about red upon it to put a draft and others weighed in. It is so hard that I'll tell you the hardest one probably was the scarce resource allocation, especially when it comes to What do you do with the patient when there's just not enough resources and there are some guidelines that have been put out by CDC. And if not, you have to have a system. And the problem is there are institutions, academic institution, especially that have systems to decide this. But nobody has the stomach to release them publicly, you know, and and there's legal implications, you might have seen that there already was a case where a group that chose to prioritise life years over lives which, if you think through it, is going to prioritize the younger over the older victims at the same level was accused of discrimination. This gets older people the flip side. If you made it equal and say that you are an institution that protects the elderly faculty, perhaps the older faculty, because they're hot risk now you could be accused of discriminating the other way. And so there are no easy answers. And so from the ethics committee, we have tried to understand that and not be too prescriptive. You know, I actually brought it up to the committee whether we should be a little more detailed and they were correct. They felt that it is too difficult of an area for us to prescribe something nationally that would apply to every situation. So we simply try to get a framework that institutions can use to develop their own based on exactly what is going on and where they're at on. Hopefully we'll have succeeded in that. I do think that there are some other groups with a C s that you know, with the right reasons, tried to come up with a more detailed guidelines. And then there was some backlash on that because unfortunately, the details cannot encompass every situation across the country at the same time. And I think that resulted in more confusion. And so I do think there's something to be said for keeping your guidelines. A little vague may be bigger than we would like, but we just there's no perfect way to do it.

Mackenzie Cook:   46:11
I want to focus on something that you mentioned there. In light of the publication in the New England Journal. Just a week or so, everything I feel like time is so dilated right now. So it was either a week ago or 10 years ago. Um, it's but it's the piece of New England Journal on the fair allocation of scarce medical resource is they specifically highlight in there that critical interventions should go first or could consider go first to front line health care workers. Ah, in light of your comment on discrimination and should we prioritize doctors, nurses, techs, the people you know, paramedics. Should we do that? Should we prioritize the care of the health care workers. 

Sharmila Dissanaike:   46:56
It's a great question, and I will tell you for me personally. And this is a personal viewpoint, not representing any of the many organizations  I'm affiliated with- good disclaimer, essential disclaimer? I think so. And here's why. It is coming, actually, and that was a good article that you're alluding to. It is coming from a place off, Utilitarianism is, and I will tell you that disaster ethics is, if you look at it closely, almost entirely based on your utilitarian principles, which is the greatest good for the greatest member in a disaster. Ultimately, it comes down to that. It's very, very difficult to implement any other foundation off ethics in disasters. Then clearly, the more health care workers you preserve, the greater the good for all right. And if you lose one surgeon or one nurse, one respiratory therapist, you have many more patients. So it is really based not on the principle that we are inherently more worthy than others. I don't think that was it in anyway, though it can obviously be misinterpreted that way. I think it was based on pure, utilitarian principles that you have to preserve your health care workers, which are also scarce resource.  And for that reason it is not unreasonable. It would be quite reasonable to consider prioritizing them. Not everyone will do it for a lot of reasons and litigation being one of them. But I think the article came out to give cover to those systems that do it. And I will tell you a lot of these guidelines coming up from a lot of societies are actually not recommendations. They're being done to give cover to people who are doing the best they can in desperate situations and should not have to worry about legal ramifications down the road. They really shouldn't it. It's not right and I think, by giving cover, so to speak, by saying you know what? If you have to do this, if you have to not operate,  then don't.  That's just providing us an option and that's how I would look at this New England article as well. It's giving us the option. Should've system choose to prioritize in that way. And I really hope that most systems in the U. S. Don't get so badly stretched that that becomes an issue. But if it were to become an issue, you have, I think, very good justification for prioritizing healthcare workers because if they recover, they can take care of more  patients.  

Red Hoffman:   49:16
Thank you for that. So as we're wrapping up, I just want to ask this question because I know you're very active on Twitter. And so I was wondering if you could just comment on the role of social media platforms like Twitter in the modern academic surgeons life, particularly during this pandemic.

Sharmila Dissanaike:   49:37
So again, I don't often see eye to eye with our current president. But I think that he was very smart to understand that Twitter is how you get to where the people are and that quite early on, before a lot of other people did, and so credit to that. It's where the people are, and that's why I do it, because again, a lot of my life and career, you know, circling back to the beginning. You asked about how I became chair. I will say it's opportunism in a good way, and that is if I'm going to do something I wanted it to count. I want people to hear it. I don't want to publish something and not have anyone read it right. And so I can put out a tweet about something that I think is important and many more thousands will see its than any paper I could hope to publish in this kind of short time and with Covid and you don't have time. I mean, a few people have done it. Credit to them. I don't know how they managed to get these real papers out as quickly as they did. That's fabulous. I don't have the time. I am running a department. I am still clinically active on the front lines. I could not do that, but I can take a few moments and highlight other people's papers that a useful I can make points to help moderate maybe our response and understand, and hopefully provide a little encouragement to those in the front lines and I think Twitter is perfect medium for that, I am also on Facebook, more for the local community. There are more people in this region who are scared and who I think listen to doctors that they know off that are in their region on Facebook. So I use it for that. But Twitter is how I communicate with the general community. And I will tell you there are many papers that I first saw on Twitter, the New England paper, the Nature paper. All of those I get immediate notification with my social media feed, and then I can go and read the paper. So I don't think that it is a substitute for standard academic reading. I think it's a method to draw our attention to the most high impact papers quickly, and it's a method to share good information and also re but some bad information that's out there. I don't think that should be a main job, because I think we will go crazy. If we try to rebut every bit of nonsense out there on Twitter. I tend not to. I can't ignore it honestly, but at least by amplifying good information, we can make some progress and a lot of great to the colleagues that recently been verified. And so hopefully that'll strengthen their voices to advocate for, you know, common sense approaches to how we approach this pandemic.  

Red Hoffman:   52:02
Sharmila, thank you so much for taking an hour out of your extremely busy day to talk to us. Is there anything else you'd like to add before we're done?

Sharmila Dissanaike:   52:10
I think you guys covered a lot of ground.  This is great and informative and I like doing you because it does help put some clarity on how I think about things as well because we're also rushed with this epidemic. Talking it out actually helps me think about framework for what we're doing and why we're doing it so thank you.

Mackenzie Cook:   52:30
And it's such a very dynamic time that, I think you've highlighted many times. And maybe I think my biggest takeaway point here is there's nuance. It's important not to lose the nuance to all of these clinical decisions recommendations, ethical decisions just because we're time pressured or the situation is so dynamic. So thank you for that point.  

Red Hoffman:   52:51
Mac, thank you for joining me again. You're awesome.  

Mackenzie Cook:   52:54
No, this is a blast. I love doing it.  

Red Hoffman:   52:56
Great. Well, thanks, you guys. I hope you have a great day. Stay safe.

Red Hoffman:   53:02
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. To learn more about the surgical palliative care community, follow us on Twitter @surgpallcare. 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,