Mastering Intensive Care

Do you play the role of the exemplary leader in the ICU? Are you charming, funny, friendly and extroverted – even when these aren't your natural personality characteristics? Do you throw yourself into your series of consecutive days in the ICU like you are going away to adventure camp? Do you outline specific objectives that a patient should meet over a timeframe of a few days to decide whether treatment should continue? And how regularly do you talk to your patient's family when you are pretty sure the patient is dying?

These are some of the questions you may ask yourself after listening to this episode of the Mastering Intensive Care podcast with American intensivist Jack Iwashyna. This is the fifth in a series of DasSMACC special episodes, where I interviewed speakers from the recent DasSMACC conference held in Berlin. Jack is Associate Professor of Pulmonary and Critical Care Medicine at the University of Michigan where he is a practicing medical intensivist at both the University of Michigan and the VA Ann Arbor Health System. He also devotes significant energy to training clinician scientists and is best known for his work defining the concept of "survivorship" after ICU and measuring aspects of the post-intensive care syndrome. Jack's keynote talk at DasSMACC was entitled "Persistent Critical Illness" and as you'll hear in this podcast he is the perfect person to talk about this given he does 14 day blocks in his ICU allowing him ample opportunity to understand what happens in the evolution of a patient's critical illness.

Despite Jack self-proclaiming he is introverted, this episode of the podcast reveals him to be a diverse conversationalist with well-matured thoughts, views and reflections on his own experience about how a consultant intensivist should act, whether that be in throwing ourselves 100% into our clinical service, playing a specifically crafted leader's role, wisely mentoring less experienced clinicians, regularly communicating to patient's families, simply having fun doing our job with our colleagues and respecting our spouses and families for supporting the work that we do. We cover a myriad of topics including:

• Jack's powerful answer as to why he loves his job
• How invigorating it can be to talk to people he has only just met
• How he has previously done 30 day stretches of continual clinical service
• As a researcher he tries not to study his own ICUs too closely
• Our fixation on short-term survival is inadequate for most patient families
• His use and the benefits of time-limited trials of life support
• How he uses a school-like A-F range grading to mark patient's progress
• The benefits of taking his children away on academic trips
• His somewhat raw reflections about not feeling as good a father and husband as he is a doctor
• The difference between mentoring in research and in clinical practice
• Our role is to try to help all trainees to improve, however good we perceive them to be
• Burnout is a systems issue – where the system is being run too hard
• The importance of sleep and afternoon naps

This podcast is my quest to improve patient care, in ICUs all round the world, by inspiring all of us to bring our best selves to work to more masterfully interact with our patients, their families, ourselves and our fellow healthcare professionals so that we can achieve the most satisfactory outcomes for all. Please help me to spread the word by simply emailing your colleagues, posting on social media or rating and reviewing the podcast.

Feel free to leave a comment or a question on the LITFL episode page, on twitter using #masteringintensivecare, on the Facebook "mastering intensive care" page or by sending me an email at [email protected].

Thanks for listening. Please do the very best you can for your patients.

Andrew Davies

Show notes (people, organisations, resources or links mentioned in the episode):

Jack Iwashyna at University of Michigan: http://ihpi.umich.edu/our-experts/tiwashyn

Jack Iwashyna on Twitter: @iwashyna

DasSMACC: www.smacc.net.au

Are you receiving elderly intubated patients where someone else says they want "everything" done? Are the doctors who refer patients to intensive care finding out what their patients really want towards the end of life? Does this frustrate you on a daily basis?

This is a huge topic in intensive care. Finding out the wishes of our patients before they end up on a ventilator with no one to speak for them is vital if we wish to deliver optimal healthcare. Yet so often we intensivists are left to deal with this situation. And whilst in most cases we do this very well, many of us like Dr Alex Psirides, a UK, New Zealand and Australian-trained intensivist, feel the despair as we hold another lengthy meeting with a patient's family. In this episode I spoke with Alex about this topic, which he had just delivered a brilliant TED-like talk on at the DasSMACC international conference in June. Alex has a great perspective to share as two of his specific clinical interests are managing dying patients and rapid response systems for deteriorating patients.

This is the fourth in a series of DasSMACC special episodes, where I interviewed speakers from the recent DasSMACC conference held in Berlin. Alex is an Intensive Care specialist at Wellington Regional Hospital in Wellington, New Zealand. His work and research in the area of rapid response systems has led to an appointment as the clinical lead for the New Zealand Health Quality & Safety Commission's 5-year national 'Deteriorating Patient' programme. He is also the clinical lead for Wellington's aeromedical retrieval service, which covers the lower North and upper South Islands of New Zealand. In his spare time, when not walking his dog or children, he builds websites & designs logos for Wellington ICU's prodigious research department, as well as sending a few tweets via Twitter handle @psirides.

Given Alex has been an ICU consultant for less time than most of my other guests, I had to talk him into doing an interview, but I'm really glad he agreed. There is so much to like about this conversation. Alex is honest and humble enough to say he's not so sure he's that good at predicting patient outcomes, at least in neurosurgical patients, which is the precise reason he has something to teach us on the podcast. We also cover topics including:

• Why Alex loves intensive care (with a great answer)
• How his consultant team work so cohesively
• The need to respect co-worker's opinions and to avoid tribalism
• How a team of intensivists meeting with a team of neurosurgeons away from the patients can make practice more consistent and evidence-based
• How his team uses simulation to reduce rudeness and lack of respect
• How efficiently his hospital ran when there was a 3 day doctors strike
• A good ward round requires asking for and addressing the nurse's concerns but also finishes with a clear plan to move the patient forwards
• Bringing his best self to work requires feeling loved at home and having a great team to work with
• Some of the non-textbook medical books Alex has been enjoying reading
• Hobbies allow him to escape from work and to use his creativity
• How far away he feels right now from burnout
• What he can get better at over the next 5 years
• How palliative care physicians can be helpful in teaching us and our trainees about end of life discussions

This podcast is my quest to improve patient care, in ICUs all round the world, by inspiring all of us to bring our best selves to work to more masterfully interact with our patients, their families, ourselves and our fellow healthcare professionals so that we can achieve the most satisfactory outcomes for all. Please help me to spread the word by simply emailing your colleagues or posting on social media.

Feel free to leave a comment or a question. I hope we can build community through Mastering Intensive Care so colleagues can share their thoughts and tell us how they are mastering their own skills. Leave a comment on the LITFL episode page, on twitter using #masteringintensivecare, on the Facebook "mastering intensive care" page or by sending me an email at [email protected].

Thanks for listening. Please do the very best you can for your patients.

Andrew Davies

Show notes (people, organisations, resources or links mentioned in the episode):

Wellington Intensive Care medical team: http://www.wellingtonicu.com/AboutUs/Staff/SMO/

DasSMACC: www.smacc.net.au

Alex Psirides talk on "Doing everything at end of life": http://wellingtonicu.com/Data/Doing%20Everything%20DasSMACC.pdf

Book "Being Mortal" by Atul Gawande: http://atulgawande.com/book/being-mortal/

Book "Do No Harm" by Henry Marsh: https://henrymarshdonoharm.wordpress.com/reviews/

Alex Psirides on Twitter: @psirides

Are your ICU patients ever in a holding pattern?

Do you aim to liberate your patients from ICU as soon as possible?

Is your caution about moving things forward harmful to our patients?

I don't think we talk often enough about the dangers of conservatism in intensive care. About how if we are cautious in thinking the patient is not quite ready to be extubated, or have the sedation turned off, or stop the antibiotics, then we sometimes don't realize the harm our inaction may cause. A topic you will enjoy hearing about in this interview with Professor John Marshall on the Mastering Intensive Care podcast.

John is a Professor of Surgery at the University of Toronto, and a trauma surgeon and intensivist at St. Michael's Hospital in Toronto, Canada. John has an active clinical research interest in sepsis and ICU-acquired infection, and in the design of clinical trials and outcome measures. He has published more than 325 manuscripts, and 85 book chapters, and is the editor of 2 books. He is the founding chair of the International Forum of Acute Care Trialists (InFACT) – a global network of investigator-led critical care clinical research groups, he is Secretary-General of the World Federation of Societies of Intensive and Critical Care Medicine, and vice-chair of the International Severe Acute Respiratory and Emerging Infections Consortium. He is also past-chair of the International Sepsis Forum, past-President of the Surgical Infection Society, and past-chair of the Canadian Critical Care Trials Group. He has given invited lectures at more than 470 meetings around the world, is a member of seven journal editorial boards, and an Associate Editor of Critical Care Medicine and Critical Care.

In this conversation we also cover topics including:

• Being both a surgeon and an intensivist – and why ICU might be more fun
• Humility and curiosity as the two most important habits for intensivists
• That surgeons seem to own their complications more than intensivists
• The benefits of family member presence on the ICU ward round
• Why we should question everything we do in a provocative dialogue
• How research helps us at the bedside
• The value of collaborative research networks
• The observations that some ICUs can feel joyless
• Withdrawing interventions may not always lead to death
• The time when John was involved in a 4 hour CPR
• If we can't define what an intervention can or cannot do, perhaps we shouldn't do it
• The privilege John feelsto be able to make mistakes that might cost people their lives
• His artistic pursuits outside of medicine (including the story of a rock band)
• The constant feeling of rejection in academia
• The skills required to give a good talk
• How developing academic capital might be the best way to get a job

With this podcast please help me in my quest to improve patient care, in ICUs all round the world, by inspiring all of us to bring our best selves to work to more masterfully interact with our patients, their families, ourselves and our fellow healthcare professionals so that we can achieve the most satisfactory outcomes for all. It would be much appreciated if you could help to spread the word by simply emailing your colleagues or posting on social media.

If you have a comment or a question, let's engage. Whilst my primary goal is to improve patient outcomes by helping us all get better thanks to the inspiring messages of my guests, I also have the goal of building community through Mastering Intensive Care, so people can share their thoughts and their own skills. So leave a comment (on the LITFL episode page or on twitter using #masteringintensivecare), send me an email at [email protected] or engage in the facebook page Mastering Intensive Care.

Thanks for listening. Please go out and do the best you can for your patients.

Andrew Davies

Do you say "I don't know" when you really don't have an answer? Might seeking that knowledge help your patients?

This is just one component of a wonderful conversation I held with Professor Flavia Machado when I interviewed her at the recent DasSMACC conference in Berlin. Flavia is doing a great job at raising the awareness of sepsis globally but her other great job is in running a large Intensive Care department in Sao Paolo, Brazil, where she told me that the resources are quite limited. To deal with this challenge she believes optimal communication is vital.

How does Flavia lead her ICU on the issue of communication? She does this (1) by having an environment where her team members can ask important questions, (2) by using the WhatsApp messenger app on smartphones, (3) by teaching trainees using courses on how to break bad news, how to speak with families, and how to deal with doctors who have different clinical opinions, and (4) by saying "I don't know" when finding the knowledge will help the patient.

Flavia is the Professor of Intensive Care at the Federal University of São Paulo in São Paulo where she is Head of the Intensive Care Section of the Anesthesiology, Pain and Intensive Care Department. Flavia has trained in Internal Medicine, Infectious Diseases and Critical Care, making the field of sepsis something she has become a world leader in. She is one of the Founders of and now the CEO of the Latin America Sepsis Institute (LASI), having been its President. LASI is devoted to quality improvement in Brazilian hospitals as well as to coordination of multicenter studies in the field of sepsis. She is part of the executive board of the Global Sepsis Alliance and the executive committee for the World Sepsis Day. Flavia has served on the board of the Surviving Sepsis Campaign International Guidelines. She is also a member of both the Executive and Scientific Committee of the Brazilian Research in Intensive Care Network-BRICNET. Finally, Flavia is the editor-in-chief of "Revista Brasileira de Terapia Intensiva", the official journal of the Brazilian Critical Care Association and the Portuguese Critical Care Association.

In this conversation we also cover topics including:

• Raising awareness of sepsis through the Global Sepsis Alliance
• Mentoring and being mentored
• The need for a multi-professional program in ICUs with a multi-disciplinary ward round
• Setting goals and using checklists
• How the limited resources in Brazilian healthcare require strict admission rules
• The use of simple and short protocols based on the evidence
• How to best deal with conflict with another doctor
• Using dinner time to connect with family
• How running is good for the mind
• The joys of reading books

With this podcast please help me in my quest to improve patient care, in ICUs all round the world, by inspiring all of us to bring our best selves to work to more masterfully interact with our patients, their families, ourselves and our fellow healthcare professionals so that we can achieve the most satisfactory outcomes for all. It would be much appreciated if you could help to spread the word by simply emailing your colleagues or posting on social media.

If you have a comment or a question, let's engage. Whilst my primary goal is to improve patient outcomes by helping us all get better thanks to the inspiring messages of my guests, I also have the goal of building community through Mastering Intensive Care, so people can share their thoughts and their own skills. So leave a comment (on the LITFL episode page or on twitter using #masteringintensivecare), send me an email at [email protected] or engage in the facebook page Mastering Intensive Care.

How did you feel the first day you worked in ICU? Was it like walking on the moon? So foreign, because you didn't understand much about the machines, the techniques, or even the words that were being used. That's what it felt like for me, all those years ago. Thanks to one of my consultants who really "held my hand" on that first day, I was OK, but I wish I could have completed a BASIC course like most resident doctors in Australia (and many other countries) do today when they start their term in intensive care.

The BASIC course that those resident doctors now complete is mostly due to the efforts of Charles Gomersall. Over a decade ago, he realised the difficulties these junior doctors had in understanding what the Intensive Care consultants were both talking about and doing, so with a bunch of friends he set up BASIC (The Basic Assessment & Support in Intensive Care) course with the aim to teach participants, over 2 days, to rapidly assess seriously ill patients and provide initial treatment and organ support. Topics like airway management, acute respiratory failure, mechanical ventilation, haemodynamic monitoring, management of shock, interpretation of arterial blood gases, transport of critically ill patients, severe trauma, neurological emergencies, oliguria & acute renal failure, cardiopulmonary resuscitation, arrhythmias, nutrition, sedation and analgesia, etc.

This week my guest is Charles who is Professor in the Department of Anaesthesia & Intensive Care at The Chinese University of Hong Kong. In his words, his minor claims to fame are persuading some friends to write the BASIC course and denying a British prime minister entry to a London Intensive Care Unit, and his remaining ambition is to become a professional chef. That's all he wanted me to say about his background but let me say that having resident doctors rapidly brought up to speed on basic intensive care skills and practice, mostly so that they can feel comfortable at the ICU bedside in their first few weeks, is something I think is hugely valuable, not only to them, but also to me as a consultant and especially our patients. So that makes Charles a hero in my eyes. Of course, BASIC has gone on to now consist of many other courses, which now help up-skill nurses, medical students, advanced trainees, consultants (by providing refresher courses) in many countries, including in the developing world.

So I think Charles is a legendary educator, an inspiring leader and an outstanding clinician. He is softly spoken, humble, unassuming but incredibly well considered. He powerfully helps the patients in his own ICU and dramatically helps patients all around the world by providing BASIC. What a master.

In this week's episode you will hear all about the BASIC course, how it came to be, and where it is right now in amongst the other work of the BASIC Collaborative. You'll also hear Charles speak about:

• How he became both a doctor and an intensivist by accident
• How difficult it is to objectively judge the value of education
• The prime importance of putting the patient first in clinical, academic and educational practice
• Understanding the good and bad that surrounds us in our Intensive Care department culture
• How ICU specialists are like the hotel concierge of the hospital
• How paying back the support we received as trainees to our upcoming trainees is vital to the system of ICU education
• His views on sleep, cycling to work and listening to music
• The story of being on duty in a London hospital after a train crash people
• The benefits of communicating humanely to our patient's families when things are not going well
• And, how there is compulsory retirement at age 60 in Hong Kong

With this podcast, and the previous episodes, please help me in my quest to improve patient care, in ICUs all round the world, by inspiring all of us to bring our best selves to work to more masterfully interact with our patients, their families, ourselves and our fellow healthcare professionals so that we can achieve the most satisfactory outcomes for all. It would be much appreciated if you could help to spread the word by simply emailing your colleagues or posting on social media.

If you have a comment or a question, let's engage. Whilst my primary goal is to improve patient outcomes by helping us all get better thanks to the inspiring messages of my guests, I also have the goal of building community through Mastering Intensive Care, so people can share their thoughts and their own skills. So leave a comment (on the LITFL episode page or on twitter using #masteringintensivecare), send me an email at [email protected] or engage in the facebook page Mastering Intensive Care.

Thanks for listening. Do the best you can for those unfortunate people in our ICUs we call patients, and strive to get better at what you do, whilst looking after yourself.

Show notes (people, organisations, resources or links mentioned in the episode)

Prof Charles Gomersall: https://www.cuhk.edu.hk/med/ans/prof_gomersall.htm

BASIC course: https://www.aic.cuhk.edu.hk/web8/BASIC.htm

Whilst the skills of applying life support and resuscitation take up most of our training, they are relatively easier to master than the skills that allow us to become good at diagnosis, good at communication, and most of all good at being resilient over a whole career so we can satisfactorily work with others and deal with the stress of working in intensive care. Peter Brindley, a Canadian intensivist from Edmonton, thinks that these "human factors" are crucial for us to master, especially in the second half of our careers, when we should be striving to be simply "a good person".

In this episode Peter reflects, tells some stories, and invites us to consider many important topics that will help us become better people. These include reflection, simulation, mental rehearsal, debriefing, dealing with upset people and the feeling of being an "imposter".

Peter is a full-time critical care doctor at the University of Alberta Hospital. He is a Professor of Critical Care Medicine, Anaesthesiology, and Medical Ethics. He has published papers and given talks widely. He was a founding member of the Canadian Resuscitation Institute; and was previously Medical-Lead for Simulation, Residency Program Director, and Education Lead at the University of Alberta. He is proudest of his two children, neither of whom care one iota what titles he may or may not possess. He is convinced that happiness rests in finding meaning and showing gratitude - he occasionally succeeds.

This is the second in a series of DasSMACC special episodes, where I interviewed speakers from the recent DasSMACC conference held in Berlin. In addition to the human factors described above, we also spoke at length about burnout, its relationship to resilience, and the potential benefits of both working less (like part-time) and of having eccentric hobbies or passions. Peter spoke on several other topics including:

• His life journey from growing up in the United Kingdom to becoming a Canadian for all of his adult life
• The country of Canada, it's national identity and it's intensive care system
• The hallmarks of good teams
• Rudeness and its iatrogenic effects (including when family members are rude)
• The components of communication – including verbal, paraverbal and non-verbal
• A situation when Peter was accused of unprofessional behaviour and how he dealt with that
• How Peter has used a mini-sabbatical to reflect and to think about the next part of his career
• Exercise and the risk that it, other hobbies and material things can become like fetishes
• How our careers can be broken into thirds of "learning, earning and returning" but that we should consider all three in even the smaller periods like weeks or months
• The benefits of having an identity that is more than simply being a doctor
• His time on a cruise ship where he worked as an anonymous doctor
• How he is more proud of his writing of poetry and travel-writing than some of the medical papers he has published.

With this podcast, and the previous episodes, please help me in my quest to improve patient care, in ICUs all round the world, by inspiring all of us to bring our best selves to work to more masterfully interact with our patients, their families, ourselves and our fellow healthcare professionals so that we can achieve the most satisfactory outcomes for all.

You can send any comments through the Life In The Fast Lane website, facebook (masteringintensivecare), twitter (@andrewdavies66) or by simply emailing [email protected].

Show notes (people, organisations, resources or links mentioned in the episode):

Dr Peter Brindley: https://www.ualberta.ca/medicine/about/people/peter-brindley

DasSMACC website: https://www.smacc.net.au/

Dr Sara Gray: https://saragray.org/

Dr Chris Hicks: http://stmichaelshospitalresearch.ca/researchers/christopher-hicks/

Do you think your procedural skills are more important than your ability to lead and to mentor?

Do you have a department head who talks about your personal wellness with you?

How do you maintain and improve your skills in leading a family meeting?

Professor Brian Cuthbertson believes that our non-technical skills, those human factor aspects like leadership, mentoring, communication and leading meetings with patient's relatives, are more important than our clinical procedural skills as we evolve in our careers. But do we talk enough about them? In this episode Brian discusses several of these important non-technical skills giving some powerful insights as a highly experienced clinician and leader in the field of intensive care.

Brian is Chief of the Department of Critical Care Medicine at Sunnybrook Health Sciences Centre and Professor in the Interdepartmental Division of Critical Care Medicine at the University of Toronto in Toronto, Canada. He is also an Honorary Professor of Critical Care Medicine at the University of Aberdeen and an Honorary Professorial Fellow at the George Institute of Global Health in Sydney. Brian's research interests include improving outcomes from critical illness and major surgery. He has over 135 peer-reviewed publications and $17 million of research grants as well as playing a leading role in a number of key clinical guidelines.

Brian was very keen to talk about how much he values the human factors we all need to concentrate on to be the best we can be. Some of the main topics of discussion include:

• Brian's love for intensive care, which began with the machines and is now much more about humans
• The benefits he has realised from having high-class mentors in different areas
• His role as a mentor to others and how there needs to be some structure to this relationship
• How leadership at the bedside is like conducting an orchestra where everyone needs to be heard
• The need for senior trainees to stay in charge of resuscitation teams even when the consultant arrives
• How being a good team-player often requires us to drop our egos
• The value of good habits at the start of a ward round
• The need for department heads to address their team member's personal wellness requirements to maximise vitality and balance
• The importance of family members being at the bedside on clinical rounds to represent the values of the patient
• The fact that the highest level skill we can have is the ability to lead a family meeting, especially in culturally-diverse cities
• Placing the patient's values and needs at the centre of any inter-professional discussions, particularly differences in opinion
• The requirement for greater academic study of all of these non-technical skills

With this podcast, and the previous episodes, please help me in my quest to improve patient care, in ICUs all round the world, by inspiring all of us to bring our best selves to work to more masterfully interact with our patients, their families, ourselves and our fellow healthcare professionals so that we can achieve the most satisfactory outcomes for all. It would be much appreciated if you could help to spread the word by simply emailing your colleagues or posting on social media.

If you wish to send a comment or respond to something Brian said on this episode, feel free to email me [email protected], leave a comment on the Mastering Intensive Care podcast page on LITFL or on Facebook, or post on twitter using #masteringintensivecare.

Please take the very best care of your patients, their families and your colleagues. And above all, consider that taking care of yourself might actually be the best thing you can do for your patients.

I hope you have a great week.

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Show notes (people, organisations, resources or links mentioned in the episode)

Sunnybrook Health Sciences Centre: http://sunnybrook.ca/

Brian Cuthbertson: http://sunnybrook.ca/team/member.asp?t=17&page=2780&m=407

Malcolm Fisher:

http://www.nslhd.health.nsw.gov.au/newsevents/Pages/MalcolmFisherICU.aspx

Nigel Webster: https://www.abdn.ac.uk/ims/profiles/n.r.webster

Marion Campbell: https://www.abdn.ac.uk/hsru/people/m.k.campbell/

Mentorship in Academic Medicine – Author Sharon Strauss: http://www.mentorshipacademicmedicine.com/

Atul Gawande: http://atulgawande.com/

What sort of things do you tell yourself when you are resuscitating a patient?

Are you self-critical about your ability to deal with the situation?

Is your inner voice so loud that you can't concentrate on the task?

This is a topic we don't speak enough about in intensive care. The inner dialogue, which can often be very negative, is commonly going on in the background as we do our work. And as Associate Professor Sara Gray, a dual-trained intensive care and emergency physician from Canada points out, it can become louder and more critical as we become more stressed with the situation in front of us (eg. a difficult resuscitation). In this episode Sara talks about how observing the inner voice and trying to make it kinder is a form of self-compassion which can lead to improvements in our performance, thereby helping us to bring the best outcomes to our critically unwell patients. Such self-compassion can also provide the additional benefits of making us happier, more mentally healthy, and helping us to perform better in other areas of life. But it's not easy to change these voices in our heads. And we need to slowly begin to develop the ability to simply observe them before we can do the more difficult work of making the voices kinder.

This is the first of a series of DasSMACC special episodes, where I interview speakers from the recent DasSMACC conference held in Berlin. This was the third SMACC conference I have attended, and I enjoyed it for its international and multi-disciplinary flavour, as well as the excellent speakers and the exceptional program including topics from resuscitation and critical care interventions to communication and our own health and well-being.

Dr Sara Gray is cross-trained in Emergency Medicine and Critical Care. She works in both areas at St. Michael's Hospital in Toronto, Canada, and is an Associate Professor at the University of Toronto. She is also the Medical Director for Emergency Preparedness at St Mike's. Her academic interests include knowledge translation and optimizing performance; specifically how to improve the care of critically ill patients in the Emergency Department. Her most important achievements are her kids, who don't care what she does at work all day, and who remind her of what really matters in life.

Sara spoke in the opening plenary session with a talk entitled "Voices in my head". In this podcast interview, we discuss the premise of her talk, which is mainly about developing self-compassion by noticing our inner voice. We speak about some resources Sara has used to develop her own self-compassion, including the use of mindfulness meditation, which she now regularly practices. Sara is insightful, thoughtful, a true leader, a caring doctor, and above all a woman blazing a path to helping us to look after ourselves, our work colleagues, and indeed our patients. She is really helping to modernize the thinking in intensive care and emergency medicine circles. We covered several other topics including:

• Sara's own career combining emergency medicine and intensive care
• The potential benefits to the organisation of having doctors trained in both specialties
• How intensivists can develop better relationships with their emergency department colleagues
• The potential benefit of teaching our children to meditate so that it becomes a normal part of an adult's life
• Sara's attitude to sleep, how she is not a good napper, and how she benefits from getting an even number of hours sleep
• How getting away by herself to read a book for just 30 minutes twice a week can revitalise her
• How doctors need to listen more and talk less – and some techniques to do that better
• How the ICU ward round in the St Michael's Hospital is structured
• Some of the phrases she uses when talking with colleagues and patient's families
• How being a patient in her own hospital reminds her to approach patients with what may seem minor complaints in a more engaged manner
• How burnout is not a binary outcome, and more something that she swings closer to or further from depending on the circumstances

With this podcast, and the previous episodes, please help me in my quest to improve patient care, in ICUs all round the world, by inspiring all of us to bring our best selves to work to more masterfully interact with our patients, their families, ourselves and our fellow healthcare professionals so that we can achieve the most satisfactory outcomes for all. It would be much appreciated if you could help to spread the word by simply emailing your colleagues or posting on social media (using #DasSMACC, #SMACC or #FOAMed)

If you want to send a comment or respond to something Sara said on this episode, feel free to email me [email protected], leave a comment on the Mastering Intensive Care podcast page on LITFL or on Facebook, or post on twitter using #masteringintensivecare. I'd love to hear what you think are your major take-aways.

Thanks so much for listening. Please give your patients the very best care you can, and take care of yourself too.

____________________________________________________________________________________________

Show notes (people, organisations resources or links mentioned in the episode):

Dr Kristin Neff's website: www.selfcompassion.org

MBSR course: Mindfulness-based stress reduction

Jon Kabat-Zinn: Founder of MBSR program

Headspace meditation: www.headspace.com

Sara Gray's previous SMACC talk on "Optimising critical care in the emergency department": https://itunes.apple.com/au/podcast/optimising-critical-care-in-emergency-department-by/id648203376?i=1000359000551&mt=2

Scott Weingart's SMACC talk on "Kettlebells for the Brain": https://itunes.apple.com/au/podcast/kettlebells-for-the-brain/id648203376?i=1000375455720&mt=2

DasSMACC website: www.smacc.net.au

Dr Sara Gray: https://saragray.org/

Is the patient the centre of every action you take in the ICU? Do you exude calm and enthusiastic energy and greet other team members warmly and genuinely? Do you seek pleasure in seeing colleagues grow to become more skilled than you are?

These are 3 questions you might ask yourself after you listen to this episode with Professor Julia Wendon, a well respected intensivist from the United Kingdom. Julia gives great advice on how helping people converse with each other, often by picking up the phone and demonstrating good consultant to consultant communication can be really valuable in helping a patient receive the best care. She also outlines exemplary behaviour such as saying hello to the patient, whether they are intubated or not, and then telling them the plan after the ward round review.

Julia, from King's College London in the United Kingdom, is Professor of Hepatology, Executive Medical Director, and a highly experienced intensive care physician. Her appointment at King's began as a consultant in 1992 and since then she has played a key role in the development of the internationally respected King's liver service, including the expansion of the hospital's intensive care bed capacity. Her primary clinical areas of interest are severe liver injury, multi-organ failure, immune dysfunction and the role of extracorporeal therapies for the management of acute liver failure. She is a respected academic, has published over 150 papers, and is regularly invited to lecture at national and international conferences.

Julia is an articulate, thoughtful, caring and compassionate intensivist, as well as a tremendous stage presenter. Julia was an international speaker at the Australian and New Zealand CICM ASM in Sydney in May 2017 and this gave me a brilliant opportunity to interview her. Having helped to develop a world-leading liver ICU service at King's, Julia gives highly useful reflections on how noone can achieve anything without colleagues and great teamwork; smiling, saying hello and thank you is an important role of being a consultant leader; seeking second opinions is a really valuable regular practice to make sure we aren't missing anything; learning from trainees who have come from other continents and cultures is a huge privilege; looking after patients should always come before attending hospital meetings; and how she revels in allowing less experienced people to step forward and grow so that they can eventually overtake her. Also hear Julia speak about how:

• After enjoying intensive care as a very junior doctor working on a cardiac ambulance team, she trained at Middlesex Hospital in London under role models like David Bihari and Jack Tinker, who taught physiology enthusiastically at the bedside
• She learned so much from the senior intensive care nurses in her younger days
• Intensive care careers sometimes need to be varied in pace, and even head off in different directions at times
• Much can be gained by visiting other colleagues ICUs and even doing a ward round to see how others interact and manage patients
• She often reflects over a cup of tea on how a day in the ICU went and how she could have done things better
• The running of a family conversation can be difficult, is often done better by some than others, is a learnable skill, and requires accurate knowledge of what is happening with the patient, as well as asking the family what their present understanding is, all with the aim that the family can cope with the memories that they will leave with
• Making time for the important things in our lives helps us manage stress; and for Julia this includes clinical work, reading papers, reflecting, doing research, spending time with family, cooking and skiing
• Everyone in a department has different needs, and these should be recognised so that people can be allowed to do what fits with their needs, whether that be research, education, management or even playing golf
• Starting a 7 day week on a Friday can allow for some relief on the sixth or seventh consecutive day if this is required; which is less possible if the week starts on a Monday
• She would love to go back and study pure mathematics
• She worries we think about stress and burn out but that we don't do enough planning for what we will do when we are finished medicine
• We could use our journal clubs to allow us to present our favourite life habit to our colleagues
• Handover has become a greater responsibility as ICU teams have got bigger

With this podcast, and the previous episodes, please help me in my quest to improve patient care, in ICUs all round the world, by inspiring all of us to bring our best selves to work to more masterfully interact with our patients, their families, ourselves and our fellow healthcare professionals so that we can achieve the most satisfactory outcomes for all. It would be much appreciated if you helped spread the word by simply emailing your colleagues or posting on social media.

If you want to send a comment or respond to something Julia said on this episode, feel free to email me [email protected], leave a comment on the Mastering Intensive Care podcast page on LITFL or on Facebook, or post on twitter using the hashtag #masteringintensivecare.

Thanks so much for listening. Please give your patients the very best care you can, and take care of yourself too.

Do you give feedback to your intensive care colleagues when they do their job well?

Have you become overscheduled because you have trouble saying no to new tasks?

How well do you listen to the views of the intensive care nurses in your ICU?

The first international guest of the podcast series, Dr Colin McArthur, is a highly experienced intensivist, anaesthetist, researcher, administrator and leader from Auckland in New Zealand. In this episode he reflects on many aspects of his career and gives loads of useful advice about aspects such as giving both positive and negative feedback, learning to say no so we don't exceed our work capacity, and listening to and respecting the views of the intensive care nurses in our ICUs.

Colin is a senior intensive care specialist and past-Clinical Director in the Department of Critical Care Medicine at the Auckland City Hospital in Auckland. He is the immediate past Chair of the ANZICS Clinical Trials Group, with which he has been actively involved since its formation in the mid-1990's. Colin currently leads research governance for New Zealand's largest clinical research facility at Auckland City Hospital, and holds adjunct/honorary appointments at Auckland and Monash Universities. He is married to Juliet and has 3 sons in their early 20's. Colin is currently in transition from being a keen runner to (in his words) a mediocre cyclist.

Colin is wise, thoughtful, hugely supportive, skilled in many areas, and highly experienced, making what he says all the more useful to intensivists and trainees at all levels. Having been a leader for much of his career, he encourages trainees to find out how intensive care is delivered in many different institutions, both locally and internationally; he describes how although self-reflection is important, hearing the views of others on our performance is even better; he discusses his attitude to sleep and how the hours before midnight count most; and he tells how the benefits of running for him have included ensuring regular exercise, helping manage stress, and weight control. Also hear him speak about how:

• He found ICU an intimidating place when he first transferred patients from surgery as an anaesthetic trainee but began to like the people who worked there
• He worked for 2 years in Hong Kong and learnt from Dr Teik Oh, a pioneer and true master of intensive care in the Asian and Australasian region
• Senior mentors in our career can teach us about communication, interacting with others and the other highly important non-technical skills
• Working in an ICU that might be considered strong has good and bad aspects but does provide leadership in looking after the sickest patients
• Intensivists need to grow in their careers to operate at a level above simply having basic clinical skills so as to allow the main focus to be overall patient management through coordination and communication
• We can learn from seeing things done both well and done poorly
• The days in which he feels he is not at his best are usually related to what he has brought to work by not being well rested, not being well fed or not having done exercise
• He likes to get to work a little bit early to enable social interaction prior to the work phase of the day
• Tough he finds it to keep the details of more than 12 patients in his mind
• A really good stress management strategy is to carefully pick our battles
• Most intensivists would benefit from having a string to their bow other than simply clinical work
• Speaking to families and patients requires regular and multiple interactions, honesty, frankness, recognition of uncertainty, recognition of the limitations of medical knowledge and the need to value what the families bring to the conversation

With this podcast, and the previous episodes, please help me in my quest to improve patient care, in ICUs all round the world, by inspiring all of us to more masterfully interact with our patients, their families and our fellow health professionals to deliver the most satisfactory outcomes to all. It would be much appreciated if you helped spread the word by simply emailing your colleagues or posting on social media.

If you wish to send any feedback or simply want to keep the conversation from this episode going, please leave a comment on this page, go to the Mastering Intensive Care page on facebook, post on twitter using #masteringintensivecare or send an email to [email protected].