Curt Tribble

There Are a Lot of Things They Didn’t Tell Me When I Signed On: Helping Trainees Land a First Job

During my training and my early faculty tenure, there was a picture of a dust-caked, grizzled cowboy that hung between the two primary cardiac operating rooms. Beneath the picture was written, There are a lot of things about this job they didnt tell me when I signed on. When we moved into our new hospital, the picture did not resurface. However, I never forgot the lesson conveyed by that picture. One of the most important obligations faculty members have is to help their trainees find a job. While their trainees have likely had part-time jobs and, of course, theyve held training positions, they usually have not had a real job before. The job that each hopes to land at this point in their lives is vastly different from any that theyve had before, and the issues that they need to consider are numerous, substantial, and, generally, unfamiliar to them. Therefore, a brief review of some of these considerations may be useful to those giving advice about the post-residency job search. I will not cover one major issue in choosing a first job: whether to look at academic jobs, non-academic jobs, or jobs that are hybrids of the two. As most know, in academics its dog eat dog, while in non-academic jobs, its just the opposite.

A technique for implantation of the CentriMag left ventricular assist device to allow ambulation and rehabilitation in patients with heart failure.

BACKGROUNDnThe therapeutic options for heart failure include inotropic agents, intraaortic balloon pumps, and left ventricular assist devices (LVAD). Implantable LVADs are not appropriate for all patients. The short-term devices require patients to stay in bed, connected to cannulas, which are usually inserted using a median sternotomy. This approach requires a subsequent sternotomy, midline cannulas (which can make sitting difficult), and immobility. We began using a right thoracotomy with cannulas placed through intercostal spaces for selected patients in need of temporary LVAD support.xa0nnnMETHODSnThis retrospective chart review examined our experience with CentriMag LVAD placement via right thoracotomy from August 2009 to June 2013. We reviewed the reasons for support, the degree of postoperative mobilization, and the outcomes of the patients treated in this manner.nnnRESULTSnThis approach was used in 6 patients. Four patients lacked financial or social support for a long-term, implantable LVAD. One patient was considered too ill to have an implantable LVAD placed, and one was treated with temporary support with hope for recovery from myocarditis.xa0 Five of these 6 patients were able to walk soon after LVAD implantation and initiate rehabilitation.xa0 One did not recover and had support withdrawn. Another suffered a stroke and had support withdrawn. Four of the 6 were transplanted successfully.nnnCONCLUSIONSnCentriMag LVAD implantation via a right thoracotomy is a feasible approach that provides adequate hemodynamic support while allowing patients to ambulate, making subsequent cardiac transplantation less complicated by allowing the avoidance of a repeat sternotomy.

Reoperative Cardiac Surgery: Part I – Preoperative Planning

While reoperative cardiac surgery has become safer in recent years, it is still more difficult and dangerous than a primary operation. In a recent review of the Cleveland Clinics experience, 7% of the patients undergoing cardiac reoperations had major intraoperative adverse events (IAEs). In that report, if an IAE occurred, there was a 5% mortality and a 19% incidence of myocardial infarction (MI), stroke, or death [Roselli 2011]. Those are sobering statistics, particularly when reported by one of the busiest cardiac surgical services in the world. The take-home message is that reoperative cardiac surgery is riskier than primary cardiac operations and that there are strategies that should be employed at each juncture to lower the risks of a reoperation.However, many of these strategies and recommendations have been more implicit than explicit. In fact, surprisingly little has been written about reoperative cardiac surgery. Thus, it seems appropriate to collect some of the lessons, adages, tricks, and tools that might make reoperations a click safer.

Knockin’ on Heaven’s Door: End of Life Decisions and Discussions

More than 2.5 million people die in the United States each year. For the majority who live out their final days in various institutions or in hospice care, decisions must be made about which treatments to administer, which treatments to stop, which treatments to continue, and which treatments to back off of. Thus, while death remains inevitable, its timing is often very much a function of human agency. Once it was common to speak of nature taking its course, but now it has become as common to view death as something about which people have some control [Meisel 2008].

A Shift to the Left: Teaching the Craft of Cardiac Surgery

I was in Chicago in 1987 when Dr. Shumway delivered his American Association for Thoracic Surgery (AATS) presidential address, and, like most in the audience, I knew he was correct. Having had the privilege of getting to do a lot of thoracic and cardiovascular surgery in my surgical training, I was preparing myself to make my own move to the left side of the operating table. In fact, I had already resolved that I would make my own shift to the left very soon after that meeting in 1987, hoping to become, like Dr. Shumway, the best first assistant I could be. Over thirty years later, I have never looked, nor moved back. However, making this move to the left side of the table - to teach surgical residents how to operate - is challenging for many surgeons in academic environments. In considering the challenges, we must remember that those of us who have agreed to teach our protégés have an obligation both to them, and to their future patients, to help them become safe, capable cardiothoracic surgeons.

Grandmother Rules: Crucial Conversations with Patients and Families

I matriculated at the same medical school from which my father graduated 22 years earlier. This coincidence gave me the opportunity to use his advice, based on his experiences as a student, to seek out some of the schools best and most memorable teachers.

Lessons from Crew Resource Management for Cardiac Surgeons

Crew resource management (CRM) describes a system developed in the late 1970s in response to a series of deadly commercial aviation crashes. This system has been universally adopted in commercial and military aviation and is now an integral part of aviation culture. CRM is an error mitigation strategy developed to reduce human error in situations in which teams operate in complex, high-stakes environments. Over time, the principles of this system have been applied and utilized in other environments, particularly in medical areas dealing with high-stakes outcomes requiring optimal teamwork and communication. While the data from formal studies on the effectiveness of formal CRM training in medical environments have reported mixed results, it seems clear that some of these principles should have value in the practice of cardiovascular surgery.

Gimme 3 Steps (With a Nod to an American Rock Song from the 1970s)

The message that patients are frequently dissatisfied with their interactions with their physicians is a common one. And, articles about physician burnout are plentiful [Shanafelt 2015]. Indeed, a recent national survey showed a nearly 9 percent increase in burnout rates over just the last 3 years [Peckham 2015]. Many factors contribute to this problem, not the least of which is the push to use electronic medical records systems, as evidenced by the recent comment from the acting administrator of the Centers for Medicare and Medicaid, Mr. Andy Slavitt, who said we have to get the hearts and minds of physicians back. I think weve lost them [McKnight 2016]. While many of the factors contributing to physician dissatisfaction are, and will be, difficult to control, there is at least one source of satisfaction that is within the relatively easy purview of virtually all practicing physicians, and that source is the patients for whom all physicians care.xa0 Fortunately, there are some straightforward, simple, and efficient ways to improve the view patients have of their physicians and the satisfaction that physicians can derive from caring for their patients. Three simple steps that can make both physicians and their patients more satisfied with the interactions between patients and physicians are outlined here. These suggestions are primarily oriented toward physicians in training caring for hospitalized patients, though they are most certainly applicable to all physicians. These suggestions are based on what younger physicians can say to, ask of, or do for a patient under their care, all of which can be easily and efficiently accomplished.

A Practical Minded Obsession: With the Possibility and Consequence of Failure.

The ACGME (Accreditation Council for Graduate Medical Education) in its description of its ‘Outcome Project’ notes that all training programs “must require its resident to obtain competencies in six areas to the level expected of a new practitioner” and these six competencies include: patient care and medical knowledge, interpersonal skills and professionalism, and systems based practice and practice based learning. Furthermore, most hospital credentialing systems require evidence of successful adoption and practice of these same six competencies. In his article entitled ‘Creating the Educated Surgeon of the 21 st Century’ Atul Gawande concludes “We are doctors, not technicians. We must educate ourselves accordingly.”xa0 [Gawande, A. The American Journal of Surgery 181: 551–556, 2001]

How I Do It: Temporary RVAD Placed at the Time of Implantation of a HeartMate II LVAD

Left ventricular assist devices (LVAD) are increasingly used to support patients as they await heart transplantation and as destination therapy for patients with end-stage cardiac failure. While the methods of LVAD implantation have become fairly standardized, early postoperative management of patients receiving these devices remains challenging. One issue that has plagued surgeons, cardiologists, and intensivists caring for patients after LVAD implantation is right heart dysfunction. While many scoring systems have been developed to try to anticipate RV failure, the accuracy of these predictive tools remains low. We present a novel approach of implantation of a temporary right ventricular assist devices (RVAD) during LVAD implantation with subsequent weaning in the immediate postoperative period, utilizing a strategy that does not require a return to the operating room for removal of the RVAD cannulas.