Episode 3: Pediatric Islands

Daniel Eison: 0:01

This is Dan.

Sarah Dabagh: 0:02

And this is Sarah.

Daniel Eison: 0:04

And we'd like to welcome you to PediPal.

Sarah Dabagh: 0:06

A new podcast about all things pediatric palliative care.

Daniel Eison: 0:09

The views in this podcast are ours alone and do not represent our respective organizations, and they do not constitute medical advice.

Sarah Dabagh: 0:17

If you have commentary on this episode, for the sake of work life balance, we will get back to you during business hours.

Daniel Eison: 0:26

Sarah, why don't you tell our listeners where the inspiration for this episode came from?

Sarah Dabagh: 0:30

I feel like this is the episode you and I have been itching to do since we started this project, is something we've talked about a lot: that dichotomy of how short this fellowship is, maybe the world's shortest fellowship as it sometimes feels, and then the job market as we saw it when we graduated a couple of years ago.

Daniel Eison: 0:46

Yeah, it's really striking that just a few months after you start fellowship, you're already figuring out what your job is for the next year. And then you end up maybe not only as an attending somewhere, but maybe the only attending somewhere.

Sarah Dabagh: 0:59

So we decided to hear some of those stories. In this episode, we're going to highlight a few voices of people who took on some of those small programs, how they're doing, how they feel, and what they're thinking for the future.

Ami Mehta: 1:12

Hello, my name is Ami Mehta. I work at Children's Hospital of the King's Daughters in Norfolk, Virginia.

Sarah Dabagh: 1:18

So Ami, my understanding is this was your first job out of fellowship. And I'm wondering if this was a position at a program that already existed or one that was made for you when you came.

Ami Mehta: 1:30

It's a position that I begged and pleaded and created for myself. But yes, it was created for me, there was nobody else there doing it. And I have to say, I think that worked fairly well in my favor, because it allowed me to do what I wanted with the program. It allowed me to focus in the areas that I wanted to focus in on, take the things that I really loved from fellowship and bring them back, integrate them with some of the expectations that the hospital had about what I'd be doing. But I was really able to create the program I wanted to create.

Daniel Eison: 1:59

Is this a "be careful what you wish for" story? Or are you glad that this is what you've ended up doing? Like, how has this turned out for you?

Ami Mehta: 2:08

It's now almost three years that I've been an attending, which still surprises the hell out of me when I say

it: 2:14

almost three years. And the program is what I want it to be, to some degree. It's my baby, I have been able to integrate the things that I love most into it, I get to do home visits, I have flexibility with whatever kind of palliative patients that I want to see. I can make it work for what I want it to be. That being said, when you're sort of a one-man show, growth is hard. Helping-- having the administration figure out how best to help me grow was difficult. I did manage to wrangle myself a nurse pretty early on, and she's my right hand man. I couldn't do my job without her. And so between the two of us, we have this shared vision for what we ideally would love this program to be. And we just keep slogging forward and hoping that at some point we'll get there. I mean, yes, it's scary, of course, being a new attending, but I had people to lean on. I had my old fellowship people to lean on. They were always there for medical questions and concerns, and "How do I figure this out?" And "What do I do? Can you talk me through this?" And then the fellows that you meet along the way, you know, you, you do meet people along the way, when you go to places like AAHPM. And the palliative care community, especially the pediatric palliative care community, is small. Start finding people that you can lean on, and you know, bounce questions off of them. And, so while you're doing it alone, you're never really that alone.

Sarah Dabagh: 3:37

So I'm interested to hear that balance of having sort of what I call the "pocket consult," which is texting and calling people you trained with and people you know, in the community versus that feeling of being the "attendiest" attending.

Ami Mehta: 3:52

That's a tough one, you know. I was always told that, you know, three years or so give it two-- maybe two years of attendinghood, you'll really start feeling better. And they're right, you do start feeling better. But man, does the imposter syndrome creeps up on you here and there. It started out pretty, you know, I walked into there as the palliative care and pain management attending at this hospital. I'm thinking, guys 10 minutes ago, I was a fellow. Like, I don't even know how to do my-- I barely know how to do my own billing. Like, this is my first time parking in an attending parking lot, okay? Can we just... there's a lot of things I'm figuring out here. And I'm supposed to know this. I'm supposed to be the authority on this somehow.

Daniel Eison: 4:31

So were there things in your fellowship that helped you get to this place? What were those things that helped you prepare to be the the person who knows?

Ami Mehta: 4:43

I don't know that anything ever perfectly prepared you to be the person that knows. But what I did have was a program that had grown other fellows, a long history of growing other fellows who went off and started programs. So I knew it could be done. Part of it was the willingness of my attendings to be resources in the future, which I don't think anybody ever is not. But it's different saying, "I know that I'm going somewhere that has a program, and I might need to bounce a few things off of you," to going somewhere where you know, you're going to be the only person, and that everything you learn here is the everything that you know. When you go to be an attending, you have what you had from fellowship. And that's it. That's all that's in your brain. And you have to make that work somehow. And so I knew that-- I knew that people had done that. And so therefore, that gave me the confidence to know that I could also do it.

Sarah Dabagh: 5:31

Who are your stakeholders? Who are the people you go to, and you say, "Hey, this is how I'm doing. And this is what I need?"

Ami Mehta: 5:38

So you know, I'm lucky, I have a practice manager and a director of ambulatory services who are on my team, they're on my side 100%. They are wonderful folks. And they get it. The harder part sometimes is convincing the administration, which is the money, people, especially now, especially with COVID, and I can't blame them, because, hey, we all know palliative care is not making anybody any money at the best of times, and it certainly isn't at the worst of times. So having to convince the money people that we're-- that, you know, we need to grow, and we need to grow in these ways, that's a little bit of a challenge.

Sarah Dabagh: 6:11

Speaking of being an only person, what is it like to have to go on vacation? Because everyone should go on vacation? Who covers you? What is that feeling of guilt when you leave, if no one is covering you? What's that, like?

Ami Mehta: 6:26

Vacation is interesting. Vacation is something we've cobbled together. Thank goodness, I have this wonderful nurse Shannon, because I couldn't do my job without her. She and I have learned that we do not go on vacation at the same time. Because my families have come to expect Shannon is always there. And if she's not there, Dr. Mehta is there. They know what they're-- what kind of care they want to get, and they know that we can provide that for them. It's really hard to detach. It's really hard for Shannon to not ask me this, like, text and say, just ask us one quick question. Because one quick question's not a big deal, but we work really hard to to block that time off for ourselves. And we're not always fantastic at it. I really try. But I can't say I'm great at it. And to be fair, I feed into it too. I check my emails on the weekends, in the evenings. You know, because we're-- it's in us to be there for our families, at the sake of ourselves, sometimes at the cost of ourselves sometimes.

Sarah Dabagh: 7:13

If somebody gave you a blank check and said, Ami, build the program of your dreams, how many FTE's, how many people, and what kinds of people would you put on that check?

Ami Mehta: 7:26

Quite the pipe dream. I love it. Alright, well, I have the people I need. I have Shannon. And I'm really lucky because I have about a third of a social worker and about a third to half of a chaplain, what I'd probably ask for them full time, and then another doc. And to be fair, it's not like I'm one person who's currently running a program that should be staffed by six docs. It doesn't work that way. So right now, I will probably only need another person, another physician or practitioner,

Daniel Eison: 7:54

Having asked you about your hopes, I will also ask you about your fears. Are there things that worry you? When you think about the future of your program? Are there things you're concerned about?

Ami Mehta: 8:04

It's funny, you asked that. So I spent the first two years worrying that I'd be fired. Literally, anytime anything came up. And some of it was me sort of joking with myself, am I going to be fired? So if it was like, "Oh, s**t, I'm really gonna be fired!" Excuse me. That's not gonna fly. I remember going to my practice manager, anytime anybody added concern about anything being like, "Am I gonna be fired? Are they going to get rid of me?" Like, what if there's not enough business? What if? What if, what if, what if? Now that we're busy, I'm starting to learn and starting to take comfort in the fact that they're not going to fire me, I'm pretty sure. And I still say that, because one never knows. But I'm pretty sure that they see the value in this enough that they're not going to fire me. But I guess part of it is that, you know, when you start out fresh, you're like, I can do this, I can do anything, even though we know we're not supposed to-- we know we have to protect ourselves and our own well being in our own mental health. I'm like, I can do this. I can work for extra hours. And to be fair, I mean, it's not like I'm there from six in the morning to eight at night, seven days a week. It's not like that. But the emotional draining, the emotional burden of this job, is something that-- how do you explain to anybody who's not in it? You know? There's no way to explain that to somebody who's not in it, much less somebody who's not clinical. So that's what scares me the most, is not that the program's not necessarily going to support me, although those things play into it. Because obviously, if I had a partner, I'd have somebody not only to lean on for emotional support, or somebody to say, I cannot literally be getting transport arranged for this baby and in clinic at the same time, which was the situation that was happening last week, you know? I can't do that myself. I need an extra set of hands for this. But my worry is that I can't do it. And that scares me more than anything else. Because what happens if I, who have wanted to do this for so long, can't do this anymore? What does that make me? One, it adds me to the to the relics of the failed program starter-uppers, which I do not want to be that person. At some point, something's going to have to give. And it needs to be the job, not the mental health of the solo practitioner.

Sarah Dabagh: 10:01

If you could give one piece of advice to the Ami who was thinking about the program that she was going to build, who was getting ready to graduate, what would that piece of advice be?

Ami Mehta: That's an easy one: 10:11

it's a "You can do it. You got this. It's not going to be easy. No, it is not. It is going to be full of self doubt and full of questioning yourself. But then there's going to be that moment where you do what it is that you've been trained to do. And you find a way to be what a family needs at that time in a way that no other physician can do. And it's worth it. It is absolutely worth it."

Daniel Eison: 10:33

That's-- that's beautiful. I think I can speak for both of us when I say we're really grateful for you sharing this and being so, so honest about this. It sounds like a huge challenge, but also just such a wonderful thing that you've created for yourself.

Ami Mehta: 10:50

I will say that, no, this is totally me tooting my own horn, which I'm only allowing myself to do because I know we don't do this often enough: I built this thing from the ground up. This is mine.If they know me, and if they like this program, it's because I did this. And so that's like a... it's not one of those things that, you know, we're not the kind people that let ourselves like revel in that for very long. You do it for a second, and then you move on to the next thing that needs to get done. But when-- those relationships that you've built, you've built those. You're not piggybacking on the coattails of anybody else, who they heard the word palliative and now they know what that means. And they like you guys, so so you know, they, they probably will like you, too. It's not that. Every bit of relationship and every bit of street cred you've bought with these families has been that you bought, you know. That's the coolest thing about being a solo practitioner.

Max Lindeman: 11:43

Hello, my name is Max Lindemann, and I work at Morgan Stanley Children's Hospital at Columbia in New York.

Sarah Dabagh: 11:49

So Max, for our listeners who may not know, I'm wondering if you can tell us a little bit about the history of pediatric palliative care at Columbia.

Max Lindeman: 11:58

Sure. I have heard kind of bits and pieces along the way. It sounds like maybe four or five years ago, there had been a pediatric palliative care team there that was similar in size to ours and very active and was doing all kinds of wonderful work all over the hospital and had an outpatient presence, was very much beloved and it sounds like they may hav been a little bit overextende or may not have been a appreciated for the work tha they were doing. And the tea kind of fell apart and wen their separate ways to differen

Sarah Dabagh: 12:27

Do you feel like you're getting to start from hospitals across the country. S there had been a few years without any kind of pediatric palliative care presence there. And the hospital really felt its absence. I think then there has been a lot of change in leadership at the Children's Hospital in like the chair of pediatrics and the head of the Children's Hospital overall. And it became much more of a priority to bring that back again. scratch and build a program the way you like? Or do you feel yourself getting back into the shoes sort of left by the previous program?

Max Lindeman: 12:59

That is a good question. We certainly feel some of the push and some of the tension from what the previous pediatric palliative care team did. You know, there's a lot of institutional memory. There are patients who were served by the previous team who, you know, have come back to the hospital, and we've been consulted for them, and they have different expectations for what we're able to offer right now. And so it's been really interesting kind of getting that kind of third hand from lots of different people and piecing together what that team used to look like and kind of explaining to them how we work now and what we can give to them. So I think the thing that has worked really well for us is everybody was so upset about the loss of the last team that they don't put a lot of pressure on us ultimately, from the administration, from the hospital system, to live up to the previous expectations that the last team had. So you know, I was very clear, when I accepted my position that I, as one person, or now we have one and a half attendings, would not be able to provide 24/7 coverage. So there would be nights and weekends where you know, there just isn't going to be anyone on call necessarily guaranteed.

Daniel Eison: 13:58

I think it's an important point that you make, though, and an interesting one and maybe one that's rare in this world, that the hospital and the residents and the nurses and the leadership, got to see a palliative care team get sort of pushed to its limit and then explode. And so now coming in, in the wake of that, it's just interesting to hear how that has maybe changed the expectations.

Max Lindeman: 14:22

You know, Columbia is this massive center for heart transplants and VADs and you know, all kinds of experimental treatments for DIPG and all these very serious life limiting conditions. And we're the center for all kinds of very complex and chronically ill kids. To not have the service available doesn't really look good for the hospital. And I think it may have been you know jeopardizing US News rankings or like magnet status or those kinds of things. So I think it was really important to them just operationally and reputationally to have palliative care back again. But certainly the leadership in particular was also just very enthusiastic about the service and felt personally and individually ashamed that the hospital didn't have it, just because they know the value of it. So it was really nice to be in that position where, you know, the system valued it for the reputation, but they also the leadership really saw its value as a service that the community needs. There just isn't a lot of pediatric palliative care in New York City at all, unfortunately. So there's a tremendous need. And you know, Columbia wants to be a leader in pediatric care. And so it's just important that Palliative Care is a piece of that.

Sarah Dabagh: 15:22

Why do you think New York is such a desert for pediatric palliative care?

Daniel Eison: 15:26

This is the question. I'm very curious about the answer to this one.

Max Lindeman: 15:29

And you know I've thought a lot about it. And New York is a very weird, insular place to practice medicine. It seems like once you get in it, like that's where you can stay forever, but it's very hard to get in and very hard to get out. And I think part of that is because New York has so many children's hospitals and so many resources. And pediatric care in general can be very easily fragmented, it'd be very easy to say like, I go to Columbia for my child's heart condition, but I want to go to Mount Sinai for their neurologist, and I want to go to Cornell to have their PT and OT done. And so you can jump around a lot. And there's always going to be a hospital offering something else somewhere else within a very close range. So I think with the number of resources available to people, and the amount of-- how easy it is to fragment your care, there isn't necessarily always going to be someone who is providing that umbrella and overseeing everything that's going on with a child and especially a medically complex child and what all their needs are. So palliative care can get overlooked in those situations.

Daniel Eison: 16:37

I've often wondered if it has something to do with the fact that New York hospitals are often operating on a much tighter margin in some ways. And so I wonder if the hospitals are, or historically have been, less willing to sort of take a risk on a money-losing service like palliative care, even if it is, you know, the right thing to do and like a moral choice to make? You know, I wonder if they-- if it's just harder in New York to say, yes, I'm going to take a loss, instead of in a place where there's more liberalized resources in some way.

Max Lindeman: 17:09

Yeah, I think that's a good point. At least our service, we're certainly still figuring out and winging a bit how best to bill and capture all the RVUs that we're generating so as to stay as competitive as possible. We don't add a lot.

Sarah Dabagh: 17:20

Is there a piece of advice you wish you could go back and give yourself becoming that first attending on that team?

Max Lindeman: 17:26

I think probably the best advice that I would have liked would be when people are all clamoring toward you, making requests of you to do something, before immediately saying yes to it, ask first,"How was that getting done before there was a palliative care team?" Because you know, there are a lot of committees and task forces who thought, oh, we should have palliative care involved in this too, and we want you guys to design a plan for how to provide critical incident debriefing more coherently for patients and for staff and faculty when there's a death in the hospital. And we want you to get more involved and be more integrated in the Emergency Room and how can we provide teleconferences down there? And sometimes the the systems that they have set up, already worked very well. And it's not clear that we're adding anything new or different, other than it feels like it should be something that palliative care should be doing or should be involved with. So I think that would have saved me a lot of grief when I felt like I was getting inundated and overwhelmed and very eager to help out with all these different things. And then realizing that, like, they didn't need me and I felt a little bit inadequate or insecure that-- why am I involved with this, if it seems like things are going well already? I think it would have just saved me a little bit of grief but eventually having to pull away and say no, would not feel as awkward.

Sarah Dabagh: 18:40

We've felt a little bit of that tug as we have built our program, and as we are trying to figure out how we fit in the hospital, of the distress flag, like the red flag

that goes up: 18:51

This is a sad situation, this is a distressing situation, I don't like the situation. But is that palliative care?

Max Lindeman: 18:58

Yeah, I completely agree. There are lots of things where it just feels like palliative care should be involved because it's distressing or it's scary or there might be something morally or ethically disconcerting about the situation. So we need to have palliative care involved immediately. But no one can really articulate what exactly they would like us to help do or solve or what we could contribute other than it just feels palliative care-ish.

Daniel Eison: 19:21

There is a sense, I think, in palliative care more than in other subspecialties, that you have to maintain a certain kind of popularity. When I consult Infectious Disease, they can turn around and be like, "Well, what is your consult question exactly?" Right? Like, do you have a question for me? And I feel like in palliative care there might be... I mean, obviously everyone in palliative care is nice and would never say something like that, but there's also, it does seem like, a bit of a pressure to be welcoming.

Max Lindeman: 19:48

Yeah, I agree. And plenty of times you can just hear the distress or the discomfort on the phone, or when they stop you in the hallway to talk to you about somebody. Yeah, and the staff support piece is really how our team, in its new iteration, I think, got a foothold. I think really doing that staff support was really what got us in to actually getting to see patients.

Daniel Eison: 20:09

Have educational initiatives played a role in also establishing that foothold? Teaching the residents, things like that.

Max Lindeman: 20:16

Yeah, absolutely. So, my first day as a fellow, I reached out to the pediatric Chiefs and said, "Hi, I'm here. I'm a pediatrician, I want to come into the Children's Hospital and do some teaching. When can you sign me up for noon conferences?" I would love to teach the residents about pediatric palliative care." And they were very enthusiastic and let me come in. And so I was coming to the-- I came to the Children's Hospital, maybe three or four times over the course of my fellowship to give lectures, and they were very hungry for it. And as soon as I started as an attending, the Chiefs reached out to me again and said, "These are the things that our residents want to learn about. There's a resident who is applying for fellowship in pediatric palliative care. What kinds of things can you put together for us?" And so that was a great way to build up a reputation or presence a little bit more, and let them know that there is an attending here now who can help with a lot of these palliative care cases that they've been kind of fumbling through or trying to manage their best on their own. So it's been very exciting to have that role to and really help build our popularity

Sarah Dabagh: 21:09

In the next couple of years, what are your goals for growth for the program?

Max Lindeman: 21:14

I would love to see us have some kind of clinic, some kind of outpatient presence. Our section is within Critical Care and Hospital Medicine. So there really is no infrastructure in our division for running any kind of outpatient practice. So it will require, I think, a lot of machinations to figure out exactly how to set that up. And we certainly need a lot more faculty and a lot more-- some kind of dedicated administrator, we need a nurse, we need people who can answer the phones and healthy prior auths for us.

Sarah Dabagh: 21:39

Yeah, nobody teaches you how to do that in fellowship. Nobody teaches you-- I don't even think I knew how to do a prior auth when I graduated fellowship. Nobody teaches you how to do negotiation, nobody teaches you how to figure out RVUs and FTEs. It's a huge growth curve. And I think that's one of the reasons starting a new attending job that also has a leadership role is so challenging, but also interesting, because that seems to be the majority of jobs that are available in pediatric palliative care for fresh grads.

Max Lindeman: 22:06

I think one of the greatest things that came out of my Chief year was finding some wonderful mentors who I then fell back on the year later, when I was actually applying for this job in my fellowship, asking them how do I negotiate a contract? And how do I like make sure I know how to set boundaries for myself? And is it okay to ask for-- or tell them that I don't want to work nights and weekends? Because I think that's part of the reason the last iteration of pediatric palliative care here failed. Are they going to take the offer away from me?

Sarah Dabagh: 22:32

I think that transition from "ask for" to"tell them" that you mentioned when you were negotiating, when you were thinking about this job is a perfect microcosm of that shift you have to make to go from a trainee to being in a leadership position without any sort of middle ground, without any sort of true transition, right? June 30 to July 1.

Max Lindeman: 22:52

Yeah, it's funny, it came out that way, in my answer to your last question, because I think that's exactly what I realized in the course of applying for the job, is I need to just start telling people, this is what we need in order for the service to flourish. And that's what I have reminded myself a lot this year, when there have been issues, it's not going to my division head to tell him about an issue and tell him what we need to do to fix it. Not so much asking is it okay if we do X, and that has been terrifying and liberating.

Sarah Dabagh: 23:20

Feel like I just met you, but I want to say I'm proud of you. Because it's a big transition. I feel like I'm still working on it. I've been doing-- I've been out of fellowship a year and a half, and I still feel like I'm still working on that.

Max Lindeman: 23:32

Thank you. I mean, it certainly didn't come easy. I certainly second guess myself and I come home and like panic, and like, "Oh, this is the day that I'm done. And this is-- I'm gonna I'm gonna call Yale back up where I did my residency and like, maybe they'll take me back as a hospitalist, because this is the end of Columbia..."

Sarah Dabagh: 23:47

You are not the first person to tell us in doing this episode, I go home and I wonder was that my last day? And am I gonna get fired, for this thing that happened?

Max Lindeman: 23:56

It is very humbling to be in a position where I am at a table making or helping to make life and death decisions within for families and for children. And I've only been doing this for a couple of months. And no one's really telling me that that's right or that's wrong. And they... I'm just-- I'm meant to be the expert. And I'm meant to be the the authority on whether it's right or wrong. So it's special and impressive and terrifying and wonderful. And I never know if I'm right. And I never know if... It's just-- it's fantastic that I get to be in this role.

Jennifer Kett: 24:35

My name is Jennifer Kett and I'm a palliative care physician at Seattle Children's Hospital. And all the views I'll express today are my own and don't represent any particular institution where I work now or have worked in the past.

Sarah Dabagh: 24:48

Perfect. So thank you for coming. And to echo or

to follow up on your disclaimer: 24:52

You're currently at Seattle Children's but where were you before that?

Jennifer Kett: 24:57

I worked at Mary Bridge Children's Hospital in Tacoma, Washington. I was there right around five years. And it was a really wonderful place to work. The team was bigger when I first joined, there were actually a few providers who did service time. But before I left, I was the only provider. And then for about the last year of my time there, I was the only member of the team.

Daniel Eison: 25:22

So this is actually very interesting for us, just in the context of the other guests we've had. You're the only one who so far has been on a shrinking team. We had one person who was the only person, started out as the only person and is still the only person. And then we had one person who kind of started out as solo and then is growing a team. And so I guess I'm curious to hear what it's like to be in that situation where you have a big team, and then slowly it dwindles.

Jennifer Kett: 25:52

You know, it certainly made me aware in palliative care, there is so much value to being on an interdisciplinary, transdisciplinary, multidisciplinary team. But sometimes there's overlap between the roles, and we don't always kind of clearly delineate like, oh, no talking about, you know, spirituality is only my job, or, you know, talking about hospice referral is only my job. You know, there's just this kind of flow and overlap of the different roles, and I was never sort of particularly aware of it, you would just kind of find a rhythm and sort of have a natural-- a natural flow with the particular folks that you work with. And as the team kind of changed in composition over time, I became a lot more aware of not just where the gaps were, like now we no longer had a person who could do really robust spiritual support that was part of the team. It made me aware of the gaps, and also the places of overlap, where I actually was giving a little bit of spiritual care support within sort of the bounds of my training. I actually was doing a little bit of what, if you kind of wrote it all out on paper, might traditionally fall in a more of a psychosocial provider role or more of a nurse coordinator role. That's a bit of a double-edged sword, because it's nice to be able to be well-trained to kind of provide a little bit of the kinds of care that folks from different disciplines provide. But you also want to make sure you're not operating outside of your scope as a physician. So I suppose being on a team with more providers, and then having the team composition adjust over time made me both more aware of some of my strengths in different disciplines, some of the missing pieces that I couldn't replace at all, and then also similar, they're kind of fraught nature of palliative care in general, where you're a physician, but sometimes the work we do doesn't always seem all that physician-y. And that can be kind of a plus and a minus.

Sarah Dabagh: 27:54

So I'm almost hearing that, as time went on, you found yourself wearing more and more shoes until there was the time you looked down, you said, "Oh, shoot, I have eight pairs on! And now I have to figure out how to walk."

Jennifer Kett: 28:07

Yeah, I mean, I think there were certainly some times it felt like that. There were also some times where it was like, oh, okay, you know, I found the place to kind of outsource the support, you know. As the team composition changed, I just sort of leaned on the different services that were outside of the team more and more. But of course, there's a different feel to it when you're kind of collaborating every day with the same group of people and developing plans together and more of a flow together. But I guess I wouldn't say that I wore all their shoes, because there were just a lot of things that I kind of couldn't do, I wasn't trained to do. Like maybe I carried like a few extra purses or something.

Sarah Dabagh: 28:50

I like that!

Jennifer Kett: 28:50

Yeah. The person who started our palliative care team is one of the best pediatricians on earth, David

Brunel, and he has this saying: 28:56

"You're the only you, but you're not the only one." And that was very powerful for me. I was at times the only palliative care person, but I'm not the only person with palliative care skills. So I had to trust that the ICU docs, the neonatologist, the, you know, oncology social worker, all the other folks that make up the kind of rich team that is a children's hospital, that they have skills too that they're bringing to the table and that they'll be able to help support the family however they need to be supported. So I kept really strict boundaries about my out of work time, particularly when I was the only the only only. I might stay late. But once I was done with my notes, shut down my computer, my pager went off. Nobody had my phone number.

Daniel Eison: 29:47

A lot of people talk about having to like build relationships with the other specialties and the other specialists and the other teams, and they talked about how important that is to doing the job of palliative care. Did you find that there were relationships that had been built by your team that you could count on? Or was there like an additional process of relationship building, when you went solo?

Jennifer Kett: 30:13

It was all sort of happening at once. You know, and there's also a kind of natural up and down, I think in palliative care, of we had a great case with this service, and they like really love us for a while. And we had like a really awful case with this service, we're not going to hear from them for six months. And you know that that was always happening, whether there were a few of us on the team, or whether it was just me. So I guess, I felt like I was always in a state of relationship building or relationship repair, relationship recovery, or relationship building, or, you know... There were certainly a few relationships that were like very stable, steady, comfortable, but there, there were always a lot of relationships that I think I was paying attention to. And I don't know that that changed so much when I became solo. Except that, you know, there's interpersonal stuff that we don't talk a lot about, where like, I'm just not the right fit for some families or some teams, or like, some providers just don't like me, even though I'm delightful and brilliant. And there's nobody else for them to ask to come participate. So if you're getting palliative care, you're always getting me. A hard part about being solo is that you just don't get any respite from the difficult cases. And so when there was a case that was really tragic, or a family that was really challenging me, or a situation with a team that was really difficult, and there was just nobody to kind of tag in and just say like, could you just take over this patient for a couple of weeks, I need a break. And so that was, at times just just really hard to manage. There was no one on a day-to-day basis, who I could just kind of talk through those cases with and be like, "Ah, this is so hard, or this is so sad, or these people were so mean to me," or like whatever it is, or, you know, I'm having imposter syndrome today or whatever. And so I managed to seek out just fellowship with some other palliative care providers in a more unofficial way. But I definitely missed that kind of day to day partnership.

Daniel Eison: 32:16

So you were doing inpatient, outpatient, hospice, prenatal consults, ICU consults, and apparently also eating, sleeping... And so my question is, what is the secret of time travel? And how did you figure it out? But actually really like, did you take weekends? Did you take vacations? Were you on call, you know, 50 weeks a year? Or what? What did it look like?

Jennifer Kett: 32:42

I took no overnight or weekend call at all. And so when I was in the hospital, it might be a 10 or 12 or sometimes 14 hour day. But when that day was over, that was it. And I did not take any call. And I would not have survived had I taken call 24/7/365. I just would have kind of crashed and burned. So that boundary piece is really important to me. And I think also allowed me that kind of repair and recovery time when cases are difficult to kind of go home for the weekend, try not to think about it. Or like your brain is sort of processing in the background and then you come in fresh the following week with good ideas. I think the kind of push-pull of that is that when you're building a program, and you're simultaneously trying to convince people how important and helpful palliative care is, but then also let them know you're only available during certain hours. I was like,"We're really important, you really need us... But we're not here all the time." And so that's just sort of a tricky balance.

Sarah Dabagh: 33:52

We've talked a lot about some of the difficulties of being a solo provider, but I'm wondering if there's anything you miss about it. Now that you're at a bigger institution.

Jennifer Kett: 34:01

It's very efficient. And there's no controversy about how to prioritize the day. It's just whatever I thought was the best place for me to go next, I would just... that's what I would do. And I could move really quickly from thing to thing and not have to feel bad about, say doing my notes are in the ICU, because I could just see all the patients, do all the notes while on the unit, and not have any anybody waiting for me, feeling frustrated that I'm not going faster, feeling like the day should be prioritized differently. I didn't have to wait for anyone else, nobody else had to wait for me. So that I think the efficiency piece is helpful. But of course you can only be so efficient when you're just one person you'd like you can't do more than one thing at a time.

Sarah Dabagh: 34:49

I'm wondering if you can talk a little bit about sort of the emotional journey of leaving a program like that where you had built those relationships, the push to leave, and the journey to a bigger place that might have felt more right for you.

Jennifer Kett: 35:03

Leaving was incredibly difficult. I mean, it's one thing to leave a program and know that the program will still be there after your departure, it's another thing to leave when you essentially are the program at that point, and that the program won't continue. Or it's not clear whether it will continue after you leave. So that was really difficult. I felt a real sense of worry about leaving patients, leaving patients behind and not being able to find a way to meet their needs. So I did a lot of kind of last minute helping everybody brush up on their primary palliative care skills and making sure that, you know, everybody knew about other local palliative care resources, and, you know, reaching out to all my patients to let them know about the transition and making sure that folks didn't feel abandoned. But that was definitely the thing that that sort of kept me up at night.

Daniel Eison: 36:03

If the opportunity arose again, in the future, to be a solo practitioner at a program, would you do it?

Jennifer Kett: 36:11

I would do it in the right circumstances. I think I could do it if there was a sense of building a program. Like you're the first person, but you're expecting company at some point. And even if it takes some years to get established and get that company, I think that would be a pretty fun endeavor. If I was the only person that was always only going to be me, that would be I think, trickier.

Daniel Eison: 36:37

Do you have advice that you would give to the Jen who was coming out of fellowship and going to this program? Is there something that you would want to tell yourself in that context?

Jennifer Kett: 36:48

Buy Bitcoin. Early. No, I mean, I think the main advice that I give to fellows now, and will probably give until the end of time is just this piece of what David Brunel taught me, which is,"You're the only you but you're not the only one." And there's this real, I think, risk in palliative care, I think we're all called because we want to be helpers. And the risk of that is that we all want to be the hero. And we want to be the one who's most connected to the family. And we want to be the one who gets the DNR and kind of like wins the day in the ICU. And the way you resist that kind of dark impulse is to remember that you're an important part of the team, but you are a part of a team. And whether that team includes a few people on a palliative care service, or whether that team is just more broad, and it's you and the oncologists and their whole service, or you and the ICU folks and their whole service, just remembering that you're part of this mesh, and that you're there to meet the needs of the patient and not your own needs. That's my advice to fellows, whether they're joining a team that's just one person or joining a really big team, is just to remember, it's not about you. And it's about the families that we're serving.

Daniel Eison: 38:16

What are our take-homes from this episode?

Sarah Dabagh: 38:18

Well, one of my take-homes in my own personal, selfish, self-reassuring way is that the feeling of "Am I going to get fired today?" is not just mine.

Daniel Eison: 38:26

Yeah, it seems like everyone feels that. Another thing is that as alone as you might feel, you're never really, really alone.

Sarah Dabagh: 38:36

I mean, we originally were going to call this episode "Pediatric Islands," and we probably still will, but what's missing in"islands" is that feeling of an archipelago, where all of us are still part of a whole, and you can still reach out to people you trained with, people you just recorded podcast episodes with, when you need advice for patients, which I did with Ami this morning. And then that community is still there.

Daniel Eison: 38:56

Absolutely.

Sarah Dabagh: 38:57

Much of palliative care is stealing other people's excellent lines and carrying them forward and selling them as your own. So we'd like to thank Dr. Jennifer Kett for the line we will steal and pass along which is, "You're the only you, but you're not the only one." I feel like that's our tagline for this episode. Thanks for listening. Our theme song is provided by Kevin McLeod. You can follow us on twitter where our username is@pedipal. We'd like to thank Conrad Williams for being our number one fan. You can find the notes for this podcast and all of our episodes on pedipal.org. If you'd like to submit thoughts, objections, or ideas for future episodes, please reach out via email on our website. This has been PediPal. We'll see you next month! I feel like this would be a good place for some sort of tropical island joke if I had ever watched any of those shows.

Daniel Eison: 39:43

I mean, there's probably a joke to be made in there about like talking to a volleyball...

Sarah Dabagh: 39:47

Only it's a Comfort Cub.

Daniel Eison: 39:50

Yeah, like if you find-- the thing is, you're never really alone. You have the other members of the other teams in the hospital and if you really are feeling lonely, pick up a Comfort Cub and talk to it like it's real. And...

Sarah Dabagh: 40:05

So I actually think this is brilliant and we should put it at the end of the episode after the music.