Episode 6: A Tale of Two Hats

Sarah Dabagh: 0:01

Hi, this is Sarah,

Daniel Eison: 0:03

and this is Dan.

Sarah Dabagh: 0:04

And we'd like to welcome you to Pedipal,

Daniel Eison: 0:07

a podcast about all things pediatric palliative care.

Sarah Dabagh: 0:12

The opinions on this podcast are ours alone and do not represent our respective institutions and they do not constitute medical advice.

Daniel Eison: 0:19

If you're looking for podcasts about other medical specialties, today, you're in luck. Sort of.

Sarah Dabagh: 0:25

In a way. Dan, you and I have really struggled naming this episode. And I think it's because for some reason, we stumbled across six or seven different metaphors. We can't seem to pick one.

Daniel Eison: It's true. I love metaphors. We both love metaphors. And it's hard to narrow it down: 0:39

hats, flowers, desserts...

Sarah Dabagh: 0:47

...chocoalate and peanut butter...

Daniel Eison: 0:48

Yeah, lots of different ways that we could present this. I think hats is the way to go.

Sarah Dabagh: 0:55

We've made this 0% clear for our listeners. So maybe I'll offer a little bit of clarity. This is an episode we have put together talking to people who wear a palliative care hat, and who wear the hat of a different pediatric subspecialty. Not to continue to mix metaphors, but one foot in each field, and their experiences, their stories and some of the challenges that come when

Daniel Eison: 1:27

And as confusing as that sounds, maybe it's even more confusing to live that. So we decided to talk to some people who are in two fields. So here they are.

Wynne Morrison: 1:41

Hi, I'm Wynne Morrison. I am a palliative care and critical care attending at the Children's Hospital of Philadelphia, where I direct the palliative care team,

Sarah Dabagh: 1:50

Wynne, I'm wondering if you can tell us a little bit about how you came to be one foot in each of those worlds.

Wynne Morrison: 1:56

I started out training and critical care at a time when you know most hospitals did not have pediatric palliative care teams. The things I loved about critical care were thinking about all systems and kind of the patient holistically, not focusing in on one system, and also being in intense and emotional situations and feeling like I was always learning. And so some of those things Sometimes when I tell people I practice in both fields, they asked me, well, aren't those like complete opposites? As if there really was, you know, almost no overlap, because the intensivist must be always trying to push the envelope at all costs, and the palliative care doctors are on the opposite end of the spectrum. And I would say that that is not my experience at all. I think there's a lot

Daniel Eison: 4:30

Do you find, even within yourself, a tension between your two roles? Do you feel them pulling you in opposite directions in in any way?

Wynne Morrison: 4:39

I do sometimes. And I need to have some self-awareness that it's not always the right answer to be less invasive and how we approach the care. I think it's often the right answer, but not always. And I probably think it's the right answer a little more often than some of my colleagues that like maybe we don't need the line or the ventilator here, and things like that. But I need to

Sarah Dabagh: 6:02

You talked about some of the ICU docs and their primary palliative care. When you are the ICU doc, do you think you pull in your palliative care colleagues sort of at the same rate that other people would? Or do you think you do your primary plus palliative care as an ICU attending?

Wynne Morrison: 6:19

I think I probably pull the team in a little less often than some of my colleagues, but not others. Because there are times where I'm like, okay, yes, I think I'm comfortable having this conversation and really sitting with this family and thinking through these things. And I have the time to do it in the moment, you know, so I won't pull palliative care in quite yet, because I

Sarah Dabagh: 7:39

Almost like you are a living example for everybody else in your department that those two fields can live in harmony in one person, those two fields can live in harmony in one unit.

Wynne Morrison: 7:50

Yes, maybe true! I hope so! I do often, however, tell the critical care fellows that you do not need to consult palliative care for every patient that is dying in the ICU. You know, it comes back to that question of where is the added value, you know. Sometimes for patient and family, there's really not a benefit to meeting a whole new team at a time when they're already being

Sarah Dabagh: 8:40

How much time do you split between the two? And what would your ideal time split be?

Wynne Morrison: 8:46

Time split, I think, is a very interesting question. And I have it come up all the time, when fellows are starting, who are dual-trained, are starting to look for jobs, because they always ask, well, what's the ideal split? What should I be looking for? And the caution I usually give them is that percent effort or FTE split doesn't mean the same thing at every institution. So you

Daniel Eison: 9:53

Do you feel like you are a palliativist to who does intensive care, an intensivist who does palliative care, or that you are some kind of hybrid of both? What is it for you, personally, in your identity as a doctor? What do you feel you are?

Wynne Morrison: 10:10

I do feel like I'm both. I don't think that I'm like, you know, a palliative-minded intensivist or a palliative care physician that has some critical care skills on the side, you know, I wouldn't see myself as either of those things. I do feel both. But I also-- the tension there that I recognize that can happen-- and again, this may be specific to me, so maybe it's good that you

Sarah Dabagh: 11:13

Do you ever have families thrown off or surprised? Or... you were here yesterday and nice clothes, and now you're here tonight in scrubs; what's going on? Do you ever have families really thrown off by the switch?

Wynne Morrison: 11:27

I actually do think a lot about when I'm first meeting the family do I introduce the dual role or not? And I frankly look ahead even at my schedule, I'm like, okay, how soon am I going to be covering the ICU? How soon am I going to be coming on for palliative care? What are the odds that I'm going to like next week be coming by and meeting this family in a different role? And should

Sarah Dabagh: 13:10

Do you ever find yourself, when you are the palliative care hat, and one of your colleagues is wearing the ICU hat, either disagreeing with their ICU management or having different opinions on what you would do, and how do you navigate that?

Wynne Morrison: 13:24

I actually think this is something that I've noticed comes up for many people that practice both palliative care and another specialty, is that sometimes we can judge the others in our own specialty more so than we otherwise would if we were not also practicing it. And how there needs to be a bit of a conscious effort to assume that our colleagues are well-intentioned and

Natasha Henner: 14:32

Hello, my name is Natasha Henner. I am a neonatologist and a palliative care physician at Lurie Children's Hospital in Chicago. And I've been practicing as a neonatologist for about nine years and as a palliative care physician for about seven.

Sarah Dabagh: 14:44

So I'm noticing a two year gap between your NICU number and your palliative care number and I'm wondering did you do a year of NICU and then do a palliative care fellowship?

Natasha Henner: 14:54

I did. It was an interesting journey. I came to Lurie Children's for a NICU faculty position without really a plan to practice in the pediatric palliative care field. I had an interest in perinatal palliative care, and thought that I should get more training but never really thought of it as a formal fellowship track. They just sort of said, hey, you're here, you look crazy enough

Sarah Dabagh: 16:29

That's a different kind of hat-switching than we've talked about with our other guests, because you're also switching the trainee hat on and off.

Natasha Henner: 16:35

Some of the hat-switching as a trainee felt comfortable, because I truly felt like a trainee. I didn't feel like an expert. You know, I did a lot of time obviously on the pediatric palliative care side where I wasn't knowledgeable or skilled or knew any of the pharmacology, right, because I trained as a neonatologist. Why would I need to know anything about, you know, ketamine

Sarah Dabagh: 17:08

When I think about the NICU, I think of it as a place that's ripe for primary palliative care skills. I'm wondering what were the things that felt really, really concrete that you got from your palliative care fellowship that were additive to your NICU skills?

Natasha Henner: 17:22

You know, as I think about it now, at least at Lurie, it's a place with a lot of surgical complexity, and a lot of very chronic patients, you know, kids who are ventilated for months, kids who have very long-term plans. And I think when I first started as a neonatologist, I was maybe more frustrated and less patient with those kids, right? Because I feel like, as an intensivist,

Daniel Eison: 19:08

I will ask the converse question now, I guess, which is what were the things in your palliative training that made your NICU work more challenging, or conflicted with your work in neonatology, if there were any?

Natasha Henner: 19:23

Yeah, it's interesting. I feel like sometimes I have to almost defend the care in the NICU. You have the sickest kids, who then perhaps end up in the cardiac ICU or in the PICU. Because there is this devaluation of babies. I don't know if other people have mentioned that before. But that's a common problem that I think we think about as neonatologists, that we tend to judge their parents chose a similar thing, it doesn't help. Like people still focus on the one baby who had a really bad outcome. And so then I try to step in more as a palliatist, I guess, and explain how people made this decision and why they made it and why it's important to keep supporting them.

Daniel Eison: 21:34

That's a really interesting perspective. It reminds me of one of the most surprising things, I guess, to me about, like, when I did my palliative fellowship, I had gone into it sort of expecting that palliative care would often be the ones asking people to pull back and saying, like, why are we doing all of this? Why are we intervening in these ways? And I found that a surprising

Natasha Henner: 22:07

With time, I think we as a group, and me probably specifically, positioned ourselves to say we're actually here to work on communication issues, to work on trust, to work on team dynamics, to work with the families who are asking for more therapies. And the ICU is actually saying, "We don't feel like we should provide these therapies." These are the sort of the tension points,

Sarah Dabagh: 23:27

Is there any advice you would give our listeners who, let's say, come from a hospital that has less cross-pollination? And are having either a hard time breaking into the NICU or forming these relationships with NICU physicians, or really implementing palliative care in the NICU? Any advice you would give them?

Natasha Henner: 23:44

Good question. I would say the first advice is to actually learn a few things about the outcomes. And then I feel like even as pediatric palliative care physicians, we tend to not quite fully, I think, appreciate how successful that part of medicine can be. And how there's a lot of value in trying the things that the neonatologists try. And to be curious about those outcomes,

Sarah Dabagh: 25:08

I hear that call for palliative care physicians to check their own biases and for NICU physicians to check their own biases against palliative care.

Natasha Henner: 25:17

Absolutely. And you're right to say that it goes both ways. I think a lot of neonatology physicians probably have biases against palliative care physicians, because they are still historically used to us as palliative really trying to negotiate that, you know, end-of-life care decisions or pathways. And time will help us break away from that. But if you as a palliatist, if all

Sarah Dabagh: 26:42

I love the message of-- you said it so beautifully-- "external noise of personal angst." I think it's really well-put.

Natasha Henner: 26:51

Yeah, because I think you know, we all practice, like we're all humans in this right? We all have a story that has rattled us, we've all witnessed outcomes that weren't the ones we hoped for. And it does color the next interaction, it just does, no matter how much you try for that experience to not sway you, and be neutral for the next one. It just can't be that. It changes our

Elisabeth Dellon: 27:19

Hello, my name is Elisabeth Dellon, and I am a pediatric pulmonologist and pediatric palliative care physician at University of North Carolina in Chapel Hill.

Sarah Dabagh: 27:28

Could you tell us a little bit about the journey that took you to palliative care from pulmonology or to pulmonology from palliative care?

Elisabeth Dellon: 27:35

Sure. I was drawn to pulmonology, you know, really, for a million reasons. I loved the diversity of conditions. the pathophysiology. I really like the complexity of kind of treatments and decision-making about managing respiratory illnesses. And I guess kind of opportunity to be the medical home, or just a really key player in the care of children with primary pulmonary

Sarah Dabagh: 28:45

How do your colleagues react to, let's say, if you are at a pulmonary conference, and you share that you also practice palliative care? What's the typical reaction that you get? Is it surprise?

Elisabeth Dellon: 28:56

It's not as as common in pediatrics. There are only a few pediatric pulmonologists and palliative care specialists kind of in combined roles that I'm aware of around the US. It's more common, of course, in adult pulmonary and critical care, with palliative care being combined. But I think it's just really supportive. It's always sort of a curiosity and, "What's the work that

Daniel Eison: 29:27

I'm wondering if you see, in your particular practice, that you're finding yourself more gravitating towards the acute inpatient side of palliative care or the, like, chronic outpatient side of palliative care.

Elisabeth Dellon: 29:39

I would say my heart has really become sort of the chronic disease population. You know, it's really watching, you know, kids and families sort of live with a burden of, say, neurological conditions that have a lot of respiratory morbidity, or a lot of challenges with, you know, aerodigestive issues, neurological symptoms, and kind of the interplay of all of that. It can

Daniel Eison: 30:32

It sounds like in a lot of ways pulmonology and palliative care are such a good mix, it's you know, your chocolate and peanut butter. And do you find ways in which you are getting a little bit of one into the other? Like, how do they influence each other in your practice?

Elisabeth Dellon: 30:48

All the time. I mean, name a domain of palliative care and, you know, talk about a child with a respiratory condition! And, I mean, there's so much back and forth, for sure, with, you know, children with neurologic impairment who have a lot of aerodigestive issues and you know, airway issues that are increasingly complicated as they're getting older or when they get really

Sarah Dabagh: Here's a question that may or may not belong in the episode, but I'm sort of wondering: 32:12

When we as palliative care at our hospital are consulted on cystic fibrosis patients or other patients who have advanced pulmonary disease but are mechanically ventilated, there's a huge tension about dyspnea management. And I'm wondering if, where you sit in both fields, you have any advice

Elisabeth Dellon: 32:42

Yeah, that's a tough one! I won't disagree with you! Certainly, the perception of most of my pulmonary colleagues and most of my ICU colleagues is that opioids, benzodiazepines that we sometimes reach for when there's a clear cluster with anxiety, really don't belong in the management of dyspnea, unless someone is near end-of-life. And now, of course, when we talk about

Sarah Dabagh: 34:06

If you could talk to the Elizabeth who was finishing her pulmonology fellowship, and tell her about this field that you now know so well, what would you tell her about palliative care to tell her why it's amazing she's going to do more training, more learning, more practice?

Elisabeth Dellon: 34:23

Gosh, you're making me feel emotional. I think I would tell her like this... this is why you went into medicine. You know, this is... this is... this is like what you're about. You love science. You have a lot of intellectual curiosity. You love talking to people, you love hearing stories, you love all these things. But what you really love most is just digging in deep and

Sarah Dabagh: 35:03

I think that's perfect. Thank you.

Daniel Eison: 35:08

Yeah, that, that rings so true. Yeah, I think for a lot of us, it's... it's about the reasons we started, or wanted to go into medicine in the first place. I think that's really...

Elisabeth Dellon: 35:17

It's true. It's like a privilege that we didn't recognize we would have. And it kind of makes it like a, you know, an amplified privilege, right? In some ways. It's kind of like exponential.

Daniel Eison: 35:31

I'm gonna refrain from handing you tissues. I've learned that that's not a thing I should do. But no, I was... I was wondering, as you think about, I guess, almost in the context of talking to your past self, as you think about yourself now and your identity now, do you think of yourself as a pulmonologist who does palliative care or palliativist who does pulmonology? Or some

Elisabeth Dellon: 35:56

Yeah, you know, I always, when I have to introduce myself, or people ask me what I do, I have to think about which one I say first. And I probably choose that based on who I'm talking to. I do find that I leave the palliative care part out with some audiences, or some question-askers, just kind of instinctively, because sometimes you're not in a place where it would be a us, it's just that we developed an interest in one or the other later on. For some of us, it might be kind of for sanity purposes, you know, you need the variety, or you can't stay totally focused on one area or the other, you know, all the time. But I think it is important to just name that we... you know, you really don't stop doing one and start doing the other. You just have to be thoughtful

Sarah Dabagh: 38:28

Alright, so Dan, do we think this hat metaphor that we've been carrying for this whole episode fits?

Daniel Eison: 38:34

Does the hat fit? I'm actually not sure it's the best metaphor. Because the way that our guests talked about their identities as palliative care physicians, it's not an identity that they can just put on and take off. It's part of who they are. And each identity affects the other.

Sarah Dabagh: 38:53

And I think if you wanted to stretch that even further, it's not just work hats. Everybody's wearing multiple... and I can't say the word 'hat' one more time I take myself seriously. But everyone's wearing multiple identities. You are a doctor and a palliativist, and a pediatric subspecialist. You're also an academic, and a clinical person, and a-- hopefully-- person who has a life

Daniel Eison: 39:27

As palliativists ourselves, it's easy for us to remember that all the other fields of pediatrics benefit from having a seasoning of palliative care-- and I'm going to use a totally other metaphor now. Sprinkling some palliative care into any other field definitely can enhance the flavor. However, the flavors of other subspecialties kind of come in and mingle with palliative care and

Sarah Dabagh: 39:55

And I think some of those differences highlights the privileges we have as palliative care folk who can spend an hour or more in a room, because that's the biggest hat I saw being taken on and off. It's not who you are as a person, it's not how you approach patient-care; it is what were your priorities and how much time did you have to spend in that room?

Daniel Eison: 40:14

Yeah, I think that's really important. And I see that we're back to hats now. So that's good. Glad we got back to that again.

Sarah Dabagh: 40:20

Thanks for listening. Our theme song is provided by Kevin MacLeod. You can follow us on Twitter where our username is @Pedipal. 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 the email on our website. This has been Pedipal. We'll see you next month. But stories of people who are palliative care and who aren't and sometimes who consult palliative care when they're not palliative care, but then later on, they are palliative care.

Daniel Eison: 40:54

...What?

Sarah Dabagh: 40:55

Yeah. I don't know!