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The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.
[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, we have a patient, Dr. Blaine Lesnik talking about turning health struggles and painful patient experiences into something positive.
[00:00:15] Dr. Lesnik: There was the moment where the residents are talking and you know, they're doing a cold test, putting ice cube on my leg, on my chest, and I can feel it, and they kind of have this shocked sort of reaction and realize they did make a mistake.
[00:00:36] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast sponsored by the Bucksbaum Institute. During this podcast, we discuss, dissect, and promote clinical excellence. We review research pertinent to clinical excellence, we invite experts to discuss topics that often challenge the physician-patient relationship, and we host conversations between patients and doctors.
I'm Adam Cifu, and today I'm joined by a patient, Dr. Blaine Lesnik. Dr. Lesnik will get both a professional and personal introduction from me. Dr. Lesnik is a clinical psychologist who has been in private practice for more than 20 years. She's a fellow and past president of the Illinois Psychological Association, is a member of the Department of Professional Affairs Licensing and Disciplinary Board for clinical psychologists, and is the president-elect of the APA's division of Psychologists in Independent Practice. She currently sees patients via telehealth from her Chicago home. Dr. Lesnik also received a bilateral lung transplant at the University of Chicago in January, 2015. She has presented many times to both professionals and patients on the subject of surviving organ transplantation and living with a complex chronic condition.
Thanks so much for letting me take some of your time, Blaine.
[00:01:52] Dr. Lesnik: I'm happy to be here.
[00:01:53] Dr. Cifu: It's probably my longest introduction I thought about.
[00:01:56] Dr. Lesnik: It's like, wow, yeah, that was wordy.
[00:02:00] Dr. Cifu: Also joining us today for reasons that will become clear later is Dr. Nicola Orlov, because Dr. Orlov is making a return appearance, I will skimp on her introduction and just remind you that she's an associate professor of pediatrics in the section of pediatric hospital medicine, associate program director for the pediatric residency training program and director for clinical coaching in the pediatric clerkship at the Pritzker School of Medicine. She's also a junior faculty scholar in the Bucksbaum Institute for Clinical Excellence. Nikki, thanks for coming back.
[00:02:33] Dr. Orlov: I'm so happy to be here, nice to see you both.
[00:02:36] Dr. Cifu: I won't talk about your daughters and my mother this time.
So, Blaine, um, Dr. Orlov introduced the two of us after you guys began working together to train our medical students. So as much as you're comfortable, can you speak about your healthcare experience and what kind of got you started on this whole, on this whole, I don't know, journey?
[00:02:57] Dr. Lesnik: It is a journey, that is for certain. Well, I was diagnosed in 1999 with an autoimmune disease, sarcoidosis, and um, you know, was sort of able to stave that off for a number of years until about 2010 I had a bad pneumonia that took some more lung function. And then by 2012 I was huffing and puffing and really, I tried several different things, methotrexate and um, all kinds of different combinations of medicines by various doctors in the field. And eventually we got a consult from Dr. Ed Garrity, who retired from here. And, um, I was on oxygen full-time and he essentially looked at my latest scan and said, "You know, I've never seen a patient recover medically without a transplant with this level of disease in their lungs and without a transplant your lifespan is one to two years." Um, when you hear that, it's pretty sobering. Um, and then that was in 2013 and for the following two years prior to transplant, you know, you get sicker and sicker and sicker until you're sick enough to get on the waiting list for the organ, and it's a really difficult thing. You have to be really sick, but well enough to sort of survive a nine and a half hour surgery and all of the recovery. Um, I think that was one part of it, and then, ten months after the transplant, I learned that I had a malignant sarcoma in the new lungs, and was a patient again facing a fatal diagnosis...
[00:04:47] Dr. Cifu: Boy.
[00:04:47] Dr. Lesnik: ...living in a world where you're filled with dread. Um, really it kind of overtook me. And I had several years of chemo, in and out of the hospital with MRSA, and all kinds of other things. And I suppose the thing that really stayed with me is there were some doctors who didn't believe me about what I was telling them...
[00:05:20] Dr. Cifu: Yeah.
[00:05:20] Dr. Lesnik: ...what I was feeling.
[00:05:21] Dr. Cifu: Yeah.
[00:05:22] Dr. Lesnik: And when I woke up after the transplant, um, I actually was lucid enough to sign for a... You know, wanting a pad and a pen and I was in a kind of pain I can't describe, and I wrote, "Need pain meds. Can't breathe," like I could... My breath was so shallow... I mean, I was... I can't explain the level of pain a person lives through. And it took about a day and a half for the pain med group and a group of residents... It so happened that my surgery was on a Thursday and so we were heading into the weekend and they just thought that I was, you know, med-seeking, pain intolerant crazy person.
[00:06:15] Dr. Cifu: Yeah. Yeah.
[00:06:16] Dr. Lesnik: And so really that story is a story that has allowed me to talk to people in the treatment field, to talk about believing your patients.
[00:06:27] Dr. Cifu: Right.
[00:06:28] Dr. Lesnik: And I think Nikki saw a patient, patients as teachers panel, that I was lucky enough to participate in where I told that story to a group of oncologists and people who worked in that arena and it felt really good...
[00:06:45] Dr. Cifu: Yeah.
[00:06:46] Dr. Lesnik: ...to be able to tell the story so that one person, one doctor would believe their patient.
[00:06:53] Dr. Cifu: Yeah.
[00:06:53] Dr. Lesnik: If I touch one patient who learns how to advocate for his or herself, um, that is a way that has helped me to bind my suffering and make it seem worthwhile.
[00:07:06] Dr. Cifu: I have two questions, which may be a little bit off the topic of, you know, where we're getting, but that I just sort of have to ask listening to your story. The first is, in your, you know, it sounds like early appointments with Dr. Garrity who, you know, was an amazing both, you know, doctor and scientist really, what was it like to get that sort of news from him that like, boy, you know, if you are going to survive this, you need an enormous procedure? You know, I imagine that's sad and frightening, but also, I don't know, maybe a little daunting to know what you've got to go through?
[00:07:45] Dr. Lesnik: It's definitely daunting. I had been hiding how sick I was for maybe let's say, five years.
[00:07:52] Dr. Cifu: Yeah.
[00:07:53] Dr. Lesnik: So to my parents it was much more shocking but I knew what was going on in my body and I had a pulmonologist in the NorthShore system who followed me until I became too sick for regular pulmonologist.
[00:08:10] Dr. Cifu: Yeah. Yeah.
[00:08:10] Dr. Lesnik: And he had used the word transplant way back in 1999 when I first was diagnosed. And I remember saying to him, "Am I going to see my daughter graduate from high school?" And he said, "Absolutely, this is way, way, way in the future." Well, I did get to see her graduate from high school in 2017 after the transplant.
[00:08:38] Dr. Cifu: Wow.
[00:08:39] Dr. Lesnik: And since have been able to, um, see her move into her first apartment, all those kinds of things.
[00:08:46] Dr. Cifu: Yeah, yeah.
[00:08:47] Dr. Lesnik: Yeah, but very, very daunting. Absolutely.
[00:08:51] Dr. Cifu: And then, I guess my other question, which maybe leads into, you know, your role in educating physicians, when you look back on the episode of, you know, kind of coming out of surgery and having, you know, inadequate pain control, um, like, what do you think led to that? And I mean, I think I'm thinking more, you know, the doctors sort of not believing it, was it that like, we have a protocol and this protocol works and, you know, you can't step outside that protocol or I don't know, what, what was there?
[00:09:25] Dr. Lesnik: Part of what I learned later by the, you know, when the residents listened to me...
[00:09:31] Dr. Cifu: Yeah.
[00:09:32] Dr. Lesnik: ...I essentially kind of threatened them to call their attending, you know, I said, "If you don't call the attending, I'm going to call my attorney."
[00:09:41] Dr. Cifu: Yeah.
[00:09:41] Dr. Lesnik: Um, and I looked completely wildly crazy.
[00:09:45] Dr. Cifu: Yeah, sure.
[00:09:46] Dr. Lesnik: But I was crazy, the epidural... I mean, I was crazy in pain.
[00:09:50] Dr. Cifu: Right, right.
[00:09:50] Dr. Lesnik: The epidural had been misplaced.
[00:09:53] Dr. Cifu: Mm.
[00:09:54] Dr. Lesnik: And so it was real the whole time.
[00:09:56] Dr. Cifu: Yeah.
[00:09:56] Dr. Lesnik: Um, but the thing, the part about this story I like to talk about as a psychologist is, I just came out of a nine-and-a-half-hour surgery, I woke up 12 hours earlier than they had expected, my folks had gone home, and I was lucid enough to ask for a pen and paper and write a sentence. Nobody took in that data and thought, "Oh my God, she's under-medicated."
[00:10:23] Dr. Cifu: Right, right, right.
[00:10:24] Dr. Lesnik: I should have been deliriously out.
[00:10:26] Dr. Cifu: Right, right.
[00:10:26] Dr. Lesnik: Right. Yeah.
[00:10:27] Dr. Cifu: God. Yeah, and the thought of not having adequate pain control, having just had a lung transplantation, when you first told me the story over the phone, you know, I was breaking out into a sweat.
[00:10:38] Dr. Lesnik: Yeah, right.
[00:10:40] Dr. Cifu: So, I mean, I think a lot of people's response to that would've been, you know, after you sort of get through the acute illness to be anger and, you know, a. I never want to see this place again except maybe to collect a check from the lawsuit, right? So I mean, what made you think about, "God, you know, I can kind of use this pain and this horrible experience for something, you know, more positive"?
[00:11:08] Dr. Lesnik: I guess it sort of happened in a way by accident. Um, you know, there was the moment where the residents are talking and, and you know, they're doing a cold test, putting ice cube on my leg, on my chest, and I can feel it. And they kind of have this shocked sort of reaction and realized they did make a mistake. Um, and I guess I started out by going to talk to the lung transplant support group here at the U of C and um, when I told my story, the next day or the day after that, the social worker called me and said that there was a woman who was in there and listened to my story and she had been afraid. She was very high up on the UNOS list to get her organs, and she wasn't sure she was going to accept the organs. And when she heard my story, she decided she would.
[00:12:11] Dr. Cifu: Oh, wow.
[00:12:11] Dr. Lesnik: And she had the surgery and that made me feel like, wow, this is... I touched that woman.
[00:12:22] Dr. Cifu: Yeah.
[00:12:22] Dr. Orlov: Mm-hmm.
[00:12:23] Dr. Lesnik: For all the suffering, like that sort of... It gives me chills.
[00:12:28] Dr. Cifu: Yeah. Yeah.
[00:12:28] Dr. Lesnik: And I have, you know, five stories like that from all of the presentations I've done, including, you know, meeting Nikki and being able to help to support the amazing project that Nikki is doing.
[00:12:44] Dr. Cifu: Yeah, yeah. So Nikki, tell me a little bit about kind of your work and how you guys connected, well, I guess I heard how you connected, but you know, how that led to kind of an educational intervention, I guess.
[00:12:56] Dr. Orlov: Yeah. I just can't hear that story and not say what admiration I have for that perspective. I think I would do exactly what you said, Adam, which is, you know, walk away and never come back here again but to take your pain and suffering and use it as an opportunity to sort of better the future of medicine and the way that we practice is just, um, feel like the ultimate deed. So, thank you.
[00:13:23] Dr. Lesnik: Thanks.
[00:13:24] Dr. Orlov: Um, gosh, you asked a loaded question, so I'm trying to figure out where to even begin with that answer. I'm just going to jump in where I want to jump in. So, you know, I do a lot of work with medical students on the clinical wards and, um, in our environment, feel like we are just constantly focused on tasks...
[00:13:49] Dr. Cifu: Right.
[00:13:49] Dr. Orlov: ...note writing, and have over the years felt like we have not prioritized the patient enough. I try to prioritize the patient all of the time, but we are so busy and I've always worried that we aren't necessarily sending the right message to our medical students, right? That we aren't reminding them on a constant daily basis and giving feedback about patient-centered care and empathy and humanism. And, you know, the way that we met was, um, really pretty. It was bashert, you know?
[00:14:25] Dr. Cifu: Yeah.
[00:14:25] Dr. Orlov: But I think that really the way that it ended up rolling out was that I had a vision for how we could better teach some of these things on the wards. It occurred to me that, like we really needed to spend more time coaching medical students, giving them feedback on their communication skills...
[00:14:47] Dr. Cifu: Yeah.
[00:14:47] Dr. Orlov: ...on their patient-centeredness and how they provide, how they show empathy and humanism on the wards. I sort of pause when I say the word feedback because feedback's not really the skill that you want to use when you're coaching students, but in brief, what I did was I proposed to Blaine a project that I would roll out, a coaching project that I would roll out on the clerkships. I am now more than halfway through our pilot year. It's a project that she's funded, and it's a project that specifically allows me to meet with every single one of the medical students who rotate through pediatrics to have a coaching focused conversation with them about their goals related to humanism, patient-centeredness, communication. I then watch them in a patient encounter. And I do it in a really unique way, and I think we're learning a lot through this project about what this unique way or sort of the opportunities for this unique way to, um, to add to medical education. What I do is I watch them over an iPad.
[00:15:52] Dr. Cifu: Huh!
[00:15:53] Dr. Orlov: So, Blaine funded the purchasing of these high-tech iPads that have an eye that will track the student in the room.
[00:16:00] Dr. Cifu: Wow.
[00:16:01] Dr. Orlov: They have really high-tech speakers and the iPad rolls into the room with the student. The student is directed actually not to put the iPad... To have the iPad face only them and not the patient. The patient obviously signs consent forms, I have those all like on file, but the patient signs consent forms, and then I watch the student interview the patient.
[00:16:22] Dr. Cifu: Hmm.
[00:16:22] Dr. Orlov: It's not and H and P necessarily, right? It's any part of the conversation, anticipatory guidance, discharge teaching, like anything, even just to check in at the end of the day before they go home, and then that gets saved and I get to watch that video. I take notes on the video. I actually transcribe the whole conversation or all of the student's words so that I can share that back with them, because they can't always... We don't remember what we say when we're in the room, we're so worried about like, what the next question is. And then I have a follow-up coaching conversation, a dedicated, like 30-minute coaching conversation with the student where we debrief everything that happened in the room.
[00:16:57] Dr. Cifu: Do the students actually watch themselves? I mean, do they see the video of them interacting?
[00:17:03] Dr. Orlov: Great question. So I have learned a lot this year and I've thought a lot about this project. I'm obviously studying it, so I hesitate to make changes in the first year. Um, I've had a few students ask me to see their video and I've sent it to them, but most of them have not asked.
[00:17:20] Dr. Cifu: Okay.
[00:17:20] Dr. Orlov: They don't really need to see it because everything they say is transcribed and I share that document with them. Um, but as I think about future years, I think there's opportunity for us to watch the video together and then there are other opportunities just to enhance the project.
[00:17:36] Dr. Cifu: And so what you're getting to see is you are getting to see a student really alone with a patient, right? Sort of doing what they're supposed to be doing. The eye, you know, the iPad probably falls quickly into the background, so it's probably a very natural interaction or as natural as a medical student has with a patient.
[00:17:57] Dr. Orlov: I think that's right, and that's what the medical students have told me.
[00:18:01] Dr. Cifu: Yeah.
[00:18:02] Dr. Orlov: They've said that it is stressful...
[00:18:04] Dr. Cifu: Yeah.
[00:18:04] Dr. Orlov: ...that they're worried about asking the families about the iPads...
[00:18:07] Dr. Cifu: Yeah.
[00:18:08] Dr. Orlov: ...that they've been shocked at how the families are so thrilled to have them do this and don't seem bothered by it at all. And that the second they hit record, it's like the iPad disappears, which we know is documented that like with direct observation, that can be a real challenge...
[00:18:24] Dr. Cifu: Yeah, absolutely.
[00:18:24] Dr. Orlov: ...having an attending in the room, and this also is an enormous opportunity to overcome the scheduling barriers that exist with direct observation, because that's really difficult.
[00:18:38] Dr. Cifu: So Blaine just, I mean, I was watching you, you know, talk about educating patients, you know, potential lung transplant recipients and, you know, that's so exciting to hear about, and I could see you sort of light up. You know, listening to this, I mean, this must be amazing to sort of get to be involved in something like this.
[00:19:00] Dr. Lesnik: It really is. I think, you know, Nikki's right, it's bashert and um, it really fits with what helps me make meaning out of my suffering. I mean, I do get something out of it, right?
[00:19:13] Dr. Cifu: Right, right.
[00:19:14] Dr. Lesnik: And when you go through something like this and you live with a chronic condition, I'm a walking patient all the time. I mean, anything can go wrong with me at any moment.
[00:19:26] Dr. Cifu: Yeah.
[00:19:26] Dr. Lesnik: And a lot of things do, 'cause I'm immunocompromised and if doctors can treat me like a human being, then it makes the experience less bad.
[00:19:38] Dr. Cifu: Yeah.
[00:19:39] Dr. Lesnik: Right? And Nikki is training medical students who will go off on their residencies and go teach their colleagues.
[00:19:49] Dr. Cifu: Right, right.
[00:19:50] Dr. Lesnik: And the idea that those medical students would listen differently or take a minute to really hear what their patient is saying.
[00:20:02] Dr. Cifu: Yeah. Yeah. I mean, that's a great point because I mean, I think that this is not only impacting these students, but since we have, you know, a history that we're so proud of as being, you know, the teachers of teachers, you know, so many of our students go on to, you know, be academic physicians, train future generations, and I think this is going to be something which, you know, is probably always going to stick with them as, "Huh. This could be part of my, you know, armamentarium, right? In the future."
Two things that sort of pop into my mind, which may be just so obvious, but I feel like I need to say them, and one you mentioned is that whenever I've done any sort of patient encounter with a student, no matter how clearly I try to say like, you know, the student's in control here, the patient's always looking to me 'cause I'm clearly the senior person because, you know, I'm a bald, old white guy. What are they going to do? So I mean, that gets around this and the reason I asked about students watching the video is that as I think... And it goes back to not only medical training, but like, you know, videos of myself in the batting cage from high school, you know, often seeing yourself is sort of shocking and you're like, "Do I really do that?" You know, and that can improve people, too. So I'll be so excited to see sort of how this unwinds over time.
[00:21:24] Dr. Orlov: Fantastic suggestion. And I really think I should start to incorporate that. Maybe provide it to them in advance of the session and have them think about some of the goals. Right? What did they notice about themselves that they would like to maybe do differently?
[00:21:38] Dr. Cifu: Yeah.
[00:21:39] Dr. Orlov: And how might they be able to do that in a future encounter, and then we can talk about that during the meeting.
[00:21:44] Dr. Cifu: You'll have to supply them with popcorn so they can...
[00:21:46] Dr. Orlov: Yeah. Right.
[00:21:48] Dr. Lesnik: I just wanted to say that, you know, watching yourself with a video recording is a part of the doctoral training for a clinical psychologist all the time.
[00:21:58] Dr. Orlov: Mm.
[00:21:59] Dr. Lesnik: Yu know, over the course of many years where you have one or two patients, depending on kind of what environment you're working in, you get permission and record the tapes and then sit and listen to them with a case consultation group or your direct supervisor at the school, or at whatever clinic you're working in.
[00:22:24] Dr. Cifu: Yeah. Yeah.
[00:22:24] Dr. Lesnik: And so it's really interesting to hear that that hasn't been done.
[00:22:29] Dr. Orlov: Yeah.
[00:22:30] Dr. Lesnik: And it's a regular part of how people become a clinical psychologist at the doctoral level, yeah.
[00:22:37] Dr. Orlov: Medical students do a lot of that in their clinical skills course, they spend a lot of time with standardized patients and are interviewed and they have an opportunity to watch those videos, but you know, those are less focused on the communication aspect, certainly there's a component of that, but this is like the course where they learn how to gather a history and physical. There is a day in the course where they focus on breaking bad news, but I think you're absolutely right, both of you, that we should think about that in the future year.
[00:23:06] Dr. Cifu: Well, I mean, you know, this kind of setup just lends itself to so much because it's also something, and it's probably in all of our fields that we sort of grow out, which is kind of stupid, right? I mean I think we could all still benefit from, you know, occasionally, even if it's just you rewatching yourself without a mentor of saying like, you know, what am I doing well these days and what am I doing poorly, because we think that we gain all this kind of insight and mindfulness as we get further along in our careers that we can monitor interactions, but we all fall short on that.
So listen, I don't want to take too much of your guys' time 'cause this was so helpful. I guess, Blaine mostly, anything else that sort of comes to your mind as you work through this and still may be outside of this education part, but of being, you know, I don't want to call you a professional patient because you have an unbelievable profession besides this, but you sort of are, and you have more interaction with the healthcare field than a lot of, you know, nearly full-time doctors.
[00:24:12] Dr. Lesnik: Mm-hmm.
[00:24:12] Dr. Cifu: So are there things that you, I don't know, just sort of tell people when they're going to the doctor of how to make the most of their healthcare or...?
[00:24:19] Dr. Lesnik: Well, my hope is that the way that I am able to advocate for myself can help somebody who's perhaps not as extroverted...
[00:24:29] Dr. Cifu: Yeah.
[00:24:29] Dr. Lesnik: ...to ask for things. I have a very good friend whose life partner just had a heart transplant and they were... I was on the phone with her and they were getting ready to send them home and she said, "Boy, I hope they send us home with a heart monitor." And I said to her, "Oh, tell them, get loud. Of course you're going home with a heart monitor." And she was like, "Oh, I'm so glad I called you."
[00:24:57] Dr. Cifu: Yeah.
[00:24:57] Dr. Lesnik: So it can help in all kinds of arenas, right?
[00:25:01] Dr. Cifu: Yeah, yeah.
[00:25:01] Dr. Lesnik: Yeah.
[00:25:02] Dr. Cifu: That's great. Well, thank you both again too. That was really wonderful, and thanks for joining us for this episode of The Clinical Excellence Podcast. We're sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago.
Please feel free to reach out to us with your thoughts and ideas on the Bucksbaum Institute Twitter page. The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.