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Luminary Lounge: Mitchell M. Levy
Luminary Lounge: Mitchell M. Levy
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Hi everyone. I'm Laura Evans from the University of Washington and it's a huge pleasure for me to join you here with my dear friend and mentor, Mitchell Levy. So it's a special honor to get to talk to Mitchell for today's Luminary Lounge and try to share some of what I've enjoyed so much about having Mitchell as my mentor with all of you for that. I know some of you watching have probably also benefited from his mentorship throughout your careers, but for those of you who haven't had the chance to interact with Mitchell, welcome to Mitchell. So Mitchell, for those of you who don't know, is the current division chief of Pulmonary Critical Care and Sleep Medicine at Brown and was a prior president of the Society of Critical Care Medicine from 2009 to 2010. And Mitchell, I'm going to kind of kick it right over to you because I think lots of people certainly know your name within our field and probably know you by reputation, but I think fewer of them kind of know you as a person and probably fewer know kind of what brought you to critical care and sort of how you, we'll take the abbreviated path if you don't mind, sort of how you ended up where you are today, just to kind of set the stage for the group. Yeah, first I want to echo what you said, Laura, it's a pleasure to have you do this interview and, you know, I also consider Laura a close friend and a true rising star in the Society of Critical Care Medicine. So it's also a pleasure and honor to be interviewed by Laura, although I may regret it by the end of this interview. If I've done my job well, yes. Yeah, that's a great question. You know, I've gotten asked that, I've been asked that a lot over the years, and I think there's something about critical care that perfectly suits my personality, which is the ability to be completely, totally speedy. I'm a New Yorker by birth and, and bring to bear my understanding of medicine on the spot and make quick decisions and not hesitate. And then combine that with the need to stop completely and be with a family or a patient who's dying and just be completely present. And I've been a Buddhist for the last 50 years, a Buddhist practitioner. And so this combination of the ability to be speedy and make rapid decisions and be able to stop and be fully present is honestly suits me very well. And I think that's what brought me naturally to critical care medicine. And how did, how did you get involved with SCCM and how did that evolve throughout your career? Yeah, so I was living in, I was chief of critical care at the University of Hawaii and people asked me why I went to Hawaii who don't, have never been to Hawaii, but I was living in Nova Scotia at Dalhousie, working at Dalhousie University at the time as the director of one of their intensive care units. And if you've ever lived in Nova Scotia, which is really wonderful, three or four months a year, it's not hard to understand why you might go to Hawaii. And I had the opportunity to, to become chief of critical care there. And it was there that I, I had previously joined the society of critical care medicine, but at that time in around 1991, I came up with this idea called controversies in critical care medicine. And we, up until then pro-con talks and controversies were not a usual part of any kind of critical care meetings. And so I, I don't even know, I probably just being an argumentative New Yorker, I sort of came up with this idea of, well, let's just, let's address these controversies and do a pro-con sessions. And so I had the opportunity, society of critical care medicine, loved the idea. And the first one we did was I believe on Maui and inviting the top names in critical care to a conference in Hawaii was relatively easy and it definitely put me on the map with my colleagues. And so then shortly after that the SCCM decided to make it kind of go from Hawaii to several, I think they were five over the course of the next year or two, different vacation resort destinations. And, and as John Liebenson said, when I was at his meeting, he said, you should answer phone calls from Mitchell because he's a good person to know because of where he's going to invite you. And it really did help make my career in many ways that in my relationship with the surviving sepsis campaign. Yeah. Well, cause I want to, I want to follow up already on two things that you said, because when I think about, you know, your career as I understand it, or as it seems to me, there's really two, there's lots of work obviously, but I think of really two big, big domains. One is your work obviously around sepsis and the surviving sepsis campaign. And the other piece that I think about that, that is really around your formative work in end of life care in terms of mindfulness. And I want, I want to go down both of those roads today if we can for that, but let's start with the surviving sepsis campaign if we can for that, because I think it's clearly a massive accomplishment and, and this represents now what, 20 years of it, 20? 2002, 20 years. Did you think you were getting into 20 years of this when you started? Absolutely not. I mean it's interesting. The origin of the surviving sepsis campaign was in fact, industry sponsorship as now the record shows. And it was right around the time that Zygris, Georgia Corridor and Alpha was stopped early for a benefit. And so the Eli Lilly company was decided to support and create a campaign for sepsis. And if you remember, this was 2001. And so although the sepsis definitions had been written initially by Roger Bone, it still wasn't truly on the map, it being sepsis. And even for CMS and it didn't make the list of top 10 diagnoses because people saw pneumonia, urinary tract infection, interabdominal infection as not codable as sepsis. And it wasn't really until I believe 95 or 96 that actually the sepsis codes came into existence. So each of the individual infections with or without organ dysfunction at that time were listed separately. So no unifying diagnosis of sepsis until 1998 or so made it to the top 10 lists of most common diagnoses for CMS. And so that's why we took advantage of Lilly's interest in creating a campaign of education for clinicians around sepsis. What are you most proud of about it in the last 20 years? That's a great question, Laura. I mean, we've, as you well know, it's been a rocky path. And we created first in 2004, the first iteration of the Surviving Sepsis Campaign Guidelines. And you were the lead author, as you only too well know, in 2021. And we've had what five iterations of guidelines, I think, since 2004. And at that time, there was tremendous competition and still is amongst all the professional societies, especially in North America, ACCP, ATS, and SECM, obviously. And to have a single set of consensus guidelines that have become the gold standard of sepsis management across the globe is really probably the accomplishment I'm most proud of. That in the face of all this competition amongst societies, to have a unifying set of guidelines, and really, truly, over 20 years, it's the only game in town. That, to me, is a major accomplishment and powered all the rest of the accomplishments of the campaign, which in particular, of course, were the development first in 2006, I think, of the six and 24-hour sepsis bundles that then evolved into the three and six-hour bundles in 2012, and then became the basis for the New York State Initiative, and then the SEP1 National Initiative in the United States. So I think I'm equally proud of that. We have, through the Surviving Sepsis Campaign, through the publications from the New York State Initiative, which involved over 100,000 patients, and multiple other publications, a couple of which were analyzed in a meta-analysis in two separate publications over the years, have clearly demonstrated improved survival associated with compliance with sepsis bundles. First, the six and 24-hour bundle, and then the three and six-hour bundle. And that gave rise to our recent proposal to the NIH, NHLBI, for a randomized control trial that you're a co-investigator on, and we've written several grants over the years and finally got this one funded that will start probably on May 1st or so, that will test through a randomized control cluster, RCT, the value of the efficacy of the one-hour bundle versus the three-hour bundle. And so I think the combination of a consensus set of guidelines and what we were able to prove of facilitating best practice through the use of sepsis bundles are the two things that I'm most proud of. Honestly, I think in my career in general, but in particular about the surviving sepsis campaign. And it's, as you well know, it's come at quite a cost. I mean, we've been soundly attacked for first taking industry funding, and then just the sepsis bundles in general. As we always like to say, academics love to argue. They would rather argue about, should it be 20 or 25 cc's per kilogram, rather than just simply do the right thing for patients. And you've had that experience. And we've seen the number of reviewer comments that you've had to deal with, with the most recent iteration of the guidelines that on the one hand, are valuable and make manuscripts better, as we well know, and, on the other hand, can be incredibly nitpicky, arguing about fine points by people who weren't on the panel and maybe slightly resent not being able to be on the panel. The only thing I would add very quickly is that I think most people's objections to the guidelines and the bundles are, they're not my guidelines and they're not my bundles. And I think if every individual could create their own bundle, I think people would be really happy with that. But the problem is, obviously, that's not the way it works and guidelines have to be written by a panel and bundles have to be written by a panel. And so we're kind of stuck with it. There's a whole lot to unpack in that. But I was hoping maybe for those who are maybe watching this who are new to the field of critical care, right? So if you're thinking fellows, junior faculty, up-and-comers within the field of critical care from any of the disciplines that are involved in critical care, there's a lot of lessons learned from this process, right? Whether or not you're going to make your career out of sepsis like you did, but there's a lot of lessons you've learned in this process, right? About how to get people to work together, right? About how to manage conflict. I mean, you've mentored somebody who's a Red Sox fan, right? That's a big amount of conflict. What advice would you give to somebody as they're sort of starting out about both the opportunities and the challenges that they're likely to be faced with? That's a great question. First and most importantly is never choose a mentee who's a Red Sox fan. Second, don't live in Providence if you're a New York Yankee fan because you will become the focal point for all Red Sox haters, which I have to say I wear proudly. I think it's a great question in that I honestly think it's about perseverance. I think every scientist, and you know this really well, Laura, you can't be dissuaded by criticism. You certainly have had the experience and I've had the experience in a much longer career of there are just some people who live for criticism of other people's work. There are people who, if you look in their CVs, that's what they do. They criticize other people's work. Getting adjusted to that, especially when you find yourself on the cutting edge, whatever it might be, of science or as a clinician, you are going to open yourself as a leader to various kinds of attacks. I think you have to be prepared for that and not not dissuaded by it. I think the most important advice that I give to my younger colleagues is stand up straight and believe in what you do and trust that you're doing what you believe in because that's the only way that you can take and handle sometimes the criticism. I know we're going to talk about end-of-life care later on, but that's also true for angry families that, to a certain extent, you have to deeply believe in what you're doing, whether it's science or clinical care, as a way of girding yourself against the inevitable criticism that's going to come your way. It will inevitably come your way. I want to say again, whether you're a scientist, a budding scientist, or a clinical leader, putting yourself out on the front lines will expose you and make you vulnerable to criticism. Perseverance and trust in who you are is the best way to get through it. What's surprised you most about where you've ended up or what you've done professionally? You're asking good questions, Laura. Trying. Yeah, no, this is great. I think it's also because of our friendship that you're asking these great questions. I hadn't really thought about this until you just said it, but I think what surprised me most is I left my research in end-of-life care to really concentrate on my sepsis work. I think part of it was because, for me, I found that my work in end-of-life care, and I was a chair of the Robert Wood Johnson ICU Peer Work Group when it first came about. We were funded with multiple millions of dollars over the years. We pulled together a group of about 20 people and published a lot of good work and in 2001, I chaired the Society of Critical Care Medicine annual meetings with John Carley. He was the first international co-chair. We had 20% of the meeting just dedicated to end-of-life care. I think it was called combining science and compassion. I was very proud of that. Yet, in 2002, I really began to walk away from my work with end-of-life care and dedicate myself to sepsis. I think it surprised me, but I believe that I did it because I found that my work in end of life care came so naturally to me. I don't know if this is going to make sense, but it was almost too easy for me. I wanted to challenge myself more as a scientist and get more involved in my sepsis work than in my end-of-life care. You can shoot this down. It sounds to me, as a listener here, that you also are using many of the same skills that you use in end-of-life care and in clinical care in the ICU and in family interactions and in this being present and being in the moment, but also taking time to step back. It seems to me like you're using those same skills in your work in improving sepsis in many ways, in terms of this trying to engage people, trying to get stakeholders together, trying to listen, be present, but also stand firm. Yeah, you're 100% right. No question about it. A good friend of mine who was a mentor to me, Bill Sibbold, who died quite a while ago but was in Hamilton, said to me once he saw me as a kind of prime minister and that I was very good at pulling people together and coercing people into coming together and then shepherding them into a consensus. I think that you're right. I certainly felt that and feel that way about the Surviving Sepsis Campaign, that I really learned how to use the skills about, just as you said, being present and patient and willing to listen, that I learned as a good end-of-life caregiver as a way to build consensus. I definitely feel like that as a clinical leader in critical care and ultimately as president of SCCM, it's learning how to work as a team and being willing to be there and listen and be present that is the crossover between end-of-life care and being a clinical leader. You're right. I want to go down the route of this concept of building your team and building your network because I think that's one of the things that when you're starting out in the field, it can feel very daunting. How do you find your network and the people that you're going to collaborate with? How do you find your mentors? Then how do you grow that circle so that you have these opportunities of being present for these conversations? We all know how much comes up organically from these hallway conversations or in the lobby at the meeting when somebody says, oh, I was having this amazing idea and then I saw Mitchell walking down the hallway and we got to talking. A lot of those don't go anywhere, but some of them do. What's your guidance to people who are kind of starting out and saying, how would you go about advising them to create their networks? Great question. There are a couple of things. First of all, I think it all starts with trusting yourself. It's so tough in our current medical system because our current medical system, as you well know, it doesn't breed trust. You trained at Columbia and Seattle. In Seattle, I would argue that there are more trusting people. There's more people. There's more cultivation of trust than most very powerful academic centers, but then you worked at Columbia. I've heard from you and others, that can be a toxic environment to be kind. For the most part, training in medicine right now is, prove to me that you're not as stupid as I think you are. It breeds this kind of lack of self-trust. I think that's probably the most important thing to overcome, which is I think slowly but surely, it's really important to develop a trust in our clinical intuition, a trust in our ability to make a diagnosis, and our trust in pursuing our science. That's very, very tough. I think that's where the mentorship comes in, that it's so important to find a good mentor who instills a sense of trust in you. Now, I want to say I want to be really careful about this because one thing I learned from Randy Curtis, who's such a close friend and was president of the ATS when I was, he always says he doesn't like to work with people who he doesn't like. Now, if you know Randy at all, he's universally beloved. It's easy to hear that from someone like me who can be contentious, but I think it's important to have a demand that if you're going to have a mentor, that mentor must make you feel trust in who you are as a clinician or as a scientist. That's gotta be almost your litmus test that whoever your mentor is, if that person is making you feel worse about yourself and more distrustful of yourself as a scientist or a clinician, they are the wrong mentor for you. And that's an extremely, that's probably my strongest advice to those of you who are listening to this is if your mentor is making you feel worse about yourself as a clinician or a scientist, it's the wrong mentor. There are other mentors out there. Now, how you extricate yourself is not always easy, but the first step is saying, no, no, no, no, no, this is not the right mentor. Let's explore the trust thing a little bit because I think we hear so much about trust as part of general society now, right? About the lack of trust, about particularly within medicine, right? The lack of trust in healthcare providers, lack of trust in science. How do you approach developing trust with a family of an ICU loved one who's an inpatient in the ICU and they may not trust you right off the bat. Yeah, that's great, great. So Randy Curtis and I just wrote an editorial called Compassionate Care in the ICU that's going to come out in AJRCCM, I think. I think it's out now, but it'll only be out by the time this shows on for Congress. Yeah, and Randy, who by the way, is dying of ALS, we just decided to reflect on our careers together. And we kind of talked about five points for ways in which we could deal with families. And the reason I bring it up is, the first one is that in order to discover compassion, first we have to be kind to ourselves. And I think that's really important. And I think part of learning how to be kind to ourselves is taking care of ourselves and trusting that we need to have self-care. And we know how prevalent burnout is, especially even before the pandemic, but especially now for the last two years during the pandemic. So we need to take care of ourselves. We need to do whatever we like to do, whether it's write or listen to music or meditate or exercise, all of the above, but taking time to care for ourselves and be kind to ourselves is extremely important. Taking mental health days if you need them, whatever the version is for you of being kind to yourself. And I think that breeds trust, that if we can learn to just ease off on ourselves, then the natural sense of self-trust, I believe arises naturally. I really do. And I'm not just saying that because I think that when we learn to be kind to ourselves and take care of ourselves, we, I believe that compassion naturally arises and also our ability to trust who we are comes naturally as well. One concept that you and Randy wrote about in that editorial was this idea of sort of this rest of when us being overwhelmed by a strong emotion, whether it's your own emotion or whether it's the emotion of somebody else in the conversation. Can you just explain that a little bit for those that may not be intuitively familiar with that idea? Yeah, so I think it's, so dealing with angry families, being willing to be vulnerable with someone's grief, whether it's family's grief or a patient's grief, if they're awake enough to express it, and our ability to live and rest in uncertainty, all of that is this quality of making a home in discomfort instead of giving rise to avoidant behavior. And I want to say that again, because this is, we see it in our colleagues and ourselves all the time where, oh, you just don't want to go in to that room with an angry family. You just don't want to go in to that room with a family that's just completely in grief, whether they're angry or not, because it makes us feel so uncomfortable. And families and patients say, why am I getting worse? Why is my loved one getting worse? How long are they going to last? When we pull the tube, how long are they going to last? And that kind of uncertainty, it's really difficult for us to become comfortable with. And I really think that the only, and what Randy and I wrote about is that the only way to truly become comfortable with it is not run away from it. Now, that's a tall order because, I mean, we're humans. You want to run away from the anxiety of not knowing. You want to run away from certainly angry families. You want to run away from people's grief. It's literally, for me, a process of forcing myself to sit there, to walk into a room, to not run away, and just understand I'm going to be uncomfortable and just simply give in and not react to the discomfort. And I really think it takes practice. And as Randy and I wrote, it really does. It takes, you need someone to role model it for you. And we've all, for you, I know you and I have gone through this together where we just walk in and just wait. And in the face of some of a family's anger or a patient or family's grief, we don't move. We just sit, stand, wait, and allow ourselves to be vulnerable. And that's the quality of resting that Randy and I describe in this editorial. It's resting in the sense of not running away. So it's not truly resting, but it's instead of running away, just stand there. It's literally the old joke of stand there, don't do anything, right? And it's hard. Yeah, I had a, attending when I was a fellow who would say one of the arts of medicine is knowing when to not just do something, stand there, and when to not just stand there, do something. And this always comes back to that idea. Absolutely, exactly right. 100%, and it goes back to the nature of critical care altogether, which you and I talked about in the beginning, which is this combination of rapid decisions, bringing to bear everything you know, trusting yourself, making those decisions, and then stopping and not running away. And we all know people who are great critical care docs who know how to make those decisions, but there are fewer of us who are simply willing to stand there and do nothing. And it's such an important art to learn how to do. And one of the things I experienced a lot, I've talked a lot to my, in both talks and also with the house staff and the fellows that when we go into a room with a family that I use silence. And it doesn't mean I don't know what to say next. Inevitably, if I don't prep house staff or fellows and I just allow myself to fall into a therapeutic silence with a family, often the house staff or the fellow will rush to fill the space. And I'm deliberately using silence. I'm not at a loss for words. And that's the discomfort with just standing there or sitting there that we all feel. Yeah, and it takes practice. Yep, absolutely. Well, this has been really, we only have a couple of minutes left. So I do wanna close out on a light note. For those of you who don't know Mitchell, nobody over orders like he does at a restaurant. Oh, if there's dinner for four to be had, we'll order dinner for 10. The pandemic has really changed, right? The way we eat and the way you travel with that. So what I wanted to ask was where's one place that you've desperately missed eating during the last couple of years and one place that you really look forward to trying? Oh, that's great. Okay, there's a couple, I have to choose one. Poetic license, you can choose a few. Yeah, so there's a wonderful restaurant in Brussels that I've been to with so many friends. It's one of the French restaurants called Ogamblick in Brussels that Laura and I have eaten at and it's just a really, really great restaurant. It's not the highest end restaurant. There's a wonderful restaurant called Comme Chez Soi in Brussels, but Ogamblick is just a really wonderful French bistro in Brussels. There's also a restaurant that's closed in New York City called Uncle Boone's. That was a remarkable Thai restaurant that also Laura and I have eaten in. There's a pattern here. And so I do miss Uncle Boone's. And then finally, I would say that the other place that I miss is in San Francisco, an amazing dim sum place called Yang Sing, which hopefully the ATS meetings in San Francisco will occur in person in May so we can go back and be at Yang Sing. But those are the three that came to mind. There were so many others, but thank you for ending on this note. It's great. Well, I really look forward to our next opportunity to have a meal together. It's been a long time. Yeah, absolutely. Whether it be at SCCM Congress or wherever it may be, it'd be really nice to see you in person and share a meal together again. And thanks so much for sharing all these thoughts and insights with us. I think it's really valuable for particularly those who are early in their careers to kind of see the pathway that people have taken and that you weren't born a division chief who was a well-known name in end-of-life care and sepsis, but rather it's a process to get there with both successes and challenges along the way. And I think that that's really helpful, I think, when you're coming up to sort of see what path people have taken. Thanks, Laura. It's been an absolute delight. This has been great. Thank you. And always, always root for the Red Sox. No. Thanks, Mitchell.
Video Summary
In this video, Laura Evans from the University of Washington interviews Mitchell Levy, the Division Chief of Pulmonary Critical Care and Sleep Medicine at Brown, and former President of the Society of Critical Care Medicine. They discuss Mitchell's career path and his involvement with the Surviving Sepsis Campaign. Mitchell reflects on his natural fit for critical care and his ability to make rapid decisions while also being present with patients and families. He shares how he got involved with the SCCM and the challenges he faced in developing the Surviving Sepsis Campaign guidelines. Mitchell also discusses the importance of trust in oneself and the need for mentors who instill that trust. He emphasizes the value of perseverance in the face of criticism and the need to be present and listen in difficult situations. They also touch on the concept of resting in discomfort and the importance of not running away from uncertainty and challenging emotions. The conversation wraps up on a lighter note, with Mitchell sharing some of the restaurants he misses and looks forward to trying once again in a post-pandemic world.
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Professional Development and Education, 2022
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Hear from past SCCM president, Mitchell M. Levy, as they share their experience and wisdom about critical care and SCCM.
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