Hello, everyone. My name is Kevin Chung. I am a medical intensivist and currently a professor and chair of medicine at the Uniformed Services University. I am thrilled to be moderating today's session for the Luminary Lounge discussion with our special guest, Dr. Timothy Buckman. Welcome, Dr. Buckman, to the discussion. Kevin, it's a pleasure to be here. Please call me Tim. Well, thank you, Tim. Tim, if I may, just a quick introduction about you, and then we'll go into the discussion. Everyone, I think Tim requires no introduction to many of you. But for those of you who don't know Tim, he's a graduate of the University of Chicago for both his undergraduate, PhD, and medical degrees. He did his general surgery residency at Hopkins and then followed that with a trauma critical care fellowship at Baltimore Shock Trauma. He is past president of SCCM, master of the American College of Critical Care Medicine, and editor-in-chief of Critical Care Medicine, and as well as the founding editor of Critical Care Explorations. He is currently the founding director of the Emory Critical Care Center. Tim, it's great to have you on for this discussion. I wanted to ask, to begin this discussion, what really the theme is going to be, how did we get here, or how did you get here? Can you talk about and talk to the audience about how you got into critical care? So, like so many people, I came to critical care by accident. In my case, literally by accident. I was a third-year resident at Hopkins in general surgery, and one day had the misfortune to be driving home, entered an intersection, somebody ran a red light, I end up getting T-boned, and the head of my femur driven into my acetabulum and my left kidney cracked. Well, through a long elliptical process, I ended up a patient in my own ICU at Hopkins and found out what life was like from the other side of the sheets. Now, in those days, this was the early 1980s, there really wasn't an intensive care medicine community. Patients in the ICU were cared pretty much by the services that admitted them, and most of that care was actually rendered by the nurses. That was my first realization that you can have an ICU without doctors or physical therapists or pharmacists or nutrition support folks, but you can't have an ICU without nurses because they're the ones who actually protect the patient, stand as the guardian at the end of the bed, and if they do their job, it looks like nothing happens because the patient is safe and has a smooth course. I came out well from my personal experience on the wrong side of the sheets, and as you mentioned, I realized that trauma and in parentheses critical care was probably a good place for me to be. I went to my then chairman of surgery who thought that this was an unusual and probably not a standard career for a surgeon, and he asked what else I might be interested in doing, and I explained that no, I actually wanted to do this for my career. As a consequence, I departed Hopkins briefly to take my fellowship at Shock Trauma, figured out how ICUs and trauma services for that matter needed to be organized, and came back to Hopkins. I thought my billet was going to be mostly in trauma, but I had been organizing the trauma service for about six or nine months, and my chairman came to me and said, you know, I need you to become the director of the ICU. It was a bit of a surprise. I asked why, and of course it turned out there was a visit from the Joint Commission coming up, and they needed to have somebody say, you know, I'm the director, but I saw that as an opportunity, because I realized that no one discipline in the spirit of Ake Grenvik, who had tried to bring critical care together as a single specialty and failed magnificently, but I realized that no one discipline could actually bring leadership to the ICU. It had to be a team effort, so I demanded that we share insight from our anesthesiology community into the surgical ICU and asked that I have an anesthesiology co-director, and we staff it balanced across the house staff. It was a bit unusual for Hopkins at the time, but there was a need. It was a way to meet it, so I got greenlighted. Not so long after that, we had a visiting professor, and the visiting professor had some unusual ideas about how to take care of trauma patients. He suggested that it would be a good idea to increase oxygen delivery pharmacologically with dobutamine and other inotropes to super normal levels of oxygen delivery, and that would miraculously improve outcomes. That visiting professor was Will Shoemaker, and as a consequence of that, he and I struck up a friendship, and one of the things I said to him was, you know, I think we need to be teaching the principles of resuscitation, not just to fellows, not just to residents. We really needed to drive this down all the way to the level of medical students, and there ought to be a standard curriculum that would provide an experience and some degree of competency as a requirement for medical students graduating with their degrees. And he said, well, that's an interesting idea. Why don't you take that on? So I did, attended my first Society of Critical Care in Medicine meeting at the New York Hilton when the meetings were small enough that we could just have meetings in hotels. Did a survey there, got some interesting responses, found some co-authors, wrote it up, and that became one of my very first publications in the journal. I mention all of this because my journey in critical care up to that point and moving forward was more or less happenstance. It was accident coming into contact with people who were enthusiastic, who were willing to share ideas, innovation, and energy and say, what can we do here? These examples continued over time. Early on in my career in critical care, there was a professor down at the University of Missouri in Columbia who had an idea that it would be important to have an organized course around critical care similar to the Advanced Trauma Life Support course at the American College of Surgeons. We needed a fundamental critical care skills course for critical care. He organized the course and put it on and asked me to be an evaluator, to sit in the back and describe how is it going. This was Phil Dellinger. It really has become a question of having people present opportunities, recognize them as opportunities, and say, what can we do? I think critical care is still a young enough discipline that those opportunities continue to abound. Tim, that's really fascinating to hear that story and that background on how you got to your first meeting. What made you come back? Is this a society that you thought right off the bat, oh, this is my home, or it's going to be my second home, or did it take a while to get to that point? I think for most young faculty, and whether that includes the community of physicians or nurses or allied health personnel, investigators, and so on, we all have our sort of specialty-specific societies, if you will. As a surgeon, there are many surgical societies, and in fact, there's an arc that you're expected to follow as a young academic surgeon. What was different about the Society of Critical Care Medicine is that it was multi-professional. It embraced the multi-professional team, celebrated the contributions that came from each of the professions, and focused on the patient and the patient's outcome. Very different feel than most professional societies. And quite frankly, it felt more like home. Right. As an intensivist, that's your day-to-day, and here's an organization where you're academically sort of interacting with all the different specialties. That sounds about right. So, tell us about how you got more involved in the leadership of SCCM. As with the leadership of SCCM, it was a question of realizing that there were tasks to be accomplished and opportunities to be taken. One of my fond memories from that first meeting, there were lunches each day. We were small enough that these were sort of sit-down lunches with tablecloth-covered tables. It was a different era at that time. And I was late to the lunch, and I found the only remaining seat in the room and sat down and introduced myself, not realizing quite what table I was at at the time, because at the table were Will Shoemaker, Hal Weill, Huckett Grenvick, and so forth. So, I was the young kid at the table with these gentlemen who were not old, but they were clearly older and more experienced. They asked me who I was and what I did and what my academic interest was. And I responded to them that I'd been raised as a virologist, but as a molecular biologist. And I thought that the response to shock might not be things fall apart, but might be a program of gene expression that went well in some cases and didn't go well in others. And I was working in the lab to describe, if you will, the molecular profiles of different forms of shock. That stopped the table cold, because they were of a generation where working in the lab was mostly amino acid analyzers and protein concentrations. And the idea that one could disassemble shock at the molecular level and begin to describe it was fairly novel for the society. So, got talking about the types of grants I was putting in and some of the folks said, I'd be happy to read the grant and give you some advice before it goes into the NIH. And that followed with my first grant made from the American Heart Association and my first R29 from the NIH. These were the people who were on the review committees. So, I had a chance, again, it was favoring the prepared mind to talk about what we might do in the realm of research. Yeah, that's really fantastic. During your time as president of the society, can you tell us a little bit about that experience and what that was like for you? Well, you never start with being the president of the society. You come up and you seek opportunities and you develop new ideas and hone your leadership skills. So, I came up through the surgery section, ultimately was elected to council, not once, but twice. I actually embarked on a path into the very new, then new American College of Critical Care Medicine. I spent a year as a regent on the board of regents and then was asked by the executive committee to be the next member of executive committee. That's a long road. You spend three years on the way to becoming president of the society. You have your presidential year, which I will describe as the best job in the world for one year. And then the joyous year of past president, which is actually, I wish it could be a direct elected position because people ask your advice, they sometimes take it and it doesn't matter whether they do or not. It's an arc of experience. But that presidential year is unique because you work so closely with the executive vice president and CEO of the organization, the paid staff, if you will. And you get to refract all of what's going on in the world through the prism of the society and back again. In my year, one of the big things that we did was take what had been a society product project impact and figure out a way to commercialize it and sell it to a for-profit entity. I'll tell you, my year as president of the society was an interesting one because the society was fairly close to broke. One of my predecessors, Carolyn Beckus, joined as president at a time where the society was using membership dues on Friday to pay payroll on Monday. And we had embarked at that point on a strategy to create financial stability for the society. So we stripped the society down to what the members thought was essential, which turned out to be the annual meeting, the journal. There was only one journal at the time, Critical Care Medicine, very ably edited by my good friend and colleague, Joe Perillo. And just a few other activities. We made a decision that we would pay ourselves first in the sense of taking whatever overage we had and putting it into the society bank account, making investments. And as you saw from the most recent issue of official communication, I think it was Critical Connections, but it may have been another annual report. The society now has close to $50 million in the bank. So it is always a leadership opportunity. And I'll tell you that every president of the society has faced his or her own unique challenges. Yeah, I didn't realize that was the case when you were president. Holy cow. I think I was just the resident really naive to the workings of the world. So along the lines of your increasing involvement in the society, what advice would you have for somebody checking out the society for the first time as a surgeon, a nurse, as a dietician, PharmD? The first thing is to realize that it's a society like no other. It's not multi-professional as lip service. It is woven into the fabric of the society. And I suggest that people look within themselves and find out whether they have joy in coming into the critical care environment each day as an investigator, as an administrator, as a clinician, as an educator. And saying, I really value the time I spend working with, not for, you know, or not, you know, supervising, but truly working with those other professions as team members. There is no other society like it, to my knowledge, in the world. Yeah, I echo that. Definitely. During that period when you were in the leadership, what do you think was the biggest clinical problem? Right now where it's all about COVID, but back then, what were you focused on scientifically and medically? As the French say, plus ça change, plus c'est la même chose. The more things change, the more they stay the same. Bear in mind, this was just the first year or two of the century. We were still struggling with sepsis. And at the time, we'd been through a decade in which biological response modifiers had been shown not to work. Anti-endotoxin, anti-TNF, IL-1 receptor antagonist, anti-IL-6. These had undergone clinical trials and each one had been shown to fail. Then came on the scene, trotocochin alpha, produced by Lilly, trade name Zygris. And it appeared to be the first biological response modifier that actually changed meaningful clinical outcomes in sepsis. You can imagine the joy through the society because our signature illness, and I think most will agree that sepsis is in many ways the signature illness of critical care, finally had a specific treatment. So widespread celebration. Of course, the tale went on and early optimism was replaced by a more reasoned reality. And today we still struggle with sepsis. It has a different cause, SARS-CoV-2, has a different name in our ICU, bad COVID. But we're still struggling with sepsis. The difference is now we know the pathogen. Right, right. Yeah, I distinctly remember treating patients with Zygris as a resident and fellow and thinking it was great. And then really as a clinician, very disappointed when it went away. What are your thoughts about that? Should it have gone away? Was it too much risk for the benefit? I think one of the challenges that we have in critical care is that we are not terribly efficient at identifying groups of patients with any degree of specificity. So let's talk about what it means to have meningococcemia, which is a very specific illness with a clearly identifiable pathogen versus sepsis, which may be due or may not be due to an identifiable pathogen. In half the cases, we can't find it. If we regard sepsis as simply a life-threatening organ dysfunction consequent to dysregulation of a specific response, if we fail to treat the underlying cause as well as to treat that dysregulation, trying to get the patient back on trajectory, we're not going to be terribly successful. And in fact, since every intervention that we provide has a bad side, has a dark side, even supplemental oxygen has a dark side. For the large number of patients for whom the intervention has no potential for good, it will retain the potential for harm. So as I see it, our future lies in being much more specific of our diagnoses and also much clearer about the endotyping process. Where I find great hope on the horizon is work that's being done, for example, like investigators such as Carolyn Kelphy, who've identified endotypes of ARDS that respond very differently to different therapeutic strategies. And if I were to imagine my crystal ball had some clarity to it, five or ten years downrange, we're going to be much better at deciding whether somebody, it's not a matter of them being septic, we have a procalcitonin that's elevated or a molecular diagnostic that says the host response is deranged, we're going to be able to identify are they sepsis alpha, beta, delta, or gamma and choose the most appropriate treatment accordingly. I imagine, I hope, I dream that we're going to go back to our arsenal of biological response modifiers and figure out which modifier fits which patient. And in that way, improve outcomes for all. Individualized critical care at its best. That's really fantastic. I think a lot of us share that vision. How do we get there within the context of clinical trials being so difficult to accomplish, expense, just the multicenter nature, complexity, the type of patients having to be identified precisely, that decreases sample size, etc. What are your thoughts about the future of clinical trials? I hope we've learned something from COVID and we have learned that by establishing a platform, such as the folks at RemapCAP did, the recovery trial in the UK, having a platform established is a necessary step to conducting trials that are meaningful. The idea that we have to assemble a clinical trial as a one-off to test a particular drug strikes me as fairly inefficient. And in my view, I'm speaking now as an individual not representing a society, a journal, an agency, anyone other than myself. In my view, the most appropriate way to proceed is to build the networks, fund the networks, and work with the various manufacturers and say, we would love to enter your product into our pipeline so that we can get the diversity of patients, the collection of their presentations, and understand how perturbing their trajectory with your diagnostic, with your therapeutic, actually changes their outcomes. And by having a large enough platform that is welcoming of a variety of diagnostics and therapeutics, we're going to get better at conducting these trials. Yeah, as a follow-on question to that, I think the platform design is something that we've gotten a lot of experience with as a community with COVID, ACTIV, ACT, those trials. And I think you're right that they're very efficient. For sepsis in general, what is the appropriate outcome? We've been targeting 28-day mortality for the longest time. People have proposed composite outcomes. What are your thoughts on the appropriate outcome for critical care studies? You've asked for an answer. I'm not sure that you framed the question. At the end of the day, what we're trying to do is restore and return patients to the best level of health attainable. In so doing, we have identified sepsis as a place along a continuum. But we have ignored the edges of the continuum, in my view, to the patient's detriment. We don't have strong enough partnerships, for example, with public health to detect and manage outbreaks. We don't have the commitment to immunization and other preventive strategies. We don't have the focus on sanitation and reduction of transmission. We don't have the focus on early recognition of an infection. At this juncture, among Medicare beneficiaries, upwards of 93% of what we call sepsis is already established by the time the patient gets to the emergency department. That's where it happens. So if we are going to do our job as critical care professionals, we really need to stop worrying about treating all these people once they become sick and figure out what fraction of our effort ought to be focused on earlier detection so we control the infection before we get the failed physiologic responses. On the other end, 28-day mortality is a convenient index, but from the patient's standpoint, it's meaningless if the patient dies on day 29 or survives to leave hospital only to end up in a skilled nursing facility because they failed inpatient rehab. That's not a good outcome for a patient. So we need to do better at figuring out how to gauge someone's potential for recovery as early as possible and then to do those interventions which have the highest chance of getting them back to the function they crave. So modify the things that we can modify. But at the end of the day, by the time they get to our ICU with multi-organ failure, it may be too late. I agree. In many cases, it is too late. The simile of the barn door and the horse. But it raises the question, have we opened the diaphragm of our lens sufficiently? Have we reached out to people, to professional communities, to data sources that might help, if you will, reduce the flow of patients coming to our ICU because they had a preventable illness? In my view, part of the future of critical care has to be partnering with people earlier and later in that continuum. And in an ideal world, we should be able to close our units because nobody ever gets to that level of need. Now, there's always going to be trauma. There are always going to be patients who need management around transplantation. But for most of the other things, I'd really like to see our units void inpatients. This at a time when our units are overflowing with patients infected with SARS-CoV-2 and their sequelae. We have a long way to go, and it's not going to happen in my lifetime or even in yours. Yeah. Empty beds, a few empty beds would be nice. So what are your thoughts about, I mean, as we talk about sort of your vision for the different clinical trials, the different outcomes that are important to target, what are the biggest challenges we face as a critical care community? As we go through this pandemic, it seems like we've exposed a few vulnerabilities. In your mind, what keeps you up at night? What keeps me up at night is that the next time I'm on the wrong side of the sheets, there won't be experienced staff to care for me. I live, I work in a very rarefied atmosphere of an academic health science center that routinely provides quaternary care. The miracles are expected and they occur. But 50 miles from our academic health science center, there are small hospitals, even critical access hospitals, which lack even the most basic resources to care for the critically ill and injured. At the same time, the consequence of the pandemic and the flood of our ICUs with desperately ill patients has reduced our workforce. Some chose to retire early. Some chose to leave for different roles in the healing arts. Some have chosen to avoid health care entirely. I think we have a workforce problem. I think we are going to have not just too few people, but I think they're going to be maldistributed. And in order to address that, I think we need to begin to reimagine what a critical care environment, what a critical care unit feels like. I believe that we're going to see critical care migrating to the ward. I think we might even see the critically ill patient, in some cases, being cared for in their own homes. One imagines that reasonable, quite frankly, most of what we do in critical care doesn't require the constant attendance of the most senior clinicians. It requires the availability of their wisdom. It requires some technical support. But I think there's much to be done in terms of task allocation. We've learned through our tele-ICU program that we can use telepresence from the other side of the world, literally from the other side of the world, to provide safe, effective, timely, and cost-efficient care to patients. What I believe will happen is that the accumulated wisdom in aging bodies that have migrated away from the bedside of our ICUs, that wisdom can be recaptured, redeployed through tele-ICU services. And we can begin to reimagine how we come together, patient, family, caregivers, both in-person and virtual, all aiming to improve the lives and outcomes of the patients in the bed. Yeah, what you just talked about makes me think about what we say all the time in the military, you know, critical care is not a place, it's a capability. And so it could be in the back of a plane, in the back of a bus, as you say, on the wards or even at home. That's really fascinating to think about. Going back to what you said about what keeps you up at night, part of the reason we're losing our workforce is due to burnout. We're just, our folks are just being worked to death. We're talking pretty much everybody on the team. What are your strategies for preventing burnout? So I'm going to challenge you a bit. Burnout is widespread. It's not universal. If I go into just about any unit, I will find fatigue, but I won't find universal despair. Some people are frankly wired differently than others. That's normal human distribution. We need to understand who is susceptible to the despair more than the fatigue. And we have to figure out how in the selection and training process, we can make them more effective, stronger. In our tele ICU, we have a line of nurses who are waiting to sign up. They work long hours. They are challenged every moment of their shifts. But because we are able to change their environment, 70% of our nurses participate in a work from home program, and almost 60% of our ICU nursing shifts are taken from home. We found ways to help them cope with their fatigue. Wow. But none of them ever giving up on themselves or giving up on healthcare. So I think that unraveling those components of burnout, what makes one person more susceptible, one person more resilient, and figuring out how to manage those two groups differently, different endotypes, if you will, going to be key in planning for critical care in the future. And individualized approach to approach to handling burnout. That's fantastic. Well, I'll tell you that there is an enormous emphasis on medicine and quality and press gaining scores that focuses on the patient, by extension, the family. I think that's important. But in my view, what we ought to be doing in critical care is focusing on our workforce. If we can support a happy, resilient, enthusiastic workforce, people who look forward to coming to work every day and doing the best job they can do, the satisfaction, the outcomes, the joy of the patients and families will take care of themselves. Yeah. Wise words. And thank you for that. If I may pivot, we have a few minutes left. As you were appointed recently, a few years ago now, as the editor in chief of critical care medicine and founded critical care explorations. Can you talk to us a little bit about that experience, how you got involved with that in the first place, how you're enjoying it, what you see going on now and then into the future. So I come from a journalism family. And my first job was this copy boy at the New York times during the summer between my high school senior year and my first year of college. The idea of taking what we learn, presenting it, reviewing it, publishing it so that everyone can benefit has been part of what I've wanted to do for a very long time. I had the privilege of becoming a associate editor of one journal, a deputy editor of another, and was actually part of the task force that was assigned to find the next editor in chief of critical care medicine. And the more I participated in that task force, the more I and my colleagues on that task force realized that I had some ideas about what the journal could become, and maybe I needed to resign from the task force and become a candidate. And the rest there is history. As far as the newer journal critical care explorations, that was born of the realization that medical journalism and medical publishing was changing and we needed to do something about it. Medical publishing was changing and we needed an open access journal. We needed a journal where we could more rapidly review and publish and publish some things that might have a short shelf life, but would be inspiring to others to go on and ask questions of their own. The society of critical care medicine now has a family of three well established journals, critical care medicine and critical care explorations that I helm. Robert Tasker, the very able editor of pediatric critical care medicine succeeded Pat Kahanek recently and has created a focus flagship journal for the pediatric side of our discipline. What's important to remember is that 50 years from now, nobody's quite going to remember the meeting that did, or in this case didn't happen in 2022, but they'll have access to the pages of our journals. That becomes the more or less permanent record of our discipline. And as the official journals of the society of critical care medicine, the record of our society. So speaking for myself and I think Robert, but I wouldn't speak for him. We take it as a very serious responsibility, understanding that we are creating the record of our profession, of our discipline, of our science, of our art, of our society in those pages. And it's our hope, I think individually and collectively that practitioners today and years from now, we'll have confidence in what they find in those pages. So to tie everything together this has been a, just a wonderful conversation and we only have a couple of minutes left. You know, the last couple of years is it's been challenging to say the least. But, you know, many of us who've been through some challenges know that there's a lot to be learned and we've become better from those lessons learned. What lessons do you think we should take away from the last couple of years that we can take as targets of opportunity for the future? Over my career in critical care, I've been through HIV as a disease that swept there. 10 years ago, we had pandemic influenza. Now we're going to emerge from SARS-CoV-2. There will always be new challenges and new opportunities. The key thing is to recognize that there are always going to be new generations of caregivers to meet those opportunities. It's my responsibility as I close in on this status as elder statesman to make sure I've done everything I've can to prepare that next generation to find the joy, find the challenges, find the solutions that will help keep our discipline strong, our society strong, and most importantly, our patients and families strong. They are our future. Wow, Tim, that's, I can't think of a better way to wrap this up. Thank you so much. Just amazing final comments. This has just been a thrill for me to be able to chat with you for the better part of this hour and just thank you for doing this for this session and really appreciate you taking the time out and giving us some of your wisdom. It's been a great conversation personally for me. Thank you, Kevin. Be safe and be well. Bye-bye. All right. Take care.

critical care medicine

ICU care

multidisciplinary team

endotyping

clinical trials

burnout prevention

medical journalism

COVID-19 pandemic