We would not want to do anything but medicine

Kateřina Rusinová, head of the newly created Department of Palliative Medicine, and Assistant Professor René Vobořil, new head of the Department of Surgery of the First Faculty of Medicine of the Charles University and University Hospital Bulovka, present their insights regarding clinical practice, academic medicine, teaching, and their direction within the fields they work in.

Could you shortly introduce the clinical or scientific activities of your department?
KR: Our department is really the first of its kind in the Czech Republic. Palliative medicine differs from other areas of medicine especially in its emphasis on a multidisciplinary approach and perception of the patient in the context of his or her life with a serious disease and suitable setting of the treatment. This is not just a biological or somatic perspective: our work has also a social, psychological, and spiritual dimension. Alongside physicians and nurses, important role is played also by social workers, psychologists, chaplains, as well as rehabilitation doctors, clinical pharmacists, and other healthcare professionals. This collaboration leads not only to better knowledge of the patient but also has a clear positive impact on outcomes of patients with serious diseases, both in terms of treatment of symptoms such as pain or shortness of breath, but also more satisfaction with the treatment, which need not lead to recovery but helps slow down the progress of the disease. Patients are less stressed, less anxious, show fewer symptoms of depression, and report a better quality of life. With MUDr. Ondřej Kopecký, we created this department as intensive care specialists and our research, too, focused on patients hospitalised on intensive care beds. The first direction our research took was development of the segment of organ donorship after irreversible failure of circulation. The principles of this donorship are now defined in standards and recommendations and we managed to develop this donorship programme in the Czech Republic. A second area of research focused on the ethical climate and appropriateness of intensive care, which in some patients leads to improvement but in others does not. The third area of research is support of and information sharing with families of patients hospitalised at intensive care units. They often find themselves in difficult, highly stressful situations when their loved ones are in critical danger. The relatives need help to provide good support to the patient or help when they experience loss after a patient, their relative, in intensive care dies.

RV: Our department can provide care to a wide range of patients in terms of general, abdominal, vein and thoracic surgery. At the department, we provide surgeries of oesophagus, stomach, small and large intestine, operations of gallbladder, biliary tract, liver, pancreas, as well as lungs, mediastinum, the diaphragm, breasts, thyroid, and surgeries of veins. And last but not least, we operate patients with peritoneal carcinomatosis and are one of but a handful of departments to provide hemicorporectomy.

Where do you see advantages of linking clinical and academic medicine?
KR: For palliative care, this connection is extremely important. This area of medicine is perceived as one that immediately deals with dying, assistance, and alleviation of pain. This, however, is too narrow a perception. The fact that the very first department of palliative medicine has been created in the Czech Republic, a department that can bring in new data, new research on aspects of palliative care, can benefit this area of medicine very much. It could help dispel this narrow perception of medicine and show that palliative medicine benefits patients with a serious disease right from the moment they are diagnosed.
RV: In developed western countries, for instance in Germany or the USA, it is quite common that surgeons who focus on their academic career have experience with research, often even basic research. This connection, when surgeons trained in purely clinical approach to a given disease acquire experience from research, helps develop an interdisciplinary view, which is necessary for achieving further advances in the treatment of surgical patients. The advantage of connecting clinical and academic medicine is thus in facilitating interdisciplinary collaboration, and that is something I consider to be of key importance.

In what ways to you want to contribute to your specialisation and to the faculty?
KR: We were fortunate to have, right from the start, the support and constant professional contact with our international mentors, such as Elie Azoulay from France, Claudia Bausewein and Andrej Michalsen from Germany, and Randall Curtis from the USA. The creation of the department now gives us an opportunity to collaborate in international research, which is very important. Our students have been saying for some time now that they would like to see at the faculty some instruction in the basics of communication, especially communication with patients who have a serious disease, communication of unpleasant news, communication about the goal of treatment, or communication in conflict situations. We would like to contribute to the life of the faculty this link between teaching of medical skills and ways of speaking with patients about their health. Another important point is the foundation of a journal dedicated to palliative medicine, the Paliativní medicína, which I founded with support of the Czech Society for Palliative Medicine based on my long-term work as editor of Intensive Care Medicine, an international journal with impact factor 17. 6. Without the support of an academic institution, it would not have been possible in Czech environment to start a journal which publishes research results, comments on important international studies, and provides space for discussions of ethical dilemmas. Last autumn, we published its pilot number and now we have also the first issue of 2021. It is an important step towards palliative medicine becoming a standard and respected medical field.
RV: I would like our department to be as successful as possible. To achieve it, we must focus on three areas. The first is the area of treatment and prevention, where I would like to maintain the current range of care. I would like to boost the formation of specialised groups of surgeons who focus on a particular part of surgery, and in order to provide continuity of care, I would like to see these teams reinforced by young surgeons. The other area is teaching, where of key importance is our ability to deal with the increase in student numbers, especially English-speaking ones, so as to maintain the quality of instruction. And finally, the third area is science, where I would like to find partner institutions with whom we could collaborate in research and science and increase the publication activity of our department.

What are the subjects of your scientific interest?
KR: For a long time, I investigated the issue of appropriateness of intensity of care at resuscitation units and the ethical situation within which decisions must be taken. If we were to reduce the complex questions related to patients’ critical state to their technical and somatic aspect, we would lose the substantial core, namely values. This is what I am interested in in medicine, linking efforts for the best possible clinical outcome and often the outermost limits of technological medical procedures with patients’ values and preferences. From a scientific point of view, I want to see how medical progress and research can be ethically incorporated into concrete patient’s system of values. For some patients, the environment of intensive care can be the best, because they want to try everything current intensive and invasive medicine has to offer in order to prolong their lives. There are, however, also patients whose values are set up differently and although they understand that treatment could slow down their disease, the risk of complications or even just hospitalisation as such have no place within their system of values.
RV: Both from a surgical perspective and in my research, I have been dealing with oncological surgery. In some solid malignant tumours the results of their treatment are relatively good, in others it is less so. But in general, one can conclude that further progress in the treatment of these patients can be achieves especially by interdisciplinary collaboration between surgeons and other clinical and paraclinical areas of medicine. And here I see a large space for collaboration.

What are your next work tasks?
KR: I am very much looking forward to preparing the syllabus and curriculum for a course in communication and basics of palliative medicine, which I will try to make interesting and beneficial for students. We have some experience from several terms of facultative subject Palliative medicine, and in the summer term this year, we are offering a course called Medical ethics and communication skills for the English parallel. The new subject should be taught from preclinical subjects up to year six, in order to organically blend with subjects such as first aid and basics of resuscitation, which is taught already in preparatory courses in Dobronice. In this subject, communication is necessary because although resuscitation saves lives, it does not always work. It is thus important for medics to know right from the start how to face a situation where their efforts did not lead to the desired outcome. The subject will definitely interface with propaedeutics. In clinical subjects, medics should learn now to face emotionally challenging situations in the doctor–patient relationships. With medics’ growing abilities in clinical subjects, they also come to face the issue of determining meaningfulness of treatment and its appropriateness as compared to just treatment of symptoms. And then, on top of this, I will have to deal with about 25,000 administrative tasks.... (laughter).
RV: Like I said before, there are three main areas linked to the department’s operation I want to focus on. Let me just focus now on one of them, the area of science. This is where we, surgeons in the Czech Republic as a group, have something of a debt in general. Surgeons like operating but do not like writing. I hope I could make especially some of my young colleagues, fresh from school, those who are just finding their way in surgery, a bit more interested in research. If they accept scientific work as a natural part of their development as surgeons, I would be more than happy.

What would you have done had you not decided to follow a career in medicine?

KR: I actually studied acting at the same time as medicine, but one cannot say it had any direct influence on where my career in medicine is going. I certainly gained a lot of interesting experiences, just like people who alongside medicine also engage in music or top sport do. But I like medicine and would not want to do anything else. I could have stayed with my original specialisation, that is, intensive medicine, but I am glad we did not give up on this new department and feel grateful to a lot of people at the faculty and in the hospital, people thanks to whom the Department of Palliative Medicine was created.

RV: My choice of a career was strongly influenced by the medical environment I grew up in. Medicine has been around me since my childhood, it always fascinated me and was a focus of my interest. After graduating from high school, I did not have a moment’s doubt, my choice was clear. I simply naturally tended towards medicine. When I think about the question you posed, I can honestly say that I chose well, and no other career would fulfil me as much as medicine has does.