Episode 031: Leeat Granek

Dr. Leeat Granek, of the School of Health Policy & Management in the Faculty of Health at York University, studies the emotional, psychological, and contextual factors that shape how healthcare workers do their jobs. Her research has helped thousands of oncologists and neurosurgeons understand how they process grief and how their emotional connection to patients influences life-or-death decisions that they face every day.

Transcript

Cameron: My guest today is Dr. Leeat Granek of the Faculty of Health at York University. Dr. Granek's research examines the emotional, psychological, and contextual factors that shape how healthcare workers do their jobs. She's studied how neurosurgeons make life and death decisions while operating on a child's brain. She's studied the emotional bonds between healthcare professionals, and their patients, and family members, and she's studied how new doctors and nurses are taught to handle these profound emotions and relationships. The care she brings to her own work comes through to anyone who talks to her. I hope you enjoy our conversation.... Leeat, welcome to the podcast.

Leeat: Thank you so much, Cameron. Thanks for having me.

Cameron: You've got a really broad program of research around healthcare and the kinds of things that affect healthcare workers. How would you describe the overall goals of your project?

Leeat: I'll talk a little bit of my research program first, and then I'll talk about the overall goals of the project we're going to talk about today. In terms of a research program, I've been interested now for nearly two decades, ever since graduate school, in looking at the relational and emotional components of medicine. In particular, focusing in on healthcare professionals, as opposed to doing research on patients, or caregivers for patients. I also look at healthcare professionals and the ways in which psychological and emotional factors can affect both the way that they practice medicine, and the impact that has on patients and their families, but also, on how relational and emotional factors affect healthcare workers, themselves. I'll just give you an example, and then if we want, we can talk more about the project we're interested in today, but one of the first projects I looked at when I started as a post-doctoral fellow, was the ways in which oncologists experience grief when their patients die. I became really interested in what's going on for them emotionally, when a patient in their care, who may have been in their care for 20 years, dies from the disease, and the ways in which those feelings of grief, or pain, or suffering might impact the way in which they care for other patients. That's an example of an innovative look into the ways in which emotional, and relational, and psychological components actually affect the practice of medicine. That thread is a thread that runs through almost all of my research projects, and it's a thread that we often don't think about or look at very often.

Cameron: If we think about the popular image of doctors that you see in hospital dramas on TV, for instance, there seems to be a kind of an overarching assumption that doctors have to somehow detach emotionally from their work in order to survive with their own mental health intact. You're talking about actually a more profound engagement of the emotions between a doctor and patients.

Leeat: Yeah. I mean, I think that's such a good point, because that's such a misnomer, it's a kind of mythology that we have around physicians. I mean, in the grief study I mentioned earlier, there is a compartmentalization that they talk about sometimes in order to get through the day, but it doesn't mean that they don't get attached to their patients, or that those attachments, that those relationships they have with patients and their families, don't influence first of all, their own wellbeing and the ways in which they respond emotionally, or more interestingly, I guess, for me, the ways in which it affects practice. For the project that you've asked me to come on today to talk about, we were going to talk about pediatric and neurosurgeons, and the ways in which they make decisions, while they were operating on children. Here's another example of this study, where relational, emotional factors really did come into decision making. We can get into a little bit more detail of that, as the interview progresses

Cameron: Now, I've obviously, your focus is quite a bit on doctors. Did you look at other health professionals, as well?

Leeat: Yeah, I mean, again, another great question, Cameron. We just finished another study a couple years ago, where we were looking at how do healthcare professionals within oncology, so it included oncologists, but it also looked at nurses and social workers, identify suicide risk in cancer patients. In that particular project, we know from the literature -- and there's so much literature on this, Literally, you could fill a stadium with piles of data -- that cancer patients are an increased risk of suicide. Yet, there was nothing in the literature that looked at how do healthcare professionals, who are caring for these cancer patients actually identify suicide risk in these patients. In this study, we interviewed all three healthcare professionals that are the frontline workers, who have contact with cancer patients. There's a series of papers that came out of that research, but just in terms of staying with the thread that we're talking about, one of the things that we found was that, if you, yourself, as a healthcare professional had experience with suicide in your own personal life, somebody that you know committed suicide, if somebody in your family committed suicide, if you had a patient in the past that committed suicide, and that you didn't have anywhere to process that, you were less likely to be able to identify it in the present. Right, so here, again, we had these historical or personal experiences with the phenomenon that we were studying that were directly influencing practice.

Cameron: Dying by suicide is something, obviously, that is a concern for healthcare professionals, in relation to their patients. Did you look at the possibility of that outcome amongst the healthcare workers themselves? Or, were you focused on patients?

Leeat: Yeah, so here, we were looking at the ability to identify suicide risk in patients. We weren't actually looking at healthcare professionals and their own suicidal ideation, but I can just tell you, because I know the literature very well, that healthcare professionals, particular physicians, that are very high risk of taking their own life, very, very high rates of depression, and burnout, anxiety. We've certainly seen a lot of that, due to the pandemic in recent years.

Cameron: Tell me about how the pandemic affects the approach that you take to research. Does it change your focus a little?

Leeat: You know, it's interesting, because in this study on pediatric neurosurgeons, for example, I did start interviewing during the pandemic. I think in the past, I would have interviewed people in-person, right? I would've set up appointments to come to the hospital and interviewed the surgeons in-person. But because I knew from the get-go that I was not going to be able to do that, we really brought in the scope to be international. We ended up interviewing from 12 different countries for the study, and it was amazing. I mean, it was just an incredible thing to be able to interview pediatric neurosurgeons across the entire globe. We interviewed 26 neurosurgeons in the end, but from 12 different countries. The really interesting thing about the international aspect is that, pediatric neurosurgery, in itself, is such a small, defined field. I mean, there's like maybe 2000 pediatric neurosurgeons across the whole globe to begin with. It's a very small population. There were many things that were very consistent, regardless of where they were in the world. Then, there were other things that were really specific, even in terms of decision making, that had to do with culture. In some places in the world, people were more willing to take risks. They had a higher risk tolerance than in other places. Like in Canada, we have very low risk tolerance in, general, and so people make more conservative decisions. In places like the States, where people are very afraid of litigation, that also influenced the ways in which people made decisions while they were operating. I think the pandemic did change it, but in a way that was actually very positive, in this particular case, because it really allowed us to broaden our scope.

Cameron: Well, you've brought up the question of how you get access to the information that you're trying to analyze. Obviously, interviewing people is one aspect of it. What are the different kinds of approaches you take to collecting data for your various studies?

Leeat: It really depends on the research question. I've done almost, not every type of methodology, but I do quantitative, and I do qualitative research. It really just depends on the question. Survey collection, we've done online, as well as in-person, using hard copies, and online surveys, qualitative data, lots of either focus groups, or one-on-one interviews. Usually, with healthcare professionals, I do one-on-one interviews, but again, it's the research question that drives the methodology, rather than the other way around. In a study like intraoperative decision making among pediatric neurosurgeons, I could not have used a quantitative method, because I would have absolutely no idea what to ask them, because it's never been studied before, so what am I going to ask them? I don't even know what are the kind of parameters of how people make decisions. Really, the only way I felt that I could answer this question, was to do these exploratory, in-depth interviews. I have to say that I just loved every minute of that study. I enjoy talking to these neurosurgeons so much, they're highly intelligent, articulate, thoughtful people, and it was just an extremely enjoyable experience, and very interesting, too.

Cameron: Do you have an example of questions that you have a clear idea of what's going on, where you might use different methods?

Leeat: Well, I mean, I guess like if we think about the oncologist project that I talked about earlier, so the first approach that we did was -- again, because the study had this question of whether oncologists experience grief when their patients die, and in what ways that impacts patient care, had never been asked before. -- the first study was a qualitative study, in order to get the scope and the range of what is this phenomena? Do they experience grief? If they do, what is the quality of that grief? What does it look like? What does it feel like? What are the ways in which they may take it home with them? What are the ways in which it might affect professional practice? Once I had a very good understanding of what the whole range of that phenomena was, I then became interested in understanding the scope. In other words, how frequently does this happen, and what does this grief come into association with? So do high levels of grief also come with high levels of burnout? That was another study that we did that we published in Cancer, where we looked at the relationship between patient death, burnout, and emotional distress. In that second question, in order to understand associations, and to understand how prevalent it was, the only way to go was quantitative. We did surveys, and then we ran the analyses, and I had a team that I was working with, and so that answered a very different type of question. But again, I could not have asked that second question in that second set of studies, where we used the quant methods, without first doing the qualitative, without first understanding what is this phenomena? Does it even exist? I wasn't sure. I didn't know. I really, genuinely didn't know.

Cameron: Tell me about how you map between the empirical questions that you've got and the literature that you're trying to engage the academic literature. How does that interplay between the problem you're trying to look at and the conversations that are already going on about it? How do you make sense of that tension?

Leeat: Yeah. Again, Cameron, such interesting questions you're asking me. I really appreciate them. They're making me think.

Cameron: It's my job.

Leeat: Yeah, so it's interesting, because most of the research that I do is research that has not been done before. Okay, so it's questions that have not been asked before. In the grief project, there were a lot of anecdotal papers about physicians just writing about "my patient," almost like you had it in sections of "The Art of Oncology," or in these kind of narrative stories that physicians would tell about losing patients, but the question had never been asked in terms of what is this grief like? Do you experience grief?

Cameron: Leeat, the fact that the question's never been asked doesn't necessarily mean that it needs to be asked. I can remember one review comment that I saw where the reviewer said, "This paper address is a much-needed gap in the literature," which is a real backhanded way of saying, "You're not asking an important question." How do you know, when something that's been ignored by previous scholars, is actually worth pursuing? Maybe it's just not significant. You must have some sort of internal barometer for the importance of the question.

Leeat: Well, Cameron, I'm not sure that you can ever know that without having done the study. Right? I mean, it is very possible, but would've done like the grief study, for example, and I would've found that nobody experiences grief, this doesn't affect patient care, or it doesn't have any relationship to burnout, and that would be that. Then, I would just say, "Okay, I've done the research, and this doesn't have any application." All of the questions that I choose to explore have clinical implications from the get-go, and I know that they're going to have clinical implications. In the suicide project that I described to you, I knew that there was an enormous gap between, and not just in the literature, but in practice, and this is a big problem, because, as I said to you, we have stadiums full of research, documenting the increased risk of suicide for cancer patients, and nothing, like nothing at all, looking at, "Well, how do we actually intervene and identify suicide risk, so that we prevent this?" There's kind of this obsession in academia I found in the suicide project, "To just document, document, document, this is a problem. This is a problem." I'm like, "Okay, I understand this is a problem.” To me, the bigger problem is, is how do we now intervene and step in to try to identify people who may be at risk, right, so that we prevent these suicides. The questions that I'm asking almost always, always have some kind of clinical significance, where I have a sense that this is a very important question to be asked. For the study that we're going to eventually talk about today, but the pediatric neurosurgeons, this started with a conversation that I had with a pediatric neurosurgeon, who I happened to know from my personal life. This is Jonathan Roth, who is my co-investigator, he was talking about this problem of how do you know to stop a surgery in the middle? Stopping a surgery, as a pediatric neurosurgeon, is a very, very difficult decision to make, because, A, what you're saying is, "I can't help this child." You're saying, "I may be having to come back and do another surgery." You're asking yourself, as a surgeon -- there an ego component here -- saying, "Look, what's wrong that I can't do this?" Now, I have to go out to the family and tell them, "Listen, we couldn't do what we said we were going to do, and I'm not sure what's next. Or, are we are going to have to have another surgery?" It's devastating news for the family, for the patient, and for the surgeon. In conversation with him around this paper that he published, and again, it was an anecdotal paper. In other words, it was an essay that he wrote with his co-surgeon saying, "Here are some of the things that we think go into making a decision about stopping the surgery." I said to him, "Well, what about other decisions during surgery that don't have to do with stopping the surgery? What about if you encounter a complication? What if something uncertain comes up while you're operating? What if something's unclear?" Which by the way, is a shockingly common phenomena, right, so that's something that I didn't know either before I started this research, that there are many times when a surgeon is operating, when it's not entirely clear, "What is the right thing to do?" Even more so with the brain, because what may work one time may not work the next time.

Cameron: Once again, you're puncturing the myths of surgery that are portrayed on popular media.

Leeat: Yeah. Yes. Well, I think the other thing, just to say about the context, is that pediatric neurosurgery, in particular, is even more complex than adults, because children have such wide variation of pathologies in their brain, and they have such wide variations of anatomy. A newborn brain doesn't look the same as a 12-year-old brain, doesn't look the same as a five-year-old brain. The range of tumors, or other problems that may arise are so different that it's not like, when you take out an appendix, every time the appendix sort of looks the same, right? Or, when you're taking out somebody's tonsils, more or less, like there are complications, but more or less, you sort of know what to do, and it's not going to be that different every time. It's gray, it's a gray area, to use a pun that we've often used on our research team. I said, "How do you make these decisions? How do you decide what to do?" That was how the study actually started, and I couldn't find a single thing in the literature on the topic.

Cameron: Tell me how you moved from the anecdotal version of it to a more academic, would you say a more theorized version? Would that be one way, in which your paper is different from the anecdotal one? Or, is it research methods? What makes it different from the anecdotal approach, in your words?

Leeat: Well, that it's empirical and that it collects data from multiple people. It's not just one surgeon, and or two surgeons in this case, sort of saying, "Here's what we do, and here's what happens." Right, it's not a story. It's not just one narrative. It's looking at multiple interviews, asking the same sets of questions, and seeing what are the patterns that emerge across all of these participants. I got to say, that out of all the research I've ever done, this was one of the most robust. In other words, the things that people told me were very consistent across all the 26 interviews, which surprised me, right. It really surprised me, because again, I said, twelve different countries, are we going to find the same things across all these geographical contexts? There were some cultural differences, but on the whole, the results were remarkably consistent. There were really very clear things that people did, in order to make these decisions. At the same time, when I would ask them, "How did you learn this? How do you teach this? How did you accumulate this wisdom or this knowledge of knowing how to make these decisions, while you're operating?" It was so ad hoc, it was almost like they absorbed it either by observing other people, or they learned it with experience, or with time, and people struggled with that, right? They struggled, especially when they were younger, in terms of knowing what are the kinds of techniques or approaches I can take to making these decisions? Like there was nothing pedagogical that helped them make these decisions. Each person had to learn about it on their own. There was no formal or informal curriculum on training surgeons how to make intraoperative decisions. The first paper we published out of the dataset was looking at philosophical approaches to making these decisions, right, so it was kind of like, "Tell me how do you make intraoperative decisions? What are the principles that guide you in making intraoperative decisions?" There, we got a very coherent -- this is what was very consistent across all the dataset -- we got this very consistent response, in terms of the approaches that they use. For example, in that first paper, we divided it up into professional practices, into caregiver practices, and into surgeon practices. The professional practices involve things like, we prepare for uncertainty in advance. We don't want to have any uncertainty while we're operating, and so we plan out 10 different ways the surgery can go, and this included things like, "I rehearse it in my mind the night before. I rehearse it in my mind the morning of. I record all of my procedures and watch them after. I take notes after every procedure, and I read them often. I keep a procedure journal." There was this very concentrated effort on preparing for uncertainty. That is something that they do teach their fellows. Then, there were things like more philosophical approaches. We approached intraoperative decision making by thinking about how can we do the least amount of harm, while we are operating? The idea always is to think about, "Do I need to do this move right now? Is it going to cause any harm?" The harm was in the short and in the long-term. It could be an immediate harm, and when I say harm, in the context of brain surgery, it's really important to understand that harm means potentially death. It means what they call deficits, so deficits can mean paralysis. It could mean loss of function, like loss of toileting, loss of being able to eat, loss of being able to walk, to see. It's the brain again, so like just understanding the magnitude of these decisions is really critical, as well. That was kind of an overarching guiding principal that they used in their professional practice. They also talked about being very systematic and empirical. Again, Cameron, you're talking about what we see on TV, so I think some of these answers are very aligned with what we expect surgeons to say, right? That they're very empirical. They're very systematic. They have a decision tree they go through, step-by-step to see is this the right decision at the moment? They were also talking about being very creative and adaptive. One surgeon talked about, you kind of have to be a MacGyver in the operating room, because you never know, maybe the equipment's not going to work that day. I'm going to be missing the scalpel that I really need, or the equipment's not going to work. That was kind of the professional approach. Then, they also talked about, in terms of caregiver and patient, is that they try to approach intraoperative decision making by thinking about what do the patient, if the patient was old enough, to tell them what they wanted. Often, it's the families, right, because it could be newborns, or young children.

Cameron: Right.

Leeat: How much risk tolerance that they were willing to take, right, so they'd have these conversations with the families ahead of time before the surgery. They would keep that in mind, as they were operating and making decisions about, for example, "How much tumor do I take out?" This is an ongoing dilemma. "If I take out the whole tumor, if it's cancerous, the potential is that this child will be cured essentially. There'll be no cancer. However, if I take out the whole tumor, I may also cause some very long-lasting neurological deficits. Or, I may cause a risk of death, or a complication, brain bleeding afterwards." This dilemma of like, a "How far do I push this here?" conversation I've had with the family beforehand about how much risk tolerance they're willing to accept, came into the operating room. Surgeons often said to me, "Sometimes, we don't do things that we think we should, because the patient's family told us not to, or we push farther than we think we should, because the patient's family said, we just want it out," as an example. There's an interesting relational component there, in terms of decision making. Then, in the last kind of philosophical approach, they talked about cultivating self-awareness, right, and so I have to make sure, as a surgeon, that when I go into the operating room, I'm not thinking about the argument I had with my spouse that morning, or I'm not thinking about my ego, in the sense that, what are my colleagues going to say about that postoperative scan? If I leave tumor, and my colleagues are going to see that at our rounds, what are they going to think about me, as a surgeon, that I'm a shitty surgeon, right? All of that is coming into the philosophical approaches. I outlined that a lot, because what I want to say about the project, as a whole, is that in some of the other papers, including the teaching paper, and another paper that's currently under review, I learned that when I was asking them like, "What concrete factors go into making an intraoperative decision? Not what is your philosophical approach. Not what it is that you're teaching your fellows, but what literal factors go into making decisions?" One of the most surprising things, was that they talked about my years of experience, as a surgeon, right? "The older I get," the surgeon would say, "Like the more wary I am of taking risks, because I have seen the impact of being very, very aggressive." There was a kind of wisdom that developed over time that said, "Do I really need to push it this far? Can we come back a second time?" Other factors they talked about was, "Do I have kids, or grandkids that are the same age as the person I'm operating on? If I do, there's a kind of empathy, or identification with the patient and the family, that makes me a little bit more risk averse." There were other people, who said that this was another factor, was my relational attachment to my patient, while I'm operating. One surgeon, I remember one of the quotes, he said, "I'm thinking about that child's smile, and when he comes out of surgeries, he's still going to have that smile." They said to me, "If it's a family that I know really well, if I'm operating the second, or the third time, sometimes, I'm more risk averse, than if I'm the consulting surgeon. I have to call somebody else in to consult, because are my emotions getting too involved here, in making this decision?" I'm juxtaposing these two papers that came out, because when we look at the project, as a whole, we see that there's a philosophy, and a pedagogy that's very well thought out, and very empirical, and very rigorous, very systematic. Then, there's also practice, that contradicts some of this philosophical approaches, and where the human enters.

Cameron: I'd like to draw our conversation to a bit of a close, and where I'd like to end up, is with this question of the relationship between your work and practice. How do the insights that you've developed through your studies move back out into the world of practice? What's the mechanism there? Do the surgeons simply read your papers, or are you engaged in talks, or something? What is the way you go about making sure that people learn from the results that you've got?

Leeat: Yeah. Yet another really great question, and such an important question for researchers, I think, to be asking themselves, “Right, how do we make this applicable?" The study I just talked about happened during COVID, and so, I haven't actually been able to disseminate in the ways that I normally would. When I look at my previous studies, I do things like grand round talks. I go into hospitals, and I give talks on the implications of my research. I write for the media. I've had editorials in The New York Times, in Slate Magazine, The Atlantic, The Toronto Star. I've been on NPR radio, CBC, right, so I make a very concentrated effort to disseminate the findings in a way that easy for people to understand. I really try to hone down on what are the main points, the take home points from every study. Then, of course, are academic publications, and academic conferences. That's always a very, very important component of academia. Before you present, you need to be able to say, "This has actually gone through rigorous peer review, and has been vetted by my peers." I think that that's actually the least effective dissemination tool out of all the ones that I've just described. In that oncology study that I told you about, I published that first paper, then it was Archives of Internal Medicine. Now, it's called JAMA Oncology. It's changed. The name has changed. It was a very good journal. I was very pleased the way that got accepted to Archives of Internal Medicine. I was really happy with that result, but I don't know, whatever, the 3.5 people that read it, or whatever the stats are for academic articles. Then, I wrote an editorial for The New York Times, just entitled “When Doctors Grieve,” and I got thousands of emails. I'm not even joking, thousands of emails from physicians all over the world, not just oncologists, but other physicians saying, "Wow, I've experienced this, and thank you so much for writing this. This is really pointing to something that no one has ever talked to me about before." It was so moving, for me, as a researcher, to see that impact. Compared to that very high-impact journal, the impact of that editorial was much more profound, and I think really did open up a field of research, because many more studies have been done since that publication in 2012, and, certainly, around the pandemic. I think there's been an explosion of studies, looking at the wellbeing of healthcare professionals, particularly around dealing with constant patient suffering and patient death. I mean, I am extremely worried about who's going to take care of us in the next generation of healthcare providers, because I think we have a whole generation of very burnt-out providers, who have not been given any supports, really, to deal with the immense stress of dealing with patients dying and sick, to such an extent. It's not only the frontline workers, who are dealing with COVID patients, it's everybody else who's had to adjust around. It's the people in the emergency room. It's the family doctors. It’s the surgeons, who operate at very high volumes as soon as things open up and then stop operating when things close down. It’s the transplant surgeons, who are negotiating with resources. It's just affected every aspect of the healthcare world, and I don't think we have adequately addressed or dealt with the impact on medicine, and health care providers, in particular.

Cameron: Well, these are very profound questions and deep issues. Thank you so much for helping us understand more about the emotional context of all this medical work that's going on. It's clear from the joy in your own voice, and the care in your own voice, that you feel very emotionally connected to this topic too, so it's been a delight to talk to you, Leeat.

Leeat: Thank you so much, Cameron. I love, love, love, love research. I love my job. I love my work. I appreciate the chance to talk about it.

Links

Leeat Granek’s research website

Credits

Host and producer: Cameron Graham
Production assistant: Andrew Castillo
Photos: York University
Music: Musicbed
Tools: Squadcast, Audacity
Recorded: November 10, 2021
Location: Toronto