Episode 309: Master Clinician Part 8: Mimi Wynn
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Hello, and welcome back to ACRAC. I'm Jed Wolpaw, and we are back with another Master Clinician episode. I am absolutely thrilled to have with me a true Master Clinician, Dr. Mimi Nguyen. Listeners will know that Dr. Nguyen came on the show before to talk about cardiac and thoracic anesthesia, especially thoracic anesthesia, of which she is really thought of as being a true world expert. We had a great conversation, and Dr. Nguyen,

folks who have worked with her during her time as a cardiac and thoracic anesthesiologist at University of Wisconsin-Madison reached out and said, listen, you have to have her on as a master clinician. She's now an emeritus professor, having retired recently, but an emeritus professor of anesthesiology at University of Wisconsin-Madison. And I'll just share with you just an example of what people said. So

She's definitely a master clinician, someone who people routinely seek out for guidance on clinical challenges for both our anesthesiologists but also for our surgeons. She's retired but still routinely fields texts and calls from former anesthesia colleagues and from surgeons for her thoughts and wisdom in challenging situations. She's a fountain of knowledge and an amazing educator. I think anyone at the University of Wisconsin anesthesia and vascular surgery departments would agree. So that's really a testament. Dr. Nguyen, thank you so much and welcome back to the show.

Well, thank you, Chad. Thank you for having me. I must say that, honestly, I am humbled to be even talking about this with you. Well, it's clearly well-deserved.

And whether you're willing to admit it or not, lots of your colleagues and residents do. So we're going to trust them. And I appreciate you being willing to talk about your expertise. So just remind folks a little bit, you know, you practiced for a very long time. Now you've retired, but still giving some advice. But when you were practicing, remind people, what was your kind of area of interest? Well, my interest initially was cardiac anesthesia. However, as time went on,

I became also interested in anesthesia for complex aortic surgery, for vascular surgery, and spent a lot of my intellectual energy and clinical care treating patients with complex thoracopdominal aneurysms. Of course, this spanned the open space.

procedures, which then transitioned into endovascular repair as well. Yeah, fabulous. And of course, that is the primary focus of what we talked about last time was those aneurysmic repairs and the anesthesia for them.

So we're going to go through some of the things that you've kind of identified as being important that you've really found to be key areas over the years. You talk about knowledge and experience and how this was really something you tried to focus on that led you to build depth. Talk about that. What do you mean and how did you go about pursuing that? Well, I think those two things are obvious and really fundamental.

And for me, this was focused, obviously, in cardiac and vascular anesthesia. And this led to depth in those areas. And although this is generalizable to other areas as well, I would not think that I could be a master clinician in everything. I think probably there are some people who are, but

However, for me, that would not have been the case. Yeah. Well, I think that's so well put. And I have this very distinct memory as a, I think as a CA1, maybe, maybe C2, but somewhat or relatively early in my training. And I was working with this very, very distinguished, very experienced cardiac anesthesiologist. And he almost always just did cardiac anesthesia. But for whatever reason that day, he and I were assigned to do a craniotomy. And I remember he said to me,

I haven't done one of these in 25 years. So you tell me what you want to do and we'll do it. And that was so funny to me because he was, you know, just such an expert in cardiac anesthesia, but hadn't done this in forever, right? So I think, yeah, you end up focused in a certain area and build your expertise there. And you do. And I think that that happens to everyone in an academic center. As faculty, occasionally you are required to do something more

out of your area of in-depth expertise. And I always felt very comfortable going to my colleagues who were experts in that area and asking them what they would do. And I think it's important to reach out to get help because we can't be experts in everything. Yeah, absolutely agree. Now,

Early on, let's say when you first started developing this interest in thoracic abdominal aneurysm repair, you wanted to build a focus there. You wanted to build some depth. How did you go about doing it? I mean, one thing obviously is just trying to do those cases, but did you read? Did you talk to others? How did you build the depth that you ended up having? Well, when we came to Wisconsin, one of our goals was to...

establish a complex aortic surgery program. And I think in addition to knowledge and experience, hands-on learning before teaching others is essential. And this can be problematic in a teaching institution, but it's still necessary.

You can't effectively teach something that you don't reliably do. And teaching faculty too often begin supervising procedures they have not yet mastered themselves. And we all know that technology and procedures progress throughout your career, and you have to learn things you didn't learn during training.

So for me, this included many things, bronchoscopy, transesophageal echo, spinal drains, and ultrasound, just to name a few. So for one thing, you have to learn from people who are better than you. And this will take you outside of your own particular subspecialty. For instance, with spinal drains, I learned over a number of years that some were difficult.

It wasn't always predictable. Fortunately, some years ago, a colleague joined our cardiac anesthesia group who had experience with chronic pain and inserting spinal cord stimulators. And so he taught me how to do spinal drains with pain.

prone positioning. We had always used fluoroscopy since 2000, but prone positioning made it extremely easy to put all drains in. It was very difficult to learn. It's very hard to learn new things. So you have to be in a culture that supports learning. Having people around you that challenge you intellectually is essential.

And being part of a team that values clinical work and thinks critically about problems in a nonjudgmental way and learns from each other is very important. In addition to that, when we started out, the dominant paradigm to prevent spinal cord injury was anatomic. And we knew that

we could not be successful unless we reduce spinal cord injury. So that was our biggest clinical challenge in building a program. It was also critical to our ability to continue caring for these patients because the ones with spinal cord injury as a result of your treatment, they live with you forever. So

From the beginning, we adopted a physiologic rather than the then-dominant anatomic approach to reducing spinal cord injury, and we applied data from animal studies to the care of these patients. We talked to people at other institutions who were doing the same work. Sometimes this was frustrating because they were dismissive rather than

interested, I would say. But you have to have curiosity and not be afraid of being wrong or following where your intellect leads you. The new paradigm we were proposing, which was largely physiologic, was not well received early on. And we were aggressively criticized for

And even ridiculed at some national meetings where we presented our outcomes. So that was difficult. Yeah. However, it was not impossible. And I have to say that because I grew up when I did, I wasn't that accustomed to having external validation.

and didn't really expect it. So this was helpful in getting through that period. But I think as a clinician, it's very important if you're talking and trying to understand a particular problem, it's very important to pay close attention to the patient's physical response to their disease and to treatment interventions.

And this also requires a database to track and analyze outcomes to see what works, what doesn't work. So we were fortunate to be working on a significant and unambiguous problem, which was spinal cord injury. It could be documented. It could be studied clinically. So in an area where randomized controlled trials are difficult,

or even impossible. You have to learn from clinical observations and use modeling to analyze outcomes. And every outcome tells you something. So if you have a team that works together, this can be addressed in a real-time fashion, and in particular when there are complications.

Yeah. And what I love about what you're describing is, you know, so here you are, you have this interest. And instead of just saying, OK, you know, I'm going to I'm going to do some of these cases and then I'll be one of the people who does them. You really kind of took it to the nth level. Right. I mean, you you talked to people at other institutions. You gathered data. You said, I'm not just going to do the cases. I'm going to keep track of outcomes and observe what we're doing and what the impact is and how it may change outcomes.

And I mean, this is how, you know, this is like a textbook of how to become a real expert in something. You can't just, just, I mean, you need the experience, but it's not enough just to do it. You have to do it in a deliberate way. And that is really what you're describing is having tackled this problem in the most deliberate possible way and thereby becoming really an expert on it. Well, we had to because the consequences of spinal cord injury for patients are

Yeah.

you may take – people may disagree. They may not like that you're doing it. They may think you're wrong. They may push back. They may even ridicule you. And so the courage to say we're going to do this anyway, we're going to look into this, and to not be fragile I think is really key, right? If you had said – the first time somebody said what you're doing is not worth it, it's wrong, it's not – there's pointless, right? If you had said, you know what, okay, forget it. Let's just give up.

you never would have ended up, you know, kind of blazing the path that you did. So I think that's so such a key lesson in what you've said is, you know, you have to stick to your guns. You have to be willing to try something and you can't let criticism shut you down. I think you also have to remove ego from your work as much as you can. Medicine can be a very competitive environment and, you know, competition is,

about winning. It's not really about understanding. So frequently people behave and speak competitively to promote themselves. And this really shuts down learning or any kind of meaningful exchange. But you have to have kind of a thick skin. And I wouldn't say I had a thick skin in every way, but we were...

doing a number of these cases, we were analyzing them and we could see that we were making improvements in outcomes. And that was reinforcing to keep on. Yeah. Yeah, that's great.

One of the things that I also think is key is, you know, kind of being willing to try things and not, you know, understanding sometimes you may be wrong. In this case, you were right. I mean, what you were doing worked. But you might try something and it turns out you were wrong. And I think you have to be careful not to let the fear of being wrong stop you from asking the questions. Would you agree with that? I would agree with that. That's exactly true. You have to follow where...

the observations and analysis take you. And you will discover things that don't fit with your premise or your understanding of events. And I think it's very important to not brush away anomalies, to not discount them because anomalies,

Though you may not understand them at that moment, in the future you may have more information and develop an understanding of that aspect, who are really outliers. There will be things that don't fit. Sometimes they say to you, well, that's the wrong explanation. But sometimes they say, that's not something you know yet.

Yeah. And, you know, so many of us bring our own biases, right? Of we think things go this way. We think this is the best way to do it. We see a patient's physiologic reaction. We think we know the best way to treat it or we think we know why it's happening. How do you if you get too wrapped up in your own preexisting notions and bias, you're never going to go anywhere new because you're just going to keep doing what you've always done. So how how do you recommend people get away from that?

Well, I think you have to be very, you have to learn to be a really accurate observer. We all have bias, as you say, and you have to try to be aware of your bias. This is a process of observing how a patient's response fits or doesn't fit your understanding. And when it doesn't fit, you have to then learn new things and

to explain observations that are outliers. And it's easier, it was easier for us because we had such a clear-cut problem to work on. I think that was fortunate. It's not always as clear-cut as that. It's sometimes much more nuanced. It's important, I think, to listen to other people, colleagues, trainees, residents, fellows,

Surgeons, if you're in an environment that allows free exchange of ideas, this is very useful because lots of times people have ideas that you hadn't thought of. So keeping an open mind and open communication is a really important thing.

Yeah, I couldn't agree more. And, you know, I often find that people are reluctant, you know, the classic example is the medical student who won't ask a question, right, because they're afraid that it's going to sound dumb. But like you said, it's

I've had medical students who, when they do ask the question, they bring something up that we actually missed or didn't think of. Right. I mean, being willing to ask the questions, not being afraid of, you know, being wrong or being seen as not knowing something you're supposed to know, pushing out against that imposter syndrome. I mean, that's so important. And then, as you say, I mean, you that keeping that open mind is.

Exactly. Stay with us. We'll be right back.

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All right, and we're back. You have to recognize that validity of what other people are saying or asking. And how does this go along with the idea of tolerating uncertainty? Something nobody does very well, right? Nobody likes uncertainty. We always want to know the answer. But I love this idea. And tell me a little bit what it means to you in terms of tolerating uncertainty. Well, I think you have to be willing to tolerate uncertainty constantly.

not knowing why something happened. And I believe that early on in our careers, we tend to want to always explain unusual events, even when the explanation doesn't quite fit. And with more experience, you learn to say, well, it could be a number of things, but I don't really know. And it's important to know when you don't know.

And I think it's okay, more than okay to say that when you don't know. Uncertainty is not a flaw. It's a strength. But you have to have a certain amount of experience and knowledge to be comfortable saying that you're uncertain. If you always impose an immediate explanation for unusual events, you will form impoverished patterns. So,

In order not to do that, you have to store the outliers away and know that you may never understand them, but you could understand them better in the future. So I would say that one thing we studied along the way was the complications of spinal fluid drainage. And most times, intracranial bleeding from bleeding

Spinal fluid drainage was suggestive of, you know, tears in the subdural bridging veins. However, along the way, there were an unusual bleed would occur, something that was quite different. And we could see that it was an outlier. It didn't fit the pattern. And it took us a couple weeks.

to realize that severe hypertension that occurred during the procedure could cause an intraparenchymal cerebellar hematoma that had devastating effects. And this was a different kind of bleeding than what the usual pattern was. The first time, we didn't recognize it.

But if we had said, oh, that's bleeding the same, then we wouldn't have filed it away as an outlier to be explained later. So forming complex patterns is critically important. And you can't do this if you try to put the square pegs into the round holes by necessity. You have to know when to file something first.

Not forget it, but return to it later when a similar thing may happen. And this is obviously easier if you're in an area where you're doing a lot of the same kind of work, because then you have a very big N and you will see lots of things that are the same. But in all the years that I did this work,

Every year or a couple years, I would see something different that I hadn't seen before. This was frustrating. Yeah. How many times do you have to do this in order not to see anything new? Well, obviously, it's a lot of times. So imagine how difficult that is if you don't have a concentrated experience. Right. Yeah. Yeah. This all – and this kind of all fits together, right? If you –

Just if you can't handle uncertainty, then you will not be able to set those outliers aside and say, I don't know. I don't know what that was. I'm going to.

I'm going to hold on to it in this uncertain bin while I wait and work on it and, you know, maybe ask some people. And to ask people, you have to be willing to take that risk of saying, hey, I don't know what this is. And there's a risk they might say, like, you don't know? How could you not know? Right? But you have to be willing to take that risk. The chances are they won't say that. But, you know, so this all fits together. But I love this idea of if you just want your patterns to be simple, they're not going to work.

for all the cases. You have to be able to say, well, our pattern isn't complex enough yet because it doesn't answer those. So we have to wait and see how we can get more data and figure out how to work those in. Maybe in the end, you end up with a unifying pattern that explains it all, or maybe you need more than one, right? That you only know that by getting all the data. Yes. And I think that you don't even realize that

you're forming these patterns as you go along. It's only later in your career that you understand it. And one evidence of this, I think for me was that, um,

Over time, I noticed that there was sometimes a voice which I attributed to my midbrain, which would raise a concern that might not even have been part of my cognitive algorithm. And I learned that this voice is informed by complex patterns that I've established over years of experience.

And it recognizes things subliminally that you might not see immediately. But I think it takes a while to hear this voice and to know that it means something. It comes with experience. And I think a lot of clinicians who are very experienced would recognize this voice.

And you think that's a voice that comes from having built these complex patterns over time? Yes, absolutely. It's based on the complex patterns that you've built without even really knowing that you're building them.

Yeah. Yeah, it is that. I mean, I'm by no means, you know, as experienced as you or many others. But already now, you know, 11 years in, I notice myself noticing or kind of almost finding conclusions happening without consciously thinking about them that I don't think I would have made five or six years ago. And I'm sure that only increases over time. Yeah.

Yes, that's right. That's exactly what happens. And I think at first you don't even realize it's happening. It's like another part of your brain talking to you when you first start hearing. My experience with it was when I first started hearing it was soft and I had to learn to pay attention to it. And sometimes it was very helpful to have a

Yes.

And I love that idea of kind of, you know, it's almost like a gut feeling that you can either pay attention to or not. And learning to, I mean, for want of a better word, learning to trust your gut when that gut feeling is informed by years and years of practice and pattern recognition and pattern building, right, is really important.

But I think that's right, that it is subtle, at least at first, and it takes time. And you have to practice listening and being willing to trust it. Right. And you also have to, I think the danger of that is following your gut feeling in a knee-jerk way because that can also happen, which is not useful. Right.

and can even be dangerous. So it's a balance. And how do you think, that's a great point. How do you think we can distinguish between a gut feeling that is knee jerk or maybe is based on recency bias, you know, as opposed to the gut feeling that is the voice of many, many years of experience saying, hey, this fits this pattern that you've seen, even if you haven't noticed it. You know, I think that can be difficult. Yeah.

As I became more experienced and towards the end of my career, I found myself worrying more about things that I had worried less about earlier in the middle of my career. And I think that was because the stakes were always high and I had so much...

Danger of bias because I had been doing things the way I was doing them. So that's a real concern. It can be sometimes hard to tell if you're too much relying on your bias. Yeah. Well, maybe the answer is it's important to recognize that voice, that gut kind of feeling and trust.

and acknowledge it and then rather than just reacting to it in a knee-jerk sort of way to then try to figure out you know is there can i figure out why i'm having this feeling is there data that i can look at is there something going on you know it's kind of like when you look at the patient and you just have that feeling like something's not right here but you're not just going to cancel the case because you have that feeling right then you're going to look into it and try to figure out okay what's going on and so you know that you you test your ideas right um

with that voice. Right. Or you test that voice with your ideas. Right. Yeah. Okay. That sounds right to me. Let's talk about failure. How have you learned to and how do you advise people to deal with failure? We all fail. We all make mistakes. We all have errors. We all have failures. How should we deal with those in a way that is productive? Yeah. That's a hard thing. Well, first of all, I think you have to own your failures. Right.

Because if you discount them or try to explain them away, you can't learn anything. So it's very important to be honest about outcomes always. You know, we've all had a near miss or a disaster with an airway at some point. A trauma patient with a fractured larynx that doesn't get an immediate surgical airway.

A morbidly obese patient with the questionable airway having a cath lab procedure that everyone wants to do with monitored anesthesia. Then things go wrong and the patient can't be intubated. So complications like this are devastating. We have to accept responsibility for them in order to grow. This is extremely painful.

I worked with many cardiac and vascular surgeons and watched this in surgeons. Surgeons who respond to bad outcomes by owning failure and considering what could have been done differently become master surgeons, master clinicians.

And this is a painful and humbling responsibility. Those who say that was the worst aorta I've ever seen, it just fell apart, or I don't know what I could have done differently, don't become better. So, you know, we do dangerous work. And so we have to accept our imperfectness. And this is very difficult on a personal level,

Because sometimes it requires accepting responsibility for a patient's death. But it's necessary. And considering how we might have followed a different plan allows us to learn from that experience without being broken by it, I think. And this is the only way I found to recover from

from failures. Always asking yourself what I could have done differently that would have prevented this complication is constructive. And I think we owe this much to the patients that we fail. This is best done as a team, I believe. And so it's important to support colleagues when they acknowledge errors or failures and

I think it's really important to be part of a team that tries to understand complications and bad outcomes rather than assigning blame. You know, there are plenty of errors to go around in complex work. And at some point, we will all have committed one. And so if you are in a group that also complains

understands this, it's easier to recover from failures. Yeah. And it's that culture, building that culture where it is okay. It's acknowledged that everyone has been there before is so important, especially I find for trainees, because when a trainee has a bad medical error or a bad outcome, it's

you know, it's so hard for them that they feel so isolated. Um, and it, and it, it's hard, but so crucial to, to get that message across to them that this is, it's happened to all of us. We've all been there. This does not make you a bad doctor. Um,

And whether they believe that or not, when you try to convince them of it is another thing. But I'm sure you've had to help trainees through errors and failures before. Any tidbits of how you've done that in a successful way? I think it's difficult to really know how to do this in a successful way. Obviously, the things that...

you just said or things that you say, but some of it is really dependent on the internal personality of the person who is in that situation. I mean, if some people are more easily able to admit error, and I think really the first requisite is to be sort of centered enough

and strong enough to accept that you made an error. Not on purpose, of course. It could be something you didn't know or something no one knew. But if you can't acknowledge that, then it's very difficult to process it. But that requires an understanding that we will all make errors.

This is difficult work. It's complicated. It's dangerous. And sometimes we will make errors that result in failures for our patients. And that's simply part of what being a doctor is. Yeah, absolutely.

Well, if you could go back to your younger self when she was just finishing residency, is there anything you would tell your younger self to keep in mind or to do? Anything you wish you had known then? Well, one thing I would say is that you don't know where you're going to end up going and what things you will ultimately do.

However, I think the most important thing is to be doing things you're interested in that grab you, that challenge you, and to allow yourself to develop that in a way that accesses other people and other ideas. Because when you're starting out, you do have quite a bit of knowledge, right?

You just don't know what to do with all of it. And if you are lucky enough to discover something that really fascinates you, this can be sustaining throughout your career. And I think it's also very important to choose an opportunity that's like a tree with many branches so that you can explore many ideas.

that you have chances for being on different branches of the tree, because that's what keeps you intellectually interested in your career for a long period of time. Yeah, that makes a lot of sense. Is there anything we haven't touched on that you want to say before we move on? I think we have covered everything.

what I think about this and I appreciate hearing what you think as well. Well, thank you. You've shared so much great just gems of knowledge and I really appreciate it. Let's turn to the portion of our show where we make random recommendations. Do you have anything you would recommend that the audience check out for fun? Well, this is not really for fun. Or for interest? Last night, I woke up in the middle of the night thinking about, I said, oh my, he's going to ask me something like that. Yeah.

And I would recommend a book called Forgive and Remember by Charles Bosque. And the book actually examines surgical errors, but applies to other specialties as well. And it addresses some of the issues we're discussing here today. And I think it's especially helpful for trainees or those just starting

finishing their training and going into their own independent practice. Because, of course, you remember, as I do, how scary that can be at times. Yeah. Well, that's great. I have not heard of it, but I'll check it out. Great recommendation. I'm going to recommend a book and a movie that are the same, Conclave.

This is a book I actually, it was great, right? I stumbled on this book before the movie was made. And I think I just saw it randomly recommended on online or something. And I read it. I really liked it. And then I just watched the movie too, which was well, the book as always is better than the movie, but the movie was actually pretty well done. So I would recommend both the book and the movie of Conclave. And I agree with you. I just finished watching the movie after having also read the book ahead of time. Yeah. What'd you think? You agree? Pretty, both pretty good. Totally agree. Yeah.

Yeah. It's rare. I find it very rare that I like a movie after having read the book, but this was one I did enjoy both. And the acting was great. Yes, it was. Yeah. Great group. Yeah. Well, Mimi, thank you so much. This has been a pleasure and I really appreciate you coming on the show again. Thank you, Judd. It's been a pleasure.

All right. Hopefully you got as much out of that as I did. That was really fantastic. Let us know what you thought. Go to the website, akrak.com, where you can leave a comment. Others can learn from what you have to say. If you are a fan of the show, you can follow us. We're on Twitter. We are on Facebook. We are on Reddit. And we are on Instagram.

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