CHAPTER
2 Embracing “The Hard Thing”
THE GOOD DOCTOR
IN MICHIGAN AND SOME other places in the organ transplant world, there is a ritual where, before the procedure to take the organ from the deceased donor begins, everyone in the operating room pauses. Someone reads a prayer or a poem, or tells the personnel in the operating room something about the donor’s life. Then for an additional 20 seconds, everyone stands in silence, not moving, not speaking. Everyone is supposed to think about the life and the loss of the person whose organ will benefit someone else, and express gratitude. After that 20 seconds, the operation can begin, and the surgeon makes the first incision to expose the organ(s) to be transplanted.
Twenty seconds of silence and immobility seems like a long time in an operating room filled with highly trained personnel revved up and itchy to move ahead. Time is their enemy, after all. They need to keep a liver or kidney or heart or lungs healthy and get them to waiting patients, who often are themselves on operating room tables in other hospitals in other cities. It shouldn’t be surprising that, during these pauses, the thoughts of the surgeons and other personnel often drift to the tasks that must be done, the logistics that must go just right—or even things unrelated to the transplant that they hope to make possible later in the day.
But one weekend in 2014, Mike Englesbe found that he could not look away. During a 36-hour period, the 43-year-old surgeon at the University of Michigan went to other hospitals in Michigan three times to procure livers for transplantation. All three times, the donors were young women who had died because of opioid overdoses. And in all three cases, the path that led to the overdoses had begun with prescription pain relievers.
“When you are about to cut into the perfect bodies of three beautiful young people and remove their organs, you can’t help but be affected,” he says. “And a pattern like that. . . .”
That weekend changed his life. He became obsessed with understanding how prescription drugs lead to opioid addiction, and what can be done to reduce that risk. It set him on a path to becoming a leader at his institution and across his state in improving prescribing practices while continuing his role as a key surgeon in one of the busiest liver transplant programs in the country.
His story shows how empathy—even with someone who is already deceased—and a reluctance to accept things as they are can push physicians to new places that enrich their professional lives.
* * *
Mike Englesbe is a lanky former long-distance swimmer who knew he wanted to be a surgeon as a boy—and even knew he wanted to be a transplant surgeon. He grew up in Voorhees, New Jersey, just outside Philadelphia, the second of two children. His father worked in finance, as did his older sister eventually; his mother was a first-grade school teacher.
Sports were important in the Englesbe household. Mike’s father had been a varsity basketball player at the University of Pennsylvania in an era when basketball at Penn and the other Big Five colleges was a Philadelphia obsession. Mike’s grandfather had also been a well-known athlete, and Mike’s sister was quite athletic, too.
Mike grew fast and tall, and had nearly reached his adult height of 6 feet 2 inches by the age of 12. And in those early years, he had the exhilarating experience of nearly always being the best in his cohort in every sport. But by the time he was 14, others were catching up, and he realized he didn’t have the talents to excel in sports like basketball that emphasized hand-eye coordination. “I wasn’t good enough to be a real athlete,” he recalls. “So just like everyone else on the crew team or the swim team, I flunked out of the skill sports.”
Mike plunged into a sport where determination mattered most—swimming. Just as he realized he was not going to be a great basketball player, he quickly figured out that he was simply not fast enough to be a sprinter in his new sport. So he focused on long-distance events, like the mile. He moved to a private school in Philadelphia, St. Joseph’s Preparatory School, and worked in long, grueling practices about eight times a week all through high school.
His sister had established a high bar. She was at the top of her high school class, excelled in sports, and went to the University of Pennsylvania. His parents supported his efforts to keep up. “Somehow, my parents let me go to swim practice a couple of days a week at 4:45 in the morning until 6:15,” he says. “My dad would wait there, and then he’d drive me into Philadelphia to start school. And most days I’d come home and have another practice at the end of the day.
“In retrospect, it was really hard,” he says. “I think it was probably the hardest I worked in my life. But part of the beauty of swimming is you learn you may never be the best, but if you grind it out and work hard, you can be the best you can possibly be.
“I think I’d say I was a good swimmer, and that I took my talents as far as I could take them,” he says. “To have been an Olympic swimmer, I would have had to have been three inches taller.” But he was a strong enough swimmer and student to be recruited to Yale, where he swam all four years and became captain of the swim team.
Still, he says, he always knew his swimming career would end with college. He excelled at the most grueling events, like five-kilometer races in open water, but “marathon swimming” would become Olympic events only after Mike had graduated and walked away from the sport. Even though he was team captain, he knew there were better swimmers out there. But he stuck with it and never missed any of the 11 practices per week.
He went to Yale instead of other schools where he could have also been a varsity swimmer, because it was Yale. “I had to work really hard to get my A’s and B’s,” he says. “When my dad dropped me off at college he said that I could come home if I got cancer or something—but otherwise, I had to stick it out.”
* * *
Mike went from Yale to Robert Wood Johnson Medical School, the medical school for his home state of New Jersey. Despite good grades at Yale, he says, “I was pretty immature. All I did was study and swim. I never had the maturity to pause and think, ‘What the hell am I doing?’ But I looked at medical school differently. I realized there was much more than just taking a test and being driven.
“In my second year of medical school, it was as though a light turned on and I figured out how to be a medical student,” he says. “I really got excited about the content. I’m not a man of deep curiosity, or at least I wasn’t as a young person. But for the first time, I started thinking, ‘This is right where I want to be.’”
The notion that he should become a transplant surgeon had first occurred to him in seventh grade, when the surgeon who had done the first heart transplant in Philadelphia came to his school. Mike started thinking it was what he wanted to do, too, but he didn’t do anything specific to move in that direction until he was in medical school. “Still, I always had that as a dream, and nothing really ever changed in my mind,” he says. “I always wanted to be a surgeon, and I never really pondered anything else.”
Once Mike started to get a real clinical experience in medical school, he was thrilled. “I loved all my rotations in medical school,” he says. “To be honest, I loved some of them more than surgery. And I can’t say I loved all the surgeons I worked with. But when I was exposed to surgeons, it was clear to me that I think like these people.”
He began to learn about the characteristics it would take to be a good surgeon. “You need resilience,” he says. “As a surgeon, you do good things, but inevitably, really bad things happen. You can’t be brought to a halt.
“The thing about surgery is that it is so humbling. You see patients, and they are so vulnerable. You try your very, very best. Sometimes, it doesn’t work out, and you have to ask, ‘What could I have done differently?’ You have to be very self-critical, but not let it crack you. You have to see setbacks as an opportunity to do better the next time.
“I like that. I find it a virtuous existence, empowering, but very humbling—and very motivating.”
The need to prioritize issues on the fly also appealed to him. “When a lot of things are going on, you have to be able to decide what to ignore,” he says. “When you are doing big operations, like liver transplants, there is a lot of bleeding, a lot going on. You can’t get bogged down in every detail, and you have to be able to focus on the fundamental issues. You have to be able to think about the physiology of what is happening and the technical aspects of what you can do. You have to think about what will be adequate. You don’t want to do too much, and you don’t want to do too little.”
He was pretty sure he could persevere through the nine years of hard work and low pay that would constitute his surgical training. “I figured if I can swim six hours a day year after year, I can do surgical training,” he recalls. “That kind of work appealed to me. Liver transplants can be a 12-hour slog, and I kind of like to do the really hard thing.”
* * *
Mike went to the University of Michigan Health System for his internship and residency. A fellowship in multiorgan transplantation followed. During a rotation at the VA Ann Arbor Healthcare System, he met a medical resident, Audrey Wu, and they married two years later. Today, Audrey also works at the University of Michigan, focusing on patients with heart failure, many who need cardiac transplantation. They have three children—two daughters and a son.
When they met, Audrey was headed to the University of Washington for cardiology training, so Mike interrupted his clinical fellowship at Michigan and arranged a two-year research fellowship there, too. (Top surgical training programs frequently include two-year research blocks.) “I studied aortas in baboons for two years,” he says. “It was vascular biology research. It was a great experience, and I met nice people and learned a lot. But it wasn’t my kind of thing.”
He knew what his kind of thing was. He liked transplants. Kidneys were good; livers even better. And that is what he focused on when he returned to Ann Arbor.
* * *
In the years after his return to Michigan, something else emerged as Mike’s “kind of thing”—teaching. His mother was a teacher, and one of his grandfathers was a professor, so he saw teaching students and residents as a reflection of his family’s values. Even though he was technically still a trainee, he joined the Education Advisory Committee for the Department of Surgery upon his return. In the ensuing years, he assumed increasing educational responsibilities—he estimates he spends a third of his time on education. He won a succession of awards for his teaching and played a leadership role in the recent implementation of a new curriculum at the medical school.
“I’m a good surgeon, but it’s not like I’m Toby Cosgrove,” he says, alluding to the recently retired CEO of the Cleveland Clinic, someone who was widely considered the top cardiac surgeon in the country during the period when Mike was training. “And I’m a good scientist, but I know I’m not going to win a Nobel Prize. As for the education piece—I’m not sure exactly why, but it’s been natural for me. I’ve always really, really liked the students and trainees, and enjoyed their success.”
He also started to win awards for the softer side of patient care. He was the University of Michigan Nominee in 2012 for the Arnold P. Gold Foundation Humanism in Medicine Award and won the Leonard Tow Humanism in Medicine Award at his medical school that same year. “I think I got more credit than I deserved,” he says. “I am a kind of tall person and a transplant surgeon, and people aren’t necessarily expecting normal human interactions from someone who fits that stereotype.
“Around that time, my social network of people at my institution from students up through faculty had really grown,” he says, recalling the pleasure added by this new dimension of his professional life. “I really knew what was going on in a lot of their lives. We have 170 medical students per class, and I wrote 40 residency letters of recommendations one year. I’ve gotten busier and been given other things to do, but I really enjoyed that period when I could go deep with so many young people. I grew a lot in those years when I was starting to do this work, and I still really enjoy it.”
* * *
Without any particular plan, these various strands of Mike’s professional life—his skills as a surgeon, his interest in young people, his readiness to admit when something was just not right—came together that Sunday in 2014 when he was on call for the liver transplant team. His role that weekend was to go out and bring the donor livers home, while one of his colleagues was preparing the recipient to receive the new organ. The three procurements took about a day and a half.
The first donor was a young woman who had overdosed on opioids. The story that came out during the pause to honor her was that she had had a sports injury and basically never been the same afterward. She got hooked on opioids and eventually overdosed. The second was another young woman with essentially the same story, but beginning with a wisdom tooth extraction. And the third was a young woman who had just graduated from high school and gone to a graduation party to which someone brought prescription opioids. She experimented, overdosed, and died.
Michigan had only recently made the pause to reflect on the donor’s story a standard part of the transplantation procedure, and the impact on Mike was profound. “Any physician is going to be affected by seeing young people who are very sick, dying, or have died,” he says. “But this situation couldn’t be more powerful. There’s a naked donor on the table, and you’re hearing the story of this young person’s journey to death.
“Among transplant professionals, there really is deep and sincere gratitude for the gift of an organ,” Mike says. “Everyone takes it very seriously. Hearing these three stories in a row was shocking. I couldn’t stop thinking about them.”
* * *
Mike could see that although the availability of these three livers was good for the recipients of these organs, it was also the sign of a devastating public health problem. “I became very interested in seeing if there was anything I could do to try to combat this, at least in my region,” he said. “But I didn’t know where to start.”
He talked to two of his closest friends—Chad Brummett, an anesthesiologist who focused on pain management, and Jennifer Waljee, a plastic surgeon and health services researcher. Both had been working on the opioid epidemic. He asked if he could join them in this work.
They first turned to the challenge of caring for patients coming in for surgical care who were already chronic users of opioids. “These people are very hard to care for,” Mike said in a 2018 talk at a NEJM Catalyst meeting. “Opioid use and misuse, addiction, pain—these are complex problems. I immediately became humbled by the appreciation of the remarkable, almost mythical grip that opioids can have on people.”
Brummett suggested that they needed to pivot in their work and focus on keeping healthy people healthy—to prevent new persistent chronic opioid use. “We learned that most heroin users, most people who overdose, get their introduction to opioids from someone like me, or from a dentist after a wisdom tooth extraction, or from an orthopedic surgeon after a sports injury,” Mike said. “So we dug in.
“When you and your friends have a good idea and are motivated, it’s amazing what can happen,” Mike says. They discussed their goals with colleagues at the University of Michigan’s Institute for Healthcare Policy and Innovation (IHPI), as well as with other researchers, policy experts, public health officials, and leaders of Blue Cross Blue Shield of Michigan and Michigan Medicaid. “Everyone was helpful. Everyone wanted to collaborate. And we began to understand this problem.”
They were stunned to learn that 6 percent of patients who have surgical care become new chronic opioid users. “Becoming a new chronic opioid user is probably the most common surgical complication in the United States,” Mike began saying in his talks.
The numbers are even higher for some subsets of patients. For example, 20 percent of women with breast cancer who receive systemic therapy, radiation, mastectomy, and reconstruction finish that journey as chronic opioid users. Jennifer Waljee wrote a paper showing that 5 percent of adolescents who have surgical care become chronic opioid users.
“Needing opioids every day can happen to any of us,” Mike realized. “The usual story is, ‘I had my wisdom teeth removed or I had surgery on my knee. I took the opioids for a couple days, then I stopped. Then I felt really bad, so I took some more, and that continued.’ Since people in the United States have an average of nine procedures over the course of their lives, we are all at risk for this complication.”
* * *
Describing the root cause of the opioid epidemic was not enough; Mike and his colleagues wanted to figure out how to fix the problem. “And that is where our partnerships became key,” Mike says.
Here, Mike’s deep relationships with students and trainees came in handy. A medical student and a resident did a study in which they interviewed every patient at Michigan Medicine who had undergone a laparoscopic cholecystectomy (gallbladder removal). They noted how many pain pills they were given at discharge, and how many patients actually took. The average number of pills received was 45; the average number taken was 6. That meant 39 pills, on average, were available to cause overdoses like those that killed Mike’s three donors that weekend.
The student then made a five-minute video for all Michigan Medicine surgeons and residents. It presented the data and posed the question, Why not prescribe just 15 pills? And since then, every patient having a laparoscopic cholecystectomy has received 15 or fewer pills. “And something interesting has happened,” Mike says. “Patients are taking only about two pills. And they report their pain care as good if not even better.” Based on these findings, they have developed new pill protocols, and many patients recover from procedures without needing opioids at all.
“This little experiment became the basis for our strategy to transform postsurgical opioid prescribing in our state, and hopefully, the United States,” he says. “In Michigan, we’re very lucky that we have this amazing platform funded by Blue Cross Blue Shield, which allows physicians to lead quality improvement across the surgical world in the entire state. We can now ask patients across the state: How many pills did you get? How many did you take? How was your care? Did you get adequate pain care?
“It turns out, if you get a huge bottle of pills, you take a lot of pills,” he says. “If you get a few, you just take a few. Your pain care essentially is the same.
“Right-sizing opioid prescribing is relatively low-hanging fruit,” Mike says. “But the story is not as simple as just writing prescriptions for fewer opioids.” The goal is to learn how to do procedures with no opioids at all in patients who can get by without them.
* * *
Mike continues to think of his primary work as being a liver transplant surgeon. When at work, he is still most at home with his hands deep inside someone’s abdomen.
But the same drive to improve that allowed him to get everything he could from his talents as a swimmer has pushed him to do all he can for patients—even the ones who have died and given their organs to others. And the pleasure he gets from teaching has turned him into a key leader in quality improvement, especially regarding opioid prescribing, in his institution and beyond.
Mike became codirector of the Michigan Opioid Prescribing and Engagement Network in 2016 and the director of the Michigan Surgical Quality Collaborative in 2017. He and his colleagues have a goal of performing 50 percent of Michigan’s outpatient procedures without opioids while improving pain care at the same time.
Mike and his colleagues identified just how many pain pills patients should receive after 15 common procedures. The recommendations were introduced in October 2017; in the next six months, opioid prescribing after surgical care in Michigan dropped by 20 percent.
“Certainly, Michigan’s a safer place today than just a few years ago,” he says. “I hope I never again have to do three donor operations in a row in the same day. But if I do, I am confident that, in Michigan, the donors won’t be three beautiful young people who overdosed on opioids.”
He is proud of this work, but shrugs off accolades and emphasizes his good fortune to be in the right place at the right time. “I work at the University of Michigan,” he says. “We feel a deep commitment to serving the 10 million people in the state of Michigan. We’re a good hospital. We have a lot of resources. We understand care pretty well. When we have something that we think could benefit the rest of the state, we have a lot of resources from Blue Cross Blue Shield and our own institution to try to drive improvement.”
Asked why he, who spent nine years becoming a transplant surgeon, is giving so much time to what is essentially a public health problem, he pauses. “It’s a great question,” he says. “I think all of us—we seek impact. We seek meaning. We seek purpose. For me, I get a lot of my energy from two things. One is the people I work with, like my friends Chad and Jen, and all these students and residents, and the patients, of course. Two, I feel a strong obligation with all the opportunities that I have had to serve the people of Michigan.
“Sure, it takes a toll on some other aspects of your life,” he concedes. “But you try to balance those things out. Taking care of one patient at a time is not enough. You have to be thinking about how your patient got to where they are, and what you can try to prevent that from happening to someone else and improve on the care for the next patient.
“I feel like I have had every opportunity,” he says. “If I can’t be successful in making the world a better place, who can?”