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Invited Commentaries

The Importance of Being Earnest

El-Dalati, Sami MD; Cronin, Daniel MD

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doi: 10.1097/ACM.0000000000003372
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We nestled into our seats in the large auditorium, our box lunches resting precariously on our laps. Normally the opportunity for free lunch was the main draw to Grand Rounds, but today’s talk was going to be different. This morbidity and mortality conference (M&M) for the Department of Internal Medicine involved a patient with endocarditis, which was the focus of much of our research. The speaker began, outlining the pertinent information.

A 40-year-old man with a prosthetic aortic valve presented to the emergency department with several days of fevers and chills. He was admitted to the hospital and started on broad-spectrum antibiotics. Shortly thereafter his blood cultures were positive for methicillin-resistant Staphylococcus aureus. A transesophageal echocardiogram (TEE) was normal, yet suspicion remained high for endocarditis. At this point, things careened off course. Several days into the admission, the patient remained bacteremic. Cardiac surgery was consulted and recommended a CT of the chest. The images filled the screen in the auditorium; just behind the aortic valve lay a large fluid collection. It seemed clear to everyone in the room that, despite the negative TEE, the patient had a large abscess around his valve. We listened in disbelief as the case unfolded, and we heard the back-and-forth that played out in the electronic medical record between cardiac surgery and infectious diseases (ID). The surgeon was not sure this collection was infected and asked for a PET scan. When this returned consistent with infection, this still did not convince the surgeon, and they asked for an aspiration of the collection. The ID notes countered that there could be no other diagnosis other than endocarditis and that without an operation, this infection would almost certainly prove fatal. It was unclear whether the surgeon and ID consultant ever spoke directly to one another. As the chart war waged, our disbelief turned to horror. The patient languished until it was too late to save him. He arrested and passed away, an autopsy confirming what we all knew, that he had endocarditis. This young man lost his life as a victim of a broken system of communication that we had come to know all too well.

Rewind 3 years. As interns we witnessed many puzzling aspects of the health care delivery process. We would often reflect that “there has to be a better way to do this.” In some cases, the answers seemed clear. Other problems loomed large without apparent solutions. One of the most striking examples of the latter was the care of patients with infectious endocarditis (IE). Each IE patient was admitted to an internal medicine service, typically cardiology, with coordination of their care left up to an intern. These cases were among the most complex in the hospital and often required ID, cardiac surgery, neurology, and neurosurgery consultations. Only rarely did the specialists communicate directly with one another despite the myriad diagnostic tests and frequently conflicting management recommendations. Each consult, each test, while often important, also takes time to complete and can, unintentionally, lead to delays in care. In highly morbid diseases such as IE, an extra day before diagnosis or surgery can dramatically increase the likelihood of a poor outcome. We came to this realization fairly early in our training and found the existing process of care quite frustrating. What surprised us, however, was that our senior residents, fellows, and attendings also recognized the inefficiencies but were resigned to their existence.

We set out to shed light on the problem, although this would prove quite difficult. Despite the fact that almost everyone involved with IE patients realized that their movement through the medical system was painstakingly slow, it was not clear to providers that this resulted in subpar treatment. Inside we were stunned—logically this model had to lead to ineffective care. However, in the world of evidence-based medicine, logic will only take you so far. There has to be data to support what really should be common sense. Searching for statistics, we soon found that no one was looking at the outcomes for IE patients at our institution. We decided to embark on our own chart review and, using an internal data resource, reviewed 1 academic year’s worth of IE patients. The findings were surprising. Our outcomes were even worse than anticipated: 29.4% of patients with definite endocarditis and surgical indications died during their index hospitalization. This number was almost twice as high as the 15%–20% reported in the published literature.1

Now that we had our numbers, we thought we could turn some heads. Instead, everyone we presented to poked holes in the study and tried to explain away the results. “We are a tertiary care referral center; our mortality rates are bound to be higher.” “Did you account for these various comorbidities?” We had tried our best to answer these questions, but we were residents researching this topic independently with no resources. We struggled to understand what we were encountering. Here was a system that subjectively seemed inefficient, and now there were objective data to support that theory. But the resistance to acknowledging the need for change was strong. Perhaps what we needed was a practical solution. If we came to the table with answers rather than problems, we might have more success.

We found several European studies about multidisciplinary IE teams that met weekly to discuss patients. Several centers had significantly reduced their mortality by implementing a standardized protocol and regular conferences.2–4 The degree of improvement resulting from these practices was shocking but not altogether very surprising. If all of a patient’s doctors met to discuss that patient’s case, it would follow that the patient stood a better chance of a positive outcome. Interestingly, the initial study was published in JAMA in 2009, a full decade ago.2 The team concept had become so instrumental to their model of care that the European Society of Cardiology included it in their IE guidelines.5 However, this multidisciplinary approach was nowhere to be found in the American Heart Association guidelines, nor was there any published literature on the topic from U.S. institutions.6 Somehow this dramatically effective intervention had been stranded on the other side of the Atlantic. At that moment, we became determined that a multidisciplinary IE team was the answer to our hospital’s and our patients’ problems.

The M&M, horrific as it was, served as a brief, albeit small, tide of momentum in our favor. As physicians, we pride ourselves on our objectivity and data-driven decision making, yet in this situation, logic and statistics had been met with significant resistance. Ultimately, though, we are all still human, and the story of a young man needlessly losing his life spoke to the humanity in each one of us. After the conference, an impromptu session was called involving the hospital’s most senior cardiac surgeon, 2 cardiologists, an ID specialist, and us. We presented our data and our plan for an endocarditis team. The same questions were raised, but this time, a new obstacle arose. Would anyone be on this team without being compensated for their efforts? If we were discussing compensation, where was the funding coming from? And thus, yet another hurdle was placed in our path. We began to lose faith that we could ever change the process for these patients, who were still dying. As our shoulders drooped, the surgeon spoke, “Don’t worry about the money, you just start doing it. You just do it, you do a good job, the hospital will take notice, and you can figure out the funding later.” That was all we needed to hear.

After mass emailing the divisions of cardiology, neurology, and ID, we pulled together 2 cardiologists, 1 neurologist, and 3 ID specialists to go with our surgeon. Like that, the team was born. All the stumbling blocks—an unwillingness to admit there was a problem without data, a natural tendency to dismiss poor outcomes, apprehension about committing to a cause without financial compensation—had been overcome. What became very clear at our first meeting was that everyone there saw the same problem and cared deeply about our patients.

As we write this today, 1 year after our endocarditis team’s first meeting, our in-hospital mortality has fallen to 7.1%. Reflecting on how we reached this point, we have come to the following realizations about change in modern health care. First, sometimes it takes fresh faces to solve old problems. Our hospital’s model of care had been stagnant for years, but people had become so accustomed to its inefficiencies that they were indifferent to change until residents looked at the problem differently. Second, data are important, and they open doors, but they only go so far. Speak to people’s humanity because it is the constant driver of why we all enter medicine. Third, identify a common goal for all stakeholders and create solutions around it. Fourth, have the courage to act without a guarantee of success. Finally, and most crucially, ground your mission in your purpose so that you can stand resilient against obstacles and setbacks. The hope that things could change for the better became the foundation of that very change.


The authors would like to thank all the members of the University of Michigan Multidisciplinary Endocarditis Team, particularly George Michael Deeb, MD, for their support in this endeavor. S. El-Dalati would like to acknowledge Elizabeth O’Donnell, PhD, who reviewed earlier drafts of this essay.


1. Bor DH, Woolhandler S, Nardin R, Brusch J, Himmelstein DU. Infective endocarditis in the U.S., 1998–2009: A nationwide study. PLoS ONE. 2013;8:e60033.
2. Botelho-Nevers E, Thuny F, Casalta JP, et al. Dramatic reduction in infective endocarditis-related mortality with a management-based approach. Arch Intern Med. 2009;169:1290–1298.
3. Carrasco-Chinchilla F, Sánchez-Espín G, Ruiz-Morales J, et al. Influence of a multidisciplinary alert strategy on mortality due to left-sided infective endocarditis. Rev Esp Cardiol (Engl Ed). 2014;67:380–386.
4. Chirillo F, Scotton P, Rocco F, Rigoli R, Polesel E, Olivari Z. Management of patients with infective endocarditis by a multidisciplinary team approach: An operative protocol. J Cardiovasc Med (Hagerstown). 2013;14:659–668.
5. Habib G, Lancellotti P, Antunes MJ, et al.; ESC Scientific Document Group. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015;36:3075–3128.
6. Baddour LM, Wilson WR, Bayer AS, et al.; American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council. Infective endocarditis in adults: Diagnosis, antimicrobial therapy, and management of complications: A scientific statement for healthcare professionals from the American Heart Association. Circulation. 2015;132:1435–1486.
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