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Calling shots on life and death
Our interview with Dr. med. Silke Merz of the Robert-Bosch-Hospital in Stuttgart was special in many respects.
We met on a rainy day in her favorite bookstore, went on to stroll through the rain with our black umbrellas, visiting a little indoor market and ending at a small café where we recorded a wonderful talk about her work at the hospital, medical innovation and decisions about life and death.
ILI.DIGITAL: Thank you very much for the invitation to Stuttgart. We started our rainy afternoon walk at a bookstore, which is always the first place that I go to in every city. What is your relation to books?
Silke Merz: I really enjoy reading and for me it is a very relaxing activity. I can really zone out when I read and I can really loose myself in books. I was always into reading, as a teenager and as a child. Many readers have times, in which they read less, but for me books are also an addition to and a distraction from my daily life. Reading gives me much more than watching TV and I only rarely watch TV. I always say that watching TV devastates my brain, as there are too many pictures at once. There is too much input and when reading a book, you can dose the input yourself. I particularly enjoy to think myself into characters and into the storyline.
You spoke about distraction from everyday life, what is your profession?
I work at the Robert Bosch Hospital, which is a foundation hospital of the Robert Bosch GmbH. The special feature of our hospital is that it is not a community hospital and this obviously has an impact on funding. I have worked in the department for general internal medicine for more than ten years now and I have also been a senior physician there for several years. As a senior physician, I have pretty regular working days, but this was completely the opposite for me when I was an assistant physician with many different shifts and duties. Nowadays, I have the luxury of starting to work at 8:00 am. This is a huge luxury for me, because I do not like to get up in the morning and this is still the case after so many years.
What does a typical day of yours look like?
My working days are very different from each other. I have outpatient days for patients who are non-stationary. One classical example for this is Monday morning, when patients come to the hospital for post-operative care after having received a new kidney from family, friends or other organ donors. I am also responsible for a station with assistant physicians and patients, who are too sick for ambulatory treatment. I also have medical round days and in addition to that, I have my own outpatient departments, which brings me great joy. That means, despite the fact that I am hospital doctor, I have my own patients. I am their licensed nephrologist and I treat them with peritoneal dialysis, which is a relatively unknown treatment.
What does peritoneal dialysis involve?
Dialysis is blood purification. The classical dialysis process involves taking blood, purifying it with a machine and then channeling it back into the body with the shunt. Patients can also do a peritoneal dialysis, in which the peritoneum is the dialyzer. For this type of dialysis, a tube is permanently implanted in the abdominal of the patient. The patients have to administer dialysis fluid via this tube four times a day. The fluid has to stay in the body for a duration of four to five hours and then it has to be removed again. The blood is purified in this time frame and the patients can perform this procedure on their own and at home. However, the patients still need a caretaker and I can look after them, as I have a permit for outpatient treatment. I take care of 20 outpatients, a negligible number compared to a family doctor, but I also support them with consultation hours.
What is the current situation with technological and medical innovations in your medical domain? How long does it take to implement innovative solutions?
It strongly depends on the type of innovations. We quickly test and implement medical innovations. This is the nice thing about our hospital, namely that we have the capabilities of a university clinic. New things are, practically speaking, already implemented because nothing that has not been in our experimental stage can be executed at a later stage.
My field of expertise is probably not the most innovative at the moment. This is particularly the case for fields such as oncology, which is concerned with tumor and cancer medicine. There are a lot of things happening in oncology, which is the result of the extensive research in this area. Nephrology is not as exciting as oncology, in terms of current developments and innovations. However, when new insights, medicines or procedures are revealed at congresses, then we are one of the first hospitals that implement something new.
So is it a big advantage to work at the Robert Bosch Hospital, in particular when it comes to access to technological innovations?
Definitely for the technical implementation and there are many cooperations with Bosch healthcare. For instance, colleagues from our department are often exempted from duty for such cooperations. One classic example that you might know from a previous stay in hospital or from series is that every doctor walks around with patient records. At the Robert Bosch hospital we have iPads and all other areas are also completely digitalized. When we make medical rounds, then we have an iPad with us. I personally do not have any physical patient records anymore, as all my patient data is completely digital.
“We quickly test and implement medical innovations.”
How do you implement or make use of technological innovations yourself? Are there specific time slots in your day that are used for the implementation or use of new digital solutions?
No, we have to do this as a sideline.
So there is always something new and then you have to make sure yourself that you are constantly up to date.
Obviously, when there is a new medical device, then there are of course trainings available. But at the end of the day, there are a lot of things happening and you are obligated to get involved with them. When the iPads were introduced, nobody asked me for my opinion. Suddenly, the iPads were there and then this was the end of pen and paper.
The daily life of a regular person does not really come into contact with hospitals. The only two exceptions are when the person visits significant others in the hospital or when the person is in the hospital. The things that people know about hospitals are often spread by TV series that still have very high ratings. Do you know why people are that interested in what goes on in hospitals?
I think that people are generally interested in the proceedings that take place in hospital and there is also a fascination that drives this interest. People want to get an insight, in order to have a slight idea of what goes on inside the life of doctors and other people inside the hospitals. I have stated before our interview that I have a lack of imagination for many jobs. Everybody knows a little bit about the profession of a doctor from visits of his or her family doctor. I think that people are particularly interested in everything that is related to emergency rooms. I really have to say that this area in hospitals is quite accurately displayed in the tv series and also researched in a very profound manner. But in tv shows the doctors deliver a baby and then they go on to perform a heart surgery. In reality things do not work like this.
Are many things portrayed incorrectly in these shows?
Yes, and that is what makes me really angry at times. It is not true, that all doctors can do everything. In reality every doctor is very specialized in one field. I am an internist and I cannot perform surgeries. During my medical degree, I attended three surgeries. Only the surgeon can operate on someone and the surgeon is only specialized in heart or stomach or head. In the TV shows every doctor can perform surgeries and also for every organ. The tv show doctors deliver a baby and then they go on to perform a heart surgery. In reality things do not work like this. This specialization is getting more and more extreme, as medicine continues to evolve. Even when you are relatively specialized like me, then it is still very difficult to oversee everything.
Does this mean that continuous innovation leads to more specialization?
Yes, absolutely. This is particularly the case for hematology and everything that has even the slightest connection with blood cancer. There are many developments in this field and we have a large department for this area at the Robert Bosch Hospital. Indeed, we are required to always develop further. In theory I could say that this drug is only administered by the oncologists, so I have nothing to do with it. However, when there are side-effects and the people get kidney problems, then you immediately have something to do with it. Your phone will ring constantly and colleagues will ask you to have a look at a patient who was given certain drug on the previous day. They say that the kidney parameters have risen and that there must be some kind of connection with the drug. In a hospital you cannot just care about your own field and this is a good thing. It is also the reason why I want to be in a hospital.
People are generally interested in the proceedings that take place in hospital
Silke Merz
Are there similar developments in the smaller medical practices which do not have as much staff or as many resources as hospitals?
I firmly believe that innovation falls by the wayside, because the doctors are often on their own. I think that medical practices with only one doctor are on the way out, but they still exist today. The people in the medical practices are confronted with so much paperwork and administrative tasks that they are probably happy to just get by. I think that you do not have time to be open to new things in the medical practices.
This immediacy is also the reason for our interest in conducting an interview with you. We have intensive contact with decision makers from the economy, several industries and the production sector. Usually, those people have to deal with very long decision making channels. Is it correct that such conditions are unimaginable in a hospital?
Absolutely. I believe that on the one hand you have the innovation and on the other you have the administration. I also have to do administrative tasks and this is where things can take a little bit longer. However, administration is not our number one priority and when you try to decide which drug will be accepted by the pharmaceutical commission, then this can be a long process. When it comes to patient care, then time is scarce and decisions have to made in the here and now. Sometimes, you only have time to speak to your colleagues and maybe to ask for some brief advice. This is something that makes my job very exhausting, but at the same time it also brings me joy. You have to make decisions quickly and decide whether you want to do something or not and if you do something, then how far do you want to go? Usually, such decisions are very hard to make.
Do you get used to the momentousness of these decisions?
Yes, maybe you get used to it too much. I don’t know, but it is just an inevitable process and you get used to it over time. This morning I had such an experience, when I was on medical round with our head physician. We entered a room and an assistant physician and a very young colleague, who just had her second day at the hospital, were already present. The patient was in a bad condition since his arrival in the hospital. The man had blood poisoning, several germs in his blood and also numerous strokes, but we did not know much about him as a person. The patient was found by fire fighters, who had to break in his door to get access to his apartment. A neighbor had previously called them, because the man was missing for a few days. Therefore, we were unable to speak with the patient and we did not know how he wanted to proceed in the event of a further deterioration of his condition. There were also no relatives to talk to. When we entered his room this morning, we immediately knew that we would have to either start with resuscitation procedures or let him pass away.
Such decisions are unimaginable for people in the business world…
Yes, I was glad that my boss was with me this morning. When you have to make such decisions, you just stand there and you have to decide within minutes about further actions. You think about if this is the alleged will of the patient. In a strange way, you also feel a little bit like playing god when making such decisions, because we decided to not do anything. I have actually noticed on various occasions that I find it hard to make such decisions, but I can back them. When we left the room, I realized that the young colleague, who just had her second day, was completely traumatized by this event. I knew that I would have to talk with her about this experience the next morning. You just notice that such decisions have become a normality after so many years. Had I not told you the story in this interview, then I would probably not even think about it anymore.
“I realized that the young colleague, who just had her second day, was completely traumatized by this event.”
When you have to make quick decisions, then mistakes will inevitably happen. How you deal with bad decisions?
Naturally, when you make a lot of decisions, then you will also make some bad ones. You make a decision at a moment in time on the basis of certain facts, but you never have all the information. Obviously, in hindsight you sometimes think: maybe I should have done this. However, you cannot always make the right decision. I think that it would be dishonest to say something different. Nevertheless, I firmly believe that it is crucial to make decisions and that you harm the patient when you do not make one. When a patient is brought to the emergency department and you do not know the cause for his condition, then you have to do something in an emergency. When you look at the computer tomography, the cardiac catheter results and laboratory findings one hour later, then it is easy to say: the patient had a lung embolism, why did you first do a heart catheter? But you only know these things after quite some time and not when the patient arrives in the emergency department. Firstly, you have to briefly check the available data and then you have to ponder what the likely or unlikely cause for the condition of the patient is. Here, extensive professional experience as a doctor will help you in making a decision. Most of the time, you only know afterwards whether your decision was correct or incorrect.
You have previously stated that the story with the patient would be something that you would have forgotten, if you hadn’t told me about it just now.
I think that you have to try to forget such experiences, because otherwise you would not be able to do this job for a long a time. But, there are also moments that are very difficult to tick off mentally. The previous story was about a patient, who was 90 years old and in a very bad medical condition. In such situations, you sometimes think that life is also allowed to come to an end eventually. I know that this might sound stupid to some people. Yet, you have to get over such situations, because otherwise you will not be able to come to work the next day and make decisions. If everybody, who has to come to terms with a hard decision, does not come to work the next day, then patients will not receive any treatment anymore and this does not serve anybody. However, there are frequently calamities for young people.
What influence does your profession have on your private life?
What you often take into your private life is that you have to make many and quick decisions throughout your working day. This leads to the fact that you almost become too lazy to make decisions in your private life. Often, I do not want to decide whether I want to eat Italian or Asian food for dinner. Such decisions feel too mundane and insignificant to me. I also notice that I do not have a lot of patience for people, who take long to make decisions.
“In a strange way, you also feel a little bit like playing god when making such decisions.”
How is the feedback of the patients and have there been any changes over the years? Do they value and appreciate your help?
My youngest patient who needs dialysis is 28 years old. She suffered from kidney failure during the delivery of her child. Out of my 20 outpatients, 10 are under 40 years of age and they give me a lot of appreciation for my work. The reason for this lies in the different communication that I have with my younger patients. You speak on eye level with older patients and you try to explain to them that they have to take responsibility for themselves. I tell them that I am confident in their ability to independently perform the treatment at home, but I also tell them that I have to count on them. I think that they appreciate the things that I make possible for them. One of my dialysis patients wants to go the Southside Festival and I can imagine that most people would say that she should stay at home. My perspective is a different one and I told her that I would find a solution for her matter of concern and that she would be able to attend the Southside Festival. Subsequently, I was on the phone for several hours during multiple evenings with a pharmaceutical company that produces the dialysis fluid bags. I tried to convince them that they should deliver the bags to some campsite at festival because I thought to myself that she should definitely go there. When you put that much effort into the requests of your patients, then they really appreciate it and thank you for that. Surprisingly, this is mainly the case for my younger patients because they notice that somebody comes through for them.
When was the first time that you realized that you have passion for helping and saving people? Was there any point in time during your adolescence or how did this come about?
I think the interest for helping and saving people was always there. I come from an entrepreneurial background and we do not really have anything do with medicine. However, my mother claims that I always enjoyed going to the children’s doctor. I think that I can confirm that and it was always fascinating for me, but I do not know how this came about. I believe that I noticed a passion for medicine in senior grade and it was clear to me that I wanted to do something with people and my hands. I could never sit at an office desk for an entire day. I used to have an office desk day for my patient records on Wednesday morning. Such days are horrible for me and I could name you a thousands things from the top of my head that I would rather like to do.
What are the current problems or challenges for hospitals?
The staff shortage is one of the biggest difficulties that we have at the moment and this also in the broadest sense connected to the economic situation in Germany. The caregivers are not paid sufficiently. A young nurse cannot live off her pay, especially not in a city like Stuttgart, where one room apartment costs at least 500€ per month. She will have to do shift work and she will not be able to live in the inner circle of the city. Therefore, she will need a car to drive to every shift, but she will not be able to afford a car from her salary. I think that we recognize that the people are not paid enough. We have skilled worker shortage and hopefully this will have severe consequences, so that there will be a change of thinking in society. We are an industrial nation and we can live well in Germany, but when I look at what we spend money on and what we do not have money for, then this is a sad situation in my opinion.
In every interview, I ask my interviewee about political changes in their professional field that would help them in making their job easier for them.
There are many things. Caregivers need to be paid much better, so that we have more skilled workers that can live off their salary. We don’t have too few caregivers, but we do not have enough people who permanently stay in the job. The apprenticeship classes are fully occupied, but you cannot do this job until retirement because the salary is too low. I firmly believe that there needs to be a change of thinking in society and people need to be made aware of this issue. I also find it troubling that there is such a wide discrepancy between stationary and outpatient. Obviously, in the outpatient sector the medical practices are businesses that have costs. They have to pay rent, assistants and sometimes they even have to pay the doctor, so they have to think much more economical than me with a fixed salary. Hence, this results in an imbalance and I would find it good to act on this point. I think that people have to understand that healthcare costs money. In my opinion, it is ludicrous that a manager still gets an enormous financial compensation after being fired for doing a mistake and caregivers, on the other hand, cannot live off what they are paid, which is definitely the case in nursing. Doctors do not have this problem, because we have a pay agreement for public service. The wage of a doctor will not make you rich, but you can live from it.
As chance would have it, I was on Facebook yesterday and I do not understand why, but for some reason there was a survey in my timeline. This poll was about the proportion of women in medical professions.
Yes, this is an exciting topic.
How can there still be a difference in the proportion of women and men?
I think the fact that more women than men are going to university should be judged as something positive and it is good that we have achieved something in this area. The women do not work as a doctor, because the profession is not compatible with having a family. We have lost between two and three women in our department at the hospital in the past few years. Normally, you could not allow that such highly qualified personnel leaves. The women were really good doctors, who had between one and two children. However, it was impossible for them to be there for their children, when they had to work shift and also on weekends. You also never know, when your work day will end. Such women go into the medical practices or into other professions and this is the delta of opportunities that we have here.
This is the problem that we have and also the reason for the shortage of doctors in Germany. I do not think that increasing the number of university places is the solution. Here, we have to help balance out this delta, so that people go into a job after having finished their training. There are only few women, who make it into the executive positions. The registrar already takes six years and a specialization adds another two or three years. It took me eight years to become a nephrologist and for this you also need work experience. We loose many women during this time period, because many women do not return after parental leave. Therefore, there are also not that many women, who are eligible for an executive position.
What are the reasons for this?
I do not want to claim that the world is bad and that women cannot get into a senior physician position. But rather, most women are already gone, when they reach the professional level for an executive position. This is the problem and here we have to do a lot to make family and profession more compatible. I do not know how to solve this problem, but I also ask myself why us doctors have to come up with a solution. I remember that there were always changes in the roster throughout my career from a small assistant physician to assistant physician and then to specialist. For instance, I was not allowed to work for 24 hours anymore at some point. We always had to develop a solution, when something needed to be changed or implemented. I am not an employment law expert, but still we sat down and we proposed some ideas to the administration.
When I think back, then I ask myself why we had to do this. The administration should get somebody, who has some expertise in this field. Now, all the women and me brainstorm for ideas. We had a lot of time to think about something for our department. Our idea was that we would practically speaking be two 50% workforces. That means, we would be a kind of tandem bicycle with a Wednesday to Wednesday work week. This approach would enable us to always cover the weekends. However, many people say that this solution would not work for them. Now, they would be at home for a whole week, but then they would require ten hour child care a day for the subsequent week. Yet, this is the only approach that works for our department. Here, we need a creative mind from a consulting firm or from some other place that can look at our processes and says: you should do it this way. I do not have the time to think about alternatives, while working as a nephrologist. I also do not have the technical know-how for better approaches. I firmly believe that this is the problem that causes the loss of many good female doctors.
