January 6, 2023

Member Profile: Michael 'Mike' Brigoli, MD

Works at: University of Washington Palliative Medicine

How long in practice: Since July 2022

Specialty: Hospice and palliative medicine fellow

Why WSMA: The WSMA represents the opportunity to have a voice. Before becoming a physician, I was an Army medic and a firefighter and paramedic. As a first responder, I saw heartbreaking situations due to lack of access to care and lack of resources. The WSMA enables me to advocate for policies that make a difference for the most vulnerable members of our community.

Proud moment in medicine: I come from humble beginnings, having spent part of my childhood homeless and in foster care. I am the oldest of 11 children in a blended family. I went to 12 different public schools from kindergarten to high school. I am from Hawaii, where indigenous Hawaiians make up 24% of the population, but only 4% of the physician workforce. As a native Hawaiian, I didn't think I could be successful with higher education. That is why getting into medical school at the age of 40 was an important milestone for me and my family. To do so, I left a career as a firefighter and paramedic. I didn't even have an undergraduate degree. Heading back to school meant the pressure of being a single-income family fell on my wife. I felt like matriculating meant her sacrifice was paying off and, even though it would take a while, there was light at the end of the tunnel.

Top concerns in medicine: According to a pre-pandemic study from the Association of American Medical Colleges, we are facing a severe shortage of physicians across the country, as much as 124,000 by 2034. I worry that the pandemic has worsened those numbers exponentially. While medical school enrollment is up, our GME positions have been limited by federal budget legislation. It is time for a change.

I am intimately familiar with the consequences of a physician shortage. My home in Hawaii had a physician deficit of 30% compared to what was needed to care for the community. As a result, the local emergency departments became much busier and so did our EMS agencies. When I picked up patients by ambulance, I would ask who their primary care physician was. They would give me the name of an emergency department physician. I would clarify by asking who wrote their prescriptions for their chronic conditions. Their answer did not change.

The conditions that I saw then are getting worse. The most vulnerable in our communities will suffer the worst as a result.

What inspires me in medicine: While we have made tremendous strides in our ability to provide medical interventions in the lives of our patients, I am inspired by the little things that the physicians around me do to make the lives of their patients better: The call to family at the end of the day to update them regarding a patient's condition; holding a patient's hand during a difficult conversation; taking extra time to ensure that all the patient's questions are answered and explained in a way that they understand. These acts of kindness are often done despite the pressure of having to see a full panel of patients, attend scheduled faculty meetings, and participate in teaching sessions for learners.

Challenges to our profession: I am concerned that we have a public confidence issue. We have gone from a respect for the education and training that are required to practice medicine to a "I've done my own research" culture. I think there has been an erosion of trust for physicians and that will continue to be a challenge in the care of our patients.

Why I wanted to become a physician: While working as a firefighter and paramedic, my district was so busy that in a 24-hour shift I would often be on the road for more than 14 hours. One day while taking a basic life support call, another 911 call came in for chest pain from my uncle's address. Since I was already on a call, the ambulance from the next town was dispatched, an additional 15-minute response time. My uncle had a myocardial infarction that day and did not survive.

Because of our community's physician shortage, our emergency department was busier, and emergency medical services were inundated with patients who felt that ambulance transport might expedite their care in the ED. It was not a good situation.

I often would visit high school health career pathway classes to discuss how I became a paramedic. While there, I would ask how many of them wanted to become physicians; knowing the need was severe. There were times that, in a class of 60 high school students who self-identified as wanting to pursue a health career, none would raise their hands.

I began to feel guilty about asking teenagers to make a sacrifice that I had not made. I also felt challenged by not being able to help them achieve the goal of becoming a physician. That's when I realized that I had a passion to pursue medicine myself. That my passion was greater than the fear of leaving the fire department or the fear of not being smart enough to accomplish my goal. I didn't know any physicians who were former foster children and knew very little who were Native Hawaiian. What I did know, however, was the consequence of a physician shortage and that I wanted to be a part of the solution for my community.

Why my specialty: My life experience with childhood homelessness, foster care, service in the Army, and time as a firefighter and paramedic allows me to understand how patients with serious life-limiting illnesses may feel they don't have many options for care. I love being able to explore who they are. Sometimes this leads to a revelation for patients about goals for their life. Based on these conversations, some patients opt not to limit the scope of their care and continue with aggressive care for the hope of a longer life. Others may opt to pursue comfort and time at home with their family, even if it means a shorter life. In either situation, the decision is made based on the values and life experience of the patient.

I also spent two decades taking patients to the hospital, seeing the ravages of acute injury, and exacerbations of chronic illnesses. I love the opportunity to give patients the option and opportunity to avoid ED visits and hospital admissions.

We are a specialty of "wonder." I wonder if there is more we can do to manage a patient's symptoms. I wonder what is most important for the patient and their family in light of their illness. I wonder what they are hoping for; what they are worried or concerned about. I sit in wonder of the amazing life stories that I get to hear about in the process of exploring the patient's narrative.

If I weren't a doctor, I'd be: A firefighter and paramedic. It was amazing to be on the front lines for any major incident in a community. You meet people where they live and help them with what may be the worst day of their life. It was incredible to go from a motor vehicle accident directly to an out-of-hospital baby delivery.

Top three leadership lessons:

1. Get to know your team. There are so many opportunities for miscommunication that can cause friction between team members. Learning about who they are helps us to see their perspectives.
2. Surround yourself with people who are good at what they do, then let them do it.
3. Start by sharing the objective or mission and see what ideas the team has on how to accomplish it. This can be the best way to find solutions that we haven't thought about before.

Best advice I ever got: The best advice I ever got was to find an activity that refreshed me and do that as often as life would allow. Something that I could do for hours on end with more energy than when I started. For me this was coaching my sons' club soccer team. This allowed me to spend time with my family and serve my community. We did travel tournaments and combined that with educational experiences. My oldest son eventually ended up attending a college that we toured while at an out-of-state tournament.

Following this advice made interviews for residency, fellowship, and physician jobs so much easier, as well. It was simple to answer the "tell me about yourself" question. I knew what gave me energy and could talk about my family and community at length. It gave me a chance to show what I could do when motivated by something I was passionate about.

The biggest benefit was that I knew what activities filled me and could schedule that activity when times get tough. My sons are older now and no longer play club soccer. I know that time with them and my wife fills me, though, and we make time to get together and do activities as much as we can.

Spare time: My wife and I love to drive around the state and visit new locations. It's all about the food and scenery of the Pacific Northwest. We will sometimes pull up the reviews of restaurants, bakeries, or coffee shops for a town and plan a trip for the day. It's a great way to explore our new home.

Hobbies: I love running and biking. I have done 10 marathons, three half-marathons, and a half Ironman triathlon. I have learned a lot about the ability to persevere toward a goal during my training and in races. No two races are the same and each offers its own challenges.

Three goals for the year ahead:

1. Find a post-fellowship job in palliative medicine.
2. Spend as much of my free time as possible showing my appreciation to my family for the sacrifices they have made for this journey we are on.
3. Schedule and complete another half-marathon.

Something most people might not know about me: I attended and graduated from medical school with the son of a high school classmate. I am literally old enough to be the parent of my medical school classmates. It was during our orientation that I recognized my classmate's last name. We began talking and eventually I found out that his father graduated from the same high school I did.

Pet peeves: Palliative medicine is not a destination. We are a specialty involved in the care of any patient with a serious life-limiting illness. I have often heard, "I don't think the patient is ready to be palliative." If they have a complex symptom management issue, could benefit from a goals-of-care discussion to align the multiple care teams with their goal, or have limited options for their care, we are here to help. For example, I wouldn't say "I don't think the patient is ready to be nephrology or cardiology."

Recommended reading: "When Breath Becomes Air," by Paul Kalanithi. I have read and go back to passages in this book frequently because it helps me to remember the vulnerability we have in life as physicians and providers. Paul does an amazing job sharing his story.

This article was featured in the January/February 2023 issue of WSMA Reports, WSMA's print magazine.