Post-ICU Recovery Clinics in the COVID-19 Era: Women Leaders in Medicine, Ep. 6

This podcast series aims to highlight the women leaders in medicine across the United States. Moderator Jaspal Singh, MD, MHA, MHS, interviews prominent women making waves in their field and breaking the glass ceiling. Listen in to gain insight on the leadership lessons learned.

Episode 6: Moderator Jaspal Singh, MD, MHA, MHS, interviews Carla Sevin, MD, and Rita Bakhru, MD, MS, about building a post-ICU recovery clinic from the ground up, and the challenges and triumphs of working in an ICU-recovery clinic during the COVID-19 pandemic. 

Additional Resources:

• The ICU Recovery Clinic at Vanderbilt. Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center. Accessed April 22, 2021. https://www.icudelirium.org/the-icu-recovery-center-at-vanderbilt
• Bakhru RN, Davidson JF, Bookstaver RE, et al. Implementation of an ICU recovery clinic at a tertiary care academic center. Crit Care Explor. 2019;1(8):e0034. https://doi.org/10.1097/cce.0000000000000034 
• Sevin CM, Bloom SL, Jackson JC, Wang L, Ely EW, Stollings JL. Comprehensive care of ICU survivors: development and implementation of an ICU recovery center. J Crit Care. 2018;46:141-148. https://doi.org/10.1016/j.jcrc.2018.02.011 
• Haines KJ, McPeake J, Hibbert E, et al. Enablers and barriers to implementing ICU follow-up clinics and peer support groups following critical illness: the thrive collaboratives. Crit Care Med. 2019;47(9):1194-1200. https://doi.org/10.1097/ccm.0000000000003818 
• McPeake J, Boehm LM, Hibbert E, et al. Key components of ICU recovery programs: what did patients report provided benefit? Crit Care Explor. 2020;2(4):e0088. https://doi.org/10.1097/cce.0000000000000088 
• Bloom SL, Stollings JL, Kirkpatrick O, et al. Randomized clinical trial of an ICU recovery pilot program for survivors of critical illness. Crit Care Med. 2019;47(10):1337-1345. https://doi.org/10.1097/ccm.0000000000003909 
• Cuthbertson BH, Rattray J, Campbell MK, et al; PRaCTICaL Study Group. The PRaCTICal study of nurse led, intensive care follow-up programmes for improving long term outcomes from practical illness: a pragmatic randomised controlled trial. BMJ. Published online October 16, 2009. https://doi.org/10.1136/bmj.b3723 
• Snell KP, Beiter CL, Hall EL, et al. A novel approach to ICU survivor care: a population health quality improvement project. Crit Care Med. 2020;48(12):e1164-e1170. https://doi.org/10.1097/ccm.0000000000004579

Carla Sevin, MD, is the director of the ICU Recovery Center at Vanderbilt, medical director of the Pulmonary Patient Care Center at Vanderbilt, and associate professor of medicine at Vanderbilt University Medical School in Nashville, Tennessee.

Rita Bakhru, MD, MS, is an assistant professor of pulmonary, critical care, allergy, and immunologic diseases and ICU Recovery Clinic director at Wake Forest Baptist Health in Winston-Salem, North Carolina. 

Jaspal Singh, MD, MHA, MHS, is medical director of pulmonary oncology and critical care education, as well as a professor of medicine, at Atrium Health in Charlotte, North Carolina.

TRANSCRIPT:

Facilitator: Hello, everyone and welcome to "Women Leaders in Medicine," a special podcast series led by our Section Editor on Pulmonary and Critical Care Medicine, Dr. Jaspal Singh. The views of the speakers are their own and do not reflect the views of their respective institutions.

[music]

Dr Jaspal Singh: Welcome everybody, I'm Jaspal Singh from Consultant360, work at Atrium Health at Canada's Medical Center in Charlotte North Carolina. With me today our two esteemed colleagues are Dr. Carla Sevin from Vanderbilt University and Dr. Rita Bakhru from Wake Forest School of Medicine. Welcome ladies, thank you for joining me.

Dr Rita Bakhru: Thank you for having us.

Dr Jaspal: Today's topic is really interesting and a very important topic to, I think, a lot of the country. It's one thing to have critical illness, it's another thing to survive it. Your work, both of you, your seminal work in the Post‑ICU recovery clinic work has gained a lot of attention. Carla, want to introduce yourself first, and tell us what you do and how you got into this work?

Dr Carla Sevin: Sure. I'm a pulmonary critical care physician at Vanderbilt University. I've been here for many years. I started out doing my internal medicine residency at Vanderbilt, and I stayed here for fellowship.

Toward the end of my fellowship, I was finagling for a faculty position, and I had somewhat abandoned my mouse research, so I was looking for a clinician educator physician. I had some ideas about what I wanted to do and where I could fill a need in the faculty and in our division.

Around the same time, we also were starting to learn a lot about the long‑term impairments after critical illness. A lot, in part, from the work that was coming out of Vanderbilt and from some of my colleagues and mentors. One of those mentors was Art Wheeler, who was the director of our ICU at the time and a mentor to me.

He had encouraged me to go into critical care to begin with, and around, it must have been my third year of fellowship, his mother‑in‑law was critically ill. She was admitted to our hospital and to our service, a service that I was on.

Although we knew intellectually from some of the research that was coming out that people were not necessarily doing well after critical illness, that was some abstract data for many of us who were not directly involved in that research.

When Art took his mother‑in‑law home with his wife, Lisa, who was also medical and despite having all the knowledge and all the resources at their disposal to take care of somebody who was recovering from critical illness, they really struggled, and she struggled and he asked himself and me, if we can't do this, how are our patients doing and what our patients doing because we were often not seeing them after the ICU.

That was really the genesis for us starting the clinic, we saw that there was a need, and we weren't sure exactly what patients needed, but we felt that they needed something. Art was a great mentor, and that he always encouraged me to be more bold than I was naturally and to just start stuff and see what happens. That was the genesis of our post‑ICU clinic.

Dr Jaspal Singh: It's a wonderful story. So no mouse recovery clinic, we have a human recovery clinic. Perfect.

That's a great story. Rita, what's your story?

Dr Rita Bakhru: Thanks for having me. My interest in recovery after critical illness stems from interest that I had during my residency and fellowship and some of the seminal work by Margaret Herridge, looking at long term outcomes after a ARDS. Then some of the initial early mobility studies.

I've been really interested in physical function recovery after critical illness, both based on interventions in the ICU, and then translating from that, what do we see long term in patients. When I came to Wake Forest, our group here came interested in starting a post‑ICU clinic. And that was back in 2014.

We've been iterating on our post‑ICU clinic ever since. It's been an interesting journey.

Dr Jaspal Singh: Post‑ICU clinic or ICU recovery clinic. I'm just picturing that. I have a different image of what that looks like. I imagine if you looked around the country and looked at these clinics, you've only seen one, you probably all look a little bit different. Tell me a little bit about what is the basis of a post‑ICU recovery clinic start with you, Carla, what does that look like?

Dr Carla Sevin: Sure. Like I said, we didn't know what we were doing when we started this clinic. We knew what we were doing in the ICU, and we felt very grateful to have a multidisciplinary team in the ICU. I was leaning very heavily on my nurses and pharmacists and respiratory therapists and physical therapists.

We had some vague idea that we needed this team approach to these really complex problems. We basically just asked those people to come downstairs with us. We didn't have an ICU psychologist at the time, although many ICUs do have that.

We had Jim Jackson, who is a wonderful psychologist who specializes in the research realm in the post‑ICU and post critical illness, cognitive impairments, PTSD, anxiety and depression.

He was really interested in this and we became partners. We had not worked together before that and now we've worked together very closely for 10 years, which has been a fantastic partnership in addition to my career for sure.

Like Rita said, there have been many iterations, we've had the clinic open for 10 years, and we've constantly been changing it based on feedback from patients. When we first started, we did a simple little...I googled how to do a marketing survey and made a marketing survey [laughs] and gave it to patients.

I was like, what parts of this do you like? What parts do you think were useful? It was a long visit, we wanted to make sure we were providing something of value, and patients gave us their feedback.

Sometimes the feedback hurt, they were like, the name is dumb. We don't like it. It was originally called the ICU survivor clinic, which they said, was too reminiscent of cancer survivorship programs, which, of course, we were also modeling ourselves a little bit after.

They were very focused on getting back to their baseline and recovering fully and having a full life. That was the impetus for our name change. We also initially had a palliative care arm in our initial model, which I thought and I still think is important. It just so happened that the patients who came to clinic did not want to engage in palliative care at that time.

This was a decade ago. Things may be different now, and I'm grateful to some other colleagues, for example, at UPMC, where they have a heavily palliative care integrated program. We have a lot to learn there, but we were just constantly trying to serve, but also asking for service from our patients and their families. Tell us what you need and we will try to make that happen.

Dr Jaspal Singh: I'm going to hear you saying is you really had no framework, you had some cancer survivorship clinic is a framework and a frame of reference for where to start with, but just rolled up your sleeves, get out your comfort zone, just start doing it and then just ask and see how it's working.

Dr Carla Sevin: I shouldn't say there was no framework because our colleagues in the UK were doing this decades before we were. We looked at some of those early studies, for example, the practical study, there were some interesting studies out of Scandinavia, but we had a hard time with a couple issues.

One is we have a bad in my opinion, fragmented for‑profit healthcare system, which made it difficult for people to get the care that they needed. A lot of those programs were looking at three months down the line. We were seeing that our patients were ending up back in the ER seven days down the line or two weeks.

We felt like we needed to do something at a sooner time point. We also had a lot of lofty ideas about what was needed, like cognitive therapy, but when we started seeing patients, we found out that there was a lot of low hanging fruit unfortunately, things that we thought were happening that were just slipping through the cracks.

Patients weren't getting home medical services or physical therapy or their oxygen or their meds, they didn't have primary care physician. There was a lot of nitty gritty impacts that we could make on just provision of basic medical care not to say that we don't also need cognitive rehab and long term outcome follow up.

Dr Jaspal Singh: That's a great segue. Rita, what's during your experience about the last nine years?

Dr Rita Bakhru: Yeah, like I said, we started in 2014. A couple years after Carla had been up and going and I had the benefit of my colleague Clark Files, and I started the clinic together. He said, there's someone at Vanderbilt named Carla Sevin who had started this clinic a couple years ago, let's get her on the phone and chat with her and see her experience.

Sure enough, we got her on the phone and talked to her. That was part of our framework for how we were going to structure our clinic. We had the same learning as Carla did that folks did not want to be called survivors, because ours was called our survivor clinic first as well. From there, we too have changed over the years.

We have a, differently than Vanderbilt, we have a screening model where our pharmacists screen patients in the ICU to see who's eligible to come to our clinic. We do have a multidisciplinary clinic with our pharmacists as well and agree the timing of these appointments is just so difficult to get perfect.

We initially were trying to see patients, one to two weeks after discharge and from our rough marketing surveys as well learned that patients just didn't want to come in that soon after they had just left us, while that may be a good window of trying to intervene, they just felt burdened by that extra appointment.

We now see them about a month out but telehealth is something we probably should talk about at some point too.

Dr Jaspal Singh: What's a good segue? All right, let's talk about that a little bit. We'll go let's see. We'll get that in a second. The telehealth piece, multidisciplinary piece, that's a great segue.

I'm hearing you say is roll up your sleeves. Look at some frameworks, that work, figure out the frequency, the cadence by which you're going to see them. Identify in some shape or fashion or ideally systematically as to who might benefit and whether it's feasible or not.

You talked about multidisciplinary a little bit. Both of you did. How it looked might look different depending on your resources and the people that are local expertise. Is that about right?

Dr Rita Bakhru: Definitely.

Dr Carla Sevin: I definitely encourage people when they're trying to start a clinic to lean on their local resources. I had Jim Jackson. That's not a resource that's available everywhere. He's a huge part of our clinic. There are other places that are known for their physical therapy programs. They have some other specialty. You should definitely leverage that strength.

We're not able to be all things to all people. A lot of what we're doing is screening for problems and referring them on to other specialists. My feeling is that anybody who works in an ICU setting, the ICU is such a strange planet. If you don't work in an ICU, the things that we are seeing that are quality of critical illness are hard to identify.

We have wonderful colleagues in primary care, for example, but they haven't been in an ICU in 20 years. Often, their frame of reference and experience is very different from what we do in critical care. I prefer the term interdisciplinary to multidisciplinary because we're not just lining up a bunch of disciplines.

We're working together and working off of each other's strengths. I learned so much from that collaborative practice with other disciplines in the clinic. That's part of what makes me want to keep doing this. Even when we run into trouble and barriers, it's a gratifying way to practice medicine.

Dr Jaspal Singh: That's a great message to what this look like and why you guys do your work. It's fantastic. I like that term interdisciplinary too. Thank you for correcting me on that. Carla, you and I talked at one point, because I did the same thing that Rita did is like, "Hey, maybe we talk to Carla. We want to start one in our health system a few years ago."

We got caught up in making it work financially and the usual metrics of what we call both position production but also business models of modern healthcare in the ambulatory setting or an outpatient care. These clinics don't pay. On a business model, they don't quite succeed as well as you would have liked.

Somebody wants something to look well. Talk to us a little bit about the challenges of the business model there a little bit and how you overcame some of that briefly, if you don't mind? Rita, start with you.

Dr Rita Bakhru: Sure. We wait for some benefit of being at a academic tertiary care system. My section chief quite honestly said, "If this is important to you and this is something you want to, based on research off of," he was willing to commit some time in the clinic for us to see patients.

Initially, this was over and above my typical clinical load in terms of I have a half day of clinic every week. I added on to it to have recovery clinic. You're right. It's not typically a money‑generating proposition.

These visits are long and probably are not well compensated for. Although probably the new billing models from CMS, where there's some time‑based care that we can bill, may improve that potential business model aspect of things. A discussion with your leadership about why you want to start this clinic, what you hope to get out of it is very important.

Then the feedback from your patients, we haven't talked about that, but feedback from your patients as far as their clinical care but also what you can relay back to the ICU in terms of, "Hey, I saw Mr. So‑and‑so in recovery clinic last week. Gosh, none of us were sure if he was going to get through this critical illness from COVID."

Here he was, walking in on two liters of oxygen three weeks later. That's potential unmeasured outcomes of clinic as well.

Dr Jaspal: That's great. Hold on to that thought. Remind me about it later. We could talk about burnout a little bit. Carla, tell me a little bit about how you overcame these challenges?

Dr Carla: I have to echo Rita. That's a very important part. We talk a lot about what we can provide to patients, but we're not always talking about what we're getting from these services. We'll talk about that in a minute.

On the financial front, when we first started, there was often this question of, what is the return on investment? It's not a money‑making proposition, but I'm not sure it's a money‑losing proposition. There's a little bit of newer data coming out, for example, from the guys in our system. They describe their experience being self‑insured.

Even accounting for the time they gave for their critical care specialists to do clinic and a dedicated nurse case manager to follow up patients in a pretty hefty multidisciplinary model, there was still a cost savings as well as a signal for mortality benefit in the patients who came to clinic, not randomized but the first data that we have in terms of the financial impact.

I want to talk a little bit about the nonfinancial or nontangible returns on investment too. I like to change the question a little bit. I don't think it's, can we afford to do these clinics? The question is, can we afford not to do these clinics? A lot of that impact is in improving our own practice and our own quality of care.

Of everything that I've learned in the last 10 years, the clinical knowledge that I've gained from seeing these patients in clinic and understanding the natural history of critical illness, which has been nowhere more important than now in COVID, which is a new disease.

That is valuable to me beyond measure and helps me every day when I'm in the ICU to counsel patients and families about critical care and recovery.

Dr Jaspal Singh: That's well said. I'm just recapping a little bit. I like your framework there, Carla, saying, "How can we afford not to?" There's both tangible. We don't lose money. We provide a value to a lot of people, including the workers, including the patients, including the families, including a whole bunch of parts of the system.

It's a very fragmented system to begin with. If you model it well enough and you study it, you may not lose as much as you might think, or you might gain other ways that are just as important, if not more valuable.

Dr Carla Sevin: Right. It's a little disingenuous to say, "I can't afford to schedule you four‑hour clinic space a week," when we have a fixed wing aircraft that will fly out to God knows where in Kenya, like people for ECMO and bring them back and put them on ECMO for 80 days.

The cost benefit analysis per patient, although it has not been well studied, remains in the favor of post‑ICU clinics. If you are going to go out and pick somebody up and cannulate them for ECMO and completely change the trajectory of their life even if you save it, we also have a responsibility to provide the appropriate follow‑up care to that, just like we would for a cabbage.

When you come in and have a baby, we don't say, "Follow up with your PCP in six weeks."

Dr Jaspal Singh: That makes a lot of sense. Now you alluded to COVID‑19. Both of you did. Now we're all thinking about this. We're all working on these post‑ICU recovery clinics. We're all trying to get a handle on them.

Then along comes this pandemic with this horrible respiratory illness that pretty much devastates the population. Over half a million have died in this country alone. The numbers are still going up. Even though the case numbers may not be as high as they were at one point or census may not be high, people are still dying of this disease or surviving and left quite debilitated.

My own parents, I think I mentioned at the beginning of this call, just recovering from COVID themselves and it's exposed a lot of other issues in the home. You start to see, they survive, short hospitalization, but there's a lot of downstream effects and I can't imagine what we're seeing now and uncovering in a massive scale, with a high‑risk population.

Talk to us, I'm sure everyone's coming to you and asking, "We're going to start it now, we're in the midst of a massive problem, where do we even begin? And how do you look at this from the COVID‑19 framework now at this juncture?" Rita?

Dr Rita Bakhru: I think each health system's response to COVID‑19 has been a little bit different. Here at Wake Forest, we've not created a special post‑COVID clinic, but I know many centers have.

We beefed up our hospitalist at home program, so that many patients can get care at home that they otherwise would have at the hospital. We beefed up our access to regular primary care appointments, and then have a framework for primary care physicians to follow with appropriate referrals to sub‑specialties, with probably pulmonary critical care being over represented in those referrals.

I alluded to that I have a regular pulmonary clinic as well that's now become most commonly a post‑COVID clinic. [laughs] I'm seeing a lot of patients in that venue. Then our post‑ICU clinic has remained ongoing. We see a subset of post‑COVID patients in that arena.

By the same token, I don't have the same resources available to me in my regular pulmonary clinic that I do in our post‑ICU clinic. I think our approach to managing post‑COVID patients is evolving. I don't think we know exactly the right approach at this point.

Dr Jaspal Singh: That's very fair. Carla, what's your approach and take on all this going on?

Dr Carla Sevin: First of all, we were very blessed. I won't say we had foresight because obviously, we did not know this was going to happen. We had already started a telemedicine version of our ICU recovery clinic about eight months before COVID hit because of what Rita alluded to, this difficulty in getting patients back to clinic in this early time point.

We were already testing and piloting a telemedicine version in order to try to reach people sooner and some people at all, who we were not able to get physically back to clinic.

When COVID hit, everything overnight basically had to turn to telemedicine, we're like, "Great, we're ready, bring it. We know how to do telemedicine, luckily." It also shows what's possible. If that project was probably [laughs] eight years in the making, and there were so many barriers to doing telemedicine and then all of a sudden, from one day to the next, everybody was doing telemedicine.

When the motivation is there, huge change can happen. COVID‑19 was that motivation. We were obviously very fixated on our NICU processes at the beginning. How to care for these patients. How to ventilate them. How to exacerbate them. How to mobilize them. How to anticoagulate them, etc., etc.

Our post‑ICU clinic was this receptacle for the early survivors that we saw, after the first survivors that we saw after our first submissions. We learned a lot from them. One of the things that we learned was surprising is that you can be very, very sick with COVID and recover completely, which was awesome.

The other thing that we learned is you can be very, very sick or not that sick with COVID, and have persistent even permanent pulmonary impairments and other impairments. As I alluded to earlier, this is like a new disease. We had to learn the natural history of it. We couldn't learn the natural history unless we had some infrastructure to see patients afterwards.

I started making little lists in EPIC like, "Oh, now, I've seen two people with this problem post COVID. Now I have all kinds of lists." Also, we put together a database just for the pulmonary problems, and people were like, just send them to us. We'll try to figure it out. If it's not pulmonary, we'll get them to the right person, which is, of course, very similar to what we do in our post‑ICU clinic.

I did also have to add another half day of clinic to try to accommodate all the post COVID consults but because I already had this mindset, clinic can be burdensome thing. If you're an ICU person, you rather be in the ICU, putting in lines and doing exciting stuff.

You might also like to be a surgeon cutting stuff, but then you don't have no post‑op visit. You learn a lot from checking your work and seeing what the outcome of your work is. I was horrified by the pandemic, and I wish we had no COVID but I was also excited to see these patients and trying to figure out what the natural history of COVID was.

Obviously, we're still very early in it. We're still learning a lot about it, but it also peeled back the curtain for everyone else in this country in the world about what post hospital needs post illness needs may be. I'm hopeful that that will make care better for all patients, not just post COVID patients.

Dr Jaspal Singh: That's great. What you're highlighting is that the system is so fragmented, that you found a mechanism by investing in this clinic, this mechanism to manage them, whether that be a virtual or an in person solution or some hybrid model, as you move forward in the pandemic, trying to take care of a very complex population, as we as we learn more, as you say, as we evolve.

We're doing it in an interdisciplinary fashion, being smart about it, but being a resource for the population that we serve in this fashion. You're right, and I do worry that sometimes we've isolated ourselves in the intensive care unit, or the floors or the clinic.

Then we have all these specialists we all work with that are in these little cocoons, but we don't step back and say, "Can we cross fertilize more intentionally, and really understand how to do how to get the work done that's needed to be done."

That's great. Both of, this is our last segment of podcasts, have taken a lot of time energy and personal investment to this. Rita, you've added some more additional clinic time, which I'm sure you love to work harder and work more. All of us in this discipline and pulmonary critical care work harder than is expected of us.

You probably invested a lot. I know there are some rewards here. This been exhausting for you. Talked a little about how you maintain some sense of wellness or work life balance, or if you struggle, like a lot of us do.

Dr Rita Bakhru: I'll be honest, it's a struggle, Carla knows, I have a seven month old, so I had a baby mid pandemic...

Dr Jaspal Singh: Congratulations.

Dr Rita Bakhru: Thank you. That was its own struggle trying to stay safe in the era of COVID, trying to keep my child safe in the era of COVID. In addition to that there was a lot of work during maternity leave that just couldn't leave undone. There was a good amount of work during maternity leave. Since then it's just been a race to try to catch up and get as much done as I could.

It's hard. To‑do list never ends. It just grows longer as I say. There's that perspective, but there's also the immense joy from family and things outside of work. I personally find it very important at the end of the day to take some time and just enjoy family and not trying to answer emails on my phone while I'm with my family and try to have some balance, knowing that it's always in the works of trying to keep that balance good.

Dr Jaspal Singh: Thank you for the honesty. I know it's that challenge is honestly it's beyond challenging. Thank you for sharing. Carla, how do you hold it up together all this?

Dr Carla Sevin: Yeah, good. I'm very good at compartmentalizing, which is protective. I had this even as a trainee, I drive out of the garage and completely forget about work, to the point where sometimes I would drive back into the garage the next morning and remember that I was supposed to prepare a presentation or something.

It's more important to be in it for the long haul. Most of us are pretty resilient to stress otherwise we wouldn't be in this job. For me personally, I've invested a lot of time and honestly money into building my life in a way where I don't waste time on things that are not important to me. I do not enjoy traffic.

I live very close to work and I walk every day and I think my good thoughts on the way in and I let go of things on the way out. By the time I reach my home after 20 minutes, I'm ready to be a family person. I have a lot of help.

I think people don't really talk about that too openly but a lot of help most of it is hired but the most important thing for people in medicine, not just women is to have a partner who's going to be your partner and sometimes your partner telling you to put down the phone is what is needed. [laughs]

That's helpful but I feel the same way as Rita. The family is a joy and a place to replenish but I also get a lot of joy from my work and I have a lot of variety in my work. If I had to pick out EPIC notes 12 hours a day every day I would not be in this job anymore.

I get to do some teaching, I get to do clinical care, I get to do research, I do a fair amount of admin. I have fantastic colleagues, this interest in ICU recovery has connected me to Rita and to you Jaspal and to colleagues all over the world. We have a lot of the work and connections that we have there started through the Society of Critical Care Medicine and the thrive Task Force.

We now have CAIRO, which is the critical and acute illness recovery organization, which has upwards of 40 active sites who are doing post‑ICU clinics and peer support.

All of that work is very regenerative. As one of our colleagues said, at one of the thrive meetings describing their peer support program, once you started getting patients and families back and hearing their experiences and the benefits that they got from a post‑ICU program, they're like, this is really addictive work.

Once you start doing this, you want to do it more. While I don't feel that anyone should martyr themselves to do the work that they think is important, if your institution is not cooperative, nobody who is doing a post‑ICU clinic has not spent a significant amount of uncompensated time doing that.

I don't know that that's too different from anything else in it in an academic setting, and if we need to do the heavy lift, so our colleagues and community practice can convince the administrators then then that's what we're going to do, but it has benefits too.

Dr Jaspal Singh: It's really well said both of you. Just quick recap and the take home points and correct me if I missed some. Sounds like build a framework for post‑ICU recovery clinic, the country patients populations need it, from both of you on this, it's rewarding work.

It provides value both to you, your teams, the institutions, organizations that you work for, but also to yourself personally in terms of satisfaction, when you look back about impact. The idea, what you both said is very interdisciplinary about this, and then study it, ideally figure out what parts survey your patients survey the people that you serve.

Figure out what parts provide value, and then keep at it and keep building on it because, this is not going away if anything, COVID‑19 has taught us that this is a problem that was existed way before COVID, but it's now getting some final attention, that attention that it deserves, and hopefully we can help to plug some of the holes in a very complex health system in the US.

Those are the main things. The idea of business models and stuff will work itself out if you have committed people to help you drown yourself with people that are committed to this work, and I think it'll eventually happen. Pretty accurate?

Dr Carla Sevin: Yep, that sounds good.

Dr Jaspal Singh: Don't burn yourself out along the way, keep focus, keep well, keep resilient, and on behalf of Consultant360, again, I'm Jaspal Singh with Dr. Carla Sevin and Dr. Rita Bakhru. I want to thank them both for all their service, especially as a country needs people like them to do what they're doing and making things better for the rest of us. Thank you, ladies.

Dr Carla Sevin: Thank you.

Dr Rita Bakhru: Thank you.