The Journey to Safety Never Ends - Dr. Daniele Rigamonti, Medical Director at Johns Hopkins Medicine International

SHIV GAGLANI: Hi, I'm Shiv Gaglani and today on Raise the Line, I'm really happy to be joined by a friend and mentor of mine, Dr. Daniele Rigamonti who's the Medical Director at Johns Hopkins Medicine International, professor of neurosurgery at Johns Hopkins University and former CEO at Johns Hopkins Aramco Healthcare. And one nice Osmosis walk down memory lane is that Dr. Rigamonti was a mentor both to me and to my co-founder, Ryan, when we were medical students at Johns Hopkins. In fact, we did some of our first neurological procedures under his supervision, and he was a very early supporter of the work we're doing at Osmosis. So this is now nice, full circle. So Dr. Rigamonti, thanks so much for taking the time to be with us today.

DR DANIELE RIGAMONTI: Thank you, Shiv. It's very nice to be here because again, it looks back to very nice memory and I'm delighted to see that the effort started then is very successful. So, congratulation to you and Ryan and I'm really delighted to see what you have done.

SHIV GAGLANI: Thank you so much. Clearly, it's been really helpful having mentors like yourself early on supporting us. I know obviously a lot about your background, but for our audience, many of whom are currently in medical school or other health professional schools, can you tell them about what got you interested in a career in healthcare and then specifically neurosurgery?

DR DANIELE RIGAMONTI: As a high school student, I was actually interested in engineering, but the death of a couple of friends changed some priorities. So, I decided to go into medicine, and I became interested in neurosurgery, even though initially I was very interested and successful in basic sciences because I admired tremendously the neurosurgery professor. He was a scientist with a lot of publications in both anatomy and physiology, and he was a surgeon who actually was different, who was actually very impressive and inspiring young man. So that was my first approach to neurosurgery.

The second thing that happened is during my summer vacation, my fifth year of medical school, I had the opportunity of traveling to the U.S. with a summer fellowship. And by total serendipity, I landed in Mount Sinai Hospital in New York, where at the time there was a gentleman called Leonard Malis, who was the premier surgeon in the U.S., in the world.

I get there. I'm a little bit familiar with neurosurgery because I saw something in Italy and I see this gentleman doing incredible things, beautiful surgery. I felt like falling in love with the specialty. So when I went back to Italy, I finished the medical school and then three years later I was able to actually to come back, and since Leonard Malis was impressed with my work ethics, he actually offered me the job as a resident. So that is how it started. Again, a lot of inspiration of human being and serendipity and I just took the opportunity.

SHIV GAGLANI: Absolutely. As Louis Pasteur famously said: “chance favors the prepared mind.” Also, that's a big point I want to make sure our audience knows, that so much of our career decisions can be shaped by mentors and luck, as you were saying, landing at Mount Sinai and meeting him and then winding up being his resident. And similarly for us, the work we're doing at Osmosis was shaped a lot by mentors like yourself, as I mentioned at the beginning.

Transitioning from how you got into neurosurgery into your leadership roles of entire hospitals like you did at Aramco…I'm obviously familiar with the venture between Johns Hopkins and Saudi Aramco, which is as most people know is one of the largest organizations -- if not the largest company in the world -- in energy. It provides free healthcare to Aramco employees and their dependents, as well as to retirees from the industry. Can you tell us a bit about how the venture began and then what led to you going to Saudi Arabia and then leading the hospital for so many years?

DR DANIELE RIGAMONTI: I was at the time the Salisbury Family Professor in Neurosurgery at Hopkins, and was very satisfied and pleased with what I was doing. I'd started and expanded several programs -- the neurovascular program, the radiosurgery program, and the hydrocephalus in CSF diseases program. One day I got the phone call from the president of Hopkins saying that we are looking for someone with experience and we need a bit of gravitas to lead this joint venture with Saudi Aramco. They explained to me that Saudi Aramco was indeed the biggest energy company in the world, and they had this huge accountable care organization where they were to provide total care starting from primary care to secondary care of pediatric and adult and elderly care. They wanted to have someone senior to be the chief medical officer.

So, I discussed it with my wife and we were all a little bit scared, honestly, because it was a different culture, a different language and all of that, but we decided we would try. So, we went there. It was a little bit difficult for my wife at the first year because she was trying to do work as a coach, but the beginning was quite difficult. But in any case, within a year, I had already accumulated good will with the people in Aramco. So they asked me to be the acting CEO. And again, it was scary because it was, I felt, an overwhelming responsibility, but I decided to accept it also because I felt like they would help me. Basically within a few months they offered me the permanent position.

And there I was. I felt like I was drinking from a fire hose because moving from neurosurgery to becoming a CEO of a huge organization was a tremendous job. But I also loved the responsibility because I realized that was not dissimilar to the philosophy that I had in the operating room with the philosophy that I had as CEO. I wanted to be first and foremost safe in providing the care because safety is the number one element of quality. And I wanted to make sure that everybody in the organization understood that and produced a safe environment in primary care, in an emergency room, in preventive clinic, and again, taking care of the elderly.

It turned out to be an extraordinary experience. We were able to increase all the KPI. Incidentally, I was dealing with engineers as you can imagine -- geophysicist and oil engineers -- very, very structured human beings. At the beginning I was a little bit overwhelmed by the fact that they were measuring everything, all key performance indicators, everything. But after a while, I actually began to like the fact that they were actually relying on data and as long as the data that they produced was actually strong and good, they were very pleased.

So that kind of attitude actually permeated in me later and I found that actually it is very important because when you are in the oil business, you do not want to have accident. No? An explosion or something that can destroy life in a second. So they were over, over cautious, and that attitude actually was nice to be seen in the organization, in the healthcare organization. I felt like it was a transition that was challenging in the beginning, but extremely enriching after a while. And again, I feel like what I learned from them is tremendous and it's something that I wish many people could actually access too.

SHIV GAGLANI: Yes, really interesting you mentioned that because we're going to talk about your current work in patient safety. A lot of patient safety in a lot of healthcare organizations have been looking at the aviation industry for decades as to how to perform better, how to be safer. But it's interesting that you mentioned some of the learnings from a large oil and gas provider and the parallels there between being data-driven and trying to prevent explosions or other negative outcomes.

We got reconnected because of your work in patient safety. You've already alluded a bit to kind of where your interest came from, but can you tell us what you're up to nowadays with regards to patient safety and the work you're doing there?

DR DANIELE RIGAMONTI: So, basically one thing that I actually realized when I was at JHAH is that we had implemented all the procedures, all the policy that were present at Hopkins. So we were actually pretty solid in performing everything that there was, aiming at increasing the safety. In spite of that, a few bad outcomes occurred and that triggered my curiosity. I said, "Why is it that in spite of having done all the training and checked all the boxes, we still have the problem?"

So that became, initially, I would call it an academic interest. It's more than academic, because all my life, whenever I dealt with something that I didn't understand, I said, "Okay, let's see if we can find a solution or an answer for this.” So digging into the problem, I realized that there is a gap between what people know and what people actually do. You can teach a lot of things to everybody, but unless the people actually practice what they learned, they make that experience a habit, there are situations in which bad things happen because under stress, weaknesses occur and they get exposed and basically bad things happen.

So, I'm interested now in finding a solution or a better track to eliminate the systemic gaps that actually prevent people from being totally safe. I mean, luckily we are safer than we were years ago, but the journey to safety never ends. Perfection is actually something that you aim at but you doubt you ever achieve. But again, but that is the will that is actually pushing me to investigating and coming up with a solution for this.

SHIV GAGLANI: So, what's your approach? Are you focused on things in the OR that lead to patient safety or elsewhere? Obviously running a large healthcare system, it was all across the board.

DR DANIELE RIGAMONTI: By experience there are three areas where the bad things seem to be, I guess, consolidating. One in the operating room, one in the ICU, and in the emergency room and it has to do with the fact that those are the places where the sickest patients tend to congregate. So, working in these three areas is basically most efficient. You can have an area somewhere else in your organization that may need the help, but the area where there are very high safety problems are those three.

What I believe is necessary in those areas is actually to get the people involved -- nurses, physicians, and technicians – and actually drill. Maybe sometimes using events that have occurred already, like a sentinel event. You go over what happened and say, "Okay, this is what happened. What is that we should have done and we didn't do?" Or, “Let's imagine a situation that has not really occurred yet. What would you do?

The reason I'm doing this -- and I believe that actually it’s going to work -- is something again that I learned from Saudi Aramco. In 2019, as a part of the engineering philosophy, we were doing drills every three or four months. In November 2018, we did a drill called Emerging Infectious Diseases, just by chance. We looked at were we ready to deal with an emerging infectious disease. Actually no, we are not. We don't have enough negative pressure rooms. We should have more respirators. So, we fixed it.

Guess what? Three months later when the pandemic struck we were, I guarantee you, the most prepared organization on the planet. And I felt like this is actually an experience that we'll always remember. If you drill, you're more likely to be ready than if you don't. And the situation with safety is this: if you're doing something in the operating room and you explore a situation that could be deteriorating, you know what to do because you are now familiar, you are looking for something, you can detect something going wrong earlier before it becomes irreversible. So that is something that I learned then again by total chance, because I was there, and I feel like there is a big lesson to be learned.

SHIV GAGLANI: That's remarkable. I was actually going to ask you about the COVID experience, both at Hopkins in Baltimore, where you are now, as well as at Hopkins in Saudi Arabia. So that's a good time to transition. So clearly, by chance -- but again, chance favors the prepared mind - you guys prepped at Aramco for an emerging infectious disease and hopefully had enough mechanical ventilators and things like that. But can you tell us about some of the changes that you saw because of COVID, and then what do you think some of the lasting changes because of COVID will be to the healthcare system?

DR DANIELE RIGAMONTI: One other lesson that I actually learned very early on -- again, because of the Saudi Aramco philosophy of engineering safety -- is something that has to do with recognizing and deferring to expertise. In other words, if you are in an oil rig and something happened, you want the guy who knows how to close the oil rig to fix the problem, not an engineer who works in the research department.

Well, when the pandemic struck, the first thing that they did, and I was very happy, was to create an incident commander, someone that everybody knew was the expert and everybody would defer to because they wouldn't claim to know better. This was the chief of infectious disease and an infection control guy. So he was nominated by me as the incident commander. He participated from that point on in every meeting of the C-suite. We would discuss how to do things, how to deal with problem and we would ask always, "Does this make sense to you?" And we had this uniform guidance, which was actually very important to me to moving the organization forward.

One of the things that I've noticed in the U.S., there are contradicting recommendations, and you do not know who to follow. Is this right? Is the other one fine? And I feel like one of the tremendous benefits also to give you the sort of peace that you are actually doing the right thing is to just know that the right guy is actually leading the ship. I was the CEO, but I would defer to him whenever there was a decision to be made. So that is something that we learned from COVID.

The other thing that we did immediately was to change a lot of the way we're providing care. Telemedicine is one thing that everybody does for that, but we were ready and basically we were able to provide non-acute care to the majority of the employees and their dependents early on, and still maintain a certain degree of elective surgery and medical care so that we didn't really affect tremendously the operation.

But it was certainly an experience that is going to change the way medicine is going to be moving from now on. I think something that was not imaginable two years ago is that you could be seeing your physician on Zoom and be comfortable that he would be asking you the right things. Regular follow-up becomes routine now, and it's probably going to save money and be more efficient and all of that.

SHIV GAGLANI: Yeah, absolutely. We've covered a lot about how telemedicine is here to stay. It's gone down a bit since people have been going to clinics more often now, but it's still an order of magnitude higher than it used to be pre-pandemic.

I think a lot about the times I shadowed you both in the neurosurgery clinic, as well as in the OR. I'm curious, first of all, are you still practicing? And regardless of that, there are so few things it seems in neurosurgery that you could do via telemedicine. Obviously, operationally, but then also, even in the clinic during the neurological exams, it's best to do it in-person. What are your thoughts on the future of neurosurgery in telemedicine?

DR DANIELE RIGAMONTI: I think that you would probably do regular follow-up when the patient feels comfortable and determine during the video visit if there is a need to be actually evaluated in-person. I believe that there is always going to be a major role for the in-person contact. Because sometimes beside the neurological problem, people have fears and concerns that you need to address, and in spite of the artificial intelligence giant step forward, there is I believe always a need for a human being with compassion just to listen and understand what the hell is going on in someone else's mind.

I think that neurosurgery was always very highly technical. I believe that in neurosurgery, the major advances that we believe could obtain due to COVID is the fact that maybe with the awareness of sepsis, maybe the percentage of infections will drop significantly in the next few years, because people realize now that washing their hands is actually very important. And even though technically everybody's supposed to do it, there is maybe a better way of doing it and a more thorough way to do it. Moving in the operating room is, in my opinion, always a source of possible infection. So, diminishing greatly the number of people that actually go in and out of the operating room is important, so that being prepared, having everything you need before you start is very important.

There are little things that are not going to change dramatically, but each one will add a little bit more safety and therefore improve the outcome just a little bit. But there's a cumulative effect. So I believe that there's still a lot to be benefited from.

SHIV GAGLANI: I've heard the saying that it is a game of inches, right? Sometimes there'll be Hail Mary type passes -- things like the checklist that can really be a step function in terms of improving outcomes -- but otherwise, it's a game of inches and trying to do incremental change that will compound. 

As you know Osmosis is a teaching company, and we educate millions of current and future healthcare professionals. If you could snap your fingers and have us develop teaching modules on any subject, where would you have us focus right now? Where are the gaps in knowledge or training that you think you would like to see addressed?

DR DANIELE RIGAMONTI: I think the emphasis on a collective approach to resolving medical problems is actually a new thing that is being shared currently in medical schools. I think that an attitude of humility is important, so that you don't necessarily know everything that you need to know. When there are three of you discussing a case, there is a better chance that you're actually going to come up with the right decision, the right diagnosis, the right protocol.

So I think that collective learning is a very strong, positive advancement and I recommend to everybody, to all the students, to actually take advantage of that. It's easier to study with other people. It's easier to learn with other people and you're going to becoming a better doctor if you work as a physician, a nurse, or a technician with other people as a team.

SHIV GAGLANI: Team-based care for sure is something we're seeing. And, I think a lot of medical schools have been transitioning from “sage on the stage” one-hour lecture formats into more problem-based learning, team-based learning, which has been good.  Hopefully, there'll be more interprofessional collaboration because I remember for my first two years at Hopkins Med, I had only one interaction with someone from another profession. There was a pharmacy rotation I did. But I think hopefully there'll be more and more of that because that is the future of care.

Speaking of students -- given again our audience of early and young career health professionals -- what advice would you give them about pursuing careers in healthcare, especially with what we've experienced over a year into this pandemic?

DR DANIELE RIGAMONTI: I think that medicine is a beautiful profession. There are many good professions, but taking care of an individual in need and being able to help gives you a satisfaction that cannot be compared to anything else, I don't think. It used to be said that if you save one man, you save humanity, and I think there is something true in it.

I think that it is important to understand that to do that, you need to offer respect and trust to your colleagues. You need to listen to their voices. And this is true for the patient as well. As a human being, you need to actually understand it and you need to inspire your team. That is so important because if you're a good leader, your team is going to do great things. I cannot underemphasize this because I feel like at the end of the day, to produce quality, safety, and good results is an incredible achievement which I wish to all of you to achieve one day.

SHIV GAGLANI: Well, that's some great advice and some great words. And my mom still wants me to go back and finish med school. So, I may see you in Baltimore in the not-too-distant future as a result.

I know we're coming up on time. What have I not asked you that you'd like to be able to get across to our audience today?

DR DANIELE RIGAMONTI: Well, I think we touched on the majority of the important topics. I think that again, you're doing great things by going to medical school and you have a great profession ahead of you. There are difficulties, but difficulties are also an opportunity to do something better than what used to be done in the past. COVID is a very stressful experience, but hopefully we will be stronger after that. So, I believe that what you're doing is great and I wish you tremendous success.

SHIV GAGLANI: Thank you Dr. Rigamonti. It's truly a pleasure again to reconnect after all these years. You were an inspiration then. You continue to be inspiration now for all the work that you're doing and the tireless dedication that you put towards it. So with that, I'd like to thank you for taking the time to be with us on today's show.

DR DANIELE RIGAMONTI: Thank you very much Shiv. Good luck to all of you.

SHIV GAGLANI: And with that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show, and remember to do your part to flatten the curve and raise the line. We're all in this together. Take care.