Reflections: My Years at MIT

William M. Kettyle

Editor’s Note: William M. Kettyle recently announced he will be stepping down after 15 years as MIT Medical Director.

Long before PowerPoint was universal, I was asked to give a lecture to a class at MIT. It was 1977. The course was HST060 – Endocrine Physiology and Pathophysiology. The topic was the anterior pituitary (one of my favorite glands). The notice was short, and I did not have time to get 35-mm slides made. This was my introduction to MIT and was the start of a relationship that has continued in various forms to this day.

At the time, I was a post-doctoral fellow in Clinical Endocrinology at Beth Israel Deaconess Medical Center in Boston. My mentor directed the Harvard-MIT Health Sciences and Technology course and the designated lecturer was suddenly unable to participate. Although it would have been difficult to decline, I was enthusiastic about the opportunity to teach at MIT! I prepared some lecture notes, journeyed to Cambridge, and gave a lecture using the blackboard. Apparently the session went well, since I was invited to give additional lectures. Since then I have continued to participate in the course and have co-directed it for the last 30+ years. I still teach some of the same topics – luckily, anatomy has not changed. Of course I now use PowerPoint and, over the years, I have added a number of other approaches to my teaching repertoire: problem sets, audience response “clicker” sessions, and most importantly, clinical sessions. I invite patients to come to class to speak about their symptoms, their diagnosis, their care, and how their condition is managed.

After completing my fellowship, I opened an endocrinology and internal medicine private practice at Mount Auburn Hospital. From that, my relationship with MIT expanded to include providing consultations at and for MIT Medical.

At Mount Auburn Hospital I worked closely with Dr. Charles Hatem who was the “hospitalist” for MIT Medical (a doctor who specializes in the care of hospitalized patients) – long before the use of hospitalists became a common part of medical practice. Weekends on call frequently meant caring for MIT patients when Charlie was off duty, and I came to know many members of the MIT community. I also received referrals to care for patients who left MIT but stayed in the area.

In 1993 I joined MIT Medical as an employee. I was pleased with the opportunity to practice at MIT – a change that allowed me to continue my teaching at MIT and to practice with colleagues whom I had come to know and respect. After a few years I became increasingly involved in administrative issues, a process that led to being appointed Medical Director in the summer of 2000.

Caring for a community

For the first half of my career in medicine, my focus was almost exclusively on individual patient care. But during my years at MIT Medical, I became increasingly interested in understanding the larger needs of the community, and ensuring the provision of services to meet those needs.

The alcohol-related death of freshman Scott Krueger in 1997 had an important impact on MIT. Shortly after his death, a medical student who had taken HST060 and who was a Graduate Resident Tutor in one of the dorms asked me to give a talk on alcohol at a study break. She suggested that I use an HST-esque format. I agreed and developed a talk that included information on the chemistry and biochemistry of ethyl alcohol: vapor pressure, fermentation, distillation, and metabolism. We discussed why many alcoholic beverages are chilled before intake. We reviewed pre-absorptive kinetics and metabolism, absorption, and post-absorption metabolism. We also discussed some of the genetically determined variations in alcohol metabolism – e.g., the Asian liver. The presentation included a problem set that predicted blood alcohol levels: a 200-pound male and a 100-pound female have very different blood alcohol concentrations with the same amount of ingested alcohol.

The talk was scheduled for 10:00. Unfortunately, when I arrived at about 9:45 am no one except for the janitorial staff was available. It turned out that the time was meant to be 10 pm. The late-night visit to the dorm provided me with an insight into the life of students at MIT. Although I gave the talk several times – almost always at about 10 pm – and the questions and discussions that followed were always lively and engaged, I am not sure what impact it had on alcohol use. I did, however, learn more about student life, especially the nocturnal aspects. This event and the related encounters with students fueled my increasing interest in understanding the health and wellness needs of our student community.

Changes at MIT Medical over the past 15 years

Over the past 15 years we have broadened the scope and scale of our community endeavors. Face-to-face individual care is still a major, vital aspect of what we do and will do going forward. But technology has changed our workflow as well as how we interact with our patients. Click here for a brief history of MIT Medical.

Before our electronic medical record (EMR) was deployed, patient care records were piles of paper in (hopefully and usually) chronologic order. There were some attempts at the functional separation of various components. Medication lists, laboratory results, x-ray reports, and EKGs were in a distinctive format that made review a little easier. Handwritten and typed notes recorded the details of care and had to be found and read.

After several years of hard work, hardware enhancements, and software upgrades, we now have a robust EMR with the ability to search for test results and other information. As of December 2014, 6.58 million pages of the “old” paper records had been scanned into our EMR system.

Virtually all prescriptions are now digitally produced and transmitted electronically to the MIT Pharmacy or to pharmacies outside of MIT. Although my handwriting has not changed, the readability of my prescriptions has improved drastically! In addition to increasing legibility, the EMR checks for possible allergies and for drug interactions, improving the safety of prescription writing.

The digitalization of medical records and the provision of health care in an asynchronous fashion – email and secure portals in particular – have had major impacts on the process and work of providing and receiving healthcare. Although the number of face-to-face encounters at the MIT Medical Department has not changed much in the past 15 years, the number of digital encounters has increased markedly, with more than 1.5 million electronic transactions last year alone. Managing an in-basket with a seemingly constant inflow of tasks is now an important component of our practitioners’ workload.

One important EMR-related development is our capability to create a “dashboard” of clinical care. These data-mining abilities allow clinicians to identify deficiencies in care at various levels: practice wide, clinician specific, and, most importantly, at the individual patient level.

For example, a dashboard allows us to see how well we are doing meeting the immunization requirements of our patients and to specifically identify individual patients in need of various immunizations.

The evolution of digitized care continues as we work to connect with our community and strive to find ways to interact, securely, conveniently, effectively, and safely.

In 2010, after several years of declining utilization, our inpatient facility closed and overnight, on-site services were discontinued. Telephonic availability in Primary Care, Pediatrics, Obstetrics and Gynecology, and Mental Health & Counseling remains available 24 hours a day. Onsite care in our Urgent Care service is available from 7 am until 11 pm daily. These changes occurred after careful study and planning and with a major effort at community education and preparation. More details about these changes were presented in the Faculty Newsletter in 2010.

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Looking ahead

The tragic student deaths that occurred this past academic year have led many in our community to seek a better understanding of the realities of the student experience and to more clearly assess the need for and supply of support for students on our campus. MIT Medical and our Mental Health and Counseling Service, along with multiple other services and offices on campus, provide timely and effective support for students. But because we are MIT, we are always asking ourselves whether we can do better. Can we further lower barriers to seeking help? Are there better ways to help students enhance resilience? Can we find additional ways to identify students in need of support? Can we continue to find ways to reduce or assist in the management of the stress of being a student at MIT?

Late-night talks in dorms and FSILGs have given me some insights, while speaking with student patients provided some additional views. Having a nephew enroll at MIT several years ago was particularly informative.

Seeing the community through an individual I knew since he was born gave me a unique perspective. For example, his emails often arrived between 3 am and 4 am, confirming my assessment that many members of the student body are functionally on Hawaiian time – shifted about six hours.

A recent survey of students (2015 Healthy Minds study), however, led me to rethink my assumptions. The data suggest that students – at least in the sample who responded – do get to bed at a reasonable time and sleep for a reasonable duration. How consistently that happens, and what the quality of that sleep is, are not revealed by the study. But I think I need to adjust my assumptions. Similarly, finding new or additional ways to support students requires a careful review of our assumptions and stereotypes about the student experience. It is important that we have an accurate picture of student experiences as we work together to find more ways to help them develop enhanced resilience.

Efforts are ongoing, and one such initiative, MindHandHeart, is a coordinated, campus-wide initiative of the Chancellor’s Office and MIT Medical. The program aims to support innovations that promote mental health and the appreciation of the importance of individual wellness. More information about this important endeavor can be found at mindhandheart.mit.edu.

The MindHandHeart initiative is just getting started, but a key component is ready for deployment. “Don’t Struggle Alone” cards and other materials are available for download at a new Web page (together.mit.edu/askforhelp). The card and pamphlet for faculty provide advice and encouragement for us to convey the message that “it’s okay to ask for help.”

What started as a last-minute invitation to give a lecture developed into an incredibly rewarding career. Teaching in the HST program has been a constant. But providing face-to-face clinical care evolved to include the entire MIT community as the patient. All the while, the style and forms of care provided at MIT Medical have evolved as well.

Nearly 300 people – employees and contractors, full- and part-time – work together at MIT Medical to provide care for this unique community. I admire, I appreciate, and I applaud their hard and devoted work. Although there have been many changes over the past 15 years, MIT Medical’s commitment to caring for our community remains fixed and steady.

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