EP. 15: GRIEF, LOSS, AND A BRIGHTER PATH FORWARD

Jun 15

WITH STEPHANIE HARMAN, MD

A palliative care doctor shares why she entered a career often filled with grief and loss and how she creates moments of meaning for patients.

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Episode Summary

As the founding medical director of Palliative Care Services at Stanford Hospital, Dr. Stephanie Harman is no stranger to death and grief. In this episode, she shares the story of how she discovered palliative care through the death of someone close and what it looks like to transform what are often the moments of greatest patient suffering into moments of profound meaning and humanism. In addition to her palliative care work, Dr. Harman is a clinical associate professor of medicine, a co-chair of the Stanford Health Care Ethics Committee, and Associate Chair for the Women in Medicine initiative in Stanford’s Department of Medicine.

Dr. Stephanie Harman graduated from Case Western Reserve University School of Medicine, completed a residency in Internal Medicine at Stanford Medicine, and completed a Palliative Care fellowship at the Palo Alto VA/Stanford program before joining the faculty at Stanford.
She is the founding medical director of Palliative Care Services for Stanford Health Care and a 2017 Cambia Sojourns Scholar Leader Awardee. She is a Clinical Associate Professor in the Department of Medicine and a faculty member in the Stanford Center for Biomedical Ethics. In addition, she serves as the clinical section chief of Palliative Care in the Division of Primary Care and Population Health, co-chairs the Stanford Health Care Ethics Committee, and is Associate Chair of the Women in Medicine initiative in the Department of Medicine. Her research and educational interests include communication training in healthcare and bioethics in end-of-life care.
In this episode, you will hear about:
• How PBS, zebrafish, and comparative literature influenced Dr. Harman’s decision to enter medicine - 3:08
• How the death of someone close propelled Dr. Harman into palliative care and informs her philosophical focus on honoring a patient’s values and wishes - 8:09
• Why Dr. Harman felt drawn to a medical specialty that so often deals with the most painful part of medicine: witnessing patients dying - 15:53
• How Dr. Harman had to advocate for the legitimacy and dignity of palliative medicine, despite being told it was “a waste of her career” - 19:18
• How Dr. Harman processes the emotional weight of her chosen field with preventive and supportive measures - 22:20
• A discussion of how the COVID-19 pandemic has forced public and personal conversations about grief to the forefront - 27:24
• Dr. Harman’s vision for the future of medicine, and specifically the broader adoption of palliative care services - 33:33
• Dr. Harman’s advice to new medical professionals and students - 38:49
Henry Bair: [00:00:01] Hi. I'm Henry Bair.

Tyler Johnson: [00:00:03] And I'm Tyler Johnson.

Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?

Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom, probing the moral heart that beats at the core of medicine. We will hear stories that are, by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.

Henry Bair: [00:01:04] Our guest today is Dr. Steph Harman, founding medical director of the Palliative Care Service at Stanford Hospital and co-chair of the Stanford Health Care Ethics Committee. Dr. Harman is passionate about teaching and researching how doctors communicate with patients, especially in the context of serious illness as well as bioethical issues at the end of life. In addition to her work in palliative care, she's associate chair for the Women in Medicine Initiative in Stanford's Department of Medicine. In this episode, Dr. Harman will share with us how her early experiences with death drew her to a career of caring for dying individuals, how she manages grief with patients, and her vision for improving the quality of life of patients everywhere.

Henry Bair: [00:01:47] We will be talking a lot about palliative care today, even though we have featured palliative care doctors on this program before. I want to give a brief primer here of what it is for listeners who are new to the show or who are otherwise unsure of what it is. Palliative care is specialized medical care that focuses on sustaining the best possible quality of life for patients with serious illness and their families. It strives to alleviate suffering not only by addressing physical symptoms such as pain and nausea, but also emotional, social and spiritual needs. While frequently provided to those with terminal illnesses. It can also be provided to patients with chronic conditions such as heart failure or neurological disorders. Palliative care can also be seen as an additional layer of support that coordinates with other members of the patient's care team to ensure that whatever care a patient receives is in alignment with their goals, values and preferences. And now on with the show. Steph, thank you very much for taking the time to join us today.

Steph Harman: [00:02:57] Oh, thank you so much, Henry and Tyler, for having me. Full disclosure, this is the first time I've done a podcast, so I'm just being real.

Henry Bair: [00:03:08] So, Steph, can you share with us briefly what brought you to medicine in the first place?

Steph Harman: [00:03:16] I think for me it was, you know, initially when I was a kid, I really loved animals. I thought I would be a veterinarian because I loved animals. We didn't get to have too many pets when I was growing up. And I remember I remember watching PBS, the show called All Creatures Great and Small, about this, like veterinarian and like the Scottish wilderness. And I remember watching him having to treat a very large cow. And I was like, I, I don't think I want to do that. So that and that was when I was like, I was a kid and kind of revisiting what I was interested in, in college, I was a comparative literature major or literary studies major in college. And so I, I really loved kind of thinking about literature across different genres, thinking about the arts and humanities. And I kind of like science too. I almost kind of double majored and I think it was chemistry. I'd had enough like met some of those requirements and some of it was that I was I was really interested in figuring out how to combine the two. I remember hearing about people who had been humanities majors, and this is back in the kind of late nineties where this was less frequent. But humanities majors who went into medicine, sometimes they did a post-bach program to finish their requirements. I snuck in kind of all those classes in college just so I could keep that option open. I wasn't sure. I took a year off after college trying to figure out if I was going to go into medicine or not. So I did work on our college campus as kind of a volunteer and at the same time worked in a zebrafish lab, cutting up little zebrafish brains and putting them in paraffin to kind of study what happens when they when zebrafish are injured neurologically and if they can regrow.

Steph Harman: [00:05:16] And I was totally random, but this was like this was where my my space was in terms of my trying to explore different things. And I think I remember going to see a good friend who had to go to the hospital urgently because he'd had this stomach condition and gotten a blockage and couldn't eat or drink anything, which was kind of terrifying that, you know, this is, you know, for a young man and also for me. And I remember thinking I wanted to be with him and also trying to think about how do we how do we make this better? How can I think about this for him and what happened and how did this happen? And I think that was for me, enough of the nudge that this would be an area and a career that I could I could grow in and get to do things that would help me be able to kind of. Walk paths along the sides of what I think about with regards to the arts and humanities and that kind of appreciation of life, as well as the mechanics of why things happen the way they happen. And I know that was a very long winded explanation, but that's how I kind of ended up deciding to apply to medicine. I still didn't know in medical school, at least when I when I first started, what exactly I would do other than be a doctor. And again, I did want to take care of something. I remember thinking when I when I was a kid as a veterinarian. So I don't feel like it's too far from there.

Tyler Johnson: [00:06:46] You know, I feel like if if this podcast succeeds in nothing else, it will succeed in disproving the idea that you have to be a biology major to go into medicine, because we've now had multiple guests who have majored in some form of the liberal arts. And I'm curious, as someone who majored in literature, in what ways do you feel like that has informed your doctoring? How has that allowed your doctoring experience to be richer or more meaningful?

Steph Harman: [00:07:13] That's a really good question. I think that literature in the arts that there is something about the different ways to kind of express human experience that I think just keeps our hearts and minds, or at least my heart and mind open to what people go through with illness. There is something around illness and suffering that just generates these expressions of narratives, stories, art, photography. I think there's so many examples of those different expressions of kind of people's experiences being able to convey and communicate what a lab value might not really do.

Henry Bair: [00:08:09] Yeah, I think that gets us closer to your work in palliative care and we've had multiple palliative care physicians as guests on this podcast so far. And when we ask the question, why palliative care? For our guests so far, it's been almost as if they saw a deep need that forced them into like they saw this as like a moral imperative. There was suffering that they could uniquely be positioned to intervene on and improve. So. What was your personal experience like? Was there something that you saw or you felt or a patient you encountered that brought you to palliative medicine out of all the different specialties in medicine?

Steph Harman: [00:08:52] Yes is the short answer. I think those different themes definitely resonate, and I should I should just speak for myself. I also think that we're often have these very crooked paths to palliative care. A lot of us in the field have either had been in different specialties or had had paths that just diverged from kind of what you would typically see. For me, I mentioned kind of heading into medical school when we were talking about how I got interested in medicine. But my first week of my first year of medical school. My father in law, who would be my father in law now, was diagnosed with lung cancer. My husband's family is not medical. No medical folks. Not a big family. As a first year medical student. It was almost as if I had. So much bio cam and all this random knowledge getting kind of poured into my head that I don't think I was as facilitative and helpful with my father, with Tom's diagnosis, other than my husband. His family felt it would be helpful for me to go with him to appointments, so I went to a lot of his appointments. Just to be another person listening and a little bit more removed to what was happening. And that continued during my first year of medical school. And I remember. You know, Tom's course was was really hard. He had ended up with metastases or spread by spring by actually by winter that year and both sides of his chest in his brain. So he underwent kind of radiation and multiple treatment regimens of chemotherapy.

Steph Harman: [00:10:42] Immunotherapy was not a thing at the time. I know Tyler is smiling. This is a while ago in 99, 2000. And I remember Tom very clearly talking about what was kind of his compass on how he was going to decide between different kind of treatment regimens and approaches. We wanted to be at home as much as he could home to the extent that he could do that and have therapies that would help him. He was never hospitalized during his entire course. He was running a steel wire manufacturing company, and this is in Cleveland. And so, you know, looking around like the the great sun, like air conditioning vents and that kind of thing, pretty industrial. And he really carried that responsibility and wanting to be able to run that business, be with his family. I remember him talking about that summer because he was at a in kind of a crossroads around doing additional therapy because the cancer had spread more and saying, well, he conveyed to his oncologist, it's really important that I go to this place up in northern Ontario on the lake where he had gone every year of his entire life since the age of three, just to fish, kind of run around and hike and a lot of memories there. It's really important that I get to go back and enjoy that. And if you are telling me I can go through additional medicines and treatments and be able to go back next summer, then I'm willing to undergo that.

Steph Harman: [00:12:30] But if you think that if I do this additional line of chemotherapy, which was third line at the time, I think and I won't I won't make it back then I would make a different choice. And he had kind of the space and permission from the oncologist to to talk about that. What was important like I'm trying to figure out how to make this decision because the toxicity would cause him to have more issues. He'd have to stay around. And the oncologist, I remember saying, hearing that you should I think you should go to Canada. We should not do this. And so. That was the summer in between my first and second year of medical school. And I was heartbroken. And he got up there. He was there. We went to the ER like at least once or twice with like fevers and things like that. But he, he got that summer. It was when classes resumed again. I remember we had some time with him. He enrolled in hospice, had talked to his oncologist again, and spent probably about six or seven weeks on hospice. That was all during my first and second year of medical school. And I remember looking at that and being like, this was of ways this could have gone. This had gone really well from the standpoint of what Tom's wishes and kind of how he's always lived his life and what was important to him. And I thought, That's great. I actually was interested in oncology at that point and I was like, Doesn't everybody get this? Doesn't everybody get this kind of tailored and goal oriented, if you will, but really kind of wishes, values oriented, care, where Tom really got to be the captain of that ship for the most part for his course.

Steph Harman: [00:14:27] You know, I think for something as devastating as that. And then going into clerkships and very quickly realizing that that's not that's not the norm and that's not even the expectation that people were experiencing. And that really tipped me into palliative care tipped, pushed, shoved, because it was this flip sides where I would kind of alternate between feeling enraged that this wasn't what everyone got to the other side, where it was really fulfilling and meaningful to be able to facilitate that kind of care in the face of terrible, terrible disease, terrible diagnoses and prognoses. And so that was my interest in palliative care. I still thought I would be an oncologist. I still did. When I applied to residency, I said, it's important. I need to have palliative care training. You know, I remember Tom's oncologist, and that was one of the things that stuck in my head. And so that was kind of my path to palliative medicine. So I wanted to make sure the residency program had a palliative care rotation. At the time, there were just starting to be palliative care fellowships. Like more structured ones. There are probably about nine or so in the country. And so I thought I should try and go someplace where there would be that opportunity.

Tyler Johnson: [00:15:53] So I'm struck because granted your father in law, it sounds like within the range of possible outcomes, had a peaceful, unfulfilling outcome. So I'll I'll stipulate that. But I'm still struck by the fact that someone faces what has to be a difficult, taxing, emotionally weighty family experience of your father in law being diagnosed with cancer and in pretty short order having it be metastatic and then dying within a year or so, from the sounds of it, that someone would experience that still mostly from the outside, even though I understand you were an early medical student, and then the response to facing that kind of suffering would be to say, I want to go into a profession where what I'm going to do is face that with my families and their patients all the time. And not only that, but when you were telling us about literature and literatures like your study of literature is affect on your doctoring. You said that the the reason that you feel like it's most important is because it has taught you to keep your heart open. So I just would imagine that for many listeners that sort of sounds like one plus one plus one equals eight, right? Like how do you how do you face what had to be this very intimate, difficult suffering with your family as a person who consciously strives to maintain an open heart and then have the answer be? And therefore, I want to go walk this journey with patients for what I do for my day job. How? Walk us through that.

Steph Harman: [00:17:25] Okay. Okay. Tyler, that is that is such a great question. It's interesting. I don't think I've completely kind of reflected on that as specifically in some ways, it was probably somewhat of a reaction to what I experienced. For me, there was still the going into palliative care, the interplay of the ways that people experience illness and families experience illness that I got to really kind of witness and sometimes facilitate in palliative care, and I got to see more of that in my training. And I get that. Like, I think people a lot of people may go through experiences with a close family member or chosen family and then don't go into palliative care or oncology for that matter. Right. And I think that some of the threads around palliative care were also around the complexity of holding things that seemingly are at odds with one another, like holding the hope. Of reaching the child's wedding and also planning out a funeral plot. There was something about that complexity and just this kind of human capacity to do that that has kind of drawn me and kept me in palliative care. I started my palliative care fellowship thinking I'm going to be an oncologist with palliative care training. I started my fellowship. I talked to program directors, which for folks who are in medicine, like if you're talking to program directors, oh, you're putting your nickel down, right, for a fellowship.

Steph Harman: [00:19:18] And I remember in my like third or fourth month as a palliative care fellow, I could hear myself talking about palliative care and realizing that I am where I'm supposed to be. And I really was not able to talk about going going into oncology as my kind of one true path. I think I could have done that, but I think in fellowship I had some space to reflect. And and also, I think the realization that I could. Be a palliative care physician. I won't say just a palliative care physician, but that I could be a palliative care physician and that it was a legitimate specialty in and of itself. Again, this was kind of early on. Some of my conviction even got stronger when people would question it. So I had folks who were like, you know, you're. What are you doing? You're going to literally hide someone, a faculty member. Say you're wasting your career. It's interesting. I think I could have pivoted because of that. And at the time I was like, Oh, those are fighting words. And and I said, I, I realized that this is this is a question that's going to come up. And maybe because I talked about a different path and also because the field had been something that had been controversial.

Henry Bair: [00:20:40] Well, would they elaborate on why they would say something like, you're wasting your career? Like, what did they think palliative care entailed?

Steph Harman: [00:20:46] Well, you know, I think that it was you know, there was a hierarchy of the work that you can do in medicine of, well, you're not you know, you're not going to be. Curing or fixing things right? I think some of it. I remember asking this particular person about why do they think that or what did they know that? I didn't know. Kind of questions. I was like, Well, you know, you could so much more from a research standpoint and some of the science. And you know, I remember not having a great response at the time because I actually felt like, oh, I want to defend palliative care. Like and and I remember thinking I'm like, huh, this is this is interesting. I think this is going to be what will be a refrain that I may hear talking about the field, talking about, you know, our existence as a specialty. It certainly forecasted and when I started here at Stanford and with a clinical nurse specialist and half time social worker started our clinical program, just kind of establishing the legitimacy of a palliative care service was a lot of that early work that that was, I think, part of it. And it was early, you know, like I think as a specialty at the time there weren't as many fellowships and just like I think in some ways it's similar to other specialties that were that are newer in terms of like why does that exist? At the same time, I did feel like. Fairly taken aback and also kind of her mother bear for palliative care.

Tyler Johnson: [00:22:20] I think maybe the animating thesis behind the podcast is the idea that keeping more closely in touch with the deeper meaning of medicine should help to guard against or ameliorate burnout. And one of the things that I think as a palliative care doctor, of all the different kinds of medical subspecialties, you know, I've known you for a number of years, and I know you as a pretty cheerful, optimistic, engaged person. You're not walking around wearing black all the time with a forlorn expression. Right. But it really is a little bit striking. Right. How does somebody who literally your day job and I'll tell listeners, Steph only works in the hospital. Right? She doesn't even work in the clinic, which means that for the most part, she is seeing the very sickest of the sick patients, oftentimes patients who are facing the end of their lives or who are facing impossibly hard decisions with significant risks no matter what they do, or talking with the family members of those patients and trying to sort of help bring them around to as peaceful a resolution as possible. But just from a practical standpoint, a day to day approach to doctoring in the hospital. How do you approach this in a way that the whole endeavor doesn't just become so overwhelming that you shut down? You mentioned early on feeling sort of called to help people engage with the suffering that is often a part of dying. But but how do you do that day in and day out and not just get terribly burnt out?

Steph Harman: [00:23:52] So I think there are several ways that I think about intentionally preventing burnout for myself. Some of it is just kind of team based work that we do, so kind of as a team externally. And then some things that I do kind of internally or myself as an individual. It is a really good question and I think in some ways there is going into palliative care. There's definitely a process of informed consent into going into the field. You know, you know what this is going to be. At the same time, every day I step into the hospital, I learn something. I see things that and hear things and witness things that I haven't seen before and that there is strategies to kind of building capacity for that for our team. And I'll just start there because I think we are a team, and that's probably one of the big things that helps us with burnout, because it's different than when we first started. And it was one doc, one clinical nurse specialist and half the social worker. We were at huge risk of burnout. That was it for two years. For two years that was our team. And what I would say is the team has been and continues to be very important that there are multiple disciplines. We have social work, advanced practice providers, physicians chaplaincy. That really gives us a scaffold to be able to to do our work in palliative care. We intentionally build in time to kind of process what we witness, what we participate in.

Steph Harman: [00:25:48] So people talk about having team meetings, multidisciplinary meetings, teaching sessions, etc. We do a weekly check in session and a bereavement session. So we we talk about all the people who have died on our service in the prior week, and we do that every week. For us, we, we lay, we have a little wicker basket and we lay a stone in that basket for each person that we name who has died in the last week. Far from it, but not not all of the people we see in the hospital die. A lot of them. This is just a one train stop for them on their course and in their lives and others. It is that last stop. And so we acknowledge that. I think that there's so much. Unaddressed, unprocessed grief that we carry as clinicians. And so that's part of it because that's a lot of what we're carrying during the week as a team. And we just check in about really hard cases, cases, people, situations, and sometimes that's because of what's happening with the different medical teams. And sometimes it's just just witnessing what's happening with a person and their family. And so I think that's important. And sometimes it's because we're having a hard time, but nobody else is having a hard time. And so I think being able to acknowledge that is really important. It doesn't mean we're fixing things as much in that session, but just saying I'm really being a really hard time with this.

Tyler Johnson: [00:27:24] Can I just ask building on that, Steph? You know, I feel like the ironically, since we've all been wearing masks for the last two years, I feel like one of the major societal functions of the pandemic has been to unmask our collective suffering. Now, in part, that's because there has been a lot of suffering. Right? And we haven't obviously had a pandemic in a century. And so society, I think, has sort of lost the muscle memory for how to grapple with the sudden onset of mass death and dying and illness and everything else. But but even in addition to that, I feel like because of the strictures that were imposed during the pandemic, where everybody was in isolation and you couldn't be physically in community with people, and you were robbed of a lot of life's daily rhythms and everything else. I feel like even suffering or difficulties that were already there have just kind of bubbled to the surface in a way that maybe they hadn't before. Like we are more because we've been faced with so much grief from the pandemic, we are more willing to talk about the grief that is usually sort of just below the surface. And and I guess as we are now, certainly the pandemic is not over, but hopefully we've learned to mitigate it enough to sort of get back to some semblance of daily life. I guess I'm wondering, what has your career as a palliative care doctor taught you about how all of us health care practitioners or not, can productively grapple with the grief and suffering that have either been caused or unearthed by the pandemic?

Steph Harman: [00:28:59] Wow. That's a big question, Tyler.

Tyler Johnson: [00:29:02] But we're just asking you to be a philosopher in addition to a palliative care doctor.

Steph Harman: [00:29:06] You know, I think that it is a strange word to use in the context of the pandemic. But I think one of the unexpected gifts we've received as a result has been an openness to dialog about loss and grief. I am hearing about more podcasts, write about grief and loss. I see more resources out there just on the Internet, on folks who are who are talking about processing grief collectively, not just not just in the context of kind of clinical care or in health care. I think that giving permission to talk about that loss has, I think, made a big difference for thinking about grief and bereavement in general. As we think about people and I think about, you know, I have three kids and I remember my middle son, who's now ten, but right when the lockdown happened, at least in California and schools were online and and for him, it was really devastating in a loss. And he's like, this is this is not school. Right. That was his reaction in kind of observing what he was supposed to be doing in second grade. Right. Which is like really like I'm in a screen and I and I think about that and that's just one example. But, you know, our kids are just it's so interesting kind of the truths that come out of their mouths and just unfiltered. And I was like, yeah, this is this is not school like we've seen ever placed in his lifetime. And the idea that we wouldn't acknowledge the loss, you know, that just seems absurd now in retrospect.

Steph Harman: [00:31:05] But at the time, like, everyone was just trying to figure out what to do. And so so I think that, you know, creating space or actually being being forced to make space to talk about grief and loss, I think has been really important. I think it's it's not a panacea for the pandemic as much as there is some power in naming the loss, acknowledging the grief, you know, even getting like emotional and little tearful, thinking about my kids. But I remember my my youngest daughter. My youngest daughter, I only have one daughter. She is the youngest, but she there is a wonderful book by Charlotte, I think a JO and I'm probably butchering that name called Maybe Tomorrow and it is about a little hippo named Elba and an alligator named Norris. And Elba has recently lost her friend Little Bird. We don't know what happened, the little bird, but I remember my daughter pulled out this book during the pandemic and she calls it the Cry Joy Book because you see Elba, who's dragging this giant box around with her that she can't let go of. And Norris comes along as an alligator with butterflies around him. And Elba tells him about tells him that she she misses Little Bird and he says, I miss Little Bird, too. And Elba is kind of like, Well, you didn't know Little Bird, but he's like, I know, and I'm your friend, and I can help you miss her.

Tyler Johnson: [00:32:48] That's that's really beautiful. And I, I agree with you that I think, you know, I think one caution we need to take as a society is to not think that we can just say, oh, well, now we have vaccines and packs of it and whatever. So we can just turn the pandemic on and go back to life as it was before. Right. There is no going back to life as it was before. And I think that grappling with loss and grappling with grief is something that we need to we need to give time and space for that to happen. And exactly how that works, what that looks like, I think, is going to be something that we'll all have to sort of discover together.

Steph Harman: [00:33:30] Yes, I. I heartily agree.

Henry Bair: [00:33:33] Earlier on in this conversation, you talked about your experiences with Tom. Who would have been your father in law? You talked about how the care he received was in alignment with his goals and his wishes for how he wanted to spend his final days. And you talked about how you thought this was the way that all medicine was practiced. And it wasn't until you started on your clinical rotations that you realized that was not the case. And that really resonated with me because I think I experienced a similar revelation. I remember the first time I heard about palliative care and its focus on maximizing quality of life and helping patients live the best life possible. And I thought, "Wait, isn't that the point of all of medicine to help patients live the best life possible?" And then I too, like you saw quickly after I started working in the hospital on my clerkships, that in practice that was not the case, that in practice most of medicine is focused on fixing whatever disease process was happening in that moment in the patient. And, you know, that approach works very well for the majority of patients. But for those who have very complex medical conditions or who have serious or terminal illnesses, I couldn't help but think that they could really benefit from some support in helping them think through the treatment options that they have and help them envision what living well and dying well truly looks like for them. So my question for you is what do you envision as the future of palliative care? How should it evolve from here? And how do we make it more readily accessible for more people? What are some things that all clinicians can learn from palliative care?

Steph Harman: [00:35:35] Well, as I think about the future and thinking about palliative care, I will say that even in my experience as a medical student with with Tom, that a lot of that was not through him seeing a palliative care specialist as much as kind of the elements of harnessing a person's goals and values. And they live their lives as the kind of compass for different treatment paths overall and approaching a serious illness. And so I think that for the future of palliative medicine, it is really that palliative care specialists will not have and don't have a monopoly on addressing the needs of patients and their families in the context of their quality of life and their decision making in terms of what will give them the best information for their decisions. I don't think as I used to, I used to think, oh, I just I'm just working to put myself out of a job, you know, thinking about the ways that we support other teams that are really providing that frontline care to do kind of what I consider kind of that primary palliative care that like my colleagues and teammates in other disciplines are doing. And I think that changes, ideally changes in our health care system and health care delivery will enable people with serious illness to have access to basic palliative care, that primary palliative care level, symptom management, addressing and learning their kind of goals and values to influence and to direct their care plans.

Steph Harman: [00:37:24] And so that, I think, is more of the future of palliative medicine when we see a lot of it more diffuse throughout a health care system and built in, and that palliative care as a field and specialty become resources for the health system and then can focus on people who need kind of that additional layer of specialty palliative care, complex, symptom management, complex, sometimes very complex decision making in terms of weighing different values and sometimes having to rank order them in order to make decisions. So that's a very long winded way of saying I do think we'll see much more of the diffuse ness and dissemination of kind of primary palliative care. You see it in kind of a lot of the different trainings that that are out there for getting certificates, but maybe not doing a full fellowship. And then people who are resources for their teams but aren't palliative care specialists per say, we don't have a monopoly on quality of life.

Henry Bair: [00:38:30] So yeah, lastly, many of our listeners are future doctors. They're still in training pre-med students, medical students. So for those about to embark on this very long training, what advice would you have for them?

Steph Harman: [00:38:49] A few things as they are embarking on their training. Thinking about who their coach or mentors are, they're channeling their BFF, their best friend as they think about their decisions and to really to stay connected with their experience as medical students. So I'll just say a little bit more about those three things. I think about coaches and mentors. They can be the same person, but sometimes they're different folks really. And mentors are often more specific to your career, and coaches are often kind of just helping, helping you get better and investing as much as it's so tempting to let your relationships slide as you get really busy in residency, to carve out a little time or carve out little time in medical school from your relationships from when you were a student or an undergrad and invest in that. I cannot tell you how invaluable it's been for me to have. I have a mentor that I've spoken on the phone with pretty much every month since 2007, and it's been so meaningful and really helpful. It's not like I would always have a lot to talk about at each of our meetings, and if we had to cancel, we could cancel. And just the act of doing that and putting that real estate on my my schedule and priorities really made a difference. I think that when I say kind of channel the voice of your best friend or your BFF as you think about kind of your career decisions, you know what you might be kind of stretching and aspiring for, particularly for me as a woman, that that's sometimes been really hard and often thinking that I'm not qualified for something or not because I don't tick off all the boxes, etc.

Steph Harman: [00:40:42] in my own head. And that's not what I would say if my best friend looking at that same opportunity or the same project, etc., you know, if I were if it were my best friend, I'd be like, you would be awesome at this. You should totally go for it. And I forget to be that friend to myself. And then lastly, I think particularly in medical school, you are the closest you will be to a regular person who is not a clinician or a physician. And your just outlook that is such a rich well to tap into as you start seeing patients more and more going into residency or whatever path you're choosing, coming out of something like medical school to to stay connected to that stay connected to your experiences as a student, students were often the people that could stay at the bedside the longest. And how much you build that relationship, you learn from those folks and their families. I think that is something to not relinquish even as you get busier as your training changes. And so to tap into that, for some people that's writing that down, sometimes it's just being able to have names of your patients that you saw as a med student that you remember. And so I think those are all things to kind of keep with you as you go through your career.

Henry Bair: [00:42:13] Well, thank you very much for those encouraging words, Steph, and for taking your time to speak with us today.

Steph Harman: [00:42:19] Thank you, Henry. Thank you, Tyler.

Henry Bair: [00:42:23] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the doctors art. If you enjoyed the episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.

Tyler Johnson: [00:42:41] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor patient or anyone working in health care who would love to explore meaning in medicine with us on the show. Feel free to leave a suggestion in the comments.

Henry Bair: [00:42:55] I'm Henry Bair.

Tyler Johnson: [00:42:56] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.