EP. 100: ONE HUNDRED VOICES LATER — A RETROSPECTIVE

Feb 20

WITH HENRY BAIR, MD AND TYLER JOHNSON, MD

Co-hosts Henry Bair and Tyler Johnson reflect on some of the most meaningful lessons and insights they have learned over the course of the first 100 episodes of the podcast.

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Episode Summary

In the 100th episode of The Doctor's Art, we reflect on the lessons and insights we have heard from guests over the past two years. We first share the story of how The Doctor’s Art podcast came to be, then we discuss some of the most meaningful and impactful episodes for us and how the show has changed the way we practice medicine and approach life. Finally, we share exciting new directions in which we hope to take the program.

We would like to take this opportunity to thank each and every one of you for listening to this show. We would also like to thank our guests for their generosity in sharing their time with us.

Henry Bair, MD and Tyler Johnson, MD are the co-hosts of The Doctor’s Art podcast. Dr. Bair is a resident physician at Wills Eye Hospital in Philadelphia, Pennsylvania and Dr. Johnson is a medical oncologist at Stanford Healthcare in Stanford, California.
In this episode, you will hear about:
• 1:45 - How The Doctor’s Art podcast came to be
• 9:20 - Reflections on the growth and evolution of the podcast
• 16:05 - The deep meaning that Tyler found in recording Episode 19 (Art, Drama and a Terminal Illness, with Ellen Dunphy), which featured a terminally ill patient under his care shortly before her passing
• 22:35 - How Episode 41 (Love and Mercy in the ICU, with Wes Ely) set Henry up for success as he began his career as a physician
• 30:22 - The insights on suffering in Episode 52 (A Space for Mystery, with Elisha Waldman) that have influenced Tyler’s personal and professional lives
• 33:25 - How Episode 65 (Everyday Wonder in Medicine and Beyond, with Dacher Keltner) helped Henry find awe in everyday moments while working in the hospital
• 36:07 - The single sentence in Episode 73 (The Physician Who Cured Himself, with David Fajgenbaum) that has stayed with Henry and reminds him to cherish how our bodies work
• 39:10 - The two episodes that challenged the way Tyler perceives the world (Episode 86: Reflections at the End of Sight, with Andrew Leland and Episode 91: Inside a Suicidal Mind, with Clancy Martin)
• 41:24 - How Dacher Keltner’s explanation of awe points to the kinds of experiences and activities we can value and why some are more transformative than others
• 44:01 - The unexpected effect that Episode 21 (Pain, Pleasure, and Finding the Balance, with Anna Lembke) had on Tyler’s perception of addiction within our modern lives
• 51:37 - What’s next for The Doctor’s Art podcast
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] 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 healthcare 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 healthcare, 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.
Tyler Johnson: [00:01:02] Welcome, everybody, to the 100th episode of The Doctor's Art. We wanted to take this opportunity, Henry and I, to do a retrospective episode, so we thought that we would sort of tell the story of the show a little bit, and then we are hoping to take some time to reflect between the two of us on what we have learned from the show, what have been some of the most meaningful and important episodes for us, and how the show has changed the way that we practice medicine and the way that we approach life. So we appreciate all of you for being here. And I guess, you know, that's the first thing that we want to say. I know this comes from both Henry and myself, is we really appreciate everybody listening. When Henry and I first met to have a discussion that eventually led to the show, this was in about December of 21 or January of 2022.
Henry Bair: [00:01:59] It was right before a winter break of 2021.
Tyler Johnson: [00:02:02] Yeah, still pretty in the thick of the pandemic. Like, I think that was around the time that like Omicron was a big thing and there were still hospitals that were filled with patients and whatever.
Henry Bair: [00:02:12] And I say winter break, because back then I was still a medical student.
Tyler Johnson: [00:02:15] Right. And Henry and I had gotten to know each other. Henry was helping to run a course on Stanford campus called Being Mortal, and I don't remember how I initially got introduced to the class.
Henry Bair: [00:02:26] Well, this class, Being Mortal, was meant to serve as an introduction to issues of human mortality, palliative care, and end of life care. Topics that most clinicians encounter quite regularly yet aren't usually discussed in medical school. For one of the sessions, we were looking for someone to teach our students how to use the Serious Illness Conversation Guide, which is this validated framework developed at Harvard Medical School for talking to patients about their goals and values in the face of major or terminal illnesses. It turns out you, Tyler, were the Stanford faculty member officially designated to teach the guide to residents. And so I reached out. You agreed to lead that session for my class, and the rest is history.
Tyler Johnson: [00:03:09] That is interesting because that was fortuitous. So I think I by that time I had lectured in the class once or twice, and Henry was helping to teach the class, and I think we sort of recognized we got talking one day after class, recognized that we had some similar interests. And so then we I think we had been to lunch or whatever a time or two before that. But on that particular occasion, in December of that year, we started talking and found out that both of us, during the really stark, bleak time of isolation in the pandemic, had thought about starting podcasts, you know, and our ideas for what that might look like were kind of roughly aligned, at least with each other. And so we, you know, talked about it a little bit then, then we talked about it again when we got back from the break. And then I was incredibly lucky because Henry was both at a place in his medical training where he had the time to and also had the interest in aptitude to just figure out all of the stuff about starting a podcast. Once that was all figured out, then we came up with our little like advertising blurb and came up with the little thing that we say at the beginning of each program and whatever, and got a couple of microphones and set up in a room somewhere on Stanford campus and, and made a list of people we wanted to reach out to and just kind of started recording. Does that sound about right, Henry?
Henry Bair: [00:04:36] Yeah, that sounds right. I don't know what I was expecting when we first started. Maybe a few friends or family members, some classmates might listen in. For me, it was just totally an open exploration. Both of the topic with you, as well as with potential guests whom I thought we'd be drawing from our local community. For the most part. You know, I thought we'd be talking to lots of students, maybe attending physicians, you know, professors at the medical school. I thought that was it. That was the mindset I brought into our first few recordings.
Tyler Johnson: [00:05:09] Yeah. And it was funny because, I mean, I think that we we had a pretty good sense that burnout was a problem and that there were important conversations to be had around the topic of burnout and around why burnout was happening and what we could do to combat it. But I think there was also a sense that there was a sort of a deeper set of themes that were related to that, but distinct from it, that also could really use exploration. And I mean, I think both of us are unusual in the sense that while we love the practice of medicine, you know, neither of us was an MD, PhD, neither of us spent a lot of time in a laboratory doing research. Right. We're much more likely to be reading. Literature or philosophy or, you know, whatever, both in terms of what we studied as undergraduates and then in terms of just what we gravitate towards now, that's much more our thing. And I think that this became both a wonderful place to interact with guests, and also a wonderful place for the two of us to sort of establish a space to be able to talk about medicine through a prism that is maybe different than the one that you would hear in a lot of other places.
Henry Bair: [00:06:35] Yeah. What's interesting is that one of our fundamental missions ended up being to explore the issue of physician burnout. In all honesty, that was not on my radar when I first conceptualized doing a podcast. Initially, storytelling and humanistic medicine was my angle towards it because, as you mentioned, I came into medicine after having done a lot of studies in liberal arts, medieval literature, to be specific. I came into medicine because of the storytelling aspect of stories, of human connection and resilience and answering the big questions in life, and I enjoyed reading those things, and I enjoyed writing about those things. So certainly in the preceding few years during medical school, I had been writing about my patient encounters and how I struggle with the emotional responses that often comes of those interactions. I had been writing them initially for myself, but then eventually I found out that a lot of medical journals actually publish these stories. So then I started publishing them. And then through that, I got readers who would respond to me, just out of the blue, readers who might be patients, who might be attending physicians, other students, even hospital administrators at one point. And then through all that dialog I was starting to have with all these strangers essentially working across medicine, that was what gave me the idea of having a podcast, because I was having all these really rich conversations, largely by text, by email, and I was learning a lot from all these individuals, which got me thinking, well, I bet there's a lot more untapped stories out there. I just needed a platform, so that was my idea.
Tyler Johnson: [00:08:24] It's interesting because, you know, I remember wanting to approach medicine in this way when I was in medical school. I just felt like like I didn't have anyone else around me who spoke that same language or who was approaching medicine from this same kind of vantage point. And actually, when I interviewed at Stanford for residency. So Abraham Verghese and a person who will not be known to most listeners, but who was very formative here at Stanford, whose name was Kelly Sheff, who used to be the program director of the internal medicine residency program here, spoke on my interview day. And both of them have much more of this bent to the way that they approach medicine than anyone I had encountered in medical school. And I immediately thought, that is a place that I want to be precisely for that reason. But even so, when I got here for residency, although it was a much, it felt like a much better fit than medical school had been. I still recognized that I was unusual in the way that I approached medicine and sort of my philosophy of care and whatnot. All of which is just to say that when we started out the podcast, I thought that at best it would be this very niche thing that would maybe, you know, find a couple people here and there who sort of resonated with our ideas.
Tyler Johnson: [00:09:44] And because I think we could both tell once we started talking over lunch and whatever, that we had similar philosophical approaches. But I think that I thought that there would be a few people out there who would maybe listen to it and resonate with it, and that would be it. But then we have been through maybe three distinct periods that I can think of when the show has sort of become available to a new set of people because of, you know, advertising in a different place or just the vagaries of social media or whatever, where it was like we would watch the Apple podcast app or whatever, and the rating, the number of times the show had been rated would increase, sometimes by tens or even hundreds over the course of a few days, to the point that now I think it has something like 3000 ratings on Apple Podcasts and I think has, you know, these better numbers better than I do, Henry. But I think it's been downloaded something like 300,000 times. Is that right?
Henry Bair: [00:10:43] Yeah. We passed the 300,000 mark a few weeks ago, which is incredible to think about, because one of the things when I when I think about the scale. Of the listenership, the growth of the scale of the listenership. I find it amusing that on my end, on our end, I don't think my workflow has changed that much. And yet, like on the other end, the receiving end of it, like it's grown like far beyond anything I could have imagined. So it's it's incredible to see the growth and the impact.
Tyler Johnson: [00:11:15] And by the same token, I think there was this moment pretty early on in the show. I still don't know why he said yes, but Francis Collins agreed to come on the program maybe 4 or 5 months into US recording. Right. So this is for those who maybe haven't heard that episode. This is the director of the Human Genome Project, one of the most famous scientists of probably the last half century.
Henry Bair: [00:11:39] And the former director of the National Institutes of Health. A pretty big deal.
Tyler Johnson: [00:11:44] A very big deal. So he agreed to come on the show when I think we had many, many, many fewer listeners could not have been more gracious or kind or generous with his time, to the point that I think he was recording it in some, like, closet that he had stepped into in the white House or something. That's right.
Henry Bair: [00:12:02] Yeah. He had agreed to talk to us shortly before a scheduled meeting with the president. I'm not sure, with some important people. Right. And I think what was amusing and what was a little bit terrifying for us at first, was we use a remote recording tool called Squadcast. When he was trying initially to access this remote recording tool, he was having technical difficulties because he was trying to open it on like some white House workstation, and they were blocking it. And at one point I remember, Tyler, you and I, we were looking at each other. I was like, is this going to happen? Are we going to have to reschedule this? And if we do, it's probably never going to happen. If we if it doesn't happen today, it might not happen. We might not get another chance. And then not only does he persevere and find an empty room with a functioning workstation, then he stays late to make up for the delayed start, being late to his important, far more important meeting afterwards.
Tyler Johnson: [00:13:02] And so then, once we had interviewed Doctor Collins, I think both of us kind of said, well, okay, what do we have to lose? And we have been so grateful and gratified to see the breadth of people who have responded and who have been willing to come on the show. And likewise, you know, we read all of the comments that are posted, the large majority of which have been incredibly gracious. And by the same token, we have been so grateful to see that the program has also become I mean, I guess I'm not sure exactly how to measure this, but I think it has to be one of the most widely recognized and highly acclaimed podcasts in this, I don't know, subject area or whatever. So at this point, it has been honored with the 2022 Medpage Today Reader's Choice Award, a 2023 People's Choice Podcast Award, a 2023 Davey Award, a 2023 Webby Award, a 2023 W3 Award, a 2023 Signal Award, and a 2024 Anthem Award. And, you know, we could go through what each of those things is. But the point is just that, I mean, some of those are a really big deal, right? Those are like awards that are going to, I don't know, Michelle Obama and Oprah and Ezra Klein and people who I've, you know, heard of all of that is just to say that we are I mean, most of the time when we do an interview, we we finish the interview, and then Henry and I just kind of look at each other and shake our heads and think that we are incredibly lucky to be along for the ride.
Tyler Johnson: [00:14:44] So all of that is to say thank you to everyone for listening. We wanted to just pause at the 100th episode and sort of recognize how far we've come. But then much more importantly than that, I think that what I can say with no hesitation whatsoever is that, you know, for me anyway, the person who's benefited the most from the I feel like from the program has been me, because the conversations that the people that we have spoken with are so insightful and bring so many wonderful ideas and sometimes not just single ideas, but entire paradigms, that it is absolutely the case that having these conversations, I mean, this maybe sounds dramatic, but it's true has changed my life. Like there are ideas that have become part of like my central operating system at this point that I learned on this program. And it's certainly true in the way that I practice medicine, but it's also true in just the way that I approach life, the way that I approach finding meaning, and really in all of the aspects of my life.And so what we wanted to do for the last, you know, 45 minutes or whatever today is just to discuss between the two of us, what are some of those ideas that have come to mean the most to us? I mean, I would have to say that.
Tyler Johnson: [00:16:05] In terms of the episode that for me personally meant the most to me was way back episode number 17, which was entitled Art, drama and a Terminal Illness. And this was the sort of final punctuation to a story that is stranger than fiction. Truly, where I got invited of all things to make a training video with, I don't know, the powers that be. At Stanford, I went to make this training video. I showed up this morning and I spent like four hours in this clinic room that had been converted into a like a film studio, sitting opposite an actress by the name of Ellen Dunphy, who was a standardized patient at Stanford and had been selected to do this for our training video. And in the video, I was playing the part of the doctor, and she was playing the part of a woman with metastatic melanoma who was on the cusp of dying. And then the point of the training video was for me to have this conversation so that she could with her so that people could see how to have these end of life conversations. Then I forgot about it. The video got made and I think got distributed to some degree at Stanford. And then about six months later, my colleague Brendan Visser, who's a cancer surgeon at the hospital, said that he had admitted a young woman who had had sort of chronic abdominal pain to the hospital. And finally, because they could find no other cause, he did a surgery where he went in and explored the inside of her abdomen to see if he could find the cause, and found bumps along the lining of her inner abdominal wall that looked suspicious. He biopsied them, and in fact, that surgery led to a diagnosis of metastatic stomach cancer. And so he said, you know, can you come and talk to her? Because this is a shocking diagnosis and whatever, whatever. I don't think he realized at the time. But when I, I started to put two and two together, as I looked at her medical record and saw her name and saw some of the clues. But sure enough, then I go into the room to see her, and it was the actress who had played a patient six months earlier opposite me in this training video, now in the hospital with her husband with metastatic cancer.
Tyler Johnson: [00:18:14] So that started like a two and a half year journey of me being her oncologist. That journey eventually involved me attending one of her plays. I mean attending, meaning watching over zoom on my floor in the middle of the pandemic in my kitchen, but still attending as best I could, and then involved her writing and producing a one woman play about the experience of being diagnosed with terminal cancer. And then we talked for a few months about having her on the podcast, which I felt a little unsure if that was an appropriate thing to ask of a patient, but she really wanted to. And so Henry and I recorded this interview, and then literally we recorded it in the morning. In the afternoon. She became ill that very afternoon. And then that evening, her husband took her to the hospital. The next day, she was transferred from the regular floor of the hospital to the ICU. She spent like five days or something in the ICU and then was sent home on hospice and died a few days after that. So that recording that is episode 17, where we talk to Ellen about her experience of having cancer and and what it was like to have a terminal diagnosis once the whole story had played out, turned out to have been recorded within a week or two of when she died at home on hospice.
Tyler Johnson: [00:19:37] So, I mean, you can hear on the recording that her voice is pretty weak and kind of raspy, like you can sort of hear the weight of the illness in her voice, but having that opportunity as her oncologist to then talk to her as a guest on the program, and then later on a few episodes down the road from that, once he had had time to sort of process the death and be able to be in a place where he could talk about it again, we also had on her husband who this was in episode number 32, where we talked with Andy Kleinen about the experience of going through her cancer journey with her, and then what it was like to lose her. So certainly on a personal level, I think those are probably the two that stick out for me the most.
Henry Bair: [00:20:21] Out of curiosity, as an oncologist, you take care of many, many patients. The kinds of questions we asked on the show, how often, if at all, do you get to have those conversations with your patients, like your patients that you see during the day?
Tyler Johnson: [00:20:37] Yeah, it's a good question. I mean, you were, I think maybe more, I guess, prophetic or more tuned in to where the show was really going to go early on than I was, in the sense that I think that I really was thinking about it in terms of kind of exploring burnout and causes and solutions, but have long ago realized that really, I feel like. What we have sort of concluded together is that doctoring gives us this privileged and rare entree into witnessing, and sometimes even participating in the most meaningful things of life, meaning birth and death. And, you know, all of the things that come in between. All of which is just to say that at the end of the day, I feel like what the podcast has really become about is what makes life meaningful. What is life? What do we make of life and of suffering? And anyway, all of those big questions and I have to say that I do actually, I feel like in sometimes explicitly and sometimes implicitly, I do get to talk about those things with my patients. I mean, I just actually yesterday had a patient who has been getting chemotherapy for a long time and had become somewhat sick and then became suddenly very sick. And so I was in the hospital with this patient and her family having a over a couple of days, a series of increasingly serious discussions about the medical situation. And that is what those discussions are. Those discussions are about what matters most and how do we cope and grapple with suffering, and what do we how do we make meaning in a life that is so often suffused with what's hard? So yeah, those things actually really do come up all the time.
Henry Bair: [00:22:35] Well, the earlier you talked about how a lot of the lessons in the stories you've heard on the show have transformed the way that you practice, or the way that you live your life and approach these issues yourself, issues of maybe suffering and mortality and illness. For me. It's a little bit different because when we started these conversations, when we began interviewing people, I was still a medical student, which means I was not a real doctor. I had not independently taken care of any patients. I had not independently counseled any patients on a new cancer diagnosis or discuss prognosis with people. So there was always a part of me that was wondering whether or not I was qualified to do this, to have these conversations, to be pontificating about what makes life meaningful and difficult parts of medical practice. When I did not know. In all honesty, I did not know what it was like to practice medicine. You know, we would have these conversations with people and they would talk about the brutality of residency. And I would not allow without actually realizing how brutal residency was, because I was still a medical student. But I have to say, I think that in many ways, the conversations that we have had have, in a way set me up for incredible fulfillment and success, if one can put it that way, even in the first eight months of my time as an actual licensed physician, as a resident. But still, you know, there are so many episodes I can think of where I can point to specific lessons learned.
Henry Bair: [00:24:14] If I were to just pick one that really packed the most punch, I would have to go with episode 41. And that's the one with Doctor Wesley. Um, that episode is titled Love and Mercy in the ICU. Yep. Doctor Wesley is an intensivist at Vanderbilt, and he was really an early pioneer in this disease entity called Post-intensive Care Syndrome. And PTSD among patients who were discharged from the ICU, and those of us who have worked in the ICU in any capacity will probably recognize these standardized practices we do now across the country in ICUs everywhere. Things like making sure that we use as little sedation as possible, trying to get people off of breathing machines every single day, having family nearby like these were things that he and his team came up with, and they're now implemented everywhere. I think it's telling that having family by the bedside is one of the key interventions to helping people recover faster. So on that episode, we heard about his own practices for restoring humanity in a place the ICU where patients are the most dehumanized. There's so much good advice that you shared. One was something as simple as get physically closer to the patient by kneeling down when you talk to them, when you interact with them, as opposed to sort of standing looming over them and talking like literally talking down to them. I started doing that pretty much day one of residency.
Henry Bair: [00:25:59] And I vividly recall at one point I was in the ICU too. That's... I started residency in the ICU and day two. It was during my morning pre-round, which is where I just go around and visit all the patients to see how they're doing, check their vital signs and their ventilator settings. And I would remembering explicitly what Doctor Ely shared. I would kneel down by each patient. At one point I was kneeling down talking to a patient. He was with it enough. His eyes were blinking. He was responding to the questions I was asking him by blinking. And the nurse runs in and asks me if everything's okay. And I was confused because this patient was fine. I asked her what happened, what brought you in here? What makes you think there's something going wrong? And the nurse says, are you checking something? Why are you by the ground? It turns out the nurse had never seen any physician do that before, so that was pretty striking. And then the week after that, I would do the same thing. And then this time a family member would come in and ask me what my role was. I was in scrubs and I had a stethoscope near me. I had a badge that said physician. The husband of one of the patients asked me, he's like, oh, what do you what do you do here? And I said, oh, I'm one of the residents taking care of your wife. And then he's like, oh, I've just never seen someone in that position physically kneeling down. I suppose if you've never seen it in the ICU or in the health care setting, you must be a pretty striking image.
Henry Bair: [00:27:26] Although I would not know because I just started residency at that point. So I mean that kneeling down, so simple, so powerful. Doctor Wesley also talked about how with every new patient he meets, he asks about their favorite foods, their pets, their hobbies, their favorite music. These are things that I do on a daily basis. And you know, it can be awkward, right? Like you're admitting a new patient and you're going through the standardized past medical history. What medications do you take? What allergies do you have? Have you ever smoked? How many you know, alcoholic drinks do you drink in a week? Oh, by the way, what's your favorite music? Yeah, there's a certain finesse, I would say to like making it to organically working those questions in. And it's definitely something I'm still working on, but I think patients appreciate it. At one point I was on an internal medicine wards at a med student following me that morning, and there was a new admission. And then I asked those questions and the med student explicitly. After we left, I asked the med student if she had any questions, and then she explicitly mentioned, like, oh, I've never heard of anyone ask about music and food and pets before. And she appreciated that. So the fact that like, it's being noticed in a positive way, like all these little tidbits of advice, I just love that that all came from that one episode. You know, these are themes again, that come up in subsequent episodes, but that really, really stands out to me.
Tyler Johnson: [00:28:55] Yeah, I, I remember that episode distinctly, too, because the kneeling thing, as I talked about in the episode, I have done that with patients in the hospital for a long time, but I've never seen anyone else do it. And hearing that there was someone, I think he's in Tennessee or something across the country who was doing that made me feel like I was slightly less crazy than I thought I was, and not all alone in doing that. And then, just like you said, after he mentioned the thing about asking about music and whatever, the next time that I was attending on the wards, I asked my team. So I can't remember if I think he does this too. But the way it is at Stanford, at least every patient in the hospital has what's called a one liner, which is really more like a paragraph that explains their pertinent medical history and then why they're in the hospital. And any important, significant thing that's happened since they've been in the hospital. Right. So a typical one would say, this is a 57 year old with a history of hypertension and diabetes who was admitted after having a non-st elevation MI and underwent a catheterization, you know, two days after admission or whatever. So I asked my team to start including in that one liner, the patient's favorite food, the name of their pets, and their favorite hobby or something. And it was amazing how quickly it started to get around the hospital that the patients on this one particular cancer service were having all of these funny, random things show up in their one liners.
Tyler Johnson: [00:30:22] But to your point, I think the reason that the word was getting around about it is because it's such a good and powerful idea, right? By the same token, I think in terms of the way that I approach. Medicine and also approached life more broadly. Maybe the episode that has most impacted me that way was episode number 52, which was Elisha Waldman, and the episode is entitled A space for mystery. Elisha Waldman is unusual because he's a doctor who started off as a pediatric oncologist. So the pediatric counterpart of of what I am. But then over time, I think sort of realized that his real calling was to be a palliative care doctor. And so now I think exclusively works as a palliative, a pediatric palliative care doctor. And that episode, I think as much as any that we have ever recorded, we really got into the weeds talking about suffering and the difference between pain and suffering, why suffering is part of being human and what we as doctors and other health care professionals are to make of it. When our patients suffer, or when we suffer, and how we are to respond when there is suffering for which we have no cure. And I still remember very distinctly there are a few paragraphs or, you know, I don't know if you can speak a paragraph, but anyway, of what he says during that podcast that still are kind of emblazoned on my mind, they're like tattooed on the inside of my skull where he talks about what he calls the molten core of suffering, which is his word for describing that when you sort of give all of your medications and you have had all of the surgeries and you've done all the things and you've exhausted all of your all of the instruments at your disposal to try to heal and cure and fix. And then there is still suffering left over after that. What do you do with that? What do you make of that?
Tyler Johnson: [00:32:31] And his episode is very different than Wesley's episode in the sense that, like at least thinking back on it, I don't remember, like a tip or trick that I took from it where I say, oh, well, now I'm going to, you know, list the four things or kneel at the bedside or whatever it is, like, there's no I don't remember anything like that, but I, I just feel like having that conversation and thinking about those things as a doctor who takes care of a lot of people who are suffering in various different ways, that has been really, really meaningful to me. Like I feel like on a deeper and sort of inarticulable, if that's a word level, that episode really changed the way that I operate as a person, both in terms of approaching my own suffering and the suffering of the people that I love who are around me, and also the suffering of of patients that I encounter in the hospital.
Henry Bair: [00:33:25] Yeah, similarly to that, like the episode that didn't necessarily result in concrete step by step advice that I could implement in a physical sense, but that nonetheless shaped my cognitive, philosophical, emotional, spiritual approach to attending to patients was episode 65, which is entitled Everyday Wonder in Medicine and Beyond with doctor Dacher Keltner, who's not a physician. He is a psychologist at UC Berkeley who specializes in human emotion. And he had at the time when we recorded that episode, he had just published a book called are, and that was what his studies were. His academic research was into the experience of awe and wonder and the sources of awe and wonder in everyday life. In that episode, he talked about the different categories of wonder, right? Things like moral beauty, and I think nature was one of them, and a life and death. And religion. And I think having that conversation in my mind just opened my eyes to all the moments where you can find on wonder day to day in the hospital, because it is really easy, especially as a resident, when you're saddled with so much paperwork and documentation and scut work. Grunt work. To just move through it without really acknowledging what's going on beneath the surface. But I think it is because of that episode I've been.
Henry Bair: [00:35:06] Trying to be more receptive to what he terms moral beauty, which are things like courage and resilience and patience and kindness. Because the hospitals are actually rife with moments that exemplify what he talked about. I mean, I can recall so many instances of me just consciously sort of taking a pause after rounds, for example, or after a conversation with a patient who is not doing so well, taking a few seconds, literally acknowledging how incredible their resilience is. And that in a way, is very rejuvenating. It sort of gives me new energy into continuing to do what I do. So that was an incredible episode. Obviously not every single episode is going to have like. A massive impact on the very way that you approach a you move through work and life like that.
Henry Bair: [00:36:07] But I mean, there are here and there little bits of when I think about it, little bits and pieces, little sentences, even phrases that stay in my mind. For example, like in episode 73 with David Feigenbaum, who the episode is titled The Physician Who Cared Himself. David Feigenbaum is an immunologist at UPenn. He became really sick as a medical student, and no one knew what was going on, and he started experimenting on tissue samples of himself.
Tyler Johnson: [00:36:36] As one does. Because, you know, why not just go take your own lymph nodes?
Henry Bair: [00:36:42] Yeah. He diagnosed himself essentially with Castleman disease, and then there was no treatment for it at the time that he was responsive to. So then he started going the lab and trying to discover his own cure, which then he did.
Tyler Johnson: [00:36:55] This is a disease so rare that doctors don't even know which specialist to send a person with the disease to, like they don't even know what category. Is it a cancer?
Henry Bair: [00:37:04] Or is it an infectious disease or is it an autoimmune reaction? It's pretty incredible. But at one point, you know, we were asking about where his head space was sitting in the ICU there. And for those who don't have the context, right before all this happened, he was like a college football player who even in medical school was going to was winning bench pressing competitions. And so to go from that to being stuck in the ICU for six weeks, you know, we were asking him like, what are some of the things that crossed your mind? Again, this was not the main focus at all of the episode itself, but one thing that stuck in my mind was his response of he was looking at all these medical students and residents attending, kind of coming in and out, and then it struck him. Wouldn't it be amazing if I could walk because he couldn't at that point, he was so sick and his legs were so swollen like he couldn't walk. And in that moment, that's all he was thinking. Wouldn't it be amazing to walk, which is something we take for granted? I don't know why that just sticks in my brain. And now it's like every once in a while I'll remember. It's amazing.
Henry Bair: [00:38:06] I can walk, you know? It's not just that too. Like in the hospital, there are plenty of patients who can't swallow properly, and so we have to put in tubes through their nose that goes into their stomach so we can like, give them nutrition or we'll do like tubes that literally go through the skin above their stomach, like directly into the intestines to feed them. When I see those patients now, I sort of remind myself or think to myself, it's incredible that I can swallow properly and taste food. It gives me a renewed appreciation for everything, and at the same time, it helps me recognize that there are so many patients in the hospital who can't swallow properly. And we typically just say, let's just put an Ng tube in there and then we just move on with our lives. But I think it means something when you take the time to acknowledge how big of a deal this is for a patient not to be able to walk properly, not to be able to use the restroom on their own, not to be able to eat that favorite food. When you take the time to acknowledge that with patients, talk them through it. Hear them out two minutes. That makes a big deal.
Tyler Johnson: [00:39:10] In thinking about that two episodes that were really illuminating for me. One was episode number 86, reflections at the End of Sight with Andrew Leland, who was a person who told us the story of being diagnosed as a teenager with a very slowly progressive condition that would eventually lead him completely or nearly completely blind. And then also episode number 91 with Clancy Martin, who is a author and philosopher who talked to us about what it is like to be a person who, since he was a very small child, like, I think he told us 5 or 6 years old or something, has been fixated on the idea of ending his own life. I mentioned those two just because, you know, I felt like in particular with the first of those two interviews, that was probably maybe of all of the ones that we have done, the interview with Andrew Leland was the one where I felt the most ill equipped and the most nervous that I was going to say something stupid or insensitive, because a lot of what we do in that episode is to try to explore what is sight, and how does sight shape the way that we experience the world. And when sight is lost, what is the experience of that loss like for people who are going through that? Right. And then by the same token, with Clancy Martin talking through what it is like to be a person who has essentially for all of his remembered life, has been in a place where he was at least intermittently considering ending his own. Life. Those interviews are ones where as much as any other interview that we have done, I felt like my. Mind was opened to the notion of considering what it would be like to experience the world in a way that is completely different from the way that I currently experience the world.
Tyler Johnson: [00:41:24] I also you mentioned the Dacher Keltner interview. You know, every once in a while you'll read or learn something that feels like the justification that you have desperately wanted, that you didn't even know that you needed until you heard someone articulate it. And one thing that, like friends and loved ones have often sort of teased me about is that I have this set of things that I just love and absolutely never tire of. So, for example, I never tire of listening to Rachmaninoff's second and third piano concertos, like Life Is More Beautiful because of my 10,000th and first time of listening than it was after only 10,000 times of listening. And one of the things that Doctor Keltner talks about is that that is actually one of the defining features of R is that it gets better every time you experience it, because that's what R is, right? It's the exact opposite of consumer culture, right? If you think about consumer culture, it's all about things that are disposable and have to be updated. And like you, you buy whatever consumer thing knowing that eventually you will throw it away. Like the point of it is for it to become expendable. And R is exactly the opposite of that. So now I feel, you know, this is a silly thing to say, but I guess I feel justified in the fact that I still love those, like certain pieces of music or those certain places in nature just as much as I did the first time I encountered them, however many years ago.
Henry Bair: [00:43:00] Yeah. No, I mean, that's a valid point, right? Because, like, it's really easy to fall into this, I guess, cynical, skeptical post, post postmodern view that there are no pleasures that are better than others. It's all it's all valid. It's like whatever you want, whatever brings you joy works. You do. You kind of thing. Yeah, but what his take home point was, no, there are some things that are more rewarding, more deeply fulfilling, more empowering, more inspiring, more transformative than other things. Yeah, things like kindness. Things like even a religious tradition that resonates with you. Like, these are things, as you mentioned, that you can't get tired of. No matter how many times I see courage, I'm not going to get bored of courage. So many times in the hospital where a patient is getting really sick and we don't know what's going on, and we try a new treatment, and with each treatment they get sicker. But every day in the morning I go in there and I see them and they're they're smiling. They're like, okay, what's today? What's a plan for today? What's next? That is never going to cease. Amazing. Me yeah, I think there's a significance there.
Tyler Johnson: [00:44:01] And I think that one of the great pleasures of being the hosts for these podcasts is that eventually you get to let your mind start to make connections between things that different guests have said. Right. And when I think about all of the ideas that we've encountered in the people that we've talked to, I feel like if I had to choose ideas that have become kind of like the hub of a wheel for me, connecting a lot of things from different places, that would be the interview that we had with Anna Lemke, which was, I think, episode number 21, I believe pain, pleasure and finding the balance. And I have to admit, that was an episode like when when I first started to learn about Anna Lemke and kind of what she did, I would not have expected that to be a transformative episode for me, because she's one of the world's foremost leading experts on addiction. And I just, you know, would not have anticipated that that was going to be something that was going to be particularly meaningful. But we ended up kind of to your point about how one of the distinguishing features of the Doctor Dacher Keltner interview was the idea that some things are better than other things, that things that bring are are better than things that are meant to be consumed. I think that part of her sort of overriding thesis, especially in Dopamine Nation, is the idea that we live in a culture that has hijacked our brain's own reward system, so that, in effect, we are all addicted to all kinds of things. Right?
Tyler Johnson: [00:45:37] The question is almost to what are you addicted? Rather than are you addicted? Right. Because you might be addicted to fast food or to social media, or to pornography, or to, yes, opiates or cigarets or whatever. But it's there's just it's sort of like there is addictive material everywhere you look. Because we live in a society where our brains are so flooded with dopamine all the time that we get to a point where if my brain is not currently being flooded with dopamine, right? Now. Then I feel depressed or anxious or like something is wrong because we need our fix, you know, all the time. And as people who listen to that episode will know, one of the things that we ask her is we say, well, okay, because she works with a lot of she's a psychiatrist and she works with students at Stanford and in the surrounding area. And she'll have people come to her who who in effect say, I feel anxious and depressed and I want to drop out of school and, and but more than that, I just feel like my life has no meaning. I feel like I'm just this sort of like consciousness that's floating in the ether, and there's no there, there. We asked her, we said, if someone comes to you and says that, what do you tell them? Like, what's your advice? I bet not a week has gone by since that interview that I have not thought in some respect about her answer, which is she said that she counsels them, that what they need to do is go into what she called the Great Quiet. By which she means leave behind your smartphone and your computer and your devices and your junk food or cigarets. Like, just go and be a person by yourself in the quiet in nature, for long enough to break your dependency on all of the things to which you are in effect, addicted. And then that will give you a place from which you can start. I feel like strains of that idea, connections to that idea, have come up for me over and over and over again in my spiritual life, in my family life, in the conversations that we have had subsequent to that one on the podcast. This sounds dramatic, but there's a part of me that wants to say that I feel like that idea is like the key to much of what ails society, and that if we could try to respond to that in a productive and helpful way, that that would be one of the most important things that we could do in trying to restore some sense of balance and perspective to what often feels like a culture that's sort of, in many important ways, careening off the rails.
Henry Bair: [00:48:21] Yeah. So, uh, how much of answering the big questions in life and trying to figure out what ails society? How much of that were you anticipating when we first started these conversations?
Tyler Johnson: [00:48:33] I mean, that's kind of what I was getting to at the beginning, is that that is what has most surprised me. I mean, I've always had an orientation in that direction to some degree. And so because I've always had that orientation, I guess in a sense it's not surprising that and I think you also have that orientation. So I guess in a sense, it isn't surprising that our conversations have taken that direction to some degree. But I guess I have been both surprised at how primed many of our guests seem to have those conversations, and then how much those conversations clearly seem to resonate with a lot of people who are listening, you know, which I think is borne out by just the number of people who are listening.
Henry Bair: [00:49:25] Yeah. So as if, uh, people have been waiting to have these conversations, to hear these conversations. In fact, I think explicitly we've had that we've had guests, accomplished guests, chairs of departments tell us I've never had this conversation before, but this was nice. This was lovely, you know, thank you for providing this opportunity. And I think that was one of our main objectives, was to create a platform for people to talk about these things, the things that sort of occur beneath the surface, but drive much of what we do on a daily basis, but also what all of that amounts to in the end.
Tyler Johnson: [00:49:58] Yeah. And, you know, I think that in some ways to kind of bring it back around to where we started. Henry and I met as part of a class in the medical school, and around the time that we were starting the podcast, we started a new class called Meaning in Medicine. The first year was kind of a I think we didn't quite yet know what we were doing, so it was a little bit unfinished, I would say. But then by the second year, I think we had we had a better focus and a and a better understanding of where we, where we wanted to go with it. And then though Henry is now in Philadelphia, I'm have a new co-teacher, and I'm teaching the class again right now. And the thing that has been maybe the most gratifying and that still continues to surprise me, is that I guess I want to say two things. One of them is that one of the things that Henry and I have discussed extensively behind the scenes and sometimes on air to some degree, but that kind of, um, brings together some of our most important learnings from the podcast writ large, and all of the 100 plus hours of conversation that we have had. Is that we can't reduce medicine and we can't reduce life to a purely materialistic concern, meaning that we can't treat the people that we take care of as doctors, as just what one philosopher called random collocations of atoms. If we make ourselves into machinists.
Tyler Johnson: [00:51:37] No offense to machinists, but if you treat people like machines, it robs medicine precisely of that sense of mystery and that sense of spiritual meaning that, I think, are the things that give medicine its beauty and its moral resonance. So on the one hand, I feel like that is a big thing that we have learned. On the other hand, the thing that continues to delight and surprise me is that to Henry's point from a moment ago, people seem to be hungry to be reminded that that is true. And so, uh, we got an email Henry and I did a couple of weeks ago from a woman who has been an undergraduate student and was applying for medical school, who basically had been listening to the podcast and in effect, said that these very ideas had been resonating with her as she had prepared for medicine. And by the same token, every year when we have this class that we teach at at Stanford, we go around the room at the beginning of the class and ask, why are you in this class? Why are you taking this? And invariably some large proportion of the answers are, I heard the podcast or I heard you, Doctor Johnson, give this lecture or I heard whatever, and nobody talks about this. But as soon as I heard you talking about it, it resonated with me how deeply important this is. And I came to this class because I needed a place where I could talk about this freely.
Henry Bair: [00:53:10] Yeah, I remember the second iteration of the class when we took, uh, you know, each of our sessions were revolved around a different theme. And when we got to the one, I think we had one specifically on spirituality, not religion necessarily, because we sort of we were obviously we don't assume that anyone subscribed to a particular religious tradition, but but spirituality is something that, you know, the recognition that there is something more beyond just physical organs and organisms that we're taking care of, that there's more there's something beyond that. There's something transcendent about taking care of a soul, a spirit person deeper, like a consciousness, whatever you want to call it, there's something there. So during that session, I remember we were having people the students were reflecting on what spirituality means to them. And at one point, one of the students said, I didn't know we were allowed to talk about this in medical school, which I found amusing. A little bit sad, but I'm glad that this was a place where they felt. Oh, and the other thing besides that, someone else also responded by thanking us for creating a safe space for having these kinds of conversations. And to me, that struck me was like, what do you mean? Do you feel unsafe talking about these issues? Apparently so surprisingly. But all of which is to say that I think these spaces are essential. Really, I think I have to say they are essential to medical schools. And now that I'm in residency, I wished there were more spaces for this residency as well.
Tyler Johnson: [00:54:36] Yeah, actually, in a weird way. And this might sound strange since I'm the person who's, you know, creating and whatever the class. But that's largely how I feel, is that it's it's gratifying and yet also strange to recognize that I feel like I have had to. Mentally give myself permission to talk about these things publicly, especially in the medical school. Like I if you had asked me 4 or 5 years ago, I think I would have said, ah, you know, we don't really talk about that here. That's not part of what we can talk about in medical school, which of course doesn't make any sense. But that's how I would have answered. Right. And so I think that that's the maybe the biggest, you know, if there are people out there who are medical educators of any stripe where whether you are a medical educator, as a you're a supervising resident who's teaching your interns or whether you are an attending or whether you are a dean or a chair or a chief or a, you know, whatever your leadership position, if you have a hand in teaching and training health care professionals, I mean, we now have 100 plus hours of what you could call evidence, right? Sort of a qualitative type of evidence with conversations of people from all different walks of medicine and outside of medicine, right? Journalists, philosophers, authors, doctors, nurses, intensivists, oncologists, palliative care doctors, surgeons, faith leaders. I mean, on and on and on and on. And I think that our single if we had to put a single most important pressing point from all of this, it would be something along the lines of that we ignore the soul of medicine, the soul of people at our peril. We believe that for all of the important changes that need to come to, you know, the digitization of health care and the corporatization and the bureaucratization and all the rest of it, I think that we nonetheless firmly believe that that spiritual core of medicine has to be addressed. If we are going to keep the practice of medicine as meaningful and beautiful as I think it can be.
Henry Bair: [00:57:02] So after having said all of that, what's next? What is your vision for where the next 100 episodes go?
Tyler Johnson: [00:57:08] I mean, I think the the thing that we have both talked about is that we would like to start to build things that leverage a arc that's bigger even than one episode. So having, for instance, series of episodes centered around a theme I think is a powerful idea, because then, I mean, we've we've sort of organically had episodes build on each other anyway, but if we have a series of episodes, then the episodes can can build on one another. What I hope we can start to do at some point is to also have real time conversations, whether that's in a, you know, maybe have two guests on at the same time who sort of play off of each other or even a panel of guests or eventually, you know, I would love to have a like a Meaning in Medicine conference, whether virtually or eventually in person, that is explicitly meant for talking about many of the themes that we address on the show. I guess the, you know, if anyone's going to be in Chicago in June, in some ways, maybe the first iteration of this is that we'll have at the American Society of Clinical Oncology meeting. We'll have Doctor Sunita Puri, whose episode we haven't mentioned, but is one of my also very favorites, Doctor Sunita Puri and Doctor Jay Wellons, who also had a fantastic episode early on. He's a pediatric neurosurgeon. They'll be on the stage with me and we're going to have, to my knowledge, the first ever discussion at the American Society of Clinical Oncology on keeping the meaningful heart of medicine in medicine. And that'll be, you know, we'll be there together in discussion. So that I think will be will be great. And I hope that we can build on and have many more things like that and that we can start to bring what I feel like is an important message to to wider and more listened to forums. What about you, Henry?
Henry Bair: [00:59:05] Yeah. I mean, similarly, I'm excited about the mini series, the idea, uh, you know, series revolving around, you know, topics and mental health. Talking about digital health, a retrospective on Covid, even. There's a lot of to explore here to build upon. I'm excited about the live events, and I know that our podcast is it's certainly being formally used in our class at Stanford. It's being used, I think, informally in quite a few medical schools, just from messages or emails that we've gotten from professors at other med schools and then residency programs also, again, informally. Um, we've gotten reviews, we've gotten responses from listeners saying how it's been making the rounds, uh, amongst the residency classes at hospitals around the country. That's really exciting to me. It is an indicator, at least, that it is making a difference. So I would like to sort of foray more into that, trying to build relationships with medical medical educators, with residency programs, to see how we can make this more valuable and accessible for medical trainees and clinicians everywhere.
Tyler Johnson: [01:00:17] All right. Well, with that, we will close by one more time. Thanking you. Who? Listen, obviously, none of this can happen if there are not people on the other, other side listening into the conversations. And as always, if you have a person and it doesn't have to be a prominent author, if you have, you know, the attending at your hospital who you think is is legendary there for being the best clinician or whatever, please let us know. We are always happy to engage anyone with important things to share in conversation. And you know, here we are two years in and or a little more than that. But anyway, and the 100th episode and we thank you all for being here.
Henry Bair: [01:00:58] I do also want to thank our guests who have been so unbelievably generous with their time, whether we're talking about incredibly busy ICU doctors, nurses and trainees, or the leaders of organizations and entities ranging from the American Medical Association, the National Academy of Medicine, Doctors Without Borders, and the World Health Organization to the world Bank, the National Institutes of Health, and the white House. All those interviews began with a cold email from me introducing myself as a medical student or resident, and somehow they all graciously took the time to come on the show. They make all this possible, and their stories have imparted lessons on Tyler, myself, and tens of thousands of listeners out there. So thank you all.
Henry Bair: [01:01:47] 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 www.theDoctorsArt.com. 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: [01:02:06] 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 or patient, or anyone working in healthcare who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [01:02:20] I'm Henry Bair.
Tyler Johnson: [01:02:21] and I'm Tyler Johnson. We hope you can join us next time. Until then, be well.