EP. 118: ENCOUNTERING SUFFERING — A LIVE DISCUSSION

Jun 25

WITH SUNITA PURI, MD AND JAY WELLONS, MD, MSPH

In this live podcast event, the hosts are joined by a palliative care physician and pediatric neurosurgeon to explore the nature of suffering, the role of spiritual faith in medicine, and the balance between personal and professional fulfillment.

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Episode Summary

For a profession like medicine in which suffering — be it physical, psychological, existential, or spiritual — is so commonly encountered and experienced, we have developed remarkably little shared vocabulary to talk about what suffering means. That is, if we even have the conversations at all.

In early June 2024, during the American Society of Clinical Oncology annual conference in Chicago, we hosted a live podcast event at Northwestern University's Feinberg School of Medicine, gathering Sunita Puri, MD and Jay Wellons, MD, MSPH to explore the great problem of suffering. Dr. Puri, a palliative care physician and author of the best selling book That Good Night: Life and Medicine in the 11th Hour (2019), last joined us on Episode 74: The Beauty of Impermanence. Dr. Wellons, a pediatric neurosurgeon at Vanderbilt University Medical Center and author of the memoir All That Moves Us: A pediatric neurosurgeon, His Young Patients and Their Stories of Grace and Resilience (2022), last joined us on Episode 28: The Brain and All That Moves Us.

The four of us, the guests and co-hosts, start by sharing our personal encounters with suffering, both in our patients and in ourselves, before discussing our philosophical approaches to and practical strategies for accompanying patients through suffering, managing spiritual distress, contextualizing our own humanity in these encounters, maintaining our own well-being, and searching for meaning amid these tragic moments, if it is possible. After our main discussion, we also answer audience questions about managing the sometimes unrealistic and complicated expectations patients have of clinicians, and the role of interfaith discussions among healthcare professionals.

We thank Kelly Michelson, MD, MPH and the Center for Bioethics and Medical Humanities at Northwestern University for making this event possible.

Jay C. Wellons, MD, MSPH is Professor of Neurological Surgery, Chief of Pediatric Neurological Surgery and Professor of Pediatrics at Vanderbilt University Medical Center. He was the Site Investigator for the private and NIH-funded Hydrocephalus Clinical Research Network (HCRN), and continues as the primary investigator for ongoing studies related to HCRN. His additional research and clinical interests include the role of neuroendoscopy in the treatment of pediatric brain tumors and hydrocephalus, improving surgical outcomes in Chiari and Chiari-related disorders, and anatomic and surgical studies of the brachial plexus and peripheral nerves.
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Sunita Puri, MD is the Program Director of the Hospice and Palliative Medicine Fellowship at the University of Massachusetts Medical Center & Chan School of Medicine, where she is also an associate professor of clinical medicine. A graduate of Yale University, she completed medical school and residency training in internal medicine at the University of California San Francisco followed by fellowship training in palliative medicine at Stanford. She is the author of That Good Night: Life and Medicine in the Eleventh Hour, a critically acclaimed literary memoir examining her journey to the practice of palliative medicine, and her quest to help patients and families redefine what it means to live and die well in the face of serious illness.
She is the recipient of a Rhodes Scholarship and a Paul and Daisy Soros Fellowship for New Americans. Her writing and book have been featured in the New York Times, the Los Angeles Times, Slate, JAMA, the Atlantic, NPR, India Today, the Asian Age, the Oncology Times, and the New Yorker.
In this episode, you will hear about:
• 3:58 - Stories of confronting suffering, both in professional and personal contexts
• 29:02 - Practical tips for coping with suffering and uncertainty as a physician
• 31:53 - The importance of psychological safety in feeling and expressing your emotions as a physician
• 36:52 - Being present in the moment while accompanying patients through difficult times
• 40:00 - Helping doctors re-connect with the deeper reason of why they feel called to medicine
• 42:24 - The inexplicable relationship between love and loss
• 52:04 - The deep sense of meaning inherent in the work of a physician and what makes it “real”
• 54:41 - Q&A: How physicians can better navigate the challenging expectations patients have as well as medical skepticism
• 1:04:05 - Q&A: How we can better incorporate interfaith dialogue into medical training and practice
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.
Henry Bair: [00:01:02] In early June amid the annual conference of the American Society of Clinical Oncology that took place in Chicago, Tyler and I hosted our first ever live podcast event at Northwestern University's Feinberg School of Medicine. The event, which counted medical students, physicians, and medical educators among its audience, featured two guests who have previously appeared on our show. Doctor Sunita Puri is a palliative care physician and author of the best selling book That, Good Night Life and Medicine in the 11th Hour. Her writings have been published in The New York Times, the Los Angeles Times, The Atlantic, and others. She last joined us on episode 74 titled The Beauty of Impermanence, on which she discussed how she came to terms with the limits of medicine and how a recognition of our impermanence allows us to unearth meaning from some of life's most troubled moments. Doctor Jay Wellens is a pediatric neurosurgeon at Vanderbilt University and the author of the memoir All That Moves Us. A pediatric neurosurgeon, His Young Patients and Their Stories of Grace and resilience. He last joined us on episode 28 titled The Brain and All That Moves Us, on which he shared lessons on courage, resilience and faith from having cared for someone with the most complicated pediatric diseases out there.
Henry Bair: [00:02:25] We gathered Doctor Whelan and Doctor Pirri to tackle the great problem of suffering for a profession like medicine in which suffering of all kinds, be it physical, psychological, existential or spiritual, is so commonly encountered. We spend remarkably little time trying to dissect it, understand it, accompany it, and learn from it. Here we try to do just that. The four of us start by sharing our own personal encounters with suffering, both in our patients and in ourselves, before moving on to discuss our philosophical approaches to and practical strategies for helping patients through suffering, managing spiritual distress, contextualizing our own humanity in these encounters, maintaining our own well-being, and searching for meaning in these tragic moments if it is possible. After our main discussion concludes, we also field questions from the audience about managing the sometimes unrealistic and complicated expectations patients have of clinicians and the role of interfaith discussions among health care professionals. We express our deep gratitude to Doctor Kelly Michaelson and her team at the center for Bioethics and Medical Humanities at Northwestern University for making this event possible. And with that, we bring you our first ever live event. We hope you find it as engaging, meaningful and inspiring as we did.
Tyler Johnson: [00:03:58] We are really grateful today to be here at Northwestern University Medical School to confront what I think is one of the most deeply embedded paradoxes in the practice of medicine. That is, that as health care workers, we constantly confront suffering. Most obviously, we confront the suffering of the patients for whom we are caring. But much of that suffering also transfers in direct and indirect ways to ourselves. And of course, all of us as health care practitioners are also human, and we also are passing through the tribulations of our own everyday lives. And those things sometimes intersect in difficult and raw and painful ways with the things that we are seeing in our patients. And yet, in spite of that, I don't know about all of you, but I know that I can say that for myself in all of my many years, probably about a decade and a half of pre-medical and medical training, I don't think I have ever attended a seminar on the meaning of suffering, or about how to confront sorrow or how to grapple with grief, which is ironic, because you would think that for people who are encountering this every day and who are confronted with it probably more than any other person in society, with the possible exception of members of the clergy or personal therapists, you would think that we would have a well-developed vocabulary for talking about this very difficult and also meaningful part of our jobs. And yet I find that not only do we not have a vocabulary, but we often don't even have the conversations at all. So here we are, four of us together today to start a conversation and to ground this in the personal. I have asked each of our four discussants today to begin by sharing a story from their own practice or their own life, a story when they have had to confront suffering, either together with their patients on behalf of something through which their patients are going, or even in their own lives, if that seems to be applicable and appropriate for discussing today. Henry, do you want to go first?
Henry Bair: [00:06:13] Sure. As the earliest one, I guess the earliest one. My clinical career. Here, I'll share an experience that I had first week as an intern right after graduating medical school. It is a fundamentally different role you play being a medical student versus being an intern, a first year resident. I remember I had this patient who came down to us from the ICU, and he had had a very long hospital course. He had been in ICU for sepsis. He had been on a bunch of pressor medications to help support his low blood pressure. He had been ventilated, but all of that was off. He was on the road to recovery. He had cirrhosis. He had heart failure. He had kidney failure. And he was, for the most of it, pretty out of it from day to day. And over that first week, I got to wrap my head around this intensely complicated medical case. I got to understand how diuresis was working. Right. We're making giving him water pills to make him pee a ton, to help his kidney function, to support his liver function, to support his heart function. And I was so happy to see that every day I would go in and the numbers were getting better, the lab numbers were getting better.
Henry Bair: [00:07:21] And then one morning I go in there and he's awake. His mental status had recovered and I was so excited to see that. And I went in there and excitedly told him how all of the lab numbers were improving. Look at your creatinine, right? Your kidney function. Look at your lfts your livers are responding so well to the treatments we were giving. And he just looks at me. And then at the end of my monologue, he says, are you the doctor? And I said, yeah, I am gingerly at first because I was not used to thinking of myself as a doctor. And he said, you're the doctor, fix me. That's what he said. He said, can you fix me? And I said, we are trying, I am. And then I went back to the numbers. You are being fixed. And he just kept saying that, fix me, I'm broken. Fix me. I had no idea how to respond beyond going back to the numbers, and I very hurriedly excused myself. I would go talk to the team, so to speak, about how we could fix him. It would take many months after this, in reflection, when I would slowly understand what he really meant by fixing him. His idea of fixing being fixed was so different in that moment. From what I thought of as fixing a patient. There was so much under their surface, beyond the lab numbers that I was just not privy to. That was a very real, very early encounter with something that I yet had again, to Tyler's point earlier, had no vocabulary for this idea of suffering.
Tyler Johnson: [00:08:52] Thank you, Doctor Bair. Doctor Puri.
Dr. Sunita Puri: [00:08:55] So there's just so many instances that I feel like I can share with you about how I have been with suffering, and how my ability to be with it has changed over the years since my training to my practice. But I'm going to give you an example from a few years ago. I was taking care of a man in his 20s who had metastatic stage four gastric cancer. And it's very unusual for someone in their 20s to have stomach cancer. And I was the palliative medicine physician, consulted first for managing his nausea and his pain, which were both extreme like I walked in to see him the first day, and he was lying on the floor of the ICU in Child's Pose, because that was the only way that he could not experience nausea. It was profound. I almost tripped over him when I opened the door, and he was there with his mother, and in my time taking care of him, I never once heard his voice. And this went on for two weeks. And in the interim, when we started talking about really what he would want for himself because he'd gone through many lines of chemotherapy and you could see it on his parents face. They really they had the eyes of refugees that they had just crossed so many borders with him and faced so much and didn't know which way to go.
Dr. Sunita Puri: [00:10:23] And one of the hardest parts of this was that the parents were on different pages about what to do next. The oncologist was offering more chemotherapy, and the father was really in this mode of we're going to fight till the end. And the mother was on a very different page. And when she and I were alone, the enormity of her suffering, the inability to protect her child, the inability to talk to her husband of many, many years, this kind of chasm between them was enormous. And then we would all sit in a room and talk, and this poor young man could not. He was. He was in so much discomfort he couldn't even speak. And this was maybe six years out of the end of my training. And I had thought that I had built up this reserve, this ability to be with suffering, to help people think about dignity and loss, that the words we really don't mine in our medical training. But I was really at a loss at that time because I didn't know how to fix it. And as much as in palliative medicine, we kind of look at ourselves and our abilities as understanding that the outcome doesn't necessarily reflect the importance of the emotional and spiritual process of disease. But I couldn't go there. I couldn't access my own clinical skill set or ability to be with the intensity of what was happening.
Dr. Sunita Puri: [00:11:54] And I would sit in these family meetings and just feel a lot of rage internally that this was happening, that I couldn't do anything about it, that the oncologist was literally prohibiting me from having goals of care, discussions with this patient. And the crux of all of that was not just the suffering of this young man and his family, but my own intense suffering over not being able to do my job. In parallel to this, there was something going on in my personal life at the time that was bringing up a lot of sadness and sorrow, and so something that happened when we were eventually getting to the point where we transitioned this young man to comfort care is I was sitting with his mom, and she was just telling me how she doesn't know how she'll ever get over this experience, how she doesn't even have the ability to cry. And when I was sitting in that room, I remember for the first time thinking about seeing her suffering almost through a clear plexiglass where I could see it and be in it with her. But it wasn't hitting and attaching to me. And I remembered around that time some of the teaching of the great spiritual teachers like Eckhart Tolle, for example, who says, the root of all suffering is resisting what is. And this is also a concept in Buddhism and Hinduism.
Dr. Sunita Puri: [00:13:23] And it was really then that I could open to being with something I cannot change to learning that lesson on the multiple axes of suffering that I was witnessing, including my own. And when I was able to say to her. There's no such thing as getting past something like this. There's only ways we carry it with us. I cannot protect you from the pain. But I think there are places and ways we can go deeply into it and not resist it, so that we can be with ourselves in a more compassionate way. We can be with the loss in a more compassionate way. And as I was saying that to her, I realized this is also something I needed to say to myself. And so it was a profound moment where the pain of another, for a different reason, was inseparable from my own pain for a different reason. And that convergence of being aware, being reminded again of the inevitability of suffering in a human life, the temporality of all of our lives, but the fact that healing is possible even when cure isn't. Just by choosing to see the suffering and not run away with it. That in and of itself was so powerful. And well after this young man died, I carried that with me as a reminder that the pain we are given is pain. We can find a way to shoulder.
Tyler Johnson: [00:14:55] Thank you. Dr. Puri, Dr. Wellons?
Dr. Jay Wellons: [00:14:58] Well, one of the things that you do when you're going to be on a book panel, at least I think you should do, is read the books that of the other people that you are going to be on the panel with. And, and so I had the opportunity to read, uh, sunita's book last week when I was on vacation with my family. And yes, it is a beach read, just for the record.
Dr. Sunita Puri: [00:15:18] So my I always joke that my book's not a beach read, but then he emails me and is like, I read it on the beach.
Dr. Jay Wellons: [00:15:25] I got a picture and everything. Um, but there's a scene in the book where she's a resident in charge of the team, and, uh, she's made a decision to take somebody who has metastatic cancer and who's come in with a blood clot, you know, most likely to be a saddle embolus. And she's made a decision to not treat it. And the reason being is that the person doesn't have much time left, and she wants to be able to relieve the pain. There's some issues with starting heparin that would, uh, potentially cause them to bleed from the metastatic cancer that he has. And so as a senior level resident, she sits with the patient. And, uh, plays bluegrass music on her phone because that's apparently what he likes. And then as there's this beautiful scene that she writes, as the darkness turns to dawn, his slowing, his breathing gradually, his breath gradually slow, and then he passes away. And that's a really beautiful scene. I definitely feel a commonality with Sunita and my own book. I write an episode of of when I was a resident. There's a lot of, um, you know, chest beating between the trauma surgeons and the neurosurgeons and the orthopedic surgeons and who's going to go to the O.R. and who's not. And why aren't you taking this person to the O.R.? They've done this.
Dr. Jay Wellons: [00:16:39] And in the middle of that comes a 60 year old man who's taken a shotgun and basically attempted to commit suicide. But the shotgun missed the brain, and it just took off his face. So there was really nothing left but holes on his face. And he had this kind of raspy breath. And, uh, there was a bloody suicide note that the police had given to me that said he just didn't want to live with suffering any longer. And, um, and, you know, there was a moment where the, the trauma surgeons who were friends of mine, uh, were like, why aren't you taking this guy to the O.R.? Clearly, he's got an injury. And I'm like, I am not taking him to the O.R.. This is what his wishes were. He has a lot of suffering. And now this is a non tenable non-survivable accident. And so I remember putting my hand under the sheet and holding his hand. And letting him know that I was there and I was pretending to do a neuro exam so that none of the other residents would say, what are you doing? But I was there with him as his breaths gradually slowed. And so I definitely feel a commonality with you because of that experience. But it's impossible to shift gears a little bit. It's impossible for me to operate on a child, a three year old child that has a brain tumor, and then go home to my own three year old at the time. Yeah, and not feel connected to that family.
Dr. Jay Wellons: [00:18:04] And so for me, I see there's what I say psychological suffering. And then there's physical suffering or psychological pain and physical pain. And I know there's a lot of discussions about the difference between pain and suffering. But, you know, for me, a lot of that psychological suffering is in not knowing what's going to happen when that family doesn't know what's going to happen to their child. Maybe their child's been vomiting for a little while. Maybe they've had a headache. They've gone to the doctor several times. The numerator of headaches that are brain tumors is vastly less than the denominator of kids that have headaches to go to their pediatrician, so I'm always quick to tamp down any blame on their primary care physician, because most of the time it's just a persistent headache that started vomiting. And then here they are. So there's that's the one aspect of Psychologic pain, in my opinion, are suffering. You know, what did Mark Twain say? Like, uh. I've had catastrophic suffering in my life only of which a little bit of actually experienced, you know, that have actually happened. And so I think some of it is not knowing. And so my chairman, Reed Thompson, talks about this concept of peace with a plan. And so when you can sit down with somebody and say, okay, this is what it is, and this is what our plan is and this is what we're going to do tomorrow morning, and then I'll come out and talk to you when we're closing up at six hours.
Dr. Jay Wellons: [00:19:24] And then we have to see how she's going to wake up, and then we have to see what the post-op scan shows, and then we have to wait for the path, which used to take five days. But nowadays, with molecular targeting, it takes like two weeks, which is hard for the families to, you know, it's hard for us, it's hard for the oncologists, it's hard for the families. So I think there's that that one aspect of it. And then there's the physical pain aspect of things too. I take care of patients that have Chiari malformations and sometimes they're put aside by the medical establishment, but I find it to be the most rewarding work that I do, because you can take people that have substantial headache and pain when they're pitching the softball on their softball team or when they're, you know, playing on their ultimate frisbee team, and you can do a decompression and you can get them back to a regular life. And that's a phenomenal feeling and ability to do that. So I think for me, I had this concept of the psychologic suffering of which you don't know what's going to happen. And then there's the physical suffering of when you actually have something that happens. And then into that, I will add that, uh, the reason why I had an opportunity to write a book back in 2018 after those two pieces in the times was because, you know, I had looked at the video screen on the computer, you know, hundreds and hundreds of times, you know, when you scroll the image and you and you see the small big, big, big, big, small, small, smaller, smaller of the of the tumor that's, you know, in the cerebellum or the cerebrum or the spinal cord or the brachial plexus or whatever it is that I'm operating on.
Dr. Jay Wellons: [00:21:02] And all of a sudden, instead of me sitting and going through the scans, somebody was sitting and going through the scans with me, and I had a tumor in my pelvis, and it was thought to be malignant. And so I had a pretty radical resection to take it out. Fortunately, it was benign about a 1 in 1,000,000 chance for it to be benign. But at the time I was kind of going Mach five with my hair on fire, you know, I was program director. I was vice chair of the Section of Surgical sciences for all research. Uh, had several research things that I ran. And this really took me from Mach five to being still, because you can't take a tennis ball sized lesion out of the pelvis and go back to work. So I was on bed rest for about two months. And so, uh, I did a lot of soul searching then. And you also can't have something like that taken out of your body and a place like the pelvis and not come out of that with some pain.
Dr. Jay Wellons: [00:21:58] It's just impossible. And so I myself have to sort through pain. Up and down comes and goes and, uh, it's a constant effort and it has really made me much more. I mean, I was already a pretty, I think, a pretty thoughtful person, you know, on the Alan Alda side of of being a surgeon. You know, I never was like the jerk surgeon. I mean, maybe a few times, but at the end of the day, you know, you see a patient. You want to be able to help them. If you can't help them, then you try to figure out what can help them, and then you move on to the next patient so that you can help them. And so at the end of the day, it's like this cumulative sense of I helped eight people and two people I had to send to neurology for headache management. That's not too bad, right? But it has made me much more concerned about people that have pain. So I think having some of your own suffering does put you on a different wavelength with other people that have it. You know, I don't recommend having suffering, you know, just to be clear, you know, but there's no doubt that experiencing it as a physician, I think that has clearly impacted the way I handle my patients.
Tyler Johnson: [00:23:09] Thank you, Doctor Wellons. I'll share a very brief story that touches on a different aspect. I think, of healthcare related suffering, which is that between my my internal medicine residency and my oncology fellowship, I was a chief resident for a year. And part of that at Stanford was that we would attend both at the Palo Alto, VA and at the Stanford Hospital. And so when I was at the VA attending. So I'm a brand new little baby attending, right? And I took care of this patient who in many ways seemed very much like patients we had taken care of before. He kind of if you were looking at him from across the room, you'd probably think, oh, this guy was probably admitted with really bad COPD or really bad heart failure or something. He had kind of that look to him. And his family reported that over the course of the past year, he had become increasingly debilitated in the sense that previously he had been relatively active and had been able to sort of take care of himself and get out and about and do things. But then starting about nine months before that, he had started to be less active, and then he had started to get short of breath with activity. And then he had started to be really tired. And over the course of that year had gotten to the point where he was very nearly bedbound. And that was what led to him being admitted to the hospital. But then we went through and we did all of our things that we do, right.
Tyler Johnson: [00:24:27] We looked at the lungs and we had him do pfts, and we did an echocardiogram, and we looked at his heart function and we looked at his metabolites and, you know, all of these different things. And he had a little bit of heart failure as he was maybe 50%, and he had a little bit of COPD. And there were some findings related to that. And he had some very mild metabolic abnormalities. But the issue was that none of those things added up to what seemed like it had become a truly debilitating illness. And so then, of course, we did the thing that we do next, and we consulted all of the people, right? We consulted cardiology and then pulmonology, and then when we really didn't know what was going on, then we consulted endocrinology and rheumatology, and even after consulting virtually everybody in the hospital, it was clear that he was debilitated. But nobody could come up with a reason why. So as he was seeming to get even sicker in the hospital, we had a discussion with his family members about what they would want to do if, because he was pretty somnolent and it was hard for him to engage in complex medical decision making, we talked to his family members about what they would want to do if he started to become truly, acutely ill in the hospital, and they said, in effect, that he had been suffering so much that they didn't think that he would want to do things like be put on pressors or a ventilator, or go to the ICU or what have you.
Tyler Johnson: [00:25:46] And so then a couple of days after we had that conversation, his blood pressure began to drop for reasons that weren't clear, and we Cursorily went over that discussion again with the family member. They can family members. They confirmed what they had told us the first time. And so instead of putting him on Pressors and lining him up and putting him in the ICU, we gave him medications to make him comfortable. Just very small amounts of opiates. And a couple of hours later he died. And I was shocked as a new attending. It was not ever my plan to have one of my patients die. This was definitely not something I had given him permission to do. And you know, if it had fit into a script, I would have been okay with it, right? If he had terrible, widely metastatic cancer and had been on chemo for three years, that I could have understood if he had had terrible heart failure and had been on three inotropes and in the CCU that I could have gotten if he had had COPD and had been admitted 12 times in the last year with an exacerbation, and had died with hypercapnic respiratory failure that I would have gotten. But even though I could see how debilitated he was because I couldn't put a name to what was happening, and I had no script for the patient to follow, I became what I think, in retrospect, I would call obsessively convinced that his death was my fault.
Tyler Johnson: [00:27:13] The family was actually totally at peace with it, you know, because they had seen him declining and had seen him suffering and thought that the fact that he had died was sort of in line with what they had more or less expected because they had watched his decline. But because of my inability to put a name to what had happened, I became convinced, in effect, that I had killed this person by not sending him to the ICU and making him die on Pressors and inotropes and, you know, whatever else we would have done to him there. And I remember very distinctly, my family was out of town this one weekend, and I ended up in the chief resident's office at the Palo Alto, VA. And I remember writing what at that time we called the discharge summary, which was basically the final note documenting how the patient had died. And that was probably the only 15 page single space discharge summary ever in the VA system, because I just wrote and wrote and wrote trying to justify why, in effect, this was not how I phrased it, but in effect, why it wasn't really my fault that this patient had died. But I think I did that because I was trying to convince myself that I had not done what I thought to be this terrible thing.
Tyler Johnson: [00:28:22] And I was also convinced, of course, that I was the only physician who had ever confronted something like this, because all of the other attendings were perfect and had never had a case like this in their lives, because nobody ever talks about it. Right? So how was I supposed to know? I just thought that I was this terrible, murderous doctor who was probably going to be showing up on CNN or something, right? Because I had done this terrible thing, which, of course, in retrospect and with more years of experience, seems silly. And I can laugh about it now. But at that time, in that moment, that night, writing that note in CPRS, I felt alone and felt like I was bearing this great weight of suffering.
Tyler Johnson: [00:29:02] Okay, so with those stories, just to establish that this is, in fact something that all four of us have confronted in our different ways over time, we really want to spend the rest of the time talking about two questions. We're going to start with the practical and then end with the philosophical. So the practical question that I want to ask is, what have you found to be practical ways to cope or grapple with the constant exposure to uncertainty and both physical and existential suffering, as doctors like, how do you metabolize the grief or how do you confront these things in your day job and then still go home at the end of the day and be a person?
Dr. Jay Wellons: [00:29:52] Yeah. You know, in my field of pediatric neurosurgery, we do see a lot of sadness for for me, it's important to have colleagues that I trust that I work with. You know, we're all in the midst of kind of seeing it sometimes after we operate on a child, the parents love us and, you know, put lots of social media posts up about us, and sometimes they never, ever want to see us again. And that you could give the same degree, the same way of treatment of one child. And it's just how the parents kind of saw it and felt it and processed it. I think if I may push into the spiritual side a bit, I think that there is a role for us in healing that is not just making somebody. Well, I think that, um, you know, sometimes showing kindness and love to people whose children are in their last moments or are going to die is something that we're called to do. And it's an odd thing to say this, but I think that providence or God has given me an ability to do it in a compassionate way. Oftentimes, nurses or students will be sent in by their leadership to watch me talk to families in situations like this. I mean, when a family has a child that is a tetraplegic because of a car accident and they have to take the child off the ventilator, or a child's had a terrible head injury or a ruptured AVM, they're not going to wake up from. I think for me, I draw from a spiritual construct. It's really important to me, and I feel like that we are called to sometimes I have this analogy in my head where to kind of just. Lay somebody down peacefully, you know, almost like, um, you know that character from the Greek myths, you know, Chiron who who kind of pulls people across the River Styx, you know, to get to the other side.
Tyler Johnson: [00:31:51] Thank you, doctor.
Dr. Sunita Puri: [00:31:53] I think some of the ways that I have evolved mechanisms for that is rethinking my identity as a doctor and my responsibilities not just for the people I care for, but how I care for myself. When I was in my residency, I really felt that to be a good doctor, I had to pile. I almost had to, like, pick up the backpack of pain and suffering and hopelessness and grief that people were carrying with them, and strap it to myself, that that made me a good, compassionate doctor to take it on. When I was in fellowship, I would stay really late to the point where my attendings were like, I'm worried that you're going to start your career and burn out very quickly. And I remember being with an Indian family. And whenever I'm taking care of people, especially from my state in India, it's a different it has a different tenor. And I carried that suffering even more strongly than I've carried some of the other suffering that I'd been with that day. And I realized very early in my fellowship, actually, that taking it on wasn't my job. It's a lesson that I've had to return to many times. And as in the other example that I relayed earlier, carrying what is not mine to carry, which is only mine to witness and care for and comfort, those are very different strategies to building a sustainable practice. So my self-conception as a doctor had to be one of greater ease. And ease is a word I've found myself using a lot more recently, having ease with the fact that I feel strong things in my training.
Dr. Sunita Puri: [00:33:38] For example, it was almost as though I was cut off from my heart and my body. I was just going and going and going, caring for other people and thinking that strapping on that backpack of suffering was part of how I did my job well. I was so isolated and so vulnerable and so and felt so ultimately alone in carrying what was not mine to carry and not being able to talk to my colleagues about it, because I would for sure have been seen as weak. And so as time has evolved, I think part of it is having a sense of protecting one's self and that word self-care, which I think is a little bit overused and wellness is another thing. It's like a catch phrase that means everything and nothing, right? I think. Yeah, it's not a zoom link for lunchtime yoga, and I do yoga like three times a day, like I'm into it and I'm there. But a link to lunchtime yoga is not wellness in my opinion. It is not getting a taco truck and saying, hey everybody, here's a free ticket to get some carnitas tacos. I mean, I'm all for that for sure, but that has nothing to do with me sitting with my vulnerability, sharing my vulnerability with my trainees, which many of them will tell you. Oh yeah, Doctor Puri will tell you exactly how she feels, because I don't want them to feel as alone as I did. And part of the sustainability is being able to feel what you feel, finding a way to comfort yourself and then go back in the next day and creating a culture that's different, that's one that recognizes what we're going through, that says it's okay that you feel that, feel it.
Dr. Sunita Puri: [00:35:30] But let's also come up with ways to comfort and hold that feeling in a in a productive and soothing way. And so for me, just very practically, I do a lot of yoga. I listen to a lot of Tupac who some might say, this is crazy, but he is my muse. Being with my friends and family and learning ways to be with my own discomfort, whether it's discomfort over something happening in the hospital or discomfort about having a broken heart, it's all about learning to manage that. And no taco truck or lunch time yoga session is going to teach you that. And I'm just going to be real here. I learned this the hard way. I learned this after suffering that nearly consumed me. And I'm not afraid to say it, because the other thing I've let go of is shame over how I feel about whatever. I have no shame about telling my trainees that was a messed up family meeting, you know? And I tell them why and then I invite them to share. So without getting too therapist y and woo woo about things, I really think so much of it is learning to tend to yourself, learning to recognize what you feel, reconnecting with everything you're taught will get in the way of you being a good doctor.
Henry Bair: [00:36:52] Yeah, well. And Tyler asks, what is the practical secret? What is the trick to being with suffering? To me, it's to be there. By the way, I'm under no illusion that I am still very early on in my training, but from the experiences that I've had had this past year, medicine gives you so many opportunities to be there and you shouldn't look away. And one story comes to mind. I had a really lovely 90 year old gentleman, the most polite patient. We were doing some terrible things to him. We were giving him some medications that were having some really bad side effects. We were taking him to the operating room when it was questionable whether or not I was going to be efficacious, but he was always so grateful. Over several weeks, I got to know him pretty well and his family was always there. And then one morning I come in and he passed away overnight, and I. I could not. Hold it back. Really? My reaction? Like I started tearing up and then the family was there and then they summoned the rest of the family. It was a very large family. They were all by their bedside in that moment. I wanted to be in the room. I didn't know if I should be in the room. Was it my place? I was still pretty, uh, emotionally compromised, so to speak. So this was a Jewish family, so they were going to recite, uh, the Kaddish, which is what I would later find out is actually a blessing, which was surprising to me, a blessing. Well, the family surrounding the patient who had just passed away and they said, would you like to be here with us? Is it my place? Nowhere in medical school had I ever been presented with the opportunity nor told whether this was kosher or not to do.
Henry Bair: [00:38:29] I chose to be there, and afterwards I had a conversation with the family. Why a blessing. And they said this to us, it's undoubtedly is a tragedy, but this is also an opportunity to reflect and celebrate life. To be honest, it doesn't always turn out like that. Sometimes there's just the pain and there's no celebration. There's no reflection. Sometimes you just the patients are there or the family is there and it's just suffering. And I do wonder, sometimes choosing to be present in those moments, what kinds of effects is it going to have on me? Is it sustainable? I can do it. I've only been here for a year. If I keep doing it, is it going to somehow? Is there like a turning point, a tipping point when it gets too much? I don't really know yet, but what I do feel is that when I am in those moments. It feels right. That is what I'm supposed to do. I think when you get things like people talk about compassion fatigue or people talk about physician burnout, I think so much of that comes from you not being able to do what you're supposed to do when you feel like you're there for, but when you're present in the moment, it might be very, very tough. But in a way it feels like I am self-actualizing at the end of it. That's what I am here for. This is the space that I can help provide. So that is one piece of practical advice that I've found to be very valuable.
Tyler Johnson: [00:40:00] I do want us to pivot to our last question, which any of you who listen to the podcast will know that we are unafraid of jumping into the spiritual and philosophical and existential dimensions of the things that we're talking about, which all of us have already done, that I think to some degree. But the genesis of the podcast, and for a lot of the work that Henry and I have done together and and that these guests and many others have helped us with, is a recognition that many physicians and other health care workers have begun to feel increasingly alienated. And as to use the, you know, the big buzzword nowadays burnt out, which is to say that we feel distant from the moral mission, the deeper meaning that brought almost all of us into medicine. Right? Like if you've done any work in medical admissions and you've ever read any essays for people who are applying to medical school, nobody says, I'm getting into it for the money, or I'm getting into it because I want prestige, or I want to be famous, or I want people around me to respect me. Nobody says that. Everybody says I'm getting into medicine because I want to help people. Some version of that, right? Occasionally with a scientific spin to it. But that's always at the heart of it. And yet there are these very nearly overwhelming statistics about how many people are burnt out and how many people have just left or are on their way out the door altogether.
Tyler Johnson: [00:41:23] And I think that this suggests to the point that I made earlier, that we have failed to develop within our own practice, a vocabulary for talking about how to grapple with some of the deeper challenges of being health care providers. Now, to be clear, there are enormous structural problems that have to do with corporatization, bureaucratization, digitization. And I don't want to question those. And there are people doing very important work to stem all of those tides, of which we are completely supportive. But the thesis, in a sense, of the podcast, is that there is a more personal, intimate, sacred space within us over which we have some degree, at least of control, where we can try to engage with some of these deeper questions in a way that will make medicine the practice of medicine more sustainable. And I think that one of the foundational questions we have to ask when we think about that issue is what do we do with suffering? And so on, a sort of existential or philosophical level.
Tyler Johnson: [00:42:24] This is the question that I want us to confront. And I'm going to offer one thing first, which I think is one of the most insightful takes on this question that I have ever heard. So many of you may be familiar. During the early and mid 20th century, there was a famous Christian writer named C.S. Lewis, and C.S. Lewis used to go around the UK, especially where he lived, but also the world, giving lectures on what he called the problem of pain. He was a very learned person and studied at Oxford and Cambridge, and he would give these long lectures about why God would give us pain, and why there would be suffering if there was an omnipotent and omniscient God. But he did all of this as a very well confirmed bachelor into his relatively old age. And then when he was probably in his 50s or 60s, he met a Jewish poet from New York named Joy Gresham. And at first they actually got married for convenience sake because she needed a green card. They didn't even live together, but they were civilly married so that she could get the UK equivalent of a green card. But then eventually they fell in love and got actually meaningfully married. And then a very short time after they were meaningfully married, she was diagnosed with metastatic cancer. And this was in the days where they had very, very few tools with which to address that problem. And so she died very soon thereafter. And long after CS Lewis's death, a play then adapted into a movie was written about the experience of CS Lewis falling in love after this lifetime of lecturing about the problem of pain and then losing his beloved very soon thereafter.
Tyler Johnson: [00:44:07] And in that play there is this very beautiful scene where they are on what amounts to their honeymoon in the English countryside, and they're looking out over this kind of bucolic vista. And she says to him, Jack, which is what she calls him, I need you to know that soon I'm going to die. And he says, no, no, no, no, no, I don't want to talk about that. We're not going there right now. This is our honeymoon. We're going to focus on the now. We're going to focus on being happy. We're not talking about that. And she turns to him and says, no, you don't understand. The pain then. Is part of the happiness now. We cannot be in the now without addressing the sadness that we know is coming. And the great lesson that that teaches me is that the reason. We suffer is because we love. And when I remember that, it doesn't make suffering easy and it certainly doesn't make suffering go away. But it reminds me that those are different threads woven into the same fabric. That is the thing that makes life meaningful. And so whether I'm confronting my own suffering or suffering on behalf of my patients, when I remember that suffering is inextricably connected to love, it doesn't make it easy, but it does grant it meaning. Other thoughts?
Dr. Jay Wellons: [00:45:50] Well, I certainly agree with that. I mean, the loss of someone beloved is a time of great sadness because of that very reason. They are so beloved, and I've certainly seen that over and over again in my own practice. You know, speaking of C.S. Lewis, I, um, a patient, uh, Hannah was a teenager or is a teenager who, uh, had a astrocytoma near her basal ganglia. And, uh, it was causing her to have weakness and difficulty moving one of her hands. She named it Little Devil. That was the name of the tumor. And so we resected it, and she had to get over the resection because, uh, it was intricately involved with some blood vessels that we had to take in order to get the tumor out. And it took her some time to get better, but she did. But, uh, when I was diagnosed with my own, I decided to name my tumor Wormwood after C.S. Lewis's, uh, character in The Screwtape Letters, whose job it was to, uh, kind of bring down the spirituality of mankind. And, uh, I just said that, you know, to me, having an anchor for for me, I'm an Episcopalian, but a pretty open minded Episcopalian, which most Episcopalians are. But for me, it was really important to have that anchor and, uh, as I've said before, spiritual construct. But, uh, but there's no doubt that, uh, seeing those two linked together, I mean, it's it's almost, you know, metronomic the experience that you have in medicine where you go back and forth from joy to grief or, you know, sadness to a miracle that there's just there for sure. Linked. Yeah.
Dr. Sunita Puri: [00:47:26] Tyler, I thought that both of you just what you said was so beautiful. And I really love this idea of that suffering and love are intertwined, and I think that goes to the root of a lot of philosophies that pleasure and pain. It's only a matter of time before one becomes the other. And in some spiritual traditions, I'm Hindu and sick, but I also practice a lot of Buddhism. And all these religions are very intimately intertwined. But so much of the point of life is to transcend these cycles of happiness and suffering. And yet to be a human in the world is to allow all of those things to usher them in. And it reminds me of a poem by Rumi called The Guest House, which is essentially saying this being human is a guest house, and he names all of the emotions that are a part of our life. And he ends with saying, welcome them all. Each is a gift from beyond to teach us something. And I think I might have butchered those last lines, but that's essentially what he is saying. Is that part of what it means to be human, or all of what it means to be human, is to be open to all of these interlinked things, even if they're going to break your heart, but also to remember that all of the things that come through life are temporary.
Dr. Sunita Puri: [00:48:55] Our suffering and pain is temporary, as is our joy. And I think that gives me a way to be with some of the toughest things, is to draw on the philosophies that I was raised with, and remember that there's nothing that I cannot shoulder, that everything that is given to me is given to me because there is something to learn from it. And when I look at things that way, I can appreciate better the cyclical nature of everything. We feel the cyclical nature of nature itself, knowing that outside my window in the summertime, the tree is going to be fluorescent green, and in a matter of months it's going to be a bright Burgundy. And that cycle will continue. And part of what it means to be fully human is to embrace it and to remember that suffering is a part of that. But also so is joy.
Dr. Jay Wellons: [00:49:52] Yeah, that's the beauty of the Hindu religion, I think, is the circle as opposed to the linear, you know, the linear ness of Christianity. You know, with Hindu, it's a really a beautiful circle. I also think about, uh, Kahlil Gibran, you know, the Lebanese philosopher that said, uh, some say joy is the greatest and others say it is sorrow, and I say nay, they are the same. While one stands with you at the board, the other is asleep upon your bed. That's a good example of how joy and sorrow are linked together.
Tyler Johnson: [00:50:22] And Dr. Bair, any final thoughts?
Henry Bair: [00:50:26] I think it's really challenging, even as the four of us have been reflecting on this and we have reflected on this for years, decades. You know, I can't help but think about all the different kinds of suffering that I've seen, you know, because as, as a physician, you see so many different kinds of suffering, right? Like sometimes it is existential suffering. Sometimes it's a patient, you tell them that the cancer has come back, and then they stare at you and scream, why? That's existential suffering. Sometimes it's just pain. Sometimes it's just a corneal abrasion and the emergency room and it's excruciating. It's going to heal, but it's excruciating. You know, sometimes it's psychological. Sometimes it's really severe depression. There's different kinds of of suffering. But I think one thing that I just wanted to add, again, just having tried my best to encounter that in as balanced and as, um, thoughtful of a way as I know best, it's to recognize that for patients, even what you think of as like just a corneal abrasion, right? It's never just something for the patient. It is something that is wholly compromising. Often a corneal abrasion will heal, but in that moment, the pain is so debilitating they cannot live their lives. So for me, it's in addition to all the amazing wisdom we've just heard. It's also the recognition to encounter every kind of suffering you see in the hospital on its own terms, and try to engage that without trying to read your own interpretation into and try to be open to what the patient is telling you.
Tyler Johnson: [00:52:04] I do want to say one final bit of what I hope is wisdom, especially for those here in the room or those who will later listen to this online, who are in your training and may listen to this and think, well, gosh, that doesn't sound like a very fun job. Why would anyone sign up to do that? There's truth to that. That it's not a, quote. Very fun job. But what it is, is real. And what it does mean is that you don't go home at night and think, as I have had friends in other fields who have told me that all I did all day was make more money for people who already had a lot of money. You may inadvertently do that too, depending on what health system you work for, but that is sort of a side a sidebar. Your work means something. So much of modernity is dedicated to getting us to ignore the deeper currents of the universe in favor of what is, at the end of the day, ephemera. That there is something deeply nourishing and meaningful about going to a job every day, where your job is to usher into the world new life, or usher out of the world. Those who are dying or to fix clogged heart arteries, or to fix neural defects on a fetus that is still in utero, or to master the power of words to have with people the most difficult conversations of their lives, or to be able to do surgery at a microscopic scale that I can't even comprehend to fix a defect in the retina or whatever it is. These are the things that deal with the parts of life that mean the most, and that are the most real, and whatever else is true. The ability to be able to do that remains, I think, a great deep privilege.
Henry Bair: [00:54:24] Thank you so much for that beautiful closing statement, Tyler. And with that, we conclude the main portion of the event, and we'll be happy to take any thoughts or questions from the audience. Does anyone out there have anything they'd like to share?
Audience Question: [00:54:41] I am thinking about your comment that every medical student writes something more meaningful as their rationale for going into medicine than, for example, making money, or maybe even being fascinated by the human body or something like that. I think that's probably true. Maybe there's some. Fields where that's not entirely true. People are really interested in, like, you know, whatever pathology or cells or something that they might, there might there might be options. But I think that's true. And I also think that there is a lot of loneliness in how clinicians, not just physicians, but all clinicians deal with and engage with these challenges. And I also think there are some people who do it at the bedside better than others. And I think my heart believes that all want to do well. I don't think the public perceives that in general. And so I'm curious, any thoughts about what I'm trying to pose as a disconnect between the actual compassion and journey of a clinician? And the disconnect that the public has about probably all of us at some extent going through that experience.
Dr. Jay Wellons: [00:56:00] Yeah, that's an interesting comment because, you know, I think during the pandemic I feel like. At least my my experience was that everybody got it. Everybody got how serious it was. You know, bodies were being put in trucks. People couldn't be with their families as the family members as they were dying. You know, it was just a time where everything in medicine got so serious. I thought that it just upped the scale internally and also externally. And then somehow something flipped afterwards. And unfortunately, I think that it's political that somehow, instead of being the people to trust, we became the people to doubt. And that disrupts the physician patient relationship. And I can tell you that at Vanderbilt, and I know this is the case from my colleagues, at least in pediatric neurosurgery, we sort through a lot more just frank anger and distrust now, whereas in the past I felt more trusting of the plan. Now there was a lot, a lot more scrutiny. And you know, how many of these exact have you done and come have exact what the outcome is? And those are fond questions to ask, but they're asked in a way that is confrontational and that that's challenging, you know, because you you want to have a relationship with the family so that you can take their child to the Or and bring them back on the other side and give them their child back and have this kind of happy moment. And maybe those those days are are less because of this doubting of our medical environment.
Dr. Sunita Puri: [00:57:41] I think I completely agree with you that the public perception of who we are as people, when we're doctors or care providers is profoundly skewed. Like, I've had very few instances of some of this happen, but I definitely had someone be like, you're just in it for the money, right? And I wanted to be like, oh yeah, I went into palliative care for money. Like, that's why I came to medicine mic drop. But it's always astounding to me on two levels. One that we are kind of as care providers, but I think especially as physicians held up to contradictory standards. Right. We're expected to be gods, but then admonished when we're a little arrogant, right? People want a human connection with their doctors, but not so human that they can understand if we have a bad day. Right? So it's this weird set of contradictory expectations that we're kind of living in culturally. And I think to some extent we do the same to each other. We don't let each other have a bad day. We hold ourselves to very high standards, and there's good reason for that. But it doesn't surprise me, then, that some of this happens with the public. And I think part of what it may mean to change that is to be more vocal about our humanity and to say whether it's through lectures or micro discussions with med students or patients who are angry to have some boundaries up and say, I understand that you're angry, but you can't talk to me that way. Yeah, that we don't just have to take it because we make excuses for people who are grieving. And that's actually something I teach all of my trainees, because they'll come to me even after the rotation and be like, they're really horrible day, and they'll tell me about someone, like picking up a chair and throwing at them during a code.
Dr. Sunita Puri: [00:59:39] And I'm just like, hold up. Like, maybe don't do this during a code, but like, call security. But we're equally in some ways to blame because we don't stand up for ourselves and we don't teach each other to stand up for ourselves, and we don't. I think this is the power of being physician authors, is that we can render our humanity on the page, that hopefully whoever reads it understands that the person you know, opening your child's brain or the person that you're having a discussion with about what matters most, like these people have families, right? Yeah. These people have, you know, lives beyond what you see. We're trying to see you in the context of your life. There's nothing against you trying to see us. For in the context of our own vulnerability and fallibility. But I feel very strongly that this is something we should be teaching students. We should be teaching them about boundaries. We should be teaching them that drawing a boundary doesn't mean you're shirking your responsibilities. You don't have to stay in a room. And I try to model it. If somebody's going crazy in a family meeting, I'll just say, you know, I know this is really hard. This is not a conversation that is easy by any means, but it sounds like now's not the right time to have this conversation. So why don't you just let your nurse know when you're ready to talk again, and we will happily come back and I leave the room.
Dr. Jay Wellons: [01:01:11] I fully agree with that. I mean, at Vanderbilt now, we finally started a program where there's signs all over the place that say, all people are welcome here. All behavior is not. Yeah.
Dr. Sunita Puri: [01:01:21] Oh that's great. Yeah.
Dr. Jay Wellons: [01:01:23] You know, I think.
Tyler Johnson: [01:01:24] It's also one thing that I've learned about a lot from discussions we've had on the podcast that I think is important here too, is the idea of moral injury, because we haven't emphasized it today. But I did mention briefly that we are aware of, and it is important to recognize the role of things like corporatization and bureaucratization and digitization. There was an article in, of all places, The Wall Street Journal, uh, like three days ago about how private equity is ruining health care. Yeah, because I don't know if you've heard this story, but anyway, these private equity companies buy hospitals or whatever. And then to try to make them more efficient, they decrease even further the number of minutes that a physician has per patient encounter or whatever, to try to squeeze more money out of the bottom line. And the point is to say that if you're working in that system and you're the person that gets squeezed that way, then you as a health care professional, end up feeling like you're in an impossible moral position because you either have to do the thing that your boss or your controlling company tells you that you have to do to stay within their good graces. That's choice number one or choice number two is that you can address the patient's needs in the way that they need to be addressed. Right. And that's what we've also I've top of the.
Dr. Jay Wellons: [01:02:35] Fact that you're being judged by the press Ganey score. Right.
Tyler Johnson: [01:02:39] And then you're. Yeah. So then you're actually being rated on it as well.
Dr. Jay Wellons: [01:02:42] Like a restaurant, right?
Tyler Johnson: [01:02:43] Yeah. And we have talked to people, I've talked to one of the kindest, most wonderful, personable, intelligent people that I knew in residency. Now is works in California for a very high priced concierge physician practice. And I was quite surprised by this, frankly, knowing the person well, because we often sort of demonize concierge physicians, as you know, kind of the bad guys of health care or something. And I talked to her one time about why she was doing that, and she said, I'm doing this because this is what I thought medicine was going to be when I signed up. I have as much time as I want with every patient. I can dictate the way that my encounters go. I can, you know, put in orders whenever I need to. I can see them however often I want. I dictate the terms based on the patient's needs. Isn't that what it was always supposed to be like in the first place? And the fact that, I mean, you have to know this person for this to really land, but the fact that this particular person has made that particular decision is, to me, a very telling indictment of what is happening because of all of these external forces, which and I think that finding ways to effectively fight back against those is important. This for those of you who haven't heard, the Stanford House staff just in December ratified their first collective bargaining agreement, I think for many of the same reasons. Other questions or thoughts.
Audience Question: [01:04:05] So I just wanted to thank you for bringing up some very important issues. I'm a practicing comprehensive ophthalmologist, so when I started hearing about corneal abrasions and pain and stuff like, oh my gosh, they're talking about what I have to deal with. But one of the things that I've enjoyed in practice here at northwestern, after being in private practice for five years, was the varieties of spiritual traditions in my department. And for at least 10 or 15 years, I've brought up with my chairman and my colleagues about we should somehow bring this together. I mean, we have practicing Jews, we have non practicing Jews, we have Sikhs, we have practicing Muslims, non practicing Muslims. We have born again Christians, we have Catholics. And I would really like to tap into some of those spiritual traditions, like what gets you up in the morning sometimes and the residents, you know, they're not quite all there. I mean, you know, they're just trying to learn the material and get through the day, but they're going to face something in the next ten years. That's going to be really difficult. And they're either going to groove down into the spiritual or or not. But that's something that I've really wanted to delve into a little bit. And we touched on it and how each of you have have come to that as a part of your wellness and not necessarily the taco and the, you know, the. That is so funny. Um, yeah. That minute yoga. But again, thank you for bringing up some very important things. And if we don't get our residents thinking about some of these issues, I wonder if they're going to burn out and not be here for for us when I need, you know, some serious medical care. So thank you so much.
Henry Bair: [01:05:58] Tyler and I started this podcast when I was in medical school, so I thought I was like, perfectly equipped. You know, I have all the tools, and most people in medical school have had no exposure to this kind of conversation. But for the last year of medical school, I was doing this on a weekly basis. So I thought I was perfectly positioned to succeed in residency. The intern year starts, and then I realized what actually animates, what motivates the vast majority of residents in residency. What is their goal when they come in the day? Their goal is to leave as soon as possible. It just is. I mean, like they will tell you about it, right? The hallmark of a good senior resident is someone who can accomplish tasks efficiently so they can get the whole team out on time. They can sign out on time. That is the prime directive of residents. And I thought that I would never be like that. Six months in, I realized I was like that 3 p.m. 4 p.m. when, like, sign out is like looming the time when the night shift comes in, I start trying to be fast, as fast as possible.
Henry Bair: [01:07:01] I promise to go back to talk to a patron in the afternoon. I might not, because I have other tasks to finish so I can sign out on time. Sort of like this peer pressure thing, because if I don't sign up on time, then my senior resident can't go home on time and they'll resent me for it. And then, you know, it's like this cycle. I think your point about why is it that there seems to be a lot of apathy towards having these kinds of conversations? It's because it's not shown, or at least it's not reinforced that this is, dare I say, I think it's pretty essential skills to be able to think about these deeper issues, these issues of suffering and faith. It's just hasn't been talked about as a priority ever. We have noon conference four times a week. We have grand rounds every single week. Right? I think that's generally how it works at most residency programs, most hospitals, not a single noon conference was dedicated to talking about anything other than guidelines, guideline based management of specific syndromes or disorders. And that's why we have to change the importance that this occupies in people's minds.
Tyler Johnson: [01:08:02] And not only that, but I will say that one. So as Henry mentioned, Henry was helping to teach a class in our medical school. I went there to give a lecture, and they asked me to talk about how to tap into meaning in medicine and also sort of more broadly, how to build a meaningful life. And I did what I considered at the time to be a very uncomfortable and daring thing, which was to tell the people in this lecture that I think that I thought they should, quote unquote, find a church. And then I told them what I thought the necessary constituents of a church were, and I was afraid I might get like, reported to the dean's office or something because of saying the word church in a medical school lecture. But then Henry and I later taught a class about finding meaning in medicine based on conversations that we've had on the podcast. And when we taught that class, it filled up in like an hour. And on the first day when we went around the room and asked people to say why they had signed up for the class, like a third of the people who responded said that the reason that they had responded is because they had been in the other class and come to my lecture, and they were so relieved to know that this was a place where, quote, we are allowed to talk about spirituality, unquote, and where it was, quote, safe unquote, to talk about religion and spirituality and the role that it plays in their lives that they wanted to sign up the class for the class, principally for that reason.
Tyler Johnson: [01:09:26] And all of that is just to say that I think there is actually an unacknowledged and in many cases unaware, hunger to talk about some of these deeper spiritual, soulful issues in medicine. Because whether we acknowledge it or not, it's part and parcel of what we do. But as we said at the beginning of the episode, we just don't have the vote. We've never developed a vocabulary as a group of practitioners. We've never developed a vocabulary for being able to talk about it. But I think that it actually matters. And I think your idea of having some sort of a forum where people who practice different forms of faith or different forms of spirituality could come and talk about that, or talk about how it influences their medical practice or what have you, I think is a beautiful idea that would probably have more uptake than maybe the powers that be would anticipate.
Dr. Jay Wellons: [01:10:16] I've got this piece I wrote about a conversation, a short piece that I'm still developing. I wrote about a conversation that I had. I was really tired. I was early on in my career. I was just trying to get the cases done, and I was just somebody called. They wanted to talk to me on the phone, and they were a friend of somebody, referred them to me, and they had a son, a teenage son, and or a young adult son in the hospital and another Delaware. And I just like I'm scrubbing to do a case. Why do I need to talk to this person? And it ended up being a very meaningful conversation. And I intersperced it initially with verses from First Corinthians, which were meaningful to me. And then I talked to a Jewish friend and I said, I want you to read this piece and help me find places in the Torah that I can intersperse instead of First Corinthians. And it's a beautiful piece. And then I talked to a muslim friend. I said, help me with the Koran and come up, you know, talk to your, you know, to your spiritual leader. And and so then I have you can insert these pieces from the Koran in there. And so you can read this piece in three different ways, and it all comes out as being, my goodness, how how relevant spirituality is to what it is that we do. And in these moments of when we find ourselves all a fluster, how it can help ground us no matter where the spiritual construct comes from.
Dr. Sunita Puri: [01:11:42] A lot of what I wrote about in my book was that I was raised by parents who are very devout Hindus, and they're both scientists. So my mother's an anesthesiologist and my father's an engineer. But I remember sometimes she would take me with her into the PACU, and I remember her talking to patients and asking if they wanted to pray before she took them to the Or, or came out of the Or, and they were in a lot of pain and it didn't matter what their faith tradition was. My mom would sit with them and pray, because I think one of the tenets in Hinduism is all different. All religions are different paths to the same place. So it's fine to pray with someone of whatever background and not impose that on them in any way, but just create a space. And so I was just really surprised when I went to med school and there was this like, God and science are diametric opposites. When I'd seen how they can live well together and are essential to live together for many people. So it has just never been something that I've understood that we can't talk about our faith with one another, even if we have very different faiths. It's a way of getting to know each other, too. It's understanding someone's lens on the world. And if there is that great diversity in your department, I think what an opportunity is, if we can get past this thing of God cannot be mentioned in the hospital, like, or at our departmental meetings, like, yeah, what if God shows up and it's great.
Dr. Jay Wellons: [01:13:19] Yeah, I guarantee you that there's more. There's more prayer that goes, that goes, that is sent up in the cafeteria of a hospital. Yeah, on a daily basis. Then I would I would argue that in churches on a Sunday, you know, more meaningful yearning, true deep prayer. Yeah.
Tyler Johnson: [01:13:39] And with that, I thank all of you so much for being here. And again, we thank you, northwestern, for hosting us. And thank you so much.
Henry Bair: [01:13:49] 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 Doctor's Art.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: [01:14:08] 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: [01:14:22] I'm Henry Bair.
Tyler Johnson: [01:14:22] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.