EP. 125: FINDING THE RIGHT WORDS WHEN IT MATTERS MOST

Aug 21

WITH SHUNICHI NAKAGAWA, MD

The director of inpatient palliative care at Columbia University Medical Center shares his remarkable journey from training as a general surgeon in Japan to becoming an expert in serious illness conversations in the United States.

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Episode Summary

For many physicians, having serious illness conversations with patients — talking about a dire prognosis or the futility of curative treatments — is one of the most daunting aspects of patient care. But to palliative care physician Shunichi Nakagawa, MD, these conversations are fundamentally about communicating the honest truth in an elegant, considerate, and humane way.

Dr. Nakagawa, the director of the Inpatient Palliative Care Service at Columbia University Medical Center, joins us in this episode to discuss both his unique personal journey, as well as his insightful approach to figuring out what really matters to patients during critical moments in their lives. He shares what it was like completing his surgical training in Japan, than coming to the United States with the hope of becoming a liver transplant surgeon, before having those hopes dashed when he found out he was ineligible to work as a surgeon in the US due to his hepatitis carrier status, and finally discovering his true calling in geriatrics and palliative care.

We also discuss cultural challenges in thinking about the end of life, why it is so difficult for physicians to communicate with their patients about serious illness, how clinicians ought to approach shared decision making, and why, when done well, this can be one of the most meaningful and rewarding parts of doctoring.

Shunichi Nakagawa, MD is a distinguished medical professional and researcher, known for his expertise in palliative care and bioethics. He serves as the Director of the Inpatient Palliative Care Service at Columbia University Irving Medical Center and is an Assistant Professor of Medicine at Columbia University Vagelos College of Physicians and Surgeons. Dr. Nakagawa is deeply committed to improving the quality of life for patients with serious illnesses, focusing on the integration of palliative care into mainstream medical practice.
Dr. Nakagawa's work emphasizes the importance of compassionate care and ethical decision-making at the end of life. His research interests include the development of innovative models for palliative care delivery, communication strategies in serious illness, and the ethical challenges faced by healthcare providers in the context of life-limiting conditions.
In this episode, you will hear about:
• 2:34 - How Dr. Nakagawa entered a career in medicine in Japan
• 5:33 - Dr. Nakagawa’s unique journey through medical training, from surgery to palliative care
• 16:25 - The three-stage process that Dr. Nakagawa follows when communicating challenging medical information to patients
• 28:10 - Delivering medical advice in a succinct way when speaking to patients and their family members
• 36:14 - Lessons on what works and what doesn’t work in sensitive patient communication
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 healthcare 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] For many physicians having serious illness conversations with patients that is, talking about a dire prognosis or the futility of curative treatments is one of the most daunting aspects of patient care. But to palliative care physician Shunichi Nakagawa, these conversations are fundamentally about communicating the honest truth in an elegant, considerate and humane way. Doctor Nakagawa, the director of the Inpatient Palliative Care Service at Columbia University Medical Center, joins us in this episode to discuss both his unique personal journey, as well as his insightful approach to figuring out what really matters to patients during critical moments in their lives. He shares what it was like completing his surgical training in Japan than coming to the United States, with the hope of becoming a liver transplant surgeon. Before having those hopes dashed when he found out he was ineligible to work as a surgeon in the US due to his hepatitis carrier status and finally discovering his true calling in geriatrics and palliative care. We also discuss cultural challenges in thinking about the end of life, why it is so difficult for physicians to communicate with their patients about serious illnesses, how clinicians ought to approach shared decision making, and why. When done well, this can be one of the most meaningful and rewarding parts of doctoring.
Henry Bair: [00:02:26] Shunichi, thank you for taking the time to join us and welcome to the show.
Dr. Shunichi Nakagawa: [00:02:31] Thank you. Thank you for having me. I'm very honored to be here.
Henry Bair: [00:02:34] So you're now well known as an educator and advocate of palliative and end of life care. But your career began all the way across the world and in a very different arena of medicine. Can you tell us more about that?
Dr. Shunichi Nakagawa: [00:02:47] So, you know, I was born in Japan. I grew up in Japan. I went to medical school in Japan. I mean, in Japan, students with high grades tend to go to the medical school, so there's not much thought about that. And also, my uncle was the orthopedic surgeon. He gave me a lot of influence. I mean, he was very he was cool. So I wanted to be like him. So that's why I chose the medicine.
Henry Bair: [00:03:20] So you chose medicine because number one, it was sort of what people around you were doing, people who did well in school. And because you had a cool orthopedic surgeon in the family. Correct. Were you planning to do orthopedic surgery when you started medical school?
Dr. Shunichi Nakagawa: [00:03:37] No, I was not sure what to do. Surgery or medicine. I mean, I used to be a surgeon after in the medical school, when I was thought about the medical specialty, I was not sure what to do. So I graduated from medical school. I chose to become a ENT. Emt was doing the lots of head and neck cancer. The surgery, I think that was very attractive to me. So I initially chose the EMT, but after three years I started to think that only focusing on, you know, around the one part of the body was not exciting enough to me. So I changed the specialty to the general surgery. I did the general surgery residency in Japan for five years, and after that, after graduation, I came to the States initially because of the, you know, I wanted to become a liver transplant surgery. So and then in Japan, the brain death was not so common as in the United States. So in order to become skillful about liver transplant, it's better to come to the United States. So that's why I came to the United States after I finished the residency.
Henry Bair: [00:04:56] Right. So to clarify, to make this very clear for our listeners, you actually completed residency in general surgery. You were you were a licensed practicing general surgeon in Japan. And you came to the US, correct.
Dr. Shunichi Nakagawa: [00:05:09] In Japan at that time. It's not as distinct as in the United States, like in the United States. I mean, you do the five years of general surgery residency, and then you become an attending physician. You're independent. In Japan, that distinction is not as clear as in the United States. But I think I can say that I did the residency in general surgery.
Tyler Johnson: [00:05:33] I still have to say, though, that I don't know if you've ever seen, but on social media, every once in a while this thing will make the rounds. That is this like phylogenetic tree for who becomes what kind of doctor, right? So it asks some some question at the beginning about, I don't know, do you like to work with your hands and then do you like to work with kids or adults and then whatever. Right. And then if you answer all the questions, then you're supposed to end up at the final branch that tells you to be, you know, like a pediatric infectious disease doctor or whatever. Which is just to say that I think if we pulled that tree up right now and we looked up ENT, general surgery, orthopedic surgery, those would probably be like, you know, different branches, but off of the same like main branch. And then palliative care would be like way over in the next solar system somewhere. Like, I'm not even sure it comes off of the same tree. It might be a totally different it's like an oak tree and a maple tree or something. I'm not. That would not have been on my bingo card for the person who had originally been interested in ortho, and then ENT and then general surgery. So how did that happen?
Dr. Shunichi Nakagawa: [00:06:33] I came to the United States. I came as a, you know, liver transplant fellow. But after I came here, I was told that, no, no, no, you cannot do the surgical training because I have a heavy from my mom vertical transmission. So I am a carrier of the hepatitis B, XD I don't have any hepatitis, but I'm an E antigen positive and I don't know if you know this, but CDC issued a guideline probably, I don't know, 30-40 years ago saying that healthcare providers with E antigen positive should not perform exposure from procedures including everything in the OR.
Henry Bair: [00:07:14] I did not know that at all.
Dr. Shunichi Nakagawa: [00:07:16] So yeah, nobody knows this when I when I shared this story. So the after you know I did the Usmle E Ecfmg, I got the license and I was so excited to come to the United States. And then I was told, oh no, no, no, you cannot do the surgery. So then I was doing the, you know, pre-operative management or post-surgery management for the liver transplant. It was not so exciting to me because I wanted to do a surgery. So at that time I had two options. One is going back to Japan and then just continue to be a surgeon or stay here. And, you know, until that time I was aware that I'm hepatitis B, and then I was aware, you know, I could transmit the disease during the surgery if I cut the hand by, by mistake or something. But I was not seriously thinking about it. But once you are told officially, you know, in the United States, you cannot do surgery, I start to think that already. So is it okay for me to just go back to Japan and then continue being a surgeon, only because there is no regulation in Japan? Because if I were a patient and I'm expecting a surgery tomorrow, and then there are two surgeons, one is positive and negative, I myself want the surgeon engine negative.
Dr. Shunichi Nakagawa: [00:08:46] So that means theoretically, you know, I'm not able to provide the best care. I believe to the patient. So that kind of started to bother me. So then, you know, I came to the States. I mean, uh, I'm here already, so maybe I should not be a surgeon. Maybe I should do something else. So that's the reason why I switched to the medicine. At that time, I was so devastated. But looking back now, actually, that was the best thing happen to me in my in my career, and I. So I did the internal medicine residency. And then after that, I started to think about what specialty I should do. At that time, I was still thinking about going back to Japan, so maybe I should do some specialty. So what was the United States better than Japan? So I was thinking about infectious disease. At that time there was no IB training in Japan, but I was thinking about the geriatrics, you know, Japan. There's a lot of older people, but there is no special, you know geriatrics, uh training program in Japan. So I was thinking about that. But, you know, I'm a kind of a surgical mind. Geriatrics is, you know, not so sexy. So I was, oh, should I really, really do this? But, uh, my wife told me that. You know what? I'm probably. You should do that. You should help the patients, the family. So. Okay. Sure. Let's do that.
Dr. Shunichi Nakagawa: [00:10:16] So then I came to the, uh, Sinai. I came to Sinai for the geriatric fellowship. During the geriatric fellowship, I had a chance to rotate the palliative care, and that was eye opening to me. That was brilliant. I rotated one month, and, uh, the attending, I rotate two weeks. The way he talked to the family, the way he led the family meeting, the way he took care of the patient. That was eye opening to me that I was hooked. I should do this. So I asked at the time I was like P.G. like 13 or 14 that I stopped counting that. But I asked my wife, can I can I do one more year of palliative care fellowship? And she said, okay, so I did that. And uh, after I finished the palliative care fellowship, I started to think that, you know, I had such a lot of training. So I want to have the experience as an attending in the United States before going back to Japan. So then I came here in Colombia. That was like ten years ago.
Tyler Johnson: [00:11:20] You know, I have this friend of mine who was a chief resident when I was an intern here, and when he was getting ready to graduate from residency, he had what at the time was sort of a crazy idea, which is that he wanted to be a critical care infectious disease doctor. So he did fellowships in both critical care and infectious diseases, and now he does. I don't even know exactly what his job consists of, but he does some version of that where he does both critical care and infectious disease in Boston. But I have to say that you are officially the only palliative care liver transplant ENT general surgeon that I have ever known so and probably that I ever will know, because I don't think anybody else would be willing to sign up for that much training. And plus, even if they were going to sign up for that much training, I don't think it would encompass all of those different things.
Henry Bair: [00:12:10] Yeah, I have to remark that, you know, for people who know anything about medical training, as Tyler alluded to, whether to go down medicine or surgery is like one of the earliest branching points, right, in medical training. It's like one of the early decisions you have to make. So you went down one path, the surgical path. You finished the five well, including medical school, almost ten years of training required for that. And then you came to the US and then the surgery thing wasn't working out. So then you had to go back all the way to the start of that branching point and go down the medical path, the non-surgical path. And, you know, it's interesting because I'm wrapping up my first year as an internal medicine. Well, I'm in prelim. I'm going into ophthalmology. But my first year of residency is all internal medicine. I'm just picturing working with a co resident who's like my same year, who's like a fully trained general surgeon and what that must be like. I don't know what your experience was like. I mean, how did it feel to have so much experience and training in medicine and yet going back to basically the start of a whole different kind of medical training, what was that environment like?
Dr. Shunichi Nakagawa: [00:13:18] No, I think there are a lot of Co-residents who had experience in other countries, and they come to the states, they do the residency. So I was fortunate that I didn't have to have the, uh, that kind of problem. And, you know, I was obviously I was very good at, you know, getting a peripheral line. So when my co-residents had difficulty putting a central line, I can do that. And then so that was a very, uh advantage.
Tyler Johnson: [00:13:52] Fair enough. I feel like I would have been enormously intimidated if one of my co-interns knew how to like, you know, do full on surgery with the whole anesthesia. And anyway. But I'm sure that you brought a wealth of experience. And, I mean, more than anything, I just have to imagine that you were so much more calm and comfortable than everybody else who's just, like, trying to figure out where the bathroom is and you, like, already know you know how to do surgery. That had to have been quite a little bit of a difference. Yeah.
Henry Bair: [00:14:21] So you talked about how as a geriatrics fellow, you did a rotation in palliative medicine, and then you were hooked by what you saw, you know. So I grew up in Taiwan. I moved to the US when I was 18. So, you know, most of my formative years, my brain is very much shaped by the cultural context of Taiwan. And, truth be told, palliative medicine, it exists in Taiwan, but it's definitely just it's not well known. You know, my I come from a family filled with physicians. My father is a physician, but the first time I ever heard about palliative medicine, the idea of it of being specialized in supportive care, symptom management, quality of life, this entire concept, I only heard about it in the end of college and then really in medical school. I remember going back to my parents and asking them if they knew what it was, and they had no idea what this was, right? Like a bunch of doctors in Taiwan had no idea what this was. I don't know what the culture is like in Japan, but I'm wondering, in fellowship for you, was that the first time you had encountered this concept of this interdisciplinary focus on quality of life?
Dr. Shunichi Nakagawa: [00:15:29] Yeah, definitely. So, I mean, in Japan, traditionally speaking, I think to be alive, to be kept alive is a good thing. To die is bad thing, very like dichotomous in Japan. And then I came to the United States and then also the, you know, the the internal medicine residency program. I did a training was also, you know, palliative care was there but not not so well established. So at the time, my understanding about palliative care is, you know, those are for like dying people, dying patients, we cannot do anything else. So you call palliative care like that. So my transformational shift that I opening was, you know, I learned that after I came to Sinai, I think when I did the training in Sinai, that was eye opening to me.
Tyler Johnson: [00:16:25] So I want to shift gears a little bit, from what I gather about your background and what you have focused on since you became a palliative care doctor and perusing through your Twitter feed. I think that one thing that you have focused on a lot, that I don't think we've ever really talked about in detail, I want to have you talk about, but I want to first set it up a little bit in the following way. So I remember when I was in medical school, probably in just before I went into the clinics, is my guess. We were asked to watch this video that was on quote unquote shared decision making. Right. And the sort of archetypal case that was in this video was a primary care doctor who had a patient who had had diabetes for some amount of time, and it had been sort of moderately well controlled on oral hypoglycemics and whatever. And now they were going to need to start taking insulin, or at least that was the doctor's recommendation, was that they start taking insulin. And so then the discussion that was modeled in the video, there was the bad example, and then there was the good example. Right. And the bad example was just the doctor kind of walks in and says, well, your hemoglobin, A1C is terrible. And if you don't start on insulin, then you're going to, you know, lose your toes and lose your sight.
Tyler Johnson: [00:17:37] And I don't know, something, something, something. And so you need to start this medicine. And, you know, here's how many units you take however often or whatever. Right. You know, this very sort of Paternalistic top down. I'm just going to sort of give you orders. Sort of approach. Right. And then the shared decision making was much more about sort of, you know, starting from a place of explaining, first of all, what is hemoglobin A-1c and what is, you know, and why is insulin important and why is diabetes bad if you don't control it and whatever. And then kind of helping to bring the patient along to understand where the doctor was coming from. And then introduced that there's this new medicine and. Et cetera. Et cetera. So it was much gentler. It was in its way more collaborative. And, you know, the idea was that you were trying to get the buy in of the patient as well as the physician. So that's all fair. And I don't mean in any way to question the difficulty, for example, of helping someone to start insulin or whatever other thing that you might, might do in a situation like that. But and so I, you know, I tried to do that, I think in my way as an internal medicine resident and a medical student.
Tyler Johnson: [00:18:40] But then I get to fellowship as an oncologist Right. And so as an oncologist, the two places where I was most likely to need shared decision making, the two kinds of situations were one helping patients to make really high stakes decisions. Right? Like, do I undergo this big, complicated, potentially morbid surgery? Or do I undergo a bone marrow transplant procedure that has a 10% mortality rate in hope of saving my life or whatever? So that was one is a high risk decision. But then the other one, which is the one that I want to talk about, given your expertise, were decisions that needed to be made around how a patient was going to receive care at the end of their life. Right. And so on. A very basic concrete level, this is questions like, if you're getting admitted to the hospital, would you want to get CPR, or would you want to be put on a ventilator if it came to that, those kinds of things. But then in a more general level, you know, there's there are decisions to be made about how long and far and hard do you push on chemotherapy? Therapy. How long do you receive aggressive and invasive care? When do you want to still be admitted to the hospital? When do you enroll in hospice? Et cetera.
Tyler Johnson: [00:19:51] Et cetera. And then eventually questions about even things like, in effect, what do you want your approaching death to look like? And what I recognized after a pretty short amount of time as an oncology fellow is that even though if you I'm sure if you had asked any oncology attending, they would have said, oh yes, of course, shared decision making is very important in those circumstances. If you had then said, okay and tell me, how do you do that? Like what does shared decision making look like as a patient is approaching the end of their life? I think it's fair to say, and this is nothing against my attendings, who by and large were wonderful. But I think just as a field, we had like no good answer to that question, even, you know, 8 or 10 years ago. I do think we've become better and we can talk a little bit about that. But all of that is a setup of a way to say to you when you have patients who are approaching those kinds of very weighty, almost existential decisions, how do you think about a model for how to engage in shared decision making, in what I think are some of the most difficult and fraught situations that we face in medicine? Things like what I was describing.
Dr. Shunichi Nakagawa: [00:21:11] Thank you. I think that's a very good question. I think one, when I get a consult, I mean, uh, in whatever situation, oncologists having difficulty clarifying goals of care or, you know, in the ICU, uh, they have difficulty clarifying goals of care. I get the consult. And, uh, when I think about those goals of care, conversation or decision making conversation, I look at that as a three stage game. Maybe I should not say game but I think that sounds like more fun. So I go to the first stage and second stage. Third stage, and I go to the I first like the first stage before going to second stage. I go to the third stage only after I clear the second stage. First stage I call that sharing knowledge, meaning that they have cancer or chemo is not working and your time is getting short. So those kind of like are giving bad news stage. We need to be on the same page about medical condition, about the prognosis. So we have to deliver that. And you know, many physicians are able to do that somehow give the news. And that is okay. But right after that, many physicians ask, what do you want? I think this want is a very bad word. You should not use it in the conversation. Want is a bad one because I usually use the computer analogy. You know, my laptop got broken and I go to the store and then there is a lot of model I don't know about the computer, so the attendant comes to me.
Dr. Shunichi Nakagawa: [00:22:44] One attendant came to me saying that, oh, you should buy this type A. I mean, this is not helpful. He doesn't listen to me. He's very paternalistic, so he doesn't help. The next one came to me saying that. So, you know there are three two options. Model A is what, five gigabyte Pro, you know, uh, CPU or gigabyte memory. And this is $1,000. Model B is like 15 $1,500. So which one do you like? Which one do you want? It's your decision. He can give me a lots of lots of information, but I still can't make a decision because I don't know what this gigabyte means. I don't know. I don't understand this. Memory means. So no matter how how detailed the information he gives me, I cannot make a decision. That is what lots of lots of doctors doing in the ICU and the hospital. I think more useful attendant is like this. So. Okay, so what do you use the computer for and how much is the budget? Then I can answer that. I can say, you know, I use Excel, I use PowerPoint, I do not edit the movie, I do not edit the music. And I can afford, you know, $1,200. Then he can tell me, okay, so you don't have to buy model B, it's okay with model A, you don't have to spend an extra $300. This is very helpful. Don't you think so? I think shared decision making. When you say shared decision making, it's not like doctor said and the patient side approach the information in the same way.
Dr. Shunichi Nakagawa: [00:24:09] Not like that. First you have to establish the goal. And then in order to set a goal, we need to listen to the customer. We need to listen to the patient. So instead of which one do you want? We have to ask the. So after hearing this bad news, what are you most concerned about and what is most important for you? What are you hoping for? What makes your life meaningful and is there any situation that you would find unacceptable? These are the questions we have to ask Many doctors ask, what do you want? Option A or option B? Pros and cons. And then they ask what. Which one do you want. It is not helpful. And after hearing the information well you know I don't want to be any pain. I want to spend time at home. You know I'm okay with not going to the, uh, you know, cruise anymore. But I want to be independent at home. Okay. Well, so in that case, you know, we have chemotherapy option. I think this chemotherapy is still helpful to achieve your goal. So I think you should choose this chemotherapy. Or you can say, you know what. At this point chemotherapy is not helpful. So you should not do chemotherapy. You should do this. So once. Second stage we clarify the goal. At the third stage we physician should make a recommendation. You should do this or you should not do this. So that is my basic, uh approach to the conversation.
Tyler Johnson: [00:25:36] Yeah I think that's such a useful and practical and powerful model, because what I see a lot of trainees doing, I think, you know, 50 years ago there was probably a very strong strain of the paternalism model, right? And I've heard stories about times when either physicians just said, this is what we are doing, or even just did the thing and didn't even discuss it with the patient. Right. They just proceeded with the procedure or whatever. And I think that there has been a really needed and helpful swing of the pendulum away from that approach, which is great. But by the same token, what I now often see is that there's almost this at least a hesitancy and almost sometimes a fear of actually saying I recommend the following. Right. And so that, like what you're talking about, it almost feels oftentimes like I tell my trainees often that it sometimes it feels like when you listen to doctors in training talk about these things, it's like they're a waiter who's just bringing a menu and saying, here's a bunch of options. Which of these options do you like the most? Right. Which is, first of all, a problem because as you say, who if just given a menu is not going to say, quote, I want everything unquote. Right? Like it sounds crazy if you frame it in those terms.
Tyler Johnson: [00:26:52] And secondly, they have no idea which of the options even makes sense. Or to use your analogy with buying the computer, which of them they can quote unquote, afford. Right. And so I think that by having your second step come before your third step, part of the reason that that second step is so important is precisely because it allows you then once you understand the things that matter most to the patient, then you're able to be not just direct, but you can be if it's appropriate, you can be vigorous or full throated in your recommendation. Right. There may be some times when you say, well, given what's important to you and given the medical reality, you have multiple options. And here's what they are. And and we can help you choose between them. But then there may be other times when you say honestly, given what matters to you and the medical reality, it's not even so much a recommendation. But like this is the only realistic option. Right? But being able to come in and say, given what I understand about what's important to you and given the realities of your current medical condition, this is the thing that I recommend. I think that that's really important and powerful.
Dr. Shunichi Nakagawa: [00:27:59] Exactly. I cannot emphasize this more. Second stage is missing all the time. I think people jump on from first stage to third stage. So that is I cannot emphasize this more.
Tyler Johnson: [00:28:10] So let me ask you this question. One of the things that I have noticed as an oncologist and as someone who spends a lot of time teaching oncologists and medical students and internal medicine residents, is that so? You mentioned that in your three stage model or your three step model, that the first step is to just make sure that everybody is on the same page about medically what is going on, right? Correct. And I have to say that in my experience, at least for oncologists, I actually often find that that is so. I think the second stage is often hard for people, because they don't even realize that it's a thing they're supposed to do, so they don't even try to do it. They just kind of skip over it. Right. And and then of course, there's some learning curve. Once they figure out it's important, they have to figure out the right kind of questions to ask and whatever. But the first stage, I think oncologists pretty much always know that they're supposed to do some version of sharing the prognosis or talking about the medical condition or whatever, but my experience is that even though almost everyone knows that they're supposed to do that, it is often exceptionally difficult to get oncologists, including myself, to do it clearly.
Tyler Johnson: [00:29:26] So I'll give you a couple examples of what I mean. One example is so there's a patient who's really sick. They have, you know, metastatic cancer, XYZ They're in the ICU and they've not been doing well for a number of days. They're not improving. And now it's time to have a sort of a big deal. All hands on deck, sit down with the whole family and have a family meeting about what's going to happen going forward. And so to start out the meeting, you might say to the resident on the service, we're going to start out by telling the family that we're going to give them an update about what is going on with their family member. And what I need you to do is I need you to give a succinct, clear sort of, you know, ground level summary that the family will understand about the big picture of where things stand, and then you ask them to do this, and then they give a 15 minute monologue that includes, like every organ system and the creatinine for the last 13 days, and the vent settings and the pressure settings and the whole thing. Right. They just talk forever and ever and ever. And it often strikes me, frankly, as a way of kind of using a whole bunch of words to purposefully not actually say anything, right? It's like you hide yourself.
Tyler Johnson: [00:30:44] You kind of cloak yourself in the words so that you don't actually have to come out and say, what's really going on. That's number one. And then number two, it just a second example of a similar thing is that you can have a person, a patient who has who has a metastatic cancer that has progressed through, you know, many levels of therapy. And everybody knows and agrees that there are no viable treatment options left. And then you again ask a trainee or for that matter, an attending to explain that fact to the patient, and instead there's a whole bunch of sort of caveating and hemming and hawing and talking about, well, maybe a clinical trial at some point. Right. And it's very difficult to just come out and say I don't think that getting further treatment would be in your best interest or whatever the thing is. So I guess all of that is just by those are examples by way of asking you, how do you help trainees to learn how to just come out and say the thing in a way that it will actually be clear and helpful to the patient or the family members who are listening?
Dr. Shunichi Nakagawa: [00:31:58] I think maybe I should go start with the second question. So I think when you expect a big conversation, the setting of preparation is the most important thing. I spend more than 50% of my time and energy in the setting. The better job you do here, the easier the actual conversation goes. So in the cancer situation, the cancer patient in ICU, I mean, first I need to try to find out the stakeholder for that patient who has the physician who has the longest relationship with this patient in cancer. Oncologist in heart failure. Cardiologist in post-surgical patient. Maybe the surgeon. So I have to get in touch with that primary stakeholder. And then, uh, I have to talk to that person. I understand, you know, for me as a consultant and then coming to the picture at the last minute, and then I look at the patient, what am I doing here? And then, uh, chemotherapy is not going to help anymore. It's really I mean, it's very easy for me to say that, but I, I have to acknowledge that for the primary stakeholder, like from oncologists to say, because oncology has a final say for him or her to say, you know what, we don't have any more cancer treatment. That's extremely difficult. So I have to get in touch with that primary stakeholder, and they have to fill out and they have to have a conversation.
Dr. Shunichi Nakagawa: [00:33:28] And then, uh, you know, what is your thoughts. And then do we think it's really helpful to have another conversation. Or do you think it's better to intubate this patient and then give the ICU care? So before even talking to the family, I think the medical side has to be on the same page. We should get in touch with the primary stakeholder. Let's say we clear that we are on the same page. And then now we start talking to the patient family that you mentioned. The trainees keep talking like 15 minutes in that first stage in explaining the medical condition. I think you should be able to summarize the medical condition within two minutes, not longer than that. I hear you that some doctors, the resident, keeps talking on and on and on. Creatinine, wide count, urine output. They don't understand that even I don't understand what they're talking about. So if you cannot summarize within two minutes, your preparation is not good enough. That is what you can prepare even before the family meeting. And also very common pitfall. I see that some residents start explaining from the most recent event like getting pneumonia, sepsis, now intubated on pressors. If you start doing that, I think you give the impression that, okay, so my loved one is sick because sepsis.
Dr. Shunichi Nakagawa: [00:34:52] So maybe you should treat the infection. He could get better. Usually that's not the case. Usually what is happening now is the manifestation of the root problem. Usually the we can identify the one single disease which is going to kill the patient. Could be cancer, could be heart failure, could be dementia. So when I start the two minute summary, I try to think that where should I start my story? It's not the time of the admission. It should be the six months ago the cancer was diagnosed. Or it might be like three years ago the cancer was diagnosed. So my my summary could be, you know, your loved one was diagnosed with cancer three years ago, and Doctor Johnson has been doing his best to treat the cancer. Unfortunately, cancer progressed. Now he's very sick, he's very weak and that's why he's now had a bad infection, the hidden loss of life support. And unfortunately we cannot do the cancer treatment anymore. So this is less than two minutes. So I think residents in the ICU are like a patient round. They discuss a patient like system by system approach. What is the cardiovascular ID pulmonary. That way of discussing is not good in the family meeting. You have to summarize within two minutes.
Henry Bair: [00:36:14] Yeah it's a really interesting point. And I didn't really consciously I have not consciously registered doing that, trying to summarize everything, distilling everything into two minutes. You know, normally in internal medicine you often have patients who are, you know sort of the team recognizes they're approaching the end of their lives and there's not many curative. Actually, there are no curative interventions that are remaining. And so we talk about we're going to have a family meeting that's usually code for goals of care conversation. And the resident who takes the lead a lot of times what they think of and I'm guilty of this, I've done this before. What they think of as great preparation is pouring over all the clinical data, all the lab values, to make sure you have them all in your mind so that you're ready to share all those things. And it's exactly as you pointed out, as you sketched out for us. That is how you open. It's like, and then I have done this before. There are so many times when I think I've done the great preparation of like being super familiar with all the medical details, all the things, all the procedures that have happened, which dates he got, you know, his blood cultures came back positive, you know, things like that. And then it's so easy when you go into that room to start with the positives, to say that, oh yeah, like he had the aspiration pneumonia, but he's responding well to the antibiotics we started two days ago. Look at this. White count is amazing. And it's really easy to fall into that trap.
Henry Bair: [00:37:33] So I think that to your point, it's so important going over all the medical data should go towards the actual preparation, which is to think about how you can boil all that down into the bigger picture, and to weaving it together into a coherent story that you can deliver in a few minutes. And I think this is where, to your point, this is something that you can practice and you should practice, right? We don't really think about it like we study medicine. We we review, you know, the pathophysiology of diseases in surgical procedures. We practice on pages, for example, in ophthalmology. But we don't often think about having these conversations as needing practice, so to speak. And I think your approach in educating us sheds light on the fact that, yes, this is something you can rehearse, you can practice over and over again, and you can actually get better. Right? So, you know, that leads me to my next question, which is over the course of you observing so many of these conversations and teaching a lot of students and doing research on what is most effective, what works best in terms of patient care. What are some of the. And you've already shared some of these with us, but what are some of the more insightful, interesting, maybe unexpected lessons that you've learned along the way into what works and what doesn't work?
Dr. Shunichi Nakagawa: [00:38:47] I think doctors are having a lot of difficulty answering questions in a simple way. I think that is a very striking to me. After you give the two minute summary. I think it often has. A lot of times it happened that the family asked us, so doctor, is he going to get better? So I see that, well, his clarity is not good. So that that that. And then then he's not going to get better or something. So no, it's opposite I think. Is he going to get a better answer should be well, probably not. And silence. That's it. When they ask you questions, I think we should answer all the questions with one word or one sentence. I think we tend to answer with because of A, because of B because of C and D. If you do that, they want to hear D. But why do you put lots of information in A, b, c? I mean they are emotional, their brain not working so they cannot absorb the information. So first you give them the answer D in a simple way with one word, one sentence. Then if they ask you why because of kidney. Because of lung, if they can ask more questions, if they can absorb more information, you just give the information. But many doctors having difficulty doing that, that I observe a lot.
Tyler Johnson: [00:40:19] Yeah. I think one thing that is sort of analogous to this, that I think functions for many of or happens for many of the same reasons is I've noticed that when I attend on our inpatient service and we're taking care of very sick patients in the hospital that, you know, if you look at an internal medicine residents note for the day, for one of our patients, the assessment and plan, which is supposed to be a concise summary in effect of sort of what's going on with the patient, is sometimes like 3 or 4 pages, single spaced, typed. Right. It's all of this like information of all of these things that have happened sometimes over weeks, that the person has been in the hospital, and then all of these sort of nuances of old lab values and this and that and the other thing. And then sometimes on rounds, there's a sort of a similar feel where it's just, you know, you're sort of wandering through these very complex lists of information. And sometimes at the end of all of that, it's really striking because I'll say, okay, thank you for all of that detailed information, but now can you just answer two questions for me, which are what do you think is going on and what are we going to do to fix it? Right. Because that requires you to sort of cut all of the fat and to just say the thing. And even more so if you're communicating with a patient or their family members, almost certainly there are exceptions, but in the vast majority of cases, they don't want to know all of that detail.
Tyler Johnson: [00:41:47] They just want to know, is the person getting better, or do you have a thing to fix the problem, or what is the main underlying problem? Whatever. Right. But the thing that I think is counterintuitive for many trainees is that the ability to distill down all of the complexity into that sort of simplicity on the far side of complexity, that's actually the thing that takes more understanding and more expertise and more experience. It's actually easier to be over detailed and make it over complicated than it is to simplify it into a form that people who are not, you know, doctors can really understand the information and know what to do with it. So usually we close by asking our guests some version of this question, which is to say, I know that a lot of what you do is this. Anyway, a lot of what you do is working with trainees and helping them as they're trying to become doctors. But if you had to choose 2 or 3 of what you consider to be your most important pearls of wisdom to offer to people who are coming up through their years of training working to become healthcare practitioners, what would you say are 2 or 3 of the most important things you would want people to know? Yeah, and.
Henry Bair: [00:42:59] I want to I know I want to sort of add to that because knowing that our listeners, me, for example, I'm not in internal medicine, I'm not going to be a palliative care doctor. I don't think I'm going to a surgical specialty. But as you mentioned, this is relevant for pretty much all physicians, maybe pathologists, radiologists less so. But in general, the vast majority of patient interfacing specialties, which is most of us, right. So our listeners span all specialties. So number one is keeping in mind that this applies to everyone in medicine. Number two is the practical realities of working in the hospital, which is to say time constraints, which is a unideal settings. Right. In the Ed, the busyness of the emergency room, the loudness of the ICU, taking all that into account, as you answer Tyler's question.
Dr. Shunichi Nakagawa: [00:43:48] You know, to get to know the patient who she who he or she is, how they are is really helpful and not. And it's more, I think, time saving, more efficient. If you only have the medical information, like 75 year old guy with advanced cancer, sepsis, intubated, then I think question is live or die? So nobody wants to die. So we have to we have to keep living. So that's why we have to do everything to keep them alive. But if we have the information to know who he is, how he is. You know, he likes to walk around, he hates to be dependent, and he's a very strong personality. And then, uh, whatever he's being fed, he hates it. So if we have that information, I think because we're professionals, we automatically know what is best for this patient. So by asking simple questions, what does he enjoy? What makes him happy? And then those questions to get to know the patient is actually saved a lot of time and, uh, energy and resource. I mean, we are not doing medicine in order to save resource.
Dr. Shunichi Nakagawa: [00:45:04] But I think if you ask these questions, that is going to make your practice more fulfilling and more rewarding if you do that way. I think everybody is grateful. And also I want to I want to say this. You know the giving bad news. I'm doing this every day. No family is telling me. Oh, you're a bad doctor. You are. You say this to us, and then you. You crush this hope. Nobody is saying that. I mean, people are so afraid of giving bad news. I think people, doctors are so afraid of being honest. But when you give the information in the best way possible, almost all the time, they tell me that. Thank you, Doctor Nakagawa, for telling that. Thank you for having this conversation. So they are so grateful. And that is very fulfilling to me. And I think that's very interesting because I'm giving them a worse news in the world that your time is getting short and no more cancer treatment. But, uh, they are so grateful. I think the physicians or trainees should be aware of that.
Tyler Johnson: [00:46:15] All right. Well, we we are so appreciative of your time. We're grateful for the good work that you do in advocating for good communication and health care and training the next generation of physicians. And we thank you so much for sharing your insights and joining us today on the program.
Dr. Shunichi Nakagawa: [00:46:30] Thank you very much.
Henry Bair: [00:46:35] 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: [00:46:54] 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 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: [00:47:08] I'm Henry Bair.
Tyler Johnson: [00:47:10] and I'm Tyler Johnson. We hope you can join us next time. Until then, be well.