EP. 147: A REBIRTH OF PASSION AND COMPASSION
WITH JOSEPH “JODY” STERN, MD
A neurosurgeon shares how losing his sister to leukemia completely changed his approach to medicine and how grief has the power to connect us in the most meaningful ways.
Listen Now
Episode Summary
Neurosurgery is known as one of the most precise and demanding specialties in medicine. It requires absolute technical mastery in a surgical field where a millimeter’s difference can be the deciding factor between lifelong disability or a life restored. But what happens when a surgeon trained to be objective and detached experiences deep personal loss? How does it reshape the way they practice medicine?
In this episode, we are joined by Joseph “Jody” Stern, MD, a neurosurgeon and the author of Grief Connects Us: A Neurosurgeon's Lessons on Love, Loss, and Compassion (2021). His book is an honest, deep, personal reflection on how losing his sister shattered the emotional armor he had built as a surgeon — and in doing so, made him a better doctor. Over the course of this conversation,
Dr. Stern discusses the complexity of neurosurgery and what it teaches about the fragility of life; why the way we talk to patients and families matters just as much as the procedures we perform; how his own grief changed the way he approaches medicine; and the pressure in medicine to stay emotionally detached and why that might actually be harming both doctors and patients. This is a conversation that extends beyond grief. It's about how we, as doctors, patients, and people, can show up for each other in ways that truly matter.
-
Propelled by his younger sister Victoria’s surprise diagnosis of acute leukemia, an unsuccessful bone marrow transplant, and later her death, followed by her husband Pat’s death from a ruptured cerebral aneurysm, orphaning their two children, Joseph Stern, MD has been exploring the impact her illness had on him, as well as the personal experiences of physicians and patients going through similarly disruptive losses. Victoria wrote a powerful journal about her nearly eight-month hospitalization, which Dr. Stern has incorporated into a memoir: Grief Connects Us: A Neurosurgeon’s Lessons on Love, Loss, and Compassion, published in 2021.
Dr. Stern earned undergraduate and medical school degrees, as well as completed internship and residency, at the University of Michigan in Ann Arbor. He has trained in Palliative Care through Harvard Medical School. He is Assistant Professor of Neurosurgery at the University of Michigan and Adjunct Assistant Professor in the Department of Neurosurgery, University of North Carolina School of Medicine. He teaches medical students and directs the “Medical Humanities” program at Cone Health in Greensboro, NC. He practiced Neurosurgery through Carolina Neurosurgery and Spine Associates (CNSA) and co-directed the Cone Health Cancer Center Brain Tumor Program.
-
In this episode, you will hear about:
• 2:37 - How Dr. Stern became drawn to neurosurgery and what has kept him in the field
• 6:00 - Dr. Stern’s quest to integrate palliative care into neurosurgery
• 10:06 - Why medical training often makes it hard for trainees to remember their humanistic calling
• 15:54 - The importance of shifting medical training to focus to more on patient-centered care
• 23:41 - Rethinking medicine to better honor the humanity of the patient
• 31:41 - Developing “emotional agility” as a physician
• 37:09 - The personal and professional insights that Dr. Stern experienced when he helped his sister through her battle with leukemia
• 47:47 - How to overcome compassion fatigue
• 54:15 - Dr. Stern’s advice for new clinicians
-
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] Neurosurgery is one of the most precise and demanding fields in medicine. It requires absolute technical mastery in a surgical field where a millimeters difference can decide lifelong disability or a life completely restored. But what happens when a surgeon trained to be objective and detached experiences deep personal loss? How does that change the way they see their patients, and how does it reshape the way they practice medicine? In this episode, we are joined by Doctor Joseph Stern, who goes by Jody, a neurosurgeon and the author of Grief Connects Us a Neurosurgeon's Lessons on Love, loss, and Compassion. His book is an honest, deep, personal reflection on how losing his sister shattered the emotional armor he had built as a surgeon, and in doing so, made him a better doctor. Over the course of this conversation, Doctor Stern discusses the complexity of neurosurgery and what it teaches about the fragility of life. Why the way we talk to patients and families matters just as much as the procedures we perform. How Doctor Stern's own grief changed the way he approaches medicine, the pressure in medicine to stay emotionally detached, and why that might actually be harming both doctors and patients. This is a conversation that extends beyond grief. It's about how we as doctors, patients, and people can show up for each other in ways that truly matter. Jody, thank you for being here and welcome to the show.
Dr. Joseph Stern: [00:02:36] Thank you so much. It's great to be here.
Henry Bair: [00:02:37] So neurosurgery, you know, both within medicine and to the public, there's this aura of intrigue surrounding neurosurgery. Like it's the epitome of the genius doctor who can do what no one else can or dares. Can you tell us what drew you to it? And what keeps you there?
Tyler Johnson: [00:02:57] It is, after all, you guys and the rocket scientists, right? You're the only ones who can't say. Well, it's not, because actually it is.
Dr. Joseph Stern: [00:03:04] I have a kind of an unusual entry into neurosurgery story. Like, there are some neurosurgeons are, like, shortly after birth, I decided I would become a neurosurgeon, and I cannot lay claim to that. I trained at the University of Michigan Medical School. I actually matched into orthopedic surgery at the University of Michigan. I was sitting in the lecture hall with one of the other interns, who was an intern in neurosurgery named Alan Gross, who later ran for Senate for the state of Alaska, who had matched into neurosurgery. And he said, you know, I really wish I had gone into orthopedics. And I said, well, I really kind of wish I had gone into neurosurgery because I really liked it. I thought it was awesome.
Tyler Johnson: [00:03:45] No way.
Dr. Joseph Stern: [00:03:46] And we we flip flopped. I remember one of the orthopedic attendings came up to me with this kind of very disparaging look in her eyes and said, you know, well, at least you're not becoming a flea. But no one could. No one could understand why I would give up orthopedics to do neurosurgery. And it was a little bit of a challenging decision. But the reason I did it was I was really fortunate that the guy who ran our program, Doctor Hoff, who I write about in our in my book, was a really kind of a mensch. He was a kind and really compassionate doctor. He was a great role model, and I was drawn to working with him, and I thought the brain was fascinating, but I also thought that I had this sense that if I stayed in the orthopedic, I mean, I don't want to get in trouble with orthopedics, but I had this sense that there was a very much of a focus on the joint and not the person, and I was interested in kind of the person as it, as they related to their illness and their, their conditions. So I guess I, I loved neurosurgery, I thought it was kind of awe inspiring and that opportunity presented itself to me, so I took it. So that's kind of an unusual path.
Henry Bair: [00:04:50] I think it's very difficult today to think about matching first in orthopedic surgery, which is very difficult and competitive, and then switching to neurosurgery, which is also very competitive and demanding. So yeah, definitely unusual. Now, you did mention that you felt going in that neurosurgery would allow you to explore that connection between the illness and the patient and how they mutually sort of inform each other. Is there a story you can share from your time in residency or beyond that really illustrates how that was the case?
Dr. Joseph Stern: [00:05:24] I just had a sense early on that I was interested in, not in like a disease process and, you know, the surgical treatment of that disease process, but more taking care of patients. And I felt that the entire patient was kind of seen and attended to by the neurosurgeons. And I think that's kind of unusual because I'm not sure that's that's so typical. But that's what kind of drew me in. And I subsequently discovered that, you know, not all neurosurgical programs are as warm and friendly and fuzzy as that. And some were pretty can be pretty brutal, but it was really a special training experience for me.
Tyler Johnson: [00:06:01] Yeah. You know, it's funny first off, because yes, I would say that if you asked most people why they're going into neurosurgery, the nurturing training environment would not necessarily be at the top of most people's lists. At least that's not the, you know, the stereotype that's out there for what it's like for most people training for neurosurgery.
Dr. Joseph Stern: [00:06:20] I subsequently learned that, and I think I have a more sanguine view than I did earlier. And I also think that much of my career and kind of where I'm going now is trying to make it a more humane experience for patients and for trainees. So I've recently, you know, I was in practice in North Carolina for almost 30 years, and I injured my elbow in a kind of I sort of work related kind of overuse injury, and I had to stop doing surgery. I came back to Michigan as a visiting professor and talked about the importance of surgical ergonomics and the importance of compassion in the care we provide for patients. And Doctor Pandy is a new chairman. He said, well, do you want to come back here and teach? And so I've just recently joined the faculty, not as a practicing surgeon, but teaching residents. And so we've been sitting in the clinic and I've been teaching the new interns how to examine patients, do neuro exams and talk with patients, interview them. And it's been really kind of an amazing experience for me. So I feel like I'm on this path of trying to humanize and improve the care that we provide patients. One of the biggest things that happened to me was that when I was in the middle of my practice, my younger sister developed leukemia and had a bone marrow transplant, Victoria and she she subsequently died.
Dr. Joseph Stern: [00:07:38] After that, she had AML in a pretty bad mutation, Monosomy seven, which has a pretty horrible prognosis. And then a year and a half later, her husband Pat died of a ruptured aneurysm in his brain. And for me, it was it challenged my view of whether I was really as compassionate as I thought I was, and whether I was really. I suddenly saw what it was like to be a patient, and I actually thought it was a pretty horrible experience, that it's full of fear, kind of terror to be a patient and to face the medical care that we provide. So that really led me to challenge how I took care of patients and to really investigate the need for greater compassion in the care we provide. Led me to write a book which is called Grief Connects Us. And then I actually after that, I decided I really needed to get some better training in palliative care because I was advocating for palliative care, but I didn't really know enough about it to be a real representative of it. So there's a program at Harvard called Palliative Care Education and Practice, or PCP, for mid-career professionals. And so I went and did that and have taken training in palliative care. And then subsequently I have been going on this path of trying to integrate palliative care into neurosurgery.
Dr. Joseph Stern: [00:08:55] I think that we have a problem in in neurosurgery, but also in medicine that we tend to look at people as their diseases and not as people with problems and try to sort out how to help those patients rather than kind of look at, you know, the patient is not is a person who has a brain tumor instead of the brain tumor. But when we tend to look at them by their disease process, I feel it's very dehumanizing. So I'm trying to change the way we do things, trying to bring palliative care in earlier and be supportive of patients. I've also been developing a communication training program, so I don't know if you guys you probably know Tyler. The vital talk. Vital talk is this, you know, opportunity to learn how to have training in more effective and meaningful communication, compassionate communication with patients and families. And this isn't really done in neurosurgery. So I've been developing this training program for communication training and in neurosurgeons. You know, we spend a lot of time learning the technical skills of surgery in very little time, learning how to talk to people, how to counsel them, and how to manage their concerns, questions and grief. And so I've been developing that here at Michigan as well.
Tyler Johnson: [00:10:06] You know, so I actually was at Yale yesterday giving medical grand rounds about sort of the lessons that we have distilled down from doing the podcast, which we've now been doing for about two and a half years. And afterwards, I had a woman who came up to me who was an MD, PhD student there, and she said something to the effect that she really looks forward to listening to the podcast every week. And one of the reasons that she said that she really looks forward to that is because she feels like it's a way to sort of stay anchored to what brought her into medicine, because it can be so difficult to stay connected to the the deeper reasons and the and the principles and the and the compassion that I think almost everybody experiences as a part of their call into medicine. And I the reason I bring this up in the context of the comments that you just made is because I was struck when you said that, you know, you had this person who was really, really wonderful, who was who sort of directed your training as a neurosurgeon, but you've since become aware that that is not a blessing that everybody has, and that a lot of people who go into neurosurgery training. And I think this could be said for, you know, many the training in many disciplines have people who are not like that. And you have talked a lot about in the comments you just made about helping doctors to learn to show compassion towards patients.
Tyler Johnson: [00:11:28] But I'm wondering if you could talk for just a minute. As someone who you know clearly now, especially in this phase of your career, it sounds like you're doing a lot of kind of next order thinking, not just about you're not doing surgery anymore, as you said, but so not even so much about your treatment of patients, but how to teach other doctors about how they're going to interact with patients and even how to teach the doctors that are teaching the doctors. And I'm just wondering if you could reflect for a minute on why do you think it is that traditionally, medicine has done, I think, a pretty good job of teaching the technical aspects of, you know, whether it's how to do surgery, if you're a surgeon or how to make elusive diagnoses and find a treatment plan, or if you're an internist or whatever. The thing is. But many trainees, I think, as that person that I spoke to yesterday, feel like, if anything, it almost beats the compassion out of them or it almost moves them further away from a lot of those. The sort of the what some people I think it's I think it's a misnomer, but sometimes people call it the softer skills of being a doctor. Why do you think that training sometimes almost feels like it makes it harder to hold on to that?
Dr. Joseph Stern: [00:12:37] Well, I think first off, if you read something like compassion where you say, you know, compassion actually heals and it's a huge part of what we need to do. And so we we do ourselves and our patients a disservice by kind of technical izing everything and making it all about numbers. And you know that while the quality of care, the quality of treatment is super important. And I'm not saying, you know, advocating touchy feely kind of, you know, warm and fuzzy relations are somehow going to take the place of excellent care. But really excellent care has to be compassionate care. And so I think you look at, you know, the burnout rates among physicians and a lot of people feel kind of stomped on. And, you know, I left the clinic, my intern is still on the electronic record trying to keep up and finish all of his his notes. The demands are are vast on us to produce and to be productive. And everything is focused on not only technical skills, but sort of throughput and productivity based care. And one of the things that's been really nice is that I, when I'm sitting with this brand new doctor, is we're spending an hour with each new patient, so there's no rush. And I feel that for me is is liberating. And I really love to be able to sit and talk to patients and kind of discuss them and what their personal experiences are and how they manage their problems. And so I know from where I sit that that is so important. But when I was initially training, it was all about, you know, making sure that I knew where the nerve root ran and where, you know, the exam fit and focusing on the technical aspects. And I think we're terribly siloed in our in our worlds in medicine that, you know, nurses are supposedly more in the empathic space, and we're in the empirical space.
Dr. Joseph Stern: [00:14:25] And the truth is we we both need each, you know, they both need to be part of all of our care. And so I feel with utter certainty and confidence that the compassionate part of the care is super important, very neglected. And when we when we squeeze that out of the care for patients, they're very unhappy. They don't feel heard, seen, valued, and the doctors don't feel like they're being valued. You know, the hidden curriculum of our training is so much of it is focused on the technical aspects and feeling like you need to fit in and to take a step back and say, we really need to bring compassion to the center of our care. And what you see it when you have excellent doctors, they are focused, they understand the technical aspects, but they are super focused on the importance of human connection. I was talking again today and I said to this brilliant young intern, I said, you know, if you spend a little extra time with your patient establishing that meaningful connection at the outset, you will reap the benefits of that through the entire duration of your relationship. You know, if you have an error or a problem or some kind of issue, because you've established that you have a basis of trust with that person when problems arise, because you have established communication and connection with that patient, you know, people don't sue you. They don't. They don't feel anger toward you. Most patients come in wanting to like their doctors, and when they end up not liking their doctors, it's a real failure of communication between.
Tyler Johnson: [00:15:54] So I'm just curious, you know, if the dean or whomever showed up tomorrow and said, we're going to make you the czar of all medical training from the first day of medical school, all the way through the last day of and you get to be in charge of all of it, whether they're being internists or psychiatrists or neurosurgeons or what have you. And so you can just do whatever you want to do. And your job is to change things so that doctors not only hold on to what they already have, but actually nourish and cultivate and nurture and deepen their sense of compassion during their training. What would you do? What would you change?
Dr. Joseph Stern: [00:16:38] Well, it's sort of ironic because the other morning as I was walking to work, I ran into the dean of the medical school, and I was telling her what I was doing, and she was super fired up. And she. Because because there's several things that are I think, first of all, I'm not sure I have the wisdom to be able to handle an entire medical school curriculum. So I appreciate the vote of confidence. I'm sure I would need to work on that. But, you know, I was telling her about this. She said, well, this is great. This is a wonderful thing you're doing with these interns and, and residents. And so we were talking about how, well, wouldn't that be a great thing for doctors who are kind of coming to the tail end of their career, how they can be folded back into training and share their wisdom and all their knowledge in a meaningful way. Right now, what happens is doctors, you know, when they they just retire and go and play golf or go do something else. But they they don't keep that wisdom and bring it back. So I think that's one thing that's a very easy thing is there are a lot of people who would love to be able to to mentor young trainees and connect them with the things that really matter.
Dr. Joseph Stern: [00:17:44] And then, you know, it's also funny because my son is a fourth year medical student, and so I'm watching him go through this. And one of the things that I always had thought was, well, now that we're, you know, we've got a lot better idea about patient centered care and medical school training is going to be nicer than it was when I was a trainee. And what is amazing to me is that it really hasn't changed that much. You know, we've really not developed or evolved as we need to. So I think it requires some courage to really be able to look at the importance of this compassion as a foundation of the care that we provide. And I think that, you know, everyone's struggling with the whole wellbeing thing. Well, the wellbeing part is, if you're not compassionate to patients and you're not compassionate to yourselves, we don't really redesign things so that care of self and care of patient are on equal footing, and they're both valued. We're not going to do a very good job. And so I think, you know, you look at the at the wellbeing crisis, I feel like it's the flip side of this whole problem.
Dr. Joseph Stern: [00:18:45] The whole throughput and kind of productivity based care is about making doctors into robotic deliverers of care, and we can't do that. So if you connect on a more meaningful way with patients, patients are happier and trainees and physicians are also happier. And that means being able to take away some of the burdens, because you look and you say, how can I possibly do my entire day's work? I come to work every day with more work than I can possibly get done. Right? And so we need to restructure and sort of look at that and go, well, this isn't really the way. This isn't a reasonable expectation that we put on each other and ourselves. So and also I think we're we tend to be isolated. We tend to suffer in silence. And we also are kind of perfectionistic as personalities. So we tend to expect far more from ourselves than we can actually deliver in a reasonable way. So I think you start hitting on some of those things and start solving some of those things, then we could really improve the way we train and teach and care for patients.
Tyler Johnson: [00:19:46] I totally agree with the things that you're talking about. I think that I have also been impressed that once you get past being a medical student or maybe an intern, depending on sort of what, you know, kind of team environment you're in or whatnot, pretty much everybody in medicine is who's in the medical training pathway, is a leader of somebody or something, right? If you are the intern, you're helping to mentor the medical student. If you're the supervising resident or the chief resident, then you're helping to mentor your team. And then of course, if you're an attending, then then you're in that leadership role. And then some people even more than that, if they're the, you know, chief or chair or what have you. But one thing that I have been really impressed with, and you alluded to this a little bit at the end of your last comments. We talk a lot about the way that we care for patients, and I do think that we need a little bit of a a clearer reminder that we also need to care for ourselves and also for each other. And I think that that's especially true in whatever. Leadership role a person occupies in the medical ecosystem. Right. I know that, for example, if as a trainee, I fear that I've done something wrong or that I missed something or that I made a mistake, it makes all the difference in the world.
Tyler Johnson: [00:21:03] You know, when I go to discuss it with somebody who is above me in the, in the ecosystem, quote unquote, above me in the ecosystem, you know, of course, sometimes those things need to be addressed and whatever. And most of the time it's not even really a mistake. Right? It's just that something bad happened that we had no control over and didn't expect and what have you. But it's all just to say that if the person in a position of authority responds with a little bit of grace and compassion in that kind of moment, or just because I'm tired and I'm not doing the greatest job presenting on rounds or whatever. The thing is, I think that one place that we can begin to make a really big impact is that if we start sort of injecting compassion into the system in the way that we work with each other, then that sort of ripples out and makes it much easier for us to show compassion when we then are working with patients.
Dr. Joseph Stern: [00:21:51] I think that's absolutely true. And I'll tell you that one of the things that has evolved in this sort of organic journey, which gives me a lot of confidence and joy, is that I have met a community of like minded people. You know, when you meet someone who is interested in compassion, you kind of know it. You already speak the same language. So hearing their voices and allowing those to surface and to kind of start to change the way we do things, I think is, is hugely important. But I have met some wonderful people on my path and have been mentors to me, but also kind of feel like we're in a community where a lot of people know what we need, and we need kind of a revolution in the way we take care of patients and each other. And and we need to rethink a lot of these systems. And we can't allow the business forces or the material, you know, productivity demands to define us, because I think what that's happening is that we're being leveraged, you know, our level of commitment and our our commitment to patients and to doing the right thing are sort of what our calling is being leveraged as a, um, an asset that, that, that, um, is being, you know, we're being it's it's I don't want to say exploitation that seems a little strong, but it's the whole, the whole, um, we can't work nonstop in demanding positions that don't that oftentimes aren't really in situations that are always not, not always solvable. So I think that flipping the design and sort of really looking from a design standpoint and saying, you know, they're making equipment that's easier to use, making systems that are easier to use, making supporting patients and providers the central kind of, um, it's not an add on at the end. It's kind of a central concern. Changes the way we do things.
Henry Bair: [00:23:41] Taking a more personal, you know, from, for me, my perspective as a trainee in a surgical specialty. So I'm an ophthalmology, which is a surgical residency. I have to say that the process by which you learn surgery dehumanizes patients. I can't see how that wouldn't really be the case with the way that it's currently set up. And here's what I mean by that. In medical school, you don't really learn surgery. You observe. Right? You can sort of intellectualize, you know, the approach to certain procedures, but they're not going to let you do anything. They shouldn't really let you operate, you know, the key steps of any surgical procedures. So you learn most of that in residency. But I mean, especially with something like ophthalmology, and I imagine that's the case for something like neurosurgery as well, where you're dealing with very delicate tissue. Oftentimes with ophthalmology, this is microsurgery. If you're talking about cataracts, right. Or if you're talking about large Reconstructions of the orbit. This is very foreign territory for most people, right? But you have to start somewhere. And so we literally conceive of patients as practice. They're like mannequins because the thinking is, well, you have to start somewhere. Yeah, you'll probably be making some mistakes. But everyone makes mistakes when they start. And the way that it manifests is that you'll often have a patient come in for, let's say again, in ophthalmology they have a big a terrible trauma. And they're they have a globe rupture, which is to say their eyeball has perforated and there's like intraocular contents, like the stuff that is supposed to be inside the eyeball is now somehow outside the eyeball.
Henry Bair: [00:25:11] And you have to go fix that. Well, we often look at that with excitement because, ah, yes, here's a practice opportunity, right? We don't see it as a person. We don't we don't really think about it as, oh, how is this impacting that individual. We the first thing that comes to us, our minds as trainees is I get to practice. Another example would be someone coming in With, you know, a relatively straightforward injury, let's say like an eyelid laceration. And I have been a part of these procedures where the senior resident or the attending surgeon will let me do a procedure or let me perform something that is not, strictly speaking, necessary. Like this did not have to be done. For example, probe like part of the anatomy of the eyelid. It did not need to be done. It was done solely for my benefit, not for the patient. It was so I could become more familiar with the anatomy, right? It didn't harm the patient, but it was not. We did not need to be done right, things like that. And I'm wondering, just from your perspective, having gone through all of like one of the most intense and technically challenging surgical training programs, neurosurgery, and now being a part of trying to rethink how this can be done. What is the compromise here? Because as much as I have thought deeply about the humanistic, humanistic side of medicine, I am just like many of my colleagues, right? When I see someone coming in with a complicated trauma or complicated procedure, The first thing I think about is with excitement, because now I get to see something interesting.
Speaker4: [00:26:38] Yeah, but yeah, but there's a part of you.
Dr. Joseph Stern: [00:26:40] That's not that's a little bothered by that because you're bringing it up. Right? You know, if it was just purely excitement, then you would not be raising that as a question, right? I wrote a piece that's called Compassion Belongs in the Operating Room. And I think that we have an obligation to our patients, that we're representing their interests while they're under anesthesia. And so I think that means that we have to always think of them as human beings and, you know, people who have needs and you're really representing their interests. So that I think it is a fundamentally compassionate act of operating on someone. And if you start to dehumanize them or look at them as objects or as, you know, surgical practice, then I think we do ourselves and our patients a disservice. So I would say that we have to become much better at holding two things at the same time in our heads. You know, we can be compassionate. We can be representing their interests and we can still learn how to do our surgeries. But I kind of feel that both are required. I really think that it's incumbent on us to always keep the interests of our patients first and foremost. The other issue, you know, if you don't, if you objectify patients, you can do things that really aren't appropriate.
Dr. Joseph Stern: [00:27:53] And we see this where surgeries aren't always super indicated and we do we do those. And I think first and foremost, we have to think of the patient as someone who should matter to us as much as our family member. You say, is this in the best interest of my patient? If it isn't, we shouldn't be doing it. So then you get into the the other thing about, well, can we do things to patients that are really not indicated? And I would say probably you shouldn't. Although if, you know, if it's something that is simple and is of no consequence, I don't I don't want to be like the schoolmarm here, you know. But at the same time, I'm looking to say, really, we stick to the task, you know, if it's something that is not indicated and is a distraction, or clearly if it does harm, I don't think we we need to do it. But I think that you're on a kind of slippery slope where you say, I want to learn, but I also don't want to do things that are not in my patient's best interest.
Tyler Johnson: [00:28:48] It's so interesting to hear you to talk about this as a person who is decidedly not a surgeon, and for so many good reasons, no one would want their loved one to have surgery at my hands. But it's so interesting to hear you both talk, because on the one hand, I'm brought to think of we had a couple of years ago, we had Wes Ely on the program, who's an author and an intensivist. One of the things that we talked about with him is that the ICU can also be very dehumanizing, right? Because most of the patients who are in the ICU are on the ventilator, and they have multiple things going into multiple orifices. And it's just, you know, it's really tough. It's like a form of torture. And because many of them are medically sedated or they're, you know, attended because of whatever their medical issues are. You can't even talk to them most of the time. And one of the things that he talked about was how to try to rehumanize people who are in a definitionally, dehumanizing situation a la intubated and sedated in the ICU. But it is very interesting for me to hear you both talk about, and then for me to think about, because I remember on the one hand, too, we had Jay Wellens, who is an author and a pediatric neurosurgeon.
Tyler Johnson: [00:29:57] I've heard him say that he feels like there is a certain amount of, I don't want to call it objectification, but that he has to put a certain distance between himself and thinking of the patient as a person, at least at the very moment that he is actually inside of the cranium doing the surgery, because he needs to focus on it, a sort of a antiseptic technical task that has to be performed in a certain way. But to your point, it's interesting to think about how surgeons or other, you know, very technically adept. Doctors have to hold both ideas at the same time, where you allow for that kind of critical distance that allows you to do your job with the technical sophistication that's required to do the thing, while at the same time assuring that doesn't, in a backwards way, leave you dehumanizing the person that you're operating on.
Henry Bair: [00:30:50] A little anecdote I have heard of an oculoplastic surgeon once told me, because oculoplastic surgeons are ophthalmologists who do pretty complicated reconstructive surgeries of the face, and, you know, the face is something that it carries a special significance to all of us because it is often, you know, it is how we present ourselves to the world, how the world sees us. The face is very special. And I've heard of an oculoplastic surgeon tell me that they're all acquired sociopaths. Like it takes acquired sociopathy to like, cut into a face, you know? And, you know, because most people instinctively shy away or are very disturbed by, like, the act of cutting into the face. Right. And like, manipulating the tissue and flipping it inside out and all that. Regardless of how you feel about it before you go into the O.R., how you feel about it after the O.R. in the moment of cutting, you have to sort of maintain some distance. That is something that I have heard. To Tyler's point.
Dr. Joseph Stern: [00:31:41] I think that's true. And I think you do have to, to an extent, you know, if you're fully compassionate and kind of, you know, thinking about your patient, then you're really not going to be able to cut their head open and, you know, cut their skull out and then go into their brain and do and do surgery. So you do have to have a, I don't want to say a mask or a kind of in the zone kind of level of concentration. But one of the things that I talked about in my book, because I really struggled with this, is how can I be a compassionate and fully sentient person and at the same time go and take, you know, sit with a patient? They cry, you know, big emotional conversation. Then, you know, 20 minutes later, I'm down in surgery, you know, doing surgery, removing, cutting their scalp, removing a window of the bone, taking out a brain tumor. How do I do that? And so one of the things I advocate for in my book, and I think it's really important, is emotional agility. If you are present in the moment, you can become much more agile and you tend to not focus on extraneous issues. So you can you can become very present, very focused in surgery. At the same time, you can still hold that compassionate ideal. I don't think they contradict each other. And so we need to have better training, not only in being compassionate, but being able to flex and to have a big range of emotional agility or emotional agility that I need to be able to be emotionally connected to a patient, be able to talk with them, and at the same time take them to surgery, represent their interests, and do complicated, intricate things.
Dr. Joseph Stern: [00:33:10] And that that is a challenging transition between multiple emotional states. But I don't think that's contradictory to me being able to do a good job and to being a good neurosurgeon and a good doctor. The other thing is, I think that you talk about Henry, the kind of objectification It comes with a lot of practice, right? If you do, the first cataract is amazing and really intricate. The thousandth is pretty routine, right? So we routinize things by doing them over and over and over again. So they become kind of a second nature. The part of the training that's missing is the communication training, where we are not taught the skill of talking to patients and also having coaching and also having some perspective on what does that sound like? How do I come across am I? Am I as, uh, good a communicator as I need to be, and do I get training in that? So I think that part of the skill of being a more compassionate doctor is learning how to do this, having some training in it. And one of the things that happens when you are trained in connected and empathic, compassionate communication, it makes for a more resilient physician. So once you learn how to do that, you develop that skill just like the skill of surgery. And you can bounce from the, you know, Communication training, which you have really taken in to the surgical training, which you also becomes kind of second nature. So I think you can bounce between these things. And if we have a focus on the training of how to talk to people and patients and families, then we do a better job with that.
Tyler Johnson: [00:34:41] Yeah, I really like I've never heard exactly that term before, emotional agility. But I really like that. I think that's a useful concept, because one way that oncology is similar to what you all are describing is that it requires, again, I like the word agility. It requires a great amount of emotional agility, for example, to be able to go into the room of one patient where you are discussing that you have no further chemotherapy options left and that it's, you know, maybe time for them to think about enrolling in hospice or whatever, and then be able to enter into the next room and tell a patient that they have their five year scan. And as far as you can tell, they're cured and they never have to come and see you again. And then turn around after that and talk with, you know, the nurse coordinator on your team about a long list of sort of routine orders that need to be done and then turn around after that, get on your bike and go home and sit and play blocks with the four year old in the living room or whatever. Right, right. And I would say that actually, especially I don't know precisely why, but especially in becoming an attending, I felt like that was one of the most vital and underrated skills that I had to develop, that I feel like sort of nobody ever told me that that was a thing. I mean, you know, obviously in thinking about it, it seems obvious that it would be a thing, but it's but we don't articulate it right. To your point, we never foreground it. And so I had just never thought about that. That was a thing that I was going to have to learn to do.
Dr. Joseph Stern: [00:36:12] But you, you have to go through those that that range is exactly the same thing. I don't think it really matters that we're doing surgery or that you're doing, you know, oncologic care. It's like you have to be able to go through those that range of experiences and be present and available for patients. I would say that one of the things that happens is we're really not taught how to manage our grief. And so, like when I lost my sister, that was a real a shock to my system. But I've been dealing with grief all along, and we're not taught how to how to incorporate that. We taught we a lot of times we're taught to push it away. And what happens when you push it away is it kind of festers. And so you have to be able to experience it and live through it, and you need to be able to go through it. You become actually a stronger and better doctor and better person when you do that. When we push it away, you see all kinds of pathologic behavior. So I think it's I think it's super important. But I think that these skills are vital to being healthy physicians and also excellent physicians.
Henry Bair: [00:37:09] Speaking of grief, I do want to spend some time talking about your personal experiences because you wrote a book on it. You mentioned earlier that dealing, managing, or accompanying your sister through her experience with leukemia, was very transformative process for you personally, but also professionally as a physician. Can you share with us what was it like in those first few weeks, first few months, when you first found out when you were helping her through the first initial moments of diagnosis and getting the management set up? Like, what was your headspace like going into this? I mean, from, from the perspective of, like a practicing surgeon.
Dr. Joseph Stern: [00:37:51] Her doctor. Doctor Fisher was really a kind and compassionate doctor, and he was very helpful because he kind of guided me and he gave me some time and talked to me on the phone. And one of the first things he said was, don't Google Monosomy seven. So then I went immediately and googled it and was kind of shocked at how bad the prognosis was. My sister's prognosis was like a 6% five year survival rate. And my sister, one of the things I had to manage was that she was. I wouldn't say it was it's magical thinking, but she did not want to let in the possibility that she might die because she said then that would become her reality. So there was a very kind of sensitive balancing act between talking about the reality of her illness and kind of being there for her and not, you know, kind of hitting her over the head with that. I'm kind of Mr. Fix it. And I tried to fix my sister and I realized I can't. So not only could I not, but I was I was sort of powerless to do anything of, of great meaning other than being supportive of her in that situation. So it really was a humbling experience. She is in perfectly great medical care, so it wasn't like I was looking at the hospitals and thinking that they were bad because they were excellent, but I just kind of saw through her eyes what it was like to be a patient and what it's like to be, you know, you surrender your identity.
Dr. Joseph Stern: [00:39:11] You you get in a hospital gown. She had her head shaved. You kind of lose who you are. And it's just a frightening, really disturbing, disorienting experience. And so then I started thinking, well, you know, I am super comfortable in my hospital, and I know it like the back of my hand, but patients who are coming there for the first time, it is terrifying. It's disruptive, disorienting and very scary. So it was it gave me an ability to see what I had already, what I had kind of lived with my whole time, but had never really saw what it was like to being on the receiving end. And then when you start to think about what it's like as a patient to go through this, it is just a very sobering experience. That's where the compassion part comes in, because you're looking, you know, I can't make the suffering go away, but at least I can acknowledge it. I can appreciate it, and I can be there for patients and for my sister. So then when I took it back to my practice and saw what it was like to be on the receiving end, for them, it was.
Dr. Joseph Stern: [00:40:10] I found it very challenging. Honestly, like what you're saying, you know, it'd be easier to look at a patient as their eyeball, right? It would be easier to look at them as their disease process. But we we strip them of their of who they are. And I don't think we serve them. We don't serve ourselves. But it is really tricky to bounce between all those, all those states. So one of the things I wrote about in my book was I interviewed a colleagues and patients, what it was like to being on the receiving end of this, because I guess one of the take home messages from my book is that this is a universal experience. This is my personal experience, which opened my eyes. But we all go through this. We're all going to have loved ones who get sick. People are going to die. We are going to die. We are going to become patients. And so it was a real eye opener to I talked with a guy named Irving Lugo, who was a who was a psychiatrist who had a brain tumor metastasis, who then died. And I interviewed him about what it was like to be sick, what it was like to be on the receiving end.
Dr. Joseph Stern: [00:41:07] I also interviewed another patient who had a brain tumor that I had taken out. And so it was a kind of intermediate grade glioma, so a primary brain tumor. It was in his supplementary motor area of his brain. We took the whole thing out and he did really well. So he never had any recurrence of this tumor. So he was delighted with how he did. And yet it was such a shattering experience for him because he was an organist and he was no longer able to use the foot pedals on the organ, so he was no longer able to do what he loved and what he did for a living. So it was interesting for me to take a step back from being a doctor and being a surgeon and saying, you know, I took out your brain tumor. Your brain tumor is fine. Your scan is not, you know, is not a recurrence. Because like five years after his surgery, we sat down for an hour and talked about, well, how did his life change and what was the impact of this experience on him professionally, personally? How has he adjusted? So I found that kind of level of inquiry and kind of curiosity with him and, and meaning to be very powerful.
Henry Bair: [00:42:12] You mentioned that you were able to gain a renewed Appreciation for how much patients go through, and then actually bring that into your patient encounters in your capacity as a surgeon. I mean, okay, besides being more curious about how a disease was impacting a patient, are there other concrete things you can point to, behaviors or approaches or words you would use that actually changed as a result of your experience with your sister?
Dr. Joseph Stern: [00:42:40] It actually, if you open up your heart and you allow yourself to be present with patients and you, you show them that you care. It makes the interaction that I have with my patients more meaningful for me, but it is a lifeline for them. And so I learned, you know, so many times we're taught to be very kind of cut and dry in terms of our, you know, surgical complications, surgical risks and kind of go through this list. And the reality is patients want to know that you care about them, that you're going to take care of them and that you're going to do your best. So we're kind of stuck on perfectionism and you know that we can't have any complications. And a lot of that's about us. I mean, the reality is we are going to do our level best for our patients. We will get them through their illness. We will take good care of them. We will care about them. And if they have problems, we will. We will do our best to care for them. So I think that kind of in a certain way, it's an unburdening because I can't I can't work to toward a standard of perfectionism or there is no perfect. I've never done a perfect surgery. It's really not possible. But to be present with patients and to show them that you care and to connect with them. I previously was very afraid of doing that, and so I feel like allowing myself to do that, to recognize how important that is, how impactful that is, how how really huge that is for patients has been a life changer for me.
Dr. Joseph Stern: [00:44:04] And I think my patients have been happier. One of the things I'm doing and now I'm writing, right now I'm not even doing surgery. I'm just seeing patients in the clinic. But we saw, for example, I saw a guy today who was pretty angry. He'd been sort of jerked around by the system and he had a non-surgical back pain problem. So he was sitting with this new intern who's brand new to neurosurgery. Bright as could be. And we just went through his the patient's exam, went through his imaging. But then, you know, I kind of sat back and said, look, you know, you really don't have a structural problem for which you would need any kind of surgery. And we talked about the various options. And he kind of melted. He seemed a lot less angry at the end of the visit because I gave him the time of day. I tried to help him. I was honest with him, and he and his wife were, I think were happy in the end, even though we didn't really do very much other than point him on a path, reassured him that he's not going to have a crisis, that this isn't going to be some horribly progressive problem, and he's likely to get better, and then gave him some tips on how to improve so it doesn't have to be doing surgery. It has to be kind of how you hold the hand of the person and help walk them through.
Henry Bair: [00:45:11] You know, you talked about how universal grief is. At the same time, I'm sure you would recognize that there are there are certain ways of supporting a patient that their loved ones do that perhaps you did while you were supporting your sister that you can't really do as a physician. That would be inappropriate, you know, because you just don't have that that shared experience going back decades with most of your patients. Right?
Dr. Joseph Stern: [00:45:33] Sure. I agree with that. Sure.
Henry Bair: [00:45:35] Yeah. What are some lessons you've learned, shall we say, from taking care of or accompanying your sister that are transferable to your patients? What are the things that you can do as a clinician to help support the grief of your patients?
Dr. Joseph Stern: [00:45:48] So, you know, I wrote I wrote a piece, it was in The New York Times, and it was about how I was taking care of a patient, a woman who had a, um, metastatic breast cancer to her brain and needed a reservoir put in for chemotherapy. It was late in the day, and I was kind of tired, and I was stressed and it was, you know, just another problem that I was facing. And then I just sat there and I saw in this woman what my sister went through, and I was really moved by her experience and the technical procedure. She needed it done. We did it. It went fine, but the acknowledgment and seeing her and hearing her was so important, both for her and for me. So I think, I think that it's marrying the surgical skill with the human caring that ends up reconnecting us with the reason we went into medicine in the first place, and the desire to help and to heal and to be compassionate. And if you do that, and you allow yourself to do that, it suddenly is like a rebirth in terms of the passion for what I do. So I, I think that we oftentimes have kind of squeezed the compassionate part, the empathetic part of our jobs. We take what is an enormous privilege to be able to take care of patients and to do surgery on them. And we turn it into a routine where it suddenly is just, you know, another day at the office and I have, you know, ten cataracts to do or 15 cataracts to do. And if you start doing that, it's no fun. And it's also it's no fun for patients. So to be able to look at them and hear them. And I think that listening and sitting and connecting with people has huge value. It actually doesn't add much time to the interaction, and it ends up being enormously beneficial, both for myself as a physician and for the patients who come to see me.
Henry Bair: [00:47:47] I appreciate all of those things, and definitely important for trainees everywhere and clinicians everywhere to hear. Nonetheless, I think I would be remiss if we were talking about connecting with patients compassion and empathy without addressing compassion fatigue and even me as an intern last year in internal medicine, I definitely early on there was maybe first month in I was taking care of this lady with, um, terrible cancer. Ovarian cancer had gotten into her abdominal cavity, so it was everywhere. She was accumulating fluid like crazy. And we would do a paracentesis, which is a procedure, a minor procedure where you basically poke a hole through the abdominal wall to drain to take out that fluid. And at this point, there was nothing diagnostic about it. We knew what was going on. There wasn't really anything we could do because the cancer had spread everywhere. So there's no surgical intervention anymore. Us taking out the fluid was just purely for her comfort, because it's really uncomfortable when your belly is all swollen up and stretched out. And there was one point, it was like a I was on call from Friday until Saturday morning, so overnight, and I was leaving the hospital and all night, like she had been calling me for calling the nurses to call me for her pain.
Henry Bair: [00:49:04] And I could not seem to get on top of her pain. And I signed out the patient in the morning to the day team to you. I told them about everything that was going on and I felt this relief like, finally, it's not my problem anymore. And then I found myself throughout the rest of the day thinking about her the entire day. And honestly, it was supposed to be my day off and it was so much. So many mixed emotions because I couldn't help but feel as if it ruined my day. I just wanted a day off. I had worked overnight. I had worked 24 hours, but I couldn't even have that because I just kept thinking about her. Right? That's what I sort of get at when I think that a lot of people worry, right? That if I care too much, is it going to ruin how I can enjoy my own life? How do you respond?
Dr. Joseph Stern: [00:49:54] Well, see, I think it's absolutely the opposite, which is if I harbor resentment toward the patient and if I say, you know, this person is keeping bothering me and I, you know, then you build up this resentment, then that festers. And the reality is if, okay, you're doing these procedures, you know, the paracentesis you're doing these procedures to relieve her discomfort and her pain. Right. But you can do that in other ways as well. They're complementary. If you go and you, you know, sit with her or talk with her or, you know, see how you can help her with her pain. I mean, because pain is complicated, right? Is it a physical, the stretching of her abdominal wall that's just causing physical pain that is purely a mechanistic thing? Or is she scared? Is she, like, realizing that she's dying? You know, there's so many levels of this. And so for you to unpack that potentially could be beneficial to you and also beneficial to her. And so if you we have a tendency to reduce our, our role as I'm doing a procedure, I'm here to put a needle in this person's belly. And yes, you have time pressure and and time constraints and lots of demands. But I'll tell you that if you're trying to relieve her pain, go in, and holding her hand and talking to her for a few minutes might make you might have made you feel better, might have cut down on the number of calls and you might have felt instead of this nagging. I mean, why did why was why were you so tortured the next day? What was really behind that I wanted? I'm kind of curious. Was it that you felt bothered or you felt guilty or that you. I'm curious because it's kind of complicated.
Henry Bair: [00:51:24] It is very complicated. It's multi-layered because at one level it was okay. I kept thinking about this person. Is she doing okay? Is she in pain or is her pain under control? Right. So that's concern level number one. Right. I am worried that's like definitely like the first layer of it. But then on top of that I think I'm off work. I'm supposed to be enjoying my Saturday day off. Right. Why am I thinking about this person? And then the third layer on top of that is, like you said, a little bit of resentment. It's like, why? Why am I thinking, why am I so worried about this? It's not my job. There is someone else in the hospital during that day taking care of her. And then the fourth layer on top of that is guilt for feeling the resentment, right? Does that make sense? There's a lot going on here.
Dr. Joseph Stern: [00:52:07] Totally makes sense. Totally makes sense. But it gets into the whole thing about compassion fatigue, because a lot of the time, I think that compassion fatigue is a reaction to all of the walls that we put up and the way we try to push stuff away. And I mean, granted, you know, there's only so much suffering that people can take, but the people who are really good at handling suffering and and being compassionate don't seem to get compassion fatigue because it becomes their superpower. Being compassionate and leaning into your your sense of compassion is a strength and not a weakness. So allowing yourself to be open to those experiences, it kind of is overwhelming at first. But I honestly, the thing I learned from my sister's experience is that is that opening your heart is not an avenue to getting crushed, and to feeling destroyed, and to developing compassion fatigue. When you really unpack it. You were worried about this woman. You felt kind of scared for her. And maybe you felt guilty about feeling badly that you were kind of pushing it away. I don't know how to solve that, except I think that if you had gone to her bedside and kind of talked with her or sat with her for a few minutes, you might have felt better and she might have actually felt felt better, too.
Dr. Joseph Stern: [00:53:23] I don't I don't know, but I do know that that the whole notion of compassion fatigue is a is a very complicated one because because I found that by leaning into those relationships and the experiences, you know, I, I had to sit out. I've been out of all medical practice for two years because of my arm, and now I'm going back in a very limited capacity, seeing patients in the clinic. And I will tell you that I just love it. I love talking to patients. I love the interaction I like, I really love being able to help them, and I miss doing surgery. But I also am kind of pleased just to be back in some capacity, being able to talk to patients. So I found it has been such a wonderful privilege to be a physician, and I'm delighted to be back in it in a limited capacity. But, you know, I wish I were able to do the whole thing, but I can't.
Henry Bair: [00:54:15] All right. Well, with our last few moments here, we want to close with a question that we often ask our guests. And I think in your case, there's definitely some special resonance here because you've changed so much through your career with this pivotal experience with your sister. And you know, you've already shared a good amount of advice for us over the course of our conversation, just organically, but just to really make it explicit, you know, if you were to go back to, you know, you as a neurosurgery intern or trainee, what are some pieces of advice you really wish they would hold on for the entirety of their career? Like a few pearls, a few practice pearls, you know, give us like 2 or 3.
Dr. Joseph Stern: [00:54:56] So the beauty, the beauty of it is I've kind of been doing that, you know, where I've gone back. And I'm now teaching people. And so I am teaching residents how to sit with patients and to listen and to show that you care. So I'm doing that in the clinical format, and I feel that, you know, teaching them how to talk to people through the communication training, looking at ergonomics and paying very careful attention to making sure that we're safe in surgery, so that because everybody focuses on the patient and the patient's safety and their and their safety in surgery, but nobody looks at, well, what is the impact on surgeons from a full career? And I want to preserve physician safety and career longevity. So these are the things I'm really very focused on being able to do. And I think if I can make a bit of a difference, I want to be the change. I want to see if I can make a bit of difference in the lives of the future generation. I think I've done, I will have done something worthwhile.
Henry Bair: [00:55:54] Well, with that, we want to thank you so much, Jody, for taking the time to join us in conversation. Thank you for writing this beautiful book, and we'll be sure to link it to the description to the episode below. Yeah, it's been a true privilege and pleasure hearing your story and your insights.
Dr. Joseph Stern: [00:56:09] Well, I thank you for what you're doing and for opening our eyes and our hearts.
Henry Bair: [00:56:16] 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: [00:56:35] 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: [00:56:49] I'm Henry Bair.
Tyler Johnson: [00:56:50] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.
You Might Also Like
LINKS
Dr. Joseph Stern is the author of Grief Connects Us: A Neurosurgeon's Lessons on Love, Loss, and Compassion (2021).
Dr. Stern’s TEDx talk can be found here.
