EP. 156: THE MANDATE OF MEDICINE

Oct 8

WITH JESSICA ZITTER, MD

A critical care physician, author, and filmmaker shares how she came to embrace a more human approach to medicine — treat patients as you would want your own loved ones to be treated.

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Medical trainees spend years mastering what to do when biology fails — countless protocols, procedures, and split-second decisions. By the end, they’re primed to fix what’s broken. But what if the mandate of medicine is simpler — and more human?

Our guest on this episode is Jessica Zitter, MD, MPH — a physician, author, and filmmaker who has spent her career at the fault line between intensive care and palliative care. Dr. Zitter was initially drawn to the technical choreography in the ICU: numbers to chase, procedures to perform. Yet, along the way, she began to notice the danger we rarely name — that in our devotion to protocol, we might drift away from the person in front of us.

Over the course of our conversation, Dr. Zitter shares personal experiences that have shaped her approach to medicine. We talk about moral injury and how it compounds: when systems push us to act against our values, care gets worse, and the hurt deepens. We talk about how bias slips in when power meets prejudice at the bedside and why chaplains — so often sidelined — can be essential guides back to the human being we’re treating. Her prescription is simple: treat patients as you’d want your own loved ones to be treated. Ask for the story. Reconstruct the person we’ve taken apart into smaller pieces.

Dr. Zitter is the author of her memoir Extreme Measures, appears in the Academy Award-nominated short film Extremis, and is the director of several documentaries, including 2025’s The Chaplain & the Doctor.

Dr. Jessica Zitter, MD, MPH is an advocate for improving the way we die. As a practicing Critical and Palliative Care physician, she uses storytelling to examine the overmedicalization of death in America. Her essays appear in her book, Extreme Measures: Finding a Better Path to the End of Life, The New York Times, and other publications. She produced the Oscar and Emmy-nominated documentary Extremis (Netflix), the award winning short documentary Caregiver: A Love Story, and The Chaplain and The Doctor. In 2021, she founded a nonprofit organization, Reel Medicine Media, to maximize the impact of her films through organizational partnerships, curriculum generation, and public speaking.
Dr. Zitter attended Case Western Reserve University Medical School and earned her Masters in Public Health from the University of California, Berkeley. Her medical training includes an Internal Medicine residency at the Brigham and Women’s Hospital in Boston and a Pulmonary/Critical Care fellowship at the University of California, San Francisco. She also co-founded Vital Decisions, a telephone-based counseling service for patients with life-limiting illness. Jessica lives in Piedmont, California with her family and practices medicine at the public hospital in Oakland, California.
In this episode, you’ll hear about:
2:45 - Dr. Zitter’s path to a career in intensive care medicine
4:52 - A day in the life of an intensivist
17:42 - Dr. Zitter’s unexpected pivot to prioritizing palliative care in her work
26:41 - The inspiration for Dr. Zitter’s film The Chaplain and the Doctor
38:36 - How chaplaincy attends to the soul of the patient and what doctors can learn from this perspective
42:51 - Navigating internalized bias as a doctor
49:42 - Dr. Zitter’s advice for her younger self
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:03] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build 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.
Tyler Johnson: [00:01:02] Medical trainees spend years mastering what to do in biology fails countless protocols, procedures and split second decisions. By the end, they're primed to fix what's broken. But what if the mandate of medicine is simpler and more human? Our guests on this episode is Dr Jessica Zitter, a physician, author, and filmmaker who has spent her career at the faultline between intensive care and palliative care. Doctor Zitter was initially drawn to the technical choreography in the ICU numbers to chase procedures to perform. Yet along the way, she began to notice the danger. We rarely name that in our devotion to protocol, we might drift away from the person in front of us. Over the course of our conversation, Doctor Zitter shares personal experiences that have shaped her approach to medicine. We talk about moral injury and how it compounds when systems push us to act against our values. Care gets worse and the hurt deepens. We talk about how bias slips in when power meets prejudice at the bedside, and why chaplains, so often sidelined can be essential guides back to the human being were treating. Her prescription is simple treat patients as you'd want your own loved ones to be treated. Ask for the story. Reconstruct the person we've taken apart into smaller pieces. Doctor Jeter is the author of her memoir, Extreme Measures, appears in the Academy Award nominated short films extremis and is the director of several documentaries, including 2025 The Chaplain and The doctor. We're honored to share her voice and stories today.
Tyler Johnson: [00:02:39] Jessica, welcome to the show and thanks for being here.
Dr. Jessica Zitter: [00:02:43] So glad to be here.
Tyler Johnson: [00:02:45] For guests who are formally involved in the health care profession as you are, we usually start by asking you to tell us how did you end up wanting to become a doctor? What is sort of your origin story?
Dr. Jessica Zitter: [00:02:56] Well, it really started when I was two. I mean, I come from a family of doctors. A family of surgeons, actually. And, you know, it just was part of the family business, honestly. And it was all men, actually, except for one woman who was really my role model, my aunt who just took their job so seriously, and my aunt, who was just this incredible, strong woman who went in and was this incredible pediatrician. And I just was so inspired by them all. So I wanted to be part of that club.
Tyler Johnson: [00:03:23] Okay. So one of the things that is a little bit unusual about you is that you combine some relatively unusual aspects of medicine into your sort of holistic job. So talk to us a little bit about, you know, let's say you get into maybe into medical school and you're maybe in your third year or whatever it was or whatever you called it then, but you're doing sort of your core rotations and kind of seeing what different kinds of doctors do and what different parts of medical life are like. And I guess in your case, also, since you had been exposed to some of this growing up, you probably had some of that knowledge even coming in. But nonetheless, as you got to the place where now you're getting ready to have to apply for residency or whatever, and you're making a decision. How did you think about what you wanted to do specifically within medicine, and what was your vision back then of kind of what you wanted to do when you grew up?
Dr. Jessica Zitter: [00:04:11] You know, the people that I knew that I most looked up to were intensivists. You know, people who did technical things, surgeons. My father's a neurosurgeon. My my grandfather was an ob gyn surgeon. There were people who sort of were very proud of their technical expertise. And, you know, when you're a kid, that's what you value. And so I really seriously considered going into surgery myself. But I knew that, you know, my temperament. I just don't think I would have been happy there. No offense to the surgeons, but it wasn't for me. But I did choose in my internal medicine foray to really pick the thing that most reminded me of the intensive work that I had sort of admired intensive care medicine.
Tyler Johnson: [00:04:52] Yeah. So talk to us a little bit about, you know, we have had some intensivists on the program for whatever reason. You know, the program has been going for more than three years now, and I think we had a number of intensivists kind of early in the program's run. We have not talked to as many lately, and I know that there are other aspects to your job, which we'll get to a little bit later, but just in terms of being an intensivist, walk us through what is kind of like a day in the life of an Intensivist like, like what does an intensivist spend their time doing? Dr.
Jessica Zitter: [00:05:23] It can be very dramatic. It can feel like you're in a movie when you're going in, you're walking in the door. You're walking down that long corridor. You don't know what you're going to see when you get there. You've got your residents and your fellows and everyone's around. It can be very, very dramatic. And I think it's really easy, you know, the procedures and the and the sort of the codes and can be really easy to sort of lean into that part of it and really get consumed by it. And I think that's what I was doing for the first part of my career, which sort of was not feeling right, but on a very subconscious level. So eventually I sort of moved into a different space.
Tyler Johnson: [00:05:57] So before we get into that movement, you know, one thing that I. To my recollection, anyway, I don't think we've ever talked about this in detail in the program. So even people who are not involved in medicine, pretty much everybody has heard of quote unquote, doing CPR, right? And many people, even if they've just watched a, you know, a medical television program or whatever, many people have heard doctors who are taking care of patients in the hospital say, call a code, call a code or code blue or whatever, right. But can you talk us through? In fact, if you are the doctor who, let's say that you have a patient who's, you know, reasonably sick, they come to the ICU, but they're still, you know, pseudo stable. And now they've been there for a couple of days. And then all of a sudden something goes south and you lose a pulse, let's say. And a code is called. And let's say that as it happens, you're the person whose turn it is that day to be, quote unquote, running the code. What does that look like from a first person perspective, like what is happening to the patient, what is happening around you, who's in the room with you, and what are you as the person running the code actually doing? Dr.
Jessica Zitter: [00:07:01] You know, the thing about an ICU and all the nurses and doctors in it is that we're set up to really be focusing on when that heart stops. I mean, we are all about blood pressure and heart rate, and when heart rates stop or breathing stops, we're right there and we have all sorts of protocols that snap in. I will say it's extremely anxiety provoking for the first little while, and frankly, I don't think it ever ends. I think most of us, even attendings who've been doing this for a long time, feel, you know, this incredible sense of adrenaline pumping. It's a it's really, truly life or death. So what happens is just that a lot of protocols start to unfold. People not only what are we going to do to the patient, what medications are we going to give, what chest compressions, what ratio. But also there's just this whole team that kind of falls into place, for better or for worse. I mean, a really good code experience requires that everybody be really communicating well that the level of hysteria below that there's quote unquote closed loop communication. So when one person does something, the other person knows. And I've been in many, many environments where everything is really pretty fluid and going well, and I've been in many situations where it's frenetic and chaotic and very stressful.
Dr. Jessica Zitter: [00:08:11] You know, the stress of a code starting is very different from how you start to get into it as the code goes on. And because we're so versed in the protocols, we sort of get into an almost automatic protocolized process. You know, it's a very scary thing to think somebody is about to die. One of the things I think that's dangerous about medicine is that we can pull away from the patient experience and focus on the protocol. Now, obviously in a situation like this, you have to focus on the protocol, because if you can save somebody from dying, you don't want to be thinking about anything else. But the problem is it's sort of it's a symbol of so many other things that happen without that level of tremendous acuity that you really just need to go ahead and do it. We sort of bring that kind of mentality into other aspects, certainly of the ICU. And I'm too busy, you know, to have a conversation. I've got, you know, this patient, this patient, this patient. I don't have time to sit down and talk about goals of care. And I think we can sort of pull that need or that desire for protocols that we need in a code into so many other aspects of our interactions with patients.
Tyler Johnson: [00:09:16] Yeah. You know, so I'm a medical oncologist. So most of the care that I deliver is in the outpatient setting. I attend on the inpatient wards a fair amount. But even so, most of what I do on the inpatient wards is, you know, going around with the team and rounding on patients in the morning, which is to say that I'm not there for that many codes, although, you know, just by happenstance, there will be some that happen during morning rounds that I'm still there for. But if I remember back to when I was an intern and a resident and a fellow, and I was there for a lot of the codes, I think the thing that is so striking about them is that, you know, most people, to the degree that you have any familiarity with CPR or quote unquote codes at all. It comes from some kind of dramatized version, right? You see on TV that a person collapses and then somebody rushes over and does CPR and, oh, the person comes back and gasps in their breaths and, you know, whatever, whatever, all of that is just to say that the thing that was so striking to me about the first time that I started to experience codes as an intern is two things. First of all, they're so different from the dramatized versions that you see because as you mentioned, there are so many people doing so many different things at the same time, right? So rather than like the person who's doing CPR to somebody who collapsed on the beach or whatever.
Tyler Johnson: [00:10:28] Often there are 12 people in the room, and there's one person at the head of the bed, so to speak, who is kind of giving orders. But then there are all of these other people who are trying to get lines and administer medications and pull up medications and check for the pulse, coming back and doing the chest compressions and all those things. It's it really is. And and it has the possibility, as you mentioned, of being very chaotic. But it can also be this beautiful, you know, sort of a symphony of order when it's working, right, where you have this one person sort of conducting and then all the different people, so to speak, playing their instruments. The other thing though, that and I think the thing that most struck me by far as I was starting to participate in codes, is just how terrible a thing it is to do chest compressions, right? Because you have this person who pretty much by definition, if you're doing chest compressions, has legally died, and you are pushing basically as hard as you can on their rib cage, in effect, trying to contract their heart by gross physical weight of force through their rib cage. Right? Which, of course, the entire point of the rib cage is to not give you access to the thoracic organs.
Tyler Johnson: [00:11:34] Right? So you're sort of battling against their own anatomy and physiology to try to get to the heart, to keep their blood pumping until something hopefully can happen to bring the pulse back. And occasionally that thing does happen. But often patients in the hospital are so sick that the CPR doesn't work, and then it becomes this sort of terrible battle against time, where the person who's running the code has to decide how long to carry all of these actions forward until they finally, as we say in the hospital, call the code, which is to say that they tell everyone to stop doing whatever they've been doing. Again, there are times when it works, right? And of course, the reason that we do it is for the rare time when it works. But there are so many times when it doesn't. And I guess I'm just especially given the later work that you went to, which we'll talk about in a moment. But I guess if I would just be interested if you could reflect a little bit on the difference between the common dramatization of these events in, you know, television, hospital dramas and whatever, and what it's like to actually be there as the person participating in or running the code on the ground.
Dr. Jessica Zitter: [00:12:32] In my book Extreme Measures, the opening scene is a code that I'm running when I. I wasn't even running it. I was just one of the interns. And it was really. It was one of the first days of my internship, and I describe it in pretty grisly detail, and it's amazing that I went into ICU medicine after that because it was pretty horrible. And most horribly, in addition to the fact that we had broken, you know, all of the ribs and you could feel bone grinding on bone and you could and you saw this person and they smelled like death. They had been really dying very seriously for a long time. And it just it wasn't just the horror of being around that physically. It was the fact that this person, this person was not really being treated like a person by me or by anybody else. It was just like this person was clearly dead. This person was dead and nobody was acknowledging it. It just didn't feel like why I had come there in the first place. But at the time, I didn't really have the words or the consciousness to understand why I came away from that code feeling so distressed. And yeah, I mean, it took me 20 years to figure it out.
Tyler Johnson: [00:13:46] One of the things that that makes me think of. So while I don't participate in codes that commonly one of the things that does very commonly happen. So as I said, I attend on the inpatient Housestaff medical oncology service. So if you're working on a general wards service, certainly people die on general ward services, but it's, you know, pretty heavily the exception. It doesn't happen very often, at least in, you know, the services that I have seen. But if you're working on a medical oncology service, it's very common to have people die. And one of the things that I have become so aware of, though sometimes still not as aware probably as I should be or as I wish I were, is that sometimes when a patient dies and I'm the attending on service, which is to say, the doctor who's supervising the team, and as you were referring to earlier, this is usually a team that has supervising residents and interns and medical students. And, you know, there's this whole entourage of people is that I have realized that sometimes, like, if we're rounding and someone, you know comes back to the circle of rounding and says, well, I you know, I spoke with the nurse manager on such and such a floor and this patient has died.
Tyler Johnson: [00:14:50] I have realized in retrospect, to my shame, that there have been times when my response to that is to say, okay, thanks for letting us know. So now back to Mr. Smith and his, you know, hyperglycemia or whatever the thing was that we're talking about, which is so grotesque, right? Like the fact that you've been caring for a person and now you have found out that the person has died, and that my reaction sometimes is to say, okay, and on to the next thing. Right? And so now I have tried to kind of unlearn my reflex in a sense, and have tried to remind myself that especially, you know, because one of the things that I realized in that, you know, to have a little bit of compassion to myself, this has come after many years of taking care of patients and recognizing that patients on the medical oncology service die. And most of the time when it happens, it's something that I have kind of been anticipating because I can kind of extrapolate their trajectory, whatever, whatever. And so I have kind of already steeled myself and already thought this through, and I've sort of pre dealt with my own emotional response to this.
Tyler Johnson: [00:15:54] Right. But what is so striking to me is that often if I do that and I'm just kind of making my way through rounds, then if I'm paying attention, I'll look and the intern who was taking care of that person, or the medical student who was taking care of that person, even though I don't say anything, and even though they often feel too sheepish to interrupt, I'll see that they're crying, right? And this is to say that this reminds me that there is a callousness that develops over time, even for me as a person who thinks about this stuff a lot and who tries to be compassionate and tries to keep a soft heart. It is an occupational hazard that you become so acclimated to this that you stop noticing that it is a thing. And I have had to remind myself when that happens, to stop rounds, stop everything and say, wow, man, we just got a really big piece of news like, can you all, you know, talk me through. How is this landing with you? How are you feeling right now? What does this mean to you? You know, whatever.
Dr. Jessica Zitter: [00:16:53] Yeah. That's why the work that we do at Real Medicine Media, which is to tell stories about, you know, usually through film, but also through story writing essays. And my book is that we really are, you know, everyone wants improved patient care. But what I really am curious about and concerned about is what is happening for the healthcare providers. What is the moral distress, the moral injury that we are all working with? That is this vicious spiral of making things worse and worse, because when you get injured, then you provide worse care, which makes you more injured, which provides worse care. And so we really believe that by showing stories of vulnerability and by putting people up on the screen that healthcare providers can relate to and see themselves in, we can generate honest conversations about what's going on for us and how can we get past it into a better place?
Tyler Johnson: [00:17:42] Okay, so you had grown up admiring people who did some of the the most demanding, precise, hard work of medicine. Right. And then you decide you want to go into internal medicine. But again, you make the decision that you want to go into the part of internal medicine that, at least as you saw it, then demanded the most of you and demanded, you know, precise, you know, almost higher than is reasonable to expect level of care from you and your colleagues. Right? So you go into critical care medicine, you're running code. You're taking care of the sickest people in the hospital. Anybody who's been to ICU rounds knows that these are incredibly complex, demanding discussions. Right. It's it's a lot of give and take between well, we want to help this organ, but that might hurt this other organ. And how do we support this thing without taking away from this thing. And anyway, so you're doing all of that. But then after 10 or 15 years, it starts to lose its It's luster, and you start to become worried both about the state of your own soul, so to speak, but also just about sort of the atmosphere that's around you and start to notice some really deep problems. And that leads to a you alluded briefly earlier that sort of leads to a change in direction. Kind of walk us through what that story looked like, both in terms of what was happening inside of you and then what you did in response.
Dr. Jessica Zitter: [00:18:58] Well, you're giving me a lot of credit. It didn't happen that way.
Tyler Johnson: [00:19:04] Okay, well, tell us the real story.
Dr. Jessica Zitter: [00:19:06] Yes. I was feeling more moral injury, more distress and a little bit of, quite frankly, depression and burnout. What happened was total luck. I happened to be in the early 2000, in a hospital, this tiny little hospital in Newark, new Jersey, public hospital that happened to have one of the early what would become palliative care teams. They called themselves the Family Support Team, and they had been funded by a grant from the Robert Wood Johnson Foundation for a project around the country. There were only four recipients, four hospitals that got this money about improving communication in the ICU. And this quote unquote, family support team, which was to become the palliative care team in that hospital, was running that study. And I was so annoyed by these people.
Tyler Johnson: [00:19:54] I'm pretty sure all palliative care physicians know in their heart of hearts that there are doctors. They really annoy all love and respect to the palliative care doctors. But I'm just saying this is a thing that they probably know.
Dr. Jessica Zitter: [00:20:06] This is something we could talk about later, but there is a massive hierarchy between ICU and palliative care doctors, and having worked and spanned both of those professions, I can tell you I see it. It is really incredible. It's just another one of the hierarchies that exists in the practice of medicine and in the halls of the hospital that I think cause toxic harms. But that's a whole other question. So it was actually not run by a doctor. It was run by a nurse, Pat Murphy. Pat Murphy, she calls herself this sort of Irish broad. And she would come in and she would and her minions, these social workers, and they'd be walking into the ICU with a clipboard like, who the hell are these people? And they're coming into my patient's room. Get out of my ICU. What are you doing here?
Dr. Jessica Zitter: [00:20:49] And they're telling me that I'm not treating this patient with enough pain medicine. And that patient over there has no idea that they're dying, even though we all know they're dying. And I was really annoyed by her. And I thought, who does she think she is? This is my license on the on. You know, I'm the one who needs to keep this person alive. If I allow this person to die, it's on my watch. And I'm going to, you know, be in trouble. So that happened. That went on for about three, 4 or 5 months. And we really I started feeling this incredible resentment of this woman coming in. And honestly, what I know is that what she was doing was she was tapping on something that was already in my head, but it was very subconscious. And then one day she stood at the doorway while I was inserting a Quinton catheter into a moaning patient who was on the verge of death. And she looked at me in disgust and she put her phone like her head, hand up to her ear, like she was about to make a phone call. She says, call the police. They're torturing a patient in the ICU. And I was standing there with my little eager, you know, resident or medical student next to me, all gowned up and ready to help me. And and then the nurse was outside waiting for me to get this Quinton catheter in so she could attach the patient to dialysis.
Dr. Jessica Zitter: [00:22:01] I mean, it was all this whole thing was happening. And Pat is standing there in the middle, basically foiling the entire machinery that we had created. And it was so obvious that she was right. And I honestly started sweating underneath my gown. I just didn't know what to do because I knew she was right. I knew that I hadn't had this conversation with that woman's husband who was sitting right there. I just had him sign the consent form, but I didn't tell him that this really wasn't going to do anything serious to help her, and that it was going to cause her terrible pain before she went on to die, and it was going to keep her him from being with her and holding her hand for that important period of time. And so I'll tell you, I'm not proud. But I did put that catheter in and she did die the next day. But something changed in me at that point. I finally felt like I could let down my guard and I could ask Pat for help. And that is not an easy thing for an ICU doctor to do with a nurse. And again, hierarchy and all of the stuff that we subscribe to in this work. And I think all of it, which is really damaging to all parties.
Tyler Johnson: [00:23:09] Isn't it funny? I have sometimes thought that the way that, like, our conscious minds interplay with our subconscious is kind of like, I'm no geophysicist, but, you know, there's this whole thing about that. Earthquakes happen because there are tectonic plates, subterranean tectonic plates that have been kind of like in tension for a long time. And then finally something puts them kind of over the allowable limit. And so what was tension becomes this rupture and the tectonic plates move. Right. And sometimes if there has been tension building up subconsciously, then some kind of comment or experience or thing that we encounter can finally like cause the rupture in the tectonic plates shift. Right. And as you're describing, then you can be in this situation where this entire paradigm that you've used. And, you know, I think it's hard for people who have not been involved in medicine or even in critical care medicine to understand how much it feels like. And I don't use this term lightly or even derisively, but it feels like a divine mandate, like you are there to save the patient's life, full stop. And so then, if pain or discomfort or confusion or alienation or whatever happens in the process of you fulfilling that mandate, Well, that's just the price of doing business, right? That's just sort of collateral damage. And and maybe there is someone else, as you mentioned, probably someone with much less prestige in the hospital hierarchy than you, who is there to clean up the mess afterwards. But that's not your concern, right? You have your mandate, and you are to do whatever you can to fulfill that mandate. Okay, so this rupture happens. You have this sort of epiphany as you're sweating under your under your sterile suit, putting this catheter in, and then what?
Dr. Jessica Zitter: [00:25:05] I then kind of crawled back to Pat the next day and I said, I need you to teach me how to do this differently. And that was really I mean, that was a moment of in a way, it wasn't shame, because I had been feeling shame all the way leading up to that. It was a moment of it's like when you're in therapy and all of a sudden you learn something about yourself and something that you just would never have been comfortable admitting before, but all of a sudden you can say the words and it's like this freeing thing. And that's how I felt. I was like, I am free to now learn something new. I will say for me, the things in my career that have been the most satisfying and given me the biggest rewards have been not what I what what I imagined them to be, which was to become a technician and really skilled. And I could save anybody's life and I could do everything. You know, I was respected in the hospital as one of the best clinicians. It was really what I learned from first, this nurse, Pat Murphy. And second, which is the subject of this most recent film, what I learned from a chaplain and the fact that my two greatest mentors were a nurse and a chaplain to me, and that I got the greatest sense of professional accomplishment and progress and satisfaction from what I learned from these two people, it's really telling me something about the way the values that we hold dear as we teach people how to be doctors. Um, and I think we have to really reframe everything about the way we're teaching people, because, again, I didn't learn what I needed to learn from the medical world.
Tyler Johnson: [00:26:41] Yeah. You know. It is an interesting thing. And I, I mean, I say this as a person who spends the majority of my professional time teaching in one capacity or another, I teach a lot of medical students, and I teach and I teach our oncology fellows a lot. So just as an example, we just had our American Society of Clinical Oncology meeting was earlier this month. We have it at the beginning of every of June every year, and I was in charge of arranging a panel that sat and for a discussion at that meeting that was on. It was a philosopher, a social worker, and a palliative care doctor talking about doctors encountering suffering and sorrow. I was talking with the panelists, sort of informally up at the table afterwards, and there were some other doctors gathered around and we were having this discussion. And the thing was that in the course of this discussion, it became clear that of the doctors who were participating in the discussion, none of them had had any instruction, conversation, anything in their medical school or other training career, which, let's be clear for doctors, we're talking like a decade to a decade and a half of training. None of them had ever been taught anything about how to think about encountering sorrow and suffering. Which, if you think about it, that is totally bananas.
Dr. Jessica Zitter: [00:28:06] Bananas.
Tyler Johnson: [00:28:06] Because that's what you I mean, you know, okay. It depends. You know, it comes in degrees. It depends a little bit on specifically which kind of doctor you are. So yes, as an oncologist. But that's the thing. We were in an oncology conference. Right. Like of all the like of all the people in the world, is there anybody except for maybe palliative care doctors who deals with more sorrow and suffering than. And even I will say. And, you know, I mean, maybe I'm sensitive to this because I organized the panel, but, you know, there was a there was a reasonably good attendance, but certainly nothing like the attendance that you would have at a, you know, experts reviewing how to sequence chemotherapy regimens for colon cancer, let alone the newest research that was available, which, to be clear, I attended all of those sessions and they were incredibly informative and important. But but the point that I'm trying to make is that I think that it's not only not that there are, Pat, easy, scripted answers to any of these questions anyway, but the problem is not even that we don't know the answers, and it's not even that we don't know how to ask the questions. The problem is, most of the time we don't even think to ask the questions in the first. We don't even know there are questions or there isn't even anything to be asking about. Right.
Dr. Jessica Zitter: [00:29:13] Absolutely, absolutely. Well, my hope is that you're going to watch our most recent film because it's called The Chaplain and the doctor, and it's about my really unusual relationship with a chaplain. And I'll tell you, one of the things that's most striking to me is that I didn't even notice her. For the first several years of our relationship, we worked together for 15 years on the palliative care service. I mean, I'm going to be honest with you. I thought she was lovely. She's. But, you know, you go in and pray and I'm going to go do the real stuff, the real palliative. I'm embarrassed because we're supposed to be so, you know, egalitarian and palliative care and there's no hierarchy. Yes. So so I didn't really notice her for for much of the first several years that we worked together. It was really only as time went on, just like with Pat, this nurse, that I started to hear and see that there was something else that was happening that I was missing. Just like with Pat, I realized I was missing the communication piece. I was not even thinking to communicate with my patients. I was like, this is what my mandate is, and I have to do it.
Dr. Jessica Zitter: [00:30:16] And Pat slowed me down and said, whoa there, Charlie, what about the justice of breaking bad news. What about the justice of giving people the information, or some of the information that you have in your head that you're not even thinking they deserve to have about their own bodies? So the second piece with Betty was about saying, whoa there, Charlie, you're not even attending to this person as a person. You are still seeing them as a symptom, as a conversation that needs to be had. But you're actually not really deeply connecting with them as a human being and as their soul. And I think that was the second thing that I learned in my, in my medical profession was, yes, you need to give people information. Yes. That's an issue of justice. People deserve that information and you have to support them through decision making. And the second step is you need to care. You need to connect. You need to be curious. You need to respect who they are as people. You need to be so committed to getting people's stories. And that's how we actually heal. And the beauty of this relationship between the two of us. Is that together? We were so much stronger than each of us could be alone.
Dr. Jessica Zitter: [00:31:27] She got so much out of being with me and we would see patients together all the time. She just got so much out of being pulled into the medical side, understanding the medical side enough that she could really provide even better counsel to the patients and their spiritual needs. And for me, obviously, the incredible benefit of being with somebody who is so comfortable being with death, facing death, sitting with people's pain, sorrow, suffering, hopelessness, and acknowledging that we judge patients and label them all the time. You know, she would see that as as the chaplain that she was she would see when we the team were thinking we had so much to do and we would shortcut, oh, this is that kind of patient, this is that kind of patient. And she would slow us down and she would say, you don't even know this person yet. Have you heard this person's story? And that was the thing she kept saying over and over again. And I did some eye rolls for the first few years, but I eventually started to really listen to her, and that's when I started to commit myself to telling her story.
Tyler Johnson: [00:32:30] Yeah. You know, it's so funny to me because I think you've mentioned multiple times the hierarchy in the hospital. The thing that is so that remains astonishing to me is the degree to which that hierarchy is almost entirely unspoken, and at least in any sort of written way, informal and yet universally recognized. And the place where I have seen this, that is the most striking, and that never seems to just smack me in the side of the head, is what happens when a person is in a room with a patient, and another person comes in to the room with the patient, and this may not be obvious to everyone if they're not a medical professional. But every medical professional knows that. What happens is that the two people, it's like animals surveying each other on the savanna or something. They, like survey each other and and they look at two and maybe three things. So the first thing is what is their respective role. Right. Are they physicians versus physical therapists versus chaplains versus whatever. And then the second thing is sometimes if it comes into play, I guess I would actually say four things. So that's the first one. The second one is where are they in terms of level of training? If one of them's a supervising resident, one of them's an intern. The third thing is, if they are in medicine, what branch of medicine are they in? Right? Are they a surgeon versus an internist versus palliative care? And then the fourth thing is that sometimes people also obviously inappropriately but unconsciously take into account what the person looks like, and they may make assumptions about where they are in their training level or whatever. Right. So a woman, a shorter woman is obviously quote unquote younger or has a lower training level or is low anyway somehow lower on the hierarchy than a tall, broad shouldered man, for example.
Dr. Jessica Zitter: [00:34:20] And don't forget, don't forget race and age and you know, all of those things.
Tyler Johnson: [00:34:25] Yeah, but the point is that they make this kind of rough assessment of each other and then almost always without saying anything and without one, like if the one who's coming in is more senior, it's not like they usually go in and say, oh, I'm so sorry. Excuse me, could I please interrupt? And they just start talking. Right. And the thing that's so weird about it is that everybody understands it so intuitively that there's almost never any fuss about it. They just the one person cedes to the other person, and it's this whole thing. So all of that is to say that I have to admit that in that established hierarchy, and I say this with a sense of sort of tragic irony, okay, to be clear, but the chaplains are like nowhere in that, like I have never, ever, ever seen a chaplain override like another person's position. Right? That just doesn't happen. And if the chaplain is in there talking with someone or praying with someone and anybody from any medical team comes in, boom! They automatically know that the chaplain seeds the room, right? I think that most people, if they think about a chaplain in the hospital, they probably think about like, I don't know, a Catholic priest on staff who, like, comes to give the last rites to a person as they're dying or some sort of official religious ceremony. Right. But clearly, what you are speaking to is much broader and deeper than that. So, I mean, it can include religious rites, of course, as well. But what is it that you feel like chaplains have to teach doctors that is so important in leavening the way that they practice medicine?
Dr. Jessica Zitter: [00:36:00] Well, first of all, there are as many different chaplains as there are different doctors. There's so many different ways to be a chaplain. And Betty's a very unique person, which is probably why I started listening to her. And frankly, so was Pat Murphy, a very unique person, very strong and very confident. Betty has gone through so many challenges in her life that she's she's pretty tough, and Betty actually has not ceded the room. You know, last year some little resident comes in and just starts talking, and Betty takes her outside and says, do you realize that I was I mean, so so some chaplains don't see the room. God bless them and God bless. Betty, I will say another thing is that once we started filming Betty and we've been filming her for a long time in the hospital, probably about seven years. So she's had this camera crew following her around. And I'll tell you, you want to change the the culture of a hospital, you just put a camera. She became royalty and I will say not to play into the the hierarchy, but the fact that Betty had a champion who was a physician, who was an ICU physician, also gave her a whole different sort of level in the hierarchy. And I think it allowed us to play with some things in a way that that come out in the film that I think really could spark a conversation about what a chaplain can teach a doctor, which is a lot.
Dr. Jessica Zitter: [00:37:25] She really values. And what I think chaplaincy teaches well is the importance of really seeing a person meeting them where they are. It's not about the religion. She figures out how to cut right into the jugular of what is most important to somebody, and then she hangs on to it. This is the thing about Betty. I mean, Betty is a very unique kind of person, and I really think that by putting her in this film and putting our relationship sort of in this wacky, it's really unusual. We crossed so many boundaries to come together. Racial boundaries. You know, she says to me, you're my only white friend. I have a lot of white acquaintances, but you're my only white friend. That's saying something pretty serious. When you work in a hospital with a lot of white people, and she's spent her entire career working as one of the only black people. That's a serious thing to say. Age. How often do 80 year old chaplains really get forecasted? Obviously our professions. I mean palliative care, ICU and chaplaincy. I think that it was an unusual relationship, and I think there's something about the throwing together of people from such different worlds that can start a new conversation. It can spark something new. And it really did for us.
Tyler Johnson: [00:38:36] Yeah. So Henry and I have been doing this long enough that we've gone to various places and given talks about the podcast and whatever. And one of the conclusions that we have come to is that, you know, I think a lot of the most powerful forms of education are about breaking down what either you thought you knew or you just didn't know. And then on the far side of that, building it back up again. Right. So as a person who teaches medical students a lot. One of the things that in arguably the main thing really that we I mean, when you come into medical school, the school, the first thing you have to do is just learn a bunch of facts. Right. You have to learn how to action potentials work and how to, you know, impulses propagate along synapses. And how does the, you know, the cardiomyocytes work together and whatever. So fine. But then once you have those facts more or less under your control, then really the kind of paradigm that you're learning is you're preparing to be a doctor is how to take a complex patient presentation, break it down into its constituent parts, whether that's a problem list or whether that's, as we often do in the ICU, going by system, and then sort of figuring out what to do with the various problems and how to sort of take those problems or those systems and then kind of come up with a treatment plan that addresses everything that's going wrong. Right. And this is to be clear, when I attend on the wards, this is what I spend the majority of my time doing, is teaching trainees how to do that breakdown and how to think systematically about a patient who is really sick and in a situation that's really complicated.
Tyler Johnson: [00:40:10] And so all of that is to say, I fully endorse learning to do that, right? Because that's what you have to do if you want to be an ICU doctor. You know, it's not going to be daisies all the time, right? You have to learn how to do the hard work of thinking like that. However, what I will also say, and I think this is the thing that chaplains so often remind me of, is that even though you have to learn how to break patients down in that way, you also have to learn how to, in effect, reconstruct them as real people. Because I think what has what often happens with us, especially in the inpatient setting and actually also in the outpatient setting, although for slightly different reasons. I think there it's more about time pressures than it is about these cognitive processes. But we spend so much time and so much effort coming up with the problem list or figuring out how to analyze them by system in the ICU, that in effect, they become their problem list. And the only thing we know how to engage with is a problem list rather than a person or a patient. Right. And I think that what chaplains do best of them, and I think that as a, as a profession, as a sort of an art form, the thing that is so powerful about chaplaincy is that it reminds us to tend to, for lack of a better word, the person's soul.
Dr. Jessica Zitter: [00:41:29] Right. And, you know, one of the things that I think really is a big point of this film is that getting connected and really seeing a person holistically is important and really starting to understand how much bias there is in the hospital. Because when we take shortcuts and think about people as just organs, or we think about them as the patient in bed four or, oh, that's that patient who's asking for Dilaudid. We make judgments about them that makes it impossible to really connect with them as the people that they are. And so I think it's that implicit bias. It's certainly about racism. It's certainly about any kind of implicit bias. By the way. There's as many biases as you could possibly imagine. This isn't just on the basis of one's color, one's gender. This is if this person reminds you of your father and they bother you, or they or they scare you, or this person reminds you of something that somebody else did that really offended you. I mean, there's so many reasons in the human brain why somebody is going to get worse care from you based on your own internal beliefs and suppositions. And I think that's what this chaplain has also taught me, which is that if you really sit and spend the time to get and honor the person's story, and then to honor your own experience, to realize how you're feeling, to look at the places where you're making assumptions, you're going to have much more ability to connect with them, and then to provide the care that you really want to be providing.
Tyler Johnson: [00:42:51] Yeah. You know, one thing that I think and this is kind of a parallel point to what I was talking about a minute ago, but I think sort of falls along the same lines, you know, when you're an intern, I feel like especially every intern has more to do than they have hours in the day. Like pretty much by definition, that's sort of what internship is, is trying to figure out how to take 40 hours worth of stuff and do it in 28 hours or 30 hours and do it in 16 hours. Right. Like, that's sort of what that is the the like, basic dilemma of internship. And so what every intern does over the course of their internship is they learn all sorts of mental shortcuts, right? They learn how to take this thing that would be really complicated and sort of repackage it into something that is simpler. And for the most part, that's a good thing, right? That's part of learning how to be a doctor is it's learning how to take the complex and time consuming and make it simpler and less time consuming. However, I think to your point, it's important to recognize that one of the easiest mental shortcuts to take, just as a general rule, is to lump people into categories.
Tyler Johnson: [00:44:05] And the issue is that that kind of hard wired tendency in the human brain is a lot of what allows all of the isms to flourish, right? Because it just becomes easier to think of all fill in the blank kind of people are like, fill in the blank, right? Yeah. And that is to say that in many instances, like I know that during the racial reckoning five years ago, a lot of the discussion at that time was about how, you know, people would say things like, well, I can't be, for example, racist because I don't mean any harm. It's not like I desire bad things to happen to black people or whatever, but part of what is at issue there is that you don't have to mean harm to someone. So, for example, as a doctor, you don't have to mean harm to people of fill in the blank category to deliver worse care, right? You may deliver worse care simply because of these sort of the outgrowth of these seemingly at first innocuous mental shortcuts that you take that then can end up actually having really profound differences.
Dr. Jessica Zitter: [00:45:10] Yeah. And I really think, you know, one of the things that's so important to me is that we don't have any kind of, like, finger wagging. This is the way the human brain, we are all vulnerable and victims to this way of thinking. It's the way the human brain works. Let's just let's just not let's not mince words. People's brains make categories. This is sort of the savanna concept of like you have to make judgments really quickly. And the problem is medicine is particularly, I think, at risk just given the hierarchies and given the urgency and given, you know, the fact that people are treating people who are not like them, we're taking care of patients who are from completely different worlds than we are. And never do I want any of this to be finger wagging. I want to show myself on this film, which I do as very quote unquote flawed. It's not even flawed, but with a lot to learn and feeling good about that and feeling, you know, that that's a virtuous thing to do instead of you did that badly. And so, you know, in this film, there's one patient who's a Holocaust survivor, and she was taken care of by a Holocaust denier the year before.
Dr. Jessica Zitter: [00:46:16] So already you're thinking, oh my gosh. And then on our team, my dear, dear friend who's extremely well-meaning, makes an assumption that this woman has resources. We're talking about her social needs, and the woman has no resources. She lives on food stamps. And there's, you know, it's an uncomfortable moment where I say, do you think it's because she's Jewish? And there are stereotypes about all sorts of potential people, and every single one of us is vulnerable to someone not liking us because of something that they're assuming about us. And I think in this moment, in this country and in the world of incredible divides and conflict and hate, we as healthcare professionals have a very big responsibility to keep our politics out of our work. That has to happen to stay curious about our patients, to be compassionate towards them, no matter what their political beliefs or political beliefs. There are so many divides here that we could take advantage of as people in power, as healthcare providers. And the main thing I would say is when power meets prejudice at the bedside, we've got serious problems that every single one of us should be concerned about.
Tyler Johnson: [00:47:34] Yeah, I think that's such a beautiful and powerful example. And in particular, the example you brought up there, because I think that in a funny way is almost less it's less intuitive to us that that situation would be a situation that is rife for misunderstanding. I think most people, if you were to say, I'm going to present you with a patient who survived the Holocaust, their intuitive reaction, the reflexive reaction would be to say, oh my gosh, you know, I'm going to try even harder. I'm going to be even better. I'm going to like, step up my game somehow. Right? Because that's such an intuitively, I don't even know the right word, poignant situation to be placed in, right? But even then, as you say, there's just this sort of hardwiring in the back of the brain, because even the idea that we should step up our game is based on this series of assumptions, right? It's all just assumptions. And and I think that's part of the point is that the problem is not animus. I mean that also, of course that's a problem if that's there. But in many cases the problem is not animus, the problem is the assumptions. And then the problem is the decisions. Because as you mentioned, if you could track a doctor's thinking along the course of a day in the ICU, for example, there are thousands of decisions that an ICU doctor is making, and the vast majority of them are either not even acknowledged as decisions or they are made so quickly that they are close to being subconscious.
Tyler Johnson: [00:49:03] And anytime you're making a decision that is, in effect, subconscious, and you're carrying around this whole host of assumptions with you about how the people got to the state, where they are and what it is they really need, and what's waiting for them at home and all the rest of it. And then the other part, of course, is that, you know, I think a lot of doctors don't necessarily think of themselves as powerful at the bedside. In fact, they may think of themselves as largely having been sort of stripped of their power precisely because of bureaucracies and hospital corporations and blah, blah, blah. And so it just becomes harder and harder to see both the prejudice, speaking of that as a descriptive, not pejorative term, and also and also the power that you wield.
Tyler Johnson: [00:49:42] So I want to ask you one thing to help us to wrap up, and that is this. If you could magically transport back to Jessica Zitter, the first year attending in the ICU and, you know, now, after many films and a book and all these interviews and all of these sort of paradigm shifts and epiphanies. If you could bring one insight to her and say, this is the thing that I want to teach you, to help you be a better doctor over the course of your career, what would you say?
Dr. Jessica Zitter: [00:50:12] It's really simple. It's treat everybody as you would want to be treated yourself. That's one of the fundamental lessons that we've learned from Rabbi Akiva, from, you know, many of our religious traditions. It's just so simple. Think about how you would want to be treated if you were sitting in that bed.
Tyler Johnson: [00:50:37] Yeah, I will say that it is still really striking to me. I'm sure you've seen this, but there's there are these things floating around about like that are patient facing documents that are supposed to prepare patients and their family members for how to engage with their doctors. And I know that a lot of people use these when they come to see me because the, you know, sort of quintessential place to use that is when you're talking to your oncologist. Right? And virtually all of them. The last thing they say is be sure to ask your oncologist, what would you recommend if I were your mother or sister or brother, you know, whatever. But it is so funny, even though I know that's a thing, and even though I know that they're often going to ask me that. It's so funny. We can have this discussion that is an hour long about all these chemo options and blah, blah, blah, and the whole thing. And then at the end they ask me that, and almost without exception, it still makes me go, oh.
Dr. Jessica Zitter: [00:51:22] Yeah.
Tyler Johnson: [00:51:23] Gosh, this really complicated thing just became significantly simpler. Let me tell you what I think, right. Which is just to say that it is so funny. And this gets back to what I was saying before about learning this great complexity, but then forgetting how to simplify it on the other side is that we can have all of this knowledge at our command. And yet then at the end of the day, there is something powerful and beautifully simple about asking that one question. Well, Doctor Zitter, we are so grateful for your tireless work and advocacy over so many years. We're grateful for your writing and your filmmaking and your caring for patients. And we are especially grateful to you for taking the time to come and join us today on the show. Thank you so much for being with us.
Dr. Jessica Zitter: [00:52:05] Oh, thank you for having me.
Henry Bair: [00:52:10] 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: [00:52:29] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient, or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:52:42] I'm Henry Bair.
Tyler Johnson: [00:52:43] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.