EP. 20: ETHICAL DILEMMAS IN THE HOSPITAL

WITH DAVID MAGNUS

Jul 19

WITH DAVID MAGNUS, PHD

A leading biomedical ethicist shares how he navigates difficult clinical encounters and how all clinicians can develop better ethical thinking and communication skills.

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Episode Summary

What happens when miscommunication between a doctor and patient leads to intractable conflict? What happens when a patient requests an intervention a doctor does not feel ethically comfortable with? In the toughest of situations, doctors turn to the clinical ethicist for help. David Magnus, PhD, an internationally regarded leader in clinical ethics, is the director of the Stanford University Center for Biomedical Ethics, co-founder and editor-in-chief of the American Journal of Bioethics, and former president of the Association of Bioethics Program Directors. In this episode, Dr. Magnus shares lessons learned from the most ethically ambiguous scenarios he has managed, the importance of ethical thinking skills for all clinicians, and the difficulties inherent in clinician-patient communication.

David Magnus, PhD is the Thomas A. Raffin Professor of Medicine and Biomedical Ethics and a professor of pediatrics at Stanford University, where he is Director of the Stanford Center for Biomedical Ethics and an Associate Dean of Research. Dr. Magnus co-chairs the Ethics Committee for Stanford Hospital and is currently Vice-Chair of the IRB for the NIH Precision Medicine Initiative ("All of Us"). He is the former President of the Association of Bioethics Program Directors and is the editor-in-chief of the American Journal of Bioethics. He has published articles on a wide range of topics in bioethics, including research ethics, genetics, stem cell research, organ transplantation, end of life, and patient communication. He was a member of the Secretary of Agriculture’s Advisory Committee on Biotechnology in the 21st Century and currently serves on the California Human Stem Cell Research Advisory Committee. He is the principal editor of a collection of essays entitled "Who Owns Life?" (2002) and his publications have appeared in New England Journal of Medicine, Science, Nature Biotechnology, and the British Medical Journal. As a frequent popular commentator, he has appeared on many radio and television shows, including 60 Minutes, Good Morning America, The Today Show, CBS This Morning, FOX news Sunday, ABC World News and NPR.
In this episode, you will hear about:
• What it’s like to be a clinical ethicist, handling the tough ethical questions doctors call on them to resolve - 5:05
• How an ethicist determines what is “right” in a given circumstance - 9:10
• How Dr. Magnus’ deals with patients who refuse to accept his recommendations for care - 11:33
• Dr. Magnus’s journey from professor of philosophy to leading thinker on medical ethics - 14:00
• How the intense specialization of modern medicine may be contributing to burnout - 23:31
• How misinterpretation of language can be a major barrier to good health care - 32:25
• Why clinicians use “hedge language” and “shield attributions” and how they can dramatically alter a patient’s understanding of their situation - 40:46
• Dr. Magnus’s advice to new clinicians on cultivating skills in ethical thinking and responsible patient communication - 50:45
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 health care 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 health care, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom, probing the moral heart that beats at the core of medicine. We will hear stories that are, by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.

Henry Bair: [00:01:03] When doctors run into the toughest ethical scenarios in the hospital, say a patient and her family disagreeing about a treatment plan due to a deep seated cultural issue or an apparently cognitively impaired patient refusing treatment, they often turn to the clinical ethicist for help. Our guest today, Dr. David Magnus, is someone who answers that call for help and is an internationally regarded leader in this work. Dr. Magnus is the director of the Stanford University Center for Biomedical Ethics, editor in chief of the American Journal of Bioethics and former president of the Association of Bioethics Program Directors. His wide ranging research interests include genetics, stem cell research, organ transplantation, end of life care and patient communication. Dr. Magnus frequently serves as a popular commentator on issues of medical ethics, having appeared on Good Morning America, Fox News, ABC World News, KNPR and more. In this episode, Dr. Magnus shares what he has learned from the most ethically ambiguous situations he has encountered the importance of ethical thinking, skills for all clinicians, and the challenges of clinician patient communication.

Tyler Johnson: [00:02:12] I want to give a sort of informal introduction that explains a little bit how I got to know Dr. Magnus. Over the past more than a decade. So in the hospital, most of what we do when we work in the hospital and even in the clinic is to make medical decisions. Right. So we're talking about what to do about antibiotics and what to do about ventilator settings and what to do about blood thinners for people who have blood clots and on and on and on. But one sort of subtext that underlies a lot of that discussion is dealing with ethics. And for the most part, you would think that ethics in the hospital is pretty straightforward, right? People come into the hospital because they're sick and they want to get better and they sort of entrust themselves to the medical system to do that. And by and large, that's usually a pretty clear, almost a contractual relationship. Right. The patient says I'm here to be healed or cured or at least made better. And the doctors say, okay, we're here to do that. And then they sort of work together and there's a give and take to to make sure that that happens as best possible. Having said that, though, every once in a while things don't quite go to plan or things are not so straightforward. And so I can just tell you from my personal standpoint, as a cancer doctor who takes care of some of the very sickest patients in the hospital, a very common scenario that we face is someone who the doctors suspect that a patient is nearing the end of his or her life and either the patient, him or herself, has a different idea about how aggressive they want their care to be than their family members do.

Tyler Johnson: [00:03:52] Or one that's really tough is when a patient or his or her family members want care that is so aggressive or so invasive that doctors feel that it would be inappropriate and feel that it really shouldn't be administered. And the reason that I paint this picture is just to say you can imagine that those are very weighty, fraught, difficult discussions. And it's only when we get to the very extreme end, when when the doctors and other health care workers have sort of exhausted all other resources, that's when we call ethics. Is when we get to the very the very toughest stuff where we've had seven family meetings and we've talked about it ad nauseam as a team. And everybody is is doing their very best to do what they feel is best for the patient. And yet you arrive at a very difficult impasse. That's where we often end up calling. There's actually a pager for a bioethicist who's on call and we call them and bring them into the hospital. And then they help to counsel us and help to try to resolve these incredibly thorny and difficult dilemmas. And so, David, with that as background, what's it like to be on the receiving end of that phone call?

David Magnus: [00:05:11] Well, so the first thing to just note, given what you just said, is that it's almost it's never the case when we're called in that things are going straight forward. It's very rare that people are calling us- it's not that it never happens, but those turn into subsides like they just don't know a policy or a rule. Those are very easy and straightforward.

Tyler Johnson: [00:05:32] Next time, David, I'll page you guys with a really nice, easy case just so that you can say you've had one.

David Magnus: [00:05:38] That would be that would be great. But most of the time when we're called in, it's because something has gone wrong in some respects in the communication and the relationships between sometimes between family members, but typically between the teams taking care of the patient and the physicians involved in care of the patient and the patient or the patient's family. And so those are quite fraught circumstances that we're walking in the middle of. And so there's a number of aspects to what we do. If you actually look at there's something called the American Society for Bioethics and Humanities, and they have created a set of core competencies for clinical ethics consultation for the background that you need. If you look at those list of competencies that you have to have to do our jobs, it's a little daunting. So the ideal clinical ethicist and the ideal world, you would have an MD, a PhD in philosophy, at least a master's in theology and a law degree and training and maybe some psychotherapy and mediation. So we all have to pick up the things that we don't know. So for somebody like me, I have a PhD in philosophy, I've had training in mediation and how to do de-escalation and things like that. You just have to really know the law and know the legal setting. And then for the medicine, that's one of the trickiest things.

David Magnus: [00:06:57] And in fact, we have a clinical ethics fellowship training program where we typically bring in PhD philosophers to get trained in clinical ethics over two years. And the whole first year is basically them learning medicine, enough medicine to really be able to understand. And what people are saying and be able to read a chart and be able to do that. So it's a little daunting, but the good news is when you have all these different tools in your toolbox that you acquire just like anything else, we have a job to do. Like the clinicians have their job that they have to do. There's pieces that we have to do. Often when we go in, patients are or there are more, even more. Typically, their family members are irate, really upset. They're escalated up to a ten. And our our job right away when we often come in is to deescalate those. And we have techniques and tools to de-escalate them. And part of this involves doing things that clinicians, just in the reality of the workload, can't do. Like sometimes it might mean letting somebody vent for an hour and a half or 2 hours and say everything that get say everything that they have to say that they're upset about and just do very active listening and not try to correct them even when they're saying things that are patently false.

David Magnus: [00:08:11] You don't correct them, you let them get it all out and do active listening of all the things that they're saying so that they feel heard and you can de-escalate things to then be able to do all the work of negotiating and mediation to get at the underlying interests and values that they have that are shared with the clinicians that you can use then as a basis of reaching some kind of agreement and get everybody on the same page. So that's a pretty typical kind of thing that we wind up doing. The other set of skills that I think is really important are as a philosopher, I'm trained to make distinctions and to think very logically about certain kinds of things. And often the cases that that come to us are very muddied. And so a lot of what we do is also make distinctions and be able to sort of see that, like if you break this down in this way, you can see that what looks like a mess is actually three things. And if you think of them separately, you can start to figure out how you're supposed to solve these kinds of each of them separately, and then that makes it easier to resolve.

Tyler Johnson: [00:09:10] Now, one thing, David, that I just have to ask, I have to admit that as an armchair amateur philosopher and theologian myself, I've always sort of hoped for an opportunity to ask you all of these questions. I'm glad to do it in a way that everybody else gets to hear. So here's one thing that I want to know, because at the end of the day, to some degree, what we're really asking you and your team to do when we consult you is to tell us and the patients and everybody involved in a difficult case what's right. I mean, that that's sort of the the crux of the question. But then that seems so un 2022, right?

David Magnus: [00:09:48] I don't think that's what we do except except in a very narrow sense. There are some times where law and policy and strong consensus dictates what to do about certain kinds of things, and then we can give that advice. So for example, in the case where you have a patient who is never going to survive to discharge from the intensive care unit and is never going to be able to appreciate the benefits of any of their interventions. So they meet the Society of Critical Care Medicine standards for medically futile or inappropriate care in those kinds of cases where they meet those standards. But the family continues to demand that that treatment be continued and to hold out hope that a miracle will happen. We still, in those cases, try to reach agreement, but there we can say the right thing is in some sense dictated by the Society for Medicine, the American Thoracic Society and the other professional societies, California law and a huge amount of ethics literature. There's not even agreement about whether you should invoke futility, but if you are going to do that and it's clinicians job, not mine. But if a clinician has made the decision to do that, California law professional standards say you can do that, but only if you follow certain processes and procedures. And so our job there is to guide on what those processes are, to make sure the right things are being followed, and then in the actual implementation, try to do the best you can to explain it in a way, because we're used to doing this that make it more acceptable or palatable to the families. And then sometimes the process itself helps.

Henry Bair: [00:11:33] So, Dr. Magnus, you've told us of situations when the right thing to do is more or less clear. But surely, even in these circumstances, patients don't always just accept what you have to tell them simply because this or that legal code stipulates a certain treatment plan. So can you tell us if a situation when a patient did not immediately accept your proposed plan and how you navigated that?

David Magnus: [00:12:01] One of the hardest cases I've ever had. We had a patient who had gotten a an artificial heart and had been waiting for a heart transplant for a long, long time and then finally stroke out and had been having like one complication after another and was no longer a transplant candidate. And the patient's spouse, you know, they had a small child. She could not cope with it. She had a very flat affect and continued to believe that her husband would be cured by a miracle from head to toe and was unable to really even consider an alternative. We went through a lot of the processes, including talking about the fact that, you know, prayer is not contrary and that God answers prayers in lots of different ways. And so let's assume for the moment that it doesn't happen the way you expect, because not every prayer gets answered in the way that we want it to. And that was the only time she broke affect. But she quickly went back to he's going to be cured from head to toe. And she fired all the chaplains who tried to work with her when we finally brought her own pastor because she was very religious and to talk to her on the phone and a family meeting.

David Magnus: [00:13:10] And he said, you know, for us, it's the afterlife we accept step this. She was just completely brokenhearted. She was never going to accept the outcome. But in a way, going forward with the process got her to start moving along in the grieving process and we gave it. I mean, it was a long period from the time the stroke to the time that the withdrawal took place. It was probably a couple of months and even from the time we were involved, we gave a lot of time for her, but it was something where she had to move on. And so one of the funny things is the 25% of the worst cases, I wouldn't say it's frequent, but we occasionally get emails sent to us after the fact from people who said, I know I was really upset at the time, but I really appreciate that you guys took the burden of this off of me and did the right thing and made me now come to deal with my grief of what happened.

Henry Bair: [00:14:00] Dr. Magnus, thank you very much for sharing that story and for giving us a glimpse into some of the difficult situations that you have to manage. And I'm sure we'll come back to that later. But for now, I would like to turn our attention to your work prior to medicine. I understand that you used to teach philosophy and worked at a college. Can you tell us more about what that work was like, how you eventually found medicine, and how your philosophical work has subsequently influenced your approach to solving clinical, ethical situations?

David Magnus: [00:14:37] Yeah, it's actually kind of funny and a lot of ways I've come full circle. So I started out my career interested in philosophy and I had fairly broad interests in philosophy. Obviously ethics was a part of it. I'm pretty well rounded. I mean, I know the history of philosophy pretty well. I can, I could. I've taught Aristotle and Plato and Descartes and Locke and all the Barkley Hume. Hume's one of my favorites anyway, so I've got a fairly strong sort of general background, but the three areas that I especially have had an interest in, in teaching and doing work in early on in my career were ethics obviously, but also history and philosophy of science, especially biology. And I did a lot of work around biology and genetics in the philosophical work that I did. And then I also have an interest in philosophy of language and linguistics. And that piece of my interest I sort of dropped as I sort of went along in my career and it's only come back in the last few years and in the work that we're doing, studying patient physician communication. So it was really for me, the way I got brought into medicine from all of this was I was a professor philosophy and but I was working on issues around genetics, genetics, diseases, things like that, which started to get me into things that overlapped with medicine a bit. And I got offered the opportunity to so talk about ethical, legal issues in genetics, genomics.

David Magnus: [00:15:59] Some of those kinds of issues gradually led me to be recruited to the University of Pennsylvania to be the graduate studies director of a master's program in bioethics and to be a professor in the medical school. And actually, I had a choice when I got recruited by Penn, I had a choice to be based in either the philosophy department or based in the School of Medicine at their bioethics center. And for me, it was a no brainer. And in a way, there's a surprisingly large number of us in bioethics, trained in philosophy, who have a background in philosophy of science, not just ethics. And the reason why I think that's important is too often for philosophers who train in ethics, they really think of all that matters is theory. And then you don't have to really know anything about what you're what you're talking about. And it always shocks me that there are these like philosophers who spend their career writing about like reproductive ethics and reproductive technologies who don't know anything about the reality of IVF, and they even learn their IVF from other philosophers. And so they systematically use language incorrectly like, I mean, you know, that they don't know what they're talking about. If you read an article where somebody talks about the IVF clinicians implanting embryos because they transfer embryos and they either implant or they don't. And so just the fact that they don't even know the right language to use is a sign that they just they just don't know anything about the topics that that they're talking about.

David Magnus: [00:17:26] That's not true in philosophy of science. In philosophy of science, I had to take graduate courses in biology. I've taught population genetics. You have to know what the content of what you're talking about that really matters in our field, because it means it would never have occurred to me that if I really am interested in issues that wind up getting interested in medicine, that I wouldn't want to really dive in and learn more about the medicine so that I know what the heck I'm talking about and that you have to really do that. You can't just be a philosopher in a philosophy department. You have to be grounded in the reality of what's happening in the medical setting. And so for me, it was a no brainer to choose to be in the medical school at the bioethics center. And as I said, I was lucky enough that especially the ICU attendings there were nice enough to let me spend a lot of time hanging out there and rounding with them and getting to start to learn more medicine. Because I knew genetics pretty well, but I didn't know very much about medicine at that point. And so and then that gradually my interest sort of gradually shifted as I spent more and more time in clinical settings.

Henry Bair: [00:18:33] Wow. That's one question I was going to ask was "How do you go from philosophy - thinking about the theoretical foundations of philosophical problems - to actually talking to patients who have no background in philosophy and ethics? And it's fascinating that for you, even from the outset, that was something that you at least thought that you were interested in exploring more. So I guess my question next is at what point did you realize that interacting with patients in very real, very high stakes clinical situations where you're dealing with human lives, at what point did you realize that that was something that you wanted to do? That was something that was meaningful?

David Magnus: [00:19:14] Yeah. That's a hard question to answer. I mean, it's something that you have to do if you're interested in certain things. It's also a role that needs to be played. And so I think that was part of it. And I think you don't know if it's going to be meaningful and you're going to be good at it or like it until you actually do it. Believe it or not, one of the things that was good training for me to be able to talk to patients and develop some of the skills like mediation, formal mediation training gave me, but that I actually had a little bit going in was actually my experience doing a lot of teaching of and advising of undergraduate students. The reality was when you're a professor teaching undergraduates, you have students who are coming in nominally to talk about a paper who will then start talking to about the fact that they're coping with the fact that their father beat them and that they're and that they're dealing with all this trauma and all these issues. And so you spend a lot of time talking with students, especially in a liberal arts context, which where I was a liberal arts college professor. You've got students dealing with all kinds of baggage and issues that are behind things that you wind up spending a lot of time talking them through. And I was really shocked at how transferable the skills I had developed at being able to counsel and speak with undergraduates were with talking with patients. Because so much of what you do in consults is really about listening and getting to the underlying things that are behind the surface of what they're saying.

David Magnus: [00:20:46] And both philosophically were trained to do that, but also that experience with students that really transferred over. I remember an early concept I had where it was an oncology patient. There were two reasons for the consult. One was that the patient was a woman, but her husband was making all the decisions for her, even though she had capacity. And there was a lot of anxiety by teams about the fact that she was being excluded from things, even though she was extremely clear that she wanted her husband to make all decisions, she didn't want to know anything. Right. And so but every time a new team came on, they were like, no, we have to tell you. Even though she didn't want it. So that was part of it. But the other thing that had happened was, as her prognosis was getting worse and worse, the oncologists had been very supportive of trying things and trying the second line therapy and then third line therapy. And they were still going like, we're still going to beat this, and they still were using all the battle metaphors. And then there was a point where the oncologist said, you know, we've crossed the threshold where there's no disease directed therapy that we really have to offer you. And now it's time for you to basically go to comfort care. And you're going to die soon because there's nothing more that we have to offer you. And that transition did not go well with the patient's husband. And he was, in the words of the team, in denial. And it just was not not going very well. And so I got brought in to help address both of those issues.

David Magnus: [00:22:10] But by just listening to him and letting him talk about like his confusion about the change in direction, talking it through with him, gradually he started to feel enough trust that he was able to say to me, Look, I know my wife is dying. I've already picked out her dress for the funeral. I know this is not going to go well. I know this is going to happen. I just want to make sure that I've done everything I can and that before we do that, I have to know that there's no hope. And so then we had a meeting with the teams and we said he just wants to make sure that there's nothing more that can be done and that all you're doing now is prolonging her dying process. And then when they said, yes, that's it, there's just nothing more to be done, then he was amenable to shifting the goals of care. But he had to be really listened to about all the things that he was anxious about and worried about and really to get to that point and all the things he had been hoping for and to recognize that he'd had two contradictory sets of beliefs at the same time, he was still hoping something would happen and his wife would get better, and at the same time, he knew his wife was going to die and had already picked out her dress anyway. And so some of the things that my experience is teaching and my disciplinary background left me situated where I thought I could. Those were the kinds of things that I could do to really get people on the same page.

Tyler Johnson: [00:23:31] So, David, let me have a switch gears here for a second. The I think biggest impetus behind this podcast is the recognition that many medical professionals are. Well, there's an epidemic of burnout, and we hypothesized that at least a large part of that. We acknowledge that many of many aspects of that have to do with systemic problems that need systemic fixes. And that's one piece of it. But we also want to argue that there's a crisis of meaning in medicine and that many health care practitioners have lost sight of or touch with the things that make medicine most meaningful. And it strikes me that you are in a very distinctive, if not unique, place by virtue of two things. One is that while you're not a doctor or in the classical sense, a health care practitioner, you are embedded down in the trenches at the very most difficult moments. Right. The kinds of stories that you've been sharing. So that's number one. So you're an outsider embedded on the inside, if you will, and you are actually a philosopher. And so I'm just curious, as someone who has been at this for decades and who has been embedded as an outsider on the inside for so long and as a philosopher, what do you think you have learned about what makes medicine most meaningful?

David Magnus: [00:25:01] Wow. That is a tough one. That's a big, big question. You know, I'll start with some of the diagnosis of the what I think is part of the problem. I think there's reasons why this happens and it may not be avoidable, which is concerning to me because of the nature of medicine and the way it's changed and gotten better and more powerful. It has resulted in the fact that to a very real degree, physicians don't provide care to patients anymore. They take care of organs or they take care of tumors or other discrete problems, but they don't take care of patients. And I see that all the time in the language that's used and the assumptions behind the language that people are using when they're describing cases, not people cases and when they're thinking about it. So there's a complete disjoint where it's like, you know, I don't take care of a patient, I take care of a heart and the heart's okay. So, yeah, it's a shame about the brain, you know, it's just too bad that the brain is completely lost. But I mean, look at the how well the heart is doing because of all the great, great things we did for it that I think drains some parts of medicine of some of the human meaning that I think is there.

David Magnus: [00:26:24] I mean, I'm always impressed by the fact that for that, the ability to fix a discrete problem, I think gives satisfaction to people. And I feel that too in my work. Right? So if I have a discrete kind of problem that I'm fixing, mine is a language problem or a communication problem. If I have something that's an actual some of the cases that I enjoy the most are where there's just this colossal misunderstanding because they're not speaking the same language, and I can figure that out and solve the problem. And there's a lot of satisfaction in problem solving that I think clinicians have, and that's a part of it. But when you're talking about meaning, problem solving is a piece of it, but it's not enough. And so I worry that that reductionism to the nature of what the problem is that you're trying to solve or the organ system that you're trying to address, drains some of the meaning out of what clinicians do. And so I worry about that.

Tyler Johnson: [00:27:27] But let me let me pause here for a second, because I want to I want to drill down on this a little bit, right? So in my field of oncology, one thing that I have seen that is even evolving in real time, I've only been an attending oncologist for six years. I've been if you include fellowship, then it's nine. But even over that decade, one thing that we have seen is that the field of oncology is just burgeoning so much that I don't think anybody can really have their arms around the whole thing anymore. Right. Like even as a GI oncologist who only takes care of, you know, there's a list of like ten tumors, it's difficult for me to stay on top of all of the research and all the advances and all the drug approvals, even in those ten tumors. Forget about if I was trying to do that and lung and thyroid and leukemia and lymphoma or whatever. Right. And so so which is just to say that then if you zoom the lens out even more and say, well, okay, now what if in addition to trying to be a really great oncologist, you also were in some fairy tale world trying to also take care of the heart and the lung and the liver and the kidneys. So all of that is just to say that as medical knowledge expands infinitely and as technology infinitely extends our reach, to be able to do all kinds of crazy things to support, as you say, organ function, it is absolutely the case that I would argue that it's absolutely the case that no person is capable of.

David Magnus: [00:28:51] I started by saying it's because of the increasing power of medicine and the fact there's more to be done and the specialization. I don't that's why I say I don't know that this is an easy problem to solve.

Tyler Johnson: [00:29:03] But so I agree with you up to that point. But here's the question that I want to ask. Is it, though, also inevitable that that that those sort of inexorable forces that are leading to greater and greater specialization also have to divorce the providers from embracing the holistic humanity of their patients? Or is there a way to try to keep that sort of appreciation while still having the medical specialization?

David Magnus: [00:29:29] I think it doesn't have to. I think it's just we have to recognize that these are forces that are pushing in that direction.

Tyler Johnson: [00:29:36] So so what we're pushing back against that look like, that's what I really want to know.

David Magnus: [00:29:40] Yeah. So I think there's several, several pieces to that. Part of it will be a change in training. And I've got one of my favorite illustrations. We had a patient in the ICU who had a large GI tumor. It was incompatible with life. So the patient was clearly dying and the family needed to hear that. The ICU knew that the attending oncologists, they were all on the same page. They were all in complete agreement about what needed to be told to the family. But we had huge problems with the fellow first case that got derailed. Before I got involved was the ICU explaining that there's patients going to definitely die. And then the oncology fellow wanted to run a bunch of other tests, which gave the family hope that maybe it could be fixed. So they decided to have another meeting. We wanted the attending to be there because the attending got it. But unfortunately the attending couldn't. He had to got called away for another case. So again, a fellow was there and so we said, but this is incompatible life, we have to do this. But again, the fellow was like, but we could find out about something about the cell receptors and maybe we should do something to the tumor. It wouldn't change the outcome for the patient, but that poor tumor there, we could learn more about it and maybe we could do something for the tumor that would shrink it a little bit, even though the patient will still die. But again, this is an ICU patient who's critically ill anyway.

Tyler Johnson: [00:31:00] Don't question the meaning of our cell surface receptors.

David Magnus: [00:31:03] David Okay. Well, so we called the attending to explain a little bit of our frustration and say, can you talk to your fellow and tell him what to say? And then he promptly pimped him on the cell receptor stuff because even though it wasn't going to have any impact at all on this particular patient, the valorization of what matters is being able to understand those things and being able to have the conversation with the patient's family about what really matters was just not important. That's not important enough to spend the time really teaching him that. So we wound up actually telling the fellow, Just sit in the corner and don't say anything and the attendings going to come and talk to the family afterwards. And that's what we did. But the fact that that fellow didn't get any training in, like what? How to see the big picture and explain it to the family. It's like it's the Joanne Lynn. And working with a philosopher talked about the Fixit model. Here's an issue. Can we fix it as opposed to something that's more goal directed around? What are the patient's goals and values and how are we trying to achieve those? So as a philosopher, I naturally am thinking about what are we trying to achieve, what are the goals, what are the values that you have? But it's not.

David Magnus: [00:32:20] It's absolutely foreign to the training of most physicians. It doesn't have to be that way. Right. So that that's clear. But I would also say it is way harder than you think. And I'd say and this is where I'm going, that full circle in my work I did in philosophy, language and linguistics very early in my training and in my early in my teaching career, has come back in a lot of the work that we're doing now. One of my favorite talks I give is for different medical groups is I have three things I want to convey to people. One is that communication is hard too, is that communication is really hard, and three is that communication is really, really hard. So the communication is hard is it's emotionally hard to have conversations and give people bad news and it's easy to lie and fall into that. And lots of data shows that physicians will self identify, that they mislead patients and things like that because it's just too emotionally hard to give bad news. So that's the hard and you have to get over that psychologically thing to be able to do the job. It's really hard because even when you want to do a good job, physicians are not usually given the tools to do it.

David Magnus: [00:33:30] They're not usually trained. It's like any other skill. You get better at it with practice, you get better at it by working on it. And and there are sets of things that can, can be done in training. And we don't do enough of that. We're doing more of that. It's really hard. And you have to do all the work to really be good at doing these things. But it's really, really hard is where I'm most excited about the research we're doing, which is that when clinicians talk to patients and try to explain things in non technical words, they use common language words that appear in the language very commonly, but they don't mean the same thing to physicians that they do to patients. And we're starting to do systematic studies of ways of of different phraseology and different expressions that clinicians commonly used in conversations and how that can lead things awry where people think they're on the same page. So one of our first studies was the term treatable and what is treatable mean. And physicians almost all think treatable doesn't tell you anything about what it just says is there's something that physicians can do. Oncologists, every oncologist we interviewed says treatable means there's disease directed therapy for an incurable disease. That's what treatable means.

Tyler Johnson: [00:34:45] A drug exists.

David Magnus: [00:34:46] A drug exists that will do something patients think it means. I've got good news for you. I'm giving you good news. And one of our things that was most interesting, we gave a scenario for a patient with metastatic cholangiocarcinoma, incurable. Less than 2% chance of survival, but they are eligible for palliative radiation and so it's still treatable. What does it mean when the commission says it's still treatable? Because we can give you palliative radiation? And it was interesting that for the patients who thought this means good news, we got basically three responses. One group said, I'm kind of confused because I thought you were trying to give me good news, but you're telling me that this is incurable and I'm going to die. So it must mean like my symptoms are going to get a million times better and I'm going to feel better. And so it's good news. I'm dying, but I'm going. We've got something for you to make. You do a lot better. So one group thought that a second group said, I know what this means. It means this physician is a liar. And I would never trust anything they say again. And then the third group said, it means there's a treatment that's going to cure me completely.

David Magnus: [00:35:47] There's some it's not in the scenario that they're giving. Right. Something very straightforward is presented to them. But the mere fact that they're being offered palliative radiation for a bunch of them meant that they're going to be cured by at least some some new research therapy or some surgery, which was never mentioned to them. And it explains why even when clinicians say things the right way to patients using language that when you record the conversations, this looks like a pretty good conversation. The patient still interpret palliative interventions as curative. Well, it's because there's some in the linguistics literature, there's a conversational in picture. They're trying to figure out what your intention is by using the words that you're using and by saying the things you're using. We don't just look at the literal, you know, too much focus and communication in medicine has been focused on the literal meaning of words. But a lot of what's going on in actual the way we use language, we use language to do things that's not all about the literal meaning of the words. And part of it is about these inferences that happen about what's the intention behind it. Do you know what time it is?

Henry Bair: [00:36:53] It's 1048.

David Magnus: [00:36:54] Okay, so I asked you a question and you ignored the question I asked you. I asked you whether you know what time it is. And instead of saying yes or no, that you know what time it is, you looked at the clock and told me the time you ignored the literal meaning of the words that I use because you made an inference.

Tyler Johnson: [00:37:11] Okay, we're cutting that from the transcript.

David Magnus: [00:37:14] And so instead you made an inference about what I was aiming at by asking that question. That's a ubiquitous feature of language. And yet the vast gulf in difference between the horizon and experience between patients physicians means that that goes awry all the time.

Tyler Johnson: [00:37:31] So I just want to say two things that I'm I'm a little embarrassed to the degree of self recognition that I have while you're talking. So I want to, I guess, tell on myself in two things. So one is that just talking about trying to maintain the humanity of the patient instead of seeing them as a person with X tumor or in my case, right. So when we had in episode six, we had an ICU physician who's done a lot of writing named Sam Brown on the podcast, and he talked about that one thing he has tried to do to do that very thing, to return the patient's humanity to them, is to make sure that all of his trainees know at least one non medical thing about all of the patients they take care of in the ICU. And when I heard that, I thought, oh, what a great idea. And so then you, I'm sure know David and maybe some of our listeners will that in the hospital every patient has a one liner, right? So the one liner is like a really more like a paragraph usually, but it's the paragraph that says like all of the pertinent stuff that you need to know about the patient for quick communication between care providers. And so I made this decision after we talked to Dr. Brown. The next time I was on service, I was going to require that my team caring for cancer patients include at least one non medical thing in the one liner for every patient, so that at least that would be there. So that when we introduced the patient or talked about the patient, we would have this one non medical thing and the next time I was on service, I totally didn't do that because there's just this almost like gravitational pull, right, that you get busy and all the things are happening, whatever that I go into like fixit mode, right? I go into what are the problems and how do I fix them? And it's just how I'm wired, which I mean, it's understandable because I am trying to fix them.

David Magnus: [00:39:05] But it's what ironically makes you a good physician.

Tyler Johnson: [00:39:07] Right. But but also what divorces me from the people that are at the center of all of the medical problems. Right. The second thing is that I have been caught a couple of times. This is so terribly embarrassing to me. But but it has happened multiple times. I'll be taking care of a patient where let's say I'm meeting them for the first time and they have metastatic cancer. And let's say it's a young patient, somebody who's in their thirties. And I know that in this particular kind of cancer, the average length of time that a person survives after they're diagnosed is, let's say, 12 months. And then as I'm looking through their chart, I see that their tumor has mutation X, Y, Z. That means that they get to have an additional targeted therapy that they wouldn't otherwise have. And I also know that that that mutation means that their average survival instead of being. 12 months is 18 months. Then I'm talking to the patient who's in their thirties and they have small children. And when it comes to the point of them asking me, how do people usually do with this disease? I say, Oh, I've got great news for you because you have this mutation. The average amount of time someone in your case would live is 18 months.

David Magnus: [00:40:23] Yeah.

Tyler Johnson: [00:40:24] And then and I have had patients where I'm just in the middle of saying all my things and whatever. And then I get to that point and I'm and I'm expecting like, oh, wow. Oh, that's such great news. Which of course is ridiculous and stupid, but like, but because from my perspective, knowing a zillion things about the cancer and what it would be without the mutation, that does seem like great news. But of course, to the patient.

David Magnus: [00:40:46] I think that's a really important point. And it infects every aspect of communication, including the meaning of the words that are being used. And so and it makes it really hard. In that case, what's likely to have gone awry is emotive aspects and the effect of aspects because and who knows what the inferences they made when you said it's great news and they have 18 months, who knows what they got from that? They may have focused on the good news part and ignored the 18 months part. Or maybe they thought, this is this is cruel that you thought this is good news, or who knows what there was and it's producing this affective response. But we're especially interested in studying how it is that the language being used leads to misunderstandings. Like we've been doing a study right now of hedge language, which is shockingly ubiquitous. We look at goals of care IQ conversations from some data from Pittsburgh sent to us.

Tyler Johnson: [00:41:38] "Hedge language" meaning people who don't really say what they think.

David Magnus: [00:41:42] It's language that makes things fuzzy when you say probably no one has a crystal ball, but and there are lots of different kinds. There's one group of things that has not been really described in the medical literature, much called shield attributions, where what you make fuzzy is who's making the claim. So when you instead of saying, I'm afraid, I think you have cancer, you say, I think it's metastatic and I think there's not much that can be done. You say we've talked about it among all of us or the literature shows blah, blah, blah, or your body is telling us that it's you know, all of those are ways of shielding the attribution of the claim from you and making a fuzzy who's making it exactly who's making the claim. And things like this are done all the time in our laboratory that we've got. Some of my colleagues did a study recently of tumor boards and and what their functions are, which was very interesting. So they've got a paper that's either just come out or is about to come out in JAMA Oncology about the different function that it has. And one of the roles among many is to help. Sometimes when patients are reticent to do things that the clinician thinks is important, it's supposed to make them feel better about it, that you've got the tumor board sort of behind it.

David Magnus: [00:42:52] But one of the questions that we asked is how does that diffusion of responsibility actually play out for people? And so in some of this hedging stuff, this would be an example of a hedge. It's not me, it's a whole tumor board. And we talked about it. And for sometimes that really does work that way, but sometimes they're like, well, if you knew that it was the clearly this was going to work, then you wouldn't have brought it to all these other people. So the fact that you brought it to all these other people and brought it to like a tumor board means you don't really know. And so I don't need this, this treatment because if you really understood this anyway. So another great example, when patients are told shortly after surgery that the margins are clear, and then what does that imply to people and what is it? The physicians have a clear understanding of what that means and what they are saying when they say that. And yet sometimes there's a significant percentage of cases where the patients balk at like, say, follow up chemotherapy that's needed and indicated because either you lie to them that the margins were clear or I don't need this. And so either way, it's either either you're not trustworthy and then why should I get the chemotherapy from you? I should get a different physician.

David Magnus: [00:44:03] Because you lied to me about the about the margins. Or alternatively, I don't really need this, and you're just trying to, like, legally cover your ass with things that I don't really need. And it's because of the way in which that using that expression conveyed incorrect things, even though it's fully understood by physicians, but not by patients. So anyway, so this is a lot of the kinds of stuff we're very interested in studying how all these different uses of language, even if they're fairly plain language, lead to misunderstandings. And I've seen that in real life. The hedge thing I was just before we even started studying it, but I was thinking that the something we were going to study, I was having an IQ conversation with a patient and the attending in the CVI ICU and the patient was doing poorly. And so the the attending was bringing up the idea that maybe it's time to think about comfort care. And she said, you know, your dad is really sick. He's really sick. We don't know that he's going to survive this. There's a good chance he is not going to survive this hospitalization. And so we think it's time to maybe at least broach the subject of thinking about whether and when it might be time to think about going to comfort care. We don't know how long he has, but we think it might be a good thing to bring up.

David Magnus: [00:45:12] And the patient said back the same words said, Yeah, I hear what you're saying. Dad's really sick. He might not survive this hospitalization, but so we should keep going and continue. And I. I remember thinking they think they're on the same page. I think they're not. And so I said, I hope I'm not being rude. But when you say the patient might not survive, did you mean that like it's 5050? Whether he's going to make it? Do you mean it's like a roll of the dice and he's got a one in six chance? Or do you mean like there's still a lot of chance that if you bought a lottery ticket, he might make it? And then she said, Well, it's like a lottery ticket. And then he goes, Oh, I thought you were giving me good news. Dad's really sick. He might not make it, but you were trying to tell me that there's still hope and you thought we should keep going. So she thought she's saying the opposite. And it's because we were thinking about I was thinking about hedges that got me to recognize that they were not they thought they were communicating with each other, but they were not communication. And that's the point of saying the communication is not just hard. It's not just really hard. It's really, really hard.

Tyler Johnson: [00:46:16] I have to say that sometimes as the doctor in those moments, I feel like I used to feel when I was like, I still remember when I was like ten years old the first time I went to a pool that had a really, really high dive that was like 30 feet above the water. And so I climb the ladder and I get to the there's this like ten foot platform to go out and dive off. And I would like go right up to the edge and then look over it and be like, Oh, maybe not. And then go back to the ladder. Right? And it took like six times of going out to the ledge until I finally got the courage to actually jump off. And sometimes that's how it feels in those kinds of discussions, is that, you know, you kind of should and you want so badly to just say the thing, but then you get right up to the moment and instead of just saying, I think your dad's dying, you say, Oh, I think he's really pretty sick and this might not go very well or something, right? Like you just can't bring yourself to jump off.

David Magnus: [00:47:05] I will tell you that the number of hedges in a conversation and goals of care, conversations and critical illness that we looked at that these transcripts of the conversations, it's like every sentence has at least one hedge. Many of them have two or three different hedges. It was pretty remarkable how how ubiquitous this is. But shield attributions are really common to it's like it's clear that I don't want to be the one to be responsible for any claims I make. So I'm going to make I'm going to put it on other on their body or the literature or experience or the whole team's.

Henry Bair: [00:47:37] So just to be clear by shield attributions, you're referring to expressions like according to his estimates or according to her knowledge, which attribute the responsibility of the message being delivered to someone other than the speaker.

David Magnus: [00:47:53] Yeah, it's rare that anybody is like, I'm sorry. And it's funny though. It's also if it is something where you we, we wanted to compare what happened when you gave something with a hedge that is a shield attribution versus the same statement more or less being made without a shield attribution. And it was interesting that when there was not for some patients not having the shield attribution actually was problematic because it's like if it's just this doctor saying it, then I want a second opinion. Whereas if it's like, oh, a bunch of other people for some that did in fact make them have more confidence, but for others it made them go the opposite direction. So the fact that there's in the literature this is called precautionary effects. The fact that precautionary effects of different locations can push in all these different directions means you have to know what those are and be sensitive to think them through. In that case that I just described, I was thinking about all those things and I'm aware of things. And again, that outsider status I have as somebody who sort of knows the lingo and spends a lot of time here, but I'm still an outsider in a lot of ways. I'm not a physician. And so that does help me see things like I could. I notice things that others don't. I just I noticed that in the medical ICU, when a patient's liver stops working, they have liver failure. Whereas in the ICU, when a patient's liver starts working, they have liver dysfunction. I don't know what it means, but I just that's the kind of thing that I would notice that nobody else will notice in the ICU. I cannot tell you over how many years. I figured out fairly early on that when the ICU docs tell somebody that they're that the patient's lungs are really stiff, that that's a bad thing.

David Magnus: [00:49:29] I figured I learned long ago that having stiff lungs is really bad. But I also have seen over the time that nobody, no patients ever get it, even though the physicians think they're being really clear with that as a metaphor. And I finally had to say, I said to a couple of different attendings, because I was just curious. I was like, you know, I've been listening to you say, I know enough to know that it's really bad. But I've never gotten the metaphor. Like, when you say the lungs are stiff, it's like I have a stiff back. That doesn't mean that they're going to withdraw life support on me. So what do you mean when you say that your lungs are stiff? And I actually got really different answers from different attendings for one person. It's like lungs are like a bellows, and it's like when the bellows get kind of stiff and you can't use them anymore. And then for another one, it was much more dynamic understanding. The lungs are like a series of springs and it's like the springs are all are all no good. And it's a really interesting, different view of it. So so they didn't even. It all mean the same thing when they said that, but they thought they were being so clear with this really clear metaphor that I know just falls flat every single time because I mean, I for all the time I spent having these conversations and I've heard that said at least a couple of hundred times, and I never known what they meant when they said that I wasn't aware that lungs were particularly floppy in the first place. So.

Henry Bair: [00:50:45] Yeah. Professor Magnus. Over the course of this conversation, we've talked a lot about things like changing the focus of medical education, not the focus, but changing medical education to place more emphasis on the bigger picture or things like changing the way we communicate in medicine to be more in alignment with who, where we are and where the patients are all for the ultimate goal of making sure that we are more aligned with what actually matters for the patient. And hopefully that will serve to help clinicians better connect with why they are doing what they're doing in the first place. That being said, I was wondering if you could share some advice. You have concrete advice for either clinicians or clinicians in training. What what are some concrete things they can start doing now to cultivate ethical thinking skills and better communication skills?

David Magnus: [00:51:38] So I'll start with the communication skills, and it's funny that different groups have arrived at the same thing. We have a theoretical framing for why it's the case in our work. But Gretchen Schwartz, who's a surgeon who works on communication and the vital talk, people all come to the same thing, which is the most important thing is to frame the conversation. Gretchen now calls this putting your cards on the table. We called it good news, bad news. But at the very beginning, the patients are looking to find out what kind of conversation is this and that frames it. And almost every conversation I go to starts with quote unquote, an update. And you've already gone in the wrong direction. When you start with an update, what you want to start with is the framing of what kind of conversation. Is this a good news conversation? Is this a bad news conversation? Is this a in between kind of conversation? You need to put your cards down on the table about what kind of conversation you're having with them right at the beginning of the conversation, because it frames everything else. And when you start with just like, here's an update, they're guessing what kind of conversation this is. And it's like, well, you're still treating them. You're giving us an update. Probably it's a good news one, and that's what it is. Or or maybe you're talking about some of the complications you're dealing with this.

David Magnus: [00:52:48] So maybe it's a bad news one. And I've seen them. The patients misunderstand in both directions because of things that were said in the thing where it was supposed to be a good news one and they thought it was a bad news one. They thought it was a bad news one where it was a good news, as I've seen it all different ways. So you need to be very clear. So that's a very concrete thing that people can can do that. Beyond that, I think the other thing I would just say is, is literally to think about empathy. And this is going to be almost impossible to actually achieve. You know, you've spent so many years in training to become a physician and learning how to become an expert and learn how to think and do things in a certain way. And that gap between wizards and muggles is really big and real, and it makes it harder to really identify and relate to patients and their perspective. So I would urge people to try as best they can as one of our study that was fascinating. There used to be a Tumblr site about eight or nine years ago called What Should We Call Medical School, which was a very funny site with gifs and things like that about different aspects of medical school. It was hysterically funny, but she did a content analysis of it and about which things got likes, and it was one of the most depressing talks I've ever seen because it was all about how isolated in through medical training they are from everybody, all their friends, their family who are not in medicine.

David Magnus: [00:54:16] They don't relate to them anymore. They don't understand them anymore. And that is a huge part of the humor that comes out. And so it's, I think, trying to remember that and try and hang on to what it's like. But I have to say, I think that's easier said than done. The people who work with me, I have people who've worked with me all through medical school, all through their residency. We've done research together. They talk to patients and study them, and I see them do the exact same thing where they're like, I'm really only interested in physicians now, perspectives now, and you see them lose that connection to patients that they had when they were first starting out in medicine. And so I don't know that there's a good thing that will inoculate people from that. In the end, you guys are wizards and so and we're muggles. And so, you know, I'm lucky that I get to live among the Wizards a lot. So I know a little bit about what you guys are about, but at a fundamental level, there really is this divide that is really, really hard to overcome.

Tyler Johnson: [00:55:12] Well, we've had a conversation that's taken us all the way from the agonizing depths of the ICU to wizards and muggles here at the end, we're. We're really appreciative of all of your insights, Dr. Magnus, and we appreciate you for being so generous with your time and for all of the good work that you do at Stanford and in other places around the country and around the world. And we wish you the very best.

David Magnus: [00:55:37] Thanks. This is fun.

Henry Bair: [00:55:41] 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 Doctors Art. 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: [00:56:00] 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: [00:56:14] I'm Henry Bair.

Tyler Johnson: [00:56:15] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.