EP. 23: STEWARDING THE VULNERABLE MOMENTS

WITH AUDREY SHAFER

Aug 9

WITH AUDREY SHAFER, MD

The founder of Stanford’s medical humanities program shares how she accompanies patients during their most vulnerable moments.

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Episode Summary

What is it like to comfort patients in the moments before they surrender consciousness to undergo surgery? What can the humanities teach us about being present for a patient when they are at their most vulnerable? As an anesthesiologist and founding director of Medicine and the Muse, Stanford Medicine’s health humanities program, Dr. Audrey Shafer has spent her career pondering and addressing these questions. In this episode, Dr. Shafer discusses how her exploits in the humanities have shaped her career in medicine, gives us an intimate and vivid picture of the vital work anesthesiologists do, and shares what her recent personal experiences with cancer have taught her about what it means to truly care for patients.

Audrey Shafer, MD is Professor of Anesthesiology, Perioperative and Pain Medicine at Stanford University School of Medicine. She was the former founding director of Medicine & the Muse, Stanford Medicine’s medical humanities program, as well as the co-founder of Pegasus Physician Writers. She is a graduate of Harvard University and Stanford University School of Medicine; and her anesthesiology training was at the University of Pennsylvania. At Stanford, she teaches various courses on the medical humanities. She is the author of The Mailbox, a children’s novel on posttraumatic stress disorder in veterans. Her poetry on anesthesiology, health humanities, and family life has been published in various medical journals and anthologies.
In this episode, you will hear about:
• How growing up in an artistic household initially pushed Dr. Shafer away from the arts and toward a medical career - 1:51
• Why Dr. Shafer chose to become an anesthesiologist - 5:51
• Dr. Shafer’s discovery of the medical humanities and how she would later create the first program of its type at Stanford Medicine - 8:57
• A discussion of what the medical humanities are and a defense of its value - 12:00
• Reflections on the profound privilege of being an anesthesiologist and a medical educator - 17:45
• A behind-the-scenes look at an anesthesiologist’s work - 25:02
• Dr. Shafer’s recent cancer diagnosis and her treatment journey - 34:29
• Advice for clinicians and medical students about seeing patients’ illnesses within the greater context of their lives - 41:15
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] The moments just before and after surgery can be some of the most harrowing and uncertain experiences in a patient's life. During surgery, patients surrender their bodies to the anesthesiologist, who takes over control of core bodily functions like breathing and blood circulation. What is it like to accompany patients during these moments? Joining us to discuss this is Dr. Audrey Shafer, professor of anesthesiology at Stanford Medicine, a poet, a novelist. Dr. Shafer was also for nearly 20 years, the founding director of "Medicine and the Muse", the Medical Humanities Program at Stanford. In this episode, she shares how her exploits in the humanities have shaped her career in medicine and how she finds meaning by guiding patients when they are at their most vulnerable. Audrey, welcome to the show and thanks for being here. To start us off, can you tell us what first drew you to a career in medicine and in what ways your early exposure to the arts and humanities have shaped your approach to this career?

Audrey Shafer: [00:02:05] I grew up in Philadelphia in an area called Center City, so it was right downtown. My mother was a costume designer for local theater. She was an artist. She was a single parent. And she raised my sister and I. My father did live in Philadelphia, and he was a playwright. So I, as a child, was completely immersed in the arts. My sister and I would be there for dress rehearsal or be backstage. We help sew on buttons and hooks and eyes on costumes. And it was in many ways a magical childhood, culturally incredibly rich. The issue, though, with artists is that it is rare for an artist to make a living. And we struggled as a family. We were never unhoused, but we would have the phone and the electricity turned off. I started working when I was eight years old, stuffing envelopes, and it became clear to my sister and me, and because of my mom's strength in ensuring that we had a great education and going to public schools that my sister and I both decided to not pursue the arts. We both became physicians. I thought the highest educational degree one could get is a PhD. So when I was in college, I love science and I started working in some labs. I liked the idea of focusing on a project. One summer when I was working where they paid the student to work in a lab and to also roam around the hospital. That postdoc in that lab had no job the next year.

Audrey Shafer: [00:04:03] So I was astounded. I think I had never asked people that as an undergrad, you might feel uncomfortable asking. I just was like, But you have a PhD. You must have a job next year. And he said, no. Meanwhile, I was roaming around the hospital and really enjoying that. I loved that there was this energy about helping people. And so I decided by the time I was a junior in college to pursue medicine. And although I couldn't say it in my interviews for med school, really a large part was I was seeking some financial stability. My sister and I helped support our mother. So, yes, that is why I went into medicine. I don't recommend it for people who are interviewing for med school to say, yeah, I want a stable job, but it does actually lend itself that way. And it's an amazing career. As a student. I came to Stanford and Stanford was was and I believe still is very much interested in creating the physician scientist. And I completely was trying to do that. I did take my first poetry writing workshop when I was a med student. There was a lot of flexibility in the curriculum back then, and you could do all sorts of things. So that is what I chose to do, and that's the first time that I really took creative writing with this idea that I would be a physician scientist.

Henry Bair: [00:05:51] So now you are in medical school. How then did you discover anesthesiology as a specialty of choice?

Audrey Shafer: [00:05:59] How I stumbled, literally stumbled onto anesthesiology was that I again, I didn't have a lot of people in my family other than my generation who were going into medicine. And I just thought when you went to med school, you became an internist. Like, I didn't really think it through and sort of assumed that I would take internal medicine, love it and go into medicine. I knew you had all these other core clerkships to do. Yes, I knew that. But I just thought that was sort of what a doctor was. I wound up not enjoying my internal medicine court clerkship and found myself at a point in time in my third year where I wondered what I was doing in medical school. I did very much enjoy my surgery rotation. I loved it. In fact, I love the field, the operating room, the teamwork, the discussion, the focus on one patient at a time. The fact that I could be useful as a medical student running, get labs and report them to the residents. However, two of my surgery attendings separately brought me into their offices and told me that women should not go into surgery. At the time at Stanford, there was one woman surgeon friend, Conley, who was a neurosurgeon.

Audrey Shafer: [00:07:30] There was no other woman in any other surgery department, and I knew that I wanted to have a family at some point. At this point, I was married and I wasn't sure I could deal with that culture. Kudos to my colleagues who did go into surgery. Women colleagues have great respect, but I decided I wasn't sure that could work for me. Some fellow med students said, Oh, take anesthesiology. It's an elective two week clerkship. You learn how to start an I.V. and you'll have to start IV's when you're an intern, no matter what. So I thought, Oh, yeah, good point. That is the only reason I took that elective clerkship in about March of my third year, and then I absolutely fell in love. It just matched who I was. And I've mentioned before this focus on a single patient. That is what the anesthesiologist does. There's this beginning, middle and end. There's an arc to it. It is so satisfying and the people in it are welcoming, love to teach, have other interests. And it just became the right thing for me.

Henry Bair: [00:08:56] So, Audrey, at this point, you were looking at a career as a physician scientist, which, as we know now, is not how things ultimately panned out. So can you tell us how you shifted your focus to medical humanities?

Audrey Shafer: [00:09:13] After residency, my husband Steve and I returned to Stanford and did research fellowships again in this idea of becoming a physician scientist. I then started to have a family and was a very junior attending and became quite unhappy about the little time that I had for my child. I wandered around in our medical library. It's called Lane Library. I was kind of a library kid as a little one, and there was a journal called "Literature and Medicine" on the shelf. I picked it up. And it was like Reading Rainbow or something. You know, this whole world opened up as I open this journal and found out there is an entire academic discipline called various things, but including literature and medicine, narrative medicine, health, humanities, medical humanities, social medicine. There's just a lot of different terms and there's a lot of overlap between those. I had done a study with a colleague where we asked anesthesiology residents to pretend and imagine that they were that particular patient that they were taking care of. And in those days, a patients were largely admitted before the day before the operation, that resident would see the patient do the pre-op, do the provide the anesthesia care and then see them post-op as well. So three points of reference and then we asked the patients to write a narrative of their perioperative experience. So I had this data. I was really unsure what to do with it. Found this journal, decided to go to the conference that was advertised at the back of the journal at that time called Society for Health and Human Values. Met these amazing people. And I was just like, this is an amazing and wonderful way for me to connect who I am and my background growing up immersed in the arts with what we do as physicians. So that was in the early nineties and there really was no program at Stanford in this field. And I began meeting people who were interested in the same thing. Began offering an elective class. The first class I offered was called literature and medicine and very, very slowly built the program that is now called Medicine the Muse.

Henry Bair: [00:12:00] I think that for many of us who have been involved in or have had a natural predilection for the humanities for a while, what the medical humanities are can seem quite intuitive. It wasn't until recently when I was teaching some pre clinical medical students about the medical humanities that I realized I struggled to come up with a concise and clear definition. Is there a difference between medical humanities and humanistic medicine? Is Medical Humanities, an academic subject that's engaged through independent scholarly work? Or is it something practical you can apply daily to the patients you care for? Does engaging in the medical humanities mean the creation of works of art, or is it more about the critical analysis and appreciation of art? Audrey I'm wondering what your responses to these questions are. What are the medical humanities and what is their value?

Audrey Shafer: [00:12:56] Yeah. Those are million dollar questions, Henry. I do think that what we do as human beings and as physicians has a lot to do with trying to understand the meaning in our lives and creating meaning in our lives. Health Humanities is a way to do that. It provides a framework and gives you permission to think about these things. In terms of your question about Medical humanities and humanistic medicine, I think there's overlap, but they're not the same thing. It's not like in medical humanities we just want you to be nice or abide by a professional code. Rather, we'd like you to think critically about why it is so difficult sometimes to be nice. Why it is so difficult to maintain curiosity about other people? What is it about us that -others- other people? Why is it so difficult and yet so important to try to open your heart to understand other people in the health professions? When I do my brief intro to Health Humanities, I have a slide is Edvard Munch's The Scream painting with a little smiley face pasted over that look of horror.

Audrey Shafer: [00:14:46] And what I'm trying to say with that image is that this is not what health humanities is about. It's not pasting on a pleasant demeanor. It's not the nice patrol. It's really being witness and being present. Being a human being with the other. And I have this every day when I am meeting a patient who's just about to go into the operating room. In general That is when I meet a patient. I have, you know, minutes, maybe 15 minutes at the most to let them understand that I care about them. And yes, you need to be pleasant. You need be kind. But there's there's something more. You need to show this person that you are a person that they can trust their lives with. So the other slide that I like to show is an image of the white coat, which is obviously a symbol of medicine. It can be a symbol of professional codes and what one should look like. But I show it because it's an it's a really interesting symbol. I mean, maybe it's because of my background, as I mentioned, with my mom being a costume designer.

Audrey Shafer: [00:16:16] But there is a lot of costuming and theater in medicine. You know, you call it the operating theater to begin with. And what is this costume that we are wearing and how does that contribute to being part of a tribe, to othering those who are not wearing that white coat? Looking at the symbolism of that coat, that is medical humanities, that is trying to understand and analyze what it is that we're doing. Another really growing part of the whole health humanities, which is a growing field. There are more and more medical schools with programs in it. So it's it's absolutely a wonderfully growing program. Another aspect that I think is growing within it is melding with the arts and looking more carefully at the arts and healing. Many times in programs, those are somewhat separated. But I think there's a lot of overlap between those like music therapy, looking at how music therapy can be beneficial for people with movement disorder or dementia or things like that, that I believe there's more and more overlap between those fields, which is exciting.

Tyler Johnson: [00:17:39] Andrea If I can shift the frame of reference for a moment to get your your thoughts on a question I think is really important. As I think about my own reading and writing, I've come to recognize that often the most powerful art uses the particular experiences of the author or artist to tap into universal themes, right? So if we just write in generalities, it seems vague and it's hard to make that powerful. But when we convey our specific slice of life's experiences, that's often the thing that that allows people to say, Oh yeah, I recognize that feeling, or I recognize that insight or whatever, even if the particulars of their life are different. And as doctors, we can do that to an unusual degree because we are allowed access into these places and these situations that are just not accessible to almost anybody else. Right. So I still remember the first time as a medical student that I watched open heart surgery, in addition to all of the technical medical things that were going on, just the entire idea that such a thing could be happening in front of me, which of course, is happening every day all over the world.

Tyler Johnson: [00:18:57] But you would never know. I mean, to watch the beating heart quiver and then be still and then watch them do surgery and then watch them start it back up again. Like the whole thing was just like something out of a magical movie, right? I mean, it was just hard to believe. And and I feel like as medical professionals, when we go to to share art with the wider public, I mean, almost the responsibility is to try to help people to understand what it's like to be in the places that we alone get to be in or to participate in the things or to do the things that we alone get to do. And so I guess as you who have been so involved for so long in the humanities, within medicine, as you think about your own experiences with this, what are some of the the themes or the insights or the experiences that you have had as a doctor that you feel are most important to be sharing with the wider world? Insights that you can only have because of the experiences that you have had that you feel are really, really important to share.

Audrey Shafer: [00:20:10] Being an anesthesiologist, I have an amazing privilege. You mentioned the open heart surgery and seeing the stilled heart, the reviving heart. There are just amazing types of experiences in the operating room and in that perioperative experience that are profound. I see parts of people that they will never see themselves. And I think that exposure and vulnerability that people have while they're having an operation and undergoing anesthesia is a privilege for me to guide my patient through that. So, for example, we sometimes have patients with cancer. The imaging has indicated that maybe it's an operable cancer. The surgeon. Opens the abdomen. And it turns out it's an inoperable cancer, whether it's studying the peritoneum, which is the lining all around the abdominal cavity. And there is this moment in time when only the people in the operating room. Have this information that is so important to the patient. And I just feel this gratitude that I. Get take care of people at a critical moment. So some surgeries are labeled minor. But in actuality, any surgery for any patient is major to that patient. Cataract surgery is considered relatively routine, but yet it's amazing. You get the patient coming back for their second cataract surgery on the other eye and their life has already changed because of their improved vision from the first cataract surgery. It was not minor to them, and I guess this renewed sense of living at the core of us as embodied and mortal creatures helps me in my life to sort out the busyness and to try to focus on what ultimately can be more important things.

Audrey Shafer: [00:23:10] And as you say, it's the details. So it's not necessarily the grand adventure that needs to be the most important thing in one's life. It can be waking up and noticing the pattern of branches in a tree. I guess what medicine has done for me is that it has allowed me to be at the center of what I think is important in other people's lives and hence it is important in my life as well. The other thing about my practice is that I'm in academic practice and I teach. This is another privilege. And teaching is, as I think most people know, is not a one way street. It is back and forth. The intelligence and generosity of our anesthesiology residents in our program at Stanford is astounding. I am learning every day when I'm interacting with them to be around the next generation of physicians I feel is a privilege and I become an enabler in that situation. I'm trying to enable and set up the situation so that that resident succeeds with their, say, very first spinal anesthetic. That is so rewarding to me. It is not rewarding to step in. It's much more rewarding to set set the stage so that so that that resident or student succeeds and and feels a sense of connection to medicine that way. So that's another aspect of my work that I find very rewarding is the educational aspect.

Tyler Johnson: [00:25:02] So if I can ask one more question in this space, we have listeners to the podcast who are at all different points along the spectrum. Some have not started any medical training, some are in the thick of medical training, and some have already finished medical training. Depending on where you are on that spectrum, you may already have an idea of this, but some may not that what we tend to think of as the quote unquote "normal" functioning of the body when we're just out walking around or whatever, is actually this exquisite interplay of all kinds of different systems that have to be counterbalancing against each other and within each other all the time. Right. And just to make sure that you're have enough blood getting to your brain so that you can think clearly or enough blood getting to your kidneys so that you're filtering all of the bad stuff out of your blood or what have you. The reason that I mentioned this is that when someone goes in, particularly for a very long but even for a short operation, because of the way that the anesthetic works and because of what's going on with the operation, it is usually the case that various parts of that normal physiology have to be suspended or interrupted, or sometimes there even alters them in a bad way to facilitate whatever the surgery is.

Tyler Johnson: [00:26:21] Because that's the case, the anesthesiologist has to sort of take over as the brains of the operation for however many hours. Right. So they're there with these very complicated sets of medicines and other things where they're turning this up a little and turning that down a little bit and starting this thing and stopping that thing and noticing this other thing and whatever. And it's like they're sitting at the this great big sort of control panel for the body having to respond to whatever is going on in the operation, including unforeseen complications and emergencies and all the rest of it. So I was hoping, Audrey, that you could just take our listeners behind the scenes a little bit and tell them what it's like to be at that control panel flying the ship of the human body for however many hours the operation is going on.

Audrey Shafer: [00:27:10] Wow. Are you secretly an anesthesiologist? That was an awesome explanation of what we're doing behind the scenes. There's a lot that a patient goes through to get ready for surgery. They may have had a bowel prep. They may have had to wait a long time because it's a joint replacement and they've been on a list for a while. So the day of the operation is a big deal for the patient and we have to recognize that. So there are a lot of checks that can be annoying. So many people meet the patient, ask the same questions of identity and what the operation is. And I think patients need to realize that those are all safety checks, that we do talk to each other, that we do read the chart, that we are aware. Some people start out the line of questioning is sort of explaining that. But just to to make that clear that it's so that each and every member of the team is on the same page. So as the anesthesiologist, I will bring the patient into the room on their gurney. So there have already, as I say, gone through a lot. They've changed into a hospital gown and less and less we use pre medication. It can be a different scene for pediatric anesthesiology or some other areas. I work at a veteran's hospital. Many of our patients have had operations before. They may be quite ill and not tolerate a whole lot of pre medications. So it would be very normal for a patient to be completely awake as they come into the operating room and then they'll be asked to move themselves from that moving gurney onto the operating room table.

Audrey Shafer: [00:29:13] There will be all kinds of further checks relatively soon after the monitors are attached to the patient or general anesthetic. The patient is asked to breathe oxygen. This is a nice moment, I feel, in the pace of providing anesthesia when you're coaching a patient to breathe deeply. And what you're really trying to do is get rid of the nitrogen in their lungs so that as much as possible they have a reserve of oxygen. They're going to go through a period between when they stop breathing and when the ventilator machines can be attached and be breathing for them. And that period of time when they're not breathing, their brain and other vital organs need to have plenty of oxygen. So I particularly like this period of time. The people in the OR in general recognize this as a major focus on the patient. It's called establishing an airway after the induction of anesthesia, after the start of anesthesia. It's a critical part and patients need to be reassured that they in some way will have their body looked after. Even when they lose this ability to think, to be conscious, they lose the ability to swallow. They lose the ability to breathe on their own because of the medications we give. So they have to be watched really closely. And that is what the anesthesiologist does. We also wind up translating the patient to monitors. So in many ways, I feel it's a metaphoric transformation where usually if you wanted to find out about a person, you talk to them and you assess them and you get a feel from this exchange. But under anesthesia, you can't talk to them.

Audrey Shafer: [00:31:18] And so you're translating what is going on inside the body to the EKG, the electrocardiogram, the pulse oximeter, the amount of carbon dioxide they're breathing out, the amount of anesthesia they may be breathing in or breathing out. These other monitors, their blood pressure. Sometimes it's a beep by beep blood pressure. So that translation also has all these other metaphors embedded in them. There are more checks while the patient is under anesthesia to make sure everything is in place before that surgery starts. And then you're absolutely right, the patient can't protect themselves. You have to make sure that the patient's body is in a position where that team can access what they need to. Access and yet the patient will not be harmed by the positioning. So there is this protective sense of being an anesthesiologist as well. And then at the conclusion of surgery, that's another very intense time as we bring the person back to that patient who is laying on the bed. The person needs to emerge again, needs to start to breathe on their own, to open their eyes, to follow commands such as squeezing your hand. And then once that happens, you can truly let the patient breathe on their own and remove the airway device. And then when the patient is doing that well, many times the patient is unable to move themselves. And so we will slide the patient over to a gurney or a hospital bed and bring them to a specialized area called the Post Anesthesia Care Unit, PACU, or Recovery Room, where a specialized nurse will keep a close eye because, again, that's another critical time and they need specialized care.

Henry Bair: [00:33:26] That was that was an incredibly riveting play by play of what you do. Its incredible. I think that this is a part I think this is a part of medical care that doesn't really get a whole lot of attention. I mean, if you watch like a medical drama, usually the surgeons are like the heroes or the main character. It's always the drama in the operation room. It's between the surgeons. I think it's wonderful that you've highlighted the incredible work that you do behind the curtain separating you. I mean, literally. There's a curtain. Literally, yeah, literally. The surgeon and the anesthesiologist are separated with the curtain. Unfortunately, there's a stereotype, I think, of anesthesiologists that they mostly interact with unconscious patients. So there's this stereotype that they're like, they don't have to cultivate that that connection with patients nearly as much as internists do, which I think it's such a wrong notion, given how much trust, just the sheer amount of trust that the patient must put in you as an anesthesiologist. You have to be able to establish a rapport to a degree that I think most people who haven't gone through it or seen it realize.

Henry Bair: [00:34:29] Audrey, you recently stepped away from your duties leading the medical humanities program at Stanford because of a personal illness. After a long period as a clinician, you became a patient last year. Not only that, but within a relatively short amount of time, you also became a family member of the patient. So to the extent that you are comfortable with, can you talk to us about what those experiences were like?

Audrey Shafer: [00:35:00] Yeah. So I, like many people in medicine, were pretty stressed with the COVID 19 pandemic and many people were fatigued. There didn't seem to be much end to it. There were different parts to the pandemic, but. It was it was stressful to be an anesthesiologist. And I was feeling tired, but everyone was feeling tired. It's a pretty vague symptom, but that was my main symptoms. I just felt tired. I'm also getting older and I already had plans in place for retirement and turning over the Medical Humanities program to a new and wonderful director. Then in this period of time when I was laying down, I started to feel something in my what I thought was in my abdominal wall. And the area that I felt it in is called the left upper quadrant. And I thought. They had some sort of thing and the muscle layer didn't really feel like a typical lipoma right under the surface. But I you know, I just didn't think it was. That big a thing. But it was worrisome. I had just maybe a month and a half prior had my annual physical, which was totally fine by my wonderful internist. I messaged her and tried to get an appointment, but the appointment is going to be a couple of weeks later. I messaged her and asked her if she would be willing to order imaging. So I had abdominal and pelvic CT scan with contrast, and that revealed an enormous tumor. So what I was feeling was something that ultimately was discovered to be growing from the far side, the posterior side of my stomach.

Audrey Shafer: [00:37:16] And that's what I was feeling on the front. I was very fortunate to be in the medical system. Because I was able to get an appointment with a GI oncological surgeon, Dr. George Poultsides, very quickly. And he was able to get me a diagnostic test where they did a tissue biopsy basically through my mouth and just topically and into the stomach. The type of cancer was scary to me in the sense that it was so big and you need to have a diagnosis before you can start treatment. It grew every day. I could feel it larger, like an alien. And ultimately on the day I started treatment, they did another CT and had grown to the size of a basketball. This kind of tumor is called gist. It's GIST. GastroIntestinal Stromal Tumor, which can arise from the cells in the stomach that control and are part of the contraction of the stomach. My surgeon felt would be important for me to be on medication, to try to shrink this enormous tumor, to improve the chances of getting it out in one piece, which was important, and to minimize as much as possible the number of other organs that had to come out along with part of the stomach. So that was diagnosed in July last year. And then in October, I had surgery at Stanford.

Audrey Shafer: [00:39:12] I have an incredible gratitude to everyone who was involved. My anesthesiologist, my surgical team, the nurses were phenomenal. They were educators. They really made so many decisions about my care. The people who helped me walk after this, I feel very grateful. The kind of tumor I have means I have to stay on medication to try to keep it in check so it doesn't come back. And that has been a bit of a struggle because of some side effects of inflammation in my mouth. So I have a again, like another team, I have an oncologist and I have a dermatology oncologists as well. So many times it's not sort of a one and done thing with surgery that there are other aspects to care of the cancer patient. And that has been my experience. I think what you're referring to in terms of the other person in my life is my sister who was diagnosed with lung cancer some years ago. She has been doing really well. She, too, has been through quite a bit and is on daily medication. It's the type of lung cancer that is treatable. But she has helped me physically, emotionally, psychologically through my cancer experience as well. And she is also a physician. So having another physician be on your team who is a family member or, you know, people have nurses in their families that they're just really valuable people for trying to interpret what is going on and the course of things.

Tyler Johnson: [00:41:15] You talked earlier about the message that you as a doctor and having been in that privileged space, can bring to the wider world. Now, having been under the knife yourself and taking a new medication that doesn't go perfectly and and having interacted with many doctors and nurses and all the rest, what message would you then bring now back to the community of doctors, particularly the doctors in training? What insights can you bring us from the world of having been a patient to help health care providers, especially those in training, to become better at what they either do or will one day do?

Audrey Shafer: [00:41:53] I think it's an emphasis on the context of that patient and that moment in their lives. Another term, and this is a term that I've come up with for health humanities is contextual medicine. It's placing that patient their experience in the broader context of their life, their family's life, the social situation, the experiences of their past, their expectations. I think that that is key to providing medical care as well as to try as best we can to understand the context that the patient is in and to provide that care. In some ways, that's a form of personalized medicine. But I think it's an opening up to the patient as a person in a way that is meaningful to that patient.

Speaker3: [00:42:59] So what does that look like in daily practice?

Audrey Shafer: [00:43:03] I think for me. It's being open to changes in the conversation. It's being observant of what is happening. So when I meet a patient and they have the blanket pulled up to their nose, you know, maybe that means that they've already given their dentures away and they're embarrassed, feel ashamed to be without their dentures. Maybe when a patient is making a joke, they're trying to be strong, but really there's a higher level of anxiety than one would think. So it's like being open in the moment to really potentially change direction, to adjust, to be flexible, to present yourself as another human being, and to just know always that medicine, even in a highly technical environment like the operating room, is human human interaction.

Henry Bair: [00:44:06] Well, with that, Audrey, we want to thank you very much for taking the time to share your story. We've really covered the gamut of your career, from educator to clinician and then most recently to a patient. So thank you for all the lessons you've shared with us.

Audrey Shafer: [00:44:21] Thank you for having me.

Tyler Johnson: [00:44:22] Thanks, Audrey.

Henry Bair: [00:44:26] 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: [00:44:44] 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: [00:44:59] I'm Henry Bair.

Tyler Johnson: [00:44:59] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.