EP. 6: MEDICINE AS MINISTRY

Apr 5

WITH SAMUEL M. BROWN, MD

The story of how a physician was spiritually called to practice medicine.

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Episode Summary

As a college student, Dr. Samuel Brown never believed he would work in medicine. Yet today, he is not only an accomplished intensivist at Intermountain Healthcare and a professor of medicine at the University of Utah, but also an acclaimed writer, theologian, and religious historian. For Dr. Brown, this career is truly a spiritual calling. In this heartfelt and frequently humorous episode, we meet with him to discuss his unusual journey to medicine and to understand how his personal philosophy helps him connect with the sick and dying.

Samuel Brown, M.D., M.S., is an intensivist at Intermountain Medical Center and assistant professor of pulmonary and critical care at the University of Utah School of Medicine. Board certified in pulmonary and critical care medicine, and a testamur of the National Board of Echocardiography. His clinical interests include life-threatening infection (“sepsis”), acute lung injury, and the function of the heart and blood vessels during life-threatening illness.
Previously, Dr. Brown graduated summa cum laude from Harvard College in Linguistics with a minor in Russian, then received his MD from Harvard Medical School, where he was a National Scholar and Massachusetts Medical Society Scholar. He completed residency at Massachusetts General Hospital and fellowship at the University of Utah.
In addition, Dr. Brown researches and is widely published in medicine, religion, culture, and history.
In this episode, you will hear about:
• Dr. Brown’s personal history of religiosity and his initial resistance to a career in medicine – 2:43
• How Dr. Brown’s belief in the divinity of each human informs his work as a physician – 11:16
• The changing social, cultural, and medical contexts of death and dying in America, and the development of the modern ICU, as explored in his book Through the Valley of Shadows - 15:09
• The depersonalization of patients in the ICU and how spirituality helps foster the doctor-patient relationship – 21:36
• Finding meaning in tragedy, especially one as massive and widespread as the COVID-19 pandemic – 28:33
• Dr. Brown’s advice for all students and new medical professionals on maintaining a healthy outlook in an often-harrowing world – 33:29
Henry Bair: [00:00:01] Hi. I'm Henry Bair.

Tyler Jonhson: [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 Jonhson: [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.

Tyler Jonhson: [00:01:03] All right. Well, this is Dr. Tyler Johnson, and we're really excited today to welcome our guest. His name is Dr. Sam Brown, and he is a little bit of an unusual character. Dr. Brown is an intensivist who works in Salt Lake City, Utah. He has an appointment at the University of Utah and does a lot of research in intensive care medicine. He is also, however, a noted author and humanist, and a scholar in religious studies and the humanities. He has written a number of different books which we will link in the notes to this podcast. I think, most applicable to today's discussion, he has written a book called 'Through the Valley of Shadows: Living Wills, Intensive Care and Making Medicine Human', published by Oxford in 2016. I should also note parenthetically that I have known Dr. Brown for a number of years and I know him to be a thoroughly kind and thoughtful person. And while he has never been my doctor, I'm confident that he is a wonderful doctor and I'm excited to be able to speak to him in this context. And so we welcome you and thank you for coming, Dr. Brown.

Dr. Sam Brown: [00:02:13] Thanks. It's good to be with you, Tyler and Henry. And just one minor note, I'm very honored to be a professor at the University of Utah. I'm also a professor at Intermountain Health Care and the senior medical director for clinical trials there. And they're my primary employer. So like to make sure that I'm open about the two substantial groups that own my academic career, so to speak.

Tyler Jonhson: [00:02:36] Great. Well, we really appreciate your work in both of those capacities. And again, we appreciate you for being here. So we wanted to start, Dr. Brown, if you could just talk to us a little bit about your path to medicine. First off, was there a particular moment when you knew you wanted to be a doctor? Or how did you come to that decision?

Dr. Sam Brown: [00:02:52] Yeah, it's a funny story. I did not actually want to be a doctor until the end of my junior year of residency. I grew up in a Mormon community and in a Mormon family. My third great grandfather was Brigham Young, who was the second leader of the Church of Jesus Christ of Latter Day Saints. And my third great grandmother was a woman Zaina Diantha Huntington Jacob Smith Young. They had a lot of surnames in that complicated cultural milieu. I really wanted nothing of either that church or of religion at all from about the age of eight to about the age of 18, and then had some experiences that moved me from atheism and agnosticism and then from agnosticism into theism as I was 18. And so my first year of college was a time of real exploration and discovery, both in the traditional and prosaic sense of getting to be with lots of really great professors and lots of really bright students, all curious about the way the world works and excited to really tuck into the intellectual feast that was available in college. But also for me, figuring out what it meant to be a Christian and specifically to be a Latter Day Saint Christian. And that was it was a lot of work.

Dr. Sam Brown: [00:04:07] I was used to being pretty defiant and really focused on my quick wits. And, you know, I grew up super poor and in broken home and all that kind of, you know, the dingy clothes that you get from the Goodwill store or the neighbors dropping them off on the front porch. And I didn't have a lot I felt like I could be proud of as a kid, except my quick wits. I was very quick witted. So for me it was this transition from one mode of being and believing to another. And as I think so many people do at the age of 18 or 19, I wondered what would be the course of my life? And I spent a lot of time in prayer and meditation and thinking and reading. I grabbed the intro textbooks to all the major disciplines I could think of, trying to figure out what would resonate with me and felt like in the course of prayer and meditation, I realized that my plan, which had been to be classics professor, that was where I thought I was drawn intellectually. I loved languages. I loved ancient cultures. I loved the pure lack of practicality of studying ancient languages no one else speaks. But I felt like I had this insight that if I were purely living a life of the mind, that I would lose my way and I didn't want to lose my way. I love classics and I have so much respect for classics professors. I'm not saying that's a somehow an undignified occupation, just that for me, I needed to be grounded in actual service. So I tried to think through what were ways I could serve and still keep my mind alive. And I felt like I got this really clear impression that I needed to be a doctor, which I thought was so stupid because the doctors I'd interacted with seemed like super nice people, but not people who live the life of the mind. They were just very much concerned with churning through the patients on their list. Again, great people, but just didn't feel like they were culturally where I wanted to be. So I made this deal with God that I would study linguistics, and this was in Cambridge, Mass. At the time I was at Harvard, and then Chomsky was still teaching at MIT. I actually took the last course by Noam Chomsky that was available to undergraduates. He's the smartest man I've ever met by far. And he actually wrote one of my medical school recommendation letters. Funny story.

Dr. Sam Brown: [00:06:23] But, so I decided I was going to study what they called then theoretical syntax or generative linguistics, whatever you want to call it. But it was absolutely useless and dizzy in its intellectual scope. Just... I loved it. So that was that was the agreement I came to with God. Fine, I will do this pre-med stuff. I will go to professional school, which I really don't want to do, but I get to major in something super cool and totally useless. And so I finished college and I felt like nothing had changed. And in some sense God had honored God's side of the bargain by letting me get an awesome undergraduate degree with these great professors and colleagues whom I loved. And that was my time.

Dr. Sam Brown: [00:07:10] So I went off to medical school and was super bored. I just didn't want to be a doctor. Holy cow. I would skip class as much as I could. I would come to the lectures and I would actually sew outdoor gear during the lectures. And I just met my wife, the woman that became my wife, two weeks before medical school. And so I courted her and it was pass fail, which was a revelation to me. I thought, tell me what percentage is pass and I will get that plus 1%. And that was that was my goal for medical school. I did feel like I needed to make sure I knew what was going on. So I read the New England Journal of Medicine every week. I mostly cut classes and tried to do as low a pass as I could in medical school, but then read the New England Journal every week and felt like I stayed intact. And then I kind of didn't know what I wanted to do still. I still didn't want to be a doctor, but I went in to residency and by that time I felt like maybe the way I could be of most service was through global health, which is mostly infectious disease historically, although there are other areas of important concern and consideration there. And so my plan was to short track. I don't know whether that still exists, but 20 years ago you could skip the last year of residency and start fellowship early if you were planning to launch a research career and didn't want to do a lot of extra clinical training.

Dr. Sam Brown: [00:08:36] So I was just about ready to short track in infectious disease to be a global health doc and had an experience doing global health. That was wonderful and I loved it, and it was really hard on our marriage. It was hard for my wife to find something that was of interest to do. We were in the former Soviet Union at the time, so she was in grad school and went back to Boston... Was in grad school and it works for other people. But for us it did not... To be on two different continents. And so I had to realize that if I wasn't doing global health, I wasn't really drawn to infectious disease in the United States. Which, this is not correct. I've since learned that there's a lot more going on even in clinical ID in the US. But my impression at the time was it was arguing with orthopedic surgeons about what antibiotics to give for how long. And I just didn't... I didn't want to do that.

Dr. Sam Brown: [00:09:28] And so I was suddenly stuck again. I still felt like God wanted me to be a doc, and I guess I was a doc. But was I really doc? I wasn't sure. And then honestly, it was... I was a resident at MGH, and I'm sure the structure has changed in the last 20 years. But back then the Bigelow was the... It was called the Wards and it was sort of the public service. MGH had the very broad harmony private service, but then it also had the public service, or the Bigelow. And as a junior resident on the Bigelow, back then you were the attending, there was an attending and you liked them and admired them, but they were only around for an hour or two a day and they were great scientists and you learned from them and they'd tell you about what their research was. But fundamentally, the buck stopped with you. And for me it was that moment that these 20 people, they were depending on me to make a difference in their time of medical crisis. And I worked my tail off and felt what it meant to have a real stewardship for the health of other people, which I hadn't really experienced through earlier phase of my medical training. And it was that moment on the Bigelow, as they called it, a JAR, a junior assistant resident. That was the pretentious and pretentious title of a second year of PGY two at MGH at the time. I don't know what they call it anymore, but the Bigelow JAR, the Big JAR - that transformed and I realized I was finally ready and willing to be a doc. And since then I count it as a privilege to be a physician, even though if we're honest, most of my work is non clinical intellectual work. I continue to be active clinically and to count it a privilege and an honor to take care of patients.

Tyler Jonhson: [00:11:12] Thank you for that. It's just interesting to me that you have this very spiritual path to medicine and you have referred to it as a privilege and a stewardship. And I don't know if you quite used this word, but it sounds like you think of it almost as a calling. And I know that you have written a lot about trying to return a sense of humanity or a consideration for the humanness of the patient to medicine, especially critical care medicine, where arguably it's even more difficult than in other spaces. Can you talk a little bit about how your spiritual aspect of being a doctor informs that part of your work?

Dr. Sam Brown: [00:11:50] Yeah, thanks, Tyler. It's a good question. I do consider it a calling. It feels like something I was assigned to do, and I'd better do it and do it well. And I think you're exactly correct. One of my med school application actually essays was about... I shadowed a pediatrician named George Durham who was a Salt Lake pediatrician and also a Latter Day Saint, and watched him really minister to his patients. Such an elegant and kind and patient person who listened clearly and I thought, well... Then I was chatting with him about it - This was after I'd had that spiritual sense that I needed to be a doc - so I was trying to understand more about what I was getting myself into. And he said, You know, we Latter-Day Saints don't have a professional clergy at the local level. And George said, I always thought I'd like to be a pastor, but, you know, my faith tradition doesn't have that. And being a pediatrician is really a wonderful alternative to that. And it really struck me that you really can minister to patients as a physician.

Dr. Sam Brown: [00:12:51] Now, I need to be really careful here because our cultural contexts are very complex and sometimes tense and quite partizan. When I say ministering as a physician, I'm not talking about proselytizing to a particular faith or performing a searching moral inventory with a person or making assumptions about their experience of vastness and fullness and divinity. What I mean is serving them with my heart in the way I am able to do, which is a combination of technical skills as a physician and empathy and listening heart that I feel has been cultivated in my religious tradition.

Dr. Sam Brown: [00:13:34] And you're absolutely right. I feel like my work clinically and the work that I've been honored to help lead, and now mostly participate in as I've had to run some other big operations through the Center for Humanizing Critical Care, is really for me a religious practice. And again, that adjective 'religious' has become so complicated in its connotations that I want to be careful. And I also want to make it absolutely clear that I don't believe that you have to be religious to be a good doctor in that caring and empathic way. I'm describing the fact that for me, it's very much driven by my religious experience and beliefs, which is that each human being is - We often talk in my tradition about being a god and embryo - that there is a kind of specific identity of human beings with divine beings that is real and true. So for me, everybody I encounter is a is a God and embryo. And that brings with it a requirement for a certain amount of reverence and awe and willingness to serve. So again, for many people who do not identify themselves as religious, there is a similar calling that uses secular language to describe it. And I honor that. And I'm so delighted to be working shoulder to shoulder on this work. And for me, this is fundamentally and quite purely a religious practice.

Henry Bair: [00:15:05] I'd like to talk next about your book in 'The Valley of Shadows', which delves into the changing social, cultural and medical contexts of death and dying in America, as well as the development of the modern ICU. In the book, you make the point that the idea of dying has changed. You're right. By the end of the death of dying, Americans had contained the terror of death by simply ignoring it until the moment of crisis. But the sanctity of death had disappeared along with its menacing presence you go on with. Since 20th century, Americans had not generally spent their lives in the shadow of death. When they came to approach death, as every human being inevitably does, they discover just how culturally defenseless they were before its terrible power. Along with this, you discuss how innovations in intensive care technology have given us ever more control over when someone dies. But it's not always a good thing, citing many studies on people discharged from the ICU. You're right. Many people leave the ICU with emotional scars as severe as those carried by combat veterans. Only a minority skate by without anxiety, depression or PTSD, or some combination of the three. So I was hoping you could tell us more about that. How did we get to this point? And where do we go from here?

Dr. Sam Brown: [00:16:17] Thanks, Henry. It's a really good question. And I feel like my head has been spinning with this pandemic because as an ICU researcher, I've just been doing all COVID, all day, every day, and most of the nights for two years. So it was refreshing to think about some of the stuff that I thought and wrote about before. This awful pandemic may soon be entirely over. But you're speaking to something that's really at the heart of medicine.

Dr. Sam Brown: [00:16:45] Now, we are paid as physicians, as clinicians, to try to help people live longer and hopefully to live with less disability. And we often do a pretty good job about it. We get yelled at periodically by various critics, but honestly, we actually do a fairly good job at that. But then there are these moments that are much more difficult that have to do with the possibility of dying in the near term. And Tyler is an oncologist experiences this with a tempo of weeks to months. And in the ICU you experience it with a tempo of hours to days. But it's the same fundamental problem. How do you serve people best when you have tools that can hurt intrinsically? Chemo can ravage a body. Being kept alive on a mechanical ventilator is very uncomfortable and is associated with substantial loss in strength. How do you deploy those tools or use those tools when you're in a situation where death may be coming regardless of what you do, and there are balances and trade offs? And unfortunately, this has gotten tied up in a lot of the culture war animosity, which has made it harder to see clearly, because the reality is that nobody comes with a label that says certainly dying in N days or X days.

Dr. Sam Brown: [00:18:13] We just don't. We have probabilities, and the probabilities range from nearly zero to mid to high nineties. But in general we're talking about probabilities and chances, and how do you manage the person in front of you with their convictions in their life philosophy and their priorities and their community of beloveds against the probabilities of biology? And we've tended as institutions and as systems to want simple categorizations and simple responses. So what I tend to see the most of is either somebody is never willing to talk about dying, just fully press on. You know that old joke about... What is a... The oncologist goes to a graveyard to disinter a patient to try to give them chemotherapy and find a Post-it note that says at dialysis. You know, we tell these sort of gallows humor jokes to communicate some of our anxiety and discomfort around those questions. But they're real. And people who are full on, always heroic, do a lot of good in the world. And then, on the other hand, we tend to have people who take the line, and here's a little more gallows humor, but, you know, the palliative person that talks to the patient leaving the dentist and says, I'm really sorry, you've got a toothache, but we'll make sure you're comfortable as you die. Right. So you've got these these two extremes, and we tend to gravitate toward those extremes. And what you'll see not infrequently is that the teams will stick with one extreme. And then when they finally feel fully pessimistic or no longer able to invest their emotional energy in an attempt at recovery, they'll transition immediately to a full on comfort care, full on transition to death.

Dr. Sam Brown: [00:20:04] And I think what we need to do is put on our big boy and big girl pants as clinicians and realize that we're going to have to do some difficult things and we'll have to distinguish the difficulty for us, which often will describe as moral distress. But sometimes we won't think clearly about what we mean by moral distress to be able to attune to the responses that we have, the work that we do to the individual needs of the person in front of us. And that's why in that book I talked about what I call Pixi. I'm an old linguist, so I like cute acronyms, PCSI, Personalized care for serious illness. And for me, that's way more important than this advance care planning or living wills or whatever. Which are these weird, theoretical Ulysses contracts to make sure to kill me if I'm ever in this circumstance, which I don't get. What people want is personalized care when they're confronting the possibility that their life is at its end. They want people who understand them and respond to their priorities and values. So I think it takes a lot of work because we're very good at being efficient. In part because we're driven to that by the incredible workloads we're under. But we're less good at being nuanced. So I guess that book was written and some of the other work I've done with colleagues who've done so much good is around trying to help us be a little less efficient in that corporate bureaucratic sense and a little more nuanced and responsive.

Tyler Jonhson: [00:21:28] Can I just ask you, Dr. Brown - many of our listeners may be headed into medicine or may not even be in medicine and may not have much experience in an ICU. But for doctors who have worked in an ICU, it is a profoundly depersonalizing experience for a patient, right? I mean, almost by definition, because they are hooked up to a whole array of monitors, they have tubes and lines sticking often out of almost every orifice. People are often unconscious and can't communicate with their doctors in any meaningful ways, or it can only give a thumbs up and thumbs down. They have a tube down their throat. I mean, it's no wonder, as we referenced earlier, that people can develop something like PTSD after having been in the ICU. But also as a doctor, at least, I have found... I'm not an intensivist, but I've had many patients in the ICU and spent a lot of time there. When I was training, I found it significantly more difficult to view a patient as a person in the ICU than in other places because they've become so mechanized. Right? It's like they've sort of become the bionic person. So I'm curious, as somebody who has such a intuitively spiritual element to his doctoring in daily practice, if you're actually working in the ICU, do you have a spiritual or meditative or metaphysical practice that you use to try to connect with that inner divinity that you were talking about earlier? When somebody often can't even talk to you and may not even be able to open their eyes.

Dr. Sam Brown: [00:22:59] Those are great questions, Tyler. And you're dead on about this depersonalization in the ICU. You you strip people naked, you put them in a uniform that's designed to provide casual access to strangers, to a person's privates. And then you start to violate all of the apertures in the body. And if it were not for the purpose of saving life and with the consent of the individual involved, there's no doubt that this would be torture. So it's hard and it's tricky and it's depersonalizing. It's really difficult to do something that rough to someone while maintaining an awareness of that humanity of the individual. And often I think as a protection mechanism, self protection, clinicians will separate themselves from the personality of the individual. For me, in terms of a spiritual practice around that, I'm not a saint except in the trivial sense that my church calls its members Latter-Day Saints. I'm just a regular schmuck, honestly. And for me, I find that I have to use heuristics and simple practices that are not particularly metaphysically complex. So for me, my orientation is to the beloveds of the patient as the world experts in their humanity. So I push very hard, and COVID has made this so complicated, but I push very hard to have family members there the whole time with us, a part of the team, and the cardiac surgeon is the local expert in the surgical management of heart valve difficulties and the nephrologist is the expert and the management of an ailing kidney. And we have experts on these multidisciplinary teams, and it's crucial to include the world expert in the humanity of the patient and family members.

Dr. Sam Brown: [00:24:56] So we, Sarah Beazley in our group, led a paper in the annals of American Thoracic Society five or eight years ago where we walk people through how you actually have family members present for ICU procedures the whole time, integrate them into the procedure, make sure that they're present. We have them on rounds. We make sure that they're, again, covid's been a mess, but outside of COVID, they can be with the patient whenever the patient wants them to be. And so for me, I feel like the nephrologist dialyizes and I avoid interfering with that process. I try not to make the nephrologist's life any harder than it is. I don't interfere with the recovery of the kidney, and the family member is that expert in the humanity. So I make sure they're present and that they have the opportunities to represent that, to keep that. And that actually makes it a little bit easier for me because you can't love with an intimate love, every person that comes through, even though you feel this desire to be truly human and truly available to the people in front of you. Because if you did, if 15% of them die, you'll be hopelessly psychically damaged by that bereavement. So you have to have a way to honor them without developing the kind of emotional intimacy that would cause your emotional destruction, your inability to take care of other people in the future. And for me, that's been recruiting a good team that includes those family members. And not only do they stand up for the patient, do they spend time with the patient, reassure them, but they also tell stories.

Dr. Sam Brown: [00:26:39] And I do try to make sure that we get stories about the patients, which I think is very helpful. And you learn... I mean, one patient that we were taking care of and you thought of him as a 75 year old with interstitial lung disease who was dying of hypoxemia respiratory failure with delirium. Right? That's a standard way of understanding the patient. Then you talk to his daughter and it turns out that he fled Holland as the Nazis were invading and he had to hide under a riverbank for 12 hours before swimming underwater across this river to flee the Nazis. And all of a sudden you've got this new image of the person. Or another guy we found out used to in the seventies, he would surf on some kind of muscle car across the western deserts at 80 miles an hour. So instead of this hectic, delirious gentleman with sepsis of urinary origin, you got this crazy ass beautiful man who used to climb on the top of a Chevy Nova and go 80 miles an hour through the desert. And so I think these extra little images of people help to maintain that humanity.

Dr. Sam Brown: [00:27:57] And then in terms of the spiritual practice, when it looks like somebody may be dying, I do try to step out of myself and slow down. And whether it's the moment of silence or a moment of honoring. But I'll try to say out loud something about the gravity of the passing of a human being. But, you know, I got... I got troubles. I don't do as well as I hope. And I regret that. And I'm always trying to do better.

Tyler Jonhson: [00:28:23] Thank you for that. You know, you've referenced multiple times during the interview the elephant in the room right now for medicine and society, which is the pandemic. And, you know, for a host of reasons, this has been difficult without precedent for most people. And obviously, millions of people have died, I guess, as a doctor who also likes to think about things with a broader lens and a larger scope, as we are hopefully somewhere on the precipice of emerging from the pandemic, at least to some degree. Can you read some larger spiritual meaning into what we've been through? Can you find some semblance of meaning in all of this suffering?

Dr. Sam Brown: [00:29:04] Boy, that's a question that's been exercising humans since they were making cuneiform indentations in clay tablets 7000 years ago. My response to the possibility of growth after tragedy is to acknowledge and mourn the tragedy and allow it to be tragic. And then to think about the fact - and yet we are alive and there is meaning and beauty to be made. So what can we do now? So for me, it becomes a very practical question. You mourn it. Absolutely. And then you think, what good can I do with it now? And that, I think, pulls it away from the endless philosophical wrangling about the problem of evil or the problem of the suffering of the innocents, and brings it down to very concrete. What avenues to the working of good are open now that were not open previously? And there I think we haven't done this well, honestly, but there have been real pockets of good that have been done. But I do think that in addition to all the just exhaustion and rage and burnout and frustration and pettiness, there's also been an awareness that we belong to each other and that we owe each other a debt of protection. And it's been true throughout this pandemic that this SARS Coronavirus Two is a quintessential Darwinist. It is absolutely blind natural selection, and it is using and disposing of the weakest among us to propagate its genome. And I think there's been, as I've watched, a sense that maybe Darwinism is not really what we want. I distinguish Darwinism for just this belief in the way biology works that's unobjectionable and not to me the point of many conversations, but this question of this Darwinian ideology that sort of percolates along and intermittently flares up.

Dr. Sam Brown: [00:31:16] I feel like this virus gave the lie to that belief. And so for me, I think this notion that maybe we can rethink our meritocratic survival of the fittest kind of ideology and might makes right and all this kind of stuff. But people have opened up space to think better about that and space to think better about being of use to people in marginalized communities. I've been in clinical research and clinical trials for a long time and, in the aftermath of the pandemic, and again, I hope this is the aftermath and not just some eye of the storm, but in the aftermath of the pandemic, everybody - the US government, the academics, the hospitals, the health care systems, the industry, sponsors and pharma - are all thinking about how do we assure that the good therapies we have available now and the therapies of the future are available in a fair and equitable manner to everybody who desires them and stands in need of them? And I've never seen this degree of broad social consensus around the need to get that right. So for me it's again, mourn what has happened and so many of us have been just stretched psychologically and people have taken their own lives and people have been hospitalized for suicidality. People have become addicted to alcohol and drugs. Terrible things that have happened above and beyond the people who've just died or been severely damaged by the virus. And we mourn that and we acknowledge that. And then I think we pick ourselves up and we get about the work of doing good.

Henry Bair: [00:33:05] I've really enjoyed hearing your stories, which have been amusing and heartbreaking. I appreciate how you carry such a vast respect for humanity, and your closeness with the physical and metaphysical aspects of our reality is truly palpable. I was wondering if you could share any advice for someone starting out and someone who might not have the same spiritual worldview as yourself? How should they approach their medical training?

Dr. Sam Brown: [00:33:30] I think it's a great question, and you're right that so much of the language that's available to me since my conversion to theism is unavailable, at least in the form I use it, to many people now. I really like the Canadian philosopher Charles Taylor. He's a liberal Catholic and also a really careful thinker. And the way he frames it, he was one of the people that was helpful in mediating the Francophone Anglophone divide in Quebec. Henry, You may be too young to remember, I've lost track of when things happen, but at some point in the last decade or two, there was a huge controversy around how to manage the English speaking and French speaking populations in Quebec. And so Charles Taylor has done a lot of thinking about allegiance to the state, allegiance to a particular ethnic group, about identity, and about how you live together in difference. And his advice is to figure out what you think fullness is. And fullness for a religious person is likely to involve some component of life in God that's relatively familiar, even if it's not available to many. But fullness is also available as a notion to somebody who's assiduously atheist and quite committed to a secular worldview. And it's... What is it? What features of the world you inhabit are better? Are more important than the every day? Are substantial or significant? And figure out what that fullness is. And Taylor's argument, which I think is true, is that once you're able to define and describe fullness, you're actually better able to communicate with people across religious divides. Because if you strip away the specific language used, I think a lot of us can understand what the experience of fullness is, and we can share together.

Dr. Sam Brown: [00:35:30] And what you find is very frequently, again, step back from the culture wars and step back from pretending that social media is an accurate sampling strategy for cultural beliefs and behaviors. Step back from that to real people. And what you find is that we share this notion, and fullness may be justice. Fullness may be beauty. Fullness may be wonder in the presence of nature. Fullness may be tasks precisely performed. But figure out what that fullness is and cultivate it and then inquire of others. What is that fullness? It doesn't have to be strangers. That's a little weird. But with your friends. But maybe weird is okay in that circumstance. But with your friends, for example, some of the time that you're together, wonder what fullness is for them. And I think that access to the sense of fullness is a mechanism for participating in some of that purpose. And then I think maintain active curiosity. And what I recommend to the trainees, particularly as you get out of medical school and you get into that first few years of training, which is so hectic, even though it's a lot less hectic than it was. Well, a lot less grueling in terms of total number of hours than it was back when I was in that training. It's probably more hectic now in terms of you're having to do the same amount of work in 10 hours that we were given 18 hours to do. So you sleep a little more, but you work a lot harder when you're physically at the hospital as you're getting into that mode where things are so busy.

Dr. Sam Brown: [00:37:10] What I've recommended is once a day, just once a day, go the extra mile with a patient. You're not going to be able to go the extra mile with every patient. You'd never go home from the hospital. You'd lose your mind. But with one, be open and curious and listen and do a little bit extra. Don't be rude to everybody else, but you can't be 150% with everybody. But you can once a day think you can manage that and then get better at it. And it becomes a kind of practice. I call it my pandemic Prozac - mountain biking. I started mountain biking in April of 2020. I hadn't done it before, but I just needed... I was working harder than I'd ever worked in my life on COVID and COVID trials and research, and I needed some time away. And what I found was when I started mountain biking, I could barely get up a moderate hill. And now that I've been doing it, I'm able to get up steeper and steeper hills and go on longer and longer rides. And I think the same thing is true as you practice that availability, the availability of your mind and of your capacities to an individual patient to hear their world a bit and try to be of extra use to them. But you can't do it, particularly when you're starting out, for everybody. But just once a day, open yourself. That's my thinking.

Henry Bair: [00:38:32] Thank you very much for your advice and for your time today.

Dr. Sam Brown: [00:38:35] Thanks. It was good to be with you, Henry. It's fun to interact with the rising generation. I'm now squarely in the middle, or maybe even the later phase of middle age. And you realize with some nostalgia and some excitement, that there are great people coming up behind you. And it's an honor to be of use to them.

Henry Bair: [00:38:58] Thank you for joining our conversation on this week's episode of The Doctors 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 Jonhson: [00:39:17] 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: [00:39:31] I'm Henry Bairr.

Tyler Jonhson: [00:39:32] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.