EP. 74: THE BEAUTY OF IMPERMANENCE

WITH SUNITA PURI

Aug 8

WITH SUNITA PURI, MD

A palliative care physician and acclaimed author shares how the recognition of the limits of medicine and of our impermanence allows us to unearth meaning amid some of life’s most troubled moments.

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Episode Summary

Despite the optimism of modern healthcare promising ever more miraculous cures, there are inevitably moments in medicine that compel us to face the fact that not all problems can be fixed. Recognizing the limits of medicine and navigating the space between what can be done and what should be done for a patient requires a fundamental shift in mindset, one imbued with an understanding that sometimes acceptance is the most compassionate response. Our guest on this episode, palliative care physician Sunita Puri, MD, has dedicated her life to probing this delicate space, uncovering wisdom along the way on what it means to live and die with purpose and dignity. She is the author of the 2019 memoir That Good Night: Life and Medicine in the Eleventh Hour, and her writings have often appeared in The New York Times. In this conversation, we explore how she discovered palliative medicine, the importance of language in medicine's most difficult moments, and how impermanence and grief help us make meaning out of a world that often seems chaotic and senseless.

Sunita Puri, MD is the Program Director of the Hospice and Palliative Medicine Fellowship at the University of Massachusetts Medical Center & Chan School of Medicine, where she is also an associate professor of clinical medicine. A graduate of Yale University, she completed medical school and residency training in internal medicine at the University of California San Francisco followed by fellowship training in palliative medicine at Stanford. She is the author of That Good Night: Life and Medicine in the Eleventh Hour, a critically acclaimed literary memoir examining her journey to the practice of palliative medicine, and her quest to help patients and families redefine what it means to live and die well in the face of serious illness.
She is the recipient of a Rhodes Scholarship and a Paul and Daisy Soros Fellowship for New Americans. Her writing and book have been featured in the New York Times, the Los Angeles Times, Slate, JAMA, the Atlantic, NPR, India Today, the Asian Age, the Oncology Times, and the New Yorker.
In this episode, you will hear about:
• How Dr. Puri’s relationship with her parents drew her into medicine - 2:46
• The inspirational way that Dr. Puri’s physician mother connected with patients - 4:49
• Dr. Puri’s experiences entering the field of palliative care - 10:56
• Reflections on what Dr. Puri needed to “unlearn” over the course of her career as a physician - 15:36
• The recognition that not all diseases can be cured and not all problems can be fixed - 21:37
• Advice on how to engage patients and families when further curative medical interventions are futile - 32:29
• Dr. Puri’s experiences on helping other doctors through difficult moments - 38:56
• Why Dr. Puri writes and how she came to write her book That Good Night: Life and Medicine in the Eleventh Hour - 43:43
• Grief, empathy, and the sacred mission of medicine - 49:24
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to the Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and 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 advances of modern medicine paint a picture of optimism, depicting or inspiring treatments and cures that just a few years ago would have been considered impossible miracles. Yet, inevitably, there are moments in medicine that compel us to face the truth that not all problems can be fixed. Recognizing the boundaries of medicine and navigating the space between what can be done -and what should be done- for a patient requires a fundamental shift in mindset, one imbued with an understanding that sometimes acceptance becomes the most compassionate response. Our guest on this episode, Palliative care physician Dr. Sunita Puri, has dedicated her life to probing this delicate space, uncovering wisdom along the way on what it means to live and die with purpose and dignity. She is the author of the 2019 memoir "That Good Night: Life and Medicine in the Eleventh Hour," and her writings have often appeared in The New York Times. In this conversation, we delve into how she discovered this work, the importance of language in medicine's most difficult moments, and how impermanence and grief help us make meaning out of a world that often seems chaotic and senseless.
Tyler Johnson: [00:02:15] Well, we are so grateful to have Dr. Sunita Puri on the program with us today. This is a special treat for me because I knew Dr. Puri, we were just saying, almost a decade ago when I was an oncology fellow at Stanford, and she was there as a palliative care fellow. And we'll talk a little bit about the path that led her to that point and what has come afterwards. But first, we just want to thank you so much, Dr. Puri, for being on the program.
Sunita Puri: [00:02:40] Thank you so much, Tyler and Henry. And please feel free to call me Sunita. I'm cool with that.
Tyler Johnson: [00:02:46] Perfect. So, Sunita, can you start by just talking to us- And for listeners who may not be familiar with the book, can you just talk to us first about how did you decide to go into medicine in the first place?
Sunita Puri: [00:03:00] Sure. So I grew up the daughter of deeply spiritual parents who were both scientists. My dad's an engineer and my mom's an anesthesiologist. And from when I was very, very young, she never really wanted to leave us home with babysitters if she could help it. And so my brother and I were often in the hospital on our days off when we were little. And it was just it became our second home. I would round with my mom in the PACU. I was very young, very little, but she would hold my hand and just I would watch her talk to her patients. And she had such a grace and a humor about her. And it was pretty remarkable now that given what I now know about anesthesiology, that she could form such a tight bond very quickly with patients she'd met just before a surgery and was rounding on after. And so I really, what she practiced was not just medicine, but and a deep act of service and compassion. And so seeing that growing up, I just wanted to be like my mom. And there's no way I could ever be half the person my mom is because she and my dad came from the post-independence India, which was war torn, and both of them came from refugee families. And so it was really that her grit came from that and it evolved into that sort of deep compassion that really enabled her to connect with her patients and with suffering generally. So I just I really wanted to be just like my mom.
Tyler Johnson: [00:04:49] You know, we have had many guests on the show who have talked about the way that their parents involvement in their young lives played into them, getting into medicine. Although I have to say that the most common version of that has something to do with. Well, my parents told me when I was young that I had three options for what I could be when I grew up, which were to be a physician, an MD or a doctor or some version of that, that kind of a thing. And so to hear someone who, instead of having that kind of a prescriptive approach, has this sort of inspirational approach and I know is a little bit unusual and I know that was one of the things that touched me the most in your book. I feel like we in many cases live in a postmodern age that likes to focus on cynicism and deconstruction and some of those things. And oftentimes familial relationships, if they're portrayed at all, are portrayed in these very kind of combative ways. Or it's a lot about sort of deconstructing the myth or the idol of your parents or coming to understand that they're really not all that you thought they were or whatever.
Tyler Johnson: [00:05:59] And one of the things that I thought was the most beautiful about your book is not that you portray your parents as, you know, Saints or perfect, but just the fact that, I mean, as best I could tell, they're good people and the influence that they had in your life seems to have been largely positive. And so much so that even later in the book, when you then are sort of going through your own maturation process as a budding doctor, you continue to go back to them as this kind of moral touchpoint and this kind of anchor that keeps you, you know, sort of connected to the things that matter most. You talked about this a little bit in the sense of sort of, you know, even as a little girl, as you're rounding with your mom and whatever, which, by the way, just the idea of bringing my children rounding with me is sort of inspiring and sort of frightening. But leaving that aside for a moment as you're rounding with Your mom.
Sunita Puri: [00:06:57] This was before HIPAA.
Tyler Johnson: [00:06:58] So apparently a little bit of a different world, but still, as you're rounding with your mom, you you saw I mean, it sounds like even more than a, you know, a particular procedure that she did or a particular, you know, task that she was about. It sounds like what most impressed you was almost her presence or sort of the, for lack of a better word, sort of the spiritual substance of what she was doing. Can you talk a little bit as you've gone through your own process of training and practicing, what have you come to appreciate? Like if you had to distill down what it is exactly that she brought to medicine that was so important? How would you describe that?
Sunita Puri: [00:07:43] So that's very right that my mom and dad are both spiritual scientists, so it was never this binary of either you can be spiritual and have faith or you can be a scientist. And I think in a lot of ways in. In society on many different issues. We're stuck in toxic binaries rather than understanding that two things or many more than two things can be true at the same time. And so I saw my mom ask people if they wanted to pray and she would ask them what their faith was and if their faith it was usually different than ours. She would let them pray and she would be there with them and bow her head and clasp her hands. And that was astonishing. It was astonishing to me when I came into medicine that that was completely taboo. I didn't realize just how rare of an experience I was getting in seeing a doctor who could hold two types of beliefs at once. And spiritually speaking, you know, my dad, in the introduction of the book, what I write about is this moment where we're sitting together watching the sunset in Louisville, Kentucky, which is where my mom was doing her residency. And I asked him why the sun, why the sky couldn't look as beautiful as it did then all the time. And he talked to me about impermanence being life's law. And that change will come for every one of us.
Sunita Puri: [00:09:17] Death will come for every one of us. And I was five, and this was very hard to wrap my mind around. But the way he talked about it, it was clear that this was knowledge that had been accumulated through great suffering. And even when I was a young kid, I could feel that. And so this was a kind of set of beliefs that they offered me and my brother. And when I went into medicine myself, the complete absence and unwillingness to engage with anything spiritual, forget religious, just even spiritual. It was so behind a curtain, just like death and suffering were behind a curtain and so I think watching how my parents moved about in the world spiritually and professionally, it kind of primed me to notice the absence of that particular marriage in my own training. And it's part of almost every interaction I have with a patient is trying to understand what is their faith about. And that doesn't need to be formal religion. It can be faith in in the universe. It can be faith in nature. Do they believe there's something more than this existence? And when I get into those spaces with people, there's some of the most vulnerable, intimate spaces to go into. And as a palliative care doctor, obviously spirituality is a big part of what we want to understand because that's a big part of people's journey.
Henry Bair: [00:10:56] So I think we're going to want to revisit that spiritual aspect of your patient care practices later on. But for now, I'd really like to explore how you came into palliative care medicine. I mean, this is something about which even today there is a lot of confusion and misconception, even within the medical community. So how did you come into it? I mean, it sounds like spirituality has long played a part in your life. Were you aware that spirituality was rather prominently featured in palliative medicine coming into medical school, or was that something you discovered later along the way?
Sunita Puri: [00:11:35] Oh, I did not know what that term was, had no idea about it. And I trained at a great institution that was full of palliative care leaders. But in our curriculum there was little to no exposure to the concepts of palliative care at all. I couldn't explain what hospice was as an intern. And so the way I was led to this was through disillusionment. To be very honest with you, I was finishing med school. I matched into internal medicine. I had thought about going into pulmonary critical care because my mom did a lot of critical care. And so I thought, if I want to be like her, maybe I should do palm crit. I thought about doing cardiology because my dad was like, This is the specialty that makes the most sense. And I was like, No, dad, there's too many Indians in it already. So basically I did an elective that I would never have thought to take unless a classmate of mine had mentioned it to me. I had one slot to fill for two weeks and I chose palliative, didn't really know what I was getting into and what I saw during those two weeks completely changed my life and my relationship to what medicine could be.
Sunita Puri: [00:12:57] I felt like I could actually get to know people. I had more time with patients. I got to really kind of learn what it meant to help people understand what was really going on. For them to help them think through some of life's hardest questions like What do you want your life to look like if it's not going to be as long as we hope it would? And I got to sit with a lot of emotion that I couldn't necessarily fix or do anything about. And that witnessing piece of it, it kind of comes from this idiom that I really like it. We all know the phrase, don't just stand there, do something. But what I witnessed was don't just do something. Stand there or sit there. And that was, I think, among the most transformative moments, because I was allowed to just sit with people as a human and there was no pressure for me to exhibit some sort of crazy amount of knowledge that had not been taught to me. For example, it was a complete adoption of new lenses through which to see people and through which to understand medicine and my own journey within it.
Sunita Puri: [00:14:18] And then when I was in residency, I did a lot of ICU time, still trying to convince myself maybe I could do both. I can be the palliative friendly, friendly ICU doctor, but what I loved about the unit the most I mean, I did love the procedures. I do want to be honest about that. I really loved doing Perez and putting lines in people and thoras and all of that stuff, but it often felt like I was doing things to people without doing things for people. And that's where I think I kind of had to be honest with myself that I really want to be the person that guides people in decision making. That helps ease the team's distress when they don't know what to do, because there's a lot of that. And so you get to in this profession, you get to help assuage many different fronts of suffering the patient and families, the teams, the multiple teams, the primary care doctors, sometimes your own teams, the residents and the med students. And it was really that draw to suffering that that led me down this path, which sounds very macabre, but I promise you this is actually a very uplifting profession.
Tyler Johnson: [00:15:36] So first off, I want to back up just a minute for those of so we have listeners all along the spectrum. Some people are not even involved in medicine per se. And then we have people everywhere from pre-medical students through all the way through to attendings. So for those who may not be familiar with the path that a palliative care doctor takes most of the. Time their variations. But most people who go into palliative care do 4 or 5 or whatever it is, years of medical school during which they get a month or two of the major specialties. Then they go into an internal medicine residency and during that internal medicine residency, which is usually three years, you might, as Sunita said, spend a couple of weeks or a month or something doing palliative care as an elective. But the large majority of your time is spent taking care of very sick patients, trying to help them get better and leave the hospital. So you're taking care of patients who are having heart attacks and patients who are in liver failure and kidney failure, people who have serious infectious diseases, immunocompromised individuals, people with cancer. All of those kinds of things.
Tyler Johnson: [00:16:41] And and there's an overarching paradigm that is that controls pretty much all of that, which is a person is sick. You figure out what's wrong, do something, make them better, and they leave the hospital. And and to that point, the vast majority of what you're doing is taking care of people in a hospital. You have some time in the clinic, but most of it is in the hospital. So and then if you decide to go into palliative care after three years of internal medicine residency, then you go on to do a palliative care fellowship where the focus is very different. So the reason that I wanted to give that framing is because I was really struck in reviewing your book that one of the so the book is set up roughly chronologically and it's kind of epochal. So it's there are sort of these different episodes. And one of the episodes in the book is the title of the, of that section of the book is The Unlearning. So can you can you talk to us, Sunita, about what was it that you learned that had to be unlearned and what did that unlearning look like?
Sunita Puri: [00:17:46] Such a great question, Tyler, and thank you for sketching out the path, because I think there's a couple things that you alluded to that I'm going to build on, which is a lot of what we learned was exactly what you said. Someone comes in sick, you need to figure out what's going on for them and you need to make it better, right? You need to diagnose and treat. And we didn't really, you know, in that framework, think about the big question of what do you do for somebody who you can't fix. And the way we're socialized in medicine is so much to be like identify a problem and fix the problem. And it's the same type of heroism that the public imbues us with that we imbue ourselves with. And then we run into what the difference between what we can do for somebody versus what we should do for somebody. And it's in that gap that actually knowing how to talk to people about their illness, what they hope for, what the reality is, and the paths open to them and which one feels right to them and which one is medically feasible. That skill set was not at all a part of what we learned. And I think sometimes we also didn't learn to call for help from the palliative care team when we didn't know what we were doing, because to be honest, not all of us, even at my residency program, which again was a big leader in palliative care, a lot of us did not understand what it was. And I think the other thing that we kind of learn is to ask questions in a very binary way. So a classic one is if your heart stops, do you want us to? There's very many different unsatisfactory variations of this, but one is, do you want us to do chest compressions and bring you back to life? And that is just such not the right way to ask it.
Sunita Puri: [00:19:56] But we were all asking very kind of variations on that theme, and we were really learning that you lay out options and let the patients or families choose. The unlearning was really kind of going into the assumptions that we'd made and the language we'd been using and and how we interpreted what people were saying and really excavating the meaning of all of it. So for example, in residency, if someone said to me, I'm a fighter and I want everything done, what I learned was never to explore that or challenge it, but just to make sure the person would get CPR and go to the ICU, even though it was incumbent on me to help them understand the context in which that decision needed to be made, it was incumbent on me to guide them and that. Was part of the unlearning. It was really unlearning my role in relationship to families and other doctors and decision making. And I think it was also kind of learning to sit back, especially early in fellowship in family meetings and listen to what everybody else was doing and saying from the other teams. And it was the kind of self education of saying, I recognize what this person is doing. And I can see it now as leading this meeting down the wrong path. But you have to learn to sit still and have the time and space to take it all in.
Tyler Johnson: [00:21:37] Yeah. You know, I'm so struck. One of the things that you mentioned briefly at the beginning of that answer was the difference between what you could do and what you felt you were supposed to or needed to do. And I know that especially actually as a young attending, you know, I always thought as a trainee that once I got to be an attending, then I don't know, I would like magically show up at the hospital one morning and know all of the things that I was supposed to know, right? Like I imagine this like magical download on the first day of attending hood, which did not happen. And I'm still a little bit bitter about that. But I work. When I work in the hospital. I take care only of patients with cancer because I'm an oncologist and usually when I would work in the hospital for a two week stint, there would be at least a patient or two who would come in terribly sick with a body riddled with cancer. But I had this built in, wired in paradigm that I was a person who was there to fix things and so on. The first day, we would identify all of the, you know, the pulmonary emboli and the renal failure and the assets and the, you know, infection in the fluid in their stomach and anyway, all of these things. And then we would go set about trying to fix all of the things. And my unspoken expectation always was if I was a good enough doctor, then they would be fixed. Right. And and often times that would be true, at least insofar as fixed means that they would leave the hospital and appear to be better than when they came in. But then there would always be one or two patients who would not be fixed and either they would languish on the service sometimes for months.
Tyler Johnson: [00:23:21] Not really getting worse, but also not really getting better. Or sometimes, in spite of everything that we would do, they would develop a new problem sometimes as a consequence of something that we had tried to do to fix the first problem, and then we would chase that second problem, and then that would cause a third problem. And then sometimes they would get into this sort of, you know, therapeutic or to use a word that doctors like, which is iatrogenic, which means "something that we caused," they would get into this iatrogenic spiral and then they would end up dying. And and what I didn't recognize at the time, but can now recognize in retrospect is that as an early physician, almost without exception, the way that I coded that experience internally was "the patient died, and therefore I'm not as good of a doctor as I should be. If I had been a better doctor, then I would have recognized earlier that I shouldn't have used antibiotic A When they got really sick with sepsis, I should have used antibiotic B because if I had used B instead of A, they wouldn't have developed renal failure." And then, you know, et cetera. Et cetera. Et cetera. And what I have recognized in retrospect, is that the glaring flaw in that what seemed to me to be a very astute chain of logic that I was using as an early attending is that sometimes people's bodies are just dying. The best medical care in the world and the most caring, compassionate, committed physician and team of physicians in the world sometimes cannot stop a dying body from dying.
Sunita Puri: [00:25:04] Yes.
Tyler Johnson: [00:25:05] But that, I feel like, is a very even though when I articulate it this way, it sounds like something that any reasonable physician would say, Well, of course that's true. But like in the unwritten curriculum of everything you do in residency and fellowship, I feel like that is sort of beaten out of us, right? Like that's not an idea that you are meant to articulate or consider.
Sunita Puri: [00:25:29] I 1,000% agree. And a couple things came up while you were talking. One is. A thing I also had to unlearn, which was not looking at the bigger picture. Right. The way I teach my students and residents about this is that I want you to be the bird on the mountain surveying the entire forest. Because when someone gets admitted and we're looking, we're kind of playing whack a mole with each problem. They came in in a pain crisis. Now their oxygen sats are dropping. Now their kidneys are failing. We're the bird on the branch, right? We're the bird on a branch of one tree. And all we can see is what's immediately around us and the lack of attention in our training to the bigger picture of people's lives and their diseases, I think is part of what traps us in this way of thinking that if only I was a better doctor, I could have fixed these problems. But when we look at what someone's coming in with in the grander landscape of everything that's happened to them, I think it's easier to find compassion for ourselves and to see the limits of the body more clearly. And I think that that lack of attention to the bigger picture doesn't serve us as practitioners and it doesn't serve our patients and it doesn't make us lesser doctors to have that orientation. It doesn't mean that we don't take fixing or treating what we can seriously. But we have to understand the difference between treatment and cure.
Sunita Puri: [00:27:09] And we need to be honest with ourselves about that. And that's something that can be found again by unrolling that map of the bigger landscape of somebody's life. The other thing I try to teach my students and residents that I learned from a very brilliant attending I had in fellowship is that nature will always win against medicine. That there, as Dr. Cox put it, in scrubs everything we do is a stall. And I love that line and I love trying to help people and their families and other doctors distinguish between what the body can do and what the person can do. Because I think we have this narrative amongst patients that if I just fight hard enough, I'll get better. And I think that does not recognize what you were alluding to, which is the body is a thing born of nature and will ultimately bend to nature's laws. That doesn't mean that we don't try everything we can as physicians to give people a good life and a long life. But I think at some point, understanding and this is what I'll say to patients is that I see and hear that you are a fighter. I can also see that your body can't fight anymore. And those are two different things. And those are the points in meetings where people slow down and really think about that, because it really is in the end, how much can we manipulate biology?
Tyler Johnson: [00:28:47] Yeah. You know, we can come back to the this broader theme maybe a little bit more at the end. But one thing that I just wanted to note in passing is that I remember so there's a company that puts out like the best of the fill in the blank kinds of American essays every year, right? So there's like a 20, 22 best essays in science every year or whatever. And the essay was about how it's so ironic and kind of like the I don't remember the word that the essay used, but the, the flavor of it was, Isn't it funny to note that all children understand that there is a difference between a person and a person's body, that those are not the same thing. And the way that the essay was framing it was since that's such a silly and obviously wrong idea, isn't it funny that all children share this silly and obviously wrong idea? Right? But I'm actually very much with you. And one thing that we have talked about much on the podcast explicitly and that Henry and I have also recognized as one of the sort of implicit messages that ties together so many of the things that we've talked about with many people on the podcast for more than a year now is the idea that a person is more than the person's body and that those are not the same thing. And I would argue that actually that intuitive sense that children have across languages and across cultures and, you know, in spite of their religion or not religion or whatever else is very much true. And I think that there is a deep honesty and a deep sort of metaphysical resonance that you're talking about when you liberate patients from the idea that they are necessarily reduced to their organs and tendons and muscles and skin.
Sunita Puri: [00:30:43] Exactly. And I think we expect I think we have this culture around illness in our society that puts a lot on the person who's already suffering with an illness. You know, they need to eat a clean diet. They need to work really hard to show their doctors that they're doing everything that they're told to do. They need to quote unquote, get stronger so they can get chemotherapy. They need to fight. And that culture is really ultimately, I think, quite toxic to people. And it it distances them from the difference between who they really are and what their body can do. And that distinction, I mean, you can trace this to many other health issues. I'm going to bring one up that doesn't maybe seem the most obvious, but, you know, people who have eating disorders, part of helping them to heal is helping them recognize that your body is not really who you are. And I wrote about my own eating disorder in the book a bit, and that was really the turning point for me, was understanding that who I am is a lot more than how big my thighs are. And there were other issues that contributed to this as well. But understanding that difference liberated me in a way, and I think we need to do a better job in all our professions, in medicine, of liberating people from the tyranny of these societal expectations and the societal culture that collapses who they are with the efforts they make and makes it makes the outcome of their illness be potentially a personal flaw of theirs.
Henry Bair: [00:32:29] So I recently started working in the hospital.
Sunita Puri: [00:32:32] Oh, yes. You're hesitant?
Henry Bair: [00:32:33] Yes. Yeah. But specifically, I started working in the solid oncology service. These patients are all extremely sick, so I currently have 12 patients on my service and of these four are more or less stable. But just today, three were transitioned to comfort focused care, a term which I kind of have an issue with because shouldn't comfort be something we are all aiming for? Yep.
Sunita Puri: [00:32:59] Preach, Henry.
Henry Bair: [00:33:02] To clarify for our listeners, comfort focused care is a term used to describe when we stop doing interventions meant to cure a patient's underlying disease, including things like chemotherapy. So anyway, three patients were transitioned to comfort focused care, for lack of a better term. One person passed away and then the remaining four people in the minds of the entire treatment team should be transitioned to hospice. But the patients and their families haven't quite come around to that idea yet. In some of these cases, there's a lot of tension between patients and their caregivers. And as much as I agree with your points, I don't know how to begin that conversation. What thoughts do you have?
Sunita Puri: [00:33:43] So you're asking specifically about situations where you may want to recommend hospice or comfort focused care.
Henry Bair: [00:33:53] And it's not even necessarily about hospice. It's more like, what are we really doing here in the grand scheme of things? Because right now, sure, we can give a patient antibiotics to treat the pneumonia that they have, but all the antibiotics in the world aren't going to cure their underlying lung cancer and they will never get back to baseline. You know, one of the worst feelings I experience when I go in to see these patients each day is a realization in my mind that this is probably the best that they will feel. It's mostly downhill from here and they don't realize it and their caregivers don't realize it. They haven't. To use your conceit earlier to come to terms with the fact that they are not their bodies. For them, their bodies are what they are. It is all they are and therefore they are still failing and need to try harder to get better. I guess my question is how do you even initiate a conversation to help patients see things in another light?
Sunita Puri: [00:34:52] So I think, first of all, at my old institution, I was very famous amongst the residents and fellows for asking, What are we doing here, guys? Right. Which is, I think, the subtext of what you're asking, that we go into these patient rooms, we have the best of intentions, but we're seeing that what we're doing to them is not necessarily what's, you know, best for them, even as they define what they hope for. And I think one of the principles I think of palliative care, but also really life in general is we have to meet people where they are. But I think understanding where somebody is and opening that conversation, I think a lot of it really begins with asking them to tell you what they know about what's going on for them. Because I would say in a good number of family meetings where what you're alluding to is going on, people may not have the correct and right information. They may not have understood it when it was presented to them. And here you are as a relative stranger. Right. Because when people get admitted, we don't know them and their outpatient doctors don't always have these conversations and can't always be a part of them. So you're coming in as a relative stranger not knowing anything about this person. And the easiest place to start is tell me what you know about your disease and also tell me how you're feeling. And talking about symptoms builds rapport, understanding what they know and correcting any things that they don't actually know. That's actually a very powerful first step in trying to resolve some of these issues. I think also just really opening the space for people to tell you why they're at where they're at. It could be that they've been told a thousand different things by a thousand different people and are really confused.
Sunita Puri: [00:37:01] And so getting to kind of the finer points or the more spiritual essence of some of these issues is just way too out of bounds. And so being patient when you're in these situations, but also having the courage to tell people what may be very hard for you to tell them and what may be very hard for them to hear, because I think that the sort of distress we all experience in these situations, some of it comes from us knowing what they don't yet know. And sometimes we must tell them what they don't yet know, even if we don't think they're quote unquote, ready to hear it, because we don't know what they're ready for. And we make that assumption, I think, as a way of distancing ourselves from going towards the hard conversations. There's no simple answer to this. But what I will say is part of navigating this is two things. One, how we treat the patient and family, and two, how we sit with our own distress. Because how we sit with our own distress and how we recognize the boundaries that exist between what we can do and what we wish we could do. That's the internal work of medicine. And I often tell my trainees, medicine isn't 90% of it is an inside job. Can I withstand the fact that this patient may die a death, that is. Terribly uncomfortable. Can I stand the fact that the patient's outpatient nephrologist has given them the impression that they can continue dialysis forever? How can I stand that discomfort of that I can't intervene on? And how can I meet people where they are and even learn about where they are with curiosity and compassion?
Tyler Johnson: [00:38:56] So one thing that sort of builds on this in a way you're even kind of doing it right now live on mic. But that I wanted to ask you about is one thing that stuck out to me, as you were describing, going from general internal medicine residency, where you had thought about cardiology and some other more sort of fixed disciplines, and then instead deciding to go into palliative care is that it would give you an opportunity not only to minister to the needs of your patients, but also to minister to the needs of the other teams in the hospital, the people taking care of the patients. Can you talk a little bit about what it's like to be in some ways sort of the doctor for the doctors in the hospital? What's that part of your day like? What's that part of your experience like?
Sunita Puri: [00:39:45] Absolutely. And you know, as you were saying, you were talking about the procedure having specialties. I think one thing that's so important for listeners to know is that in palliative care, words and language are our tools and communication is our procedure. So there is a way to learn to talk to people that is every bit as scientific and is every bit reliant on precision and understanding as going into a surgery is. We don't think of it that way because I think there's this idea that, Oh, you just go talk to this person, you know? But to be good at communication requires the same oversight that we need to place central lines. And I think part of the unlearning, to go back to that question earlier, is identifying family meetings and goals of care discussions and code status discussions as procedures. But to answer your the other question, which is it's a huge part of my work, is dealing with the teams and their distress and sometimes their conflict with each other. I think we tend to keep a stiff upper lip in medicine. It's how we're socialized, right? We can't show emotion. We need to just get through our days emotionless while we're attending to the terrible things that are happening around us to our fellow human beings.
Sunita Puri: [00:41:14] And so sometimes I'll be honest, trying to get at how a team is doing or feeling can be really tough because they're not in settings where they can really either individually or collectively, truly tell me how they're doing or feeling. And so what I try to do when it's clearly a tense case and there's a lot of conflict is to give them space if they choose to take it to vent. And I'll just say, like after a family meeting, after every family meeting, I debrief with the teams. Like if someone starts walking away down the hall, as often happens, I'll be like, Nope, nope, come back. We're going to debrief for five minutes and we try to find a private place and sometimes it's just about what happened in the meeting, you know, in terms of content. But a lot of times it's about I just cannot stand that person's spouse. Like she totally derailed the meeting. And you can feel the anger and distress coming up and then you name it and say it sounds like that was amongst the hardest parts of this meeting for you were listening to her and people will open up. We just don't give teams the opportunity because they are in the mode that we were all in in residency of like, I'm going to be here.
Sunita Puri: [00:42:37] I need to fix this. This decision maker is getting in the way. And it's when you get when you give them the space to open up either individually or as a team, that things these things come out and they're important learning and, dare I say, bonding opportunities for them. And then there's some times where I can recognize someone's not doing well and I will usually just like find them on the ward and say, Hey, I was going to get a coffee, do you want to come with me and give them the opportunity individually? Because I think, again, the teams distress is often over the things, the difference between what they can fix and what they can't fix or control. And even just saying, we all go through this and you're not alone. And I see you and I hear you to be seen, heard and understood is what we all want as human beings. It's what we want to give to our patients. And I think it's very much what I really enjoy giving to the teams, even when there's a lot of conflict and it's really hard.
Tyler Johnson: [00:43:43] So clearly, as you're making your way through your training, you are very reflective. You have a lot of self-awareness about why you want to do what you want to do, how you're sort of walking your your training path. But how do you go from that place to writing an entire book exploring this journey of becoming a palliative care doctor? Like, why do you write generally? And then how specifically did the book come about?
Sunita Puri: [00:44:23] So I will say that I was always a writer at heart. I think that's really what I am at heart is a writer. When I was a kid, I was so lonely to be very honest and vulnerable here because I was like the last kid picked up from school. I was the first dropped off. You know, I didn't always fit in where I grew up just because of the demographics. And so I often felt isolated. And I remember I would just walk around the playground making up stories to tell myself to keep myself company. And my dad, you know, he really wanted me to be a good communicator and a good writer. So he used to make me write a page of anything that I wanted most days of the week. And of course, I hated that at first. And then I started to really like it because I could write about whatever the hell I wanted. So I always had that at heart and like the highlight of high school was when I won this National Councils of National Council of Teachers of English Award, and it was just anything that had to do with writing was the thing that kind of made my heart beat and could also still my heart. So it was always a part of me. I actually think it's why I got into palliative care in some level because there's such an attention to language that I have to pay and narrative and how what is the story people are telling themselves about their disease? What's the story the team is telling them? What's just the story the team is telling themselves? So I had always kind of journaled and written and it slowed down obviously during medical training, but I had these half finished pieces and I wrote a piece that came out in 2016 in the New York Times about my first job out of fellowship, doing house calls, hospice work in South LA.
Sunita Puri: [00:46:30] And just the vast difference between what I'd seen doing hospice in Palo Alto and what I'd seen in South LA and the social, cultural and economic factors that a made people in South LA die younger and and in far worse condition. But B that if you don't have a family and an income, hospice cannot fix that. So dying a good death does not always mean to some people dying at home. And that was eye opening for me. And so I wrote this piece and it was really just kind of a lucky break after that that I got editors writing to me, inquiring about the book I was writing. And so my book kind of came about that way. But I had been writing the substance of it for many years. And the writing life, I think what writing and doctoring share is, is the necessity of observation, right? Patient comes in a room, we're instantly observing them. And in writing, you're really observing human nature. And I'm not saying that I'm some lofty, great interpreter understanding of all human nature, but the things you want to write about are the things that depart from the narratives we want to believe.
Sunita Puri: [00:47:57] So, for example, I had a New York Times piece out recently where I really looked at this this myth of what it means to accept that you're dying. And that is something we think people need to come to. But in truth, that narrative, that socially bound narrative only exists for us to feel better. And it has nothing to do with what people actually need at the end of life or what acceptance, the many faces of acceptance. And so I think what I tried to do in the book was really depart from the easy stories like, Oh, I'm a palliative care doc and I make everyone feel great. No one's going to believe that. Narrator Because that's not real life. And so a big part of writing is putting yourself on the line and making yourself vulnerable and opening, owing up owning up to your mistakes, because that's the only way people are going to, like, actually want to listen to anything you have to say. So a lot of the writing life is reflection. I write because sometimes I'm in great pain. And I need to understand why. And I don't know what I'm writing until suddenly I do. And sometimes I write because I don't want to forget something. And then I come back to some of these pieces months, sometimes years later, and I suddenly know what it's actually about.
Tyler Johnson: [00:49:24] So I wanted to highlight one piece of writing that I know is something that particularly touched me. I still remember reading it. It was written just about a year into the pandemic and published in The New York Times. And this was a time, you know, I was commenting with my team as we were sitting in our team room in between seeing patients this morning, that it's remarkably in the course of just a few years, it's become so easy, at least on the surface, to forget what life was like two and a half years ago. Right. So the pandemic has started in early 2020, really started to take hold in the United States in sort of the second quarter of that year. And then by sort of from spring to fall of 2020, we're hearing things about rationing of care and running out of ventilators and what's the wave going to look like and are we ever going to have vaccines? And really all of these things are sort of in the air. And at that time, Sunita wrote a piece for The New York Times called "We Must Learn to Look at grief even When We Want to Run Away." And she tells the story of a man who was in the ICU dying from Covid. So at the time, as was the case in many hospitals, the family members of patients in this hospital were not allowed to visit even if they were dying. And so she describes the process of watching this man's wife watch the man die from a cross a glass door, and then reflects a little bit on the meaning of it. So I just want to read some of this briefly.
Tyler Johnson: [00:51:06] "A nurse pushed pain medicine through his vein. The respiratory therapist removed his breathing tube in one graceful arc. My patient's wife pressed harder against the door and inched closer. Her husband took slow, shallow breaths for a few minutes, and then he was still. She dropped her head and folded forward like paper, curling toward the fire that consumes it. The imprint of her palms remained on the glass door. It's natural and perhaps instinctive to want to look away from mortality, to deny its existence or banish it to a shadowy world. But before us is an opportunity to examine, rather than bury the loss and grief around us, even if especially if it is not our own. Bearing witness is essential to everything I do in palliative care, be it treating a person's cancer pain or discussing what matters most to them in their lives. I try to make visible to my patients and colleagues what is hard but necessary to see. Witnessing requires seeing another's pain as no different from our own. This approach is a powerful way to move through the pandemic together. In the throes of loss, people reach for certainty and control. My patient's wife asked me what percentage of people as sick as her husband had survived and whether a risky therapy could promise life. I couldn't offer her easy answers, only a willingness to stay and listen in. Together, we wrestled with the burden of uncertainty. She shared photos of her husband over Zoom. They had sailed and cooked and taken selfies on the beach. Her photos said what words couldn't. This is the person I have lost. Earlier in my career, looking closely at this particular kind of pain was as blinding as looking at the sun. I distracted myself afterward with Saturday Night Live marathons and slabs of chocolate cake. Eventually, I realized that it wasn't my job to protect people from their grief or to solve it."
Tyler Johnson: [00:53:10] So first off, I just want to say that's really beautiful writing, particularly the the description of the woman watching her husband. But I also wanted to ask one of the things that Henry and I have recognized as we have talked with many people on this podcast is that. In order to allow medicine to remain meaningful, we have to recognize that at its core is this beautiful, ineffable, for lack of a better word, sacred encounter between two humans. And what strikes me as I read your prose there is that that sanctity. Still holds, whether this is a patient who we, quote unquote, get better and send out the door, or whether it's as harrowing and desperate a situation as the one that you're describing there in that anecdote. And so as we get close to closing here, could you tell us, as a palliative care doctor who's now a good number of years into your own attending hood, what have you learned about? What it is that is at the core of medicine that at the end of the day makes it irreducibly sacred.
Sunita Puri: [00:54:32] What a great question, Tyler. I think for me that what makes medicine sacred is actually a line from that piece is the opportunity to see someone suffering is no different than your own. Someone's vulnerability is no different than your own. It's an opportunity to recognize everything that will come to pass for you in the person that you're treating. Part of what I think can make life so meaningful is learning to see that the difference between you and I is infinitesimally small. That your pain. If we see ourselves truly as a human family, your pain is my pain, your suffering is my suffering. And I think even though those are heavy things that we see in medicine to try and to to kind of metabolize and witness, I think at the core of things, that thing that all human beings will share is, is suffering and the finitude of our life and impermanence. We won't all, for example, have families, we won't all have heart problems, but we will all go through what it means to love something and to let it go, or to see something be ours until it's not. And I think the meaning for me comes from being reminded of that when I'm taking care of patients, because that is a very, very sacred lesson in life. But also seeing that people endure the things we think we cannot endure.
Sunita Puri: [00:56:14] There's a quote by Marcus Aurelius that I love, and I finally just wrote it out and put it on my desk today. But it goes as such. The impediment to action advances action. What stands in the way becomes the way. And I love that because I think that kind of summarizes for me what it means to practice medicine that. You know, everything we're seeing that could that we think is going to block our futures or block what we hope for, that that actually can be the way through. And that's part of I think that's how I would summarize where I get the meaning. And this might sound very depressing to everybody out there. And, you know, I can't I will not pretend that anything I write about is a beach read. But I do think that having the opportunity to even ask this ask and answer this sort of question, Tyler, is, I think, a sacred act between two human beings, regardless of whether we were in medicine. And I also just want to say on a personal note that my friendship with you during my fellowship meant more to me that I can say in words. And I think that is also where I find meaning in knowing that I'm not alone in the journey.
Tyler Johnson: [00:57:47] Well, I thank you for that.
Henry Bair: [00:57:51] You know, I think, as Tyler mentioned, we've interviewed so many we've had conversations with so many thoughtful practitioners of medicine. And like you mentioned, one of the themes that we've uncovered that kind of unify all of it is precisely what you said. And I think you've you've brought us through the past hour, through your own stories, through your clinical experiences, through your insights and wisdom, learned to that point in a very eloquent way. You've taught us that the people around us, the humans that we take care of on a day to day basis, are just as real and rich in their lived experiences as ourselves with equal claims to dignity, understanding and compassion. And I think that really is what is so morally rich in this practice. And so thank you so much for sharing your story and everything you have to teach us through your writings.
Sunita Puri: [00:58:53] Thank you so much for having me. This has been truly an exhilarating conversation.
Tyler Johnson: [00:58:58] The one last thing that I just that I want to close with because I think it's such a beautiful thought back to where we started with talking about your mother and you as a little girl accompanying her on rounds and sensing even then something that I'm sure well, I'm sure you were very articulate, five year old, but probably even you could not have articulated it at five. But his I love this beautiful quote from T.S. Eliot, we shall not cease from exploration and the end of all our exploring will be to arrive where we started and know the place for the first time. And I love that idea of you in writing the book and just in living your life. Coming full circle to becoming the physician who embodies the presence that you sensed in your mother as a little girl, but couldn't then have articulated and now have, in effect, spent your life trying to understand what the substance of that spiritual encounter was and then trying to figure out how to articulate it in your prose and now have in some. Your book is dedicated among to other people, to your mom, to have put into tangible form an attempt at articulating what that was and what it means. Just strikes me as a deeply beautiful act. And I think that this conversation in its way is a sort of a microcosm, a sort of a distillation of that same idea.
Sunita Puri: [01:00:27] That's beautiful. Tyler And just so well put. And thank you for seeing me. Thank you for seeing me.
Tyler Johnson: [01:00:35] You're welcome. Well, thank you for talking with us. And we we so appreciate your time and look forward to sharing this with our listeners.
Henry Bair: [01:00:47] 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 www.thedoctorsArt.com. If you enjoyed the episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [01:01:05] 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: [01:01:19] I'm Henry Bair.
Tyler Johnson: [01:01:20] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.