EP. 83: MORAL IMAGINATION IN MEDICINE
WITH LYDIA DUGDALE, MD
The Director of the Columbia University Center for Clinical Medical Ethics discusses how she cultivates “moral imagination” in medical trainees and how she acknowledges and responds to suffering.
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Episode Summary
Moral imagination is the ability to transcend one's own immediate context and experiences to explore diverse moral perspectives and ethical scenarios. In medicine, where decisions can reverberate profoundly through a patient’s life, moral imagination allows us to navigate the ethical complexities of particular situations while honoring the dignity of others. But how can this capacity be developed? Can we actually teach moral imagination to clinicians? In this episode, we are joined by Dr. Lydia Dugdale, director of the Center for Clinical Medical Ethics at Columbia University, who has deeply explored these issues through her writings and research. She is the author of multiple books, most recently The Lost Art of Dying: Reviving Forgotten Wisdom, (2020). Over the course of our conversation, Dr. Dugdale shares her efforts to nurture moral imagination in her students, the importance of acknowledging suffering not just between clinicians and patients, but also among clinicians themselves, what sustains her through the most challenging or mundane moments in medicine, and more.
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Lydia Dugdale, MD is the Dorothy L. and Daniel H. Silberberg Associate Professor of Medicine at Columbia University Vagelos College of Physicians and Surgeons and Director of the Center for Clinical Medical Ethics. She also serves as Associate Director of Clinical Ethics at NewYork-Presbyterian Hospital/Columbia University Irving Medical Center.
A practicing internist, Dr. Dugdale moved to Columbia in 2019 from Yale University, where she previously served as Associate Director of the Program for Biomedical Ethics. Her scholarship focuses on end-of-life issues, medical ethics, and the doctor-patient relationship. She edited Dying in the Twenty-First Century (2015) and is author of The Lost Art of Dying (2020), a popular press book on the preparation for death.
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In this episode, you will hear about:
• 2:31 - Dr. Dugdale’s calling to medicine
• 5:06 - How Dr. Dugdale became interested in clinical ethics
• 8:49 - Why it’s difficult to engage the spiritual side of medicine
• 16:18 - The importance of cultivating imagination, especially for physicians
• 21:44 - The place that higher education has (or doesn’t have) in shaping the “souls” of students
• 27:25 - The importance of creating space to reflect on the patient connection
• 36:14 - Dr. Dugdale’s advice for trainees and clinician on how they can better approach addressing suffering with patients
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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] Moral imagination refers to the ability to imagine and explore diverse moral perspectives, ethical scenarios and values, transcending one's own immediate context, experiences and cultural and social norms. In medicine, where decisions can reverberate profoundly through a human life, moral imagination allows us to navigate ethical complexities of particular situations while recognizing and honoring the dignity of others. It sounds lofty and wonderful, but how can this capacity be developed? Can we actually teach moral imagination to clinicians? In this episode, we are joined by Dr. Lydia Dugdale, director of the Center for Clinical Medical Ethics at Columbia University, who has deeply explored these issues through her writings and research. She is the author of multiple books, most recently The Lost Art of Dying: Reviving Forgotten Wisdom, published in 2020. Over the course of our conversation, we discussed Dr. Dugdale's efforts to nurture moral imagination in her students, the importance of noticing and acknowledging suffering not just between clinicians and patients, but also among clinicians themselves, what sustains her through the most challenging or mundane moments in medicine and more. Lydia, welcome to the show and thanks for being here.
Lydia Dugdale: [00:02:29] Thanks so much for having me.
Henry Bair: [00:02:31] To start us off, can you share with us what brought you to medicine in the first place?
Lydia Dugdale: [00:02:36] Well, I'll probably disappoint you on this front, but I never really wanted to be a doctor and often still find myself questioning this career many years later.
Tyler Johnson: [00:02:46] Oh, wait, sorry we can't talk to you on the podcast, actually, so we'll just have to end right there. Sorry.
Lydia Dugdale: [00:02:52] Just kidding. So the I guess the short of it is that it was sort of an idea that grew gradually over many years and was sort of spoken into my life as well as, I guess combined with a sort of internal sense that it was what I was supposed to do. And this kind of grew and grew and grew over several years. And I kept trying to get away from this sense that I think I'm supposed to be a doctor. When I told my mother that I thought I was supposed to become a doctor, she tried to talk me out of it. She told me biology was her least favorite class in high school, so why would I want to study that? And besides, I've always needed my sleep, so how would I make it through medical training? So that was the kind of encouragement I had in contrast to so many of my friends who had no choice but to, you know, be a doctor, lawyer or engineer. And so eventually I just couldn't get away from the sense that that's what I was supposed to do. And so I applied to medical school and went. So I guess it's a bit of a disappointing story, but but that was it. I mean, some people would use the language of calling that this was some sort of calling to medicine, and I think that's probably the best language for it, whether it's a religious conception or a secular conception, a non-religious conception, sort of this idea that it was not my my choosing, but it chose me.
Henry Bair: [00:04:15] Were there encounters or conversations that you had leading up to applying to medical school that kept drawing you to this vocation, to this calling?
Lydia Dugdale: [00:04:24] Yeah, lots and lots and lots of them. I studied international development in undergraduate and spent a lot of time overseas doing a lot of volunteer work, inadvertently, did a lot of health care, volunteer work. So there were certainly people in rural Haiti, in rural Russia, with whom I was volunteering, who sort of spoke this into my life. And then I had a very close friend growing up whose father is a transplant surgeon. I don't come from a medical family at all. I come from all humanities people. So that family also sort of really spoke it into my life. And yeah, there were just a number of conversations that went on and on for years.
Tyler Johnson: [00:05:06] So, you know, some people decide they want to be a doctor and then they grow up and they become a doctor. And most everything they do is being a doctor, taking care of patients. And then there are other people who decide they want to become a doctor and then they become a doctor. And then they do 15 different things. And you seem to be a little bit more in that second camp than in the first camp. So can you just walk us through a little bit because I think it'll be important for framing questions and conversation that we want to have over the rest of the episode. What do you do? How do you split your time right now?
Lydia Dugdale: [00:05:38] So for my first ten years out of training, I was primarily a primary care doctor, so almost full time primary care, and I negotiated to have a day a week self-funded that I could write and be a human being and do a little bit of ethics work. When I got to medical school, I was amazed by sort of how concrete the thinking was, having grown up in a very humanities rich environment, to find myself, you know, I wasn't pre-med, right? So I didn't know that this is like a thing that you could be totally science minded. And so I was super shocked. And I went to University of Chicago, which at that time was still eight hours a day of lecture, very old school kind of curriculum.
Tyler Johnson: [00:06:24] Where fun goes to die.
Lydia Dugdale: [00:06:27] Yeah. And it was great fun. I mean, I love being a student, right? That's the best. So it was great to study. But, you know, I liked learning about how the body worked. I didn't love it. I wasn't passionate about it. And so when I got to medical school and at dinner parties, all we could do was talk about the cadavers. I felt that something needed to change, right? So University of Chicago has a huge ethics center, and I very quickly found myself gravitating toward that space. And what I loved is that it was interdisciplinary. There were people wrestling with questions of really goodness and truth and the good life, right? If you think about what ethics is going back to antiquity, but the stakes were really high, right? So many of the questions that clinical ethics. Face are life and death questions. And I trained in debate as a high school student and college student. And so being able to wrestle through these things was just those were my people. So then I realized I needed to do ethics. And Dr. Mark Siegler, who directed the Ethics Center there for for decades, founded it and directed it. He sort of called me to ethics, and that just resonated deeply with who I understood myself to be. So then, as a primary care doctor for those first ten years, lots of primary care, very little time for ethics, but that sort of gradually grew. The ethics part of my life gradually grew and then sort of inverted when I took the position at Columbia to direct an ethics center here. I'm now able to do a lot of ethics, and I still am clinical, but that's a smaller part of my week. I also do a lot of teaching, so we've been able to create both formal courses at the university here and we have a lot of extra curricular para curricular might be more accurate opportunities for students to sort of cultivate a really sort of philosophically rich imagination as they sort of make their way through medical school and medical training. And I still write. I try to write, so keep all those things going.
Tyler Johnson: [00:08:36] So I'm going to cite a particular part of your CV and then make a comment about something we've observed on the podcast and then ask you a really big picture question. So get ready. You have a minute to wind up.
Lydia Dugdale: [00:08:49] Buckle up.
Tyler Johnson: [00:08:49] When you were at Yale, you founded the program for medicine, Spirituality and Religion at the Yale School of Medicine. When we set out to start the podcast a year and a half ago, in effect, the observation that we had is that there is an epidemic of burnout in medicine. We know that there are lots of causes, right? The electronic medical record and bureaucratization and corporatization and yada yada. But we also had a sense that in addition to those kind of big picture, systemic issues, that there was also a loss of a shared sense of meaning, that there was a philosophical or even if you like, spiritual problem that also needed to be addressed. Having said that, though, when we started out the podcast episodes, in effect, what we would do with every guest with some variation, depending on who we were talking to, was to say, What do you think is causing this and what can we do to get back in touch with the meaning that brought most people into medicine in the first place? And I think that what has been somewhat surprising to us is how consistently we have heard really just a few of the same themes. One of those themes, which is the one that I'd like you to talk about, is that on the one hand, it's not that anybody ever articulates this as a formal rule, but there is a pretty much omnipresent sense among doctors and other health care workers that whatever you want to call it, a metaphysical side or a spirituality has no role in the medical world.
Tyler Johnson: [00:10:25] It's almost verboten is the way that many people understand that their higher ups understand that situation. And yet almost everyone that we have talked to, regardless of whether they themselves are particularly religious or secular or anything else, there seems to be this deep hunger for precisely that dimension to come or to come back. It's like there's this sense that medicine is incomplete, in part precisely because we don't even have a vocabulary in many quarters for even talking about those elements of medicine anymore. And so with all of that as background, I'm hoping that you can talk about what forces you think may have made it more difficult for us to engage with the spiritual side of human experience in medicine, and then what kind of work you were doing both in the center at Yale and in your ongoing work to try to address that problem?
Lydia Dugdale: [00:11:22] So I'll say this as a primary care doctor at Yale, I had to see 30 patients a day, and I found that it was individual patient encounters where for whatever reason, we were able to connect on a level that was deeper than blood pressure management and diabetes medication shuffling, right? That I would come out of those patient encounters no matter how. Just exhausted. I was completely energized because this is what sustains people in medicine, is these kinds of deep connections with patients. You know, call them spiritual. I mean, that's may very well be the best way to describe those sorts of encounters. So, yes, I think those moments sustain us. I think a physician has to have a certain kind of shaping of the imagination to. Be able to anticipate those sorts of encounters with patients. So if all you see in your training as a medical student is treating patients like they are objects on a conveyor belt, and you're sort of just tweaking the machine right as quickly as possible, you will never cultivate the kind of imagination as a medical trainee to sort of see patients, you know, to begin to see them in the fullness of who they are. And, of course, we can never see anyone in the fullness of who they are. I mean, Emmanuel Levinas, the Jewish philosopher, talks about this, that there's a there's an infinity behind each person, right? Each person is sort of a window into the infinite.
Lydia Dugdale: [00:13:00] We can't know them completely, but can we approach patients with wonder and curiosity and sort of a deep desire to know who they are, what makes them tick? I think that does, as I've written about elsewhere, that does sort of re-enchant the practice of medicine. So yes, we need to shape young trainees imaginations. That's part of what we're doing here at this ethics center. Having said that, any system that requires the same physician to crank through enormously complicated patients at the rate of 30 a day is inherently a corrupt system. You know, human beings do not suffer efficiently. The way that human beings are in the world is not is not efficient, and it's not conducive to addressing deep needs in 15 minutes or less per patient. So, yes, there is a general sort of failure to shape young imaginations, but you also have systems that are just killing people. There's nothing. And so I realized this early on when I thought, Wow, I'm super well-adjusted. I have a great marriage. I have healthy kids. Right. Healthy kids in daycare is a miracle in and of itself. My kid's never out sick. And, you know, I'm a young attending. I'm drinking tons of coffee, just cranking through being idealist. Right. Trying to do it. All right.
Tyler Johnson: [00:14:22] And yet I'm just laughing that that's on your list of things to make sure that you are healthy.
Lydia Dugdale: [00:14:28] Oh, no. Yeah. Oh, man. And when I had a Uri, it was also the Sudafed, which holy cow came back on those years. It's like, what was I doing to myself? But right, this is the way doctors are is, you know, Sudafed and caffeine and you're fine. You can power through anything. And yet if I was recognizing sort of super well-adjusted, well-supported, great community, deep spiritual practices of my own, all of these things were in place. I was lined up. Everything was lined up for me to succeed, to be optimized. And yet I felt like I was crumbling routinely as a primary care doctor because the systems expected me to perform in ways that just were not human. And so that's when I started thinking a lot about sort of system stuff. So yeah, I think it's both. I do think we need to sort of cultivate young imaginations and draw them back, pull them into bigger stories of what it means to be human. Where in medical training do you have a class on what it means to be human? Nowhere, right?
Tyler Johnson: [00:15:31] Except we started one at Stanford. But. Okay. Well.
Lydia Dugdale: [00:15:34] Good for you at Stanford. But where in medical school do students talk about what the purpose of medicine is? Right. What medicine's telos is to use the Greek term, what the ends of medicine are. You ask students, you know, isn't it just sort of glorified Amazon wish fulfillment? Isn't that what medicine is about? Right? You want a new nose? Fine. We'll give you a new nose. You know, we can sort of do whatever you want. That's within the limits of our license. And even the limits of our license will push a little bit. So that's what a lot of students think medicine is for. And, you know, and I think this is subject to debate and rigorous examination, but we don't make space in medical training for questions like that. But I'm glad you do at Stanford.
Henry Bair: [00:16:18] So you've used the word imagination multiple times, which is a really fascinating choice of words. I'm wondering if you can expound upon that and tell us what you actually mean by that. And also, how do you even teach students to cultivate a capacity for that imagination?
Lydia Dugdale: [00:16:33] So imagination is interesting. I'm sort of just beginning to work on it, I guess, as an aspect of my scholarly work. There's one way to think about imagination where we kind of take symbols that we know or recognize and apply them to things that don't make sense. So this is where, you know, classically there's the Necker Cube or something, right? The cube on paper that you can it looks three dimensional on paper. You know what I'm talking about. Yeah. And you sort of try to see it as a box with this face forward or the box with this face forward, you're applying what you know about cubes to this two dimensional sketch on a piece of paper. That's one way that we use imagination. But can imagination be cultivated such that you see an image on a piece of paper or you confront anything that is just not recognizable and you then have sort of cultivated practices or abilities to say, okay, this does not fit any pattern that I recognize, but how can I sort of expand my understanding of patterns or how can I think about things in new ways? So I think imagination is very much wrapped up in creativity, which is also tied very deeply to wonder and awe and beauty and experiencing beauty the way that we can be arrested by an image or a confrontation of an exquisitely beautiful person or gardens.
Lydia Dugdale: [00:18:12] I love botanical gardens just to see, especially being in Manhattan where there's nothing to see is something that's so amazing growing. It's natural sometimes, you know, botanical gardens especially, you see plants that don't normally grow there. And it's it's astounding. But then suddenly the wheels start turning in new ways. Wow. If this is possible, what else is possible? Right? So experiences of beauty, contemplation, silence. We have filled our world with so much noise. And, you know, we certainly need discipline, digital discipline as well. I just actually this morning was listening to a podcast. This person was saying that the average person today is interrupted every 12 minutes, whether it's by a text message or an alert or, you know, someone knocking on the door every 12 minutes.
Tyler Johnson: [00:19:03] I thought you were going to say 12 seconds.
Lydia Dugdale: [00:19:06] I think it was 12 maybe.
Tyler Johnson: [00:19:07] I mean I mean, I'm not I'm not questioning your statistic. It's just I feel about like, I think about how much my cell phone buzzes and it's, like incessant.
Lydia Dugdale: [00:19:15] Yes. And in the hospital, it's horrible, too, especially with the messaging systems through the electronic medical record. But if you think about that and imagination, creativity, wonder or reflecting on beauty, reflection itself all takes time and quiet. We are not cultivating those imaginations, right? Because we are not giving ourselves space to do it. So So then how do we do it? So here at Columbia, I was fortunate enough to persuade a friend of mine, colleague of mine who who's a philosopher, but who has worked in health care for many years to join me at the Ethics Center. And so we together have started up something called the Columbia Character Cooperatives, where students apply and go through an interview process to be a part of a really sort of an intentional kind of learning community. A cooperative is what we're calling them where monthly over dinner and we cater in these dinners or sometimes we go to restaurants or fancy places, but in quiet rooms over dinner. We spend several hours talking about kind of a deeply philosophical curriculum that my my colleague curates. And last year was our pilot. 100% of the students who were in at last year's first years wanted to stay. And all of the fourth years who were staying for a fifth year wanted to stay.
Lydia Dugdale: [00:20:35] So this year we now have two groups. We have first fourth year cohort, and then we have a second and third year cohort. And we're spending hours, one evening a month really going through this curriculum that they will have read in the meantime. And then in the interval periods between the dinners, we invite all of them to mentoring sessions with us. And there's really no agenda. It's sort of however, they want to unpack what they're thinking about, how they're relating to their medical training. And what we're talking about is just sort of open space to talk. So that's the way we've been trying to create imagination. It's interesting because even now some of our students who went through the pilot last year and now just starting the second year are saying things such as, you know, we're sitting in lecture and can't stop thinking about the stuff we're reading and talking about, and yet we know that we're sort of alone because other people's minds haven't been so shaped. They're not reading the same things. And so I think the students are now at a point of starting to think about how to maybe purposefully integrate some of what we're shaping them to be able to think about into their their broader experiences of being a medical trainee.
Tyler Johnson: [00:21:44] I just love that. And I also think that it hearing you talk about those very purposeful efforts towards cultivating a way to teach moral imagination to medical students reminds me of what I think has been a really meaningful and wide ranging debate over the last decade about the very purpose of higher education in the United States in general. And in particular, it makes me think of this really pointed and to me fascinating exchange that happened about ten years ago. William Deresiewicz, who used to teach at Yale, writes this very now very famous or infamous, depending on who you ask, essay in The New Republic called Excellent Sheep, where he makes this argument that higher education sees itself, especially elite higher education, sees itself as having these very sort of noble ideals and cultivating free thinkers and all these things. But that what it actually does, as he puts it, is mints, excellent sheep who are really shiny and really good at high test scores and getting, you know, prestigious internships and whatever. But if you kind of look under the hood and look under the surface, there is often not a lot of there, there, is the argument that he makes. But the thing that actually interests me much more than his original argument is that then as a very pointed response to his original essay, Steven Pinker, who's a world famous psychologist at Harvard, wrote this response essay, and I'm going to quote a paragraph from his response essay.
Tyler Johnson: [00:23:16] He says, "Perhaps I am emblematic of everything that is wrong with elite American education, but I have no idea how to get my students to 'build a self' or 'become a soul.' It isn't taught in graduate school and in the hundreds of faculty appointments and promotions I have participated in, we've never evaluated a candidate on how well he or she could accomplish it. I submit that if building a soul is the goal of a university education, you're going to be reading anguished articles about how the universities are failing at it for a long, long time." And the reason that that interests me so much is because it's clear from the tone, even in just that quote, let alone if you read his entire essay, that he views this whole idea of -I'm not saying that building a soul is exactly the same thing as cultivating a moral imagination, but I certainly think they're at least related- And it's clear that this person, who, as I said, is a world famous psychologist at Harvard, one of the preeminent thinkers, I think, in his field of his era, views that derisively.
Tyler Johnson: [00:24:20] Right, like 'building a soul' is in scare quotes to make sure that everybody knows that he thinks it's such a silly idea that he would never put it without scare quotes in his own writing. Right. And I just find that to suggest such an impoverished view of what education is, like, what it means, what we're doing as people who are teaching, sometimes medical students, sometimes undergraduates. And so all of that is to say that I give endless applause to you and your colleagues because I feel like what is needed is this sort of- because in medical school what that becomes -my formulation of what Steven Pinker is saying in medical school- is that it becomes entirely mechanistic or technocratic. Right. We are complicated machinists fixing complicated machines, which, you know, on one level is sort of fine. Like, you know, fixing the human machine can still be exhilarating in its way. But I feel like it just cores out the heart of the thing that brought us into medicine in the first place. And no wonder that we're all burnt out if we're working 90 hours a week being really complicated machinists, you could almost guess that that would be what would happen.
Lydia Dugdale: [00:25:27] Right, there's a reason why real machinists are unionized, right? Because you need to cap that at 35 hours a week or 40 hours.
Tyler Johnson: [00:25:35] I want to go home. Sure.
Lydia Dugdale: [00:25:36] Yeah, go home and don't do that anymore. Be a human being.
Tyler Johnson: [00:25:38] It's not a calling for most people. Right? Zen and the Art of Motorcycle Maintenance aside, like, it's just that's not like the right. It's just different. And to your point from before, I think that if you pair the work of a calling with the logistical feeling of a technical pursuit, at some point the resulting friction is just going to be too much.
Lydia Dugdale: [00:26:03] That's right. I hadn't thought about our work as shaping souls, but I think helping people to be human beings, you know? And then you ask the question, well, what does it mean to be human? And even early on we thought, okay, relationship number one, human beings are deeply relational. And what we know is that people in isolation die more quickly. Okay, so then why are we training students to sort of go through their careers in isolation? No relationship is huge. You also don't make it. You wither and die if you're not fed and nourished. Okay. Food is requisite, right? So, you know.
Tyler Johnson: [00:26:40] Intern year notwithstanding.
Lydia Dugdale: [00:26:42] Eat and drink and talk and talk about things that, you know, imbued with meaning and purpose. And, you know, early on, we as we were talking about sort of what to do, we read Plato's Euthyphro and it's a Socratic dialog. But anyway, one of the the statements that comes through there is, is the need to if you're going to do things well, you need to attend to the young first. And there's a metaphor of farming tending to the young shoots first. And we thought, okay, we're going to start with medical students. We're going to take care of those young shoots and nurture them. Cultivate them. Right and think about what they need to flourish rather than wither. And so that's sort of been the pursuit of what we've been doing.
Henry Bair: [00:27:25] So I'm currently an intern spending my first year in residency in internal medicine. I don't know what other residency programs are like, but I suspect it's more or less the same in this regard. But my program doesn't have built in space and time for reflection. I recently came off a challenging month long block on the pulmonary medicine service. I had a co intern on the service and incidentally, two days after we left the service, we learned that one patient, we each had been taken care of since day one on the service had both passed away. My patient passed away from an exacerbation of idiopathic pulmonary fibrosis, which basically means that the lung is extensively scarred and we don't know why. And my co-interns patient passed away from massive bleeding in the adrenal glands caused by lung tumor metastasis. Since I learned of my patient's death, it has been on my mind a lot. I keep thinking about how much more we could have done. Why didn't we initiate the lung transplant process sooner? I had tried to be encouraging with the patient and his family about the prognosis, and as a result, they hadn't really spent much time at bedside thinking they'd have more time. He had gone from talking and laughing with me and with his family over the phone to needing to be intubated and then dying in the span of 36 hours. About a week after they both passed away, my co-intern sent me a brief text asking me how I was doing.
Henry Bair: [00:29:01] I told her a little bit about what was occupying my mind about this patient, and all of a sudden it's as if the floodgates opened for her and she began pouring out this distress she was experiencing from her patient's death. She was troubled by why she hadn't pushed harder for the surgeons in the hospital to locate and fix the bleed sooner. Why she hadn't been as straightforward about matters of life and death with this patient. It turns out both of us were wrestling with these feelings of how wrong this all felt, that even though we had been trying to help our patients, what if because of what we had done, their lives and their families were now worse off? We ended up discussing this for a long time. And even though it obviously didn't change what happened, in a way it was rather therapeutic knowing that we weren't alone. So to your point about having space to reflect on what it all means, how these moments impact us and how we can be more mindful for the next time having this space is crucial. It's just a pity that we had to find our own time for this in at 9 p.m. too, after we had gotten home from long workdays. So I don't really know what the practical solution is here for busy trainees and clinicians. What do you think?
Lydia Dugdale: [00:30:19] Yeah, Henry, thank you for sharing those stories. I'm sorry that you've gone through that. I suppose there will be many more such experiences in your training, but the question you leave me with here is what should be done differently, right? Because you will face more experiences like this. I'll say that Professor Ashley Moyes, who directs our cooperatives, he's been connecting with all of our last years, fourth years, who are now in residency programs. And what they've all told him and he shared with me is that in terms of mentorship, in terms of people who are actually creating space for the trainees to kind of debrief this difficult stuff, it's all been peers, which, you know, as you know, Tyler and I as attending physicians, that's I mean, we're glad that peers are supporting one another. But there is also a role in any sort of formative experience of having the sort of teacher come alongside the learner to help make sure that space is is there. I do remember from my training one very in-tune attending physician when I was about to quit internship, she said, Dugdale, you are not quitting medicine.
Lydia Dugdale: [00:31:36] And she was super feisty. She didn't quite grab me by the collar and pull me outside, but it kind of felt that way. She was she was short and really feisty and trained in the in the really hard years of women in medicine. And she took me outside and sat me down on a bench in the sun in front of the hospital and basically gave me a list of all the reasons why she thought I should stay in medicine. But it's amazing that in three years of residency I can remember one attending physician who did that. So I guess my encouragement to the trainees is, yes, continue to be that sort of peer mentor to one another. Keep your eye out for your colleagues. But then my encouragement to those who are further along in training or more senior is we you know, we have to keep our eyes on the young shoots, right? We have to be nurturing and cultivating those who are still learning and coming up because these experiences either shape you for good or they corrode you and fuel the epidemic of burnout.
Tyler Johnson: [00:32:40] And I think to your point, one of the things that strikes me about those encounters, like the one that you're describing with the feisty attending or resident or whoever it was when you were in training, is that it doesn't necessarily have to be a long or a complicated thing. Like it's more about the sensitivity to notice that something needs to be said than it is about the number of words that you say, Right. Or even about saying specifically the right thing as if there were a right thing. It's really just that. I mean, I don't mean to put words in your mouth, but I can imagine that as an intern, what mattered the most to you was just the fact that an important person noticed that you were having a hard time and then cared enough to take you outside and say something and give you a shot in the arm.
Lydia Dugdale: [00:33:27] That's exactly it. And it's actually a wonderful sort of image of I'm just thinking of a patient that I wrote about once who was, you know, so called frequent flier to our hospital was always, always hospitalized and was so mean. He was so mean to everybody. And people did everything they could to avoid him. And I took care of him as a resident every single year. And then I would take care of him as an attending when I attended on the wards. And then before I left Yale, the last time I attended on the wards, he was my patient yet again and he completely gave me a shake down in front of my whole team, completely humiliated me. I remember just feeling I could feel the red just come down my face as he's just berating me in front of my team. And finally one day he asked me just to listen to his story. He. He said, I went to check on him. He said, Sit down. I got to tell you something. And this wasn't a guy you fought with. And I sat down, but he then took an hour to basically unpack. What a long, arduous journey this had been for him with his illness and everything he lost and his community and his church life and how he's basically been in the hospital, whatever, 279 days out of the last year. And what this has done to him as a person and I was so moved, I ended up writing a journal article and I can't remember where I published it, but I was so moved.
Lydia Dugdale: [00:35:02] And when I went back before I published the article, I wanted him to read it and I knew he'd be in the hospital. I just looked him up and he was there and I went and I read it to him and he started weeping. This man, who was for years tortured me. He started weeping and he said. Someone finally noticed. You know, when you think how many medical students and residents and attending physicians and how many years and how many days in the hospital. And this man felt unnoticed. And I think that that is true also for our trainees. Right. How many 30 hour shifts or whatever the equivalent is now? How many 16 hour days, How many nights with no one at home and like bad, crappy Chinese food takeout, Right. Or whatever it is, like whatever sort of the experience of really, this is what my life is and people don't notice. So you know how this is part of imagination. This is part of getting off of our phones to see who's in front of us, right? How can we cultivate eyes to see. Right. And to see our colleagues, our peers, our patients who are just asking to be noticed because life is hard.
Henry Bair: [00:36:14] I want to be mindful of the time we have, which we don't actually, which is unfortunate because we haven't even talked about your book yet, which there are so many questions I want to ask about. But maybe as we approach the end here, I want to ask about the themes in the book by way of this question. So we've been talking a lot about, well, your story illustrates the importance of noticing someone's suffering in bearing witness to someone suffering. Right. And I think in many ways, your your book, The Lost Art of Dying, discusses or reframes how we can think about mortality, illness and suffering. And I would love to know what advice do you have for trainees and for clinicians, for how we can better approach addressing these issues of suffering and existential angst sometimes with our patients? Yeah, that's.
Lydia Dugdale: [00:37:05] A great question. Sometimes people hear me speak on the book or read the book and ask me if I'm Buddhist, which I'm not. But you know, there are practices, as I understand it, or as people have explained it to me within Buddhism of sort of sitting with. Right. And this is I mean, sitting with your fear or your sadness, walking toward it, allowing yourself to feel that's a human thing that's not necessarily belonging to to Buddhist practices, I would say. And I think that's sort of the approach that I advocate in the book, which is that a lot of people are really nervous about how to start this sort of bad news conversations or the death conversations or the, you know, sort of existential angst conversations. But once that door is open, in fact, I'll tell you that the statistic is that boomers would much prefer to talk to their kids about sex than to their parents about end of life. Okay. And as a mother of teenage girls, it's interesting to me. But the point is, is that death is the thing we don't want. You know, if the birds and bees was always awkward. The one thing we don't want to talk about is death. But studies show that once that door is open, people are really willing to talk. And so in my, you know, many years of being primarily a primary care doctor and having thousands and thousands and thousands of end of life conversations, there are fewer than five patients probably that completely lost their stuff when I attempted end of life conversations because everybody's wanting to talk. They just don't know how to start. And so honestly, Henry, what I usually do as a primary care doc is kind of pretty basic. But I just say, you know, Miss Smith, it's flu season.
Lydia Dugdale: [00:38:57] If you get really sick from flu, who should we call? Okay. You want us to call your spouse? Fine. Does Mr. Smith know how you feel about engaging the hospital? Well, what do you mean? Well, do you know how you feel about engaging the hospital? What do you mean? Okay, well, let's talk about some basic things. With bad flu, you might need a breathing machine that's a tube down your throat, right? So you start with this sort of basic stuff, but the door's already open at that point. But we're in this safe space of talking about her surrogate decision maker, her life partner and the flu. But then you can build from there. And you know, as a GP, I would have these conversations every year because Medicare made me have this conversation every year as part of the annual wellness visit. And so we would build, right? So then we're starting to talk about more and I'm also watching their health hopefully not deteriorate, but watching their health change as it does with age. And so sometimes these conversations then would sort of be way up to the next year when they did get that cancer diagnosis. You know, last year we talked about this, but we are in a new space now. Let's go deeper. Where are you at? You know, and so pushing. But then from there, those conversations can also lead into questions of for some people, it's what do they believe? I remember a woman came in and I said, You're here for your annual, but I want to make sure there's nothing else on your mind. And she says, I just turned 70 and I realized I don't know what I believe is sort of, okay, well, let's solve that one. And like.
Tyler Johnson: [00:40:26] Let's see, what's the code for that? I don't let me look.
Lydia Dugdale: [00:40:30] You can bill for existential angst. It's something like that. Yeah.
Tyler Johnson: [00:40:33] There's not really a thing.
Lydia Dugdale: [00:40:35] Yeah, there's an ICD ten code for.
Tyler Johnson: [00:40:37] Oh my gosh, I really that sort of makes me mad in a backwards way.
Lydia Dugdale: [00:40:42] It's a little bit strange, but more than 15 minutes of my 30 minute visit was spent counseling over existential angst. I suppose that will satisfy the billers. But so yeah, I think just opening the door a little bit, people are ready, ready to walk through and you know, having so many of these conversations over time and then also caring for many, many patients on the wards who just really, you know, ended up dying these highly medicalized deaths that their families, in retrospect, said, you know, I never want to go through that again. I don't want to die that way. I'd hate to have that happen. That's sort of what led me to thinking about preparation for death and helping my patients be as prepared as possible.
Tyler Johnson: [00:41:22] So we've talked about so many things. We have one minute left. I just this this idea of cultivating a moral imagination, whether it's imagining where your patient, who is 70, may be in their existential angst, or you're attending imagining where you were as an intern, or you imagining where your students are and what they need and, you know, building their own moral imagination. The golden thread that I keep being reminded of, G.K. Chesterton was one of the primary inspirations for C.S Lewis, and C.S Lewis quotes him sometimes and he wrote this beautiful thing that I come back to so often. He said, "How much larger your life would be if your self could become smaller in it? If you could really look at other people with common curiosity and pleasure, if you could see them walking as they are in their sunny selfishness and their virile indifference, you would begin to be interested in them precisely because they are not interested in you. You would break out of this tiny and tawdry theater in which your own little plot is always played, and you would find yourself under a freer sky in a street full of splendid strangers." And I feel like that's just such a beautiful sort of summation of the invitation that I hear you making, that all of us in medicine, wherever we are in our training or anything else, try to enter into that world that is a street full of splendid strangers. So we we thank you.
Lydia Dugdale: [00:42:42] I love that. Thank you so much, Tyler. Thank you, Henry.
Henry Bair: [00:42:44] Thank you so much.
Henry Bair: [00:42:48] 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: [00:43:06] 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: [00:43:21] I'm Henry Bair.
Tyler Johnson: [00:43:21] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.
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LINKS
In this episode, we discussed Alan Deresiewicz book Excellent Sheep: The Miseducation of the American Elite and the Way to a Meaningful Life (excerpt from which is published in The New Republic) as well as Steven Pinker’s response essay The Trouble with Harvard.
Dr. Dugdale is the author of The Lost Art of Dying: Reviving Forgotten Wisdom.
