Communication Between Patients & Clinicians in the Age of AI

Transcript

• 00:00Started. We have a pretty
• 00:01full program today. I'm Roy
• 00:03Herbst,
• 00:04from,
• 00:05hematology oncology, the the cancer
• 00:07center. And, I thought we'd
• 00:09start by saying a few
• 00:10words about the Iris Fisher
• 00:11lectureship,
• 00:12which is endowed by David
• 00:14Fisher,
• 00:15in nineteen ninety nine.
• 00:17And, I know that his,
• 00:19their his daughters their daughters,
• 00:20Francie and Karen, are online
• 00:22with their spouses and their
• 00:23grandchildren,
• 00:24and, we'd certainly welcome you
• 00:26to come in future years.
• 00:27David passed away,
• 00:29this year or last year,
• 00:31so he's not here. But
• 00:32I I remember over the
• 00:33last fourteen years sitting in
• 00:34the front row hearing him
• 00:35introduce this lecture and realizing
• 00:37how important it was to
• 00:38him.
• 00:39On the next slide,
• 00:43you can see see David.
• 00:45He was involved with the
• 00:46Yale School of Medicine for
• 00:47nearly sixty years. He was
• 00:49the first medical oncologist in
• 00:51the New Haven community,
• 00:52but sometimes people debated that,
• 00:54and he remained in private
• 00:55practice for thirty years before
• 00:57joining Yale Cancer Center in
• 00:58nineteen ninety three as a
• 01:00volunteer in full time in
• 01:01nineteen ninety five. This fellow
• 01:03has volunteered in more than
• 01:04many of the faculty who
• 01:05we paid.
• 01:06He chaired and co chaired
• 01:07the cancer committee for Yale
• 01:08Cancer Center, Yale New Haven
• 01:10Hospital since nineteen ninety seven.
• 01:13Among his other things, he
• 01:14was very involved with hospice.
• 01:15He was on the board
• 01:15of Connecticut Hospice. He also
• 01:17won the twenty twenty,
• 01:19Yale Cancer Center lifetime achievement
• 01:21award. You can see from
• 01:22these pictures, you can see
• 01:23he was a, you know,
• 01:24a a stalwart in the
• 01:25Jewish community on the left.
• 01:27You can see him with
• 01:28some of the kids and,
• 01:29you know, wearing his Yale
• 01:30hat. And especially important for
• 01:31me is when I first
• 01:32came here, I said to
• 01:33David, we need to emphasize
• 01:35education and teaching. And David
• 01:37actually sponsored. And to this
• 01:38day, we give out the
• 01:39David Fisher Awards in hematology
• 01:42and oncology for teaching and
• 01:43mentorship.
• 01:44And, you can see David,
• 01:46that's about eight, nine years
• 01:47ago.
• 01:48These lectures, as I say,
• 01:49have been extraordinary, and you'll
• 01:50hear about today's, speaker who's
• 01:52amazing.
• 01:53Quality of life issues held
• 01:54more than a professional interest
• 01:55for David.
• 01:57These issues were are a
• 01:58personal concern for him and
• 01:59his wife, Iris. And this
• 02:01is actually
• 02:02the the lecture he dedicated
• 02:03in her honor who was
• 02:05a brilliant concert pianist. I'm
• 02:07sorry I never heard her
• 02:08play, but I had been
• 02:09to David's house a few
• 02:09times, so I did see
• 02:11pictures. And she was diagnosed
• 02:12with sarcoidosis,
• 02:13which is, of course, a
• 02:14very painful and incurable disease
• 02:15of the heart and lungs.
• 02:17The couple's treatment decisions were
• 02:18weighed and balanced against the
• 02:19impact of therapies that were
• 02:21they would have on her
• 02:21personal well-being, hence his his,
• 02:24desire for for this lecture.
• 02:25This is, like, the twentieth
• 02:26lecture.
• 02:27It even went on through
• 02:28COVID.
• 02:29Doctor Fisher's hope was that
• 02:30this lectureship would serve as
• 02:32a lasting memorial to his
• 02:33wife, Iris, while providing an
• 02:35extra occupational opportunity for our
• 02:36physicians and staff for the
• 02:38benefit of our patients at
• 02:39the cancer center.
• 02:40Both are missed.
• 02:42David, we miss you enormously.
• 02:43Your wonderful presence. You cared
• 02:45about the patient. You're a
• 02:46brilliant clinician and scientist.
• 02:48So, we're thinking of you
• 02:49today. And now I'm gonna
• 02:50turn this over to Laura
• 02:51Morrison to introduce today's speaker.
• 03:01Alright. Hi, everyone, and welcome
• 03:04to Smilo Grand Rounds today.
• 03:07I'm privileged with my colleague,
• 03:08Jen Capo, to introduce our
• 03:11guest speaker.
• 03:13I am,
• 03:15one of the hospice and
• 03:16palliative medicine doctors here at
• 03:19Yale. I serve as an
• 03:20attending on the York Street
• 03:21campus, and I direct our,
• 03:24palliative medicine education program.
• 03:27And within that, direct our
• 03:29our Yale serious illness communication
• 03:31program.
• 03:33And Jen Capo
• 03:35is our chief of palliative
• 03:36care.
• 03:38Doctor Bach is our guest
• 03:40speaker today. Tony Bach has
• 03:42been a mentor to both
• 03:43of us for over a
• 03:44decade,
• 03:46even in developing our program
• 03:48here at Yale.
• 03:50He's an internationally
• 03:52renowned,
• 03:54palliative care specialist and innovator
• 03:56and researcher.
• 04:00He is currently a professor
• 04:02of medicine at the University
• 04:04of Washington,
• 04:05where he is also a
• 04:07board certified oncologist and palliative
• 04:09care specialist.
• 04:13On the innovation front,
• 04:15he is best known for
• 04:17being a cofounder of what's
• 04:18called VitalTalk.
• 04:20VitalTalk is a national, a
• 04:22nonprofit
• 04:24that was founded
• 04:26to further serious illness communication
• 04:28and make it more accessible
• 04:30and of higher quality for
• 04:32our patients and their families.
• 04:35What's unique about the model
• 04:36is
• 04:37really creating a skill set
• 04:40that can be
• 04:41both,
• 04:43taught and learned
• 04:45and disseminated
• 04:46widely internationally
• 04:48and nationally.
• 04:50And I think what I
• 04:51wanted to share that I
• 04:52appreciate the most
• 04:54really about the innovative model
• 04:56that doctor Bach and his
• 04:57cofounders
• 04:58created was really the spirit
• 05:00of curiosity
• 05:02and drawing upon
• 05:04expertise from
• 05:06many peripheral,
• 05:08fields,
• 05:09even the start up environment
• 05:11that's so rich in the
• 05:12Bay Area,
• 05:14but also from k through
• 05:15twelve education,
• 05:17the literature of psychology,
• 05:20specifically adult learning theory,
• 05:22the field of mindfulness
• 05:24and the science of communication.
• 05:27And I think it's just
• 05:28something for us all to
• 05:29really
• 05:30appreciate and carry forward.
• 05:35Great. And I just wanted
• 05:36to share, one one small
• 05:38example of how doctor Brock
• 05:40actually has influenced the Yale
• 05:41palliative care program.
• 05:43Back in two thousand ten
• 05:45when I was being recruited
• 05:46by Tom Lynch who was
• 05:47the cancer center director at
• 05:48that time,
• 05:50doctor Lynch asked me to
• 05:51envision what Yale Palliative Medicine
• 05:54could be with the right
• 05:55vision and the right mission.
• 05:57And it happened at that
• 05:58time where I received this
• 05:59request to be at a
• 06:00retreat for rising,
• 06:02leaders of the palliative care
• 06:04field. In fact, Andrew Putnam
• 06:06and Laura Morrison were, with
• 06:07me at that retreat, and
• 06:09I happened to be assigned
• 06:10to Tony Bach as a
• 06:12mentee.
• 06:13And he graciously spent over
• 06:15an hour walking around this
• 06:17beautiful lake, in Illinois,
• 06:19talking to me about what
• 06:21Yale Palliative Care could be.
• 06:23And after that meeting, I
• 06:24knew that this was gonna
• 06:25be an amazing opportunity.
• 06:27So it's partially,
• 06:29probably
• 06:30really importantly due to that
• 06:32conversation that I experienced with
• 06:33doctor Bach that I came
• 06:34here, and I've had this
• 06:36amazing last fifteen years,
• 06:38interacting with all of you
• 06:39and having the chance to
• 06:40grow palliative care here with
• 06:41this amazing interdisciplinary team with
• 06:43whom I work. So thank
• 06:44you. We're grateful. We're so
• 06:46thrilled you're here, and we're
• 06:47looking forward to your talk.
• 06:55Well, thank you so much.
• 06:56Can you guys hear me,
• 06:57miss Mari? Okay.
• 07:00While we get our slide
• 07:01switched, I'm gonna do two
• 07:02things. I would like you
• 07:03to, first, turn to the
• 07:06person next to you. And
• 07:07if you don't know them,
• 07:08introduce them yourself.
• 07:09Or if you do know
• 07:10them, say hello and have
• 07:12a quick check-in.
• 07:14And then the second thing
• 07:15is, can you spend a
• 07:17moment then remembering
• 07:19one of your teachers, one
• 07:21of the people who taught
• 07:22you something important about communication?
• 07:25So go forward, and we
• 07:26will I will be back
• 07:27with you in about a
• 07:27minute. Thank you.
• 07:30Why don't you do the
• 07:31honors
• 07:36there? Thank you, everybody.
• 07:41Thank you.
• 07:45Thank you for coming and
• 07:46starting in kind of an
• 07:47untraditional way.
• 07:49One of the things
• 07:51I am interested in, especially
• 07:54now that we can get
• 07:55back together, is what makes
• 07:58something worth coming to in
• 07:59person. Right? And I would,
• 08:03propose
• 08:04that
• 08:05part of the ritual of
• 08:06coming together for a discussion
• 08:09about how do we practice,
• 08:10how do we improve, how
• 08:12do we reflect on what
• 08:13we're doing, is actually
• 08:15seeing your community and being
• 08:17together. And and I think
• 08:18it's one of the things
• 08:19that we kind of lost
• 08:20during COVID that,
• 08:22we are now rebuilding.
• 08:24So thank you for doing
• 08:25that. I'm just curious of
• 08:26those of you who thought
• 08:27about someone who
• 08:30from whom you learned something
• 08:31important about communication. For how
• 08:33many of you was it
• 08:34a patient? Can you raise
• 08:35your hand? A few. How
• 08:37many was it a mentor?
• 08:39How many was it someone
• 08:40else? A family member or
• 08:42friend or something like that?
• 08:44Well, thank you. Because I
• 08:45think what that shows is
• 08:49how we learn to relate
• 08:51to each other is actually
• 08:53a combination of many things.
• 08:55It's not just a skill
• 08:56set. It's not just something
• 08:57you learn online and learn
• 08:59on an app. It's actually
• 09:00learn in a relational context.
• 09:02And so that's one of
• 09:03the things I'm gonna be
• 09:04coming back to today.
• 09:06Here's my title slide. And
• 09:07so my title slide, disclosures,
• 09:09I don't have any formal
• 09:11disclosures, but I will just
• 09:12say that this title slide,
• 09:14I, created using AI. Just
• 09:16in the spirit of this
• 09:18talk.
• 09:18And you'll notice it's a
• 09:20little bit too much and
• 09:21a little bit not enough
• 09:22all at the same time.
• 09:23Right?
• 09:24I asked for an Asian
• 09:25doctor,
• 09:26and I said I got
• 09:28this and I said, actually,
• 09:29I think I need someone
• 09:30older, and it made me
• 09:31some made me look way
• 09:32too old, and so I
• 09:33went back to this. But,
• 09:36you know, these days, you
• 09:37know, you can go to
• 09:38chat g p t and
• 09:39go, you know, can you
• 09:41write me a talk? And,
• 09:43if you wanna do this,
• 09:44you can look at all
• 09:45the stuff it scraped from
• 09:47all the stuff in that
• 09:48I put in the medical
• 09:49literature, and you could probably
• 09:50get something from it. But
• 09:52what AI can't do,
• 09:54what it cannot do is
• 09:56it cannot meet this moment.
• 09:58Right? And we are meeting
• 10:00today at a very
• 10:02a very distinctive moment in
• 10:03the history of our country,
• 10:04in the history of medicine.
• 10:06And just to channel,
• 10:08doctor Sherwin Newland, Shep Newland,
• 10:10who's part of the reason,
• 10:12that I am here,
• 10:14he, in reviewing
• 10:17an amazing book called The
• 10:18Spirit Catches You and It
• 10:19Falls Down in The New
• 10:21Republic back in,
• 10:22nineteen ninety seven, he said,
• 10:25the challenge
• 10:26as a doctor, he's talking
• 10:27about, is to respond to
• 10:29a reality whose enormous consequences
• 10:32are too often underestimated or
• 10:34ignored. Patients bring to doctors
• 10:36not only their diseases,
• 10:38but their entire lives. And
• 10:40so by channeling Shep, I
• 10:42I'd like to just put
• 10:43out here that
• 10:45what we are doing in
• 10:46medicine right this moment is
• 10:48we are still responding to
• 10:50this challenge. Right? And the
• 10:51challenge changes
• 10:53every time new technology comes
• 10:55in, and that's partly what
• 10:56we're doing now.
• 10:58But what I wanna step
• 10:59back to is,
• 11:01like, as we think about
• 11:02why we are communicating and
• 11:04what we are here to
• 11:05do, it is so easy
• 11:07to look at what is
• 11:08happening now, the slash and
• 11:09burn politics of what is
• 11:11happening,
• 11:12the undercutting of the NIH,
• 11:14and to and
• 11:15to think, wait a minute,
• 11:16is is public is medicine
• 11:18just a business?
• 11:19And actually, the reality is
• 11:21it is not a business.
• 11:23Medicine is a public good.
• 11:25Right? There are economics to
• 11:27medicine. We need to fund
• 11:28it. We need to make
• 11:29it sustainable.
• 11:30We need to make it
• 11:31possible for all of you
• 11:33to spend the time with
• 11:35patients that they deserve and
• 11:36that you deserve to do
• 11:38the best job that you
• 11:39could. But the reality is
• 11:41that is not part of
• 11:42a business plan that we
• 11:44can just, by squeeze, by
• 11:45pushing people onto AI to
• 11:48order their exams for themselves.
• 11:50Right? Like, we could get
• 11:51to the point where they
• 11:52could order a CT scan
• 11:53through their app or whatever,
• 11:55but actually, that is not
• 11:57the kind of medicine that
• 11:58I would wager that any
• 11:59of us would wanna practice.
• 12:01You know, when I was
• 12:02starting my career, this was,
• 12:05a while ago, nineteen eighty
• 12:06four, you know, one of
• 12:07the reigning
• 12:09new kinds of thinking was
• 12:11actually by a Yalie. This
• 12:12was, doctor Jay Katz. He
• 12:14was a physician and a
• 12:15lawyer here at Yale, and
• 12:17he wrote an incredibly influential
• 12:19book, The Silent World of
• 12:21Doctor and Patient, which actually
• 12:24still stands as
• 12:26a milestone in the field
• 12:27about
• 12:28how patients
• 12:29behave and how doctors behave
• 12:32together. And the silent world
• 12:34he was talking about was
• 12:35a kind of silence where
• 12:38patients didn't really say what
• 12:39they thought. Doctors said everything
• 12:41that they thought, and there
• 12:42was a kind of silence
• 12:44in between them. And part
• 12:45of his innovation
• 12:47was to say at the
• 12:49level of ethics, at the
• 12:50level of someone in the
• 12:51field, that we should actually
• 12:53break this open, that we
• 12:55should
• 12:56expose
• 12:57this whole conversation
• 12:59to real air. And
• 13:01he was an innovator in
• 13:02his time. Of course, he
• 13:04was an academic. Right? And
• 13:06so this was happening in
• 13:07the happening in the halls
• 13:08of academia.
• 13:10Outside, the same year, right,
• 13:12this was, the year I
• 13:13graduated from medical school as
• 13:15a young gay man.
• 13:17This was happening. Right? We
• 13:19were in the middle of
• 13:20the AIDS epidemic.
• 13:22People my age were dying
• 13:23left and right.
• 13:25I was watching
• 13:26patients in my medical school,
• 13:29being treated like, honestly, like
• 13:31specimens at the zoo. They
• 13:33would come into Durham clinic,
• 13:34and we would all parade
• 13:35by and stare at their
• 13:36Kaposi sarcoma
• 13:38and make, you know, snotty
• 13:40jokes in the hallway about
• 13:42how they had gotten it.
• 13:43But what these guys taught
• 13:45us is that it is
• 13:47not okay
• 13:48just to sit down
• 13:51and wait for other people
• 13:52to help you. Right? I,
• 13:53as a gay man in
• 13:55that time, I can tell
• 13:56you that the situation looked
• 13:57pretty bleak. It was pretty
• 13:58obvious the government wasn't gonna
• 14:00help us. It was pretty
• 14:01obvious
• 14:02pharma wasn't gonna help us.
• 14:04What were we to do?
• 14:05And and the fact was
• 14:06it took a whole series
• 14:08of kinds of
• 14:09public action
• 14:11and articulation
• 14:12of what was needed
• 14:13and creation of whole new
• 14:16models of care that included
• 14:18hospice, that included palliative care.
• 14:20And so in many ways,
• 14:21my career
• 14:22was developed in the crucible
• 14:25of one of the most
• 14:27devastating
• 14:28epidemics of our time. And
• 14:30the lessons here from
• 14:32what they did as social
• 14:34change agents is still with
• 14:36us, and I'm here to
• 14:38remind you about them today
• 14:40because we still need them.
• 14:41We need them now more
• 14:43than ever. Right?
• 14:45The public good of medicine
• 14:47actually isn't something that lives
• 14:50in the insurance companies. It's
• 14:52not something that lives in
• 14:53the libraries or the Internet.
• 14:55It lives in community.
• 14:57The public good
• 14:58of what medicine means lives
• 15:01here in this community, and
• 15:02that's why I asked you
• 15:03to introduce yourself or catch
• 15:04up with each other. That's
• 15:06why I asked you who
• 15:07else in your life had
• 15:09really influenced you because you
• 15:10are all part of these
• 15:12big communities
• 15:13that create
• 15:15ideas and standards and practices
• 15:18about what it means to
• 15:19care for each other.
• 15:21Right? And I learned that
• 15:23from a whole bunch of,
• 15:25gay men who actually died
• 15:27and gave their lives for
• 15:28this moment. They didn't have
• 15:30anything, but they had community.
• 15:32And it was a really
• 15:34powerful lesson for me that
• 15:35I did not expect because
• 15:36I thought, well, they're not
• 15:37they don't have Ivy League
• 15:38degrees. They don't have,
• 15:41experience. They don't know how
• 15:42the system works. But here's
• 15:43what happened is they learned
• 15:45how the system works. They
• 15:46got onto the NIH study
• 15:48sections. They got onto the
• 15:50front page of the New
• 15:51York Times. And by doing
• 15:52that, that multi pronged approach
• 15:55that was a part of
• 15:57social change at the time,
• 15:58that changed the world, and
• 16:00it changed how we practice
• 16:02medicine today. Right? That's not
• 16:04the only kind of community.
• 16:05Here's here's the community around,
• 16:08a woman, who had breast
• 16:10cancer, Jennifer Marandino.
• 16:11This is her rowing community
• 16:13that she created,
• 16:14after she was diagnosed with
• 16:16a really serious breast cancer.
• 16:18And I'll get back to
• 16:19her later because, you know,
• 16:20this is a community of
• 16:22people
• 16:23that you don't see who
• 16:26are behind every one of
• 16:28the patients who walk into
• 16:29your office. Right? And then
• 16:31here's the community of us.
• 16:32Right? One of the things
• 16:33we learned when we were
• 16:34creating VitalTalk was that we
• 16:36needed our own community of
• 16:38clinicians.
• 16:39And so this is, people
• 16:40in,
• 16:42Europe and Australia and Japan.
• 16:44This guy translated our our
• 16:46book.
• 16:47But just to show that
• 16:48a key part of what
• 16:49we were doing was we
• 16:50were not just creating skills
• 16:52to tell people what to
• 16:53do, like nobody wants to
• 16:54do that. Right? You guys
• 16:56don't wanna be told what
• 16:57to do. What is really
• 16:58powerful is a community of
• 17:00practice
• 17:01that
• 17:02creates and develops
• 17:04better ways
• 17:05of doing what we all
• 17:07do because we all own
• 17:09it, we all share it,
• 17:11and we all use it.
• 17:12Right?
• 17:14So what do I mean
• 17:16by a sense of community?
• 17:17And I will get to
• 17:18the communication part here in
• 17:19a minute.
• 17:20Community is not just a
• 17:22bunch of people together.
• 17:24Community is a sense of
• 17:25belonging.
• 17:26You are part of a
• 17:27community to the degree that
• 17:29you feel like you belong.
• 17:32And, actually, in this atomized
• 17:34age of
• 17:36Internet and apps and TikTok
• 17:38and,
• 17:39Tinder. Right? Like, swipe left,
• 17:42swipe right. That's your pretty
• 17:43soon we're gonna be selecting
• 17:44doctors like that. Right?
• 17:47The way that you feel
• 17:49like you belong
• 17:50turns out is gonna be
• 17:51a really big ticket item.
• 17:53And my prediction is after
• 17:54the attention economy, that is
• 17:56what we're in now, everyone's
• 17:57fighting for your attention, it's
• 17:58gonna be the belonging economy.
• 18:00Who do you feel connected
• 18:01to and who do you
• 18:02care about?
• 18:04This is Jennifer,
• 18:06the day she was diagnosed.
• 18:08Right? This was quite a
• 18:09while ago. Her husband, Angelo
• 18:11Marandino, is a photographer who
• 18:13lived in New York City
• 18:14at the time, and she
• 18:16was diagnosed in two o
• 18:17o seven with
• 18:19with breast cancer. It metastasized
• 18:21two years just two years
• 18:22later, and she died a
• 18:23year and a half after
• 18:24that. I mean, this was
• 18:25the old days of breast
• 18:26cancer.
• 18:27And they decided to,
• 18:30document her journey
• 18:32and publish all the photos
• 18:34publicly,
• 18:35in a way that had
• 18:36never been done before because
• 18:37they wanted to open up
• 18:39the experience of people living
• 18:41with a serious illness. And
• 18:42so I'll show you some
• 18:43of his photographs, and they
• 18:45are quite remarkable. And as
• 18:46you can see,
• 18:48this is not an AI
• 18:49creation.
• 18:50Right? There is something in
• 18:52her presence and how he's
• 18:54captured it that makes her
• 18:56predicament
• 18:57as a person living with
• 18:59a serious illness
• 19:01immediately
• 19:02palpable.
• 19:03Right?
• 19:04And, of course,
• 19:06you know, this is the
• 19:07pre iPhone, pre selfie days.
• 19:10He was documenting her experience
• 19:12in a way that actually
• 19:13was starting to teach everybody,
• 19:14teach all of us what
• 19:16it meant to really live
• 19:17with a serious illness.
• 19:18Right?
• 19:19And, you know, as a
• 19:21young woman,
• 19:23who's facing something that she
• 19:24didn't really wanna face, you
• 19:26know, who knew
• 19:28how all of this would
• 19:29unfold? And I will say
• 19:30that one of the things
• 19:31that you don't see here
• 19:33in these pictures
• 19:34is how the breast cancer
• 19:36activists
• 19:37who took over
• 19:39the development
• 19:40of what breast cancer therapy
• 19:42has become. They actually took
• 19:44lessons from the AIDS activists.
• 19:46And the reason they took
• 19:47lessons from them
• 19:49was to find out how
• 19:50to make their voices known,
• 19:52how to collaborate with the
• 19:54medical establishment,
• 19:55how to get funding for
• 19:57breast cancer research. And here
• 19:58we are, you know, twenty
• 20:00years later,
• 20:01and the,
• 20:02outlook for people with metastatic
• 20:04breast cancer is actually entirely
• 20:06different. And it's entirely different
• 20:08because of people like this.
• 20:10Right. And he was an
• 20:11artist
• 20:12who was doing his part,
• 20:14but what it did was
• 20:15all of a sudden, the
• 20:17stigma around cancer was you
• 20:18know, these were days when
• 20:19nobody told each other they
• 20:20had cancer, when the doctors
• 20:21didn't even always tell you
• 20:23you had cancer.
• 20:24Like, this was the kind
• 20:25of pioneering work
• 20:27that helped all of us
• 20:29create
• 20:30the need
• 20:31and the importance
• 20:33of talking frankly with the
• 20:35people that we work with.
• 20:37You know, I was talking
• 20:38with, doctor Billingsley, who's an
• 20:40old friend of mine. You
• 20:41know, we actually sat in
• 20:42a whole lot of tumor
• 20:43boards, in the Seattle VA
• 20:45back in the day. And
• 20:46he I asked him, you
• 20:47know, was there something he
• 20:48wanted me to bring up?
• 20:50And the thing that I
• 20:51he mentioned was trust. Right?
• 20:53And I think it's something
• 20:53we are all struggling with.
• 20:55Right? Like,
• 20:58what's happened all of a
• 20:59sudden? I feel like I've
• 21:00woken up twenty years later
• 21:02and nobody trusts me. Well,
• 21:04I I wanna turn to
• 21:05this theorist,
• 21:07Nicholas Lerman,
• 21:09who wrote about trust and
• 21:11power and the reciprocal relationship
• 21:13of them. Because this philosopher's
• 21:15point is that complete inter
• 21:17information
• 21:18is unattainable. Right? You could
• 21:19just never have that as
• 21:20a decision maker.
• 21:22What has happened in the
• 21:23world is that trust is
• 21:25the mechanism by which individuals
• 21:27willingly reduce uncertainty and risk.
• 21:30I put my trust in
• 21:31doctor Billingsley
• 21:33because I think he is
• 21:34a guy who could do
• 21:35a surgery that would genuinely
• 21:37help me. And I don't
• 21:38know every date detail about
• 21:40this surgery, and I don't
• 21:41even know that much about
• 21:42him, but I trust him.
• 21:44I'm willing to put my
• 21:45trust in him. And his
• 21:47power
• 21:48to be legitimate
• 21:49has to be underpinned by
• 21:51trust. And so there is
• 21:52a direct relationship between trust
• 21:54and power
• 21:55in these
• 21:57environments that we live in.
• 21:58Right?
• 21:59We have a lot of
• 22:00power.
• 22:02They have to meet us
• 22:03with trust. But the issue
• 22:05is is that the complexity
• 22:07of what we are doing
• 22:08now has ramped up so
• 22:10much
• 22:11that actually,
• 22:15they are the people that
• 22:17we are serving
• 22:18are getting lots of different
• 22:19kinds of information everywhere.
• 22:22The complexity of what we
• 22:24do makes it difficult for
• 22:25us to be completely transparent.
• 22:27And so all of a
• 22:28sudden this trust and power
• 22:30relationship is breaking down. Right?
• 22:31Think back to a time
• 22:33fifty years ago when you
• 22:34were William Carlos Williams driving
• 22:35around in your, you you
• 22:36know, sedan writing poems in
• 22:38between patients and and giving
• 22:40paid medicine to the occasional
• 22:41person out of your bag
• 22:42where where your entire pharmacy
• 22:44was in your black bag.
• 22:45Right? There was a kind
• 22:46of transparency
• 22:47there that was radically possible
• 22:50which meant that your patients
• 22:51would pay you in chickens
• 22:52or eggs or dollars, whatever
• 22:54they had and you would
• 22:54just roll with that. Right?
• 22:57And and because you were
• 22:58that person's physician for a
• 23:00lifetime,
• 23:02there was kind of this
• 23:03unspoken thing about, yeah, I
• 23:05trust you. And and you
• 23:07knew that. You had seen
• 23:08him at your house. You
• 23:09knew he would come back.
• 23:11All your neighbors knew.
• 23:13We're in a different world
• 23:14now. Right? And so
• 23:16we have patients who are
• 23:17now
• 23:20trying to figure out the
• 23:21best treatments for themselves.
• 23:22They are on peer to
• 23:24peer networks.
• 23:25They are reading things. And
• 23:27what this has kind of
• 23:28led to is a real
• 23:29questioning of what is the
• 23:30expertise
• 23:31that we all have.
• 23:33Do we really know what
• 23:34we're talking about? Right? And
• 23:36so this book, which started
• 23:37from a,
• 23:39an essay in in,
• 23:40Politico,
• 23:42actually really gets at the
• 23:44sociology of what is happening
• 23:46to experts now. And, you
• 23:47know, you're seeing it right
• 23:49here. Right? This is a
• 23:50self styled doctor who's giving
• 23:53advice about vaccines and saying
• 23:55so much science is now
• 23:57bought.
• 23:57Right? And people are looking
• 23:59at this and believing it.
• 24:00And what it is resulting
• 24:01is is this. Right?
• 24:03Unvaxxed,
• 24:04unafraid. I mean, it seems
• 24:06preposterous.
• 24:07Right? But in fact, this
• 24:09is
• 24:10happening in our government. Right?
• 24:12So
• 24:14I just say that to
• 24:15mean that the environment that
• 24:16we are operating in has
• 24:18radically shifted.
• 24:19And when you are now
• 24:21communicating with people, you actually
• 24:23have to think of different
• 24:24levels. There's the communication at
• 24:26the level of the person
• 24:27you are sitting with in
• 24:28clinic. There's the communication of
• 24:30the level of your colleagues
• 24:32and peers.
• 24:34Right? And then there's the
• 24:35level of actually, our interactions
• 24:37as a profession with the
• 24:38public. And I would submit
• 24:40that that is a way
• 24:41in which we are now
• 24:42challenged in our communication
• 24:44to work at all of
• 24:45those levels because, actually, if
• 24:47we aren't responsible for them,
• 24:49we're just gonna get more
• 24:50of this. Right?
• 24:53Technology
• 24:54is
• 24:56upending us. And I feel
• 24:57like, you know, one of
• 24:58the things about AI is,
• 24:59yes, it's gonna be our
• 25:00great savior. It'll save us
• 25:01time in clinic. We can
• 25:02just look at our phones
• 25:03and type questions in when
• 25:05we don't know something, and
• 25:06the patient will just sit
• 25:06there and wait patiently for
• 25:07us. I'm I'm not sure
• 25:08what's supposed to happen there.
• 25:09But,
• 25:11the idea is is are
• 25:13they just gonna replace us?
• 25:14Are people just gonna be
• 25:15getting all their cancer care
• 25:16from apps and then ordering
• 25:17CT scans by themselves?
• 25:20I would just submit that
• 25:21technology has upended medicine before.
• 25:24This is part of an
• 25:26old pattern that we have
• 25:27seen a number of times
• 25:29and that we communicators,
• 25:30people who care about the
• 25:32relationships that we have with
• 25:33the people that we are
• 25:34working with,
• 25:35honestly have struggled with over
• 25:37the years. Right?
• 25:39And here, just to go
• 25:40back to Jen and her
• 25:41story for a minute,
• 25:43you know,
• 25:44Eduardo Brera and another international
• 25:46group of experts looked at
• 25:48and tried to map out
• 25:49the illness trajectories of incurable
• 25:51solid tumors. Right? Here's the
• 25:53old story. Right?
• 25:54You were good for a
• 25:55while and then you declined
• 25:57and if you had some
• 25:58kind of good treatment, it
• 25:59would push out the curve
• 26:00a little bit. Right? That
• 26:01was the classic
• 26:03kind of mental model that
• 26:05we had and continue to
• 26:06have for many kinds of
• 26:07incurable cancer. But actually,
• 26:09now there's some other things
• 26:10that are totally different. What
• 26:12happens when
• 26:13somebody starts to decline, gets
• 26:15targeted therapy, or gets a
• 26:17liver resection.
• 26:19Right? And then, actually,
• 26:20their,
• 26:22function and quality of life
• 26:23bumps back up for a
• 26:25while, and they feel like
• 26:26they are as good as
• 26:28new and are going,
• 26:29and then start to decline.
• 26:31That's a
• 26:33cultural experience that we have
• 26:35no benchmarks for and that
• 26:37patients are struggling with because
• 26:39they
• 26:40come to you and to
• 26:42me
• 26:43and say, well, I I
• 26:45won the lottery, and I
• 26:47the medicine worked, and I
• 26:48got more time, and now
• 26:49I'm not sure what I
• 26:50should be doing. Right?
• 26:52I am doing this study
• 26:53with psilocybin for people with
• 26:54metastatic cancer, and this is
• 26:56the thing that I am
• 26:57hearing over and over. Well,
• 26:59yeah. It worked, and and
• 27:00now what?
• 27:01Right? They're really not sure.
• 27:03Here's another kind of trajectory.
• 27:05You know?
• 27:06Immunotherapy,
• 27:08it keeps you going, but
• 27:09kind of at a different
• 27:10level, and then there are
• 27:11all these side effects, all
• 27:12this autoimmune stuff, all this
• 27:13stuff you have to do
• 27:14with their diet. So, actually,
• 27:16this is a way in
• 27:17which the complexity of what
• 27:19we are seeing in terms
• 27:20of clinical trajectories
• 27:22has complexified
• 27:23in a way that makes
• 27:24it much more difficult for
• 27:25us to be very
• 27:27certain with our predictions or
• 27:29to be
• 27:30reassuring that we know what's
• 27:31gonna happen next. It's super
• 27:33hard.
• 27:34Right? And and actually, our
• 27:38indecision or our ambiguity
• 27:40or uncertainty
• 27:41is often seized upon
• 27:44as a problem.
• 27:45It's often seen as
• 27:47a reason that we don't
• 27:49possess the expertise that we
• 27:50really do. So what I'm
• 27:52saying is is actually,
• 27:54our job got a little
• 27:55more complicated with all this
• 27:57new anti cancer technology.
• 27:59And and actually, that's the
• 28:01a good problem, but it's
• 28:03a new problem of the
• 28:04situation we're in. You know,
• 28:05I mentioned cancer on the
• 28:07Internet. This is in the
• 28:08American Cancer Society, I love
• 28:10this user beware.
• 28:11Right?
• 28:12Then there's this whole thing
• 28:13about finding out about your
• 28:14CAT scan results even before
• 28:15you go to your clinic.
• 28:17Right? Everybody's looking them up
• 28:18online and then doing massive
• 28:20Google searching and then coming
• 28:21to you. I think that
• 28:23has totally changed the dynamic
• 28:25of what happens in clinics.
• 28:26And and we haven't really
• 28:28figured out how to adjust
• 28:29to it. And because the
• 28:30funding for these kinds of
• 28:32studies is just, you know,
• 28:33far different than other kinds
• 28:35of studies,
• 28:37honestly, I think we're still
• 28:38struggling to know what the
• 28:39best practices are. But what
• 28:41I will tell you is
• 28:42that the effect is
• 28:44quite big. And just to
• 28:46illustrate that, I'm gonna go
• 28:47back to an old study
• 28:48I did about patients who
• 28:49wanted to have physician assisted
• 28:51suicide. This was in Washington
• 28:53state before physician assisted suicide
• 28:55or death with dignity was
• 28:56legal anywhere.
• 28:58And we did these longitudinal
• 28:59interviews with patients and patients
• 29:01who were looking for physician
• 29:02assisted suicide in their families.
• 29:04And one of them actually
• 29:06really changed me. It was
• 29:07the partner of a gay
• 29:08man
• 29:09who had advanced HIV,
• 29:12before the antiretrovirals
• 29:14ended up dying. And the
• 29:15partner recounted,
• 29:17a a last meeting with
• 29:18the doctor, where the doctor
• 29:20was talking to him about
• 29:21his
• 29:22intractable thrush. I mean, you
• 29:23guys probably younger of you
• 29:25probably can't even imagine this,
• 29:26but there was intractable thrush,
• 29:27and it actually would lead
• 29:29it was one of the
• 29:30last things that happened to
• 29:31people with advanced HIV.
• 29:33And the the quote there,
• 29:34our doctor was like, you
• 29:35do not wanna die of
• 29:36thrush. And, basically, he said
• 29:38the thrush would grow and
• 29:40shut off your esophagus so
• 29:41you wouldn't be able to
• 29:42swallow.
• 29:44My partner would drool constantly
• 29:45and end up starving to
• 29:47death. The doctor said, you
• 29:48don't wanna die like that.
• 29:50And that is the moment
• 29:51when he decided to do
• 29:52a hasten death. Right? Because
• 29:54the doctor
• 29:56didn't have a better way
• 29:58of approaching this issue of
• 30:00what happens when the illness
• 30:01gets really bad or what
• 30:02happens when the illness gets
• 30:03worse.
• 30:04This was actually the anecdote
• 30:06that made me
• 30:07think that there was something
• 30:09much bigger to communication that
• 30:11we all needed to understand.
• 30:13And you know what? This
• 30:14problem, this technology issue is
• 30:16not over. This is the
• 30:17proportion this is the number
• 30:19of medical assistance in dying
• 30:21deaths in Canada
• 30:22where both physician assisted you
• 30:24suicide and euthanasia are both,
• 30:27legal. And you will see
• 30:29that in Canada, as in
• 30:30the other countries where euthanasia
• 30:31has been legalized, the incidence
• 30:33of
• 30:34use is just going up,
• 30:36up, up, up, up. And
• 30:38I don't know that this
• 30:40is necessarily
• 30:42a bad thing. I I
• 30:43feel quite torn about, these
• 30:45practices. But what I can
• 30:46say is I think part
• 30:48of this rough reflects
• 30:50how we
• 30:51talk to and deal with
• 30:53and communicate with people about
• 30:55what they're facing. Because it's
• 30:57when they feel like we
• 30:58don't have anything more,
• 31:00you got nothing,
• 31:01that's when they go, yep.
• 31:03This is the way I'm
• 31:04gonna do this. So I
• 31:05think this is another kind
• 31:07of cautionary tale about a
• 31:09new kind of technology.
• 31:11The last my last cautionary
• 31:13tale is here. You guys
• 31:14know this epic. I'm right.
• 31:15The Elk Cancer Center uses
• 31:16epic.
• 31:17I'm just gonna compare AI
• 31:19as an example to the
• 31:20introduction of the electronic medical
• 31:22record. Like, how many of
• 31:23you are old enough to
• 31:24remember when we just wrote
• 31:25them with notes and charts?
• 31:26I know. Yeah. Yeah. Well,
• 31:27so
• 31:28the electronic medical record was
• 31:30supposed to solve all our
• 31:31problems. Right? You never had
• 31:32to go, wait. That volume
• 31:34of the chart hasn't been
• 31:35found. Right? You wouldn't have
• 31:36to suffer through some of
• 31:37your colleague's horrible handwriting.
• 31:39Right? All the meds would
• 31:40be in a nice list.
• 31:42The technology was gonna solve
• 31:43a lot of that. Right?
• 31:44Well, what happened?
• 31:46Well, actually, I would submit
• 31:48the technology has been co
• 31:49opted
• 31:50by forces that think that
• 31:52the reason for your existence
• 31:53is to bill. And the
• 31:55entire system is designed around
• 31:57maximal efficient billing.
• 32:00That doesn't leave a lot
• 32:01of space for the other
• 32:02stuff that you want. So
• 32:03for example, when I read
• 32:04the chart now, I'm like,
• 32:06what is happening with information?
• 32:08Because I feel like I'm
• 32:09reading like eighty five percent,
• 32:11you know, cut and paste.
• 32:12And and I I feel
• 32:13like in my own mind,
• 32:14I'm back to, an oral
• 32:16culture of medicine where I
• 32:17only know what's happened if
• 32:18I, like, talk to another
• 32:19person who actually saw the
• 32:20patient. Right? Because you can't
• 32:22tell from the chart.
• 32:23So I I just mentioned
• 32:25this as a way that
• 32:26saying that technology is not
• 32:28automatically gonna make us better.
• 32:29And that we,
• 32:31as the clinicians and people
• 32:32who are using it, need
• 32:34to be involved in a
• 32:36different way with AI than
• 32:38we need to than than
• 32:39we were involved with electronic
• 32:40medical records.
• 32:42You know, here's the
• 32:44study that really got
• 32:46palliative care put on the
• 32:47map. This is Jennifer Temel's
• 32:49study of people with metastatic
• 32:50non small lung cancer. Now
• 32:52kind of old, a little
• 32:53dated even she would say.
• 32:55The treatments aren't the same.
• 32:56But what it showed was
• 32:58that, patients who had early
• 33:00palliative care
• 33:01had better depression symptoms, better
• 33:04anxiety symptoms, and a better
• 33:06PHQ nine. So those are
• 33:07all measures of mood, and
• 33:08they actually lived longer. And,
• 33:10you know, what I would
• 33:11submit is that this
• 33:14improved mood and symptom control
• 33:17happened because of a multiphase
• 33:19communication process. I I was
• 33:21one of the team part
• 33:22of the team that helped
• 33:22Jennifer analyze all the notes
• 33:24from that study, that very
• 33:25first study. And what we
• 33:27saw was that, you know,
• 33:28in the beginning, there was
• 33:29a lot of stuff about,
• 33:31you know, relationship,
• 33:32discussing the cancer treatment,
• 33:34illness understanding.
• 33:36The real decision making came
• 33:38much later. And and what
• 33:40that says to me is
• 33:41that when you are working
• 33:42with a patient, you know,
• 33:43the communication
• 33:44that you do
• 33:46is completely
• 33:47contextualized
• 33:48to the moment that you
• 33:49are in with that cancer.
• 33:51And the moment that they
• 33:52are in is as much
• 33:54about their mindset
• 33:55as about what you were
• 33:56reading in the chart about
• 33:58their
• 33:58Cigna Terra or whatever, you
• 34:00know, whatever product prognostic thing
• 34:01that you were using these
• 34:02days. You know, the nuts
• 34:04and bolts of this, like,
• 34:05there are some fabulous people
• 34:07here, Jen and Laura and
• 34:09others,
• 34:10who will actually take you
• 34:12through the kinds of experiences
• 34:14that you actually need to
• 34:15get this under your belt.
• 34:17But what I'm saying I
• 34:18am just showing this to
• 34:19say that there is a
• 34:22fair amount of data that
• 34:24shows how communication
• 34:26actually has a real influence
• 34:28on the kinds of medical
• 34:29outcomes that we would call
• 34:30solid medical outcomes. And, of
• 34:32course, you know, more technology,
• 34:34telehealth versus in person, and
• 34:36it turns out telehealth is
• 34:37pretty good. It turns out
• 34:38you can do
• 34:40a a great deal of
• 34:41this work
• 34:42on Zoom. Who knew? Right?
• 34:45But what this also showed
• 34:47was that there was a
• 34:48difference in the rate of
• 34:49hospice referrals,
• 34:51at the end of life.
• 34:52And so there are some
• 34:53decisions where it looks like
• 34:54there is some intangible
• 34:56quality
• 34:57of being together in person.
• 34:59And the one of the
• 35:00reasons I'm so grateful to
• 35:01all of you for coming
• 35:02today in line, because I
• 35:03don't go to a grand
• 35:04rounds very much either, honestly,
• 35:06is there is an intangible
• 35:08quality of being here together
• 35:11and having a common experience
• 35:14and walking out of the
• 35:15room after lunch and going,
• 35:16what did you think about
• 35:17that guy? Right? It's part
• 35:19of the whole
• 35:20ritual, but it's also part
• 35:22of
• 35:23what helps us process what
• 35:25what we're dealing with here.
• 35:27You know, so
• 35:28the other thing that I
• 35:29would wanna say from summarizing
• 35:31all the research is communication
• 35:33works as a recursive process.
• 35:35Right? There is this thing
• 35:36you are doing with information.
• 35:38There are ways patients are
• 35:39participating, and you go back
• 35:41and forth and around, and
• 35:42you influence each other. And,
• 35:44you know, what I would
• 35:45say is that there are
• 35:46trainees who ask me, well,
• 35:47what about when the patient
• 35:48says such and such?
• 35:50I can't do my skills
• 35:51protocol or whatever. I wanted
• 35:53to get to this and
• 35:54I couldn't. And and you
• 35:55know what I would say
• 35:55is that's part of this
• 35:58process that you are in
• 35:59and the way that you
• 36:01adapt yourself and adapt this
• 36:03communication to what they are
• 36:05after, what they need,
• 36:07the things that they need
• 36:08that they can ask for,
• 36:09and the things that they
• 36:10can't ask for. Right? That
• 36:12they are,
• 36:14too embarrassed
• 36:15to ask for, too ashamed
• 36:18to ask for,
• 36:20too whatever.
• 36:21Those are the ways in
• 36:23which you make this process,
• 36:25really go.
• 36:26You know,
• 36:28will machines be as good
• 36:29as this as we are?
• 36:30Right? That's kind of the
• 36:31AI question. Right? Like, now
• 36:32you can have a chatbot
• 36:33that does your therapy, and
• 36:34you can text in the
• 36:35middle of the night and
• 36:36all that stuff. And there's
• 36:37some data that suggests that
• 36:38teenagers use the text in
• 36:40the middle of the night,
• 36:40and they're texting their chatbot
• 36:42at three in the morning
• 36:43to say, I feel like,
• 36:43you know, cutting myself.
• 36:46What do I think about
• 36:47that?
• 36:48What I wanna take you
• 36:50to is a little bit
• 36:51of background about how physicians
• 36:53think and behave.
• 36:54And so this is some
• 36:55research that we did, with
• 36:57a group that actually does
• 36:58interviews with physicians,
• 37:01where they ask them to
• 37:02bring in images. And these
• 37:03images are actually all images
• 37:05that physicians brought in in
• 37:07response to a question about
• 37:08what does palliative care mean
• 37:09to you? What are you
• 37:10trying to do?
• 37:12And I mean this as
• 37:13a sense of, like, describing
• 37:15the landscape of where you
• 37:16are. So these people said,
• 37:18I have to tell people
• 37:20the right information and path.
• 37:21It is so confusing.
• 37:23I feel like I am
• 37:24the guidepost here. Right?
• 37:26My job is to be
• 37:27informational.
• 37:29My rules are based on
• 37:31objective data. Right? I am
• 37:32trying
• 37:33to be systematic.
• 37:35I am looking for the
• 37:36protocol. I am looking for
• 37:38guidelines.
• 37:39Right?
• 37:40And
• 37:42they don't allow themselves to
• 37:43make mistakes. Right? It's been
• 37:44hammered into us. Right? That
• 37:45if you fail, it is
• 37:47your fault. So you have
• 37:48to be at the top
• 37:49of your game, and you
• 37:50have to be perfect.
• 37:51And that kind of perfectionism
• 37:54has rolled into a whole
• 37:56syndrome of
• 37:57physician
• 37:58well-being or on the flip
• 38:00side, physician depression that results
• 38:02has resulted
• 38:03over decades
• 38:05in physicians having the highest
• 38:06suicide rate of any white
• 38:08collar profession. Right? So there
• 38:10is a cost to this
• 38:11and there is a reason
• 38:12for you to keep an
• 38:13eye on this. Right?
• 38:15And then and this is
• 38:17part of how we physicians
• 38:19manage the complexity of the
• 38:21information that we're dealing with
• 38:22is that we rely on
• 38:24algorithms to get the best
• 38:25care. In in cardiology and
• 38:26in oncology, we use algorithmic
• 38:28guidelines.
• 38:29We use judgments.
• 38:31And that, to my mind,
• 38:32is not only a way
• 38:33of creating best practices, but
• 38:35it's a way of reducing
• 38:36the complex. Because if there's
• 38:37too much complexity, you just
• 38:38actually can't function because there's
• 38:40so many details and so
• 38:41many things to remember.
• 38:43So
• 38:44in all that, I I'm
• 38:46gonna show you one last
• 38:47picture of Jen. This is
• 38:48the first picture in, Angelo's
• 38:50book. And he now lives
• 38:51in Cleveland, but he gave
• 38:52me permission to use, his
• 38:54photographs,
• 38:55in when I was talking
• 38:57to other clinicians
• 38:59to just remind
• 39:00us and remind me to
• 39:02talk about the fact that
• 39:03amidst all these algorithms,
• 39:05there are many sides of
• 39:06people that you will never
• 39:07see
• 39:08in clinic that, in fact,
• 39:10are at at the core
• 39:11of them.
• 39:13Yeah. You know, when we
• 39:14are talking to them, you
• 39:15know, our our can we
• 39:16be as empathic as a
• 39:18chatbot? Right? You guys probably
• 39:19saw this thing. It's about
• 39:20how chatbots are more empathic
• 39:22than
• 39:22than,
• 39:23physicians, and their their responses
• 39:25were rated as more empathic
• 39:27and, you know, what do
• 39:28I think about that? Well,
• 39:29here's what I would say.
• 39:31Don't be fooled by analysis
• 39:34of empathic words.
• 39:35Right? Empathy
• 39:37does not come from words.
• 39:38Right? And now there's even
• 39:39this thing about fake AI
• 39:41therapists
• 39:42that are making recommendations
• 39:44to anorexic people to eat
• 39:46less,
• 39:47to not worry about cutting
• 39:49themselves,
• 39:49it's, you know, the whole
• 39:51next wave of what we
• 39:53are gonna be facing, what
• 39:54what you are gonna be
• 39:55seeing in clinic. Right? It's
• 39:56completely crazy. Right? This is
• 39:57from the paper yesterday.
• 39:59Right? This is how fast
• 40:00this is unfolding.
• 40:02Right?
• 40:05So I would just like
• 40:06to pause with all this
• 40:07in in this question of,
• 40:09you know, where does empathy
• 40:11come from?
• 40:12To, cite my zen teacher,
• 40:14this is Roshi Joan Halifax
• 40:16in Santa Fe, New Mexico.
• 40:18I mean, what she teaches
• 40:19is that empathy
• 40:21is
• 40:23something that is embodied, that
• 40:25you are able to
• 40:27experience
• 40:28because you possess a body.
• 40:29And when you see that
• 40:30picture of Jen
• 40:32and something in that resonates,
• 40:34it actually resonates in your
• 40:36body and the effective parts
• 40:37of your brain. And that
• 40:39experience of empathy
• 40:41is what allows your cognition
• 40:44to process
• 40:45what that means to be
• 40:46having an experience like that.
• 40:48Because even if you haven't
• 40:49been her,
• 40:50you you might have had
• 40:51an experience that's kind of
• 40:53like that or you might
• 40:54have worked with a patient
• 40:55who's kind of like that,
• 40:57and your ability to simulate
• 40:59that within your own body
• 41:01is what creates that empathic
• 41:02moment.
• 41:04Roshi Joan would also say
• 41:06that what compassion is is
• 41:09compassion is a response that
• 41:11comes from you emergently, that
• 41:13there is no formula for
• 41:15compassion. There is no thing
• 41:17you can say. There is
• 41:19no gesture you can always
• 41:20do.
• 41:21That
• 41:22compassion is a unique response
• 41:24in every moment to a
• 41:25unique situation between two people.
• 41:28And what
• 41:39process
• 41:40to happen,
• 41:41to work from a core
• 41:42set of ethical values,
• 41:45and to
• 41:46pause long enough to allow
• 41:48that moment to unfold. Right?
• 41:50And so
• 41:51what this is saying, I
• 41:53think, is within us. There
• 41:54is,
• 41:55a kind of belonging, a
• 41:57kind of community, a kind
• 41:58of expertise that is deeper
• 42:00than your personality.
• 42:01Right?
• 42:03And how do I know
• 42:04that? Well, I know it
• 42:06from talking to patients who
• 42:07have received palliative care, who
• 42:09are receiving the kind of
• 42:10care that you give, and
• 42:11this is what they talk
• 42:11about. They don't talk about,
• 42:13you know, having a lot
• 42:14of services. They don't talk
• 42:15about having the latest algorithm.
• 42:17What they talk about is
• 42:19they talk about feeling validated.
• 42:21They talk about feeling given
• 42:22back agency.
• 42:24They talk about feeling guided.
• 42:26They talk about
• 42:27developing a new identity that
• 42:30allows them to live well
• 42:32in the face of a
• 42:33serious illness. Right? And so
• 42:34here's what they say. They
• 42:35say illness is a thief.
• 42:37It came into my life
• 42:38uninvited. It took a lot
• 42:39from me. It left me
• 42:41in a place of devastation.
• 42:43This woman brought this image
• 42:44of the California wildfires
• 42:46as as an example of
• 42:48how she felt after being
• 42:49diagnosed. I'm angry at my
• 42:50illness for what has done
• 42:52to me.
• 42:53And palliative care and all
• 42:54the work that you do
• 42:56as communicators
• 42:58can flip that around. Right?
• 42:59You they choose it to
• 43:01they choose to bring you
• 43:02into your their lives.
• 43:04You help them recuperate mentally
• 43:06and physically.
• 43:08You put them in a
• 43:09place of stability and
• 43:10clarity, and you motivate them
• 43:12to continue forward. Right? That
• 43:14is the real work that
• 43:16you are doing with the
• 43:17communication. It's not about getting
• 43:19code status seeds or signing
• 43:20these things or putting your,
• 43:21you know,
• 43:23advanced care plan in Epic.
• 43:24What you're really doing is
• 43:26this. Right? And and, of
• 43:27course, in VitalTalk, what we
• 43:29tried to do was set
• 43:29up a whole bunch of
• 43:30conditions to,
• 43:33allow that to happen and
• 43:34allow you to build a
• 43:36foundation that you would not
• 43:37have to think about so
• 43:38much so that you can
• 43:39focus in on the real
• 43:41work. And, actually, the web
• 43:42designer that I was working
• 43:43with at the time, he
• 43:44said, you should just put
• 43:45up the pictures of the
• 43:46people because, actually, this is
• 43:48really about
• 43:49being a person
• 43:51and being yourself while you
• 43:53were being a doctor. And
• 43:54in fact, he was totally
• 43:55right and we are still
• 43:56using portraits of our original,
• 43:59group.
• 44:00And I just wanted to
• 44:01give a shout out to
• 44:01doctor Cropp, who's actually one
• 44:03of our very first
• 44:05study subjects. Right? Like, I
• 44:07know him from way back
• 44:08and,
• 44:09have followed his career over
• 44:11the years and and really
• 44:12thrilled to see him as
• 44:13as one of your community.
• 44:17The other way that I
• 44:19know that the internal part
• 44:20of you really matters is
• 44:22with some recent work that
• 44:23I had been doing with,
• 44:24psilocybin for doctors and nurses
• 44:26with burnout and depression from
• 44:27their work during the pandemic.
• 44:29There were a lot of
• 44:30doctors and nurses who felt
• 44:32like,
• 44:33something has changed. There were
• 44:35cases that broke me,
• 44:37and I don't feel the
• 44:37same. And so we had
• 44:39a randomized study for those
• 44:41people.
• 44:42We
• 44:44did some psychotherapy.
• 44:46We gave them
• 44:47synthesized psilocybin,
• 44:49and this is what happened.
• 44:51This left panel is all
• 44:53the people who had placebos
• 44:55instead of psilocybin but had
• 44:56the therapy.
• 44:59The yellow lines
• 45:00each line is an individual
• 45:02person who had psilocybin therapy.
• 45:04And you can see there's
• 45:05a pretty big difference
• 45:07in their,
• 45:08symptoms of depression at day
• 45:11twenty eight after treatment, and
• 45:12these these improvements
• 45:14persisted to
• 45:16six months. So what the
• 45:17reason I'm mentioning it here,
• 45:18and I I am not
• 45:19saying that you have to
• 45:20have psilocybin to be a
• 45:21good communicator,
• 45:22is that what happened here
• 45:23is we didn't change any
• 45:24of their external
• 45:26attributes. We didn't change anything
• 45:27about their environment.
• 45:29The only thing we changed
• 45:30was them. We changed how
• 45:32they felt internally about themselves,
• 45:34and actually, that had a
• 45:36huge
• 45:37lasting impression.
• 45:39So
• 45:40I just mean that to
• 45:41say that what you do
• 45:43with yourselves
• 45:44and what you do with
• 45:45your teams
• 45:46actually has tremendous value
• 45:49in how you yourself will,
• 45:53persist through now what is
• 45:54a really difficult time.