 Boom, what's up everyone? Welcome to simulation. I'm your host on socket and very excited to be talking about humanizing health care We have an epic guest joining us today. We have dr. Jessica Zitter. Hello. Hello. Thank you for coming on to the show I really appreciate it and I'm super excited you initially met Ron at the JCC doing an event there And then Ron taught me about you and I got really excited about you and then I looked into your work And I got even more excited because this is something that we haven't talked about and that society is not really talking about Maybe more ancient cultures have had a better rooting and feeling for how to deal with death in a very humane way And how but now the health care infrastructure has gone very complex and there's so much to talk about here Jessica Zitter is a ICU and palliative care physician in Oakland at Highland Hospital Last ten years now. She's also the author of extreme measures finding a better path for the end of life She is also has the feature in extremis, which is this is extremis extremis extremis is better to pronounce extremis Which is a 26 minute 24 24 minute short documentary about kind of what you're right about in extreme measures and Yeah, and so this is this is really important pressing stuff that I guess is not being talked about so And that's really important to talk about so why don't we let's start with talking about who you are before we get to the To the these pressing themes of the book. So how did you even get your footing in desire for? Being a physician and being in health care because you did some Stanford and some Harvard some UCSF some Berkeley And that's a lot of awesome schools to go through to get to where you're at Well, but the time I got to that Round of going to those schools. I had already sort of decided I was going to be a doctor I decided I was going to be a doctor when I was kind of a baby. I came I was born into a family. It was a family business really My family was a bunch of immigrants and very quickly once reaching Canada, which is where I was I'm from Montreal The both sides of my family, you know immediately started producing doctors This was like something that was very much a part of our family culture. Maybe a part of our religious culture It was sort of this very venerated Profession and I had all these role models of mostly men Who were very intense? surgeons and running, you know er's and and different kinds of very interventionalist types of doctors who had kind of grown up in this time of Specialization within the health care system, which really started in the 60s. You know, that's when we started specializing medicine. And so I decided that the way that I could be Useful in the world was to follow in their path and to learn how to use A variety of different technologies and machines to really keep people alive and to take care of them that way So I went in to this very intensive training Sequence uh at these schools and kind of in these programs and I came out the other end as a pulmonary and critical care doctor And that's how I ended up in medicine Your family that was so funny. You were describing your family like they're like pumping out like Doctors like that's so interesting that when you have really strong like a family that's Has a really strong like kind of like values and mission that they know what they are doing in the world But then the kids kind of are more easily able to I guess find something that they want to do versus Parenting that is a little bit more kind of like Well, whatever so true It was so much easier for me than a lot of my friends because I just sort of Came out into this path and I I uh actually remember You know after college few years after college just watching some of my friends who'd been in the liberal arts and who were kind of like Trying to figure there and I was just like I got my beeper on my pocket and I'm going and it was it was kind of an easy I I mean, I don't say that proudly. It was kind of an easy Straight ahead and it's brought you lots of meaning in life. And that's really important Well, you know, I think it Brought me meaning Mostly once I started to make it mine. Um, I I initially Went into this With an idea of what I was supposed to do and the health care medical training experience Was very happy to tell me. Um, I thought I was supposed to be this sort of high intensity physician and There's many quick and there's paths to doing that that are very easily taught Protocols and you know learning how to do different kinds of technologies and treatments and catheters and all that stuff So I just got sucked into that whole training path The meaning came once I started to Step back and say, okay, now I'm doing this and how do I want to make this something that feels Better to me because I was starting to experience some moral distress in the way that I was practicing medicine Yes, protocolized approach Yes So you you just laid it out right there So there's this protocolized approach and we've heard we've had doctors talking to us before about Going off protocol and being able to do things in a way that actually helps with either The morals of the patient or the it said there's so many different ways to talk about this But you specifically I see you you actually actually what the statistic in the book is quite I think quite high is it was it 40 percent of deaths Occur in the ICU at the peak in like the 80s and 90s Yeah, the and that number's gone down. I think the most recent data shows that 30 percent of people Die either in an ICU or having recently been discharged from an ICU. Okay. Okay 30 So that's a lot. That's almost a third of people are dying in like in ic in ic user right afterward and that's like Whoa, so what that's and what you've been dealing with in that case And I want you to explain what palliative care is but just that there is a lot of people that are Without their family without people that, you know, love them right there when they're in the icu that they're having some sort of Stress about what do I need to do with the medical system? What options are there? Right? Yes, start telling you so, you know what you're telling me the fact is look I am in no way throwing technology under the bus. I am not throwing icus under the bus. I have And then many of my colleagues we have saved many a life using these technologies and sent people back home to their families And there is nothing sweeter than that. That is one of the beautiful things about the our modern healthcare system The problem is that that There's there's several reasons why We're not only taking people who can benefit from it, but we're sweeping everybody into it And when when you take people who are not really Going to have that kind of benefit of a recovery and going home and you take everybody even, you know The frail the elderly the terminally ill the dying and you still do that same treatment to them I call that the end of life conveyor belt because what it is is this this like churning Protocolized literally conveyor belt that just takes everybody indiscriminately and does the same things to them the same Support of organs as they start to fail As you would with somebody who really could potentially Then recover but you're doing this to people who won't recover and we do it That's what caused me this distress was I realized Subconsciously it wasn't even like I had words in the beginning that we were taking so many people who I knew Weren't going to benefit from this type of treatment and doing these things to them Which really as you alluded to Can cause tremendous suffering because what it means to be attached to machines is several things number one You've got machines going into your mouth. You can't talk You've got your arms tied down frequently because we can't have you pulling these things out So people are lying there in bed on their backs things in their mouths with their arms tied down you've You're kind of sedated. You may be in pain. We don't necessarily know if you're in pain. So there's a sort of haze of Possibly depends again on who you are and what's going on but of pain and slight mild delirium which is very confusing and and distressing and most importantly as you said The family the whole Structure from which you came is not there. You're in this very foreign Sterile place your family's kind of even if they are in the room They're kind of back. They're afraid, you know, you're coming in you're going to touch all these different tubes You sort of stay away. So it's a very isolating experience And that is I think part of the reason that so many people are dying badly in this country Wow, yeah, and there's this whole idea of a good death and we'll we'll get to that I want I want you started He's really started talking about all of the variables that are going into the equation of like an oven of an of a human experience inside of an ICU in this in this case with family twos The delirium that's coming in potentially sedated this there's so much that that is there and then Look, there's this whole like end of life conveyor belt Okay, tell us about palliative care because yeah, this was quite interesting for me to learn about for me cloaking This is cool. Okay. Well, so I'll give you a little background You know, um, and I talk about this a lot in my book because it feels like you know that movie Um Was it zealot well forest gump and zealot where there's this person who like finds themselves in places That were kind of like turning points in a movement and and that's what I kind of when I was writing my book felt happened to me in 1996 a big study came out and I by the way had just Finished my pulmonary fellowship. The study came out was called the support trial and it looked at How people die in america And it was a shock To the people who are conducting this study. It was a huge study five centers in america and the reason I say it was a zealot moment for me was because The study had been conducted during medical my medical school years And one of the centers that conducted it was case western where I went to medical school And in fact, one of the the head person of that site was uh, dr. Albert Alfred conners who was my icu Attending mentor the person who taught me about icu and I was in medical school So he was conducting this study to understand how are people dying in america with other five other centers in the united states The study wasn't published until several years later in 1996 when I was already finishing up my fellowship in pulmonary and critical care But what the study showed Was an alarming State of how people are dying in america huge percentage of people again dying on machines Who probably wouldn't were not ever going to be helped by those machines a huge percentage of people Whose preferences if they had had them Were not known by their physician the sort of clear lack of communication between physician That was very alarming a lot of pain, etc. The second phase of that trial that's crucial those dying preferences are crucial Crucial I think that I can't remember the statistics right now, but I think 31 uh I'm not going to even talk about them because I'll mess it up, but Very few people who had preferences had this had been information that their physicians knew so, um They did a second part to the trial the first part was observational What's going on? What's the state and as I said the state was not good The second part was okay Let's figure out an intervention where we can come to the physicians We can provide enhance the communication We'll provide information from the patient and family to the physician from the physician back to the patient and family will enhance communication, etc No change no improvement very very disturbing And even though this wasn't the etiology or the reason that the palliative care movement started to rise I'm sure it was a big factor because people started to say wow People are really dying badly in america so the palliative care movement um Started I'd say I mean people will disagree with me But it was the early 2000s that they really started putting money into studying this robert wood johnson foundation Started giving grants to sort of study This new approach, which is palliative care and actually before we go into that. Let me tell you what palliative care is To pal palliative care comes from the word paliare In latin paliare means to cloak And you can sort of imagine this person this sick person this patient there's somebody coming and cloaking them sort of Caring for them that attending to everything that might be frightening them scaring them causing distress Yeah, and so the palliative care approach, which kind of came from the hospice movement, which had been started by in the in in the 80s by dame cecily saunders in england This sort of modern hospice approach to bring this multi disciplinary approach To caring for patients from us thinking about the social variables Thinking about all of the things that a nurse might think about thinking about the things that a chaplain Spiritual suffering, which is something we don't even think about in the hospital. We don't even consider that we keep religion away That's not real medicine So we you know and of course physician the the management of the symptoms Binding with the infinite is actually so Crucial in the process of Of death. Well, let me just give you a quick statistic about that because I just did a talk about The faith issue. I I'm Jewish but and I you know, I'm sort of agnostic in the way many many of us are I don't feel comfortable praying at the bedside with my patients And there are a lot of my patients in a public hospital in oakland, california are our christian african american very communal prayers and so a lot of the praying that might go on in a hospital like mine is very communal and and and and loud and and and active and it's not something that I feel like I know how to do I certainly don't you know feel skilled in it. Um, and I also feel like well, that's not really mine to do and most importantly As a doctor and the way our culture works We sort of feel like that's supposed to be separate like if we get into anything that has that looks like faith It's sort of like it diminishes us is the way we are thinking we are supposed to keep science and faith separate And so I never Thought that I was needed even as I started practicing palliative care more and more when this you know When that was needed. Well, the chaplain has it and I'll go on to the next patient and What I'm learning science and faith. They're kind of merging together more into the future. It's interesting I think it really well because here's the data The data show that 91 of people consider themselves spiritual 74 of people affiliate with an actual faith group And I don't remember the number but a very large percent of people Want their physicians would want their physicians to talk with them and even to pray with them to but to acknowledge their faith And it's almost never happening and I know it ain't one happening with me And so what I've learned is when I Just stay present and I stay with my chaplain. Who's amazing in the room That means so much to my patients that enhances our relationship. This is part of the cloaking that's happening It's just this multi this inter we call trans Inter inter professional cloaking of a patient where we all work together on a team That's so different from what I experienced in the intensive care unit where it's very hierarchical the doctors up here No one's really, you know, the doctor's making all the decisions Whatever else is happening is sort of happening in an ancillary way. Yeah. Yeah, and it's it's not and I'll tell you Remind me to tell you a couple of examples of that I could give you an example after example But how it really hurts not only the patient, but it hurts all the healthcare practitioners And and and takes again the humanity sucks the humanity out of the experience of caring for people But anyway, that's what the palliative care movement was and it was sort of growing in the 80s the 90s And 96 the support trial and then early 2000s Robert late 90s different kinds of groups Um, especially the robert wood johnson foundation started giving money to try to enhance the types of Interventions that palliative care teams do in different environments So there was this grant called enhancing communication in the intensive care unit and it came out from the night It was a call for proposals in 2002 robert wood johnson foundation Four hospitals won that grant One of them My chance happened to be one that I had just started working at in newark, new jersey Two months before and I was a new icu attending newark, new jersey in this hospital And all of a sudden they had won this grant I don't even know about the grant yet, but all of a sudden these people start showing up in the icu Called the family support team because no one knew it No one knows what palliative care is the family support team I was like, well, who are these people and they're talking to my patients there They'd come up to me and say, hey, did I don't think that family understands their prognosis and I was like Who are these people? Yeah, that's fun. Wow. That's a great first comment to say It's like does the family even get what's going on? Well, they were and I but I was annoyed. I was like Who are they? This is my patient. That's funny. You know, I can handle this. I'm a good communicator I'm compassionate And then I had my epiphany moment So I'd been working there about I don't know eight months nine months and this nurse who ran the family support team pat murphy She says to me when I'm one day, I'm putting in this catheter into a dying patient and I know this patient's dying And she's standing in the doorway and I look up and I see her and I'm like down to my gloves And I'm about to put this thing this woman's moaning under the bed sheet And I'm putting this huge catheter in her neck Geez Pat stands at the doorway and she goes like this Call the police. They're torturing a patient in the icu The nurses were there the medical student was there everybody's around and What? Me torturing somebody I'm just trying to do my job Anyway, what an interesting perspective on when a patient is basically dying. They're at their last Moments. There's no there's not that faith that family that those things that the dying preferences are not there It's just like Jamming of more of the conveyor belt of medical devices and things to try and get nanoseconds more And not even asking her You know what you know what permission I got I got permission from her husband who by the way I had sent off to the waiting room So he was away from her for these two hours Which were two out of maybe another 16 hours that she would be on this earth Telling him we're gonna do this because it will do this and it will help in this way And he's like okay. Okay. Thank you. We're gonna help I you know, she died the next day I knew you know really I knew she was coming to the end didn't even tell him that there was a chance This wouldn't do anything there was a big chance it wouldn't do anything And didn't give him really the option because he's a good husband. He wants to help And if the doctor's suggesting this next Yeah, yeah, yeah thing what husband's gonna say no Wow So that was an epiphany and then so that is so interesting that you ended up being Right there when the grant was made crazy And then then you were right there with the palliative care kind of movement crazy forward Early stages because it didn't get become a subspecialty in medicine until 2008. So this was 2003 It was many years beforehand And uh, I feel so lucky. I mean I at first was really Like defensive and you know, wait a minute and and but that moment because I had been feeling this sort of distress building And when that happened it took me a few days I got angry at first and then and then I went up to pat I went I remember I walked into her office and I said, you know what? Teach me to your teacher. You're right. Teach me what to do. Yeah, and that's when I She said, okay, so my mentor people say to me who I want to give you high five. That's who are your biggest mentors a nurse And a chaplain. Yeah chaplain So the fact that you had the moment where you came to your own realization that it It's the humility. It was the humility. I love that. I think it's so so crucial that more of us Realize that hey somebody else that has a different perspective on the situation can actually help make these situations across the world better for us together That's beautiful. And when you can actually like anything like with any humility in life the humility of Learning that you weren't a great parent in this moment, which I learned a lot unfortunately and try to you know humility actually once you can just Let it be and say, okay, you know what? I didn't do a great job. I didn't do a great job there It's such a relief such a relief and it opens you up to something so much more powerful and I've had many many many many many many moments of humility And I think it's one of my biggest teachers. I'm just writing an article that's going in about I call it putting it's called putting my patience in front of my ego, but it's oh interesting It's talking about how even as a palliative care doctor. I have to admit I still feel like I'm supposed to be the most important person in the room Yeah, as the doctor And I'm learning that I'm not the patient is and they're dying The first yeah But a lot of times the chaplain has so much more to offer Than I do and you know what I need to just sit there and witness I'm not used to that. I'm not used to that and I'm learning how important it is and And I feel really grateful for it, but it's so it's a it's a very different You know a different way from how I was trained and and anyway, I feel the world opening up a little bit Your learning experience is becoming our learning experience And it's so fascinating because we get to live through you through your experiences In the sense and and I'm I'm happy that you came to that moment of openness and now Yeah, I'm imagining like the way that the chaplain's interacting with the patient and the patient kind of like Almost drops into their their body in this in the spirit and the infant more than Potentially being like, okay, we're going to give you a couple more hours In this in this way. Um, yeah, wow, there's so much to talk about so okay So then over the last like 10 years has been kind of this developing out of the you know The humility getting more and more doctors to be Working with this more disciplines of of people that can help Actually tend to the patient's needs first the palliative care Whatever it is that the patient needs finding out what the patient needs Finding out where the most suffering is whether I'm the ICU attending or the palliative care attending It's always about the patient and eliciting from them What they need what they need to know what they want to know And how we can help them achieve what's most important to them Yeah, yeah, so then okay, so then through this this 10-year period So did Highland get also did you kind of bring palliative care to Highland? No, I mean how do that? Yeah, tell me about how that period worked before we get to extreme Sure, sure. Well palliative care has been growing now. You know, in fact, uh, there's a I mean the movement has it's fascinating actually Really It's it's it's it's captured in some ways. I think it's captured the imagination of many In in in the non-medical community saying Wow, I I didn't know death could be so bad because it's we're starting to talk about it more even in the lay press And people are starting to say whoa, wait a minute So this is that many grassroots movements are born from the non, you know from from the grassroots So we're hearing a lot of we're having a lot more kind of activity and movement in the out there in the non-medical community Saying wait a minute. I don't want to I don't want this to be my only option and then within the medical community There's so many people like me So many people who just needed a little something to wake them up To say yeah, I don't I don't want to be working like that as an automaton I do care about my patients and want to be connecting in a humanistic way The vast majority of people who go into medicine are really good people And people I work with are fantastic and giving you give them one little Alternate route alternate approach and they want it just like I did and when we're finding at highland Is that it's just been amazing just in the past even the past year We have watched our consult numbers rise rapidly and what's interesting There is that You know, you're seeing this called culture change within the Within the healthcare world for a while people are like, you know what that kind of stuff like I used to think If I just had more time I would do it. I'll get to it I'll get to that conversation with a patient all I am caring. I am compassionate, but I think what people are starting to realize is Number one, I don't have the time so I do need some support from the palliative care division. Number two I need some spiritual support. I need some social support. So let's pull in palliative care And also less from the practical perspective of I need these types of things that the palliative care Community group can do I think there's also just this this incredible sense of Wow, there is so much suffering at the end of life And I don't want to do this alone So what what we you know have to figure out in as a movement in palliative care is is How are we going to How are we going to Leverage our presence we can't have Enough palliative care doctors to attend to all of the suffering that's happening What we can do is we can teach Other doctors like I was taught by pat how to do some of this work themselves how to do some Illicitation of preferences and values from patients, which we never really learned how to do formally how to do some Matching of preferences and values with what we're going to do next in terms of medical decision making How to manage pain because pain is a very big problem people are dying in pain at very large numbers And I mean I didn't I wasn't really taught a huge amount about managing pain for me In the icu the whole goal was keep the blood pressure up And let me tell you some pain and sedation medications lower the blood pressure There were many times I'm embarrassed to tell you where I didn't even think about treating pain in a patient who was dying I thought about keeping their blood pressure up primarily That's not That's not okay And so we're we can spread that information out to other practitioners so that a lot of what they're coming to us for Right now that's causing us to just honestly not be able to keep up with the workload is stuff that we can have them Do what's called primary palliative care palliative care that's delivered by the primary team not by us That were more specialty palliative care interesting Now this seems as though it's been going on Actually in different capacities for like thousands of years And then it's just interesting that now the west kind of in some ways mess some things up. Yes, you put it perfectly Yes, that's exactly right Do you want to know the history of how we messed it up in the west? I would like to know that and I want to also tell you that I think that a lot of people would actually Probably prefer if they were only had like a day or whatnot left I would love to go and die in the middle of mere woods or on stints and beach or something like that like I would Like amongst people with family and whatnot, but me laying there amongst the trees animals and beach and water and not In a hospital, you know, most people agree with you And the problem is you know, we have those data that shows, you know 80 percent of people say they would want to die at home Oh, yeah, yeah, which is not happening I mean at this point the numbers the most recent numbers are 40 percent of people are dying at home But that's even an overestimate because of that 40 percent There's a huge number of what we're calling and a rising number of something that's called burdensome transitions Which means people are getting home But right before they die from the hospital So that 40 percent is an overestimate people are not dying the way they would like to die Now the fact that you would like to die in mere woods is great information That's a dying preference. It's dying preferences. You have to ask people have to no, I don't want to even the the medical world shouldn't be asking you You should be thinking this death consciousness. Yes, exactly. We are so we're pretending we're never going to die So we're gonna think about it like our own dying preferences. No with our own 10 like what we care What we want to do? Yeah, the buddhas say Deaths I'm gonna butcher this but death should always be on your shoulder We have a service that we use called we croak that sends us daily death quotes like five times a day Yeah, it's so good and that way what's what's the quote right now? What does it say? I see he's on his Yes, it's All right currently croak says Whatever you're meant to do do it now The conditions are always impossible There you go Well, the fact is I was just speaking with frank ostacevsky Who's you know the founder of zen hospice an amazing man a buddhist? We're gonna actually be in conversations soon in april. I'm really excited Maybe we should have him on sometime. He's terrific. That'd be great. Very smart guy And he said that you know having an awareness of death Is what lets you live your life better and I I agree with that. It's so true You know we probe agrees. Yeah, but you know Helps you live more. He also said and I totally agree with him that so much of this Movement that's really arisen in the past few years But this interest this grassroots interest in death and making death sort of an amazing experience Is Is complicated because You know It puts too much pressure on that moment You're focusing so much on that moment. So if that moment doesn't quite go the way you want it to That could be seen as a big failure The real focus should be on how is this you're living all those days leading up to that That moment you want to do everything you can to make it It consistent with your goals. It would be great if you could die in mere woods You know, you might not be able to die in mere wood and um You know as I said, um, I've seen many stories of people doing everything perfectly Bringing in hospice at the right time having this incredible supportive family in place having a great community, you know community Faith community that comes and checks on them and plays guitar and all that stuff And the fact is that that doesn't always guarantee a good death either So it cannot just be focused on how do you make that moment of death? So great It has to really be, you know, yes, you want to try to enhance that But like putting all the other stuff in place during your life. That's what it should be about Yeah, and that's where we find a lot of our meaning in life is by putting the right pieces together That we care about that leads us to the most meaning in our lives Okay, now that this this has been super solid. I want to see what we can get to with some of the Oh, I was gonna tell you tell us. I was going to tell you how we screwed it up. Let's tell us the screw up Okay, it's actually fascinating. Okay. Um, I do a talk that's called all that glitters and it's about Excuse me It's about the rise of the intensive care unit With all of its other associated What are they called? Um condiments around it. Oh the condom the condiments There's a multi-thousand dollar add-ons the add-ons, right the siloing of health care The hyper focusing that started to happen in the 1930s Do you remember the well, you're young but you know the heart lung machine the iron lung Did you ever see pictures of that? That sounds somewhat familiar the iron lung machine Saved, I don't know tens or hundreds of I think hundreds of thousands of people From dying from polio in the polio outbreak of the late 20s and early and 30s and 40s Oh, this thing is crazy. Yeah a negative pressure Ventilator also known as iron lung or polio Nearly obsolete mechanical respirator which enables a person to breathe on their own in a normal manner when a muscle control is lost Oh, what? So here's the thing. Oh in the night in the 1920 in 1928 there were two Got two guys. Excuse me I'm sorry about my cough. Okay two two guys from the Harvard School of Public Policy I believe it was or or some kind of school at Harvard and they decided To create a machine. They literally took two engines out of vacuum cleaners And they used them to reverse suck air out of a chamber and That earliest prototype kind of sat in the base at basement at Harvard And then when it came time in the sort of mid 30s late 30s for the polio epidemic to start to kick in They started to put people into these these chambers and the chambers basically would suck air out So it would inflate the lungs of a person rhythmically And tens and I think hundreds of thousands of patients who would have died from polio Which causes a weakening so you cannot you can't you know the muscle strength to breathe Survived my anti-fanny survived and went on to live normal lives And but how do you gain muscle strength though? How does that don't because polio is a virus? And so once the virus kind of got out of your body and you could regain It it was a bridge. Oh, it's a bridge. I see a bridge until the virus gets out of the body Okay, just a bridge kept them alive. You can they had these like so we thought we could iron lung out all of the And we did we had huge success with it. It was unbelievable Then Around world war two and korea during those wars was the first time that physicians learned how to manage shock And they could manage, you know massive hemorrhage and shock infectious shock on the battlefield They had these shacks like mash the movie mash, you know, this is the tea. Yes They would be right near the fighting and they would go and they would drag these people back into these things And they would resuscitate them. What so for the first time ever in warfare Young and healthy soldiers Were resuscitated who would have died and sent home. Yeah through the shock And so that's through is that mostly through the cardio through the well, it was it was using Hemodynamic management, which was again this sort of new This prison principles of physics and really of resuscitation So people are learning how to resuscitate bodies that would have died. This was new in the mid 1900s 1958 The first intensive care unit at johns hopkins was created And you know, you need room. These are these machines. By the way, the iron lung gave way to the modern Mechanical ventilator, which we use now to to inflate lungs. Now. It's not negative pressure. That's sucking open Sorry It's Positive pressure that's pushed into yeah So anyway You need room for these things you need electricity You need tubes that have vacuuming because we need to use a lot of vacuuming to suck away things You needed a space and so the intensive care unit was formed and that was 1958 in the next 10 years Every hospital in america had at least one intensive care unit Oh, thank you Every intensive care unit had at least one now we have now Almost created this ridiculous situation. We have an intensive care unit for every possible thing you could want Pediatric intensive care unit the pick you neonatal intensive care the nicu medical intensive care unit the micu surgical intensive care the sick you I just heard about and they're a huge multitude cardiac intensive care unit There's a digestive diseases intensive care unit. So not only do we have intensive care units We have the most intricate subspecialties That you can imagine. Yeah, hepatology You know various eye types of all of these doctors who are now going in and soup subspecializing. Yes When I was doing my residency at the Brigham We had 60 graduates at the end of my residency. How many of those do you think went into primary care out of 60 half Three three and Everyone else specialized now Things have changed since 1995 Many more people go into primary care, but that's pretty That's a pretty important thing to think about. These are these are this is my generation of doctors. Yeah Specialization earns more money and there's More opportunity There's many reasons. Thank you Ron There's many reasons why you could Look you could you could wonder why people subspecialized and here are a few of them People certainly make a ton more money geriatricians family practice doctors and primary care doctors And palliative care doctors make the least amount of money. Yeah. Yeah, okay It is About 260 dollars. I think you get from Medicare to do a biopsy skin biopsy, which takes about six minutes If you want to sit and have a conversation with somebody about end of life Practices and their preferences you get paid. I think it's 78 dollars for half an hour I mean, it's it's really discrepant. Oh, I see what yeah, it's where you get The things that we're valuing in our health care system financially and also in terms of prestige Are doing doing things to people. Yeah, we're we're in just in in a there's like I think it's half of all of the health care expenditures are going towards the orphan related diseases That are affecting such a very very small tiny amount of people versus the Again, if we value staying healthy And and and these These preferences the patient preference is putting the patient before the ego like you're writing about right now Okay, let's let's dive into we have been already touching on a lot of the things and extreme measures But I want you to give a kind of like a big picture overview Tell us about that. So the book is really it's it's it's kind of part memoir It's my transition story through this this this change this change in In in my goals You know, again, you know going from being really disease focused or or an organ focused physician to A whole human focused physician and it tells that story of that moment of epiphany and What you know It talks about a lot of the challenges that exist in our health care system that prevent so many of us from Going through that transition. Why is it so much easier to be An organ focused doctor Why is it so much easier to focus on a procedure than it is to focus on talking to somebody and it really kind of gives that whole story both hopefully for a physician audience to sort of For us all to come together and talk about some of these psychological things that are happening inside of us that keep us from Doing the things we want to do and also for for the lay community because this book was written for both To sort of explain what's going on to give perspective and hopefully to empower People to understand what the end of life conveyor belt is How at risk they are for being swept onto it because we all are And how important it is to empower yourself to start to think about the things that are important to you How you live and how you die and make sure that those things Stay front and center throughout your life And particularly in the health care system Yeah, I liked going on your journey and that you also explained it to us the journey of the of this through from the Early 1900s until now where things have kind of been going and And it it totally seems like we're integrating back to the principles of patient first and using The faith based and and other end of life caring about what their preference are preferences are You also were teaching us about how it's so important to have a sense A really deep sense of empathy with a patient and have a you know, if they are asking you to pray with them Maybe pray, you know pray with them. Yeah. Yeah, that kind of stuff. Um Acknowledge your discomfort acknowledge your fears But I think it's still important to to do that and to seek out Figuring out what they want from us that will be most helpful. Yes And then their decisions to go with certain and the certain The treatments that can sometimes be burdens actually decreases if you get if you build a relationship with them, right? and that's borne out Not only in my own experience But in the palliative care literature that when We do engage in communication and in a relationship and the communication and relationship have to be Established before you start Making decisions about do you want to be full code or not full code or do you want to do this surgery? You have to have a relationship a therapeutic trusting relationship with somebody Before you can really start knowing what the right decisions are and helping them make those decisions but What we know is that when we do engage in creating those kinds of relationships Um patients tend to choose lower levels Of intensity of treatment at the ends of life And they die less commonly in the intensive care unit. They tend to die more often in hospice. They tend to die in less pain It works it works. Yeah Relationships really work. Yeah. Yeah the eye to eye human connection asking them what they care about what their preferences are that that works Yeah Okay, I want to See what is going on with your future? Where are you going moving forward with things? What are you thinking? Well I'm a storyteller And a coffer and a kafa I really I am moved by story For my own personal growth The things that move me are the little moments like just the other day I was in a room in the pulmonary clinic. I was in pulmonary clinic and I was talking to a patient Is kind of dying and I wanted to start to talk to her about her end of life preferences and um We had the translator on the phone because she spoke Cantonese and um It was so it was just such a moment like of We're sitting here. It's very hard to use a translator on the phone to talk about these really profound things But these uncomfortable things and so And this translator I would say something and somehow What he would say would stretch out probably eight times longer than what I would say And and not only was I just like ah, but the family was like ah So it was this bizarre experience and then there was some kind of problem with his phone So every time he'd be talking it would he he'd be it sounded like he would be pressing a button for a sec So he goes beep I mean it was just a funny Moment a poignant moment of like an attempt to have a connection with my patient and just all of these things conspiring against it and um I just thought like okay. That's a moment. I have to write about But so for me writing stories and noticing these moments these little things. That's what that's what that's what fuels my growth and makes me think about ways that we can do things differently hopefully better one day And um, I just will keep telling stories. I'm going to be writing and writing and writing What I also believe is that that stories as I I think we found with the movie extremists Telling these stories and by the way that the two main stories in extremists the movie are also in my book He'll recognize them if you pay attention They go in my book in much deeper detail about those two main stories But um, I really believe in sort of the power of using story in both lay communities and in medical communities to try to get people to To examine themselves and try to grow And so I've been working with a variety of different Teaching teaching experiences that Pull in story and use prompt questions and really try to get people to reflect In their own sort of minds on some of these things that are really hard to talk about and try to open up an honest conversation We did it at ucsf for their department anesthesia And I think that this program could be used in a whole variety of medical training Environments and now we're starting to use it in in in lay communities, but I think using story to Change behavior is is really an area that I I would like to go and and creating new films that also themselves have A Story to them and a lesson to be learned through watching other people's experiences We have two films that are coming out and and and a few more that I would like to work on so Well film and then also writing and then this is all based on self-awareness or awareness increasing about this about this field About the subject Hopefully it'll help people to become more interested and aware instead of just providing them data Hearing a story and saying that's interesting that and being moved by that to start thinking differently about it. Yeah. Yeah That's huge work. Okay. May okay. We'd like to ask a couple questions on the way out of the show I'm interested to hear your thoughts about it What do you think we're alone in the cosmos? How could we possibly be I mean I don't the numbers just don't support that That we'd be alone, right? I mean When I really start to think about it. I go crazy, but I can't imagine that there isn't another form of intelligent Of intelligence out in the universe and when you want to talk about humility I mean I think it's kind of No, maybe this isn't fair, but I kind of think it's arrogant to think that we'd be the only intelligent life in the universe How could we possibly be? So I just I guess in some ways I do I would love to see proof of it, but What do you think? Are you not supposed to tell I'm not oh no, I just it's uh, it's very yeah, it's very complicated and interesting I'm very fascinated by what exists past the three dimensional perception systems that we have. Um Do you think we're in a simulation? Hmm Oh, that's interesting. You mean do you think we are a simulation by some higher power? I think it's possible I have no idea, but I do think it's possible Like an experiment What what what kind of nudges you in that direction of thought? Well, I mean As I said, I I think there must be more intelligent forms of life out in the universe. I just do think that um And given that um They must know about us I would think I wish I could I wish I knew for sure, but yeah I don't know if we're an actual experiment, but I wouldn't be surprised Kind of freaky to say that. Yeah. Yeah, it's fun. It's fun. And it's kind of I don't know if we're passing by the way If our simulation is working. Oh, oh, yeah. I'm afraid we may have failed in some areas here. Yeah Well, not We if it's an experiment They are failing. Oh, that's interesting. I just want to throw that out there, you know, if it's a simulation That's a good point. Okay. Yeah oh Interesting question the experiment side of things very interesting. I'm glad you brought that up. She's the first that Said that I think about an experiment. Yeah, I think so. Yeah, yeah, we we've We frequently enjoy that sort of a the zoo hypothesis is a hypothesis. That's Yeah, that that we are Not being discussed about until we evolve to the capacity at least some sort of an intelligent capacity To unlock communication with them like teleportation or something like that Yeah, we've seen that saturday night live skit with um, kate mckinnon where she's they're talking about how she You haven't you haven't seen oh my gosh. It's hilarious. There's this whole series of ones that they do where like three people got sucked up into a Some kind of machine from outer space. Sure. And it had this like this amazing experience the two of them They talk about how beautiful it was and she's talking about well, I don't know about you but and she's smoking a cigarette It's it's hilarious. You should watch it. What did she say? She's just talking about What are you saying these beings from a higher planet? Yeah, like, you know, they put something up McEaster I mean she is just it's totally irrelevant. I mean irreverent and hilarious. You should watch you would get a kick out One of my favorite kate mckinnon series Very funny. Just the last question. What do you think is the most beautiful thing in the world? There's so many But if I had to reduce it to one It's the human ability to Connect with you know people to connect It's just this sense of like what happens when you Connect with other people whether they're friends or people on the street or your patients or your kids your husband And you sort of get this sort of connection of Like like minds and and not being alone in the universe Yeah Because really if you think about it, I mean that's very human Well, it's not just a human thing my my dog snuggles up with me, but I don't know. There's something just really profound about About Connecting with something else and not just being this sort of little robotic loan thing That would have to be it. Yeah, it's beautifully said Jessica, this has been such a pleasure. Thank you for coming on and teaching us about all this Oh, thanks for listening We're living through your Experiences and and that's been that's been very interesting to us and hopefully so many of you that are tuning in because Who would have thought that that people on the way? to death Are just not having the ideal good death preferences that they so want You need to be willing to talk about these things we do We can make it better. We can make it so much better. Yes. Oh my gosh Yes, there's a lot of low-hanging fruit out there. Yes Thank you, Jessica. Thank you so much for coming on the show. We greatly appreciate it. Thank you Thank you. Thank you. Thanks everyone for tuning in. We greatly appreciate you Give us your thoughts in the comments below many of us Maybe having this these scenarios happening to us in our lives with our families and our near friends So go and share with other people about dying preferences having good deaths, etc Also, thank you to Ron for producing and directing Give us your thoughts again everyone. We love you very much for tuning in. Thank you. Thank you And go and build the future manifest your destiny into the world check out extreme measures links in the bio Also, Jessica's website links in the bio or twitter links in the bio. Go check all that out everyone extremists Links in the bio as well. Okay, everyone much love. We'll see you soon build create Bye