People are dying in ways that don’t match their values.
Hospitalist, philanthropist, and Netflix documentary producer Dr. Shoshana Ungerleider joins us to talk about how she balances a clinical career with a passion for transforming public perception around end-of-life care. She is the founder of the End Well Foundation, designed to reimagine the end of life experience in ways that are universally available and serve the needs of the individual.
Is our “default” level of care appropriate for all patients?
No matter how old you are, how sick you are, or what your diagnosis is, in this country chances are you’ll get aggressive, expensive care by default if you’re wishes aren’t made clear. Remember when we talked about what a full code might really look like?
Is there another option?
Palliative care consults are too often seen by patients (and many caregivers) as “those people you call when you’re ready to just give up.” However, often the earlier patients are referred, the more supported they feel, the better they do, and the more apt they become to deal with both physical symptoms and “existential” distress.
Hospice and palliative medicine specialists and associations like AAHPM have dedicated themselves not just to helping during the dying process, but to extending the length and quality of life. So how do we work with the palliative team?
Palliative care is a key intervention.
Consult early. These pros (usually part of an interdisciplinary team) are trained to have the difficult conversations, build rapport, and really get to know the patient’s values and goals around care so they can help ease suffering at all stages of a patient’s course.
Hospitalists, surgeons, and other healthcare professionals often need help not only in identifying patients with whom they should have these challenging conversations, but in the specifics of the conversations itself.
Palliative care helps manages symptoms that matter to patients.
Think of palliative care on one level as a symptom management service, where patients can receive pain management and treatment for a wide variety of physical and subjective issues. This type of care is focused on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family and caregivers. It can be appropriate at any age and at any stage in a serious illness, and it can be provided alongside “curative” treatment approaches.
Where do you start?
Utilize our palliative care colleagues, and encourage our patients and caregivers to have the conversation. If you need help breaking the ice about making wishes clear, check out our music video “Ain’t The Way To Die.”
You can also check out the documentaries Dr. Ungerleider has helped produce on Netflix: Extremis (focused on the wrenching emotions that accompany end-of-life situations and decisions) and End Game (where terminally ill patients meet extraordinary medical practitioners seeking to change our approach to both life and death).
ZPac, check out the original video on Facebook and the free podcast version on iTunes and Soundcloud. Leave your thoughts, comments, and let me know if you like this in-depth interview format (it might be better to listen on a long commute if you can’t do an hour of video!)
– Should we do this?
– Let’s do it!
– I think we should do this. All right guys, I have Dr. Shoshana Ungerleider here. She is a fellow hospitalist, awesome, the pain. The pain is universal at CPMC Sutter Hospital in San Francisco, she is also a philanthropist, an executive producer on at least two Netflix documentaries: Extremis and End Game and she is the founder of the End Well Foundation, and that is a 503 (blah blah), what is it?
– Something like that, a not-for-profit focusing on end-of-life issues, palliative care, that sort of thing, am I right?
– And I am thrilled because I’m here in the Bay Area in this cool rental, how dope is this house, by the way.
– Amazing house.
– Us doctors can’t afford a house like this. It’s 1,500 square feet, do you know what the Zillow price is? It’s 3.3 million dollars. Yeah, I know, Elizabeth I’m coming. Talk about palliative care. I need palliation for the mortgage on a place like that so we’re hearing this beautiful thing as I’m in the Bay Area doing interviews and we connected because we’ve known each other’s work and I was really excited because it always fascinates me that someone can do hospital medicine, particularly nights like you do and still do other stuff to actually improve the system as a whole. I mean, how did you get into the whole end-of-life and all that in the first place?
– Whoo, well, actually it was early on in my residency. So like you, I did, I don’t know, four, five ICU months during my intern year. I didn’t know anything about medicine. I walked into the ICU my first week of being an intern and just had my mind completely blown on how stupid I was but once I–
– I know that feeling.
– Right. And once I sort of understood what was going on there, I realized that what we do in this country is, no matter how old you are, no matter how sick you are, you’ll get admitted to the ICU and get aggressive invasive care by default. So that was surprising, somewhat shocking to me, it wasn’t something I thought about before until I was in that moment and what I realized is most the time, A, those patients and families have no idea what’s going on, they’re not a part of the conversation that lands them on that path.
– In that default path. They don’t even realize it’s a default.
– Yeah, they just think the doctors think this should be done because no one’s had the conversation.
– Exactly, and how it plays out is these patients are often getting care that they maybe don’t want, and they don’t understand and then it’s not in line with their goals and their values of how they’ve lived their lives and that, to me, is what good medicine is all about, whether we’re talking about the end of life or we’re talking about diabetes and high blood pressure. It should be all about tailoring care based on asking a patient what’s most important to them.
– I mean we talk about shared decision-making in this kind of thing a lot but it actually is accomplished in the hospital very rarely. It’s not the default mode of communication and like you said, what shocked me in ICU is that we spend so much emotional energy and time and money at the end of life and it wasn’t what the patient wanted, if you really asked them, if you really dug in, they would say, “Well no, what I want, “if you could ask me, what I want “is to be comfortable at home.” Most people want to die at home but yet we don’t give them that. So as a hospitalist, there you were–
– I was an intern.
– As an intern, so you’re doing all these months of ICU and was it something where you said, because I tell you, I had these conversations with myself, where I was like, “Can I do this for a living? “I’m being paid to torture people until they die.” That’s how it felt and we had palliative service but it was kind of a nascent thing, it was new.
– So luckily, we have a very robust palliative care service at CPMC so they provided amazing mentorship for me and I really sought it out through residency because I saw them as really the only people in the hospital setting that know how to engage in shared decision-making, how to sit down and communicate effectively with patients and so I think that really kind of turned the course for me in terms of what I wanted to do.
– You didn’t think like a lot of the specialists sometimes will say, “Oh these are the guys you call “when everyone’s given up,” so you call the palliative team when everyone’s just, if the oncologist can’t pull another nail out of the coffin and continue to work on the person who’s basically a cadaver at this point, or the nephrologist can’t do dialysis anymore because, all the access is blown and that’s when, that was the sense sometimes I got is it’s a failure and you call them in to swoop in and the patients too, have this perception that here come the vultures. Have you ever heard that–
– Oh absolutely. I think that that has been the way things have happened over time, I think it’s changing. I think now more medical students have coursework in palliative care, I think more physicians, especially hospitalists are on board with the fact that palliative care is an extra layer of support for patients and their families, who are facing a serious illness and can and should be used at any time during the course of illness, not just the end-of-life. So the earlier they get referred, as you well know, the better these patients do, the more supported they feel, whether we’re talking about physical symptoms, psychosocial stuff, existential suffering around illness, all of these things so I do think that while in medicine, we try to, well, we definitely, in our medical culture think death is a failure and that’s how it’s taught to medical students, I think it’s changing.
– I think you’re right and what I see… You work with these guys too, the Hospice Palliative Medicine Associations, AAHPM, and the guys, when you speak to them they literally are the enemies of suffering. These are people who have dedicated their lives to not just the very end of life but making the quality of life that you have as long and as high-quality as possible. So it’s not just about extending life, what we find too is the hospice holiday and that sort of scenario. If you listen to somebody, if they feel heard, if you address their existential sort of issues. I’m looking at an abyss towards another side that no human has come back from and told us about that we can document, unless you’re religious and how do I deal with that? In one of the movies that you executive-produced and we can talk more detail about that in a bit but BJ Miller, who’s an amazing doctor and has suffered his own sort of life-changing look into the void said, “We’re hardwired to run from death, “yet death is a part of life.” So how do we reconcile that and as a hospitalist, we’re both paid to do stuff to people, either RVUs or we’re salaried or whatever. Is relieving suffering, is providing palliative care, is consulting and working with the palliative team doing something in your mind, is it something that is an intervention in itself or is it what some doctors still believe is kind of a giving up?
– Oh my goodness, it’s absolutely an intervention. I can tell you from my own personal experience and the data supports it, when you have somebody who knows and cares coming into a room to talk to a seriously ill patient and their family and really getting to know them as a human being, building rapport, doing the things that, making eye contact, sitting down in a chair, things that doctors are not taught to do, turns out, JAMA study came out in 2016 surveying physicians showing that 70% of them said that they hadn’t been trained in how to have difficult conversations with patients.
– How can that be?
– Blows my mind. And surgeons, we know, spend somewhere around seven, eight, nine, 10 years learning how to operate in the operating room. We spend zero time teaching doctors how to talk to patients when a really thoughtful conversation can change the trajectory of someone’s life just like how a surgery could, you know what I mean? Really make a huge impact and so when I realized that, I was like, “Oh my gosh, I don’t wanna be a cardiologist. “I wanna be a palliative care evangelist.” This is something that everybody needs to know about and talk about and understand.
– So as a hospitalist and this is like some confessional stuff that I haven’t really said publicly but I always felt that I could be swapped out of my position with any number of people who could do my job, hospital medicine, as well as I could and it would be a relatively seamless operation but what I thought was special that I did was the ability to, I would walk in the room and I would come and I would pull up a chair every time I could and I would turn the pager off or put it on vibrate, put it away and make eye contact with the patient and spend time and those were the interactions that meant something to me and I hope they meant something to the patients, I got the sense they did.
– I’m sure they did.
– And I got the sense that that was not something that was hot swappable with any other random doctor because we aren’t trained to do that. The reason it came with my package is my mother is a psychiatrist, that’s how she raised me is to sit and talk and make eye contact and–
– My dad’s a psychologist–
– There you go, that’s right, he’s a sport psychologist?
– He is.
– It shouldn’t be, in my mind, it shouldn’t be that you have to be born with some gift to be able to do that. It seems like we can train Buddhist monks to be hyper compassionate, why can’t we train our doctors to sit down, to listen, to read some body language. You don’t have to have an infinite emotional intelligence to be able to learn some of those things. So for hospital medicine, if you could bring that to hospital medicine, you’re already on the 90th part of the bell curve. In palliative medicine, if I were going back to full, so now, we were talking earlier, like I see patients in the county hospital a few days a month as a hospitalist with our house staff to try to teach, if I were going back full-time to paid clinical medicine, I would be doing hospice palliative medicine because it feels like that’s where I can have the biggest impact. I guess a question I have when I saw one of the documentaries that you executive-produced and we’ll talk about how you got about becoming an executive producer for a Netflix doc like Tom Hinueber on my team, my producer would love to do that and he can’t do it and he went to film school but you were able to do it for two films, both of which had huge impact; Extremis, which by the way, if you haven’t seen, it’s on Netflix, it’s documentary at Highland Hospital ICU in Auckland and I knew Dr. Bhargava who was in that documentary and it just kind of follows through what’s it’s like in these end of life discussions for patients that are struggling to come to acceptance with it and the team that’s struggling to even communicate about it and I remember watching it and getting this visceral reaction like, “No, that’s not how you have that conversation,” or, “Yeah, that’s right, yeah, do that. “Oh, that patient is, oh,” you feel it. And then I saw End Game, which is the recent one and it was a different level of connection with me because here was Steve Pantilat who’s one of the attendings at UCSF, palliative care guy or is he a hospitalist?
– He’s hospitalist and palliative care, yeah, both.
– It’s like you, it’s the double threat and then the triple threat is of course, the dancing, I haven’t told you about the dancing yet. Please tell me you dance.
– I sing.
– We’re gonna do a duet, it’s gonna be ebony and ebony. We’re just trying to be a little different, they already did the other thing. So this idea that Steve Pantilat, who I respect, who was my attending and small-group back at UCSF in the 90s to see him aged 20 years and so wise and sitting with the family and sitting down and having that conversation and here was a family that was an Iranian-Persian family, which is my genetic background to see the husband’s resistance and he said, “I don’t wanna let her go.” And the wife, who was the patient, presumably with cancer, bald and in bed with the bruises and the sleeve, it hit so close to what we do, the arc of humanity that what we do. I think BJ Miller used that exact term, the arch of humanity and how the heck did you get involved in such a beautiful, I imagine that your wisdom somehow infused the angle, how did you get involved?
– Well, it actually started with the involvement with Extremis, the first one, the wife in the ICU. Actually Jessica Zitter is a good personal friend.
– The doctor, the attending in that movie.
– She’s ICU and palliative medicine trainer which is a unique combination and she and I were sitting down having coffee one day and just in a random conversation she said to me, “Did I ever tell you they’re filming a documentary “in our ICU?” And I was like, “What, no.” And so she put me in touch with the director who’d been there for months actually. They got buy-in from the hospital and really had on and off and been a very small team just shooting patients and he, Dan Krauss is his name, he sent me a rough cut of the film like a five minutes and I remember being on call at the hospital, watching it on my iPhone and being completely blown away. I’m not a super emotional person. I kind of have my game face, was in tears in the unedited cut of that and so I thought, gosh, he has something here. These are stories that need to be told and so I called him up the next morning, I said, “Dan, this is freaking amazing.” He said, “Thank you, I really appreciate that. “We don’t have the money to do this film, “so we’re gonna put it on the shelf.” And I said, “No, let’s make a movie.” So that’s how it all came together. It was really very, very far at the end in terms of I provided post-production fundings was a major funder of the film and we thought the film would live in the New York Times as an op doc initially because at that time Netflix and Amazon and Hulu weren’t buying short docs.
– Explain what an op doc is.
– Well, the New York Times cuts up parts of films and pairs them with pieces of writing.
– Mm-hmm, oh I see.
– And so then online, someone can access, something like a short, yeah.
– Click through and watch it.
– And this was actually in 2015 before Netflix and Hulu and Amazon started buying short documentaries. I think we got really lucky and obviously the film was wonderful so that helped too but we were the very first short doc that Netflix ever bought.
– And then we premiered at Tribeca, the one Tribeca and then we’re nominated for an Oscar and two Emmys for that film and so–
– I hate you so much.
– Completely blew my mind. I got to go to the Oscars last year which was just an amazing, overwhelming, insane.
– You know what, this interview is over.
– Here I am, I make videos, more or less for a living, no Oscars, no Netflix.
– You got plenty of time, come on.
– So now this gets me to the point, how does a hospitalist, not that far out of training–
– No, couple of years.
– Couple years out of training executive produce, was this a family foundation that you guys have, that’s my understanding is.
– Yeah, so you were able to channel this sort of… You have a history of giving in your family ever since we were young through your dad and was that how it was done or how did it happen?
– Yeah, for sure, growing up, my grandmother, my father really, and part of my Jewish tradition is about giving back. So one main tenets of Judaism is what we called tikkun olam so repairing the world and so I feel like that has just been a part of my life forever and maybe one of the reasons I went into medicine because I really wanted to help people but I think when I finished residency, I started a philanthropic fund from a family foundation supporting palliative care education, so really doing the work of training all doctors where I work in how to have these difficult conversations, how to think about palliative medicine on the spectrum of people’s lives in the course of their illness and then talking a lot about physician wellness because as we know, the rates of burnout in medicine are like through the roof so I’ve sort of transferred my focus or shifted my focus a bit onto public education which is how the Netflix docs came about and really it was through Extremis that I met the team that was doing End Game, it was a totally different filmmaking team.
– Wow, so they’re not related at all, that just purely, you had the connection through there.
– Exactly, I was on the board of Zen Hospice project, where they were they were filming.
– BJ Miller’s project?
– And met them years ago, actually, right as Extremis had finished and for a few years, talked about what the film could look like, thinking about the right patients to follow, was it at UCSF, was it at Sutter, was it gonna be at Zen Hospice and the film team is Rob Epstein and Jeffrey Friedman who are multi Academy Award-winning documentarians. They’re like legit filmmakers and really were so thoughtful and really passionate about this topic. Even after BJ left Zen Hospice a few years ago, we said, “We want you in the film.” This is really important to sort of ground what we’re talking about in a lot of his wisdom and thought leadership and so, yeah, fast forward a couple of years and here we are.
– That’s amazing, so in a way, we both took different angles, you and I to public communication. I took the let’s be a professional clown on YouTube, evolved that into a professional clown on Facebook and then tried to be a more professional, professional clown on Facebook. You took the philanthropic angle with the organization, with the executive-producing of Netflix videos which reach a lot of people, a lot of people. I can’t tell you how many people had messaged me about Extremis and I hadn’t heard about it because I don’t watch a lot of TV or a lot of Netflix and I was like, “What is going on here? “What is this thing?” And I saw it and then I made the connection and I was like, “Wow,” and I recently saw End Game, it only recently was released, I think, in the last couple three months.
– May 4th.
– May 4th, may the fourth be with you. I know what you did there, it was a Vader thing people, force; anyway, so when it was was released I recently took a look at it and it was a totally different feel in Extremis and it was pure emotional resonance, like you’re not intellectualizing that film but so much happen in the film and so guys, I gotta say this. Let me put in a plug for this because it is absolute required watching if you work in healthcare or if you don’t, you have a loved one, you yourself are wondering what happens in end-of-life, the conversations they had, it was a fly-on-the-wall kind of thing, it’s not like you’re sitting there watching a whole ton of interviews. It’s just, this is what happens. BJ Miller having that conversation with the elderly lady who was dying in his office as an outpatient, it’s like an outpatient palliative care.
– UCSF has the most amazing outpatient palliative care program.
– How on earth does that even work? So people come in, they know they have a life-limiting illness and they come in and they have these sort of sessions.
– Yeah, and they manage symptoms. So it’s a symptom management service, that’s what they call it at–
– That’s why they call it symptom management service, right?
– Yeah, it’s incredible, what they’re doing.
– We call that the dilaudid services at Las Vegas.
– Well now, it’s gotta be something else, we can’t get the dilaudid anymore.
– We can’t get that dilala, that’s right, now it’s all Toradol.
– So Toradol.
– Right, it’s obecalp XR, placebo spelled backwards but the extended-release but when when BJ sat there, and this, to me, was one of the most remarkable conversations I’ve seen another doctor have. She came in and she said, “So the assignment you gave me, “which was to make friends with death, I failed it. “I failed it utterly, I can’t do it. “I like being alive, I love being alive.” And BJ Miller is sitting there and he’s this, so if you guys don’t know who BJ Miller is, he’s a doctor, he’s a little older than me, maybe, maybe the same age, really distinguished guy has prosthetic legs and is missing a good bit of his left or right arm, I forget because of a accident he had when he was 19. He was standing on top of a train and it was an electric train and an arc of electricity went through his watch and basically fried his legs and his arms and nearly killed him and that life-changing event, he finally came to terms with and came out as an almost enlightened being and is giving back so much to other people so he sits there and he says, “Okay, well, “maybe let’s not make friends with death. “Let’s have a conversation, “let’s develop a relationship with it.” And then he goes on to talk about, we don’t know what happens when we die, I don’t think anyone can know that so what can we accept and he chips away at this relationship with death in a way that was so beautiful and I remember making notes in my mind, going, “I’m gonna steal that, I’m gonna do that, I’m gonna do that “with myself when I’m dying, “I’m gonna do that with my loved ones,” it was beautiful. I think that the documentary guys were able to capture this, is a rare and wonderful thing. Were you happy when you saw the final product?
– Yeah, oh absolutely, it had been many years of filming and trying to find the right patient and the right family to work with and tell the story, yeah. No, I think I’ve probably seen it 50 times at this point and every time I like it more and more.
– There’s something else.
– There’s something else, you sort of connect with the film and it actually gets more and more sad for me. And I am, as I said, I’m not an emotional person so I’m like, “What the heck is going on here?” It really is beautiful and tells a very true story for people.
– It’s the veracity, the truth of the story, I think that resonated with me. So I was watching it again this morning because I knew you were coming today and my family was gone and like there was one scene and I don’t even remember what it was. I’ve been a little bit hyper-emotional lately because I’ve been doing a lot of serious pieces, stuff about kids being left in cars and forgotten and dying and terrible stuff. So I’m a little prime but I just got very emotional because these are universal truths and we see it in the hospital and you know what we do, so a lot of times we’re like, “Yeah, I’m not gonna process that right now “because I got another 10 patients to round on.” And like you said earlier, there’s a game face right, so we put on our game face and we have to have that because otherwise, if we’re falling apart all the time; well, first of all, it’s not sustainable for us, it probably means we’re empathizing more than compassionatizing so we’re feeling their pain as our own effective empathy and we’re not just kind of detaching one step and feeling love and concern for suffering and so feeling that in the documentary, I mean that’s a gift to give others because they feel that and they feel the truth of it and they may make a change. They may say, “I’m gonna have this conversation. “I’m gonna change how I look at this.”
– That’s the hope. I mean we really want to shine a light in these places, whether it’s the ICU or it’s being in a hospital bed. That woman in the movie, Mitra, had been sick for five years so you’re just catching a very, very short snippet of time for her and she’d actually known those providers forever so that whole time and we really, I mean, I can speak for myself, really want to empower people out there to be able to understand what are the questions I should be asking my doctors, what are the conversations I should be having with my family about what matters most to me so that if I’m in that situation, I can get care that I want and that I understand and that is in line with my goals and my values because that’s what it’s all about.
– I’m gonna talk to these guys for a second because I think when I watch this documentary, what I realized is there was so much teaching there for how to have these conversations and it’s not in any way a didactic lecture it’s a you watch these people who are brilliant mentors, Steve Pantilat, BJ Miller, there was another doc talking to Mitra, the patient who was dying after five years of struggling with cancer, talking to her about we wanna do a research project where when she dies, talking to the husband, we need to look at the organs and see where the cancer is and that may help others fight, with research, et cetera to prevent this from happening and to see the family struggle with that. And I remember the mother of Mitra, a wonderful lady, spoke in Farsi a lot and they translated it and she thought she was being kind of a sly, she’s like, “They have me on the camera all the time,” she’s saying this in Farsi and then someone told her in Farsi, “They’re gonna translate this “and it’s gonna be subtitled.” And she’s like, “Let them translate it, it’s true!” She turned to the doctor and said, “So if this were your loved one, would you do this, “would you let them cut open the body at death “and take the organs out and do all this?” And the doctor said, “I would, I would, “but it’s a personal thing.” She said, “I want to do this but this is my daughter.” And these are the conversations that they give you the feeling that you’re living a purpose when you practice because you get to have those conversations.
– And I will say and it’s shown in the film, there is a team there. So it’s not just the physicians. We got the nurses, we got the social workers, we have the chaplains, we have a whole kind of wraparound of care for people because it’s not just about medical care. It’s all these other things that come into play. I think palliative care does the best job of any medical service to be inclusive and to talk about this team-based approach to caring for people and a lot of those conversations were from Bridget Samsa, the social worker who’s boarded in palliative care as a social worker. She connected with that family for many, many years and so I think important to point out that everybody is part of the team in making a difference but yeah, absolutely.
– Let’s talk about that more because when I spoke for AAHPM, AA–
– You got it, AAHPM.
– AAH, it gets too many letters, just call it like The Palliative Hospice Cool Folks, Enemies of Suffering. Enemies of Suffering, EOS. The EOS guys.
– Love it.
– So when I spoke to EOS, I remember talking about Turntable Health, our clinic, and how it was this team-based approach, the social worker, nurse innovator, we called her or him, physician, health coaches, a phlebotomist, everybody on the team taking care of the patient and I just said, “You guys were my first introduction “as a medical student to what “a team-based care looked like.” And the reason was and since then, you see it in transplant, you see it in surgical teams, you see it in cancer but I saw it initially in hospice palliative care at Laguna Honda in San Francisco. And I was a medical student rotating through, I think I was second year so I didn’t know what the heck was going on, they throw you in these clinical situations and you’re just goingand Laguna Honda was an inpatient hospice for county-level patients as I recall.
– Yeah, no, it’s right and Zen Hospice Project sends their volunteers there to care for folks who are hospice eligible and so new to the end-of-life.
– Got it, and so they would sit in Interdisciplinary rounds; doctors, social workers, case manager, nurses, everybody who was taking care of the patients and they would sit in around and they would talk about that patient like they were a member of the family, all the psychosocial stuff and the personality stuff and the resistance and the pain, the medical stuff and every single person had an equal voice. And I remember, being instilled in the hierarchy of medicine already as a first year, being crapped on by everybody I was like, “Wait a minute, “everybody’s voice is equal in service of the patient.” They all bring different gifts and that changed the course of how I thought about medicine because I used to think about it like my dad’s kind of medicine, 1.0, like it’s cowboy doc, everybody listens.
– Bunch of men.
– Bunch of men, right, exactly, exactly. And at least, I didn’t have a bunch of white men because my dad being Indian, I was like, “Okay, they don’t have to be white, okay, buddy. “But they still have to be men.” And so so all that conditioning started to unwind a little bit when I saw that and palliative medicine does that. So in your documentary you show a social worker and they’re all sitting there singing and they’re doing different things for that specific patient. Where do you feel the hospitalist fits in in that team?
– It’s a good question. I think it depends a little bit on the type of practice that’s set up in terms of the hospital, some hospitalists also do palliative care, so they’re part of that team just naturally. I think in academic medical centers, of course, it’s parsed out and because palliative care is a consultative service, meaning they have to be called in to see a patient, I think the hospitalist plays an integral role in recognizing, hey, flagging and saying, “Hey, I think this patient “would benefit from a palliative care consult “or a conversation and it’s above my abilities “to manage their pain to talk about discharge planning,” to deal with whatever is coming up that you would need a palliative care provider so I think absolutely. I mean hospitalists are the ones that open the door for this kind of conversation.
– We are the key master and the gatekeeper and Gozer the Gozerian gives us our orders and also our pay. Actually, relating to that, I learned the most about constipation management from one of our hospice people.
– Me too.
– They are so good at it. Because you’re on high-dose narcotics, you have other issues that cause slow bowel transit and constipation, and constipation is a life altering kind of suffering, you guys. You wonder why older people are so obsessed with their bowels, because it determines the course of their day; am I gonna have a good day or a bad day? Am I gonna be bloated and uncomfortable and in pain or am I gonna be like ah, I dropped the kids off the pool the right way and these things matter and that’s, I think, one of the magic cool things about palliative care is they care about subjective human experience, which is, a lot of times, ignored or at least, it’s an inconvenient thing like, “Oh, she’s having an experience.” That’s not what we deal with, we deal with the skin and the eyes and the organs and the blood and the chemicals in the blood and send it off to the lab and we don’t deal with how’s your day today? As a hospitalist, you’re under a lot of pressure, you got a chart, you got to see patients, you got a block from the ED, you’ve got a block from the clinic. Where is the role of listening to your patients subjective experience for you?
– Well, I think, now that I’m done with residency and sort of less harried in terms of my overall way I think about patient care, I am actually very often, taking the time to sit down and talk with patients because that’s like the best part of my day, or actually, for me, it’s my night but when I can really connect with people, I think I’ve been given this blessing to be able to sit down and talk with people in these really intimate conversations with strangers, people I’m just meeting for the first time but to me, that’s what is fulfilling about medicine; is to really connect to people on a human level and I think it’s unfortunately, really missing for a lot of people. We don’t value, as you’re saying, these conversations. We’re not paid to sit and talk with people. We’re paid to do things to people and I think that’s really contributing to a lot of the burnout in our profession.
– Now, speaking of burnout, you are recently married, from what I read, I’m not a stalker, I’m just–
– How did he know that?
– Dr. Google is my friend. You recently married, you do all this philanthropic work, you’re running the End Well Symposium and the organization. You’re doing the executive producing and you’re a nocturnal hospitalists, a nocturnist, if you will. Ho do you do that all without going crazy? I read something about, you were on your honeymoon and you just gave up and started working. Well, I guess I’ll preface this all by saying the work that I do is so important to me that it brings me a ton of joy so for me, I don’t see it as work, I’m compelled, it’s my passion. I am lucky in that I work part time so I do a handful of nights at the hospital and the rest of the time, I am off, either traveling or working on other projects. So I feel lucky that I’m able to do that and really focus on things that I care a lot about as we’ve talked about. So it’s just like everybody. I feel like if I had to work full-time as a physician, I would be way even more burned-out. I mean the work that doctors do who are full-time, in the ring, just totally insane.
– Let’s talk about that, because nurses, doctors, everybody on the front lines, a lot of them are trying to scale back if they can afford to do that. When I worked full-time hospital medicine, I was pretty roasted by the end but a lot of people, friends of mine, who’ve dropped to half time, they take a big cut in pay obviously, but they are so much happier. So is it that there’s a certain amount of money that you need to be able to feel safe and secure and such on and then after that, it’s just too much pain? In other words, you can’t do those things that you’re talking about where you’re talking about supporting a cause you care about. You used the word joy and I always love to think about that word because in our flow state when we’re doing something we love, joy emerges as a thing. And you see it in the comments on my videos, people will say the best experience I had is this, or this and that and you can feel that joy but then you can also feel when the joy is not there; when it’s a job or when it’s slog or when it’s hurtful to them because they’re being laterally abused, there’s a lot of stuff in healthcare that is, that the patients can get violent now with the opioid epidemic, with poor mental health services and all of those things.
– Well, I think overarching the whole thing is we’re working in this very broken system and everybody feels like whatever part that they’re playing, that they’re maybe putting a Band-Aid on a much bigger problem or you have a lot of distress about the fact that we can’t serve our patients the way that we want to or patients can’t afford their medicines or any number of things and so absolutely, health care is an incredibly challenging place to be that no one prepares you for in your training. You show up and you’re like, “Wait, what?”
– This is how they prepare you, you ask your mentors, “Hey, would you do it again, what’s going on?” And they say no.
– They say no or they say, “No, I would go and be a X “or a lawyer or a business guy or I go get an MBA, “I’ll leave Medical School and I guess work for a start-up, “I’d do this,” that’s not mentoring. That’s talking to somebody for whom the joy has gone. It is not their fault but there is the systemic thing and that’s one of the missions of our show, that’s why I like to talk to people like you because you found a balance where you recognize system is broken but instead of complaining, becoming joyless and slogging, you say, “You know what, “I have a few gifts that I’m able to work less “than full time which allows me then to do X, Y and Z “that I care about,” and you’re passionate about and you’re changing people’s lives by showing them ways to do things that are better and that’s key. Do you think… A couple things I want to make sure I ask you about; one is the new research on psychedelics like psilocybin which comes from mushrooms, LSD, mostly psilocybin because it’s a kinder, gentler psychedelic so it doesn’t have as much of the baggage from the 60s at LSD does, it’s come back. Michael Pollan wrote a book called How to Change Your Mind, which I’m about halfway through which is a transformative book, you should definitely read it although I’m gonna do a full book report when I’m done with it.
– My husband started reading it, thinking it was about literally changing like your mind politically and then was like halfway through like, “Wait, what?”
– [Both] No.
– It’s way bigger than, politics is nothing, it is nothing compared to what Michael Pollan is talking about, he’s talking about using a guided psychedelic trip under medical supervision with a guide at high dose to literally reboot and have a induced mystical experience, where you see the true nature of things and go, “You know what, I’m no longer afraid of death. “I’m no longer paralyzed by my grief. “I’m no longer paralyzed by my PTSD.” And the descriptions of patients who’ve had these guided trips where their ego dissolves and they see things as they are instead of as our conditioning sort of evolves, it’s beautiful. What do you think the role will be in palliative care when people are staring at existential issues.
– Yeah, I definitely am feeling hopeful that we can get past whatever baggage around the use of psychedelics and for recreational purposes that this country has. I think in Europe they’ve been studying it over the last five years, even more than we have because they have different regulations around this. There’s some amazing researchers, one guy, Tony Bossis from NYU spoke about this at End Well Symposium last year. The data is really compelling. I think that they have found something here and if we can get out of our own way, we can really start helping people.
– I agree, I agree, and MDMA is another one that I think has some promises, a little less untoxic than psilocybin so there’s some downside but yeah, listening to Pollan and having had my own experiences with those drugs in college, they were some of the most significant experiences of my life because you see things, again, your ego kind of dissolves and you see things almost as a child does but with wisdom. So whereas a child sees the world unfiltered by conditioning, they also have no perspective and no wisdom with which to contain that. An adult can have that experience that’s why I think Michael Pollan says, “Those entering middle age or at the end of life “may benefit from these experiences in a guided setting.”
– And then the therapeutic things that we measure in medicine like subjective things about suffering and existential fear and pain and anxiety, things that come with a serious illness diagnosis, those seem to wash away for whatever reason and there’s a lasting effect. So six months out, those people reported very positive feelings, very positive outcomes and no adverse side effects. Can you think of a drug that meets that?
– It’s really amazing and we always have to watch out because you and I will speak about this in effusive terms because we know the potential of the research but we almost have to be careful because I would hate to sabotage this research by being too positive because then people don’t think it’s real. I always worry about how to talk about this because I think that we have to study it and I’ve said this about cannabis, I’ve said that about a lot of things, just study it, see what works but with the psychedelics, there’s a… And Sam Harris talked to Michael Pollan about this, it was an amazing podcast and the idea that, there’s a gentleman, I think he was a journalist, he was dying of pancreatic cancer, had a true existential angst. He couldn’t see past this idea of dying. It was so terrifying and he had this guided psilocybin trip and he had almost like a complete dissolution of the ego, saw his death there, had a relationship with it. And also saw his brother or someone who had passed and was there with him and just really reset his brain and that’s why they call it How to Change Your Mind. It’s like you said, long-lasting reset of how we think. Now, you don’t have to do drugs to get that. Chaplains can help you, meditation can help you, any pursuit, skydiving can have a mystical experience. It changes your life.
– It’s just one more tool potentially out there.
– It’s one more tool. That piece, I definitely am glad I got your perspective on because I think it’s important. The other piece is, there’s so much going on now in public discourse about the sexual abuse, all the other stuff that’s happening in various professions. In medicine, I went through the UCSF Stanford mill and at UCSF, I didn’t see this as much but at Stanford, there was, it was a sort of very patriarchal kind of, there were a lot of attending physicians abusing power, dating medical students, dating residents, a lot of stuff like that that I saw and then a lot of implicit bias which I also have, having been conditioned in the 70s. As a woman going through all that, working in San Francisco now in a hospice environment, have you encountered a lot of that or has it not been there?
– Good question, where I trained which actually happens to be where I work, so Sutter Health CPMC, I didn’t actually. I came through 2010 to 2013. I think I actually chose CPMC because when I interviewed there I felt like it was such a positive, diverse, welcoming environment. So different than I what I’ve heard like UCSF and Stanford might be, although obviously, I can’t speak from my own experience.
– It’s variable.
– And who knows now what’s going on and interestingly, my entire residency class was female.
– Every single one, intro to medicine?
– Intro to medicine.
– So times are changing.
– Oh, absolutely, times are changing.
– My wife too didn’t really encounter that in internal medicine and radiology at Stanford but it’s seems like many have and I get a lot of messages and I think it depends on where you trained and setting and those kind of things.
– I don’t wanna say it’s not happening, it totally is happening still around the country. I just didn’t happen to experience it, thankfully.
– Which is great and again, that goes to say that this isn’t a universal thing. It is possible that we can have both genders doing medicine without tremendous drama and inequity. That’s a goal that we’ve been looking for for a long time and hopefully, it can happen, especially because for me, I always have to recognize my implicit bias because it’s there. I’m conditioned in the 70s, two immigrant parents who obeyed very specific gender roles. And so it took a lot of unwinding and occasionally, it’ll surface, I’ll make a statement like I think they were ants swarming on my feet, I was doing a live out in my parents’ place and I’m like, “Oh my god, if I start screaming “and running like a girl, it’s gonna be,” you know, and like 30 women got very upset with me about using that but the thing is I’m like, that’s my implicit bias it’s gonna come out and it’s also how we said horrible things when we were kids. We used the r-word to talk about people who are developmentally delayed. We do a lot of things, so it pops out, so I think partially, it’s kind of not getting too crazy about that stuff, this is just my opinion but appreciating what people are trying, they’re trying to progress and I think there’s a lot of implicit bias in women too about roles and things like that.
– So what I will say is, very, very often, I’ll tell my Uber driver or I’m talking to somebody that I’ve just met that I work in health care and they’re like, “Oh, you’re a nurse.” “No, I’m a doctor,” and they’re like, “Oh.” It’s kind of like blows their mind. It’s rare that somebody hears me say I work in health care and goes, “Oh, you’re a doctor.” When it happens, I’m like, “Yes, thank you!
– I know, finally!
– Your mother must be a doctor! And patients often too, when I walk into a room even though I have my white coat on, I still wear my white coat, they’re like, “Hello, you must be the nurse.” happens all the time.
– It does and for some, that bothers them a lot and so I’ve had a lot of messages about that confusion being a fundamental problem for them because they are also struggling to find their identity in this massive system like we all do. For them it wasn’t a good thing. How did the nurses treat you when you were training, I’m curious?
– Oh my god, nurses are some of my closest friends. I got super lucky, again, that I trained in a place where people are generally pretty happy and nurses were super helpful, I can’t even tell you how many times I asked the ICU nurses what the heck I was supposed to be doing as a new resident, I literally didn’t know anything. So I very rarely have had issues with nurses. I actually love them and super value their insight and think that, to me, they’re the real heroes in medicine, just they’re doing their work.
– That’s how I felt and so often, it’s an antagonistic relationship one way or the other because I hear a lot of this stuff too, again, because having our platform, there’s a lot of inbound. So I get hundreds of private messages a day and can you talk about this, this happened to me, here’s a story that happened to me? More often than not, people just want their story heard by somebody that they think can understand it. I listened to this story, I may not be able to respond but I read every message but I then get a good sense of wow, maybe where I trained, this never happened but this is a big problem, community hospital versus academia, big dichotomy.
– Well in the West Coast and East Coast, we’re very lucky in the way we think about things, maybe in the places in the middle, there are still serious issues that they’re facing that we haven’t thought about in years.
– That’s true and even East Coast versus West Coast academic environments are so different. Hopkins versus UC.
– It’s really, really interesting. What and when if you have spawn, like Darth Vader had Leia and Luke, if you have children, what would be your advice to them about medicine if they showed an interest in it?
– Well so, I don’t want children.
– Good for you!
– I like to put that out there because a lot of people also get surprised that, “Where are your kids, you’re almost 40? I’m like, “Well, not for me; at least, “not in this lifetime.”
– I didn’t want them either, my wife strong-armed me into it and then I had them and I’m like, “Okay, I’ll take them.”
– They’re good.
– But I understand that perspective.
– I’m torn about the medicine thing. Right when I finished training, I was so burned out. I was so disillusioned by it all. I pretty much just said to my dad, I’m like, “If you ever have anyone talk to me “about whether they should go to medical school, “I’m gonna tell them no!”
– Hell no.
– I still feel like it is, objectively, such a huge investment of your time, your emotional energy, your money that you have to really be committed. It has to be something that you fully, as much as you can, have a grasp of what you’re getting into. And so what I always like to say to people and the advice that was given to me that only now makes sense because I’m done, is if there’s anything else that you would be fulfilled and happy doing, do that.
– Go do it. Do it first.
– And I think especially, for women, so we’re talking a lot about women, I think it’s a different conversation for women because from the age of mid-20s to mid-30s, that’s a time in your life that, biologically, if you are interested in children or partnering, whatever, those are years that are really hard. I can’t tell how many, I missed my best friend’s wedding. I missed the birth of their children because I was a resident and you don’t get sick days, you definitely don’t get time off to go see your friends. And maybe that speaks to issues in medical education but I think for women it’s a slightly different conversation than for men but–
– I think you’re right and I think the other thing that we don’t talk about a lot is because women delay having children to finish their training, there are fertility issues and then they’re increasingly common so now you have to do expensive fertility treatments and you have to go through all of that.
– Plenty of people have kids during residency, I will say, there was many women in my program, they got pregnant and they just figured it out. I can’t say it was easy by any means, I can’t even imagine how they got through it, you can do it but it’s really hard and you people do, more often than not, end up delaying.
– But some people say having the kids grounded them and gave them a sense of purpose and meaning that I certainly lacked, like purpose and meaning was a tricky piece. You said when you finished residency, you were super burned-out, man, I’m with you on that. I have never been that burned-out as the day I finished third year.
– I’m still recovering, five years out. I’m serious, I’m a very different person than I was when I started and in some good ways but also in some not so good ways and I think this gets back to the importance of talking about this and finding, thinking about ways that people can have balance in their lives and finding joy in their work because we have 10,000 baby boomers turning 65 every day in this country, those people are gonna need care and if we don’t figure out a way to keep doctors and the nurses and everybody else practicing, who the heck’s gonna care for them?
– That joy piece because you’re right. When I finished residency, man I was… I told my residency director, great guy named Kelly Skeff–
– Oh yeah, I know him. I interviewed with him for residency, they didn’t pick me.
– I do the best Kelly Skeff impersonation, Kelly, if you’re watching, we need to teach the learners how to learn, how to teach the teachers, how to be taught and I think that’s what separates Stanford from other programs, is that we teach the teachers to teach.
– You know he’s gonna see this, right?
– Yes I do and I love him, he’s really, truly one of the great mentors and what I told Kelly at the time was like late second years, like I wanted to do a GI, now I hate GI, did the rotation, now the idea of doing this for a living makes me want to gouge my eyes out, being a hospitalist sounds like a cop-out, to me, it felt like, you know what, it’s just more residency, hell to the no, primary care, have you seen the amount of documentation they have to do and the other specialties just didn’t interest me so I said, “Oh crap,” so I ended up like taking a year off after residency, which infuriated my program because it messes up their numbers because oh, he didn’t go and do anything. So I went to worked for a couple startups and did like this sort of medical tech stuff and this is what I realized doing that, we were talking about joy. You’re sitting there going, “Oh, we’re gonna generate a profit and we’re gonna bring “this product to market and it’s gonna impact “this many people,” and you’re just sitting there going, “You know what, I used to save lives, “I used to sit at the bedside and hear people “when they were at their most vulnerable “and now I’m sitting here listening to this guy, “Sundar telling me about technical deep dives “and field level traction and it means nothing to me.” And that’s when I realized okay I’m done. This hospice gig came up, I’m like, “You know what, “it was a cop-out, I’m copping out, I’m gonna do it.” I fell in love with it. You know what it was, you said something earlier where how you get to come back and kind of spend that time if you want, hospital medicine is nice that way because there is some flexibility. You run the room, there isn’t administrator yelling at you telling you to stop spending that time as much, so being back in that space and then being a mentor to the little younglings is a great thing and you teach now, right?
– I do, yeah, I’m back at the place where I trained so we have brand new residents, we have brand new interns actually this month and yeah, I get to work with them at night.
– How do you like nights?
– So it’s funny, I actually hate being up all night. I’m somebody that loves getting tons of sleep. My ideal bedtime would be like 9:30 if I was–
– That’s mine too.
– But what I realized, my second year, I did a bunch of night float admitting so just admitting at night. I loved admitting.
– Just straight admitting.
– I love undifferentiated patients, where you don’t know what’s wrong and you gotta figure it, that puzzle, that intellectual challenge of medicine that I really love. I realize that you can really only do that at night as a hospitalist unless there’s some weird kind of thing where you can be a daytime admitter full-time–
– Some people do that–
– Which they don’t really do that.
– But it’s not normal.
– So at night you get to admit all night long and that’s what I love so that’s why I do it.
– So I used to I used to do nocturnish shifts for extra cash, it was like $1,000 a night or something and so you go and do, you admit all night and it was like, I loved it. I would sit up in that little Stanford call room and it was just like being a resident again but I knew that I didn’t have to go in in the morning and see all those patients and I would just admit and the ER would call and I was friends with them, there was a relationship and it was like us against disease and trying to figure out what’s going on and challenging patients. That kind of thing, again, you talk about joy, joy emerges in the strange places. Sometimes it emerges at 3:00 in the morning, where are my night shift people at? Leave some comments on this if you’re a night shift person. So all that being said, I wanna respect your time because you drove all the way from San Francisco down to the Peninsula to spend some time with us, which we deeply appreciate, you are definitely somebody off the bell curve in terms of what you’re doing, and as a fellow hospitalist, I have nothing but mad love for everything you’re doing in palliative care, in hospital medicine, in communication. Any parting words for the pack?
– Oh man.
– I’m gonna leave links to End Well, I’m gonna leave links to your documentaries.
– I don’t have any lasting words. I think, for me, figuring out how to find balance in my life through this work and the things that I’m passionate about which are serious illness, end of life have really made all the difference and turned really a burned out, angry person into somebody who gets up every day with a smile in my face and I get to challenge myself to learn new things all the time so.
– That’s a nice way to end this, thank you darling for everything you do. Z pack, do me a favor, this is a podcast as well because it’s long so if you wanna chill out and check it on the road, that is on iTunes, search for Incident Report. We’re on SoundCloud, we’re on Stitcher, we’re on all those things, if you like this format, leave some comments, we’ll do more in-depth interviews with really cool interesting people that aren’t me, for a change, because I used to be the only interesting person I knew until I met anybody else. So that all being said, Shoshana Ungerleider, thank you for everything you do.
– Thanks for having me.
– Oh, it’s a pleasure. And go check out End Game on Netflix, watch Extremis on Netflix and you have new stuff coming up soon?
– Hope to, it’ll be on my website.
– No doubt, and we’ll put a link to the website as well, and we’re out, peace.
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