What is palliative care? WAY more than you may think…
Dr. Sunita Puri is Medical Director for Palliative Care at the Keck Medical Center of USC and author of the remarkable book “That Good Night – Life and Medicine In The Eleventh Hour” — a visceral ride that gives readers a true feel for what palliative medicine and hospice means to a vision of Health 3.0.
But most importantly, she’s a sister from another mister who is a fellow UCSF/Stanford alum and a massive hip-hop fan, so best believe this interview KEEPS IT REAL AF!
– What’s up Facebook supporters? You guys get to see this first. If you’re watching this on the replay, it’s because you’re not cool like our Facebook supporters who subscribe, $4.99 a month, and get access to live stuff, just for a tribe of people that cares deeply about building Health 3.0. Now the rest of the world will get it eventually. Maybe if you’re good, but in general what I’ve found with the supporter tribe, is that it is a safe place to talk about healthcare transformation, where people are actually nice to each other. Heaven forbid, that is not the internet I knew, but it is the internet I signed up for. So anyways, today guys, and thank you. By the way, it’s still Nurses Week, so we want to give a shout out if you guys are watching some of the replay, you missed Nurses Week, and if you didn’t thank a nurse, you suck. Today, I have a guest that is going to be crazy fun. She is the author of this here book, That Good Night. It is Dr. Sunita Puri, who is the Medical Director of the Palliative Medicine Service at USC, the University of Spoiled Children. I mean, University of Southern California, and she and I share a lot in terms of our training, in terms of our South Asian ancestry, and in terms of our love for hip hop, but the reason I really wanted her on the show is this book, is like must reading for anyone who cares about having conversations about end of life. About what palliative care actually does. About how to live well and die well. So Dr. Puri, welcome to the show.
– Oh, thank you so much for having me.
– I am so glad you could come. I’m sure the parents are so happy to see you.
– They’re watching right now. They’re very happy. It’s too good.
– Both, I read the book, and I was like, at first I was, so a lot of doctors send me books, and let me tell you, doctors are generally the worst authors. It’s like all this footnotes, Ibid.
– [Sunita] Ibid!
– Ibid, I’m like IBID has no place in a book.
– I don’t even really know what IBID means.
– [Zubin] I don’t either.
– I feel like a bad writer for not knowing that.
– It’s a mystery still, and so you sent me the book and I’m like, I couldn’t get it to work, and then finally I got a PDF of it, and I was like okay, let me try to read this, and I read a few paragraphs and I go okay. Typical Indian chick writing a book about her experience, what haven’t I seen? Then I start getting into it, and I’m like oh my God. I was along for a ride, with you through medical school, and internship and residency and fellowship, and my same, similar path. UCSF, Stanford, and what struck me about it is, you told your story through personal stories, and through patient stories, that did not end happily all the time. They ended as they end in real life. I found myself going, I’ve had that happen. I’ve had that happen. Getting emotional going, yeah, I remember that I thought it was just me, and you come out feeling like you’ve done a palliative medicine fellowship, the important parts. About having conversations, about connecting with other humans, and about the why that it matters. I mean, how the hell? Where does it all start for you? Why did you even do this? I don’t even know where to begin. I’m a fan.
– Well, I’m a fan of yours, which makes it extra special to be here talking to you about it, and I’m so glad you liked the book, and really thank you for having me on today. I was always a writer before I went into medicine. I grew up, we have so much in common, especially in terms of our background, and I grew up with a Punjabi father, who would read me stories.
– I’m so sorry. It’s so hard. Telling you Parsi fathers, same thing.
– [Sunita] He loves the Whiskey.
– Oh God, my dad loves the Johnny Walker black one.
– That’s what all the uncles, slash druncles, as I call them, the druncles. I knew a lot of druncles in my day.
– [Zubin] Yes, me too.
– An the great thing about druncles, and my father, is that they have these incredible stories, and my father has this command of language. In English, in Punjabi, and in Hindi, so I really grew up immersed in a love of language, and in trying to figure out how to tell stories in my way and my father really wanted me to be good at English, so every day when I was a kid he would have me write a page, and it could be about anything. I mean I wrote about parakeets who wanted new names. I know.
– I wrote about cats who became friends with owls.
– [Zubin] Oh, that old story.
– Exactly, and so I just found myself turning to writing and to the page and to the characters I would make up in my mind, as kind of friends, and it was this whole other world that was just mine, and I think if I had had any guts, I would have just been a writer, but I came into medicine, because my mother’s a physician, and I wanted to be just like her.
– I’m gonna interrupt you for a second, because you said a couple things. If I had any guts, I would have just been a writer. Man, I am so with you. If I had any guts, I would have gone into music and entertainment and those things, but the truth is I don’t regret a minute of it.
– [Sunita] I agree with you, yes.
– Right, because we went on that path. You had a line in your book that I remember that I highlighted, and you know I haven’t highlighted shit since I was a frickin’ medical student, and then it was just to show that I was doing something even though I didn’t really read it, you said you went into medicine, because that’s where your mother was.
– Yeah, I followed my mother into medicine, because that’s where she was.
– That’s the quote.
– And I still remember the moment, that that line came to me. I had just come home from fellowship and I was writing and I was sitting in my mother’s bedroom, on the couch there, and one of her cats was sitting next to me, and I was just kind of sometimes when I write, it’s almost like word vomit on the page. You don’t censor yourself, but that line was probably the only line I kept from that whole page of word vomit that day, and I grew up loving and hating medicine. I loved it because my mom loved it so much and I could see that in her work in anesthesia. That was really where she was meant to be, but I hated it because she was always on call, and she was always away from me, and when I was born, I mean, talk about lack of work life balance back in that day, my mother worked up until the moment she went into labor as an anesthesia resident, and she got two weeks off after I was born, so I actually was raised, by my Nani G. My maternal grandmother, in Mumbai, for months, after I was born, because my mom couldn’t juggle being a resident and being a mother.
– For the world that thinks this is an anomaly, I have the exact same experience. Mother gave birth to me, worked right up to the day of my birth as a pathology resident. She ultimately rematched in psychiatry, because she’s like pathology is gross. She hated it. Hated everything about it, and I was raised for the first six months of my life, by my paternal grandmother in Punai, just South of Mumbai. Same thing. When I was reading your book, you were talking about being fed bottles of warm milk, and her rocking you on the plane, same exact. I started getting emotional, because that was the same experience, and then later in the book when you talk about her passing, and that experience, it was the same thing for me, and being distant and the diaspora of it, but the idea that we went into medicine, because we followed our parents into medicine because that’s where they were, and for me it was both parents, and so I felt the same thing. It’s almost like, you were desperate for their attention.
– I think that word desperate was really applicable. I remember just coming into my mom’s room when I would come home from school and she was post call, and I would just jump on the bed, because I just wanted her to wake up and love me, and I was, my brother and I were both, as she describes us very sensitive children, which actually meant clingy, and it was very hard for us to be apart from our mother, and now I remember somewhere in the book I wrote about when I was a resident, and I thought my life was so hard, right? Internship in San Francisco, and oh my God, I’m on the liver transplant service. It’s all so overwhelming, and then I thought to myself, when my mother was the age I was at that point, she was already married, had left her home, for a continent she had not a single blood relative, and had already had two children, and was in Louisville, Kentucky.
– Every time, I just went on a rant for supporters about how we really have to pay our dues, before we can claim to have moral injury and burnout, and now I’m seeing a lot of young students coming out and they’re already so preburnt out that they’re saying I can’t work more than a 12 hour shift, and this is not a learning experience for me. It’s like, well, it’s almost disrespectful to the ancestry that we come from, the lineage that we come from, that they paid so many dues, so we could have it better, but that means that we have to put in our effort too. This is a calling.
– Completely agree. Completely agree. We didn’t sign up for this profession to have a cushy lifestyle, and I think when it was modeled for us that the sacrifices that have to be made to be a good doctor, I never really expected that I would have a sort of perfect work life balance, because I saw what it took to take good care of patients and I would round in the PACU with my mom actually.
– [Zubin] Wow.
– When I would go to the hospital with her, and I was sitting in the surgical lounge waiting for her to come out of the O.R., when she did, she would take me with her through the PACU to see her patients, and I saw what it took, and even though I have such mixed feelings about it because it kept her from me, I still wanted to be that sort of doctor.
– Yeah, I had the same experience. My dad would take me on rounds at the community hospital. Go through the ICU because it was all open in those days. One doc did everything. He was the primary care doc, and he rounded the hospital, and it’s a small little community. Everybody knows him, and what struck me is the collegiality.
– [Sunita] Yes.
– All the nurses and he and his colleagues were all nice to each other. What’s weird is then you run into your actual practice and one of the biggest struggles is our colleagues.
– [Sunita] Yes.
– Interacting with our colleagues.
– It’s so true, and I think in palliative care, it’s a special sort of struggle, because you’re kind of misunderstood, even in the name of your field.
– [Zubin] Explain that.
– I think when people hear the term palliative care in medicine a lot of times they think, that’s synonymous with giving up. It’s synonymous with waving the white flag, or more insidiously, calling palliative care means I as a physician have failed, and so I think it really strikes to the core of some of our biggest insecurities as physicians, in wanting to cure it all. Wanting to save our patients. Thinking that the extension of life, is our primary duty, when in fact our primary duty is to cure sometimes, but to care always. I have to, I find myself explaining and reexplaining my role. Whether it’s I treat cancer pain. I don’t just put people on hospice. Or hospice and palliative care are distinct things. I think of hospice as a type of palliative care, in the last six months of life, but our intention is to work with the primary team, and not to kind of have an either or situation where a patient can either get cancer therapy or they can have palliative care. The beauty is that you can do both, and to walk alongside a patient, and a family as they’re going through that sort of journey, and to get to know them from day one, I think that’s one of the most profound parts of a journey to walk with a patient and family and with your colleagues, because some of the most meaningful moments have been when I sit with my colleagues, and I can acknowledge, I know this is hard for you, because you’ve known this patient for years, and I’m coming in at the 11th hour. Let me help you. It’s okay that you’re attached to them, but let me help you too.
– It’s really hard for a lot of our colleagues, and that becomes so clear in the book. What I loved about this book, and I think what distinguishes it from something like Being Mortal by Gawande which was a great book I read. Totally different vibe. Now that’s, this is, your experience, and how you learn through these cases, and the great thing is, they don’t always turn out the way you like them, because that’s life.
– [Sunita] That’s life.
– There was a story at the end. First of all, some of the most beautiful stories were your home visits, where you’re really doing palliative medicine. You’re forming these deep relationships with the guy who went to his granddaughter’s graduation and he was the guy who got disseminated cancer and is in a lot of pain, and wouldn’t do narcotics, because he was afraid he’d be too tired, and he wouldn’t be able to make it and also afraid that he was gonna be robbed, because of it. The social determinants of health affect us not only during life, but during how we’re dying.
– [Sunita] Exactly.
– It took me on this journey, that reminded me too of my own training and the hardest conversations I’ve ever had. My favorite, and I gotta say, I hope I won’t be giving too much away, because people will read the book, and get their own out of it, but at the very end you had a conversation with Teresa and Ray, which I imagine are nom de plumes, because of HIPAA and they have a dad whose had a massive stroke, after diabetes, CHF and all that, and every ounce of them is screaming personalty disorder. Every ounce of them is screaming, how am I ever going to get through to these people? They are belligerent. They are questioning everyone’s competence. They are threatening to sue. They want quote everything done, and I’m like how many times? In the thing, what’s beautiful is you describe your path. Like, and then I felt this and I put it in check, and then I felt this and I put it in check, and I said this, then I felt this. Then I was like hell no. I’m just gonna let it go now. This is what I said. Even you letting it go was pretty professional. That takes practice.
– Yeah, well I try to abide by that famous line, check yourself before you wreck yourself.
– Before you wreck yourself. You know why? Because Oxycontin in your life is bad for your health. That’s what separates ZDogg Industries from other so called interview circuits. When it gets too deep, we take it deeper.
– [Sunita] We take it deeper.
– Into the game.
– Exactly, exactly, but sometimes you have to wreck yourself.
– [Zubin] That’s right.
– Because you’re only human.
– [Zubin] Heaven forbid.
– Heaven forbid. I know.
– I got that out of your book. Holy shit, she’s letting the world into this very deep secret that we’re human beings who have internal conflicts and struggle. Not just the palliative side, but the colleagues we’re working with.
– [Sunita] Exactly.
– And what your training was like, and how your ICU rotation at UCSF, I was having PTSD man. That was it. It’s like lines and tubes.
– Nine and 14 Moffet.
– 14 Moffet the Death Star, we used to call it. I just kept thinking, power and the glory. Money and the power. Minute after minute, hour after hour. We’re hip hop fans, if you can’t tell. Why did you write this book?
– That’s a great question, and it’s one I get a lot, and my dad also asks me this.
– [Zubin] Bitta, why?
– Why did you write?
– So much opportunity cost. Keep churning the consults.
– He also, when I gave it to him, he was like, it’s this long. I have to tell you actually, later, about what my dad said when he saw my review in The Atlantic for the book, but to go back to why I wrote it, I think when you’re a writer, I always felt like that had chosen me. That sounds really pretentious, but let me explain. It was almost harder not to write the book than it was to write the book, because all of these stories, the best way I can describe it, is they were kind of pushing against my bones. They wanted to be let out and I wanted to write a book, that really helped me to understand my own path, but in a way that would be helpful to others. Sometimes I think I wrote the book, because I wanted a book like this, when I was in my training. One that showed me exactly what it meant to take care of patients whose treatment paths were not clear. They weren’t textbook treatment paths, but also one that showed me it’s okay to be human and fallible as a doctor, because we’re not really allowed to be that, and I wrote it to honor my parents and their journeys because they are two major characters in the book and I also wrote it to honor my patients and their families and my colleagues, even the ones that pissed me off and broke my heart and made me cry, and made me feel incompetent, because I think that’s all part of this great tapestry of living in medicine, right? That it isn’t perfect. It is messy. It is complicated, and yet, it is still such a profound profession to be a part of, even when there were times where I was like screw it. I’m just gonna leave and be a real writer, and I almost left at the end of medical school. It was when I did my palliative care rotation that I found this is a home for my medicine, and it’s also a home for my love of language. Really this book is also a love letter to the power of language in medicine.
– I think you pretty much effectively described the vibe that I got when I read it, which is this is her therapy, but it’s also a gift to others, and it’s a gift to the legacy of her patients and a gift to the legacy of your parents. It infuses the book. This idea that we’re simultaneously, respecting our parents. We’re simultaneously rebelling against our parents, and we’re simultaneously wanting to be like our parents.
– To please them, and this is, I don’t think it’s just an immigrant thing. I think this is a human thing.
– I agree.
– What was beautiful is the way that you treat language in the book as a surgeon treats a scalpel, which is you can do great good and great harm, with the wrong words. On this show it’s interesting, because we are the proponents of let’s be as unpolitically correct as F-ing possible, and let’s use language as a flourish and as an art, but understand that we’re not gonna censor ourselves. When you’re sitting in a conversation with a patient, about end of life, with a family meeting there, and your colleagues there, this is a surgical procedure.
– [Sunita] Yes.
– Everything, and it was funny, because you were talking about how you prepped for it, and it’s the way a surgeon might mentally go through and go through Cunninghams and go through the whole thing and I thought that was beautiful, because it elevates also the practice of palliative care and hospice and what you do to the art that it is, and the sciences that it is.
– Yes, exactly, and I think I read in, I think it was a piece by Gawande, a palliative care doctor had described, communication as a procedure, and I remember when I read that the wheels completely turned in my head, because I think when I was going through medical school, I never really got any great training, in how to talk to patients. How to break bad news, how to sit with someone, after you’ve told them something really difficult. How to lead a family meeting. I think the implicit message was those are soft skills, that you know, and if you don’t know them, you’ll figure it out, it’s okay, but I think I wrote about this a bit in the book that when I was learning to do paracentesis, and thoracentesis and central lines in my residency, I was supervised by a senior, and sometimes the senior was supervised, by someone supervising me, and that if we had that sort of intense, dedicated teaching and supervision in learning how to do a family meeting, how much better would our healthcare system possibly be?
– Maybe that’s the real reason I loved this book and didn’t just like it, was that it elevates relational therapy, in a non psychiatric setting, right? To a procedural art. Like you said, you should be supervised. This should be taught. You were talking about extubation. We’re taught to intubate. People will supervise. Are we in the esophagus. Let’s make sure we didn’t do that. How far have we gone in? You don’t want to rupture the trache. We don’t want to do anything else. Make sure the vent setting’s right. We’re over supervised on that. Oh it’s time, mom does not want to be on this tube. We want to pull it back and make her comfortable. Who teaches you that? You know what, honestly who taught me that, in residency was respiratory therapy.
– I was just going to say RT, RT will teach you, and they will hold your hand and stand by you, and I’ve been in the room when, you know in the ICUs when there’s anesthesia residents who are extubating, and don’t know how to titrate an opiate, to keep the patient comfortable. I’ll be in there with them, and I can see especially if it’s their first or second time how difficult that is, and that not knowing how to undo what we’ve done.
– You said that, you’re like, we’re really good at doing these things, and then you know, how do we? Elizabeti Peters, let’s take a few comments. Love this, thank you. Feeling not so alone in end of life care. I’ve been doing it for the last 26 years, trying to help people understand it means not giving up. You did a great job at the end of the book especially where you said, this is what do everything means to various people.
– It was a laundry list of shit, and I was like, yep, I’ve seen that. Yep, yep, yep. It was really well done. Let me just reiterate. Medical students, nurses, any student of healthcare. Any practicing physician. Anybody whose a healthcare professional should read at least part of this book to understand how we can better accomplish this because like you said, our whole system will improve. Because we do it so badly. You know why? This is my guess, and you probably know this, because you went to, where’d you go to medical school again? Remind me.
– Oh you were a UC medical student. That was me, UCSF medical student. Then you stayed for residency.
– Yes, I did.
– I fled because the place was dark. I was like I’m outta here. I went to Stanford where it was cush. I did my residency there, and still burned out. When you had that space between medical school and residency, where you’re like do I do this? I had that space after residency, where I was like, I’m gonna go work in tech for a year, because I was in the Silicon Valley, and I was like I can’t do this. I was so decimated by my training. By the human element of the training, and how can I take all this on as myself and still survive? The idea that what I ultimately realized was I was using empathy, taking people’s pain as my own, and not using compassion, which is a detached love in the face of suffering where you said it in the book. You said you hover just below, just above the depths.
– [Sunita] Like the pelicans.
– Like the pelicans. They can pick out the little fish and there’s a shark there. There’s terrible stuff in the deeps, and if you go swimming every day, you’re gonna get sucked down.
– [Sunita] You’re gonna find it, yep.
– How do you find that balance? In the book, there were great examples where you failed and great examples where you succeeded. What’s your tip for people? That is such an important question, and I think for me, my strategies, around maintaining compassion, but not having compassion fatigue, they kind of change and fluctuate, depending also on what’s going on in the outside world in my life. Not just in the hospital, but what I tel the medical students, is I now do this exercise. Before I go in a patient room I take a deep breath and I ask God to help me, and I ask him to help me to see their suffering, but not be enveloped by it, and then when I’m sitting with a family, even if they’re a bunch of Teresa and Rays, I visualize a clear plastic or glass between us, so that I can fully see them and hear them, and be present with them, but whatever emotions they may be throwing at me, don’t come at me, and I need to practice that kind of visualization to go and be fully present with a family, or my colleagues, almost in a meditative kind of way, because when I’m really talking to someone like we’re talking now, I’m not thinking about anything else. I’m fully focused on the words, but I think in order to maintain that intense concentration and hold people in compassion, I also need to be able to keep the emotions away from me so I can walk into the next room and do the same thing again.
– That’s a beautiful description, and it’s interesting because you’re a very spiritual person infuses the book. I discovered spirituality late in life, in the sense of meditation, in an almost Buddhist kind of thought, and it is an equanimity, in the face of overwhelming emotion, and that doesn’t mean you don’t feel emotion. It doesn’t mean you don’t get lose in the sauce from time to time, but the example that you gave of Ray and Teresa was a great one, because I was there listening. I was reading the thing and I was there in the room, and I could feel that transference. Where Teresa is attacking you. Wait a minute. How much did you study, that you’re still asking me what do everything means? It means do everything. Are you stupid? What’s wrong with you? You can feel it. Even now my blood pressure starts to rise, because I’ve been in those rooms.
– [Sunita] Do you need some Amlodipine?
– I might need more than that. The only thing that helps me starts with a D woman, and you got it, you got it.
– [Sunita] The D ain’t for free.
– It’s Diclofenac, son. It’s interesting because the minute I met you too, people might get the sense now, because we’re having this intense discussion, well these are two intense type people.
– [Sunita] Exactly, very type A.
– Wrong. The minute you and I met for the first time in the lobby, we’re like bitch what’s up? What’s up? What’s up with Waka Flocka man?
– Waka Flocka is a genius.
– [Zubin] He’s a genius.
– I mean that line, girl your booty got me lost like Nemo.
– Your booty got me lost like Nemo. If language is a scalpel, that shit is a Samurai sword right there.
– I mean that could be my next professional stop, is writing lyrics like that.
– I needed a fly girl, and I had Logan, but he’s not fly now.
– [Sunita] He’s not. No, compared to me, come on.
– Plus how demeaning is that? You can be my fly girl, because you’re a woman. It’s like how about you be the main rapper, and I’ll be your fly girl?
– That would be amazing.
– [Zubin] I think it’d be dope.
– Let me be your Cardi P.
– Cardi P. I like it like that.
– [Sunita] I do like it like that.
– Do you wanna do like a hospice palliative care rap?
– [Sunita] Yes, absolutely.
– That’d be dope, with Cardi P?
– [Sunita] It could be like a PSA.
– Totally, totally. Like I like it like that and then I can come out and fake Spanish or Punjabi. We’ll just put some fake translation. That’s awesome.
– Just have my dad walking around in the background.
– My dad, walking around.
– [Sunita] All of the South Asian dads.
– Everyone, everyone. I want to get back to the spirituality piece, but first let’s read some comments. Sorry, I always have to take my ADD back on point. John Arnold Jr. Says E.R. doc for 15 years. This convo is reaching me personally and professionally. You know what, that’s a beautiful comment, because in your book, you talk about some of the hardest things, are working with colleagues.
– Yeah, t’s so true.
– [Zubin] Explain a little bit. I think because many of my colleagues, were not exposed to palliative care in their training and if you even look at the culture of medicine and how we’re socialized, it’s really to keep people alive, to extend survival benefit, it’s even coded into the language of how we study interventions, and to take a step back and say, maybe our role is more than just keeping people alive. Maybe we need to think more critically, about the gap between what we can do for patients, and what we should do for patients, especially when they’re living with, incurable chronic illnesses, or final blow that we cannot reverse. So we think when you’re not socialized to think about medicine in that way, it can be. It’s almost like you’re speaking different languages to colleagues, and that’s where when a colleague might consult me and say, I don’t really know if we need you, but my resident is really pushing for it, so what do you think, and one of the most interesting questions, I love to ask this question is, well tell me what you’re hoping, that I can help you with. Tell me what you think your resident was thinking, and then you get people to explain to you the details of the case, and to get them to say out loud, but I think I can fix this, and then I get to ask them, tell me what fixing this looks like. What are we fixing them to? What would this patient’s life look like, if he leaves the hospital? What will it look like when he’s still here in the hospital? I think that’s when you kind of have to almost do a palliative care consult on your colleagues to get them to look at their hopes, and the reality of the situation, and try to meet in the middle somewhere. I think the challenge with colleagues, is we’re just so, we just want to fix things. We’re such fixers as physicians, and I am guilty of it too, even in palliative care. If I may say, sometimes I have felt like if I can’t get a patient to agree to be DNR when it’s so obvious that they should be, I feel like I haven’t fixed the situation, so I am no less prone to this, than my other colleagues are.
– I mean, in the book, there’s this conversation you’re having with a nephrologist in your car, and this patient that you’re taking care of at home, you’re seeing this patient at home. They’re skipping dialysis. They’re missing dialysis. They are dying, and they don’t need to be on dialysis. They need to be with family, and doing all the work that happens at the end of life, in your mind, and you call the nephrologist, and he goes, well listen man, she needs to tell me she doesn’t want dialysis, because I’m gonna keep giving her dialysis. I’m not the one to make that decision. Basically saying I’m not playing God.
– [Sunita] Exactly.
– But you know, you have the conversation, and when you get off the phone, you’re okay, that’s great. I’ll go ahead and I’ll keep having the conversation with her and you hang up and you start banging on the horn and saying, fuck you! Honestly, man, I’ve been there.
– Yeah, I’m sure you have.
– I’ve been the recipient of the fuck you, because I have been the guy who wants everything done at times when I feel like I’m attached, or something’s happened, or there’s transference where you talk about the auntie in the ICU, and it’s like every Indian, auntie, you feel the transference, and that’s why I think it’s another, this is one of my soapboxes, is like empathy, feeling other’s pain is a spotlight. You take the pain. I’m talking about emotional empathy, affective empathy. In other words, I see someone who looks like my mother or who looks like my daughter, or who looks like me, racially or socioeconomically, and I’m able to feel their discomfort more acutely as my own and act from it in a way that may not be a higher compassion. Empathy in itself is a spotlight. It tends to favor your own kind, nationality, tribe, whatever and we need to try to start to disentangle that from what you described which is walking in and there’s a thin but transparent membrane, where you can understand all the suffering, but it doesn’t reach out and consume you, and affect your decisions.
– Exactly, and I think that is such an astute point, because I have definitely taken care of people, some of whom have been fellow physicians, and my judgment has been clouded, because to see one of your own, whose very sick, whatever one of your own might mean. Whether it is ethnicity, or profession or something. My judgment was completely clouded, and that’s when I think having the self awareness and the insight to say, if this was the patient in bed eight, I would not be saying this, so why am I doing this to the patient in bed three? To be brave enough to confront yourself about your own biases and your attachments, especially when those get in the way of the right things being done for patients.
– It’s the hardest thing in world, physician, know thyself. Hardest thing in the world, because those biases and transferences and stuff, they can be so damaging to doing the right thing, but we’ll convince ourselves that we’re doing the right thing because of the transference. By the way, Suzanne Anderson says something that I’ve heard very often. Why do they put nails in coffins? To keep the oncologists out. What is your experience? You talk a little bit about oncology in the book. This is hard, because I have a lot of love and compassion for my oncology colleagues. They’ve trained to save lives by treating cancer, and when they are unable to do that they become attached to their patients. It’s very hard for them to let go, because they’re a hammer, and maybe that patient is a nail, but also they care. They really do care about the patients and we had Louise Ramondetta on the show. She’s an MB Anderson Cancer doc, and her thing is mixing palliative with oncology, so she’s much better about integrating, but what’s your experience with oncology? How do you handle those situations?
– Oncology is interesting, because I’ve known a number of oncologists who say in theory, that they appreciate and support palliative care, but many of them many also think that chemotherapy is palliative care, and sometimes I can’t really disagree with them if someone has a big tumor burden and it’s very chemo responsive, the best treatment for the symptoms could be chemo, but I think where things become difficult is that there’s a number of them who might think that they know how to have these discussions and think that they are having these discussions and when I see the patients that’s not the case. Where something is being lost in translation. The oncologist may think they’re saying, this is an incurable tumor, but what the patient is telling me they understand it is still curable, and actually something I’ve long wanted to do, is just shadow in the oncology clinic, and observe those conversations. Not to be critical but just to understand, because I think I can help them the most if I approach from a place of understanding.
– You nailed it. If we walk in each other’s shoes, if I was a nurse for a week, could you imagine the empathy or the compassion I would have for that job? It’s Nurses Week, and a couple things relating to that. How you approach colleagues is crucial. It’s a kind of surgery. If you come off as condescending, or holier than thou, or you’re trying to pull the plug on all their patients, they are going to immediately entrench, because we are defensive by nature in medicine because we’re attacked all the time.
– Yes, it’s so true.
– We’ve gotten good at it. How about in residency? You gotta be a wall. You gotta block this admission. You gotta argue. That was a UC and a Stanford thing. He’s a sieve. That’s the deepest insult. He’s just letting everything through. What kind of punk ass bitch is that? You need to be a wall, and here’s Polly Barker Walker says, I’m a stage four breast cancer patient. I’ve had the same oncologist for 15 years. We have a great professional relationship and he does well with my palliative care, but I know many who are not as great.
– Yeah, and I think it’s something that I’m hoping to do is to push for more palliative care training in their fellowship, and at USC the oncology fellows have an incredibly busy crazy schedule, so there’s not as much time as I wish there was for them to rotate with us, but we work with them a lot, at the Norris Cancer Center, so just seeing them on the wards, having them call consults, helping them to understand even basic things like when to start a long acting pain medicine. How do you choose a long acting pain medicine, and when you do call for help? Because if I were to meet the palliative needs of every oncology patient, I would never leave the hospital, and so part of the trick is teaching them what is the primary palliative care skillset, that they can do themselves, and then when do you call for help, because if, even as internists, if we had no basic understanding of how to treat AFIB, and we called cardiology for everything, they would hate us even more than they already do.
– [Zubin] Exactly, and they do hate us.
– And they hate us, yes. So it would be, that’s kind of the analogy I would draw, that all of the oncologists need to have that basic competency, and the more we can get programs to really adhere to the ACGME requirements around that, I think the better off all patients in the future are gonna be.
– I’m with you 1,000%. The other thing we need to fix is reimbursements for palliative care.
– [Sunita] Oh yes.
– Because y’all are broke. I’m just saying. I’m sure your parents are like, Bitta, why? You could have been cardiologist. What are you doing?
– My dad, I think to this day, still secretly hopes that I will go back and see the light and become a cardiologist.
– Can I tell you what my dad still tells me? He’s like, so you are moving back to the Bay Area. Is that because you failed again? No, we’re actually growing and we think we can do better there. I want to be next to the social networks that I built there over the years, and the three Universities that are in spitting distance. So it’s not too late to do a GI Fellowship? I’m 46, dad. I love what I do. I found my calling. It’s never too late. It’s never too late.
– It’s never too late. Has he met your Medimoji Dr. Crapyndra?
– Poomoji? I think he has because he’s on my email list, although he got expunged because for some reason he has an AOL email and I think Mailchimp thought AOL was a scam because anyone who still has an AOL, is like 100 years old. My dad the other day, I haven’t seen any of your videos for a month, and I’m like really? We have some good ones. You’re on my list.
– [Sunita] He better watch this one.
– He better watch this one. Exactly. You know what though? Here’s the thing. My parents are not supporters of the show. In other words, they’re not subscribers, and this is why. My dad asked me, so am I supposed to pay $4.99 to see my own son do this nonsense? I said no dad, I’ll figure out a way with Facebook how to get you a free subscription. No such way exists, so this is my safe space, where I know. Now this is gonna go public, and he probably won’t watch it, because he’s like an hour. Who wants to listen to two Indians talking for an hour? I could go to any function and hear them yapping away. They go to the function. None of the kids are going to eat the spicy food.
– I’ll have my Johnny Walker.
– Not red, because that’s cheap. Black. Don’t do gold. Why waste the money? Blue, who spends that kind of money?
– [Sunita] Blue, I didn’t know there was a blue.
– There’s a blue, but my dad would say, money doesn’t grow on wines.
– [Sunita] Wines.
– It grows on work of the back. Sweat of the anus. Anus. Let’s read some comments. British Palliative Care Dr. Katherine Manick has a video circulating on her BBC about her book. She’s amazing regarding the power of taking control in a dignified death. She’s done talks to all around the world. Palliative care doctor for 30 years. Look her up as well. Kari Hinchlef. Kari’s a U.K. nurse, medically retired. Let’s see I would pay to listen to ZDogg for an hour. Elizabeth Siragar. My dad is Facebook famous, and Resa Duboir says, defensiveness equals self preservation.
– [Zubin] It is.
– I think that’s very true. Very true, and it’s about trying to see what does the defensiveness serve? Does it serve you? Does it serve your patient?
– Yeah, there are times when we convince ourselves where we’re fighting for our patients, but really we’re defending some ego structure that says I’m right and you’re not.
– Totally, this is what my psychiatrist brother and I talk about all the time.
– [Zubin] Oh, your brother’s a psychiatrist.
– My brother’s a psychiatrist.
– [Zubin] Sid.
– [Zubin] That’s right. I read the book.
– Yes, you did.
– I feel like I know your whole family. Like I could just show up, Auntie please let me in. I heard you make a mean Dal.
– She will make for you chicken tiki marsala.
– Oh God it’s so good.
– [Sunita] It’s so good. It’s too good.
– But you know I’ll tell you, you told the story. No, I won’t break. This is a piece of great wisdom in the book. I won’t tell, but is there a part of the book you want to read for us?
– Absolutely. I would love to. Let’s see.
– Do a reading. We haven’t done a reading on this show. This’ll be a first, and I’ll give you a beatbox if you like.
– [Sunita] Well can someone just drop a beat in the background?
– These two?
– [Sunita] Yeah.
– Look how white Tom is. Except he’s actually deeper in the hip hop game than I’ll ever be.
– Should I put on some Snoop Dog? I mean I was listening to Nothing But a G Thang on the whole flight up.
– That is the only thing you can listen to. Was it Southwest?
– Yeah, it was Southwest.
– You have to listen to that.
– You have to block everything out, and listen to Snoop and Dre. It almost sounded vaguely Indian.
– [Zubin] It does!
– That song came out when I was in seventh grade, and you grew up in the 90s in L.A., you have to be all about Snoop and Dre.
– [Zubin] Yeah, I still am.
– And Tupac. I mean he is the best.
– Become a Pac. Mr. International. Player with a Passport.
– [Sunita] Exactly.
– And don’t forget one, two, three, and to the four. Snoop Doggy Dog and Dr. Dre is at the door. Ready to make an entrance so back on up, because you know we ’bout to rip shit up, and give me the microphone first, so I can bust like a bubble. Coming Long Beach together. Yeah, you know we in trouble. Ain’t nothing but a G thang baby. Let’s see, hospitalist and palliative, and we’re crazy. ZDogg LCC is the label that pays me. Unfadable so please don’t try to fade me. Dude, I love it. So you were listening to a lot of hip hop when you wrote the book.
– I actually was, and I’ve never talked about the process of writing the book very much. To be honest, I don’t know how I wrote this while working full time. For a while, I was the only palliative care doc covering two hospitals at USC. The KEK hospital, and the Norris Cancer Center. It was me and my amazing social worker, John Pappas. I have to give a shout out to John Pappas.
– Pappas don’t preach. Greek guy?
– I think half Greek and half Italian.
– Wow, that’s a fiery mix.
– He’s a fiery mix. He’s an amazing amazing social worker. He’s just got a heart of gold, and it was the two of us seeing like 700 consults a year for awhile.
– And the interdisciplinary aspect of palliative is special. Like the social workers, the nurses.
– So important. I have a fantastic nurse practitioner, Flor Elorta. She is Filipina.
– [Zubin] I not go.
– Yes, I always talk to her about how much I love buko pandan.
– [Zubin] Oh it’s so good.
– It’s so good.
– It’s so good, the pancet. It’s so delicious, but make sure to check the magnesium.
– [Sunita] Magnesium, yes.
– Magnesium and the calcium.
– [Sunita] And the calcium.
– Okay, very good. Okay, sorry.
– But the interdisciplinary nature of palliative care, because one person with medical training which is decidedly narrow, one person cannot possibly attend to all the domains of suffering, that patients and families and colleagues are experiencing the physical suffering, the emotional suffering, the spiritual suffering, and that’s why you need a team. I might go see a patient, and have a certain assessment, and then John might go see a patient, and have a very different assessment. It’s so useful to have two lenses on the same situation. That’s kind of how I think about it is different lenses in this circular shape. All kind of on the same situation, and we see very different things. It might be that a patient responds much better to my nurse practitioner than to me. It might be that I’m seeing a Punjabi family and John can come with me and make sure that I don’t have a whole lot of transference going on. You need that team. The team is everything in palliative care.
– You know, I did the keynote for the American Association of Hospice and Palliative Medicine.
– [Sunita] I know, I wasn’t there that year.
– [Sunita] I’m so sad I missed it.
– Because you’re a hater, and haters need to back off, okay, number one. Number next, I remember being awed by the fact that the hospice and palliative care space has been Health 3.0. Collaborative, team based, hol-archical, instead of hierarchical. In other words, everyone practices at the top of their training in a team where you may be the best at this. Someone else is the best at this, but no one is really dominating anyone else, in this hierarchical way, and you guys been doing that forever. I was like, y’all are the enemies of suffering and you’ve been doing 3.0 forever. I don’t even have to give the talk. You already know this. It was fantastic, and it was in Chicago, and they had that deep dish though.
– Do you know I’ve never have Chicago deep dish pizza.
– Dude, you’re missing out on one of the wonders of the world.
– [Sunita] I know.
– But you gotta be careful, because some of them are whack. You gotta get the right one.
– The right one. I’ll have to, the next time I’m headed out there, which.
– [Zubin] The Z Pac will back you up.
– I’m just gonna hit you up. I’m gonna text you and be like, I’m going to Chicago.
– Hit that illuminatis.
– Let me do a reading before I forget.
– [Zubin] Yes, yes, yes, yes.
– And I think what I’m actually going to read, is from, the part of the book where I’m doing home visits, because that is something I really miss doing, because now I do only inpatient, and I opened a clinic about a year and a few months ago, but I really miss. There’s something about being in the home, which is where hospice, and then palliative care really began. Needing to look at the environment, really understanding what social world your patient inhabits, and trying to make the most of whatever forces have structured their lives, at the end of their lives. Knowing that you can’t fix it all. I’m going to read from the chapter called Drive. I park and walk along a sidewalk lined with broken concrete, to my first patient’s home. On my way, I pass a commercial building, adorned with a painting of a young man with a double chin, small mustache, and short spiky hair. Below it, in black lettering, are the words, RIP, Always in our hearts. I turn the corner and walk past another home with the cross made of fresh pink flowers nestled outside its security fence. A photograph of a young man rests against it. Loss lives everywhere here. I knock on the door of Sergio. A patient I have met twice before. Once on a home visit two weeks earlier, and once in the hospital shortly after that. I wait on his narrow porch, next to a Safeway grocery bag, filled with used blue hospital gloves, and empty hand sanitizer bottles. I can’t see anything through the steel security screen that guards the store and most stores in this neighborhood. If I squint I can just barely make out the shadow of an approaching figure. Sergio’s wife, Maria, opens the door and hugs me hello. Sergio smiles weekly from his bed, five feet away from the front door. His smile is outgrowing his shrinking face. He cannot eat because stomach cancer has blocked off his bowels, triggering nausea and vomiting, if he even takes a sip of water. At 45, Sergio isn’t thinking about how to die a good death. He is still grappling with why death has come for him so soon. He tells me that he’s feeling much better today, than he did last week. The medications I’ve prescribed took away his nausea and pain. Maria had taken him to a movie. He had the stamina to talk for nearly an hour on the phone with an aunt he hadn’t seen in 20 years. He’s also been able to sleep through the night for the first time in a month. I can dream again, he tells me with a wide smile. I noticed an open photograph album on his bed. I want to show you who I used to be, he says. I did not always look like this. I barely recognized the man in the photos he shows me. He was probably twice his current size. A round, joyful looking man, who lived in cotton T-shirts, and a size too small jeans. His wife’s arms wrapped tightly around his muffin top. My friend took these he says, as he shows me his wedding photographs. He and Maria married in the church they still attend. They don’t have family in the United States. Each left Mexico, 10 years earlier, and happened to meet in dance class. We don’t have much, he told me on our first visit, but we do have God. There is a rosary draped around the bottle of liquid morphine at his bedside. With the help of a neighbor, Maria tries her best to get him in and out of bed, bathe him, and recognize when to give him different medicines for pain or nausea. Her brow furrows, and there are deep lines between her eyebrows, that Sergio tells me are new. I know that the hospice nurse has instructed her to give one medicine if he has pain and another if he’s nauseated, but Maria is afraid, as so many caregivers are. Sometimes, I don’t understand what problems I should be looking for, she tells me, and I could never forgive myself if I missed something. If he suffered because I am not a nurse. Her worry keeps her awake at night watching the rhythmic rise and fall of Sergio’s chest. Alert to changes in its tempo. Fearful that she might be asleep, if it suddenly halts. She tells me that she sleeps next to him as his caregiver. It’s been a long time since she’s felt like his wife. It helps her when I show her the various ways the body demonstrates distress. Does he ever breathe like this, I ask in Spanish. Heaving my own chest rapidly, and wearing the look of distress. She shakes her head. I act out other symptoms, aside from the obvious grimacing in pain. The nausea that can accompany, even the tiniest sip of water. The confusion and agitation that can characterize the final hours. I start to write down which medicine to give in each instance but remember that Maria cannot read very well. That she instead identifies medications by the color and size of each one. We instead discuss which medicines can be useful in each scenario. The liquid or the pill, but I know she will not remember it all. I cannot expect her to. Her own breathing becomes rapid and shallow every time we discuss these things. I feel a heaviness in my chest, when she asks me why hospice cannot pay for caregivers. I wish I knew. I wish our system were different I tell her. Silently wondering as I often do, why our healthcare system will pay for last ditch effort chemotherapy for a dying patient, but not for one trained caregiver, to help them remain comfortable at home. After I wrap up my visit, Maria walks me to my car. She is barely five feet tall, yet she is protective of me, and walks me out every time I visit. Her arm around my waist. When we reach my car, she turns and asks me if I believe in God. I don’t know why this happened to him. He’s only 45, and he’s done nothing wrong. Nothing at all. Maybe if we beg God, maybe if you beg God, he won’t need your medicines, and I won’t be alone. She barely finishes the last sentence burying her face in her hands and weeping.
– I’m pouring some out for my previous career. I’m going into palliative medicine. Seriously, that was a beautiful story. That pretty much, and I wet my foot with that pour out just now. That was a beautiful story, and I remember reading it in the book and this idea that, we spend so much money on end of life. On stuff that doesn’t matter, and what you just did there, is a bigger intervention, and having a caregiver is a bigger intervention that anything else we could do, and yet here we are. What I was really pouring it out for, was our healthcare system, because it’s been dead for a long time and it’s time we took about 360 Jules. We need to get it off of life support. Resuscitate it and get it poppin’. Man, and that’s an example of what I was talking about in that book. You’re in this place with the patients and with you and you’re in the head space of the doctor and if you don’t understand what palliative is after reading that book, then it’s not comprehendable for you, because you might be a psychopath.
– [Sunita] Then you have failed.
– Then you have failed. Then you, speaking of failure, while you were doing that, I was looking at comments, and people are saying, I’m literally welling up. Rachel, Mark, Antonio. You’re a very special person. I’d be a puddle with every single patient. Taking that on. Who the hell is chopping onions here, Seth Nuremberg. That’s a dude right there, okay. Sexism. Even a dude is crying. I really think if I read this book I would be changing careers and entering end of life care, although I’d be keeping Kleenex tissues in business Alexandra Powers, and then the setting of all this, my dad texts me.
– [Sunita] No way.
– Of course he’s not watching, because he’s not paying the $4.99 because he’s a cheap Indian dad, and he says referring to the Nursing video that he just got the email for, because I put him back on the list. Always a Nurse video that we put out. What is the original title of the song, and who did the singing? In other words, he doesn’t believe that I sang the damn song. I don’t know whether to be insulted.
– [Sunita] Epic fail dad.
– Epic fail, dad.
– But I also love you Uncle.
– [Zubin] That’s right.
– I will come to the Central Valley and drink some Johnny Walker with you.
– He would have you. He has a bar in our old house.
– [Sunita] I’m sure he does.
– Ranch style house.
– [Sunita] I’m sure he does.
– Clovis, California.
– I can envision it.
– There is a bottle of blue, and understand why the Johnny Walker blue is there, because my brother who is effectively like a every Persian business man you meet, in Southern Cal, like in Orange County. He’s that guy, right? Gold chain, cologne. I’m making this up.
– [Sunita] He should be in your videos.
– He should. He decides he’s gonna impress my dad by buying a bottle of Johnny Walker blue because he’s like if Dad likes black, this will be my way as a good son to impress him. Give him the blue, and in my mind, I know my dad better. I’ve been alive longer. I’m like, uh uh. Watch what happens, and this is what happens. Blue? He goes right on Google. Types with his chicken fingers.
– [Sunita] Of course he does.
– That’s $150 a bottle. Are you crazy? Why did I support you all those years, so you can waste money on this? It taste the same as blue. Black tastes better.
– I love your dad so much. One thing I do have to let him know right now is I’m more of a bubbles girl. So I will have a presecco and once I’ve had presecco, I can have some Johnny Walker.
– No shame in that, because exactly. That’s correct. It’s culturally correct.
– It is. It’s for me, I kind of, in order for me to deal with the taste of Johnny Walker because it is not my favorite, sorry Dad. Not your dad, my dad. They’re all the same. My dad’s like don’t be such a girl. Punjabi men, we can talk about them. Very deeply masculine.
– [Zubin] Yes.
– In so many ways, and I find it so fascinating to have grown up with a father whose very masculine, who kind of raised me as a boy, because and thank you so much for this dad, he told me when I was a kid, I think I was six or seven, I will not leave you dependent on anyone in this world.
– [Zubin] That’s beautiful.
– You need to stand on your own two feet, so I will raise you like a boy.
– I feel like I know your parents reading the book. Your mother in particular, because she’s such a central character in the book, and that idea of just being with her in the hospital and how the hospital operator knew your name as a child. That was me, and the answering service and all that. They’d be like, oh hey Zubin. Yeah, no, I think your dad’s in a consult somewhere but I’ll let him know.
– That’s so much about how much a hospital was part of our world as children. It was like a second home.
– And we were both in utero in the hospital right?
– [Zubin] That’s a great point.
– It’s really interesting, because I think about that sometimes, because I love and hate medicine like you. There’s a thing, a tension. There’s a humanity that’s so often ignored. There’s this idea that we do so much stuff that’s wrong and yet, and yet, there’s this fatal draw to it, that we can’t quit. I can’t quit you medicine. You complete me.
– You couldn’t hit it and quit it.
– Exactly, I couldn’t hit it, quit it, lick it, and split it. We had to go into it, and I think some of that is our in utero conditioning and then the fact that is it part of who we are. Karma is an interesting thing, and I think it’s really causes and conditions that are set up from birth and before birth, in the sense that one things leads to another leads to another, and when your parents are in medicine, and you’re being conditioned, you’re gonna start to get and it is good, because it led us down a path where we think we’re actually doing some good in the world.
– [Sunita] Yes.
– What’s your advice to medical students coming up in the game? You know what I’m saying.
– You mentioned karma, so can I just make an allusion to a genius line from a Lil Wayne featuring Drake song?
– The idea of genius line and Lil Wayne, that’s just redundant.
– Truly, yes. Karma is a bitch so just make sure that bitch is beautiful.
– Oh snap! Yo, little Wayne just owned us, Tom Hinueber.
– I will answer your question, but once you said karma, I have to say I was very distracted for the rest.
– [Zubin] It’s a good line.
– It’s a great line.
– My daughter asked me if karma was real, and I had to have this discussion, because look, look, and this is an interesting discussion too, and I forgot what question I asked you before this went off the rails. What was it?
– [Sunita] What advice would I give med students?
– We’ll end with that, because we’re coming up on an hour. Coming up in the game. Can’t trust nobody. I know. Thoughts on Cypress Hill.
– You’re gonna hate me and all the viewers are gonna hate me. I don’t have particular thoughts on Cypress Hill. They don’t move me one way or another.
– [Zubin] Because they came up in the game in ’94, ’93.
– They did.
– [Zubin] The nine trize’.
– I was just besoughted by Pac and Snoop.
– [Zubin] By Pac.
– I was just all about them. There was no more room in my heart, for anyone else in the ’90s.
– [Zubin] That brings us back to pharma.
– Except maybe Usher.
– Oh Usher, Ursher. Do you know we did?
– [Sunita] I did love Usher.
– We did a parody of Yeah.
– I know. I’ve seen it. We watched it in our palliative care team room as we watched all your videos on rounds. It’s genius.
– Look out! Mouth to mouth’s ridiculous! In the club when the mouse was sickulous. Yo, your protocol’s all out of date. Blowing air down his pipe is so 2008. So forget about that. I’m gonna squeeze the chip. CPR hands only when your homie arrests! I gotta say.
– I would make him DNR.
– I would totally make him DNR. I would be like I’m not doing this hands only CPR. How about no CPR?
– You could do it with no hands. As Waka Flocka says.
– That’s exactly right. So back to karma, since all roads lead to that. My daughter’s like karma, and she understands I’m kind of an agnostic Buddhist more or less. I believe in, I’m a spiritual, I meditate. I believe in. I think we’re all consciousness. That’s what I think. So I explained to her that karma is simply cause and effect that stretches back far into history before you were born, and the stuff that was. It’s nothing metaphysical. It’s actually simple science. If consciousness is a thing, it’s unfolding, and what you say, what you think, what you do, how you affect others in this vast social network, it ripples out into your community and into the universe in ways that you can never predict, but you can intend for good, or you can intend for ill, and that will come back in an effect in some way and she looked at me blankly like, bitch, just forget it.
– Is it real or not?
– Is it real or not, because I feel like I’ve done some bad stuff and I don’t want to get in trouble.
– But I think what you hit on there is intention, and that was something that someone said to me maybe about a year ago, that if you’re doing something, you can’t always. The outcome of what you do, you can’t always control. You could say something to someone with the greatest and purist intention and they could take it the wrong way, but the only thing you can control is your intention.
– [Zubin] Yeah, that’s right.
– That was so empowering to hear, because I have always been someone that’s a people pleaser, that’s wanted to protect people from bad feelings so I’ll take on the bad feelings for them, and that’s very toxic, and I think in medicine this can get to my advice to med students, we’re all people pleasers. We all want to get the A on the test. We all want to fix the patient’s disease. That’s what we want to do. I would say to med students coming up in the game, try to be compassionate with yourself, because I think the Buddha also talks about you cannot have compassion for another.
– [Zubin] B Diddy.
– B Diddy, yes, exactly. He’s my Om boy. I think you’ve met your match here.
– I really have. It’s my sister from another mister. Wait, wait, so you said, you cannot have compassion for another.
– Unless you’re compassionate for yourself.
– [Zubin] 1,000% true.
– I think I learned that the hard way in my life and also in my training, and I go into some of it in the book.
– That was a real twist in the book, because towards the end you start talking about how you started starving yourself basically in, was it junior high or high school?
– [Sunita] High school.
– After your freshman year, and you started eating less and losing, and you’re like now my jeans fit better and now I noticed, and your parents started to get concerned but they never really directly took you to the pediatrician. They thought you had cancer, and I started looking at that going I did that in junior high. The exact same thing. I’m like I’m chubby. I need to do something. You know what really got me in that story was, your father making you peanut butter and jelly sandwiches which is such a gift. It’s an Indian parent thing. Eat, eat.
– [Sunita] Just keep eating.
– Keep eating, and you throwing it away when he wasn’t looking and starving yourself. What was going on there?
– I’m glad. I haven’t actually talked about this in any interview about the book, and I’m glad to talk about it, because I think it gets at this theme that we have in this discussion which is so beautiful and essential is that doctors are also painfully human and all the mess and beauty of a human life applies equally to us. I think I had grown up in a community where I was a chubby child and called fat and mannish by the aunties. You know the aunties.
– I know that, Zubin’s belly is so big. He must be really enjoying the dal.
– I used to do katak, and I was always asked to play Krishna because I was more boyish than the slim little girls, and I had a complex about it, and I think there were some very sad things that happened to me as a kid, and I think one of the ways I sought to kind of get a sense of control back over my life and to achieve this false illusion of perfection was by hurting myself in that way, but I didn’t see it as hurting myself. I saw it as containing myself and being perfect, and being perfect in a way I never could otherwise, because no matter how many straight As I got, no matter how many spelling bees I won, I was still the chubby child who was asked to play Krishna. While all the other girls could be feminine, and I think I started to buy in to some level that myth that thin makes you feminine, and coming out of that, I don’t know that you ever fully, that I ever fully will come out of that self perception to be totally frank, and I’m saying that because I think, we are sometimes expected. There’s a trope in this country of, facing suffering and overcoming it. Fighting through it.
– [Zubin] That’s right.
– But I don’t know that if you suffer in that deep way and you hurt yourself in that way, that what’s made you prone to that level of suffering ever fully goes away, and that’s part of what it means now for me to find compassion for myself. When that crazy voice starts, I say oh crazy voice. You are part of me too. I mean, not the #MeToo movement, but you are part of me.
– [Zubin] You’re part of #MeToo.
– Yes. You are part of me as well, and I see you and I hear you, and I’m gonna shut you down now, and I couldn’t see that distinction when I was in high school.
– Man, I mean so many people need to hear this story, because you’re successful, you’re the medical director in a major academic center, you’re living your story and sharing it with others in a book that really I found to be transformative and wonderful and beautiful, and you can suck it Atul Gawande, because this is kicking your ass. Okay, I’m looking at you Atul. Call me. Call me, I miss you, but telling that story actually, it resonated with me too, because I went through a very similar thing as a guy, which is strange, but I was a real chubby kid. This was the whole story I always tell, my mom walking into Mervyn’s and being like where is the husky section? Then wearing those toughskin jeans, because I couldn’t wear good designer jeans because they never fit, because I was too short and fat, and my mom was like, I’m not going to take you to the tailor. That’s crazy. Toughskins work great. It’s saggy. I was sagging before it was cool, bitch. I was in that game.
– I wasn’t allowed to sag.
– I didn’t have no choice, because I was fat, and so I had the same thing, so in junior high I starved myself and my parents would give me four dollars to buy Hot Pockets and stuff every day for lunch in junior high and I would take the money and just hoard it away. I didn’t even need the money. I was just putting it away, and so one day my mom discovered. She saw me losing weight, and you know Indian moms. Oh crap. What are you starving? You have cancer? Same thing.
– You must be on meth, or have cancer.
– Exactly, so my mother was like, she saw it right away. She was a psychiatrist. She’s like you have an eating disorder. What are you doing? I’m like no no, no, no, no I’m fat and I need to get in, everyone else is doing multiple pullups. I can do 10 pullups now. I couldn’t do one. Everyone else is getting presidential in P.E. I’m getting nothing. I’m getting made fun of. This is the best I’ve ever looked. This is great. All sunken and looking like shit. Probably had electrolyte abnormalities. Probably stunting my growth.
– I totally think about that. Like my potassium. I mean you could have, either of us could have just arrested.
– Arrested, in the middle of the night.
– Exactly, and then we would have been one of the stories in your book. Right, it’s true. We would have been the people with the parents by the bedside the whole time and feeling all the shame and all this, and we managed to dodge that bullet but I remember my mother just being so listen, what the hell? But my dad coming in the room and being like, okay buddy I heard what you’re doing. If you need money you just need to tell me. He thought it was all about the money. Like I was saving the lunch money, and I’m like you know what, I kind of like that better. It’s easier to deal with,, but yeah, you outgrow it, but it’s part of who you are, and it does, those voices do come back. Every now and again I’ll just be like, I’ll show my kids like see this, daddy, didn’t always look like this. Like the story you tell. Daddy didn’t always look like this. I used to have a full 360 muffin top, but it was really wonderful that you shared that piece and you didn’t have to dive in further.
– It was just enough.
– [Zubin] Just enough.
– I think in some of the other doctor memoirs I’ve read, I have longed as someone who loves literature for the mess and the beauty, and I really wanted to be as human as I could, with my readers, and that’s why I just put a touch in there, and I didn’t need to go on. Just the amount I said was all I wanted to say.
– It was perfect. I actually noticed that exactly as a meta-phenomenon. She just put it enough, because people can get in the weeds, but that’s not what this book is about. This book is about a human being’s journey through this path with other human beings and the karma that results. I’m saying karma. Yeah, I’m an atheist. I’m saying karma and stuff.
– And stuff.
– B Diddy, what’d you call him my Om boy.
– [Sunita] Buddha is my Om boy.
– B Diddy is my Om boy. You know what I’m saying. Pour a little out. Pour a little out. You know what I’m saying. Hey Mara, I see you Mara. You try to step to me. Mara’s a bad guy. Apparently, I don’t know. I’m not really a Buddhist. I’m more like like the vibe of it. Anyways, I think we’ve gone an hour and 15 minutes or something. Just to respect our audience’s sanity. By the way, the comments are, it’s amazing how many healthcare experiences, how many in healthcare experience trauma in childhood. Sam Newkirk. Right?
– The wounded healer.
– The wounded healer. Nurses in particular, because there’s nurturer types. Not all doctors are nurturer types like you. A lot of them are like.
– Maybe that’s a different manifestation of whatever trauma they’ve had.
– [Zubin] Expectations.
– I think no human being makes it through this life unscathed. How much you dive into the ways that you have been hurt, and the ways that you have suffered, that’s what’s up to you, but the fact of the suffering is inescapable.
– Inescapable. The thing is that means you don’t deny suffering. One of the things you say in the book was we’re here to bear witness, more or less, I’m paraphrasing, to suffering. To your grandmother. That’s what it was. She was having the COPD and the emphysema and she was suffering but what she needed was you were there to bare witness because people suffer in silence and that’s the hardest.
– That’s the hardest.
– I think we can go out with this comment which is, where was it, damn it. Was late to the party. What’s the name of the book? It’s called That Good Night. Shazam. It’s on Amazon. We put link in here. This whole thing will come out soon. It’s just for supporters right now, but definitely go get this book. Get this book and read it. On Kindle or whatever you like, and there was another comment about our chemistry. Ah! Amy Hakim says your chemistry. Have her on regularly. She is amazing too. Dude.
– Cardi P.
– [Zubin] Cardi P.
– Hashtag Cardi P.
– Dude, I’m in. I’m in.
– Hey, I will come back here any time.
– [Zubin] I love it. We would have you any time.
– You should come to USC.
– Oh hell yeah. I would totally do that. Let’s go through the LBC.
– [Sunita] Dr. Dre is involved.
– If Dr. Dre, the Drize. Dr. D-R-E, digital rectal exam. We still want to do that. Still DRE. Tom wants to make it happen. All right guys, listen, if you love what we’re doing on this show, Dr. Sunita Puri, is just by far one of my favorite guests of all time because we have too much in common. People are probably like, I don’t get it, but I’m like this is it. Become a subscriber. If you don’t want to do that hit like and hit share. Share this video. It’s so important and whether you buy the book or not, spread the word about what palliative care does because it is central to building Health 3.0. All right, I don’t know girl. Any parting words of wisdom?
– Your booty got me lost like Nemo. To quote Waka Flocka Flame.
– [Zubin] Waka Flocka Flame.
– Feel like he sums up this whole conversation.
– He kind of takes it to that next level.
– He does. I think it’s just, in all seriousness, although I do think Waka Flocka’s very serious, but thank you for having me on. Really, everything you do brings my team so much joy. We watch your videos all the time. Every med student that comes on my rotation, they usually all know about you but if they don’t, it’s a learning objective of palliative care rotation. You bring a lot of joy, and to be a part of this was just amazing. So thank you.
– It’s continuing musical education, bitch. West side!
– Two of the best from the west side.
– That’s right. Follow as we ride. All right, we out. Let’s do a thumbnail. Look at the camera right there, and do something thumbnailish. You see that one up there with the red light.
– Oh, there!
– Yo, what up?
– West side.