The Peter Attia Drive - #135 - BJ Miller, M.D.： How understanding death leads to a better life

00:00:00.000 Hey everyone, welcome to the drive podcast. I'm your host, Peter Atiyah. This podcast,

00:00:15.480 my website and my weekly newsletter all focus on the goal of translating the science of longevity

00:00:19.800 into something accessible for everyone. Our goal is to provide the best content in health

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00:00:28.880 If you enjoy this podcast, we've created a membership program that brings you far more

00:00:33.280 in-depth content. If you want to take your knowledge of the space to the next level at

00:00:37.320 the end of this episode, I'll explain what those benefits are. Or if you want to learn more now,

00:00:41.740 head over to peteratiyahmd.com forward slash subscribe. Now, without further delay, here's

00:00:48.080 today's episode. I guess this week is Dr. BJ Miller. BJ is a hospice and palliative care specialist.

00:00:55.940 We talk a lot about what that means, but the reason I wanted to speak with BJ is I've been

00:01:01.300 really thinking a lot about better understanding what end of life means and how understanding the

00:01:07.700 end of life could help us better understand, frankly, what we want out of life. And by an

00:01:12.860 amazing coincidence, BJ and I met very, very briefly many years ago in medical school,

00:01:18.900 although I don't think he remembers it. But when I saw him again, giving a TED talk several years ago,

00:01:24.560 I immediately realized, Hey, that's the guy I met at a party, you know, 20 some odd years ago and

00:01:30.440 became really interested in his work and then reached back out to him and said, Hey,

00:01:35.340 would you be interested to sit down and talk about this? And so in this discussion,

00:01:38.740 we talk a lot about his personal story because you can't really avoid it. And frankly, his personal

00:01:44.000 story is a big part of why he ultimately chose the life path he did, which is doing something that

00:01:51.100 many of us, including people who go into medicine would find just too difficult to do, which is

00:01:55.720 basically help patients die as a means to reach this culmination of their life. We get into all

00:02:03.040 sorts of things, the difference between death and dying, the difference between palliative care and

00:02:08.320 hospice, the differences between loss and regret, what the medical system that we're a part of is good

00:02:14.280 at and what it's not so great at. We talk about what really happens at the end of life, how enlightened

00:02:20.020 or transcendent is it? And he tells a number of stories that are quite moving about patients and

00:02:26.420 also from his own life. And finally, we conclude with a discussion on both the hastening of death

00:02:32.540 and also what he's most optimistic about, including the use of psychedelics.

00:02:38.080 This is another one of those episodes that I think people at the surface might think, gosh,

00:02:41.940 I don't really have an interest in that. I would encourage you to push through that. I think it's

00:02:45.800 natural to find this topic unpalatable. And I think that's exactly why people need to listen to

00:02:52.100 this. So without further delay, please enjoy my conversation with BJ Miller.

00:03:02.760 Hey BJ, it's a real honor to be sitting down with you, even though we're not in person together.

00:03:08.380 Thank you, Peter. I appreciate you having me, but I'm looking forward to this.

00:03:11.940 Now, I don't know if you remember this. In fact, you can't have remembered this because I'm not

00:03:18.620 memorable in the way that you are, but we've met a few times at parties in medical school. 0.99

00:03:24.400 No shit. 0.97

00:03:25.380 You went to UCSF and I went to Stanford. And I don't know if we were the same class, 0.99

00:03:30.760 but we were pretty close. What year did you matriculate at UCSF?

00:03:35.020 97.

00:03:36.100 Yep. So we were the same class. And I don't recall you guys ever coming down to Palo Alto,

00:03:42.320 but we sure as hell went up to San Francisco a lot.

00:03:45.380 For social reasons or for school?

00:03:47.420 No, just for social reasons.

00:03:49.000 Oh yeah. Yeah. Yeah.

00:03:50.420 We just had friends in common and stuff like that. And so it's almost 25 years ago. And I remember

00:03:56.020 one of the things that stood out was you had a dog, right?

00:03:59.780 Yep.

00:04:00.820 What was your dog's name? I don't remember.

00:04:03.420 His name was Vermont, like the state.

00:04:06.160 Got it.

00:04:06.760 Yeah. Wow. I'm so psyched you remember him, Peter. He was a huge part of my life. I can tell you.

00:04:13.440 That's beautiful.

00:04:14.200 Cool. So I will admit something, BJ, which is that I never had the nerve to come up to you

00:04:23.000 and say, hey, what happened? Because it wasn't subtle, right?

00:04:30.420 Yeah. No, it's pretty, it's pretty bleedingly obvious. Yeah.

00:04:34.200 Yeah. So as I would learn later, your life changed shortly after Thanksgiving in 1990, right?

00:04:43.640 That's right. You got it, bud. Yep.

00:04:46.400 And that change, which I think on the surface would sound like a change for the worse,

00:04:52.000 maybe wasn't for the worse after all. Can you tell folks what happened that night?

00:04:56.780 Yeah. I mean, it was a big moment in my life as you're pointing to, Peter. Yeah. I mean,

00:05:00.960 and there's a lot to talk about it. So I'll try to just kind of parlay the basic facts and then we

00:05:05.820 can talk about any of it. So just back from Thanksgiving holiday, and I was very happy to

00:05:11.240 see my friends. We were all kind of that early college. We were just basically in love. We

00:05:18.060 couldn't wait to see each other. Being away for Thanksgiving break was a bummer, really. So anyway,

00:05:23.360 we got running back and we immediately decided to go, a handful of us would go out and have a drink

00:05:28.520 and just run around. I was actually on my way to the computer lab to print a paper when it kind

00:05:34.480 of got intercepted and off we ran to go have some fun. Nothing crazy. It was, we didn't go nutso,

00:05:40.960 but we were heading to the Wawa market, which in the East coast is sort of like a 7-Eleven,

00:05:46.380 late open all night place to get a sandwich, kind of joint chips or whatever. Anyway, so we're walking

00:05:51.280 to the Wawa market and this is at Princeton University where there's a commuter train that runs right up

00:05:57.820 along campus because Princeton's sort of a bedroom community for New York and Philly. And so this

00:06:02.460 commuter train was called the Dinky of all things. It was just sitting there, non-operating hours. So

00:06:08.160 I was just sitting there and we stumbled across it and just decided to climb on top of it, just 0.93

00:06:13.280 relatively innocently for things we had done, but felt much stupider. But anyway, we decided to jump

00:06:19.960 on top of it, climb it, climb a ladder, just stand up on it like you would a jungle gym or a tree or

00:06:24.740 something. And when I got up on top of the train, I had a metal watch on and the electricity arped to

00:06:31.100 the watch when I stood up because I got close enough to the line. And that was that. The

00:06:36.100 electricity entered the arm, my left arm, and then ground down. And eventually there's a big explosion

00:06:42.520 and whatever else. And that was that. I survived that, but ended up losing both legs below the knee

00:06:48.840 and that one arm below the elbow. Very touch and go in the burn unit in Livingston, New Jersey,

00:06:53.860 St. Barnabas Hospital for, I don't know, maybe a month or so. Then I was in there another month in

00:06:58.620 the burn unit and then eventually out of there and into rehab and then a long process of reentering

00:07:04.640 the world. But anyway, that was my big, the thing I call the cosmic spanking, that big, big moment that

00:07:09.800 just came along and completely reoriented me, changed things around. Do you remember the actual

00:07:17.540 shock or is that sort of so traumatic? A lot of times trauma patients, for example, when they're hit by cars

00:07:25.820 or sustain a significant gunshot wound, especially if it's followed by a prolonged period in the ICU, they

00:07:32.040 suffer some anti-grade amnesia. So they forget things in front of them, not so much behind them. But a lot of

00:07:38.860 times that includes the actual event. So what is the last thing you remember? Do you remember actually climbing

00:07:44.580 up on the train? I don't. No. I remember the night is all very fuzzy. I remember sort of snippets from

00:07:51.200 the hours preceding, but I don't have any recollection of approaching the train or getting on top of it.

00:07:56.660 This is just pieced together through stories from my friends who are with me. But the first memory I

00:08:02.820 have around the accident itself that night, I can picture a lot of it, again, because my friends have

00:08:10.280 told me. But my own memory really began in the hospital that night. I was taken to the local ER

00:08:17.700 where they just did basic things that are called fasciotomies, which is, you know, with electrical

00:08:23.380 burns, you burn from the inside out. So you've got all this heat running around in your system and it'll

00:08:28.000 keep burning you. So they've got to vent that heat. Basically the local ER, they cut these fasciotomies

00:08:33.420 to vent me and then stuck me in a helicopter to go to the New Jersey's one burn unit at St.

00:08:39.720 Barnabas. I can remember being loaded into the helicopter vaguely. I was very tall. I was almost

00:08:45.780 6'5". And I just remember the pilots, there was this awkwardly trying to get me into the cockpit

00:08:52.640 because I was too long. So all the amputations I had were surgical. So at that night, my legs were

00:08:58.240 burned. I still have them. So then you get to a burn unit and you're with now a team of doctors

00:09:06.300 and nurses who have seen the worst of things. For what it's worth, just as a bizarre coincidence,

00:09:12.820 in general surgery, which is what I went to do after medical school, you rotate through all the

00:09:17.600 different disciplines of surgery. It's quite random. You'll spend a month on this, a month on that,

00:09:22.760 a month on all of these different things. And my very first month of internship was in the burn

00:09:29.700 unit. I had never done any of that during medical school. So to show up on day one at sort of the

00:09:37.920 premier burn unit of Maryland, which basically meant it was the referral center. So if you got burned in

00:09:43.820 Pennsylvania, you were still coming down to Hopkins. I mean, it was another world.

00:09:49.060 You got it. I mean, it was very difficult to get used to doing dressing changes on patients and

00:09:57.080 just seeing the amount of pain people were in when they suffered these burns. And the other thing that

00:10:03.380 was remarkable, at least to me, was how otherwise alive people could look when they came into a burn

00:10:12.360 unit, but yet how poor their prognosis could be based on the amount of surface area that was burned.

00:10:17.840 We basically had actuarial tables that would say, well, he has this much of third degree and this

00:10:23.200 much of second degree. And even though he's sitting here actually able to even communicate with us,

00:10:29.060 this person has a very high likelihood of not surviving this injury.

00:10:33.780 Yep. It's interesting that you say that because one of the early memories would piece together for me

00:10:39.160 by a nurse with whom I became very close was when I landed in the bay at the burn unit.

00:10:46.720 This was not uncommon, but apparently the techs and the team were sitting around basically taking

00:10:51.700 wages on whether I was going to make it. It was probably based on very much the same kind of

00:10:56.620 what you were just describing. That sounds kind of harsh, but I'm sure it wasn't. I think that was

00:11:00.620 just, as you know, these things get depersonalized in that setting almost by necessity. It's a brutal

00:11:06.120 setting. But anyway, we can talk more about that. But I'm in a way glad, Peter, to know that you know

00:11:12.000 what a burn unit is like. It is another world that I've always struggled to impart to people

00:11:17.680 what it's actually like in there. It is a wholly unnatural place. I mean, nature is completely kept

00:11:22.900 at bay. Yes. And there's a reason that it's very separate. I mean, in small hospitals, they do what

00:11:28.680 they can, and I'm sure they don't have dedicated burn units. But at tertiary care centers, they have

00:11:33.680 dedicated ICUs that are exclusively for burn patients that don't take other medical or surgical

00:11:39.980 or neuro or pediatric cases. And it's also a very special type of nurse that works there and a

00:11:46.260 special type of doctor because everything from the, frankly, just at times the grotesque nature of the

00:11:52.060 disfiguration of the skin, these dressing changes that we talk about doing several times per day on

00:11:57.460 a patient, they require incredible sterility at the bedside. Frankly, in the early days, early days of

00:12:03.560 the patient's admission, even the smell of burned tissue is a very foreign odor to people. So

00:12:09.900 everything about it, it places, by the way, everything I've said says nothing to what the

00:12:15.060 patient and their family must be experiencing as they're coming to grips with this. So when did your

00:12:20.780 parents arrive? I'm sure you don't remember it, but based on the stories.

00:12:24.900 They came almost, my poor parents, man, they got the classic in the middle of the night. They were in

00:12:30.480 Chicago where I grew up at the time. So they get a call from New Jersey at 4 a.m. or something

00:12:35.360 ridiculous. And basically not a lot of information, just everything was emergent and scary. And

00:12:42.480 basically your son's here with us. He's very badly injured. Might not make it through the night. Get

00:12:49.280 here as soon as possible. Basically one of those calls. So my parents were there as quickly as could be

00:12:54.840 the next morning. To your point about this place. So what they've learned, burn treatment science is

00:13:01.120 infection is very often the thing that kills people. Hence all the sterility. So someone might

00:13:07.240 look just fine, but they're so exposed, their body's so exposed that you're so susceptible. So

00:13:13.520 that means whoever's in your room, they're in spacesuits and whatever else. And for a while,

00:13:19.080 I was not allowed many visitors. There were friends who would come, but they couldn't come in the

00:13:23.180 burning it. Eventually they allowed my parents at the bedside one at a time. That was it. But it was

00:13:29.080 really powerful, very potent visits. I remember them very well as did my parents. As you describe

00:13:35.620 your experience as a student, as a trainee, it's not much different because it's such a foreign, 1.00

00:13:41.460 exotic environment that works against intuition in a lot of ways. The things that touch, for example,

00:13:47.520 something you have to avoid at all costs, smells, everything is foreign. There is just no place 1.00

00:13:52.980 to sort of rest into a familiar. You can imagine if it was that way for you as a student trainee.

00:13:58.820 It was certainly that way for myself and my parents. But in a way too, that foreignness, 0.98

00:14:05.700 and by virtue of me being so undeniably vulnerable, I was not moving. I was completely at their mercy.

00:14:12.880 In a way, it allowed me to very quickly submit to the place and to the people working there because

00:14:20.140 I clearly had nothing approaching an option. Very quickly, I was aware of my vulnerability and

00:14:27.060 immediately trusted that people were working on me in a way because I had to, but also as a comment of

00:14:32.380 how skillful they were if there were. Do you remember the actual discussion you had with the

00:14:38.260 doctors about the need for amputation? Because obviously when the fasciotomies are performed initially,

00:14:44.400 it's with the hope of salvaging the limbs. Presumably at some point, they came to the

00:14:50.360 realization that trying to salvage the limbs was actually going to threaten your life due to

00:14:54.700 infection. They had to go. I've been around those discussions. Do you remember that?

00:15:00.780 I do. I do. I do. My first memory, real vivid memory besides that helicopter moment,

00:15:08.880 was the night before my initial amputations. The part I remember about it, which was maybe five

00:15:15.600 or six days in, Peter, that's when I was hemodynamically stable enough. More to the point,

00:15:20.860 the demarcation of viable tissue versus unviable tissue was a little bit more obvious. Surgeons had

00:15:26.100 a fighting chance to remove the right amount. Dr. Mansour was the main surgeon, an amazing,

00:15:33.780 amazing person. I remember he came in the night before and said something. All I remember is a

00:15:40.640 conversation. And then I remember falling asleep. I fell asleep in my little room. And somehow,

00:15:48.100 you know that feeling, Peter, where you wake up from a dream and there's a moment of reorienting

00:15:53.720 yourself and maybe it wasn't a very pleasant dream. And you take a little second and you get your

00:15:59.200 bearings and you go, oh, oh, it was just a dream. Oh, thank God. You know, the classic thing is people

00:16:03.780 show up like taking an exam naked or something. So they're late for their wedding or some moment

00:16:09.620 and you wake up and, oh, thank God that was a dream. I remember I woke up in the burning and having

00:16:15.440 that sensation. Strange. I remember I looked around and I had this weird feeling like, oh,

00:16:20.820 this whole amputation thing that I was just hearing about was a dream. Oh, I'm fine.

00:16:25.880 I got to go to the bathroom. So I, in my haze, managed to extubate myself. So not an easy thing

00:16:33.860 to do. Extubate myself, pull my central lines out of my neck, unstrap my arm from the bed.

00:16:40.500 And all the while, I can remember this so clearly. I'm looking around my room with all these cues

00:16:44.740 that obviously I'm not in my bedroom. But for some reason, I'm just thinking, oh, yeah, this is my room.

00:16:49.460 I'm just going to go to the bathroom now. And I got up and out of bed eventually and started

00:16:53.780 walking to the door with all these alarms going off in the middle of the night. Somehow,

00:16:58.420 I don't know where the nurses were, but there was a gap there. And I started walking to the door

00:17:02.840 just to take a leak on my crispy little feet. And the Foley catheter line ran out. And as you know,

00:17:10.000 they're usually attached to the bed. So when that line ran out, it yanked on that Foley. And that's a

00:17:17.240 pain that I won't soon forget. And that catheter ball was not deflated. We can explain this for your

00:17:23.340 listeners. But anyway, I was just about to say, we're going to hit pause and explain everything

00:17:27.920 you just said. But let's start with the extubation. So you have a tube that is in your airway and a

00:17:35.520 machine that is breathing for you. So the act of pulling that out means you now have to breathe on

00:17:41.180 your own, something you have not been doing for the previous week. That alone could have killed you.

00:17:46.180 Yeah. Right. You then pulled out a bunch of central lines, which if not compressed, 0.57

00:17:52.440 so central lines are very, very long intravenous lines that go into the main veins inside your body,

00:18:01.160 veins that most people don't even realize they have called the vena cava, subclavian vein, etc.

00:18:06.900 To pull those out without the appropriate protocol of compression could also lead to internal hemorrhage

00:18:13.220 and all sorts of crazy things. You're dodging death. You're three for three on this.

00:18:18.400 Yeah. I mean, yes. In retrospect, I smile almost with pride because it feels, it sounds so daring.

00:18:25.060 I mean, obviously at the time I had no freaking idea what I was doing, but now it's-

00:18:28.160 You're unkillable. 0.90

00:18:29.680 Yeah. 0.89

00:18:31.100 But then the thing that finally gets you is a catheter about the size of an HB pencil

00:18:38.700 that is in your urethra up to your bladder, which stays in place with a balloon that's dilated to

00:18:47.160 the size of a very large gumball. And said gumball prevents the catheter from ever coming out. And before

00:18:55.380 we take these catheters out of the urethra, which is by itself unbearable, I myself have had one,

00:19:02.320 we have to deflate the ball because trying to pull a gumball sized device out of the urethra would

00:19:10.820 be tantamount to torture. But of course you just went ahead and through the force of walking towards

00:19:18.560 the door, basically removed your own Foley catheter minus the balloon removal or-

00:19:25.700 Yeah.

00:19:26.020 Yeah.

00:19:26.380 You're still alive, but all of a sudden that dream-

00:19:30.780 But not happy.

00:19:31.940 Yeah. It is amazing that you're right, that you must have done this all very quickly

00:19:36.720 to make it happen. So now you're sort of having that moment of maybe that wasn't a dream.

00:19:43.440 Mm-hmm. I will never forget this. It was the clarity, that world, all the haze cleared up

00:19:49.980 instantly when I felt that Foley dislodge from the bladder. But incidentally, it didn't come all

00:19:53.760 the way out. So it's somewhere halfway-

00:19:55.800 Which is even worse.

00:19:57.040 Yeah. It was just terrifying. So I immediately fall to the floor and I'm screaming and now a

00:20:02.300 nurse comes in. I don't know what the delay was. Incidentally, that poor nurse, we never saw her 0.99

00:20:08.060 again. She was never signed in my room again. Poor thing. Part of her explanation, she was avoiding 1.00

00:20:12.620 my room. She admitted in some ways because she had a son my age who looked just like me and it was

00:20:18.500 really hard for her. Anyway, so eventually, so I'm on the floor now screaming, trying to break the

00:20:23.740 catheter line, which is impossible. But it's the only way I could, I thought I could break the

00:20:27.400 tension. But anyways, they came in, got me back in bed and all that stuff. And away it went. But

00:20:34.300 to your question, Peter, it was instantaneous that I realized this wasn't a dream. And all the relief

00:20:40.600 that I had experienced moments ago in the other direction just immediately went away. And I was very,

00:20:45.480 very clear on where I was and what was happening to me. Instantaneously. It was a wild,

00:20:51.620 wild, wild moment. I won't soon forget.

00:20:54.980 So what kind of a mourning process did you go through postoperatively when you come out with

00:21:01.720 both of your legs amputated and your left arm?

00:21:06.140 Short answer is my mourning process took me a while. And my conscious mourning process was delayed because

00:21:12.260 I, at that time, embodied the sort of absorb the American notion that no, what you do is you pick

00:21:20.540 yourself up, you get back on the horse immediately. The less you acknowledge what's gone on, the

00:21:27.040 better. The tougher you are, the faster you'll be functional again, et cetera. So early on, I didn't

00:21:32.320 do any mourning, not consciously. I was kind of going the other direction, joking around, making light of

00:21:37.680 it. And both a moment of somewhat of denial and also probably something pretty poignant too. I remember

00:21:44.240 when I came out of that first surgery. So I didn't know that there were people, I knew my parents

00:21:49.380 were there. And oddly, Peter, I don't know how this was possible. My parents moved into the hospital.

00:21:54.240 Somehow they got a room in the hospital from Chicago. They lived there. All the time I was

00:21:59.100 there. I don't know how the hell that, never heard of that, but they did. Maybe they had huge wings of 0.70

00:22:03.940 St. Barnum's that weren't being used. I'm not sure. But I knew my parents were there. So I come out of

00:22:09.160 the OR, come out and I'm heading, they're wheeling me back. The leg amputations were what they did

00:22:14.800 first. And I knew whatever the case is, I had absorbed what Dr. Mansour told me the night before

00:22:20.040 eventually. I woke up from that surgery with no surprises, but I'm wheeling back to my room.

00:22:27.140 And as a brief moment where you're going from the OR suites back into the burn units, and you go to

00:22:32.480 this little hallway and I come out, it was packed with people. My friends and some friends had flown

00:22:38.760 in from Chicago. I was so moved. I had no idea that they were there. And it was just a brief

00:22:44.440 second. There was no time to talk, but there was just a lot of love. I just remember their facial

00:22:49.180 expressions. I was very, very moved. And then I went back into the room and I remember my mom came

00:22:54.180 in and we were sitting and she was crying. And my mom had polio. She'd been disabled my whole life,

00:23:01.340 most of her life. And I just remember, this is going to sound, I don't know, it was part denial

00:23:07.420 driving it. But I just remember my thought when my mom came in was, my response to her was,

00:23:13.300 oh, mom, well, now we have so much more in common. Now we're both disabled, almost like a cheeriness.

00:23:18.920 I love my mom very much. We're very close. And I honestly felt like I was joining this ranks of

00:23:24.940 folks that I always knew existed and felt very much a kinship with the disabled community by virtue of

00:23:30.360 being close with my mother. My first response was weird kind of immediate acceptance, but I had to go

00:23:37.240 back and it wasn't a thorough acceptance. It was where I wanted to be, but it wasn't really where

00:23:42.960 I was. But anyway, that was my first statement. It took really weeks. It took actually my nurse

00:23:49.680 kind of trying to work on their member time, maybe a week or two later where one of the nurses with 0.86

00:23:55.260 whom I was very, very close, Joy Varkata poem. And Joy came in one day and she was just really

00:24:03.360 moody with me. She was just like throwing, she was just strangely moody. And I was just sort of

00:24:09.140 joking around. And anyway, she's like throwing bedpans around it. I was like, Joy, what the

00:24:14.280 heck? What is, what's wrong? What are, are you okay? And she's just basically lit in me. She's like, 0.71

00:24:19.180 I am just sick and tired of you not taking this seriously. You're just joking around. You haven't

00:24:24.140 even cried. This is a big, big deal. You're not being real. And she just led into me. She led into

00:24:31.160 me until I finally cried. It was the first time I'd cried. I was weeks in. It was the most magical

00:24:37.660 thing, Peter. I will never forget that one either. In part because it was like a dam had broke and so

00:24:44.060 much came pouring out and it felt so good. It felt like such a relief. I hadn't realized,

00:24:49.700 I hadn't consciously fought back tears or tried to be tough. I just thought that's what I was

00:24:54.000 supposed to be doing. And I was on otherwise on autopilot too. But what was also weird about those

00:24:59.640 tears was for the moments the tears were falling, I had really no physical pain. I've never looked

00:25:06.260 into this, but I wonder what the connection is between the act of crying, not just feeling sad,

00:25:10.940 but actually crying and anesthesia. It was a fascinating moment, but it really moved me and

00:25:17.420 it began my relationship with, began letting in that this was a bigger deal than I had managed to

00:25:23.320 let it be. I offer that to say the mourning, the grieving was very gradual. Took me a while to wake

00:25:29.860 up to my own feelings about it all. That took months and years, really. Do you think that that was

00:25:35.400 mostly a sadness and a loss that came through expectation of these are things I wanted to do

00:25:44.380 that I will no longer do and I am sad as a result of that? Or do you think it was tears from a

00:25:51.440 different sadness, a sadness that's more born of anger? Like how could this have happened? It's such

00:25:56.720 a random event. I've done far stupider things in my life. Like why was I wearing that watch? You can sort 0.98

00:26:03.260 of go through all those things. Like, do you have a sense of where you were in terms of that dam,

00:26:08.980 the floodgates opening? Yeah. Yeah. My sense is, Peter, it's a sense driven by most of how grief

00:26:15.840 materialized for me over the months and years. But my sense is for a number of reasons. I did not have

00:26:23.380 a lot of why me moments. And there's a lot to say about that. But to answer your question,

00:26:29.860 no, I think it was more like, first of all, the physical pain. I hadn't really let myself,

00:26:37.900 I had just been literally gritting my teeth. And for as vulnerable as I felt, as so exposed as I felt,

00:26:45.920 I was looking for anywhere where I could look or feel or act or present as strong. And that's the

00:26:52.200 only way I could think of, I think, was to kind of keep this stuff in. And so I think part of it was

00:26:57.260 a release around just the physical pain. And I think the rest of it, it didn't have a lot of

00:27:02.960 clarity around the object of my sorrow. But the sorrow, I really think, had to do with

00:27:09.140 embarrassment for doing this, for ending up here, putting my parents through so much pain. I could

00:27:16.240 see it in their faces. I slowly began to see what it did to friends, too, and others around me.

00:27:21.880 And it's the feeling, I think a lot of the pain, or a lot of the tears had to do with,

00:27:26.240 here I was taking so much from so many people. I was embarrassed about that and ashamed about that.

00:27:33.200 I think that was a big part of it. And I think there was also an image, I had just kind of come

00:27:39.040 into my body as a 19-year-old. And I think there was a sadness. I didn't know if I would ever have

00:27:45.600 sex again, what women were going to think of me, what my friends would think of me. I'd been around

00:27:50.300 disability my whole life, and I'd watched how cruel people could be, and the projections they

00:27:55.440 make. And I think part of it was the more tears that I knew what I was going to be walking into

00:28:00.580 with that. I think, yeah, all of those things. But low, low, low on the list, Peter, were the

00:28:06.440 why me questions. I owe a lot of that to the prep work that my mother, my family wife had set in.

00:28:12.700 It was always much more the question of why not me? If anything, I felt guilty for having

00:28:16.680 too perfect a life before that. Separate from all of this, BJ, there's another

00:28:21.680 kind of really transformative event in your life that has to do with your sister.

00:28:26.220 When did that take place? So that was 10 years later. So that was...

00:28:31.740 So you're in medical school. Yeah, exactly.

00:28:34.680 And I want to come back to how you got to medical school. But can you tell me a little bit about

00:28:39.520 your sister and the relationship you had with her in the 10 years that followed this,

00:28:43.880 and then ultimately her demise? It's a good segue. It's a link of... The way I grew up was

00:28:49.360 I was no stranger to pain. I was around it. And there are all sorts of reasons to feel like

00:28:56.440 that life was inherently hard. And that was something about... I felt almost a perversion

00:29:01.640 that I could feel happy ever. That almost felt wrong. I don't know how to explain it. But

00:29:07.540 part of my growing up was growing up with a sister. I have one sibling, Lisa. Lisa was four

00:29:13.660 years older than I am. Wild, brilliant, fascinating, just intense person. And our whole family life

00:29:23.160 so much centered around her and her moods and her thoughts. So I was enamored with Lisa. She was

00:29:30.780 my older sister. She seemed so smart to me. She had emotions around things that I hadn't even thought

00:29:36.980 of. And she had these developed psychological, emotional responses. I just felt like she must have

00:29:42.220 insights in the world that I just couldn't see. And she had such conviction. And she was harsh,

00:29:48.340 harsh, harsh, harsh. That conviction, older sister I wanted, I aspired to her. So I chased her moods

00:29:54.700 around. Anything she told me, I took at face value. I mean, she owned me in so many ways as her younger

00:30:00.340 brother. And she was very troubled. And part of my adulthood was coming in to realize that Lisa

00:30:07.280 wasn't just full of conviction. Lisa was also full of some other things. And so in my 20s,

00:30:13.500 here I am going to med school, I'm finally learning to have some separation from chasing my sister's

00:30:19.680 moods around. And then in December, December 1st of 2000, roughly almost exactly 10 years after my

00:30:28.500 injuries, Lisa decided to kill herself. Lisa decided to leave the planet. So yes, that was another,

00:30:36.760 one of the major, major life events for me. And that was deep into medical school. And one of the

00:30:42.580 things that precipitated my deciding to leave medicine, I was going to get out of medicine at

00:30:47.660 that point. No, I didn't know that actually. Yeah. I want to come back to this. Can we talk for a

00:30:54.580 moment though, just to make the connection of how you ended up deciding to go into medicine? Because

00:31:01.140 when you were in your freshman year at Princeton, I get the impression that medicine wasn't even on your

00:31:06.640 radar, correct? Yeah, that's right. You got it. Yep. No interest. I hadn't even crossed my mind.

00:31:12.680 Yeah. So after returning to Chicago, going through a very lengthy process of rehabilitation,

00:31:20.980 you re-enrolled at Princeton a full year later, correct?

00:31:26.380 Almost. Yeah. The following fall. So I went back in September of 1991.

00:31:30.940 1991. And you changed your major to art history. Is that also correct?

00:31:35.460 You got it. Yep.

00:31:37.480 Why did you do that?

00:31:39.100 I had been there too far. That's a word. I had been studying Chinese language and was

00:31:44.980 heading for a major in East Asian studies. But when I was away, when I was in that,

00:31:50.760 you know, the burning, it's such a, it's like a torture chamber interspersed with like incredible

00:31:55.540 boredom. Like you're just so, you're so, and this is so wild. When I look back on these, I'm sorry.

00:32:02.440 I'm just a quick digression. So this was the first Gulf war was happening. It was so strange. I was

00:32:08.460 watching a war. Remember it was like a televised war. Such a wild thing. Bored stiff in horrible pain

00:32:15.600 to and from that tank room for daily debridement. So horrible pain interspersed with slight relief

00:32:22.080 and boredom. No touch with it. There's not even a window. It's such a weird thing. And I would

00:32:27.000 toggle between on the television, between watching the war and some cooking show. It was just the

00:32:33.540 strangest. I don't know why I bring that up. It was just how I spent my days. But now I forgot your

00:32:39.420 question, brother. What were you asking me about?

00:32:41.980 The decision to change to art history.

00:32:44.140 Oh, golly. How did I get to that? But anyway, well, I know because I'm sitting in this bed,

00:32:50.980 bored stiff. And of course, even with my little structures that were still in place that kept me

00:32:56.940 from crying or acknowledging a lot of things, of course, there was no getting around some stuff.

00:33:02.140 And I was beginning to let into my consciousness and my daily thinking, like, you know, sort of

00:33:06.760 preparing, imagining my life down the road. When am I going back to school? Will anyone want to be

00:33:12.140 friends with me? But I'm basically bottom line is I'm sitting there very much pondering the value of

00:33:19.100 my life. What am I now? Am I less of a person? Do I have less to offer the world? What will people

00:33:26.640 see in me, want in me? So basically questions of meaning and questions of identity. Who am I?

00:33:34.100 What do I do with myself now? What can I do? I found myself in that mix, just sitting there

00:33:39.860 pondering questions like the meaning of life. Not in a recreational or intellectually kind of Ivy

00:33:46.100 leaguey, write a term paper way, but in a way that was very obviously relevant and therapeutic and

00:33:52.120 practical. These existential issues became very practical. And that's where they belong,

00:33:58.280 by the way, I think. So sitting there, one of my friends and closest friend, Justin, would come

00:34:03.900 visit me at the Bernier eventually. And we found ourselves talking about art. It's this thing that

00:34:08.820 humans do. So I was looking for meaning making, what humans, how humans work with pain, how do humans

00:34:14.720 work with things they can't control? And that led me to thinking about art. Why do human beings make

00:34:20.280 art? Why do we take the material of our life and create with it and fashion something from it that

00:34:26.400 wasn't there before, but now exists thanks to us? It's kind of a stunning impulse that human beings

00:34:33.000 have. Whether you're making art that's going to hang in a museum or you're just futzing around your

00:34:36.880 house, we are a very creative species. That was lighting up for me as a very important and telling,

00:34:43.220 and that maybe, maybe the art world had something to teach me. So when I went back to college that fall,

00:34:51.000 I rejoined my class. I just had to finish the exam somewhere in the summer. And I had a free

00:34:55.480 semester. I was supposed to be in China the second semester of sophomore year anyway. I didn't have to do

00:35:00.320 much to jump back in with my class. And that was very important to me. I wanted to be back with my

00:35:05.580 buddies. That was a real driver. So anyway, I head back to Princeton, joined my class and changed my

00:35:11.820 major to art history, to studying art. And that was a really consequential decision, one I'm actually

00:35:18.100 very proud of. I've talked about it before on this show. I think it's even come up during a discussion

00:35:24.820 where someone asked, what's the best major that I would recommend for someone who wants to go into

00:35:30.400 medicine? And I don't have great insight on this, but the one thing I generally suggest is anything

00:35:35.020 other than pre-med. Because I think whether you study art history or engineering or a foreign

00:35:41.400 language and a foreign culture, you're probably going to get something out of it that you would

00:35:46.160 never get if you studied pre-med. Yet most of everything you study in pre-med, you're going to

00:35:51.260 pick up in medical school. Which is not to say that studying pre-med is not a good idea, but that's my

00:35:56.460 two cents is that the people who came in with totally different backgrounds often were people who

00:36:03.140 didn't actually plan on going into medicine, as is the case in yours. The stories are usually pretty

00:36:09.280 interesting. So when in the journey of art history, do you then realize you want to make what I think

00:36:17.560 is even probably a greater stretch or leap, which is to actually go to medicine?

00:36:23.020 Yeah. So let me first see your two cents and raise a mind. Unless we want medicine to simply be

00:36:31.600 the stuff of technicians, a technical pursuit, which of course it is in many, many ways.

00:36:37.600 I teach in med school. I haven't as much lately, but I've spent a lot of time teaching in schools

00:36:42.140 of medicine and nursing and love it, love it, love it, love it. And if we view medicine as a technical

00:36:49.100 pursuit simply, then okay, pre-med, focus, great. But the trick is of course in medicine is our job

00:36:55.960 is not just to, it's one thing to know details about molecules, how they work, but it's a very

00:37:03.500 different thing to know why it's amazing to have molecules in the first place. And if you have not

00:37:08.440 thought one way or another, it doesn't have to be art, it doesn't even have to be through school per

00:37:12.400 se, but you better find a way to, if you're going to go into the healing professions and clinical

00:37:16.500 professions, you better find a way to delve into why life is amazing and horrifying. Why is it so

00:37:27.220 hard to let go of? Why is it so hard to love life when you know it's going away? What is this all

00:37:33.560 about? In other words, questions around meaning and identity. One way or another weak physicians,

00:37:39.700 and you can see what happens in a healthcare system that is somehow has crowded those thoughts out as

00:37:45.620 somehow being irrelevant. You're left with a lot of zombies. You're left with a lot of people with

00:37:50.140 pulses, but have no idea why it's amazing to have a pulse in the first place. So anyway, I could go on

00:37:56.280 and on and on, but boy, I really, really, really love the notion of people who study humanities then

00:38:02.960 going into the healing professions. I think it's, some people see that as like a left turn, like, oh,

00:38:09.140 but I couldn't make a bigger case for art history was some of the best preparation for medical

00:38:14.600 school I could imagine. I think you're bringing up really great points, BJ. And I think medicine

00:38:19.220 needs all of the above. You need people who have probably gone incredibly deep on a very narrow

00:38:26.400 subset of science. You need people who come in with engineering backgrounds. You need people who come in

00:38:30.900 with humanities backgrounds. And I haven't, to be honest with you, paid much attention to how medical

00:38:36.380 schools are doing these days in terms of recruiting talent, what the war for talent looks like

00:38:41.960 in medical school versus business school versus law school versus other graduate schools. But I would

00:38:47.640 hope that they've figured out what you're saying and they're making adjustments in that direction.

00:38:52.940 I think they are. I know UCSF, my alma mater, has. They've really invited folks like myself. I didn't

00:38:59.500 tell any of the pre-meds at Princeton. I did all the pre-med work after college. And UCSF has purposely

00:39:05.400 attracted a lot of folks who are starting med school a little later in life, have some other life

00:39:09.440 experience, et cetera. Something of a trend there. I'm with you, right? It takes all of the above.

00:39:14.980 Medicine is also a technical pursuit. I guess even if someone wants to be a pre-med major,

00:39:19.960 take that more conventional route, my advice to them was just make sure you actually love it. Just

00:39:24.380 make sure you love the nuts and bolts so you're not just doing chemistry just as a means to the end

00:39:29.080 of medical school. You find something to study that actually cultivates you loving something.

00:39:35.380 I think that's a major, major distinction. That could be engineering. That could be art. That

00:39:40.200 could be chemistry.

00:39:41.600 Yeah. I've always felt that the history of science is also equally beautiful. And so when you're

00:39:45.840 studying physics and you're studying chemistry, to be able to study it through the lens of how

00:39:51.440 the people who discovered it went along their journey probably creates or at least fosters some

00:39:58.160 of that intellectual curiosity and passion that I think can be found across multiple disciplines.

00:40:02.840 But still, I want to get a better sense of what made you decide to take a very bold step,

00:40:08.980 which is, I think, to leave a comfort zone of you've now spent four years doing very well.

00:40:15.780 And you've got this degree in art history from one of the best schools in the country.

00:40:20.140 And you now decide to presumably go back and do a post-bac year to do a bunch of pre-med courses to

00:40:25.880 go and do something that seems about as orthogonal from that as anything. I'm sure it had a lot to do with

00:40:32.480 your experience, but can you speak specifically to what it was and how it, for the lack of a better

00:40:40.040 word, marinated over the previous four or five years?

00:40:43.700 Yeah, no, absolutely. I can track this out. So one of the things the injuries did for me,

00:40:50.360 cut to a spoiler, one of the therapeutic endeavors here, one of the ways to get through something is

00:40:54.720 in some real ways to let yourself be changed by it. I knew enough that thanks to my mother and the

00:41:01.320 disability rights movement, that the goal for me was to not get back to where I was before the

00:41:07.600 injuries. First of all, practically speaking, it wasn't possible. I wasn't going to get my old body

00:41:12.620 back. Also, why cut myself off from all those lessons and all the experiences that happened during

00:41:19.000 that period? It's not something I could forget, but nor is it something I would want to forget. It's

00:41:24.040 too dang rich. So the idea was really always, I knew versus a certain normal language and thoughts

00:41:32.480 around disability. And it's like, it's something you would want to overcome, put behind you. And I

00:41:38.220 think a lot of lay people or able-bodied people think the highest compliment that can offer a disabled

00:41:43.500 person is, oh, I look at you and I don't see disability at all. I know what they're trying to 0.83

00:41:48.820 say, and we can talk, we can open that up too, if you want to go down the road here, but trying to

00:41:54.120 say, but in a way, it's not really a compliment. I don't want people to ignore major parts of me

00:42:00.560 just to look at me. I'm not getting over these injuries every day. I'm reminded this is not

00:42:05.100 something of the past, something I live every day. So when I hear comments like that, and you just feel

00:42:09.520 like you're still aware that you're not, someone isn't really seeing all of you. That's problematic in a

00:42:13.900 number of ways. So I knew, I knew that I wanted to work with these experiences. So that was a major,

00:42:20.100 major theme. And medicine lit up as just theoretically as a way to put these experiences

00:42:26.380 to use. And the linkage between studying art and studying human endeavor and the study of medicine

00:42:32.580 was not such a big leap. The interest, the through line, the baso continuo for me was

00:42:38.700 just being very interested in human beings, human pursuits, human endeavors, and human creativity.

00:42:47.380 Art was one application of those interests and medical science was another. As I pondered what

00:42:52.760 I wanted to do, I thought, well, gosh, medicine would be interesting. If a doctor walked in to see

00:42:58.240 me in the shoes that I'm wearing now, that would affect me in a positive. This was some way I was

00:43:04.400 actively looking for an outlet where my injuries weren't something that someone would look past or

00:43:10.040 forgive, but were actually in some way, something of an advantage. And in this way, for me in medicine,

00:43:16.960 I can tell you that having this silhouette, having this body has really been an advantage in a lot of

00:43:21.900 ways. If the goal is empathizing with your patients and their families, if your goal is seeing yourself

00:43:27.680 as a fellow human being next to them, if you know or believe that's where healing happens,

00:43:32.120 then this kind of stuff, it's the best prop I've got going. I really feel for my able-bodied

00:43:38.260 clinicians who don't have some obvious source of pain and suffering that imparts to your onlookers,

00:43:44.680 to parts to your patients, that you've been through some stuff, you've scraped a barrel.

00:43:49.320 So anyway, I'm going on and on about that. But to get back to your question, that through line,

00:43:54.200 I knew I had a hunch that that would serve me in medicine just as it did in art, and that I could

00:43:58.360 apply these lessons into sort of a therapeutic application of studying perspective and meaning

00:44:05.700 making. So medicine lit up as a potential thing that I could do that would be fascinating. I could

00:44:11.120 make a living and I could exercise these lessons in a novel way. So it makes unbelievable sense,

00:44:17.460 actually. And I suspect it changed many things for you. I mean, look, if you just described yourself as

00:44:25.040 a six foot four handsome guy who goes to Princeton, you probably are a pretty ambitious guy. You're

00:44:33.620 going to go off and study foreign relations and do all sorts of cool things. And then everything kind

00:44:40.860 of gets taken away in an instant. How does that change your relationship with your own ambition or

00:44:47.960 what it means to try and fail? Had you ever failed at anything, by the way,

00:44:52.160 athletically and sort of academically? Even in the 90s, I imagine getting into Princeton was

00:44:57.260 almost impossible. Yeah, I exceeded in ways, but also so true. And I just had some green lights right

00:45:04.280 in front of me. I had this amazing education. I had some basic abilities. I could make a case for us

00:45:10.060 that I had suffered and struggled in various ways up until that point. And some things hadn't always

00:45:15.380 gone right for me. But there are such a different scale. There's such a different scale. But even as

00:45:21.620 a kid, so in some ways, no, I really hadn't experienced loss in some big way. But what I

00:45:26.600 had experienced was loss through people and others that I cared about watching post-polio syndrome take

00:45:31.900 my mother's physical function down, watching my sister struggle. So in some ways, part of my charge

00:45:38.720 as a young person was, I hated that I didn't have more wrong with me. I felt there was a mismatch.

00:45:43.620 I felt at odds with the world. I felt this pain around me, but I didn't really feel like I had my

00:45:50.040 own access to it. My problem was I didn't really have anything to complain about. I knew that life

00:45:55.520 was really, really hard for many, many people. And internally, my life was hard just imagining that.

00:46:01.560 And in some ways, getting this new body. And in some ways, I have to say, I made it such,

00:46:06.880 I cultivated this idea. But in a way, I got the body that much more mirrored how I felt inside.

00:46:14.240 Fragmented, broken, confused, unintegrated, different. In some weird ways, this body really,

00:46:21.500 the physiognomy of my body actually suited me in some real ways. I chose that. I ran with that.

00:46:28.720 It was true. But it also is a way for me to get into this body eventually and quit wishing it were

00:46:33.320 something else. By building on what this body was showing me, I knew the clever thing was I knew

00:46:40.440 what I was doing was building a case that this was the right body, that this was a good body. This is

00:46:46.420 the one for me. And then you can imagine that really cuts down on the regret and the second

00:46:53.160 guessing. And if only I had four limbs, then blah, blah, blah, blah. That's the kind of mindset I was

00:46:59.800 heading for and trying to cultivate. Now here again, brother, what did you ask me that I went

00:47:04.660 down on that tangent? No, actually, I was talking about this idea of this could have actually liberated

00:47:11.680 you a little bit. Yes. Yes.

00:47:14.880 And I think you've articulated that very neatly. I want to come back to your sister. We all do this

00:47:21.240 when we get to medical school is we start to learn things that explain things we've seen in our past.

00:47:29.140 For example, it's the first time you would have learned, I suspect on some detail, what the polio

00:47:34.680 virus looks like and what a virus does, how it is that your mom actually came to contract this virus

00:47:41.400 and how a vaccine ultimately would go on to make sure people wouldn't get that virus. And I would

00:47:47.520 learn about the cardiovascular disease that ran so deeply in my family and really understand the

00:47:52.240 pathology of this. At some point, did you start to suspect that your sister had whatever you want

00:47:58.920 to call it, formal mental illness, or did you not think that that was the case at all? Or how did you

00:48:04.440 think about your sister once you were in medical school and you began to learn about mental health in

00:48:10.180 a somewhat formal way? Quick answer here is no, I didn't. The only time I actually let myself

00:48:16.760 do that sort of the pathological overlay was after the fact after she had died. Leading up,

00:48:23.740 it's telling. I mean, leading up to that, even through medical school, studying manic depression,

00:48:29.860 something that she was posthumously diagnosed with. Oddly, it never registered as me reading about

00:48:35.880 someone like my sister. Somehow, and I referenced this a little bit earlier, was somehow the way she was

00:48:42.780 or the hour dynamic. And it wasn't just me, it was my parents too, and her psychiatrist too. She was

00:48:49.160 a master manipulator. She could have anyone thinking exactly what she wanted them to think.

00:48:55.980 And particularly me as her little doting brother who just looked up to her.

00:49:00.600 If I absorbed anything from Lisa, it was that Lisa was right. Lisa had it right, including her angst and

00:49:07.040 her pain, that the world is a painful place. And Lisa was reflecting that. If anything, I saw Lisa was

00:49:12.660 the standard. She was right. Everyone else was wrong. But she kind of rolled with what she was

00:49:18.440 selling. I did roll with what she was selling and deeply to the point where any idea of pathologizing

00:49:24.180 her just completely bounced off my head. It didn't register as relevant to her. She was the right one

00:49:30.020 until she ended her life. And then that prompted all sorts of revisiting that thinking. Also then

00:49:38.540 eventually, you know, my parents, what they did to try to make sense of all this, they went through

00:49:42.660 her diaries with the psychiatrist. And it was in that act, I didn't join them in that, but I received

00:49:49.260 the news, and I believe it, which is she was just textbook bipolar. I mean, just outrageously textbook. 1.00

00:49:56.800 And sometimes I'd get my quitting, wanting to quit medicine did have some, this was right after Lisa

00:50:01.920 died on the list of why I want to get out of medicine. It was like, Jesus, I can't, I didn't

00:50:06.020 even see right under my nose. I'm trying to become like a healer person. I can't even acknowledge that

00:50:11.020 my sister's sick. This was demoralizing on some level, but, but I also comforted myself. She had a

00:50:16.840 shrink for better than a dozen years who didn't notice this, who didn't was, who was somehow shocked

00:50:23.220 that Lisa killed herself. Weirdly, I, I remember on the one hand here, I didn't see any of these

00:50:30.640 signals coming. And at the same time, I remember where I was when I got the news of her death. I

00:50:35.700 was with my dad in a car and my buddy, Justin, my mom called and my dad picked up in his kind of

00:50:41.840 usual sing songy way. And there was a pause. And then he immediately starts bawling.

00:50:48.820 I knew instantaneously that Lisa was gone. And when I heard it was suicide, there was not a single

00:50:55.920 cell of surprise in my body. That's just an observation. So I'm telling you two things.

00:51:01.380 On the one hand, I didn't see it coming. On the other hand, I completely saw it coming. I don't know

00:51:05.360 how to reconcile those two, but that's just the case. So you're in your last year of medical school

00:51:12.500 when this happens, you've now alluded to this twice. Were you not planning to do a residency at

00:51:17.900 this point? Or was this the event that sort of tipped you to not pursue your residency that

00:51:23.500 following summer? Well, all through med school, I just assumed, because I wasn't so enamored with

00:51:29.360 medical science per se. That was just a bag of tricks. I was interested in gaining a career

00:51:34.740 work that allowed me to continue to thinking about these things and work with others and serve

00:51:40.620 others around these ideas of identity of loss and trauma. And I just figured the best place for me

00:51:47.940 to exercise that would be in the rehab setting. So I was sort of beelining for physical medicine and

00:51:52.640 rehabilitation. So deep into medical school, UCSF didn't have a program. So I went and did an externship

00:51:58.900 somewhere, rotation elsewhere, at least. And during that, I'd already begun to apply for

00:52:04.820 residencies in rehab medicine at that point. And so then I hear the rotation, having already committed

00:52:09.920 to this field, and I hated it. The rotation was, I just really did not enjoy it for all sorts of

00:52:16.200 reasons. One, it was all mechanical, this idea of like, rehabilitation. First of all, the phrase is

00:52:21.820 problematic. Rehab, like the goal would be to get back to where you were before the injury,

00:52:26.140 which I've been saying, I just don't believe is true. It's importantly untrue. And this idea that

00:52:31.360 it was so mechanical had nothing to do with the personal transformations that happened.

00:52:35.660 And that's where I realized I was so interested. And that plus I realized as I was walking out of

00:52:40.480 patient's room, I kept hearing nurses say, look, Timmy, you can be just like BJ. He's a doctor now.

00:52:47.060 I could hear myself being served up as a poster child. And I didn't like the mechanics of the job.

00:52:53.980 I didn't want to be a poster child. Ipso facto. I was like, I got to get out of this.

00:52:59.200 And one of my promises to myself going into medical school, having learned what I had learned was,

00:53:04.900 hey, life's short, life's important, life's hard, life's beautiful. I'm not going to just

00:53:10.200 get stuck somewhere and have a sacrificial life. I know a lot of our colleagues in medicine who went

00:53:16.100 into it because their parents were doctors, and they hated it. But what else am I going to do now?

00:53:20.720 I've gone this far. Or one way or another, they just sign up, willfully sign up for a life of

00:53:26.100 misery. I knew I wasn't going to do that. So I promised myself. And at this point, another thing

00:53:31.020 I learned from the injuries, which was so critical, was the ability to, I was much less afraid now. I

00:53:35.960 was much less afraid of failure. I was much less afraid of falling. So you asked me earlier if I had

00:53:40.980 anything really go wrong before in my life. In some ways, the answer is no. I was a very frightful,

00:53:46.260 melancholy child. Sensitive, but to end up manifesting as fearful at times. Now I was

00:53:52.160 going the other direction, man. Fear, I had a totally different relationship with fear.

00:53:56.120 I saw falling as a skill. So anyway, the bottom line there was I was willing to try medicine and

00:54:02.820 willing to dump it. And in fact, it felt empowering to do so. It was a reminder that my life was bigger

00:54:08.520 than just a job choice. Anyone's life is. So there I am, deep in med school, already applying for

00:54:14.480 residency. I said, screw this. And so as I promised myself, so I called, dropped out of the match,

00:54:19.780 talked to my dean, said, hey, I'm finished. I'll graduate. But you know, I'm going to do other

00:54:25.240 things. She talked me into, she said, okay, okay, right. I had begun to be disillusioned with medicine

00:54:33.100 before my sister's death. But that was sort of the straw that brought the camel's back. As you've

00:54:38.380 referenced, I think we bring in idealism one way or another into the healing professions.

00:54:44.220 And then you have to go through this process of disillusionment where the practice of medicine

00:54:49.640 isn't necessarily jiving with the ideals that you bring into it. And that can be very stressful.

00:54:54.980 But I do think it's important for any trainee at one point or another to go through some

00:54:59.280 disillusionment. My response to that disillusionment was to get the hell out of it,

00:55:04.720 especially as I realized I didn't like rehab medicine. And again, Lisa's death was just like

00:55:10.180 proof that I'm just not, I don't want to do this and I'm not cut out for it.

00:55:13.640 But then I got talked into doing my internship that first postdoc year. And my family was in

00:55:19.800 Milwaukee at the time. I had gone away. I had left home when I was 15. And given Lisa had just died,

00:55:26.660 given I didn't know what I was doing in some ways, I said, okay, well, I'll move in with mom and dad.

00:55:32.640 We'll recongeal as a family, spend that year together. And I'll bang out my internship and

00:55:38.320 just get that done and be done and move on. But it was during that internship that I stumbled into

00:55:42.960 palliative care. And that's where everything changed again.

00:55:47.220 So PJ, what is it that you saw during your internship that both made you change your

00:55:54.880 decision leaving medicine and also concentrated or focused you on an area of medicine called

00:56:00.920 palliative care?

00:56:02.380 So a couple of things happened. One of the things I just sort of stumbled into this elective during my

00:56:08.840 internship, we had basically one month of an elective time, if I remember correctly,

00:56:13.960 maybe more, but I'd spent a little time with a hospice doc at one point. Actually, my best friend's

00:56:20.080 mother was involved with the hospice and she turned me on to the idea. But again, I was so hell bent on

00:56:25.300 rehab medicine, figuring that was the place for me and wasn't sure that I had anything special to

00:56:30.700 offer beyond that sort of rehab setting. But I had absorbed that hospice was simply just where people

00:56:36.500 go for the final days of life. I thought I understood what that meant. But anyway, I stumbled

00:56:42.820 into this palliative care elective at the Medical College of Wisconsin, which just happens to have

00:56:47.220 been one of the early adopters of palliative care. David Weissman, an oncologist there, had built one of

00:56:52.840 the early great palliative care programs, which just happened to be there. And on that first day,

00:56:58.820 we went and saw a patient. I watched David talk to her about code status. This was in the hospital.

00:57:06.260 This woman with heart disease, advanced heart disease. And David was trying to talk to her about

00:57:10.960 her wishes, what kind of care she wanted for and trying to impart how serious her heart condition

00:57:16.680 had become. Tricky conversations, very emotionally, psychologically loaded content,

00:57:22.840 really tricky. The zone that medicine traditionally does not handle very well.

00:57:28.020 And so I'd seen all these counterpoints. But here I'm watching this guy sit with this woman,

00:57:31.920 sits on the edge of her bed with her, just immediately this very different rapport.

00:57:36.600 He's talking to her like a human being, not hovering over her like a superior, someone who's

00:57:42.880 there to fix her. He was there as a fellow human being. And he just showed it in his body language,

00:57:49.100 and his tone, and his word choice. It was beautiful. And he said to her, and I just watched

00:57:54.360 how she responded to him. And it was remarkable. And he said something to her, he tried to get to

00:57:59.800 the code status question, said something essentially like, when you die, do you want us to help that

00:58:05.300 process along and make sure you're comfortable through that process? Or do you want us to really

00:58:10.400 fight that? You want us to go to war with that notion and do our best to pull you back?

00:58:14.880 Something along those lines. But the magic moment was him looking her in the eye and saying,

00:58:21.000 when you die, of course, as human beings, it's a very reasonable thing to say, because we all die.

00:58:27.620 It's not if, it's when. In the medical setting, that is not the way these conversations generally

00:58:33.480 work. I was so moved by watching this. And he dared to acknowledge this woman's death. And what I saw

00:58:40.120 on her face was not shock or anger, but relief that this man was talking to her plainly about

00:58:48.920 her life. And it was so gorgeous, so poignant. That moment really, really stuck with me.

00:58:55.880 And as I went home that night, I remember thinking about it. It's like, well, this is what I've been

00:59:00.160 looking for. This is, in this world, we take, in palliative care world, illness, disability, death

00:59:08.080 are normal. They're not anomalous. This field treats these life events as normal life events,

00:59:15.120 which of course they are. The starting point for palliative care is something's happening that you

00:59:20.800 can't fix, that you can't change. And that was, for me, all along, in rehab, you could see would be

00:59:28.420 similar. Like rehab, the events already happened. Something's gone wrong. Now what you do? I knew I

00:59:33.200 was interested in the now what? But here, this field was digging into all the, it's not just the

00:59:38.740 angle of the joint it was concerned with, but the angle of the thoughts and the way that we see

00:59:44.700 ourselves and the words we choose to describe our place in the world and how we either suffer for those

00:59:49.560 words or how we really confine ourselves to something more therapeutic. And it was such a craft.

00:59:56.520 It was such a stuff of words, not of a instrument. So anyway, I really was really, really moved. But

01:00:03.660 the first access that opened up was, I'm not here to fix people. I'm here to be with people as they

01:00:10.340 find their way, as they deal with things that they can't control. And that was the hope for me in so many

01:00:16.080 ways. How would you explain to someone the difference between palliative care and hospice,

01:00:20.540 which I think many people use interchangeably, but I don't think they really are interchangeable,

01:00:25.680 are they? They are not. Thank you. Thank you. Thank you. Quick public service announcement,

01:00:31.280 because it's a really big problem for a number of reasons. But palliative care is simply the

01:00:36.940 interdisciplinary pursuit of the quality of life. Within the context of serious illness,

01:00:41.940 palliative care is that mode of care, which helps you feel as well as possible,

01:00:46.820 emotionally, physically, spiritually, you name it. My job is to help you deal with the facts of your

01:00:52.920 life and to feel as well as you can. There is nothing in the definition of palliative care that

01:00:58.040 makes it that you need to be dying anytime soon. Time is not mentioned. There is death is included

01:01:03.540 in this, but it's not the focus. It's simply the pursuit of quality of life. And if you need to pose

01:01:09.400 it, like we do in medicine, if you need to have objects of your efforts, an enemy, as it were,

01:01:14.460 the thing we're after, palliative care, the thing that we treat is suffering versus disease. And

01:01:21.120 there's a lot to that. We can unpack that. But so that's palliative care. Hospice is a subset of

01:01:27.060 palliative care, which is that mode, that type of care, but reserved for the end of life, the final

01:01:32.100 months of life. So hospice really is essentially end of life care. It's palliative care that's applied

01:01:37.380 at the end of life. But that's just hospice. But palliative care, there's no mention of time. You just

01:01:42.940 have to be struggling. You just have to be interested in quality of life, not have to be

01:01:46.840 dying anytime soon. This is a huge, huge distinction because of all of our deaf folks, because they 1.00

01:01:53.140 think palliative care and end of life care or hospice are the same. No one wants to talk about

01:01:57.880 it. No one wants to face that because of all the baggage around death. So consequently, people

01:02:03.620 suffer for years where they could get a lot more support from palliative care. But because of this

01:02:09.040 misunderstanding, they don't elect palliative care because they think that's only relevant

01:02:13.420 for them if they're dying soon. And nothing could be farther from the truth. So does that make sense?

01:02:18.580 It really does, yes. And I appreciate that distinction.

01:02:21.380 Good.

01:02:22.280 What do you think it is about us as a species? I can only speak to us because other species,

01:02:27.940 I don't think, share our metacognition. But why are we in such denial about death? It's been said by

01:02:34.440 so many people. We are all terminally ill. And yet most of us, myself certainly included, don't act

01:02:40.880 that way at times. We tend to fixate on things that absolutely don't matter. For many people,

01:02:48.260 there's frank denial of this thing. It's out there, it's some sort of abstract idea, but it's certainly

01:02:53.720 nothing that warrants any attention in terms of decisions one makes today. That's really the first

01:03:00.180 question I have. And then there's other things I want to explore here with you. But what is your

01:03:03.780 take on our just inability to look at death? I think for starters, I know in my field and

01:03:10.820 elsewhere, for folks who have kind of dared to turn their attention to mortality or have been forced

01:03:15.360 to, then you look back on the rest of the world and you see a world so invested in ignoring this part

01:03:22.080 of life that it can feel a little perverse. And I think a lot of us are quick to say the world,

01:03:26.960 or Americans in particular, are in denial. And there's some truth to that for sure. But I also

01:03:33.000 think we should cut each other some slack. Just physiologically, neurohormonally, we are wired to

01:03:39.340 run away from death. Any threat to our existence, we have deep wiring that makes us fight that thing

01:03:45.960 or flee it or go limp. So we have that impulse in us. And then I think on top of that, there's as old

01:03:53.560 as human beings has been this knowledge that we die, that any adult in this world, maybe not even

01:04:00.320 just adults. One way or another, human beings eventually come to the realization that death happens,

01:04:06.420 including their own death. And I'm not sure that any other species has to live, has to walk through

01:04:13.320 life feeling that. So it is quite a predicament we humans have. It's elemental. It is at the root of the

01:04:20.420 Judeo-Christian tradition. It's a root of many religious belief systems, a lot of philosophy

01:04:26.680 of thought. It's at the root of song and artwork. I mean, this is a huge, huge subject that humans

01:04:32.320 really, really struggle to wrap their heads around. So I just want to give us plenty of breadth. And I

01:04:38.500 don't want us to be ashamed that we haven't figured out this death thing. So on top of those old threads,

01:04:44.220 modern times, the last 150 years, medical science, we're sort of a victim of our own success. Medical

01:04:52.120 science has gotten much better. It's easy to be seduced. My life has been saved by medicine.

01:04:59.080 It's easy to believe that medicine can forestall death, perhaps indefinitely. So you throw all these

01:05:05.120 things together and social cues around anti-aging this and that, and you got to stay healthy and

01:05:10.620 beautiful forever and put all that stuff together. And we've conspired to set up a pretty tricky

01:05:16.180 relationship to this piece of our nature. No harm, no foul. But I think the reason to push back on this

01:05:23.680 is A, people die much more miserable than they need to because they haven't dared to look at this thing

01:05:30.760 called death before it's too late. And because also we have a healthcare system that it's not an intuitive

01:05:36.180 thing to navigate anymore. And thanks to our technology, it's not impossible to end up on a

01:05:41.260 series of machines and that by some definition of life, you have a pulse, but that's not a life that

01:05:47.760 a lot of us want to live is hooked up to machines. So we have this weird technological moment that you

01:05:52.500 can kind of live forever by some very reduced definition of life. Anyway, there's a little bit

01:05:57.700 of a rundown why it's so dang hard to turn our attention to this. But when people do, and I'm coming to

01:06:04.740 the climax here, brother, but one of the things you learn, whether through religious and philosophical

01:06:11.360 thinking, or frankly, in clinical thinking, whether by choice or by force, once you have to actually

01:06:19.260 try to stare at this thing called mortality, this thing called death in the eye, not only do you realize

01:06:25.520 that, hey, maybe it's not so terrifying after all, and that you can do it, but it has a secondary

01:06:31.820 effect of once you come to terms with your time as precious, and that time is relatively short,

01:06:38.980 or at least not endless, it has a secondary effect of helping you really, really appreciate what you

01:06:45.200 have. The fact that it ends is what makes it precious. So there are reasons why we don't look

01:06:51.840 at death, and there are some really good reasons to help each other find a way to do so.

01:06:57.200 I think that's just such an eloquent description of what I consider to be a huge dialectical challenge,

01:07:04.140 which is the problem that I focus on, BJ, in medicine is how to live longer, how to do so

01:07:10.940 without requiring the heroics of medicine at end of life. So just as you became disillusioned with

01:07:17.440 medicine, so too did I. But it was for a slightly different reason, which was, boy, we sure do put a

01:07:24.640 staggering amount of resources and effort into things that with probably one-tenth of this effort

01:07:30.600 could have been forestalled or prevented altogether. And I didn't think I could do anything about it,

01:07:35.880 so I left for a period of time before ultimately coming back to it. But I think that what you said

01:07:41.700 is I completely agree that we can do both, right? We can do everything in our power to maximize our

01:07:50.960 lives here, just as medicine allowed you to live that day. There's a very good chance at a different

01:07:57.940 hospital under different settings you would have died 30 years ago, but you didn't. Now, you're still

01:08:04.740 going to die, just as I am, of course, and everyone listening to this is going to die. So we can do both. 0.95

01:08:10.860 We can figure out a way to live the best life possible, the longest life possible, should we choose

01:08:16.440 that to be the case? But none of that diminishes what you've said. And I think that's the part

01:08:22.400 that a lot of people don't appreciate, is that it's one or the other, and it can't be both.

01:08:28.920 Amen. You just hit on a real kind of a root cause. One of the ways we struggle so much these days is

01:08:35.280 from our structures, our constructs, our ways of thinking. And as long as we think it's either life

01:08:40.820 or death, either you love life and try everything you can do to extend it, or you love death and just

01:08:47.820 completely accept that it's going to come today, these false dichotomies are the problem. And I'm

01:08:53.920 so with you, and it's one of the reasons I'm so excited to be invited on your podcast, but it's

01:08:58.080 because our relationship with death is maybe a problem, or it's just under-realized, but if there's

01:09:04.700 a problem here, it's the false dichotomy. It's the either-or thinking when the both-and thinking is

01:09:10.340 really where it's at. So I love that you and others are trying to think through how to live

01:09:15.020 longer and live better. I love life. My relationship to death, even my acceptance of

01:09:20.900 death, is only to do with my love of life. It would be a real shame of a shortcut that if in

01:09:27.500 order to prepare yourself for the inevitability of death, you somehow stopped loving life. You

01:09:33.720 somehow welcomed depression, so therefore you wouldn't love life so that much, so therefore you're 1.00

01:09:39.860 ready to die because life kind of sucks. It could be so, so much better than that. And if we can find 0.97

01:09:45.740 a way to include death into our view of reality, like I don't love death. I love reality, and reality

01:09:52.720 happens to include death. Therefore, I'll deal with death. I'm in no way concerted around it. I'm in no

01:09:59.780 way incentivized to make death happen. Again, I appreciate you having this conversation with me. I think

01:10:06.000 there's a lot to be learned by pushing past the either or of this.

01:10:10.400 You've spent more time with people who are closer to death than almost anybody listening to this,

01:10:17.420 certainly. You're in a profession that very few people go into. As you've pointed out,

01:10:22.880 there are many reasons for that. Do you get the sense that when someone is at the end of their life,

01:10:30.120 they are more afraid of death in the sense of being gone or the act of dying and presumably what

01:10:40.960 the actual mechanism of death and or suffering is? Yeah, it's a really great distinction,

01:10:47.240 a very helpful one clinically. Presentation may be someone's freaked out about dying or some of

01:10:52.680 existential anxiety. But of course, as is the case with these things, it pays to look a little bit more

01:10:58.540 closely and tease some things out here. One of the major things to tease out is, are you afraid

01:11:03.760 of the dying process, like you're mentioning here, the suffering you imply that must happen during the

01:11:10.220 dying process? Is that what you're picturing? Therefore, is that the source of your anxiety?

01:11:14.640 Or are you really afraid to be dead? Whether your belief system suggests there's a judgment day and a

01:11:20.460 reckoning, perhaps a hell, perhaps who knows what? Are you afraid of what may be coming next?

01:11:26.780 Are you afraid to be gone? Are you afraid to miss out? Does it freak you out that the world will go

01:11:33.020 on without you? A major pull here or a major divide, crossroads, let's say, is are you afraid of dying or

01:11:39.640 are you afraid of being dead? The former, one of the reasons to tease this out is the former afraid of

01:11:45.500 dying. Well, we know a fair amount about that. There's physiology to mark. There are medications to

01:11:51.680 help. There are ways to help a body come down for a gentle landing. As I say, there's no need to be

01:11:58.160 miserable and in pain at the end of life. For the most part, we can do a lot with medications. We can

01:12:02.340 do a lot to ease the suffering at the end of life and the dying process. So the answer, if that's your

01:12:08.040 fear, then the answer is reassurance. If your concern is being dead, well, I don't have answers for

01:12:14.220 you, but I can, as a fellow traveler, I can accompany you there. We can think about that together.

01:12:19.200 We can talk about it. And then we can make a life that responds to that big question.

01:12:24.580 So if you're afraid of, your belief system has you afraid of a judgment day, well, let that spur you

01:12:29.240 to behave a little differently in the time you have left. Or let that help you wade into non-duality.

01:12:36.100 Let that help you wade into the world beyond yourself. That's my favorite response. If anyone's

01:12:41.320 interested in living forever, my favorite means to living forever is to think about the world beyond

01:12:47.180 yourself, invest yourself in the world beyond yourself. So when your self dies, that thing you

01:12:52.500 love keeps going. Anyway, this is where it gets really, really fascinating, the relationship between

01:12:57.660 self and other and what to do about that. Religious thinking, spiritual pursuits, this is what can open

01:13:04.480 up when you admit that you're freaked out to be dead.

01:13:07.920 It's such an interesting way you explain the idea of, again, for me, it's very clearly the

01:13:15.300 latter, not the former. And I guess that's just because I have the luxury of medical training

01:13:19.200 and I understand where and when one can draw the line for themselves with respect to what

01:13:25.800 measures are taken, how heroically they are, and obviously the power of medicine to greatly

01:13:30.540 reduce the suffering. But it's this other piece of missing your family, missing out on future

01:13:38.700 generations, leaving behind people you love. To me, those are the hardest things. And of course,

01:13:44.820 your point is you can live through those things, but you have to do something about it. It doesn't

01:13:50.180 happen automatically. You have to make the investment. And the irony is the time to do that

01:13:55.460 is while we're alive. Amen. You just gave me chills. You just completed the circle. Yep.

01:14:01.660 Which almost suggests that palliative care needs to begin much earlier in life.

01:14:06.600 Amen. Which is why it's such a shame that we forestall and keep it at bay when it's this

01:14:11.180 thing that can help us so, so much, whether actually a palliative care referral or a palliative

01:14:16.680 care mindset. But one way or another, finding our way into the subject while we've got plenty

01:14:21.160 of road in front of us is absolutely the right, best way.

01:14:25.460 You know, it seems that there's a continuum where you have life, you have acute illnesses,

01:14:32.100 more life, acute illnesses, chronic illnesses, life, and death. The hospital and the entire

01:14:40.220 medical system is really only geared to treat with the acute problems. It has virtually no tool

01:14:49.140 dealing with life or even chronic conditions. And certainly not death. I don't want to get into

01:14:56.120 the why is that the case. We can sit here and debate about incentives all day long. I think

01:15:01.900 it's straightforward. I mean, I think we understand that the incentives are such that reimbursement

01:15:08.120 follows the treatment of acute conditions and to some extent chronic conditions. I guess the more

01:15:14.040 relevant question is, what would have to change to realign the focus of resources to make it such

01:15:22.860 that medicine could be more about helping people live and then helping them die when that time comes?

01:15:30.900 As a part and parcel of helping them live, then relate those two things. So I think a couple answers

01:15:36.560 to your question. I think one is in a big office somewhere at HHS when they're trying to redesign

01:15:43.720 a healthcare system and even redraft a mission statement. I would challenge HHS, I mean, to read

01:15:50.060 the definition of palliative care and tell me why the definition of palliative care isn't the mission of

01:15:54.080 all of healthcare. So one answer to your question is, you can see that both the strengths of the

01:16:00.040 healthcare system and the trouble that comes from it is a design flaw. Because you and I both know

01:16:04.880 healthcare is littered with people who really, really care and are trained to the hilt. And yet

01:16:10.820 the care we're able to meet out too often falls short. I don't think the problem is the people.

01:16:16.820 I think the problem is there's a design flaw. And for my money, the design flaw has to do with the

01:16:21.480 system is focused on disease, not on the people dealing with disease. And the second you make it

01:16:27.680 about the person living with the disease, not the disease itself, well, you've welcomed all sorts of

01:16:34.160 things into the mix beyond just their physiology and anatomy. You've welcomed their social, emotional

01:16:38.840 and spiritual lives into the mix. You've also welcomed your humanness into the mix as being

01:16:44.920 relevant, you as a clinician being relevant beyond just your technical skills, which will push back

01:16:50.800 on burnout for one thing. You've also made yourself in service of a human condition, which means for us

01:16:56.660 clinicians, the expectation management, we're not expected to work miracles. We know that it's

01:17:02.800 someday everyone's going to die and that that's not a failure for us. The person didn't succumb to

01:17:08.180 the disease and we doctors didn't fail to make them live forever. Once we align healthcare with

01:17:15.380 the human condition and we're serving human beings, so much of the trouble will work itself out because

01:17:21.740 we will be designed around the right thing. So that's one answer to your question. I think it's that

01:17:27.540 simple and that hard on some level. And then medical, of course, medical training would have to follow

01:17:31.660 suit and revisit how we think about these things. I mean, for example, think about your medical school

01:17:36.260 training, Peter. 100% of your patients die. Any rotation that you ever go through, no condition

01:17:42.280 befalls 100% of your patients. But 100% of our patients suffer. 100% of our patients die. And given that,

01:17:50.980 wouldn't you think that a responsible medical school curriculum, that we would start and end,

01:17:55.620 day one and the last day would be around conversations like we're having now. The

01:17:59.800 palliative care would not need to be a specialty. It would be baked in to how all of medicine works.

01:18:05.580 So for my money, that's a major thing that needs to happen. Policy will flow, et cetera.

01:18:10.500 I also think to make that happen and to not wait for that happen, that we human beings,

01:18:17.760 we people, irrespective of our professions, need to kind of come together as a society and to take

01:18:24.280 these issues on, especially right now when we're all so polarized and so divided and so aware about

01:18:29.780 the things that we don't have in common with each other. What a perfect time to revisit where we

01:18:35.000 actually do have so much in common. And where we do have so much in common revolves around everything

01:18:40.100 we're talking about right now. Black, white, rich, poor, young, old, I don't care. These issues affect

01:18:46.000 all of us. This is a genuine way for us to work on the points in common. So we can make political

01:18:52.580 comments about why now is right for that. The healthcare system itself can't keep doing what

01:18:57.620 it's doing and can't keep death the enemy because it's going to lose that war again and again and

01:19:03.640 again. And one way you can keep score on that is just cost. Yep. Cost alone is a metric by which

01:19:10.380 we're losing. Healthcare is obviously one of two things that will either bankrupt the United States

01:19:17.200 if they can't print their way out of it or create sort of seismic economic shifts. And I do think

01:19:23.040 that part of it is, as you said, we've taken the wrong strategy in a war that probably ought to be

01:19:29.480 deemed more of a truce than put our resources in the wrong place. Can I ask you a question on that

01:19:34.840 though? Yeah, yeah. Why would you say that we are so focused on acute care and not on chronic care?

01:19:42.380 If most everybody is going to die of most of chronic conditions, et cetera? I should say, I think we do

01:19:47.980 focus a lot on chronic care. I just don't think we're good at it. So what I meant to say was, I think

01:19:52.920 where medicine is very good is on acute care. And I think where medicine is really bad is on chronic

01:19:59.080 care. And I think those are the two things it works on. It has nothing to do with sort of

01:20:04.540 healthy life to prevent acute or chronic issues. And it has nothing to do with death. So that's

01:20:11.080 sort of, yeah, just thanks for asking me to clarify that. But yes, I think we disproportionately focus

01:20:15.260 on chronic despite our relative lack of success with it. Why do we keep doing that? Do you have a

01:20:21.240 sense? Well, I think in some cases, we don't know what to do to prevent the condition. So certain

01:20:27.480 conditions never show up as acute. Cancer does not show up acutely. I shouldn't say that. It kind of

01:20:34.160 does, but it doesn't really fall under the rubric of acute care medicine the way appendicitis does.

01:20:38.800 But we don't really have a great sense of cancer. You know, we know smoking and obesity are the two

01:20:45.160 greatest risk factors for it. But there's many other risk factors, including chance that we

01:20:50.640 probably don't understand. And even the ones that we do understand, like obesity, we don't really have

01:20:57.200 the infrastructure to help with prevention. So you talked about how in medical school, we didn't have

01:21:03.680 a single course on dying. We also didn't have a single course on nutrition or exercise or stress

01:21:11.980 management or the psychology of eating and our relationship to food and how you can help patients

01:21:17.800 make better choices with nutrition and things like that. So I don't buy the narrative that we have an

01:21:22.900 obesity crisis just because sort of people are fat, dumb, and lazy. I think we live in a toxic 1.00

01:21:27.860 food environment and we don't have a healthcare system that's really geared to help people out of

01:21:33.180 it because frankly, physicians aren't compensated to do that. You just don't have the billable structure

01:21:39.520 in which you can do these things. So instead, I think we focus on where our tools are and our tools

01:21:46.620 are drugs. Drugs become a good tool to use in a chronic condition setting.

01:21:53.520 Righto. I think I'd add to that, maybe encapsulate this list three ways. One is the design flaw that

01:21:59.420 we're the phobic and we see ourselves as victors when we cure something, when we fix something.

01:22:05.880 So chronic illness by definition is something that we can't fix. So I think it presents us with a sense

01:22:12.400 of failure, which I think is an emotional barrier to developing it further. That's one big piece of

01:22:18.840 the design flaw. I think a second big piece of the design flaw is the way the busyness of medicine

01:22:23.260 goes. We are left to see medicine as a series of transactions, which in acute care, it makes a lot

01:22:30.300 more sense. In chronic care, it becomes part of the experience. You're not kicking this thing out of the

01:22:36.180 body. You've got to learn to live with it. So illness and health becomes protracted over time and

01:22:41.320 therefore becomes an experience. But we're wired for transactions. We don't have the systems and

01:22:47.080 structures in place to be cultivating experiences together with our patients. That's the second

01:22:51.880 thing. And I think the third thing is this reimbursement and we are incentivized away from

01:22:57.260 thinking about care over time. So anyway, I just want to complete that question for both of us. I think

01:23:02.260 that's why we're where we're at. Yeah, I appreciate that structure that you've put to it. I want to ask you

01:23:08.720 about patients that you interact with during hospice. So these are now going to be the patients

01:23:14.560 who are probably in the final months of their life. And that could be cancer is obviously a very

01:23:21.360 common pathway that you'll interact with hospice patients. Is that the most common proximate cause

01:23:26.900 of death for hospice patients in the United States? Cancer? Yes. No, it is no longer the majority.

01:23:32.400 Until recently, it's less than 50% now. Progressive neurological illnesses are on the rise,

01:23:37.440 cardiovascular, organ failure. But yeah, fewer than 50% of deaths. The hospice deaths are cancer

01:23:44.000 at this point. What do patients say most to you? When I was in medical school, I did a stint at the

01:23:51.120 National Cancer Institute. And then I went back there for my formal training fellowship. And people that

01:23:57.820 came to the NCI to where I was, and I suspect to elsewhere in the NCI, were generally patients who had

01:24:03.980 progressed through all forms of treatment, all standard treatments. So they had metastatic disease

01:24:08.580 that had failed to respond to any form of treatment. So therefore, they were at the NCI

01:24:13.120 for experimental treatment. And at least for the type of cancer we worked on, the survival was between

01:24:18.700 10 and 20%, meaning 80 to 90% of the people we met were going to die very soon, within six months,

01:24:25.660 typically. I remember obviously feeling very attached to many of them and also spending time with them

01:24:31.540 and asking them questions like, what do they wish they could do? How do they want to spend this time

01:24:37.120 that they have left? And sometimes they would share regrets. And I always remember thinking,

01:24:41.960 I wish I could write a book about this, just interviewing people like this. But it felt,

01:24:47.060 it didn't feel right to me. It was one of those things that just felt like it should be shared,

01:24:50.840 but I wouldn't know how to share it. I suspect you've had more of those discussions than you can

01:24:55.860 remember. And I wonder what things you've learned from them.

01:24:59.820 These vicarious deathbed moments, I have a lot of them. I think a lot of us in this field,

01:25:04.300 and maybe in medicine general, like to say how privileged we are to be in this position,

01:25:08.500 how lucky we are to have our patients let us in to these very poignant moments. It's so intimate.

01:25:15.260 So yeah, there's a lot to be said for those moments, including your wanting to protect those

01:25:19.120 moments and not necessarily ram them into a book, although there I'm sure is a way to do that

01:25:23.540 skillfully. The world could benefit from it. But the regrets that pop in that I see at the end of

01:25:30.160 life, the conventional ones are, sure, you hear people say things like, I wish I had spent more

01:25:34.900 time with my family than at the office, things like that. Yeah, sure, that comes up. But in a way,

01:25:40.900 by the time someone's actually in their deathbed, and again, these days, most of us dying from chronic

01:25:46.440 illnesses, that means we have some protracted period of time to think about our death specifically.

01:25:51.700 We will be introduced to the thing that will end our life months or years in advance. And so by the

01:25:57.660 time those folks get around to their end of their life, they're beyond the sort of pat regrets.

01:26:02.360 They shouldn't have worked so much, for example. Oftentimes, if they're regretting anything,

01:26:07.200 they're hanging on to anything, including regrets, it's more likely, I wish I had loved,

01:26:12.660 dared to love more. I wish I hadn't been so afraid. I wish I had just let myself be myself.

01:26:19.200 I wish I hadn't been so hard on myself or criticized myself. Those regrets, they all have something to

01:26:24.940 do in common. And the commonality is, it's sort of like, oftentimes, a common pathway is they wish

01:26:30.960 they had let themselves come to terms with death earlier in their lives, because it would have

01:26:35.720 changed the decisions they made. I think one of the things that people come to realize on their

01:26:41.400 deathbed, and one of the things that I saw getting close to my own was really grasping it in our guts

01:26:48.420 that death is coming no matter what we do. Even in your work, promoting a longer life, as you said

01:26:55.100 earlier, doesn't mean that death isn't still coming. It's coming later. Given that, this is the freedom

01:27:00.800 that comes from reckoning with death, which is, if, okay, you're telling me that no matter what I do,

01:27:07.160 if I'm a good person, a bad person, I eat my veggies, I don't eat my veggies, I smoke, I don't

01:27:12.240 smoke, whatever it is, either way, if I'm going down, eventually, in other words, if failure is in

01:27:19.360 this way, quote unquote, failure is guaranteed, then in some ways, the pressure's off, like the pressure's

01:27:25.660 on for me to take my life seriously. But the pressure's off for me to get everything just perfect.

01:27:31.640 Like there's this biphasic effect that I see in myself and some of my patients, which is

01:27:37.200 they see the grip that fear has had on them, distraction is done to them, and they realize

01:27:45.780 that no, man, the only thing I have to lose is wasting my time. So I'm not going to waste my time.

01:27:52.580 I'm going to take this stuff seriously. I'm going to say what I want to say to people. I'm going to do

01:27:56.520 what I want to do. Because if failure is guaranteed, then I'm no longer doesn't make much sense to be

01:28:01.740 afraid of failure anymore, or not be limited by it, because I'm going to fall either way. So

01:28:06.700 might as well try. So I have the death gives me the reason to try, and gives me the reason or the

01:28:12.160 way of forgiving myself for quote unquote failing. So it really in this way can be a real liberating

01:28:18.760 force. And I see people grok that and the regrets have something to do with not coming to that place

01:28:24.580 sooner. You presumably encounter patients who have the sort of proverbial dying wish,

01:28:33.720 never saw the Grand Canyon and I really want to go and see it, never seen the Mona Lisa and I want

01:28:38.740 to see it, or I've never taken this vacation with my family. How much of your work is trying to help

01:28:46.180 patients navigate those wishes medically? For example, is someone strong enough to physically go

01:28:52.740 to the Grand Canyon? And can you put in a last ditch heroic effect to get them there? I mean,

01:28:58.780 how much of that do you do?

01:29:01.000 Some. I'm involved with an organization called the Dream Foundation out of Santa Barbara. And what

01:29:05.280 they do for a living as an organization is help make those trips to the Grand Canyon or whatever

01:29:09.720 those final wishes actually happen for adults in this country. It's beautiful. And I have been

01:29:15.460 engaged in some of that with some patients, whether a handful of occasions where someone was here who

01:29:21.520 may have lived here for a long time, but grew up elsewhere and wanted to get home as it were back to

01:29:26.620 the Philippines or back to somewhere else and helping this sort of one last trip happen. I've been

01:29:32.840 involved with that a lot. I've been involved with some bedside weddings in a hospital just before

01:29:37.080 someone died. I've been involved with some trips done to the Grand Canyon. So some of that,

01:29:42.660 that is true. Some of my job, especially if I can be engaged with someone soon enough while there's

01:29:48.060 still energy and time to work with, then making those sort of last wishes happen is great. It's

01:29:54.740 fun. It's great work. It's powerful. It's delightful. And it's stunning. But I will say, and so I do some

01:30:01.440 of that. But for whatever reason, I'm more engaged with people around letting go of that wish

01:30:11.020 or that need to go see the Grand Canyon or whatever it may be of letting go of the things that they're

01:30:18.180 not going to be able to do, or at least grokking that fact. So yes, sometimes the response is to

01:30:24.980 mobilize energy to do that thing. I'd say more often and right alongside that wish is also helping them

01:30:31.940 see the world and see themselves in the world in such a way that they can let go of those things that

01:30:38.680 they never got to because they realize the things that they're not going to get to is a very long

01:30:44.780 list. And on a developmental level, you've got to find a way to come to terms with all the things

01:30:51.200 you're not going to get to do. So that's where I spend a lot of my time. Movies lead us to believe

01:30:57.620 that people become enlightened and hyper-transcendent at the end of life. But my experience with

01:31:05.900 patients at the end of their lives is that oftentimes they're so heavily medicated that

01:31:12.080 they're not really even able to communicate much with their loved ones. And that's the price we'll

01:31:17.200 pay to keep them comfortable. Especially patients with metastatic cancer, the pain would be so

01:31:21.900 debilitating. It would be inhumane to let them suffer without those medications. And frankly,

01:31:28.380 in the circumstances when we're lucky enough to do so, we can get expressed direction from the

01:31:36.080 patients before they get there that, hey, I don't want to suffer. And I don't want a breathing tube

01:31:41.040 put into my chest. I don't want to be intubated. And I don't want you to do chest compressions on me

01:31:45.620 when my heart stops. I just want enough medicine to be comfortable. And so you don't have these sort of

01:31:52.380 diving into a person's soul in the last day of their life kind of thing. Is that your experience

01:31:58.120 also? Absolutely, it is. There are exceptions, but not many. The last day or two of life is not

01:32:04.800 necessarily the greatest time to be digging into someone's soul. And I will say, you're right about

01:32:10.720 medications as a big piece of this. But I will also say, just for your listeners, a refinement here,

01:32:15.920 again, pushing on the either or kind of thinking. It's not either take meds and be comfortable

01:32:21.100 or don't take meds and be lucid. Intractable pain is a great route to delirium. And even if you're

01:32:28.400 not delirious, trying to have an exchange with someone when your body is in absolute agony is

01:32:33.500 a pretty quixotic experience. I will say that another plug for a pound of care is with a very

01:32:39.420 expert and judicial use of pain medications, where we can often thread a needle and get someone

01:32:44.040 comfortable enough, but not so overly medicated that they can't interact. But just want to name that

01:32:49.840 refinement a little bit. Either way, Peter, your point's still taken. The very, very final hours

01:32:55.880 of life, you're not generally reviewing much. You're not having big philosophical conversations

01:33:00.860 at that point. In so many ways, whether by medication or force of the disease, it's too late.

01:33:06.240 Which I think speaks to what you said earlier, that there really is no time like the present to say

01:33:11.460 what it is you want to say to people who matter. It's not the movie where your final breath

01:33:17.200 is asking for forgiveness or telling somebody you forgive them or that you love them.

01:33:22.800 That's very unlikely to happen.

01:33:24.580 That's very unlikely to happen, as is anything sort of cleanly, like closure. I love pointing

01:33:30.700 this out to folks. One of the things in my world and in part of care world, one of the things you

01:33:34.920 want to forestall with knowing so much pain's coming is you want to forestall the avoidable

01:33:39.260 regrets and avoidable pains. But you're not necessarily going to get there in your final breath.

01:33:45.180 Tell me the story about Randy Sloan. How did you meet him?

01:33:49.780 Randy was a beautiful young man. So I met Randy, he worked at a motorcycle shop.

01:33:55.340 So when I first met Randy, one of my wishes for myself, once I became an amputee, was to get

01:34:00.260 back on a motorcycle at some point. I've always loved biking. I'd always wanted to get on a

01:34:05.360 motorcycle. Every once in a while, I was swinging through a motorcycle shop and see if there was any

01:34:09.800 way to convert a bike. Every time I walked in there, I couldn't get anyone to take it on. I

01:34:15.260 think they all just freaked out like, no way, dude. We're not putting you on a death machine.

01:34:19.820 Never. I didn't try that hard, but I never could get anyone really interested in.

01:34:23.040 One day, I walked into a place called Scooteria West here in San Francisco and just met a wholly

01:34:29.220 different energy. These guys were actually interested in trying to make it happen.

01:34:35.240 saw it as a creative exercise. That's exactly the spirit you need. Randy was the mechanic who

01:34:43.120 put his hand up as wanting to help make this happen. Randy, he was a bike mechanic. He took my

01:34:49.320 bike and he managed to figure out a way for me to operate it with just one hand by a series of

01:34:55.480 modifications. He helped make this dream come true for me. It was beautiful for both of us. He loved

01:35:03.280 making it happen, and I sure loved that he did. Then we had this gorgeous, teary moment when I

01:35:10.140 picked up the bike and rode off in the sunset. It was just a beautiful but time-limited interaction

01:35:17.520 with Randy. Then not that much longer, I can't remember now, months or maybe a year later. Randy

01:35:24.800 was in his mid-20s, by the way. Randy ended up, somehow his mother reached me and let me know that

01:35:30.680 Randy was in the hospital and something really big time was going wrong. Randy and I had remembered

01:35:35.700 each other because we were both moved by this story. His mom reached out and he knew I was a

01:35:40.500 doctor. Blah, blah, blah. Eventually, I got to Randy's bedside. Randy had been walking up a hill in San

01:35:46.760 Francisco, found himself a little out of breath, went to urgent care. They took an x-ray and he had

01:35:51.600 turned out to have mesothelioma. Which is essentially unheard of in someone in their 20s. This is a cancer that

01:35:59.840 is almost exclusively associated with long-term asbestos exposure in elderly folks. I don't

01:36:06.860 know enough about motorcycles to know if there was asbestos in them, but even if there was, you'd

01:36:11.140 think this is something that would still be 40 years later. You're right. Total freakish. Even if

01:36:17.640 you had had exposure, it's rare to find exposed to asbestos these days, much rarer. At that age,

01:36:24.080 you just don't have even time to develop the cancer. It takes a while after exposure. Just a real

01:36:29.080 mystery how this young man came down with widely metastatic mesothelioma. Even at the time of

01:36:34.320 diagnosis, scans revealed it was in his brainstem. He's one of these guys who went from walking,

01:36:38.860 talking to that day was in the hospital on death's door and people scurrying around trying to make a

01:36:45.540 plan what to do. I met him. I walked in that situation. By the time I even got to the hospital,

01:36:50.720 he had had a dose of whole brain radiation because brainstem lesion was very precarious.

01:36:58.000 They needed immediate care. He had already been radiated within hours. I walked into a situation.

01:37:05.360 Here's a young man trying to deal with this diagnosis, come to terms with it, and all that

01:37:09.680 it meant. It meant that his life was measured in weeks at that point, right from the time of

01:37:13.900 diagnosis. I became his palliative care doctor. We were together for the rest of the time. I saw him

01:37:21.260 into, at that point, I was working at Zen Hospice Project in San Francisco. He moved in there with

01:37:26.380 us and he played his life out with us. It was an amazing experience. I think one of the most amazing

01:37:31.980 things about it, besides the medical mesothelioma and this young man, blah, blah, blah, the really

01:37:36.880 interesting stuff was how Randy responded to this diagnosis. He and his mother and I were all,

01:37:43.300 it just didn't make sense. It was too soon. We were all gearing up to think that somehow

01:37:47.380 treatment was going to help him. It was a sober conversation. There was nothing that was going

01:37:52.140 to help him at this point, except for love. That one dose of whole brain radiation really threw him

01:37:57.520 for a loop. I'm trying to talk to him about the fact, trying to bridge him to the point to the

01:38:02.860 realization that he has no good cancer fighting options. You're watching this guy's world shrink

01:38:09.060 miserably by the second. To find a way out of this tailspin and to find a way forward,

01:38:16.420 we had our dutiful kind of pad of care conversation, which included a question in there eventually about

01:38:22.040 what was really important to him? What about him that he want to protect as his body was falling

01:38:28.720 apart? What did he love most about himself? Somehow the question to Randy became, what are you most proud

01:38:35.580 of in yourself? As a young man in development, it seemed like an important question. His answer

01:38:40.960 was immediate. His answer was, I want everybody I ever come into contact know that I love them.

01:38:46.100 He answered the question immediately. It was remarkable coming out of a 27-year-old bike mechanic.

01:38:52.620 There it was. I said, okay, we need to keep you as comfortable and conscious as possible for what

01:38:58.100 time you have and be in a position that your friends and people can visit you. That meant,

01:39:03.640 let's get you in the hospice house out of your teeny apartment, walk-up apartment where you have three 0.51

01:39:08.480 roommates. Let's get you into this hospice house. Let's get you out of the charade of treatment.

01:39:13.580 Let's treat your symptoms and open up your door and get as many people in here as you want. 0.85

01:39:18.740 That's what we did. He just had a steady stream of visitors. He just basically became this radiant

01:39:24.460 beam of love for what time he had and just made sure to love as many people as he humanly could.

01:39:30.660 And with that, his mother and his stepfather came out and got married at the hospice house

01:39:37.340 around the time he died. He got in the bay one more time for a swim. He got to be with his dog

01:39:44.700 and he let everyone know what Randy meant was love. And that became his legacy. And he died smiling.

01:39:52.000 And quickly, this all transpired over what felt like hours.

01:39:57.380 What role does euthanasia play? I'm ashamed to admit I'm a little bit ignorant about the legality

01:40:02.260 of it state by state. Obviously, I know that Oregon is a state where it's legal. How many states in the

01:40:08.660 U.S. have legalized euthanasia or some form of physician-assisted suicide?

01:40:12.380 I believe the number is now nine. I have to double check, but it's unfurling as we speak.

01:40:18.920 There's efforts going on in every state house. But I'm pretty sure the number is nine. The first

01:40:23.680 was Oregon in 97, California in 2016, and others have followed suit. Montana, Oregon, Colorado,

01:40:31.980 California, D.C., others that I can't remember right now. It's coming slowly but surely state by state.

01:40:39.740 Has it demonstrably changed the practice of hospice or palliative care? Or is it almost moot because

01:40:49.280 so much of threading that needle as you described it, effectively, it doesn't happen maybe in as

01:40:57.940 dramatic a fashion. But in the end of life care that you're discussing, for example, in the case of

01:41:03.700 someone like Randy, if Randy had said, let's say a few weeks sooner, I want to go down the path of

01:41:11.860 euthanasia, what would have been different than what he ultimately ended up doing at Zen Hospice?

01:41:17.480 There was a moment there I could imagine he would have really elected it. The world was falling apart

01:41:21.800 too quickly. It was too painful for a little while there for Randy to see straight. The process,

01:41:28.580 we can talk, is a little bit wonky. There's a two-week wait. You need to have two physicians. You need to

01:41:32.660 write a letter. They're fail-safes. Because what the state wants to avoid is making it too easy for

01:41:38.740 people to do something that they otherwise might regret. Because I think many of us have moments

01:41:43.140 where we just as soon get off the planet, especially when we're dealing with something

01:41:46.820 like a terminal diagnosis. It's a funny thing where life's ending soon. Some folks have this

01:41:52.700 response, okay, I'm dying. So now that I realize I'm dying, well, now I can't die soon enough.

01:41:59.060 It's almost like once you pierce the veil of indefinite life, which people really long for,

01:42:04.560 on some level think they long for, then all of a sudden they're terminal and then they can't die

01:42:08.400 soon enough. It's sort of a final act of control and a bit of an F you to death. Well, you think

01:42:14.740 you're inevitable. I'll show you. It's the quit before getting fired impulse in some ways.

01:42:20.940 There are other ways. There are many things that drive the impulse, but that's just sort of a side note.

01:42:24.740 But to answer your question, if Randy had enacted this procedure and ended his life, hastened his

01:42:31.040 death before nature otherwise would have had it, well, Randy would have died sooner. Randy would

01:42:38.500 have been able to schedule the moment of his death. It would have been something. And on some level that

01:42:44.440 could have served him. But the realization that Randy had a mission to sort of prove love,

01:42:52.620 to show love, to be love, he had a reason to keep going. There's a moment where if it had been too

01:43:00.360 easy for him, he probably would have elected to hasten his death. But because he didn't, and because

01:43:05.780 he let it play out a little bit longer, he got to a lot more people. He had a lot more final moments

01:43:12.100 with friends. He got into the bay and he had the pride of playing his body all the way out. He played

01:43:19.320 every cell all the way out, which for Randy served him very, very well. And I think it makes the point,

01:43:28.100 one of the problems with the dying laws, and let me just pause there too, by the way, Peter, the

01:43:33.280 language of physician-assisted suicide has gone away in favor of aid in dying or assisted dying to get

01:43:38.980 rid of the word suicide, emotional baggage around that word. And importantly, these laws are for people

01:43:44.660 who already have a terminal diagnosis and for whom death is coming soon. So it's importantly

01:43:49.520 different. But if we had just exceeded his wishes and said, oh, sure, you want to die of Randy sooner

01:43:55.000 and later? Yeah, we'll make that happen. Just in the name of helping him not suffer, we've made that

01:43:59.660 happen, and it would have been a mistake in his case. Because as I think a lot of us know intuitively

01:44:05.200 or explicitly, a meaningful life, a good life is not the absence of suffering. Suffering teaches us too much.

01:44:13.520 It's too important a vehicle for us, actually. A full life requires it. And I don't mean to castigate

01:44:20.920 anyone who does choose to hasten their death. For some people, it is exactly the right decision. When it is

01:44:26.260 seen as a meaningful response, not a flight from suffering, but a moving toward something meaningful. And for some

01:44:32.920 people, a final act of will is very meaningful. But for more people, what ends up being more meaningful

01:44:40.240 is them being more than their pain, being more than their suffering, and letting their body play

01:44:46.220 themselves all the way out and dealing with and adapting every moment along the way, trimming their

01:44:51.380 sails along the way, letting themselves be changed, letting themselves grow right up into the moment of

01:44:57.360 their death. That's actually a more meaningful pursuit for the bulk of people.

01:45:01.580 It's really that pain matters more than being numb.

01:45:05.740 Yeah. Yeah. When it comes down to it, when it comes down to it, for most of us, and this is a

01:45:11.600 realization that came clear to me when I was in my hospital bed, pain is very obnoxious. And I don't

01:45:17.660 like this stuff. We can be more than our pain. Pain isn't ultimately avoidable in a full life, like I

01:45:23.880 said, and it can teach us some things. And really, I'd much rather feel some exceptions, and there's

01:45:30.620 ways to paint this otherwise. But in general, I'd rather feel something, even if it's pain, than feel

01:45:36.500 nothing. Anesthesia is a way, a numbness is a way to die before we have to die. That seems to be a

01:45:43.500 bigger tragedy to me than is death in the first place.

01:45:46.660 Have you had any experience with the use of psychedelics in end-of-life care? Are people

01:45:54.120 doing any research on this? Obviously, I'm aware of the research on psilocybin in patients with

01:46:01.820 cancer. I believe there was research done helping with end-of-life depression. Are you aware of any

01:46:08.840 other agents that are used besides psilocybin for that research? Anything with MDMA? I'm not

01:46:14.600 sure if, which obviously I know MDMA is being used to treat PTSD, but what does the scope and

01:46:20.200 breadth of that look like today? Substances being researched along these for end-of-life

01:46:25.180 anxieties, fears of death, studying a patient population dealing with terminal illness or serious

01:46:31.420 illness. I can't quote to you all the latest details of studies. There are studies ongoing for

01:46:37.140 yes for psilocybin, but also for MDMA. Then related, similar but different, is ketamine and

01:46:44.400 the way ketamine is proving its way to new therapeutic values. Yes, I'm most excited around

01:46:51.860 the research on MDMA and psilocybin. The research so far, we've got a little ways to go, but the data

01:46:58.240 are pretty darn stunning. The impact is huge and offers access. The psilocybin stuff is the most

01:47:04.360 remarkable, I think. One guided session where setting matters, dose matters, the integration

01:47:10.580 process matters. It's not just people going out in the woods and having fun. But with this process,

01:47:16.080 there are really no adverse events to speak of. People who are gripped by a fear of death,

01:47:22.460 gripped by a sense of meaninglessness and not belonging and not feeling connected,

01:47:27.580 come out of this one session losing their fear of death, feeling part of something larger than

01:47:33.180 themselves, having a totally different relationship to fear. This is one session.

01:47:39.840 The effect lasts for months. It's not just a chemical effect per se. We don't have anything

01:47:45.560 remotely like this to offer in medicine. The closest thing I have in my conventional work as a doctor,

01:47:51.460 if someone comes to me with death anxiety, two things I can do. I can talk them out of it and try to,

01:47:56.660 with enough time, we can find a new way of seeing themselves in the world, a framework that allows them

01:48:01.540 to feel like they belong in their own framework. It takes time if we can get there at all.

01:48:07.980 And the other thing I can do is if you're really anxious, well, I can numb you out. I can give you

01:48:12.740 Valium or whatever else. I can put a wet blanket on your system. That's the best we've had to date.

01:48:18.360 I don't have an intervention that helps me connect you to meaning, connect you to the cosmos.

01:48:24.240 But these medications are offering exactly that and it is beautiful. So we've got a little ways to go,

01:48:30.900 but I am thrilled for this potential.

01:48:33.880 Are these tools the things you're probably most excited about in your field in terms of being

01:48:39.260 able to kind of revolutionize how you're able to help the patients who want or need that type of

01:48:46.480 intervention? Or is there anything else that even rivals this?

01:48:49.540 Yes. There are two things. So strictly speaking from a medical, medication-y, medical physiology-ish

01:48:57.560 kind of overlay, the medical lens, I would say the research going on around these substances,

01:49:04.240 psilocybin, MDMA, ketamine, et cetera, are my favorite thing going. Maybe even bigger,

01:49:11.520 maybe the other thing that gets me more excited is the work going on on the periphery of healthcare

01:49:17.360 and outside of healthcare. That conversations like the one you and I are having, Peter, and I thank

01:49:22.720 you for it up and down. One of the things we're doing is we're kicking the conversation beyond just

01:49:28.520 medicine. It's like we were saying earlier about the design flaw, that medicine focuses on the

01:49:33.120 disease, not the person. And one of the great things that happens when we focus on the person is

01:49:37.580 that we in medicine become part of something larger than ourselves. And we can partner with

01:49:42.300 architects and artists and designers and other disciplines and death doulas and quasi-medical

01:49:48.820 folks and alternative and integrative medicine folks. All of a sudden, we are part of a much

01:49:54.180 larger family working on behalf of something much larger than even medicine. And that's where I get

01:49:59.800 really excited that people, that society, that culture is waking up to these issues. Death has become

01:50:06.280 a medical issue. It doesn't belong there. Suffering and death are way bigger than medicine. Medicine may

01:50:12.580 have something to offer this. Getting back to your question, the thing that I'm more excited than

01:50:17.220 anything else is the rise of commerce, multidisciplinary work, other institutions and

01:50:24.480 vehicles tuning into this idea of life and death so that medicine doesn't have to carry all that

01:50:30.740 water by itself. That people are going to start taking care of people and not handing themselves

01:50:36.460 over to doctors to do the trick. PJ, I really want to thank you because your work and the work of

01:50:43.340 people like you has actually had quite a profound impact on the way I think about life. I'm in the

01:50:50.680 process of sort of barely putting the finishing touches on a book about longevity. And I've kind of come to

01:50:57.460 the realization lately, it's very difficult to do this without writing about death in some

01:51:03.540 way, but not as an enemy, but more in a manner that is sort of symbiotic with life. So maybe not quite a

01:51:13.340 friend, but certainly not a hostile combatant. I just think the way that you've been able to speak about this

01:51:18.880 so eloquently for many years now has been a great benefit to not just the people you've helped, which is

01:51:24.480 obvious. I think those of us who are presumably a little bit further from needing that help.

01:51:30.520 Peter, I can't wait to read that book, man. And that is right on. I think you will help so many

01:51:35.160 people. Just this frame shift of finding a way to include death in your view of reality

01:51:40.880 is one of the great services you can do the world, man. And I, oh, I can't wait to read it.

01:51:47.120 Well, thanks, PJ. And thanks more than anything else for all of your time this afternoon.

01:51:51.060 Thanks for having me, man. Thank you so much.

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The Peter Attia Drive - November 02, 2020

#135 - BJ Miller, M.D.： How understanding death leads to a better life

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