Normalcy, Introspection, & the Experience of Serious Illness: Bill Gardner, Juliet Jacobsen, and Brad Stuart

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: Alex, we’ve got a full house today.

Alex: We have a full house today. I am honored to introduce Bill Gardner, who’s a child psychologist and professor of psychiatry and epidemiology at the University of Ottawa. We have a Canadian theme going. We just had Harvey Chochinov on. He studies the mental health system in the ways in which it has failed children and adolescents, and he writes about his experience with cancer in a blog, the Billgardner.substack.com, Billgardner, one word. Bill, welcome to the GeriPal podcast.

Bill: Thank you.

Alex: And we are delighted to welcome Brad Stuart, who is an internist. He’s worked in the ICU in the emergency department. He spent a long time as hospice medical director and he founded a national model of care that many of our listeners will be familiar with, AIM, which stands for the Advanced Illness Management program, which has influenced CMS policy. He has a book, which I have read, Facing Death, and we will discuss Facing Death: Spirituality, Science, and Surrender at the End of Life. Brad, welcome to GeriPal.

Brad: Thank you. Great to be here, guys.

Alex: Just a quick sec … Brad authored a brilliant April Fool’s blog post when we were… a blog that got a lot of attention about this mirrectomy procedure that would remove a clinician’s empathy so they didn’t have to feel empathy when caring for patients with serious illness because it was so troublesome, that whole empathy thing. And then we had this wonderful response from this right-wing blogger who was like, “How dare they? Can you believe that this is happening?” Somebody in the comments on their blog response said, “Did you check the date? Was it April 1st?” [laughter]

Eric: Oh, I forgot about that.

Brad: I completely forgot about that. That’s great.

Alex: That was great. We’re also delighted to welcome back to the GeriPal podcast, Juliet Jacobsen, who’s a palliative care doctor. We were co-fellows about 100 years ago.

Juliet: It was great.

Alex: She is working in Sweden and researching in Sweden, in Lund. Did I say it right, Lund?

Juliet: Lund, yeah.

Alex: Lund.

Juliet: You got it right.

Alex: She’s also associate professor at Massachusetts General Hospital in Harvard Medical School. She was a prior guest with Rachelle Bernacki on our most listened to podcast of 2022, Should We Shift from Advanced Care Planning to Serious Illness Conversations? Welcome back to GeriPal, Juliet.

Juliet: Great, thank you.

Eric: We’ve got a ton to talk about living with serious illness, but before we do, who has the song request?

Bill: I think it’s me. I basically sent Alex a request that was boiled down to anything by Bob Dylan. And so, he’s going to play Like A Rolling Stone.

Eric: Can I ask why did you choose this song?

Bill: Well, actually, I gave an album and he chose the song from the album. It is a great song.

Alex: So here I’m going to play a little bit of the song. I love this song.

(singing)

Eric: Thank you, Alex.

Alex: Well, that’s on two hours prep. I’ll record a different version for our listeners who are not on YouTube. That’s fun. Great choice.

So we’re going to jump into it where I left off with introductions. Juliet, last time we talked to you, you were talking about shifting from advanced care planning to serious illness conversations. You interviewed some geriatricians. You’re a senior author on this article in JPSM, where you interviewed some geriatricians and other people caring for older adults, nurse practitioners, social workers, et cetera. The title of this article is just fascinating and provocative and I think our listeners want to hear about it though we’re just going to talk about it briefly, Aging is not an Illness: Exploring Geriatricians’ Resistance to Engaging in Serious Illness Conversations. Juliet, could you tell us a little bit about this work just a little bit for our listeners?

Juliet: Super. Thanks, Alex. So first, shout out to Alex, Alexis Drutchas, who was the first author on that paper, did a fantastic job. What happened is we’re in the serious illness care business and so we were busy rolling out our serious illness conversations at Mass General and we were getting resistance, which we expected from oncology and primary care, but then we started getting resistance from the geriatricians. I thought we were on the same team, like matters most, serious illness conversation. I thought we were playing together and so-

Eric: What kind of resistance?

Juliet: They were like, “We don’t want to do your program.” I was like, “Really?” Ricky Jackson’s like, “Can you sort this out?” So we did these focus groups. I was like, “I guess it’s time to get curious.” We get everyone together and we asked why? Why don’t people want to document serious illness conversations? Why don’t people feel like this resonates with them? Why don’t our geriatricians feel like this resonates with them? We got what was in the paper, which is the labels that we were using, this label of serious illness. It’s not right for aging people. I think it labels people as sick at a time when geriatricians see their role as really encouraging positive adaptation, right?

It gets to our point actually of normalcy. People are trying to find their new normal and their doctors are trying to help them do that in a positive way, and when we label that as serious illness, it’s too heavy for that work. And so, that’s what we learned from them. I think this is actually bread and butter geriatrics. So the geriatricians are probably all like, “Yeah.” But I’m a palliative care doctor and so I tripped on this. This is a blind spot for me. What my colleagues told me is when someone’s sick, when they’re in the hospital, when there’s an acute change, then it feels like it’s okay to call the serious illness conversation, but not when they’re living at home it being okay.

Eric: Because aging is not an illness, right? Is that what the geriatricians are saying?

Juliet: That’s what they’re saying, although it gets a little tricky when you get the multimorbidity and the frailty and you keep adapting, you keep adapting, you keep adapting, and you’re getting more symptomatic and closer to the end of life. We keep wanting to grab that group of people somehow either by prognosis or by function or by symptoms. We want to call those people, the people that have serious illness.

Bill: Juliet, to paraphrase Cormac McCarthy, if it isn’t illness, it’ll do until illness shows up. [laughter]

Juliet: That’s my motto, but it’s not working for people. Yeah.

Alex: We have to pivot from this, although I’m sure we could talk more because I suspect that geriatricians were engaging in these conversations, but not calling it serious illness. I see you nodding your head, not calling it serious illness conversations. So the term changed-

Juliet: Yeah, I think its open question what we should do about this,

Alex: Yeah. Right. Does the term need to change or…

Juliet: Ongoing debate. I’ve been thinking about it for a number of years now. I haven’t quite figured it out. I think it’s problematic. Yeah.

Alex: So I want to pivot to the more central topic of today, which is talking about, I don’t know what to call it and I’m interested in your thoughts on this podcast, what to make of the serious illness experience. So let’s talk about people who are experiencing serious illness. Juliet, I know we’re going to stick with you for now that you have some colleagues who publish some work showing that many people with serious illness and cancer in particular in this case are striving towards normalcy. This sort of stands in the face of what you and I learned in palliative care that illness is an opportunity for spiritual growth and transformation from what we have strived towards in caring for many of our patients. I think about my own dad and his experience with serious illness and the ways he grew spiritually and that inspired me to study spirituality when I was in medical school at UCSF and the joint medical program in Berkeley and yet there’s empirical evidence here saying that I just want to live a normal day. Juliet, could you talk briefly more about that work?

Juliet: I feel like I stumbled upon this number of years ago actually. I was taking care of this young guy, cancer, and he was planning a trip to California. I was asking about what was going to be special about the trip or if they were going to do things with their family. I was pulling for meaning and purpose and he looked at me and he is like, “It’s really hard to live every moment as if it’s meaningful.” I was like, “Yeah, you’re right about that. Right.” He turned to his wife and they were laughing. They’re like, “Everyone wants to make every moment of our day special.” They’re like, “We just want to live a normal life.”

And so, I feel like that was this moment where I was like, “Oh, I missed something,” because I kept trying to get at the meaning part of my work with this patient and he wanted something really different from me, which is why I was paying attention when this work came out in Europe in the last few years, our normalcy, a couple of different studies with cancer patients. One colleagues of mine in the Netherlands did just interviews with 30 cancer patients and this theme kept coming out. This is Hannah… Oh gosh, what’s her name? It’ll come back to me. But Norland who they said throughout the interview, there was this focus on normalcy to the point where the conclusion of the paper was we should ask about this. We should at least ask if it’s important and we should start to think about how is medical care interrupting normalcy for our patients. I think that’s one thing that’s come out of the literature recently.

The other paper is a colleague of mine here in Lund, Karen Dolhammer, and she had people over time, right? So she had them early in diagnosis and then a little bit later. And so, she got a little bit more into this idea of what normalcy is over time. I just love her conclusion because what she realizes is when you’re first diagnosed… This is research. I feel like I’m talking to people who’ve had experience. We’ll talk about this, but many people want the old normal, right? They want to go back to before the illness, before the cancer. That’s what normal means when you’re first diagnosed, wanting to go back to before the illness.

Then there’s this middle time where you’re managing symptoms and it’s just about controlling the symptoms so you can be normal day to day, which is a different kind of normal than before. And then there’s this other time, and this gets to the geriatric patients, where you’re adapting to change and loss and then it’s a new normal that you’re trying to adapt to. So there’s actually three different kinds of normal. And so, when we ask about normal, it’s good to know, at least have this map for ourselves as clinicians, what kind of normal you might be helping your patient to articulate as you’re working with them. [inaudible].

Eric: Well, I’m going to jump around a little bit because I’m going to go, Brad, I had a chance to read some of your book and one of the chapters was on your own prostate cancer diagnosis. I wonder, reflecting back to that time, I think, what, you were 55 when you were diagnosed, does any of that resonate with you?

Brad: Yeah. God, that was almost 20 years ago now, Eric. I’m 74 a month or two ago and I still feel like I’m in my 50s. When I was 55, I still felt like I felt like I was in my 30s. I had a chance PSA, got diagnosed after a biopsy and it was like I read about in the book, it just blew the walls out of my house. I mean, it’s worse than a bomb going off in your living room. It was a complete shock. Here I’d been dealing with dying patients for decades and I thought I had it wired and I did not. When it happens in your own body, it’s a new world. So yeah, when it happens like that, I think I really wanted to deal with it and get on with my life. Luckily, we caught it just in time. I mean, it was very close to the capsule of my prostate, very high grade, unusual at my age, but I do one for radical prostatectomy and I assume I was cured. It hasn’t shown back up. So yeah, I assumed I would go back to normal.

That’s a whole different case than the new world we’re in now where resuscitation science and critical care has created a situation where people have all kinds of time to be that far away from the end and really contemplate it, and like Juliet is saying, adapt to it, deal with it, and be at the correct stage. It’s on us as healers and physicians to ask the right questions so we can be there, I think, with them as close as we can be without falling into the abyss and accompany them through that. I had a urologic physician who was dynamite at UCSF and he was fantastic. He really helped me a lot through the shock and awe of being diagnosed with cancer. You do not have any idea what it’s like to be diagnosed with cancer until it actually happens to you.

Eric: Despite being a palliative care physician who’s been dealing with mortality, I think one line that I read you said is I think, “I assumed I had the death thing wired, but when you have to confront your own mortality.”

Brad: Yeah. I mean, this is a lesson for all of us or anybody who thinks that they understand what death is about. Lots of people say, “Oh, I can deal with it.” That’s all in your mind and it’s based on fantasy. Until you’re actually up against it and your body is in the battle, that’s when you get to really deal with it. Prior to that, it’s fantasy land, I think, in my experience.

Eric: Well, Bill, I got a question then for you. So I also had a chance to read through your multiple blog posts.

Bill: Thank you.

Eric: They were absolutely fabulous, dating back to the very first one where you acknowledged that you were just diagnosed not too long ago with an incurable throat cancer, I think you were calling it against age diagnosis.

Bill: No, it sort of evolved to that, but initially… So I have oropharyngeal squamous cell carcinoma, which in most cases is a pretty treatable beast. If it’s not, it’s a very difficult, dangerous thing. But initially, I went through 35 sessions of radiation with the expectation that there was maybe an 80% chance of cure. Didn’t work out. At that point, I was given a prognosis of less than a year. I’ll try to keep this short. From there, I was able to, because I was fortunate in my biomarkers, start pembrolizumab, which is an immunotherapeutic drug. Got about a year and a half of good life out of that, but that too failed. And so, now I’m in, I guess, a second relapse.

I’m doing a palliative protocol of carboplatin and paclitaxel or paclitaxel or something. I forget exactly how you do it, but it’s a sort of classical chemotherapy. My oncologist, who is fabulous, is very frank. He says, “This may slow things down, but it’s not going to work in a curative way.” So now I am sort of in a feeling of, yeah, I’m dealing with a terminal process. Is that sort of catch you up? Yeah. Okay.

Alex: How does Juliet, this notion that Juliet mentions about that?

Bill: It’s very interesting. I would love to read these papers because I’d never thought of what I was trying to do is… Well, no, that’s not true. Initially, when I was starting radiation, restoring normalcy was my goal. The interesting thing I discovered with cancer was it’s not like you actually believe you’re going to live forever, but you think you’re going to live 10, 15 years or so. That time horizon is so far away and all the big goals in your life you currently have can get done in that. It’s as if there’s no fundamental limit. And then when you get cancer, it’s like mortality. It’s like a car wreck. Suddenly that car in front of you is rushing towards you.

Probably, like most of you, I had been on this annual cycle of either NIH grant submissions or CIHR grant submissions, which is the Canadian equivalent and everything was planned out in five-year things that we’re going to do this specific aim one, specific aim two, and it was a wonderful life, but when you’ve only got 18 months maybe, you can’t do that anymore. I suddenly began to see how much of my life had been adapted around that very long-term thinking rather than thinking about the stuff that was much temporarily closer. So there was a different kind of normality, I guess, that I had to achieve, Juliet. I’ve got to think that through, but it felt to me like more, all right, I’m not living anymore with my shoulder to the wheel entirely to try to improve the treatment experience for kids and their family. Now it’s what?

In a way to get to another question you raised, that was partly why I started writing. I had been blogging for a long time on health policy for a blog called Theincidentaleconomist.com, and we wrote an immense amount about the Affordable Care Act and a bunch of other stuff, but I hadn’t done anything personal. I was very much inspired by Christopher Hitchens’ writing about his cancer experience, which if you haven’t read it, it’s fantastic. Although I’m a very different person than Hitchens and come to value different things in some ways, he’s a tremendous writer and I could… Well, we’re all probably writers and the way we think and understand our life is not just to ruminate, but actually to write and try to get our thoughts coherent. So that’s why I was writing. I’ve had the floor too long.

Alex: Brad, I want to come back to you before I go back to Juliet for her reflections. Brad, why did you write a book?

Brad: I got into medical school and I won’t say where it was. It was down the peninsula from you guys. Their mascot is a tree. Their logo’s a big red ass. That’s all I’m going to say. I was horrified in my third year of medical school. This would’ve been 1975, but when I went on the wards… I tell the story in the book about my very first patient, and I won’t say here what happened, but I was horrified by how we cared for people who were really sick. It just made me crazy literally. I looked around and nobody else had a problem with it. There was something weird about me, I guess. So I said to myself after that patient died, which happened fast, I said, “I have got to write a book about this.”

I was walking down the hall in the hospital out of the patient’s room that had been stripped bare the day after he died, everybody forgot about him, and this voice that was very loud said to me, “You’ll write your book but only when you don’t want to.” I looked around and there was nobody there and I thought, “What was that? What is that?” It was a Zen koan and it just came out of nowhere. I still don’t know where it came from. It took me 50 years to write this book, literally. I’m a very slow learner. That’s how long it took me to see a lot of patients go through my own cancer and discover that the most important thing, and this astonished me because I was raised without any religion, most important thing about all this is what we call spirituality. That had never dawned on me that that was important.

So I decided to finally write my book. After I wrote it, it took me a while to catch up with what I wrote because it came from a deeper place than where I normally live. As it turned out, I wrote the book I needed to read back then, not the book I wanted to write because the book I wanted to write, I wanted to burn the place down. This is the book that I think would’ve helped me a lot if I read it back then because it’s really about who are you really. We are not who we really think we are. If you look deeply into all spiritual paths and really all religions, if you set the church thing aside, that’s what it’s all about is who are you really? Deep down that is accessible. It’s also empty. It’s not a place that’s full of thoughts. It’s not a place where your mind should even go. It’s a place where you need to go if you want to really be yourself and if you want to help with other people’s healing.

I discovered when I wrote the book, that’s where I went when I worked with people who were suffering. That’s where I came from and I didn’t even know it, like Bill, you were saying, until I sat down and wrote it through and realized that’s what that was about. It was always spiritual. My concern honestly is not so much with patients and people, it’s with doctors. We don’t get it yet. I’m a scientist. I got into my medical school writing papers about imaging studies of the brain. I know that stuff. Imaging studies coming out now about meditation, about psychedelics are key, key studies and near-death experiences, that’s new data that’s very disruptive to our current scientific paradigm. A third part of the book is devoted to that. I think science needs to wake up and I think doctors, all of us need to wake up. It’s a spiritual awakening and it’s very ordinary. It’s not anything magic or grandiose or anything else. It’s very basic.

Alex: Juliet, I want to come back to you here, these reflections from Bill and Brad who have both faced serious illness, dealt with serious illness and have agreed with you in that in some sense there’re striving for normalcy and yet as you can see, and as we’ll talk more about in a few moments, have really also taken this opportunity to engage in deep, deep questioning of what does this mean to be seriously ill and to be human and engaged in sort of spiritual introspection in various ways. That seems on a surface level at least fairly distinct from a strive towards an ordinary day like the way it was before. Juliet, your thoughts?

Juliet: Well, just as an aside, Brad, one of the ideas I’ve been playing with for some time when you’re talking about doctors not getting it and the need for spirituality, I have been wondering if there’s some sort of intergenerational team that we need. Are the young people enough or do you actually have to live more of a life or have more challenge? I often wondered if we’re missing that element when we think of how we put our teams together and who’s on them, so I’m with you on that part. But this question of this meaning-making, I am a big fan of terror management and Sheldon Solomon’s work and this idea that throughout life we’re managing our existential anxiety. He puts it by making a contribution to a meaningful world, that there’s something about doing that, that we are practicing always.

So then I have this question, and it gets to what you were saying, Bill, when people get sick, by the time I see them, it is hard to do stuff anymore. Even if you’re feeling well, it’s not what you want to be doing anymore. And so, it feels like the time of those contributions, the book, that time is winding down. And so, I guess my question for Bill, I’m not going to answer your question, Alex, I’m going to ask Bill, is meaning-making and normalcy, are those the same? Is the meaning the normal or are they different realms and we sometimes make meaning and we sometimes want to live a normal day and they don’t have to be the same? I think it’s the same question that Alex is asking, and I don’t know. I don’t know personally how that feels.

Bill: Okay. So great question. Just a small point to start I guess is I would never say make meaning because I’m actually… So I was raised Christian and I remain very much a practicing Christian. I also spent many years studying with Vajrayana Buddhists, I mean, the most famous one being the Dalai Lama. I was very fortunate to receive the Chenrezig empowerment from him. They were very generous. They accepted me despite understanding who I was, that I did not accept their metaphysics and such like that. I just wanted to learn what they knew and understand their spiritual point of view.

So I’m more interested in finding the resources in the traditions that are ancient and I feel like reflect the spiritual wisdom of a larger community rather than making meaning for myself, although of course any person in assimilating a tradition has to some degree, if they have any respect for truth and integrity, come to their own terms about it. So it’s a subtle point. If you are just purely doing this on your own, I would say God bless you. But to me, I am trying to discover things that are to some degree outside of myself to be found, if that helps.

Eric: It also feels like the blog in itself is somewhat meaning-making, is that you are learning this stuff and you’re sharing it with others.

Bill: Absolutely. It all feels very different from the context of my illness, right? I mean, it makes it immensely more intense, right? I mean, normal life for many years was what? We have five children, and at one point we had five adolescents in a small house in Pittsburgh all together. I can’t quite describe the chaos and just noise level and broken furniture, four big boys among other things. And so, the normalcy is, God, I got to go pick up the kids, right? Now, in an empty nest thinking about the fact that I’m going to die fairly soon probably and they’re maybe quite a bit of suffering on the way to that path, how do I prepare myself for that and what does that mean? How do I reconcile that with a whole bunch of other things I believe?

Eric: Yeah. I want to also give the listeners and readers just an example. I think a series of your blog posts feels like it was looking at different spiritual traditions, so look how people and patients with cancer, patients with terminal cancer cope with suffering and what suffering means. This is the first time… Actually, Alex sent me your blog post. I think he got it from Brad on Stoicism, but you looked at Stoicism, Buddhism, Christianity, and I think it was all around this concept of how people approach suffering.

Alex: Mm-hmm. Could we hear more about Stoicism? I had that privilege, and it is a privilege to go to Italy this past summer. If anybody has an opportunity to go, please go. We went to Rome first, then Florence. In Rome, I was just shocked by the Colosseum. I mean, what a magnificent structure. There’s all this cement there. I said, “But when did they add the cement?” They said, “No, the cement is original. The Romans knew how to build cement and it’s better than any cement we have today because they added quick climb and all this sort of stuff.” I was just astounded. And then they forgot how to make cement, right? We forgot, right? And then I went to Florence. We learned about the Renaissance and this sort of recurrence, resurgence of evaluation of Greek philosophy, ideals, music, et cetera, in Roman. Could you tell us though? I think most people have misconception about Stoicism, so reading that in the contest of going to Italy, it was like, “Oh, this is so great.”

Bill: Yeah. So, sure. Cut me off because I know we’re limited on time if I talk too much. So Stoicism is now this really popular thing among certain groups of people and for I think a good reason.

Marcus Aurelius was a Roman emperor. He may be the first person for whom we have a diary, a journal, something he wrote for himself as a sort of tool of self-improvement and survived. I mean, he didn’t write it for publication. What you see here is a guy trying to cultivate virtue in some way that the virtue he was most interested in or the one that matters the most here would be something we might call courage or fortitude. How do you handle suffering?

Well, one way he wanted you to do it was to think is whatever thing that’s hurting me or person who’s insulted me or job I’ve lost or whatever it is, I mean, these are words he might not have used, but did it really injure my true interests? He felt his true interest was virtually pursuing his mission, which was to be emperor, right? We can talk about why that was important. A lot of people have taken this up because he’s very serious about trying to reflect on who you are, why you’re reacting emotionally about these things, what you should really do to cope with this. Now, I don’t think his solution is one that I want to pursue or is mine, but that’s what people are there for. Is that enough?

Eric: It sounds like a mix between mindfulness and just a lot of cognitive aspects to it too.

Bill: It is. I mean, a cognitive behavior therapist would read this stuff and say, “Wow, this guy really…” I mean, somehow this is a piece of what we talk about that dropped into the second century, right? It’s impressive. Here’s the thing that I find limiting about it. It’s all individual. He is just doing it for himself, pursuing what he sees as the mission, which is serving the needs of the empire, which he thinks it’s the embodiment of a rational logos, Greek term, that that’s the foundation of civilization. Nobody ever shows up. My wife helped me get through this particular problem, or here are my comrades, because actually he was a soldier more than anything else. He spent his entire reign on campaign burning villages and enslaving people and doing all the terrible things that Roman emperors did, but he thought that was the way you protected civilization, which was embodied in the thing.

I mean, what I think is key for me in both Buddhism and in Christianity, it’s first and foremost not a set of propositions you’re believing in the world, about the world. It’s a community of people you’re joining to whom you’re going to be in bonds of love and that this is the key to coping with suffering, I guess if I had to put it in five words or whatever, how many words that was. So that’s my one sentence thing about why I’m not Stoic. I don’t believe in the empire or I don’t believe in the American empire either for that matter, but I do-

Alex: Spoken like a true Canadian. Yes. [laughter]

Bill: I’m an American expatriate, guys.

Alex: Okay. American expatriate. Gotcha. But wait, but on this notion, I think in addition to your bridging to Christianity and Buddhism, we can also think about the history of virtues-based ethics and that originally those virtues were very much male-gendered virtues and that virtues based ethics had a wane. I think it’s the wane because it decreased in importance over time as we moved into Principlism, particularly in bioethics. But it had a resurgence then in the 20th century when particularly motivated by feminists who argued that we live in relation to each other and many of the ethics we should strive towards are things like compassion and empathy, and also, in research, logically… I probably shouldn’t go there, but much of the outrage about the Nazi atrocities and experimentations came not from any logic or rational, but from just profound empathy for the suffering of the Jews and others who were experimented on. Before I turned to Brad and talk to him more about his book, Juliet, any thoughts before we go back to Brad?

Juliet: Just I think this notion of communities coming more into our field. I’ve been here in Europe the last few years, and there’s a big public health palliative care movement, and it’s really trying to pull so much of this outside of the medical system and into community living, restoring relationships with people, reframing grief as not so much of a diagnosable illness as something that is treated with contact with other people. It is very active here. I don’t know. It’s reminding me of what you were saying, Bill, of the individual is not enough and it’s how we sit in these other broader communities that really matters, particularly around these existential questions.

Alex: Mm-hmm. Brad, I want to come back to you and dive a little bit more deeply in your book. I know we only have about 10 minutes left, but I wanted to ask you a somewhat simple question on its surface. What did you learn? What have you learned about what it means to be a healer?

Brad: Oh, man. Well, one of the problems I had with my medical training and listening to you all, I think things have changed a lot. I’m not sure they’ve changed enough, but in my training, the focus was on curing and it was assumed, never spoken, that healing and curing, you were talking about the same thing, help people get better. It struck me like in my third year of medical school that you can kill people trying to get them better if that’s all you think about. What do you do when options run out and you can’t cure anymore? There’s got to be something else after that. So I got into healing very early on. I mean, in fact, I made my way through with the last part of medical school as fast as I could because I felt getting out and being with patients would be the best way to learn it, and turned out that is exactly what happened.

Healing, I think healing is… This is way more than 10 minutes, but healing, going back, we might as well bring in this whole thing about community. I mean, we’re trained with scientific medicine in the background all the time and ever since, as you mentioned in the enlightenment, it’s been like the object and the subject. The subject is the investigator and the object is what you examine and that’s kind of the way we treat patients. I wasn’t aware of it when I started changing myself, but I realized if you’re going to help with people suffering, and that’s what struck me immediately was people are suffering and we are ignoring it. It’s like you focus on the disease, grab it by the lapels and shake the hell out of it and only after the battle is over do you look around at the person and say, “How are you doing?” And they’re frequently not doing very well, and they weren’t all the way through.

I had this urge that came from I didn’t know where to get close to where that person was when they were going through it, as close as I could get without getting… You can’t get pulled into it or you’re no good to anybody at that point, but you have to get so close that you start to bridge this gap between the individual you are and the individual they are. You can never know what’s happening inside someone else. You can’t know. You have to ask questions, but the less you make that gap. The closer in you get, the more of a healer you become. It didn’t dawn on me till a lot later when I had time to sit back and think about it that that’s the spiritual part of medicine. We’re taught it by example. There are some really incredible teachers who embody that. I don’t think we have a good language for it. I would love to improve on that. But I think healing is finding the place in yourself where you are automatically connected to the love that goes into all creation.

Bear in mind, I’m not religious, I never have been, but I am experienced in psychedelics luckily when I was younger. I think the studies coming out now, psilocybin, LSD, psilocybin has been studied the most. 80% of people who have horrible dread and death anxiety, who have incurable cancer, 80% respond really well to psilocybin and lose their fear of death and I know why, because it dissolves… Psilocybin inhibits the brain network that keeps you trapped in your sense of self. That’s the psychedelic experience, the self dissolves, which by the way, in deep meditation, Buddhism, mystical Christianity, all spiritual traditions, thousands of years, that’s the secret. If you get underneath inside yourself, you can then be connected to anyone else in that same place. Doesn’t matter if they’re aware or there, you can connect there and that’s when healing happens, but first, the work is find that place in yourself.

Eric: Go ahead, Juliet. I think-

Brad: That’s why I wrote the book. I think that distinction between yourself that you think you are and the real you that’s waiting on inside, that getting clear on, that’s really important if you want to know how to help people heal.

Eric: Yeah. Juliet, you were going to say something?

Juliet: It’s so interesting that you’re saying there, Brad, because I’ve been reading about existential threat and some of the neuroimaging is that the idea of threat is not stored itself. We stored in the other part of the brain, which is I think why we always see people struggle so much to really comprehend their own mortality because it’s stored as other, it’s not stored as me. So it’s interesting what you’re saying about how psilocybin works with the self because maybe that makes it easier if it’s more …

Eric: I’m just going to throw out a caveat. The studies and psilocybin are relatively small. I think palliative care also has a tendency to jump on medications without a lot of evidence. I’m very excited that we’re building that evidence base, but-

Alex: We’re going to jump. We’re running out of time here so we’re going to jump into our magic wand questions, how we often close podcasts. I think for this one, I’d like to ask each of you, if you could wave a magic wand to change the way clinicians are trained, palliative care docs, geriatricians, primary care docs, psychologists, if you could wave a wand to change the way they’re trained or what they’re trained or how they’re trained, it’s up to you, I’m going to go Bill, Brad, Juliet with this, what would… You get one wish, only one and try to make it different from the person before you, if you could. Bill, I’m going to start with you.

Bill: Okay. So that’s a great question. Since I’m not a physician, I haven’t really given it that much thought, but I can point to at least one thing which I think would help. When I got a terminal prognosis for the first time, what happened was the guy basically just offered me either palliative care or medical assistance in dying, which is a legal thing in Canada and without debating the… He said, “Basically, nothing else will help you at this point.” I would say even though I’m a veteran in the medical system and fairly resilient person, that was quite a shock. I would think for most people, they would not be prepared to think rationally about those choices when everything is dropped on them in about five minutes. I’m sure that medical training does call attention to that problem now, but it didn’t get through to this particular ENT surgeon and I would like to see people give more thought to how you structure the presentation of treatment choices for people who really are in terminal situations.

Alex: Thank you, Bill. Thank you for sharing that story. And you do write about that as well in your blog. I think you wrote about it for the late press as well. We are considering a podcast on what’s going on with medical aid and dying in Canada, so we’ll revisit this as well. Brad, thoughts from you about how we could change the system or training?

Brad: Well, I think it would be great if every resident, I won’t say intern because they’re already in the middle of it, but if every resident and maybe every fellow were required to sit with someone who’s dying and knows it, not someone who is battling in the hospital, this should happen in the patient’s home, not… I mean, all my work’s been to bring this into people’s homes because in the hospital it’s really difficult. And then come back and do a brain dump about what the spiritual meaning was of what happened when they sat with that person and asked them questions about how they were really doing as a person and came back and discussed it. Don’t talk about spirituality. Talk about your own personal response, not reaction, but how you responded to how that person was doing when they knew that they were dying.

Alex: Mm-hmm. Yeah. Juliet?

Juliet: I want to go back, I think, to a grade school, elementary school through high school. I feel like we don’t start soon enough and it would be some sort of like existential skills class because I want to solve two problems. One, I want my patients to live meaningfully before they get sick. I feel like early palliative care is not early enough. I want to go back into the adult lifespan and help people do that better because it’s too late, I think, when people get sick. And then I also think communication skills are so important. They actualize our true selves and we just don’t teach that. It’s just a skill that needs training for years. I think if we just taught that to children, adolescents, high school students, then by the time we got them in medical school, they’d be good, Bill. They’d be able to talk with you kindly about your options. That’s a skill issue, right? It’s a communication skill issue. But anyway, that’s my dream.

Alex: That’s great.

Eric: Well, I want to thank all three of you for joining us on this podcast. I highly recommend both the book by Brad and Bill’s wonderful essays on his blog. But before we end, Alex, you want to give us a little bit more of Bob Dylan?

Alex: (singing)

Eric: And with that, thank you everybody for joining us on this podcast.

Bill: Thanks for the opportunity to participate.

Juliet: Thanks.

Eric: And to all of our listeners, thank you for your continued support of the GeriPal podcast.