Hey everyone, welcome to the drive podcast. I'm your host Peter Atia this podcast my website and My Weekly Newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness. And we've assembled a great team of analysts to make this happen if you enjoyed
This podcast we created a membership program that brings you far more in-depth content. If you want to take your knowledge of the space to the next level at the end of this episode. I'll explain what those benefits are or if you want to learn more now head over to Peter Atia m.com forward slash subscribe. Now without further delay. Here's today's episode. I guess this week is dr. BJ Miller. BJ is a hospice and palliative care Specialists. We talk a lot about what that means. But the reason I wanted to speak with
Is I've been really thinking a lot about better understanding what end of life means and how understanding the end of life can help us better understand frankly what we want out of life and by an amazing coincidence DJ and I met very very briefly many years ago in medical school, although I don't think he remembers it. But when I saw him again giving a TED Talk several years ago, I immediately realized hey, that's the guy I met at a party, you know, 20 some odd years.
Ago and became really interested in his work and then reached back out to him and said hey, would you be interested to sit down and talk about this and so in this discussion, we talked a lot about his personal story because you can't really avoid it and frankly his personal story is a big part of why he ultimately chose the life path. He did which is doing something that many of us including people who go into medicine would find just too difficult to do which is basically help patients die as a means to
Reach this combination of their life. We get into all sorts of things the difference between death and dying the difference between palliative care and hospice differences between loss and regret what the medical system. They were a part of his good at and what it's not so great at we talk about what really happens at the end of life when lightened or Transcendent is it and he tells a number of stories that are quite moving about patients and also from his own life, and finally we conclude with
A discussion on both the hastening of death. And also what he's most optimistic about including the use of psychedelics. This is another one of those episodes that I think people at the surface might think gosh, I don't really have an interest in that I would encourage you to push through that. I think it's natural to find this topic unpalatable. And I think that's exactly why people need to listen to this. So without further delay, please enjoy my conversation with BJ Miller.
BJ it's a real honor to be sitting down with you even though we're not in person together.
Thank you Peter. I appreciate you having me but I'm looking forward to this
now. I don't know if you remember this. In fact, you can't have remembered this because I'm not memorable in the way that you are but we've met a few times at parties in
medical school. No shit.
You went to UCSF and I went to Stanford and I don't know if we were
the same class but we were pretty close. What year did you matriculate at?
UCSF? 97?
Yep, so we were the same class and I don't recall you guys ever coming down to Palo Alto but we sure as hell went up to San Francisco a
lot for social reasons or for school
now just for social reasons.
Oh, yeah. Yeah. Yeah,
we just had friends in common and stuff like that. And so it's almost 25 years ago. And I remember one of the things that stood out was you had a dog, right?
Yeah, what was your dog's name? I don't remember.
His name was Vermont like the state God. Yeah. Wow. I'm so psyched. You remember him Peter. He was a huge part of my life and tell you that's beautiful. So
I will admit something BJ which is that I never had the nerve to come up to you and say
hey what happened because it wasn't subtle.
All right. Yeah. No, it's pretty pretty pleadingly obvious. Yeah,
so as I would learn later your life changed shortly after Thanksgiving in 1990, right?
That's right. You got it Bud.
Yep, and that change which I think on the surface would sound like a change for the worse maybe wasn't for the worse after all. Can you tell the folks? What happened that night?
Yeah. I mean it was a big moment in my life as your
In 2 Peter. Yeah, I mean and there's a lot to talk about it. So I try to just kind of correlate a basic facts and then we can talk about any of it. So just back from Thanksgiving holiday and I was very happy to see my friends. We were all kind of that early college. We are just basically in love we couldn't wait to see gently being away for Thanksgiving break close a bummer really. So anyway come running back and we immediately decided to go handful of us will go out and have a drink and just
Run around I was actually on my way to the computer lab to print a paper when it kind of got intercepted and off we ran to go have some fun. Nothing crazy. It was we didn't go nuts though, but we were heading to the waa Market which in the east coast is sort of like a 7-Eleven lay open all night place to get a sandwich god joint chips, whatever anyway, so we're walking to the Wawa Margot and this is a Princeton University where there's a commuter train that runs right up along campus Because Princeton, sorry.
Bedroom community for New York and Philly and so this commuter train was is called the dinky of all things. It was just sitting there non operating hours. So I was just sitting there and we stumbled across it and just decided to climb on top of it just relatively innocently for things we had done with felt much stupider. But anyway, we decided to jump on top of it climate climb a ladder to stand up on it like you would a jungle gym or a tree or something and when I got up on top of the train, I had a metal watch on and the
Electricity art to the watch when I stood up because I got close enough to the line. And that was at electricity entered the arm my left arm and then ground down and eventually there's a big explosion and whatever else and that was that I survived that but ended up losing both legs below the knee and that one arm below the elbow very touch-and-go in the burn unit in Livingston, New Jersey Saint Barnabas Hospital for I don't know maybe a month or so then I was in there another month in the burn unit and
Then eventually out of the air and into rehab and then a long process are re-entering the world. But anyway, that was my big that thing I call the cosmic spanking that big big moment that just came along and completely reoriented me change things around.
Do you remember the actual shock or is that sort of so traumatic a lot of times trauma patients, for example, when they're hit by cars or sustained a significant gunshot wound, especially if its fall
Led by a prolonged period in the ICU they suffer some antegrade Amnesia. So they forget things in front of them not so much behind them. But a lot of times that includes the actual event. So what is the last thing you remember? Do you remember actually climbing up on the train? I don't
know. I remember the night is all very fuzzy. I remember sort of Snippets from the hours preceding but I don't have any recollection of approaching the train or getting on top of it. This is just pieced together through stories from my friend.
For with me but the first memory I have around that accident itself that night. I can picture a lot of it again because my friends have told me but my own memory really began in the hospital that night. I was taken to the local ER where they just did basic things. They are called fasciotomies which as you know with electrical Burns you burn from the inside out. So you've got all this heat running around in your system and it'll keep burning you so they've got a
Vent that heat basically the local ER they cut these fasciotomies to vent me and then stuck me in a helicopter to go to the New Jersey's one Burn Unit at st. Barnabas. I can remember being loaded into the helicopter vaguely. I was very tall. I was almost six five and I just remember the pilots to there's this awkwardly trying to get me into the cockpit because I was too long so all the invitations I had wear surgical. So at that night my legs were burned I still have
So then you get to a burn unit and you're with now a team of doctors and nurses who have seen the worst of things for what it's worth just as a bizarre coincidence in general surgery, which is what I went to do after Medical School you rotate through all the different disciplines of surgery. It's quite random. You'll spend a month on this a month on that a month on all of these different things and my very first month of internship was in the burn.
Unit I had never done any of that during medical school. So to show up on day one at sort of the Premier burn unit of Maryland, which basically meant it was the referral center. So if you got burned in Pennsylvania, you were still coming down to Hopkins. I mean, it was another
world. You got it. I
mean it was very difficult to get used to doing dressing changes on patients and just seeing the amount of pain people.
Al were in when they suffered these Burns and the other thing that was remarkable at least to me was how otherwise alive people could look when they came in to a burn unit but yet how poor their prognosis could be based on the amount of surface area that was burned. We basically had Actuarial tables that would say, well he has this much of third degree in this much of second degree. And even though he's sitting here actually able to even communicate with us.
The person has a very high likelihood of not surviving this
injury. Yeah, it's interesting that you say that because one of the early memories been pieced together for me by a nurse at with whom I became very close was when I landed in the bay at the burn unit. This was not uncommon but apparently the text and the team were sitting around basically taking Wagers on whether I was going to make it. It's probably based on very much the same kind of what you were just describing that sounds kind of harsh, but I'm sure
Wasn't I think that was just as you know, these things get depersonalize the net setting almost by necessity. It's a brutal setting. But anyway, you can talk more about that. But I'm in a way Gladiator to know that you know, it'll burn it is like it is another world that I've always struggled to impart to people what it's actually like in there is a wholly unnatural place. I mean nature is completely kept at Bay.
Yes, and there's a reason that it's very separate. I mean in small hospitals they do what they can and I'm sure they
Don't have dedicated burn units, but at tertiary Care Centers, they have dedicated. I see use that are exclusively for burn patients that don't take other medical or surgical or neuro or pediatric cases and it's also a very special type of nurse that works there in a special type of doctor because everything from the frankly just a times the grotesque nature of the disfiguration of the skin these dressing changes that we talked about doing several times per day on a patient. They require incredible sterility.
At the bedside frankly in the early days early days of the patient's admission. Even the smell of burnt issue is a very foreign odor to people so everything about it it places by the way, everything I've said says nothing to what the patient and their family must be experiencing as they're coming to grips with this. So when did your parents arrive? I'm sure you don't remember it but based on the stories,
they came almost my poor parents and they got the classic the middle of the
The night they were in Chicago where I grew up the time so they get a call from New Jersey at 4 a.m. Or something ridiculous and basically not a lot of information just everything was emergent and scary and basically your son's here with us. He's very badly injured might not make it through the night get here as soon as possible basically one of those calls. So my parents were there as quickly as it could be the next morning to your point about this place these so what they've learned burn.
Treatment scientist infection is very often the thing that kills people hence all the sterility. So someone might look just fine but they're so exposed their bodies. So exposed that you're so susceptible. So that means whoever's in your room there in space suits and whatever else and for a while but I was not allowed many visitors there were friends who would come but they couldn't come into burning it eventually. They allowed my parents at the bedside one at a time. That was it, but it was really powerful.
Powerful and very potent visits. I remember them very well as did my parents as you describe your experience as a student as a trainee. It's not much different because it's such a foreign exotic environment that works against intuition. A lot of ways the things that touch for example something up to avoid at all costs smells everything is foreign. There's just no place to sort of rest into it a familiar can imagine if it was that way for you as a student trainee. It was certainly that
Wave for myself and my parents but in a way to that foreignness and by virtue of me being so undeniably vulnerable. I was not moving. I was completely at their Mercy in a way. It allowed me to very quickly submit to the place and to the people working there because I clearly had nothing approaching an option very quickly. I was aware of my vulnerability and an immediately trusted the people
At me in a way because I had to but also as a comment of how skillful they were at their work. Do you remember the
actual discussion you had with the doctors about the need for amputation? Because obviously when the fasciotomies are performed initially it's with the hope of salvaging the limbs presumably at some point they came to the realization that trying to salvage the limbs was actually going to threaten your life due to infection. They had to go I've been around those discussions. Do you?
Remember that
I do I do I do my first memory real vivid memory before besides out helicopter moment was the night before my initial amputations and the part. I remember about it, which is maybe five or six days in Peter. That's when I was hemodynamically stable enough and more to the point the demarcation of viable tissue versus unviable tissue is a little bit more obvious. So surgeons had a fighting chance to remove the right amount so
Doctor men sewer was the main surgeon an amazing amazing person. I remember he came in the night before and said something all I remember is of a conversation. And then I remember falling asleep. I fell asleep in my little room and somehow you know that feeling Peter where you wake up from a dream and there's a moment of reorienting yourself and maybe it wasn't a very pleasant dream and to take a little second and you get your bearings and
It's just a dream. Thank God, you know I think thing is people show up like taking an exam naked or something. So they're late for their wedding or some moment you wake up and oh thank God. That was a drink. I remember I woke up in the burning it having that sensation strange. I remember I looked around and I had this weird feeling like, oh this whole amputation thing that I was just hearing about was a dream. Oh, I'm fine that I go to the bathroom. So I in my
my Hayes has managed to extubate myself. So not an easy thing to do excavate myself pull my central lines out of my neck unstrap my arm from the bed and all the while I can remember this so clearly I'm looking around my room with all these cues that obviously I'm not in my bedroom, but for some reason I'm just thinking yeah, this is my room up just going to go to the bathroom now and I got up and out of bed eventually and started walking to the door with all these alarms going off in the middle of the night somehow. I don't know where the nurses were.
Was a gap there and I started walking to the door just to take a leak on my crispy little feet and the Foley catheter line ran out. And so, you know, they're usually attached to the bed. So when that line ran out it yanked on that Foley and that's a pain that I won't soon forget and that catheter ball was not deflated. We can explain this for your listeners. But anyway,
I was just about to say we're gonna hit pause and explain everything you just said, but
let's start with the extubation. So you have a tube that is in your Airway and a machine that is breathing for you. So the act of pulling that out means you now have to breathe on your own something you have not been doing for the previous week that alone could have killed you.
Yeah,
right you then pulled out a bunch of central lines, which if not compressed. So Central lines are very very long intravenous lines that go into the main vein.
Inside your body veins that most people don't even realize they have called the vena cava subclavian vein Etc to pull those out without the appropriate protocol of compression could also lead to internal hemorrhage and all sorts of crazy things. You're dodging death. You're three for three on this. Yeah.
Yes in retrospect. I smile almost with prime because it feels good sound so good hearing and obviously time. I had no friggin idea what I was doing, but now it's your unkillable.
Oh, yeah,
but then the thing that finally gets you is a catheter about the size of an HB pencil that is in your urethra up to your bladder which stays in place with a balloon that's dilated to the size of a very large Gumball and said Gumball prevents the catheter from ever coming out. And before we take these catheters out of the urethra, which is
Itself unbearable. I myself have had one. We have to deflate the ball because trying to pull a gum ball sized device out of the urethra would be tantamount to torture. But of course you just went ahead and threw the force of walking towards the door basically removed your own Foley catheter - the balloon removal or
yeah. Yeah,
you're still alive, but all of a
sudden that dream not happy. Yeah. It is amazing that you're right that you must have done this all very quickly to make it happen. So now you're sort of having that moment of maybe that wasn't a
dream. Mmm. I will never forget this it was a Clarity that world all the haze cleared up instantly when I felt that Foley dislodged from the bladder but incidentally didn't come all the way out. So it's somewhere halfway, which is even worse. Yeah. It's just terrifying so I immediately
The floor and I'm screaming and now nurse comes in. I don't know what the delay was incidentally that poor nurse. We never saw her again. She was never assigned to my room again poor thing part of her explanation. She was avoiding my room. She admitted in some ways because she had a son my age and look just like me and it was really hard for her anyway, so eventually so I'm on the floor now screaming trying to break the catheter line, which is impossible, but the only way I could I thought I could break the tension. But anyways
They came in got me back in bed and all that stuff. Anyway, I went but to your question Peter, it was instantaneous that I realized. This wasn't a dream and all the relief that had just had an experience moments ago and the other direction just immediately went away and I was very very clear on where I was and what was happening to me instantaneously. It was a wild wild moment. I won't soon forget.
So what kind of a mourning process did you go through?
Operatively when you come out with both of your legs amputated and your left arm,
so the answer is my mourning process took me awhile, and I my conscious mourning process was delayed because I at that time embodied the sort of absorb the American notion that know what you do is you pick yourself up you get a back on the horse immediately unless you acknowledge what's gone on the better the tougher you are the faster.
You'll be functional again, etcetera. So early on I didn't do any morning not consciously. I was kind of going the other direction joking around making light of it and both the moment of someone of denial and also probably something pretty poignant to I remember when I came out of that first surgery, so I didn't know that there were people I knew my parents were there and oddly Peter. I don't know how this was possible my parents moved into the hospital somehow. They got a room in the hospital from Chicago. They live there all the time. I was there I
How the hell that never heard of that but they did maybe they had a huge wings of st. Barnabas that weren't being used. I'm not sure but I knew my parents were there so I come out of the or come out and I'm heading there Wheeling me back the leg amputations what they did first and I knew whatever the case is I had absorb what doctor meant sewer told me the night before eventually I woke up from that surgery with the no surprises, but I'm Wheeling back to my room and as a brief moment, where you
I'm from the or sweets back into the burn units and that you go through this little hallway and I come out it was packed with people my friends and some friends have flown in from Chicago. I was so moved. I had no idea that they were there and it was just a brief second. It was no time to talk but there's just a lot of love and it's remember their facial expressions. I was very very moved and then I went back into the room and I remember my mom came in and we were sitting and she was crying and my mom had Polio she
Disabled my whole life most of her life and I just remember this is going to sound I don't know. It was part denial driving it but I just remember my thought when my mom came in was my response to her was. Oh Mom will now we have so much more in common. Now, we're both disabled almost like a cheeriness. I love my Mom very much. We're very close and I honestly felt like I was joining this ranks of folks that I always knew existed and felt very much a kinship with the disabled.
Immunity by virtue of being close with my mother. My first response was so weird kind of immediate acceptance, but I had to go back and it wasn't a thorough acceptance. It was where I wanted to be but it wasn't really where I was. But anyway, that was my first statement. It took really weeks. It took actually my nurse kind of trying to work on their member of time maybe a week or two later where one of the nurses with whom I was very very close. Joy for Carta poem.
Enjoy came in one day and she was just really moody with me. She was just like throwing think she's just strangely Moody and I was just sort of joking around. And anyway, she's like throwing bedpans running things like to play. What the heck? What is what's wrong? What are you? Okay, and she's just basically live image that I am just sick and tired of you not taking this. Seriously. You're just joking around you haven't even cried. This is a big big deal. You're not being real and she just let into me.
She letting me until I finally cried was the first time I cried was weeks in it was the most magical thing Peter. I will never forget that one either in part because it was like a dam had broke and so much came pouring out and it felt so good felt like such a relief. I hadn't realized I hadn't consciously fought back tears or tried to be tough. I just thought that's what I'm supposed to be doing and I was on otherwise on autopilot to but what was also weird about
His tears was for the moments. The tears were falling. I had really no physical pain. I've never looked into this but I wonder what the connection is between the act of crime not just feeling sad but actually crying and anesthesia. It was a fascinating moment, but it really moved me and it began my relationship with a began letting in that. This was a bigger deal than I had managed to let it be offer that to say the morning The Grieving was very gradual. Took me a while.
Wide Awake up to my own feelings about it all that took months and years really
do you think that that was mostly a sadness and a loss that came through expectation of these are things I wanted to do that. I will no longer do and I am sad as a result of that or do you think it was tears from a different sadness a sadness? That's more born of anger. Like how could this have happened? It's such a random event. I've done far.
Things in my life like why was I wearing that watch? You can sort of go through all those things like do you have a sense of where you were in terms of that? Damn the flood gates opening?
Yeah. Yeah my senses Peter and it's a sense driven by most of where how grief materialized for me over the months and years, but my sense is for a number of reasons. I did not have a lot of why me moments and there's a lot to say about that but to answer your question.
Question. No, I think it was more like first of all the physical pain. I hadn't really let myself. I just been literally gritting my teeth and for as vulnerable as I felt as so exposed as I felt I was looking for anywhere where I could look or feel or act or present a strong and it's the only way I can think of I think was to kind of keep this stuff in and so I think part of it was a release around just a physical pain.
And I think the rest of it that didn't have a lot of clarity around the object of my sorrow, but the sorrow I really think was had to do with embarrassment for doing this for ending up here putting my parents through so much pain. I could see it in their faces slowly began to see what it did to friends too and others around me the feeling I think a lot of the pain a lot of the tears had to do with here I was taking so much from so many people
'well, I was embarrassed about that am ashamed about that. I think that was a big part of it and I think there was also an image. I had just kind of come into my body as a 19 year old and I think there was a sadness. I didn't know if I would ever have sex again. What women were going to think of me what my friends would think of me? I'd been around disability my whole life and I've watched how cruel people could be in the projections they make and I think part of it is the more tears that I knew what I
Going to be walking into with that. I think yeah all of those things but low low low on this Peter worth of why me questions. I owe a lot of that to the prep work that my mother my family life. It said in it was always much more the question of why not if anything I felt guilty for having to perfect life before that
separate from all of this BJ, there's another kind of really transformative event in your life that has to do with your sister. When did that take
place? That was 10 years.
Years later, so that was so you're in medical school. Yeah, exactly
and I want to come back to how you got to medical school. But can you tell me a little bit about your sister and the relationship you had with her in the 10 years that followed this and then ultimately her demise
good segue. It's a lake of the way I grew up was I was no stranger to pain I was around it and they're all sorts of reasons to feel like that life was inherently hard and that was
Something about I felt almost a perversion that I could feel happy ever that felt that almost felt wrong. I don't know how to explain it but part of my growing up was growing up with a sister. I have one sibling Lisa Lisa was four years older and I am wild brilliant fascinating just intense person and our whole family life so much centered around her and her moods and her thoughts so I was enamored with
With Lisa, he was my older sister. She seems so smart to me. She had emotions around things that I hadn't even thought of and she had these developed psychological emotional responses. I just felt like she must have insights in the world that I just couldn't see and she had such conviction and she was harsh harsh harsh harsh that conviction older sister. I wanted I aspired to her so I chased her moods around anything. She told me I took at face value and she owned me and so many
Wait, since your younger brother and she was very troubled and part of my adulthood was coming in to realize that Lisa wasn't just full of conviction least was also full of some other things and so in my twenties here, I am going to med school. I'm finally learning to load to have some separation from chasing my sisters moved around and then in December December 1st of 2008 roughly almost exactly 10 years after my injuries.
Lisa decided to kill herself Lisa decided to leave the planet. So yes, that was another one of the major major life events for me and that was deep into medical school. And one of the things that precipitated my deciding to leave medicine. I was going to get out of medicine at that
point. No, I didn't know that actually. Yeah, I want to come back to this. Can we talk for a moment though? Just to make the connection of how you ended up.
Deciding to go into medicine because when you were in your freshman year at Princeton I get the impression that medicine wasn't even on your radar.
Correct? Yeah. That's right. You got it. Yeah, no interest and even cross my mind. Yeah.
So after returning to Chicago going through a very lengthy process of Rehabilitation Yuri enrolled at Princeton a full year later.
Correct almost. Yeah The Following fall, so I went back.
In September of
1991 and you changed your major to art history as that also.
Correct? You got it. Yeah, why did you do that? I had been there to for that's a word. I had been studying Chinese language and was going to heading for a major in East Asian studies, but when I was away when I was in that the burning at such it's like a torture chamber interspersed with like incredible boredom. Like you're just so there's useful.
And this is so wild when I look back on these. I'm sorry. I'm just a quick digression. So this was the first Gulf War was happening. It was so strange. I was watching a war members like a televised War since a wild thing bored stiff in horrible pain to and from that tank room for daily debridement. So horrible pain interspersed with slight relief and boredom no touch with the there's not even a window. It's a weird thing and I would toggle between them television between
During the war and some cooking show. It was just the strangest. I don't know why bring that up. This is how I spent my day, but now I forgot your question brother. What were you asking me about
the decision to change to art history?
Oh golly. How did I get to that? But anyway, well, I know because I'm sitting in this bed bored stiff and of course even with my little structures that were still in place of kept me from crying or acknowledging a lot of things.
Of course, it was no getting around some stuff and I was beginning to let into my Consciousness and my daily thinking like know sort of preparing imagining my life down the road. When am I going back to school? Will anyone want to be friends with me ha but I'm basically bought a - I'm sitting there very much pain during the value of my life. What am I now? Am I less of a person do I have less to offer the world? What will people see in me wanted me? I mean how so
Basically questions of meaning and questions of identity. Who am I? What do I do with myself now? What can I do? I found myself in that mix just sitting there pondering questions, like knitting a life not in a recreational or intellectually kind of Ivy League write a term paper way, but in a way that was very obviously relevant in therapeutic and practical these existential issues became very practical and I that's where they belong by the way, I think
So sitting there one of my friends have closest friend. Justin would come visit me in the Burn Unit. Eventually we found ourselves talking about art is this thing that humans do so I was looking for meaning making what humans how humans work with pain? How did humans work with things they can't control and that led me to thinking about art. Why do human beings make art? Why do we take the material of our life and create within fashion something from it that wasn't there before but now exists thanks to us.
It's kind of a stunning impulse that human beings have whether you're making aren't it's going to hang in a museum or you just futzing around your house. We are a very creative species that was lighting up for me as a very important and telling and that maybe maybe the art world had something to teach me. So when I went back to college that fall, I rejoined my class. I just had to finish the exam somewhere in the summer and I had a free semester. I was supposed to be in China the second semester sophomore year anyway.
If I didn't have to do much to jump back in with my class and that was very important to me. I wanted to be back with my buddies. That was a real driver. So anyway, I had back to Princeton join my class and changed my major to art history to studying art. And that was a really consequential decision when I'm actually very proud of
I've talked about it before on this show. I think it's even come up during a discussion where someone asked what's the best major that I would recommend?
For someone who wants to go into medicine and I don't have great Insight on this but the one thing I generally suggest is anything other than pre-med because I think whether you study art history or engineering or a foreign language and a foreign culture, you're probably going to get something out of it that you would never get if you studied pre-med yet. Most of everything you study in pre-med. You're going to pick up in medical school, which is not to say that studying pre-med is not a good idea. But that's my two cents. Is that the people who came
Min with totally different backgrounds often were people who didn't actually plan on going into medicine as is the case in yours. The stories are usually pretty interesting. So when in the Journey of art history do you then realize you want to make what I think is even probably a greater stretch or leap, which is to actually go to
Medicine. Yeah. So let me first see your two cents and raised in mind.
Unless we want medicine to Simply Be the stuff of technicians technical Pursuit, which of course it is in many many ways teach in med school. I haven't as much lately, but I've spent a lot of time teaching in schools of medicine and nursing and love it. Love it. Love it love it. And if we view medicine as a technical Pursuit simply then okay pre-med Focus great, but the trick is of course in medicine is our job is not just to it's one thing to know details.
Tales about molecules how they work but it's a very different thing to know why it's amazing to have molecules in the first place. And if you have not thought one way or another doesn't have to be art. It doesn't even have to be through school per se but you better find a way to if you're going to go into the healing professions and clinical professions. You better find a way to delve into why life is amazing and horrifying. Why is it so hard to let go of why?
It's so hard to love life when you know, it's going away. What is this all about in other words questions around meaning and identity one way or another week Physicians and you can see what happens in a Health Care System that's is somehow has crowded those thoughts out as somehow being irrelevant. You're left with a lot of zombies. You left a lot of people with pulses but have no idea why it's amazing to have a pulse from the first place. So anyway, I can go on and on and on but boy, I really really really
I love the notion of people who study Humanities then going into the healing professions. I think it's some people see that as like a left turn like oh, but I couldn't make a bigger case for art history was some of the best preparation for medical school. I could imagine
I think you're bringing up really great points PJ and I think medicine needs all of the above. You need people who have probably gone incredibly deep on a very narrow subset of science. You need people who come in with engineering
Backgrounds you need people who come in with Humanities backgrounds and I haven't to be honest with you paid much attention to how medical schools are doing these days in terms of recruiting talent, but the war for talent looks like in medical school versus Business School versus Law School versus other graduate schools, but I would hope that they've figured out what you're saying and are making adjustments in that direction.
I think they are. I know UCSF my alma mater has they've really invited folks like myself.
I didn't tell any of the pre-med to Princeton. I did all the pre-med work after college and UCSF as purposefully attract. A lot of folks who are starting med school a little later in life have some other life experiences Etc something of a trend there. I'm with you, right it takes all of the above medicine is also a technical Pursuit. I guess even if someone wants to be a pre-med major take that more conventional wrap my advice to them was just make sure you actually love it. Just make sure you love the nuts-and-bolts. You're not just doing chemistry just as a means to the end.
Of medical school you find something to study that actually cultivates you loving something. I think that's a major major distinction. That could be engineering that could be art. That could be chemistry.
Yeah. I've always felt that the history of science is also equally beautiful. And so when you're studying physics and you're studying chemistry to be able to study it through the lens of how the people who discovered it went along their Journey probably creates or at least Foster's some of that intellectual curiosity.
Our city and passion that I think can be found across multiple disciplines. But still I want to get a better sense of what made you decide to take a very bold step which is I think to leave a comfort zone of you've now spent four years doing very well and you've got this degree in art history from one of the best schools in the country and you now decide to presumably go back and do a post back year to do a bunch of pre-med courses to go and do something that seems about as orthogonal.
From that is anything. I'm sure it had a lot to do with your experience. But can you speak specifically to what it was and how it for the lack of a better word marinated over the previous four or five years.
Yeah. Absolutely. I can track this out. So one of the things injuries did for me cut to a spoiler one of the therapeutic Endeavors here one of the ways to get through something and since Som real way so let yourself be changed by it. I knew enough.
That thanks to my mother and the disability rights movement that the goal for me was to not get back to where I was before the injuries. First of all practically speaking. It wasn't possible. I wasn't even get my old body back also why cut myself off from all those lessons and all the experiences that happen during that period it's not something I could forget but nor is it something I would want to forget it's too dang Rich. So the idea was really always I
new versus the certain normal language and thoughts are on disability and it's like that. It's something you would want to overcome put behind you and I think a lot of lay people are able-bodied people think the highest compliment that can offer disabled person is oh I look at you and I don't see disability at all. I know what they're trying to say and we can talk we can open that up to if you wanted it down the road here, but trying to say but in a way, it's not really a compliment. I don't want people to ignore.
Major parts of me just to look at me. I'm not getting over these injuries every day. I'm reminded in this is not something of the past something I live everyday. So when I hear comments like that and you just feel like you're just aware that you're not someone isn't really seeing all of you. That's problematic in a number of ways. So I knew I knew that I wanted to work with these experiences. So that was a major major theme and Medicine lit up as just theoretically as a way to put these experiences to use and the linkage between
cutting art and studying human endeavor in the study of medicine was not such a big leap the interest the through line the bay. So continuo for me was just being very interested in human beings human Pursuits human Endeavors and human creativity art was one application of those interest and medical science was another as I pondered. What I wanted to do. I thought well gosh medicine would be interesting if a doctor walked in to see me and the shoes
I'm wearing now that would affect me in a positive. This was some way I was actively looking for an outlet where my injuries work something that someone would look past or forgive but we're actually in some way something of an advantage and in this way for me and medicine I can tell you that having this silhouette having this body has really been an advantage in a lot of ways if the goal is empathizing with your patients and their families if your goal is seeing yourself as a fellow human being
Next to them if you know and believe that's where healing happens then this kind of stuff. It's the best prop. I've got going. I really feel for my able-bodied clinicians who don't have some obvious source of pain and suffering that imparts to your onlooker two parts to your patients that you've been through some stuff you've scraped the barrel. So anyway, I'm going on and on about that. But so get back to your question that through line. I knew I had a hunch that that would serve me and Medicine just as it did in art and that I could apply.
These lessons into sort of a plethora therapeutic application of studying perspective and meeting thinking so medicine lit up as a potential thing that I could do. That would be fascinating. I could make a living and I could exercise these lessons in a novel way.
So it makes unbelievable sense actually and I suspected changed many things for you. I mean look if you just described yourself as a six foot four handsome guy who goes to Princeton.
You probably are a pretty ambitious guy. You're going to go off and study foreign relations and do all sorts of cool things and then everything kind of gets taken away in an instant. How does that change your relationship with your own ambition or what? It means to try and fail had you ever failed at anything by the way, athletically and sort of academically even in the 90s. I imagine getting into Princeton was almost
impossible. Yeah.
Exceeded in ways but also so tremendous had some green lights right in front of me. I have this amazing education. I had some basic abilities I could make a case for us, but I had suffered and struggled in various ways up until that point and some things had always gone right for me. But there are such a such a different scale. There's such a different scale but even as a kid, so in some ways know, I really hadn't experienced loss on some big way, but what I had experienced was lost through people
Others that I cared about watching post-polio syndrome take my mother's physical function then watching my sister struggle. So in some ways Bart of my charge as a young person was I hated that I didn't have more wrong with me. I felt there was a mismatch. I felt at odds with the world. I felt this pain around me, but I didn't really feel like I had my own access to it. My problem was I didn't really have anything to complain about I knew that life was really really hard for many many people and internally my life.
Hard just imagining that and in some ways getting this new body and in some ways I have to say I made it such I could cultivated this idea. But in a way I got the body that much more mirrored how I felt inside fragmented broken confused unintegrated different and some weird ways this body really the physiognomy of my body actually suited me in some real ways. I chose that I ran with that was
True but it also is a way for me to get into this body eventually and quit wishing it were something else by building on what this body was showing me. I knew the clever thing was I knew what I was doing was building a case that this was the right body. But this was a good body. This is the one for me and then you can imagine that really cuts down on the regret and the second guessing and if only I had four limbs then about Bubba. That's the kind of
Mine said I was heading for and trying to cultivate now here again, brother. What did you ask me that I went down on that engine?
No, actually I was talking about this idea of this could have actually liberated you a little
bit. Yes. Yes,
and I think you've articulated that very neatly. I want to come back to your sister. We all do this when we get to medical school is we start to learn things that explain things we've seen in our path.
Past for example, it's the first time you would have learned I suspect on some detail what the polio virus looks like and what a virus does how it is that your mom actually came to contract this virus and how a vaccine ultimately would go on to make sure people wouldn't get that virus and I would learn about the cardiovascular disease that ran so deeply in my family and really understand the pathology of this at some point. Did you start to suspect that your sister had whatever you want to
Call at formal mental illness or did you not think that that was the case at all or how did you think about your sister? Once you were in medical school and you began to learn about mental health in a somewhat formal way
quick answer here is no I didn't only time I actually let myself do that sort of pathological overlay was after the fact after she had died leading up it's telling I mean leading up to that even through medical school studying manic.
Depression something that she was posthumously diagnosed with oddly. It never registered as me reading about someone like my sister somehow and I reference this a little bit earlier was somehow the way she was or the our Dynamic and it wasn't just me. It was my parents too and her psychiatrist too. She was a master manipulator. She can have anyone thinking exactly what she wanted them to think and particularly me as her little doting brother who just
Up to her if I absorb anything from Lisa was that Lisa was right Lisa had it right including her angst and her pain that the world is a painful place. And Lisa was reflecting that anything. I saw Lisa was the standard. She was right. Everyone else was wrong, but she kind of rolled with what she was selling. I did roll with what she was selling and deeply to the point where any idea of pathologizing her just completely bounced off my head. It didn't register as relevant to her.
She was the right one until she ended her life and then that prompted all sorts of revisiting that thinking also then eventually my parents what they did to try to make sense of all this today went through her diaries with the psychiatrist and it was in that act I didn't join them in that but I received the news and I believe it which is she was just textbook bipolar. I mean just outrageously textbook and sometimes I'd get my
Wanting to quit medicine did have something this was right after Lisa died on the list of why I want to get out of medicine was like Jesus. I can't I didn't even see right under my nose. I'm trying to become like a Healer person. I can't even acknowledge that my sister sick. This was demoralizing on some level. But but I also come to myself. She had a shrink for better than a Dozen Years who didn't notice this who didn't was who was somehow shocked that Lisa killed herself weirdly I did.
I remember on the one hand here. I didn't see any of these signals coming and at the same time. I remember where I was when I got the news of her death. I was with my dad in a car and my buddy Justin my mom called my dad picked up and it's kind of usual sing-songy way and there was a pause and then he immediately starts bawling. I knew instantaneously that Lisa was gone. And when I heard it was suicide there was not a single cell of
In my body, it's just an observation. Also. I'm telling you to things in the one hand. I didn't see it coming on the other hand. I completely was saw it coming. I don't know how to reconcile those two, but that's just the case.
So you're in your last year of medical school when this happens you've now alluded to this twice. Were you not planning to do a residency at this point or was this the event that sort of tipped you to not pursue your residency that following summer.
Well also med school. I just
Zoom because I wasn't so enamored with medical science per se that was just a bag of tricks. I was interested in gaining a career or work that allowed me to continue to thinking about these things and work with others and serve others around these ideas of identity of loss and Trauma and I just figured the best place for me to exercise that would be in the rehab setting. So I was some beelining for physical medicine and rehabilitation so deep in the medical school. UCSF didn't have a
So I went and did an externship somewhere rotation elsewhere the East and during that I had already begun to apply for residencies in rehab medicine at that point and I thought side then I hear dear rotation. I haven't already committed in this field and I hated it. The rotation was I just really did not enjoy it for all sorts of reasons one. It was was all mechanical this idea of like Rehabilitation. First of all, the phrase is problematic rehab like the goal would be to get back to where you were before the injury, which have been saying
I just don't believe it's true. It's importantly untrue. And this I did that was so mechanical had nothing to do with the personal Transformations that happen. That's where I realized. I was so interested and that plus I realized as I was walking out of patients room that kept hearing nurses say look Timmy. You can be just like BJ's a doctor now I could hear myself being served up as a poster child.
And I didn't like the mechanics of the job. I didn't want to be a poster child hip so facto. I was like, I gotta get out of this and one of my promises to myself going into medical school. I Having learned what I learned was. Hey life's short life's important life's hard life's beautiful. I'm not going to just get stuck somewhere and have a sacrificial life. I know a lot of our colleagues and Medicine who went into it because their parents were doctors and they hated it. But what else am I going to do now?
Now I've gone this far or one way or another they'd assign up willfully sign up for a life of misery. I knew I was going to do that. So I promised myself and at this point another thing I learned from the injuries, which was so critical was the ability to I was much less afraid now as much less afraid of failure. I was much less afraid of falling so you asked me earlier if I had anything really go wrong before in my life in some ways. The answer is no I was a very frightful Melancholy child sensitive, which would end up manifesting is fearful.
Now I was gone the other direction man fear. I had a totally different relationship with fear. I saw falling as a skill. So anyway, the bottom line there was I was willing to try medicine and willing to dump it and in fact, it felt empowering to do so, it was a reminder that my life was bigger than just a job Choice anyone's life is so there I am deep in med school already applying for residency in screw this so as I promised myself so I called dropped out of the match talked to my Dean.
Dean said hey I'm finished. I'll graduate but you know, I'm going to go do other things. She talked me into said Okay, okay, right. I had begun to be disillusioned with medicine before my sister's death, but that was sort of the straw that broke the camel's back as you've referenced. I think we bringing idealism one way or another into the healing professions. And then you have to go through this process of disillusionment where the practice of medicine isn't necessarily.
Jibing with the ideals that you bring into it and that can be very stressful. But I do think it's important for any trainee at one point or another to go through some disillusionment my response that disillusionment was to get the hell out of it, especially as I realize I did like rehab medicine. And again Lisa's death was just like proof that I'm just not I don't want to do this and I'm not cut out for it, but then I got talked into doing my internship that first postdoc year.
And my family was in Milwaukee at the time I had gone away I had left home when I was 15 and given Lisa just died given. I didn't know what I was doing in some ways. I said, okay. Well, I'll move in with Mom and Dad will re congeal as a family spend that year together and I'll bang out my internship and just get that done and be done and move on but it was during that internship that I stumbled into palliative care and that's where everything changed again.
So PJ. What is it that you saw during your internship that both made you change your decision leaving medicine and also concentrated or focused you on an area of medicine called palliative care.
So a couple things happened one of the things I deserve stumbled into the selected during my internship We have basically one month of an elective time. If I remember correctly. They've been more but I'd spend a little time.
Time with a hospice dock at one point actually my best friend's mother who's involved hospice and she turned me on to the idea. But again, I was so hell-bent on rehab venison figuring that was a place for me and wasn't sure that I had anything special to offer beyond that sort of rehab setting but I had absorbed the hostage was simply just where people go for the final days of life that most I thought I understood what that meant. But anyway someone into this kind of care elective at the Medical College of Wisconsin, which is he
Happens to have been one of the early adopters account care David Weisman an oncologist are built from the early great palliative care programs just happened to be there. And on that first day. We went and saw patient. I watched David talked to her about code status. This is in the hospital. He was a woman with heart disease events heart disease and David was trying to talk to her about her wishes. What kind of care she wanted for and trying to impart how serious her heart.
Addition had become tricky conversations very emotionally psychologically loaded content really tricky the zone that medicine tradition does not handle very well. And so I'd seen all these counterpoints but out here I'm watching this guy said with this woman sits on the edge of her bed with her just immediately this very different Rapport. He's talking to her like a human being not hovering over her like a superior someone who's there to fix her. He was there as a fellow
The
Bing and it just showed it in his body language and his tone and his word choice. It was beautiful and he said to her and I just watch how she responded to him and it was remarkable and he said something to her. He tried to get to the code status question since I've been essentially like when you die, do you want us to help that process along make sure you're comfortable to that process or do you want us to really fight that you want us to go to war with that notion do our best to pull you back something along those lines?
Vines but the Magic Moment was him looking it in the eye and saying when you die, of course as human beings, it's a very reasonable thing to say because we all die it's not if it's when in the medical setting that is not the way it was nice conversation generally work. I was so moved by watching this and he dared to acknowledge This Woman's death and what I saw on her face was not shocked whore anger but relief that this man
I was talking to her plainly about her life and it was so gorgeous. So poignant that moment really really stuck with me. And as I got done-- home that night a number thinking about it's like well, this is what I've been looking for. This is in this world we take in palliative care World illness disability death are normal. They're not anomalous this field treats these life events as normal life events, which of course they are.
Are the starting point for palliative care is something's happening that you can't fix that you can't change and that was for me all along in rehab you can see would be similar like rehab the events already happened. Something's gone wrong. Now what you do? I knew I was interested in the now what but here this field was digging into all the it's not just the angle of the joint. It was concerned with but that the angle of the thoughts and the way that we see ourselves in the words we choose.
Five our place in the world and how we either suffer for those words or really confined ourselves to something more therapeutic and it was such a craft such a something words not of a instrument. So anyway, I really was really really moved. But the first axis that opened up was I'm not here to fix people I'm here to be with people as they find their way as they deal with things that they can't control and that was for me.
How would you explain to someone the difference between palliative care and hospice which I think many people use interchangeably, but I don't think they really are interchangeable. Are they
they are not thank you. Thank you. Thank you that quick Public Service Announcement because it's a really big problem for a number of reasons. But palliative care is simply the interdisciplinary pursuit of the quality of life within the context of serious illness palliative care. Is that mode of care which helps you it was well as possible.
Emotionally physically spiritually you name it? My job is to help you deal with the facts of your life and to feel as well as you can there is nothing in the definition of palliative care that makes it that you need to be dying anytime soon time is not mentioned. There's death is included in this but it's not the focus. It's simply the pursuit of quality of life. And if you need to pose it like we do in medicine if you need to have a object of your efforts and enemy as it were the thing we're after
Gattaca think we treat is suffering versus disease and there's a lot to that we can unpack that. But so that's kind of Care Hospice is a subset of palliative care, which is that mode that type of care but reserved for the end of life the final months of life. So hospice really is essentially end. The Vlog here is palliative care and it's applied at the end of life, but that's just hospice and palliative care. There's no mention of time. You just have to be struggling. He's after the interested in quality of life.
Had to be done anytime soon. This is a huge huge distinction because of all of our deaf vote because they think kind of care and end-of-life Care Hospice are the same. No one wants to talk about it. No one wants to face that because of all the baggage around death. So consequently people suffer for years where they could get a lot more support Medicare because it is one of misunderstanding. They don't have that kind of care because they think that's only nothing could be farther from the
so does that make sense?
It really does? Yes, and I appreciate that
distinction good.
What do you think? It is about us as a species? I can only speak to us because other species I don't think share our metacognition that why are we in such denial about death? It's been said by so many people we are all terminally ill and yet most of us myself certainly included don't act that way at times. We tend to fixate on things that absolutely don't
Better
for many people. There's Frank denial of this thing. It's out there with some sort of abstract idea, but it's certainly nothing that warrants any attention in terms of decisions one makes today. That's really the first question I have and then I there's other things I want to explore here with you. But what is your take on our just inability to look at
death? I think for starters I know in my field and Elsewhere for folks who have kind of dared to turn their attention to mortality or been forced to
Then you look back on the rest of the world and you see a world so invested and ignoring this part of life that it can feel a little perverse and I think a lot of us are quick to say the world's and are Americans in particular are in denial and there's some truth to that for sure. But I also think we should cut each other some slack just physiologically neurohormone Ali we are wired to run away from Death any threat to our existence. We have deep wiring that makes us fight that thing or
Flea it or go limp. So if we have that impulsiveness and then I think on top of that there is as old as human beings has been this acknowledge that we die that any adult in this world. Maybe not to even just adults one way another human beings eventually come to the realization that death happens including their own death and I not sure that any other species has to live has to walk through life feeling that so it is quite a
Predicament we humans have its Elemental. It is at the root of the judeo Christian tradition. It's a root of Many religious belief systems. A lot of philosophy of thought. It's at the root of song and artwork in this is a huge huge subject that humans really really struggled to wrap their heads around. So I just want to give us plenty of breath in and I don't want us to be ashamed that we haven't figured out this death thing. So on top of those old threads in modern times last
Hundred and fifty years medical science or sort of a victim of our own success Medical Science has gotten much better. It's easy to be seduced. My life has been saved by medicine. It's easy to believe that medicine can forestall death perhaps indefinitely. So you throw all these things together and social cues around anti-aging this and that and you got to stay healthy and beautiful forever and put all that stuff together and we conspired to set up a pretty tricky.
Relationship to this piece of our nature no harm no foul, but I think the reason to push back on. This is a people die much more miserable than they need to because they haven't dared to look at this thing called Death Before It's Too Late and because also we have a Health Care system that it's not an intuitive thing to navigate anymore and thanks to our technology. It's not impossible end up on a series of machines and that by some definition of life. You have a pulse.
But that's not a life that a lot of us want to live is hooked up to machines. So we have this weird technological moment that you can kind of Live Forever by some very reduced definition of Life. Anyway, there's a little bit of a rundown why it's so dang hard to turn our attention to this, but when people do and I'll I'm coming to the climax here brother, but one of the things you learn whether through religious and philosophical thinking or Franklin clinical thinking whether by choice or by
By force once you have to actually try to stare this thing called mortality This Thing Called Death in the eye. Not only do you realize that hey, maybe it's not so terrifying after all and that you can do it but it has a secondary effect of once you come to terms with your time is precious and that time is relatively short or at least not endless. It has a secondary effect of helping you really really appreciate what you have.
Fact that it ends is what makes it precious. So there are reasons why we don't look at death and there's some really good reasons to help each other find a way to do. So,
I think that's just such an eloquent description of what I consider to be a huge dialectical challenge, which is the problem that I focus on BJ and medicine is how to live longer how to do so without requiring the heroics of medicine at end of life. So just as you
Became disillusioned with medicine. So too. Did I but it was for a slightly different reason which was boy. We sure do put a staggering amount of resources and effort into things that with probably one tenth of this effort could have been for stalled or prevent it altogether and I didn't think I could do anything about it. So I left for a period of time before ultimately coming back to it. But I think that what you said is I completely agree that we can do both.
With right we can do everything in our power to maximize our lives here just as medicine allowed you to live that day. There's a very good chance at a different hospital under different settings. You would have died 30 years ago, but you didn't now you're still going to die just as I am, of course and everyone listening to this is going to die so we can do both we can figure out a way to live the best life possible the longest life possible. Should we choose
Choose that to be the case, but none of that diminishes what you've said and I think that's the part that a lot of people don't appreciate is that it's one or the other and it can't be both. Amen.
You just hit on a real kind of a root cause one of the ways we struggle so much these days is from our structures are constructs are ways of thinking and as long as we think it's either life or death, either you love life and try everything to do to extend it. Are you
Love death and just completely except that it's going to come today. This false dichotomies are the problem and I'm so with you as long as I'm so excited to be invited on your podcast, but it's because our relationship with death is maybe a problem or just under realize but if there's a problem here, it's the false dichotomy. It's the either or thinking when the both and thinking is really where it's at. So I love that you and others are trying to think through how to live longer and live better.
Oh, I love life my relationship to death even my acceptance of death is only to do with my love of life. It would be a real shame of a shortcut that if in order to prepare yourself for the inevitability of death you somehow stopped loving life you somehow welcome depression. So therefore you would love life so that much so therefore you're ready to die because life kind of sucks. It could be so so much better than that and if we can find our way
Include death into our view of reality. Like I don't love death. I love reality and reality happens to include death. Therefore. I'll deal with death. I'm in no way concerted around it. I'm a no way incentivised to make Death happen again. I appreciate you having this conversation with me. I think there's a lot to be learned by pushing past the either or of this
you've spent more time with people who are closer to death than almost anybody.
By listening to this certainly you're in a profession that very few people go into as you've pointed out. There are many reasons for that to you get the sense that when someone is at the end of their life, they are more afraid of death in the sense of being gone or the act of dying and presumably what the actual mechanism of death and or suffering
is yeah. It's a really
A great distinction very helpful one clinically presentation, maybe someones freaked out about dying or some existential anxiety. But of course as is the case with these things it pays to look a little bit more closely and tease some things out here and one of the major things to tease out is are you afraid of the dying process like your mention a year like the suffering you imply that must happen during the dying process. Is that what you're picturing? And therefore is that the source of your anxiety or is it are you really afraid to be?
Dead whether your belief system suggest there's a judgment day in a reckoning perhaps a hell perhaps, who knows? What are you afraid of what may be coming next? Are you afraid to be gone? Are you afraid to miss out? Does it freak you out that the world Will Go On Without You a major poll. Here's or major divided Crossroads would say is are you afraid of dying or are you afraid of being dead the former? One of the reasons to teases out is the former afraid of dying well,
We know a fair amount about that. There's physiology to Mark. There are medications to help their ways to help a body come down for a gentle Landing as I say, there's no need to be miserable and in pain at the end of life for the most part we can do a lot with medications we can do a lot to ease the suffering at the end of life and the dying process. So the answer if that's your fear, then the answer is reassurance if you're concerned is being dead. Well, I don't have answers for you, but I can as a fellow
Fleur I can accompany you there we can think about that together we can talk about it and then we can make a life that responds to that big question. So if you're afraid of your belief system has you afraid of a judgment day will let that spur you to behave a little differently in the time you have left or let that help you wade into non-duality let that help you wade into the world Beyond yourself. That's my favorite response. If anyone's interested in living forever. My favorite means to living forever is to think about
Out the world Beyond yourself invest yourself in the world Beyond yourself. So when your self dies that thing you love keeps going. Anyway, this is where it gets really really fast in the relationship between self and other and what to do about that religious thinking spiritual Pursuits. This is what can open up when you admit that you're freaked out to be dead.
It's such an interesting way you explain the idea of again for me. It's very clearly the latter not the
the former and I guess that's just because I have the luxury of Medical Training and I understand where and when one can draw the line for themselves with respect to what measures are taken how heroically they are and obviously the power of medicine to greatly reduce the suffering but it's this other piece of missing your family missing out on future Generations leaving behind people you love to me. Those are the hardest things. And of course your point is you can
Live through those things but you have to do something about it. It doesn't happen automatically. You have to make the investment and the irony is the time to do that as well. We're alive
amen gave me chills. You just completed the circle.
Yep, which almost suggests that palliative care needs to begin much earlier in
life. Amen, which is why it's such a shame that we forestall and keep it at Bay when it's this thing that could help us so so much whether actually a palliative care referral or
Or app out of care mindset but one way or another finding our way into the subject while we've got plenty of road in front of us is absolutely the right best way,
you know, it seems that there's a Continuum where you have life you have acute illnesses more life acute illnesses chronic illnesses life and death the hospital and the entire medical system is really only geared to treat with the acute problem.
It has virtually no tool dealing with life or even chronic conditions and certainly not death. I don't want to get into the why is that the case we can sit here and debate about incentives all day long. I think it's straightforward. I mean, I think we understand that the incentives are such that reimbursement follows the treatment of acute conditions and to some extent chronic conditions. I guess the more relevant question is what
I would have to change to realign the focus of resources to make it such that medicine could be more about helping people live and then helping them died. When that time comes
as a part and parcel of helping them live. Then relate those two things. I think a couple answers to your question. I think one is Anna big office somewhere at HHS when they're trying to redesign a healthcare system and even read
raft a mission statement. I would challenge HHS. I mean to read the definition of palliative care and tell me why the definition of palliative care isn't the mission of all of healthcare. So one answer your question is you can see the both the strength of the healthcare system and the trouble that comes from it is a design flaw because you and I both know Healthcare is littered with people who really really care and are trained to the hilt and yet the care were able to meet out too often fall short. I don't think the problem is the people
The problem is there's a design flaw and for my money the design flaw has to do with the system is focused on disease not on the people dealing with disease and the second you make it about the person living with the disease not the disease itself. Well, you've welcomed all sorts of things into the mix Beyond just their physiology and Anatomy you've welcomed their social emotional and spiritual lives into the mix. You've also welcomes your humanness into the mix as being relevant you as a
Clinician being relevant Beyond just your technical skills, which will push back on burn out for one thing. You've also made yourself in service of a human condition, which means for us clinicians the expectation management were not expected to work miracles. We know that it's someday everyone's going to die and that that's not a failure for us. We didn't person didn't succumb to the disease and we doctors didn't fail to make them Live Forever The Once We align Healthcare with the
Condition and was serving human beings so much of the trouble will work itself out because we will be designed around the right thing. So that's one answer to your question. I think it's that simple and that hard on some level and then medical schools medical training would have to follow suit and revisit how we think about these things being for example, think about your medical school training Peter a hundred percent of your patients died any rotation that you ever go through no condition befalls a hundred percent of your Visions, but a hundred percent of our
A patients suffer a hundred percent of our patients die and given that wouldn't you think that responsible Medical School curriculum that we would start and end a 1 and the last day would be where I'd conversations like we're having now the palliative care would not need to be a specialty would be baked into how all of medicine works. So for my money that's a major thing that needs to happen policy will flow etcetera. I also think to make that happen and to not wait for that happen that we
Human beings we people irrespective of our professions need to kind of come together as a society and to take these issues on especially right now when we're also polarized in so divided in so aware about the things that we don't have in common with each other. What a perfect time to revisit where we actually do have so much in common and where we do have so much in common revolves about everything we're talking about right now black white rich poor young old. I don't care these issues affect.
All of us this is a genuine way for us to work on a points in common so we can make political comments about why now is right for that the Healthcare System itself can't keep doing what it's doing and can't keep death the enemy because it's going to lose that war again and again and again
and one way you can keep score on that is just cost. Yep cost alone is a metric by which we are losing Health Care is obviously one of two things, that will be their
Grip the United States if they can't print their way out of it or create sort of seismic economic shifts and I do think that part of it is as you said, we've taken the wrong strategy in a war that probably ought to be deemed more of a truce than put our resources in the wrong place. Can I ask you a question on that though?
Yeah, why would you say that? We are so focused on acute care and not on chronic care if most everybody is going to dive most of chronic conditions Etc.
I should say I think we do 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 where medicine is very good is on acute care and I think where medicine is really bad is on chronic care and I think those are the two things that works on. It has nothing to do with sort of healthy life to prevent acute or chronic issues and it has nothing to do with death. So that's sort of yeah, just thanks for asking me to clarify them. But yes, I think we disproportionately focus on chronic.
Like despite our relative lack of success with
it. Why do we keep doing that? Do you have a sense?
Well, I think in some cases we don't know what to do to prevent the condition. So certain conditions never show up as a cute cancer does not show up acutely as shouldn't say that it kind of does but it doesn't really fall under the rubric of acute care medicine the way appendicitis does but we don't really have a great sense of cancer. You know, we know smoking and obesity are the two greatest risk.
Factors for it but there's many other risk factors including chance that we probably don't understand and even the ones that we do understand like obesity. We don't really have the infrastructure to help with prevention. So you talked about how in medical school we didn't have a single course on dying. We also didn't have a single course on nutrition or exercise or stress management or the psychology of eating in our relationship to food.
And how you can help patients make better choices with nutrition and things like that. So I don't buy the narrative that we have an obesity crisis just because sort of people are fat dumb and lazy. I think we live in a toxic food environment and we don't have a health care System. It's really geared to help people out of it because frankly Physicians aren't compensated to do that. You just don't have the billable structure in which you can do these things. So instead I think we focus on where our tools are an art.
Tools are drugs drugs become a good tool to use in a chronic condition
setting right out. I think I'd add to that maybe the capsulate this list three ways. One is the design flaw that where the phobic and we see ourselves as Victor's when we cure something when we fix something. So chronic illness by definition is something that we can't fix. So I think it presents us with a sense of failure, which I think is an emotional barrier to develop
It
further that's one big piece of the design plus I think it's second big piece of the design flaws the way the busyness of medicine goes. We are left to see medicine as a series of transactions, which in acute care makes a lot more sense in chronic care. It becomes part of the experience. You're not kicking this thing out of the body. You've got to learn to live with it. So illness and health becomes protracted over time and therefore becomes an experience, but we're wired for transactions. We don't have
The systems and structures in place to be cultivating experiences together with our patients. That's the second thing and I think the third thing is this reimbursement and we are incentivized away from thinking about care over time. So anyway, I just want to complete that question for both of us. I think 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 about patience that you interact with during hospice. So these are now going to be the patients who are probably
A final months of their life and that could be cancer is obviously a very common pathway that you'll interact with hospice patients. Is that the most common proximate cause of death for hospice patients in the United States cancer? Yes.
No, it is no longer the majority until recently. It's less than 50% now Progressive neurological illnesses are on the rise cardio vascular organ failure. But yeah fewer than 50 percent of deaths the hospice deaths are cancer at this point.
What do
Patients say most to you when I was in medical school. I did a stint at the National Cancer Institute. And then I went back there for my formal training fellowship and people that came to the NCI to where I was and I suspect to elsewhere in the NCI. We're generally patients who had progressed through all forms of treatment all standard treatments. So they had metastatic disease that had failed to respond to any form of treatment. So therefore they were at the NCI for experimental treatment and at least for the type of
We worked on the survival was between 10 and 20 percent meaning eighty to ninety percent of the people we met we're going to die very soon within six months. Typically. I remember obviously feeling very attached to many of them and also spending time with them and asking them questions. Like what do they wish they could do how do they want to spend this time that they have left? And sometimes they would share regrets and I always remember thinking I wish I could write a book about this just interviewing people like this.
But it felt it didn't feel right to me. It was one of those things that just felt like it should be shared but I wouldn't know how to share it. I suspect you've had more of those discussions than you can remember and I wonder what things you've learned from them
these vicarious deathbed moments. I have a lot of them. I think a lot of us in this field and maybe a mess in general like to say how privileged we are to be in this position how lucky we are to have our patients. Let us in to these very poignant moments. It's so intimate. So yeah, there's a
Had to be said for those moments including your / wanting to protect those moments and not necessarily Ram them into a book. Although there are sure as a way to do that skillfully the world could benefit from it. But the regrets that pop in that I see at the end of life. The conventional ones are sure you hear people say things like I wish I had spent more time with my family than at the office Nia things like that. Yeah sure if that comes up but in a way by some someone's actually in their deathbed and again these days most of us dying from
Chronic illnesses that means we have some protracted period of time to think about our death specifically we will be introduced to the thing that will end our life months or years in advance. And so by the time those folks get around to their end of their life. They're beyond the sort of Pat regrets. It shouldn't work so much for example often times if they're regretting anything. They're hanging on anything including regrets. It's more likely. I wish I had loved dared to love more. I wish I hadn't been so afraid.
I wish I had just let myself be myself. I wish I had been so hard on myself or criticize myself those regrets. They all have something to do in common in the commonality. Is it sort of like oftentimes a common pathway Aires? They wish they had let themselves come to terms with death earlier in their lives because it would have changed the decisions. They made I think one of the things that people come to realize on their deathbed and one of the things that I've saw at getting close to my own was
Really grasping it in our guts that death is coming. No matter what we do even in your work promoting a longer life. But as you said earlier does it mean the deaths is and still coming just come in later given that this is the freedom that comes from Reckoning with death, which is if okay, you're telling me that no matter what I do if I'm a good person or a bad person. I eat my veggies. I don't eat my veggies. I smoke. I don't smoke whatever it is. Either way if I'm going down.
Eventually, in other words if failures in this way quote unquote failure is guaranteed and in some ways the pressures off like the pressures on for me to take my life seriously, but the pressures off for me to get everything just perfect. There's a biphasic effect that I see in myself and some of my patients which is they see the grip that fears had on them distraction is done to them and they
Is that no man? The only thing I have to lose is wasting my time, so I'm not going to waste my time. 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 what I want to do because if failures guaranteed then I'm no longer doesn't make much sense to be afraid of failure anymore or not be limited by it because I'm going to fall either way, so might as well try so I have the death gives me the reason to try and gives me the reason or the way of forgiving myself for quote unquote failing, so
Really in this way. It can be a real liberating force and I see people grok that and the regrets have something to do with not coming to that place sooner
you presumably encounter patients who have the sort of proverbial dying wish never saw the Grand Canyon and I really want to go and see it never seen the Mona Lisa and I want to see it or I've never taken this vacation with my family how much of your work is trying?
To help patients navigate those wishes medically for example is someone strong enough to physically go to the Grand Canyon and can you put in a last-ditch heroic effect to get them there? I mean how much of that do you do
some I'm involved with an organization called The Dream Foundation out of Santa Barbara. What they do for a living as an organization is help make those trips to the Grand Canyon or whatever those final wishes actually happen for adults in this country is beautiful and I have been engaged.
Aged in some of that with some patients whether a handful of occasions where someone was here who may have lived here for a long time but grew up elsewhere and wanting to get home as it were back to the Philippines or back to go somewhere else and helping this sort of one last trip happen. I've been involved with that a lot. I've been involved with some bedside weddings in a hospital just before someone died. I've been involved with some trips done through the Grand Canyon. So some of that that is true like some of my job, especially if I can.
Engage with someone soon enough whether still energy and time to work with then making those sort of Last Wishes happen is great is fun. It's great work. It's powerful. It's delightful and it's stunning but I will say and so I do some of that but for whatever reason I'm more engaged with people around letting go of that wish or that need to go see the Grand Canyon or whatever it want man.
Maybe of letting go of the things that they're not going to be able to do or at least grokking that fact. So yes, sometimes a response is to mobilize energy to do that thing. I'd say more often and right alongside that wish is also helping them see the world and see themselves in World in such a way that they can let go of those things that they never got to because they realize the things that they're not going to get to is a very long list.
And on a developmental level, you've got to find a way to come to terms with all the things you're not going to get to do. So that's where I spent a lot of my time
movies lead us to believe that people become enlightened and Hyper Transcendent at the end of life. But my experience with patients at the end of their lives is that often times. They're so heavily medicated that they're not really even able to communicate much with their loved ones.
And that's the price will pay to keep them comfortable especially patients with metastatic cancer. The pain would be so debilitating. It would be inhumane to Let Them Suffer Without those medications and frankly in the circumstances when we're lucky enough to do so, we can get expressed direction from the patients before they get there. That way I don't want to suffer and I don't want a breathing tube put into my chest. I don't want to be intubated and I don't want you to do chest compressions on me.
My heart stops, I just want enough medicine to be comfortable. And so you don't have these sort of diving into a person's soul in the last day of their life kind of thing. Is that your experience? Also?
Absolutely it is there are exceptions, but not many the last day or two of life is not necessary the greatest time to be digging into someone's soul and I will say you're right about medications is a big piece of this but I will also say just for your listeners a refinement
I hear again pushing on the either or kind of thinking it's not either take meds and be comfortable or don't take meds and be Lucid intractable pain is a great route to delirium and even if you're not Delirious trying to have an exchange with someone when your body is in absolute agony is a pretty quixotic experience. I will say that when another plug for palliative care is with a very expert in judicial use of pain medications, but it can often thread a needle and get someone comfortable enough.
So overly medicated that they can't interact with this one of name that refinement a little bit either way Peter your point still taken the very very at Final hours of life. You're not generally reviewing much are not having big philosophical conversation that point and so many ways whether by medication or force of the disease, it's too late
which I think speaks to what you said earlier that there really is no time like the present to say what it is you want to say to people who matter it's not the movie.
She wear your final breath is asking for forgiveness or telling somebody you forgive them or that you love them. It's very unlikely
to happen. It's very unlikely to happen as is anything sort of cleanly closure. I love pointing this out to folks one of the things in my world and impact of care world. One of the one things you would want to forestall with knowing so much pains coming and you want to forestall the avoidable regrets and avoidable pains, but you're not necessarily going to get there and your final breath.
Tell me the story about Randy Sloan. How did you meet him
ready was a beautiful young man. So I met Randy he worked at a motorcycle shop since I first met ran one of my wishes for myself. Once I became an amputee was to get out of back on a motorcycle at some point will always love biking that always wanted to get on a motorcycle everyone Smiles through a motorcycle shop and see if there was any way to convert a bike and every time I walked in there I couldn't get anyone to tour take it on. I think they
I'll just freaked out like no way dude. We're not putting you on a death machine never I didn't try that hard, but I never could get anyone really interested in one day. I walked into place called Scuderia West here in San Francisco and just met a wholly different energy. And these guys were actually interested in trying to make it happen saw it as a creative exercise and that's exactly the spirit you need and Randy was the mechanic who put his hand up as wanting to help make this happen.
So Randy he was a bike mechanic and he took my bike and they managed to figure out a way for me to operate it with just one hand by the series modifications and so he helped make this dream come true for me and it was beautiful for both of us he loved making it happen and I'm sure love that he did then we had this gorgeous like teary moment when I picked up the bike and rode off into the sunset, so it was just a beautiful.
Little but little time limited interaction with Randy and then not that much longer. I can't remember now months or maybe a year later and Randy was in his mid-20s. By the way. Randy ended up somehow his mother reached me and let me know that Randy was in the hospital and something really big time was going wrong and Randy and I had remembered each other because we were both moved by this story and his mom reached out and he knew I was a doctor so blah blah blah eventually. I got to Randy's bedside and Randy.
Been walking uphill in San Francisco found himself a little out of breath went to Urgent Care. They took an x-ray and he had turned out to have mesothelioma,
which is essentially unheard of in someone in their 20s. I mean, this is a cancer that is almost exclusively associated with long-term asbestos exposure in elderly folks and I don't know enough about motorcycles to know if there was asbestos in them, but even if there was you'd think this is something that would still be 40 years later. You're
right, so too.
Total freakish and even if you had had exposure it's rare to find exposed to asbestos these days much rarer, but at that age, you don't have even time to develop the cancer takes a while after exposure. So just a real mystery how this young man came down with widely metastatic mesothelioma. He met the time of diagnosis scans revealed. It was in his brain stem. He's one of these guys went from walking talking to that day was in the hospital on death's door and people scurrying around trying to make a
And what to do I met him. I walked in that situation by the time I even got to the hospital he had had a dose of whole brain radiation because brainstem lesion was very precarious and they need an immediate care. So he had already been radiated within hours and walked into a situation. Here's a young man trying to deal with this diagnosis come to terms with it and all that it meant and it meant that his life was measured in weeks at that point right from the time of diagnosis, so I became
His palliative care doctor and we were together for the rest of the time and we got him into I saw him into that point. I was working at Zen hospice project in San Francisco. He moved in there with us and he played his life out with us. It was an amazing experience. I think one of the most amazing things about it besides for the medical like mesothelioma and this young man blah blah blah. The really interesting stuff was how Randy responded to this diagnosis and he and his mother and I were all it's just too didn't make sense. It was too soon. So
All gearing up to think that somehow treatment was going to help him sober conversation. There was nothing that was going to help them at this point except for love that one dose of whole brain radiation really threw them for a loop. I'm trying to talk to him about the fact trying to bridge him to the point the realization that he has no good cancer-fighting options and you're watching this guy's World shrink miserably by the second and to find a way out of this tailspin and a find a way.
Forward we had our dutiful kind of pad of care conversation which and included a question in there eventually about like what was really important to him? What about him that he want to protect as a body was falling apart? What did he loved most about himself? Somehow the question to Brandi became what do you most proud of in yourself as a young man in development? It seemed like an important question and his answer was immediate his answer was I want everybody I ever come into contact know that I
Answer the question immediately. It was a remarkable coming out of a 27 year old bike mechanic. So there was I said, okay we need to keep you as comfortable and conscious is possible for what time you have and be in a position that your friends and people can visit you. So that meant let's get you in a hospice out of your teeny apartment walk-up apartment where you have three roommates. It's get you into this Hospice house. Let's get you out of the charade of treatment. Let's treat your symptoms and
in up your door and get as many people in here as you want and that's what we did. You just had a steady stream of visitors. He just basically became this radian beam of love for what time he had and just made sure to love as many people as humanly could and with that his mother and my stepfather came out and got married at the hospice house around the time. He died. He got in the the bay one more time for a swim. He got to be with his dog and
Let everyone know what Randy meant was loved and that became his legacy and he died to smiling and quickly this all transpired over what felt like hours
what role does euthanasia play ashamed to admit. I'm a little bit ignorant about the legality of it state by state. Obviously. I know that organ is a state where it's legal how many states in the u.s. Have legalized euthanasia or some form of physician-assisted
suicide? I believe the number is now 9
I have to double-check that are still it's unfurling as we speak. There's first going on in every state house, but I'm pretty sure the number is nine. The first was Oregon in 97, California in 2016. And others have followed suit, Montana, Oregon, Colorado, California DC others that I can't remember right now. It's coming slowly but surely state-by-state
because it demonstrable e changed the practice of hospice or palliative.
There were is it almost moot because so much of threading that needle as you described it effectively. It doesn't happen maybe in as dramatic a fashion. But in the end of life care that you're discussing for example in the case of someone like Randy.
If Randy had said, let's say the few weeks sooner. I want to go down the path of euthanasia. What would have been different than what he ultimately ended up doing that Zen
hospice. There was a moment there I could imagine he would have really elected it. The world was falling apart too quickly. It was too painful for a little while there for Randy to see straight the process we can talk a little bit of walk in there's a two-week wait, you need to have two Physicians you need to write a letter or fail-safes because what the state
Eight ones to avoid is it making it too easy for people to do something that they otherwise might regret because I think many of us have moments where we'd just as soon get off the planet, especially when we're dealing with something like at a terminal diagnosis. It's a funny thing where life's ending soon. Some folks have this response for okay, I'm dying. So they're okay now that I realize I'm dying. Well now I can't die soon enough. It's almost like once you pierce the veil of indefinite life which people really long for on some level think they long for
and then all of a sudden their terminal and then I can't die soon enough.
It's sort of a final Act of control and a bit of a nephew to death. Well, you think your inevitable I'll show
you. It's the quit before getting fired impulse in some ways. There are other ways are many things that drive the impulse but that's the sort of a side note, but answer your question. I mean if Randy had enacted this procedure and ended his life hastened his death before nature otherwise would have had it well,
He would have died sooner. Randy would have been able to schedule the moment of his death. It would have been something in on some level that could have served him. But the realization that Randy had a mission to sort of prove love to show love to be loved. He had a reason to keep going. There's a moment where it would have been too easy for him. He probably would have elected to hasten his death, but because he didn't and because he
Let it play out a little bit longer. He got to a lot more people. He had a lot more final moments with friends. He got into the bay and he had the pride of playing his body all the way out. He played every cell all the way out which for Randy served him very very well and I think it makes the point one of the problems with the dying laws and let me just pause there too. By the way Peter the language of physician-assisted suicide has gone away.
In favor of Aid in dying or assisted dying to get rid of the word suicide emotional baggage around that word and importantly these laws are for people who already have a terminal diagnosis and for whom death is coming soon. So it's importantly different but if we had just seated his wishes and said, oh sure you want to die Randy sooner and later. Yeah, we'll make that happen just in the name of helping him not suffer. We've made that happen and it would have been a mistake in this case because as I think a lot of us know intuitively or explicitly
Ali a meaningful life a good life is not the absence of suffering suffering teaches us too much. It's too important vehicle for us actually a full life requires it and I don't mean to castigate anyone who does choose to hasten their death for some people it is exactly the right decision when it is seen as a meaningful response not a flight from suffering but a moving toward something meaningful and for some people that final Act of will is very meaningful.
But for more people what ends up being more meaningful is them being more than their pain being more than their suffering and letting their body play themselves all the way out and dealing with in adapting every moment along the way trimming their sails along the way letting themselves be changed letting themselves grow right up into the moment of their death. That's actually a more meaningful Pursuit for the bulk of people.
It's really that pain matters more than being numb.
Yeah.
Yeah, yeah, when it comes down to it when it comes down to it for most of us in this is a realization that came clear to me when I was in my hospital bed pain is very obnoxious and I don't like the stuff we can be more than our pain pain isn't ultimately avoidable in a full life. Like I said and it can teach us some things and really I'd much rather feel some exceptions in there's ways to paint this otherwise, but in general, I'd rather feel something even if it's painful.
And feel nothing and decision is a way of a numbness is a way to die before we have to die. That seems to be a bigger tragedy to me than his death in the first place.
If you had any experience with the use of psychedelics in end-of-life care are people doing any research on this. Obviously. I'm aware of the research on psilocybin in patients with cancer. I believe there was research done help.
Thing with end-of-life depression. Are you aware of any other agents that are used besides psilocybin for that research anything with MDMA? I'm not sure if which obviously I know MDMA is being used to treat PTSD. But what is the scope and breadth of that look like
today substance is being researched along these and for end-of-life anxieties fears of death studying a patient population dealing with terminal illness or serious illness. I can't quote to you all the latest details of studies. There are
Is ongoing for yes or psilocybin but also for MDMA and then related similar but different is ketamine then the way ketamine is proving its way to therapeutic new therapeutic values. So yes, I'm most excited around the research run MDMA and psilocybin and the research so far. We got a little ways to go but the data are pretty darn stunning. The impact is huge and offers access the psilocybin stops the most remarkable, I think.
One guided session we're setting matters dos matters. The integration process matters is not just people going out in the woods and having fun. But with this process, there are really no Adverse Events to speak of people who are gripped by a fear of death grip by a sense of meaninglessness and not belonging and not feeling connected come out of this one session losing their fear of death feeling part of something larger than themselves having a totally different relationship.
Ship to fear. This is one session the effect lasts for months. It's not just a chemical effect per se. We don't have anything remotely like this to offer in medicine. The closest thing I have in my conventional work as a doctor. Someone comes to me with death anxiety two things. I can do I can talk them out of it and trying to with enough time. We can find a new way of seeing themselves in the world of framework that allows them to feel like they belong in their own framework and takes time.
If we can get there at all. The other thing I can do is if you're really anxious. Well, I can numb you out. I can give you valium or whatever else. I can put a wet blanket on your system. That's the best we've had to date. I don't have an intervention that helps me connect you to meaning connect you to the cosmos but these medications are offering exactly that and is beautiful. So we got a little ways to go but I am thrilled for this potential.
Are these
tools the things you're probably most excited about and in your field in terms of being able to kind of revolutionize how you're able to help the patients who want or need that type of intervention or is there anything else that even Rivals
this? Yes, there are two things so strictly speaking from makassar medical medication e medical physiology ish kind of overlay. The medical lens. I would say the research going on around these.
Substances psilocybin and MDMA ketamine Etc are my favorite thing going maybe even bigger maybe with other thing that gets me more excited is the work going on on the periphery of healthcare and outside of healthcare that conversations like the one you and I are having Peter and I thank you for it up and down. One of the things we're doing this were kicking the conversation Beyond just medicine. It's like we're saying earlier about the design flaw that medicine focuses on the design.
he's not the person they're one of the great things that happens when we focus on the person is that we in medicine become part of something larger than ourselves and we can partner with Architects and artists and designers and other disciplines and death duel has and quasi medical folks and alternative and Integrative Medicine folks all of a sudden we are part of a much larger family working on behalf of something much larger than even medicine and that's where I get really excited that people that society that culture
her is waking up to these issues death has become a medical issue. It doesn't belong there suffering and death are way bigger than medicine medicine may have something to offer this getting back to your question. The thing that I'm more excited than anything else is the rise of Commerce multidisciplinary work other institutions and vehicles tuning into this idea of life and death. So that medicine doesn't have to carry all that weight Water by itself that
People are going to start taking care of people not handing themselves over to doctors to do the trick
PJ. I really want to thank you because your work and the work of people like you has actually had quite a profound impact on the way. I think about life. I'm in the process of sort of barely putting the finishing touches on a book about longevity and I've kind of come to the realization lately. It's very difficult to do this without writing about death in
In some way but not as an enemy, but more in a manner that is sort of symbiotic with life. So maybe not quite a friend, but certainly not a hostile combatant. I just think the way that you've been able to speak about this. So eloquently for many years now has been a great benefit to not just the people you've helped which is obvious. They think those of us who are presumably a little bit further from needing that help
either. I can't wait to read that book man, and that is right.
And I think you will help so many people just this frameshift of finding a way to include death in your view of reality is one of the great Services you can do the world man, and I oh I can't wait to read it.
Well, thanks PJ and thanks more than anything else for all of your time this
afternoon. Thanks for having me. Thank you so
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