Dr. Zara Cooper: Surgical Palliative Care Researcher

#004 - Join host Dr. Red Hoffman and co-host Dr. Mackenzie Cook as they interview Dr. Zara Cooper, associate professor of surgery at Harvard Medical School, Kessler Director of the Center for Surgery and Public Health at Brigham and Women's Hospital and a prolific researcher in the field of surgical palliative care.  Zara shares how she first became interested in the field of surgical palliative care, the importance of maintaining curiosity when talking to both patients and fellow surgeons, and the need to make certain that future research in palliative care helps to drive policy change.  Zara manages to be incredibly smart, remarkably insightful and refreshingly approachable all at the same time, which makes for a great interview!

Learn more about the Center for Surgery and Public Health here.

Zara's articles discussed in this episode:
Resident education and management of end-of-life care: the resident's perspective
Racial variation in the use of life-sustaining treatments among patients who die after major elective surgery
End-of-life care intensity for physicians, lawyers, and the general public

Recent New York Times articles on dying at home:
https://www.nytimes.com/2019/12/11/health/death-hospitals-home.html
https://www.nytimes.com/2019/09/03/well/live/is-dying-at-home-overrated.html
https://www.nytimes.com/2018/01/06/opinion/sunday/hospice-good-death.html

To learn more about the surgical palliative care community, visit us on twitter @surgpallcare.

Transcript

spk_0:   0:12
surgical. Palliative care may seem counterintuitive, but surgeons have a rich history of pallid both their patients and their families. I am Red Hoffman in acute care surgeon in Asheville, North Carolina, and one of 79 surgeons currently board certified in hospice and palliative medicine. Join me as I interviewed the founders and the leaders of the Surgical Palliative care movement, a diverse group of surgeons dedicated to providing a high quality pallid of medicine to all surgical and trauma patients. Welcome to the surgical palliative care podcast way hell with more than steel.

spk_1:   1:07
Hi, everybody. This is Red Hoffman. Thank you so much for joining me for another episode of the surgical palliative care podcast. My co host today is Dr McKenzie Cook. Mac is an assistant professor of surgery in the Division of Trauma, Critical Care and acute Care surgery at Oh, HS use School of Medicine in Portland, Oregon. Thanks for being here today, Mac.

spk_0:   1:32
Thank you for having me.

spk_1:   1:34
Mac and I are so excited to be interviewing. Doctors are a Cooper. Zara is an acute care surgeon also certified in hospice and palliative medicine at Brigham and Women's Hospital in Boston. She is an associate professor of surgery at Harvard Medical School and is the Kessler director of the Center for Surgery and Public Health. Zara, thank you so much for your time.

spk_2:   1:59
Oh, it's wonderful to be here. And I'm really excited that you're doing this. Podcast Red. Congratulations.

spk_1:   2:04
Thank you, Zara, As we're getting started, can you tell us a little bit about yourself, where you grew up, where you trained and how you decided to become a surgeon?

spk_2:   2:14
I grew up in New York City and, ah, it was a die hard New Yorker. I guess I still am. And I'm amazed that I've been in Boston for us long as I have been. I went Thio undergraduate at Northwestern University with the intention of becoming a journalist and then, quite frankly, realized that I didn't want to write wedding announcements. I really wanted my own op ed page on The New York Times, and since that wasn't e, I wasn't really in the cards for me. So I turned my attention to advertising, which was actually the family business. My father had an advertising agency, and so I worked in a large advertising agency in Chicago, which was my first job out of college, and I was doing volunteer work for an organization that raised money for a less. And I was helping write their communications for the lay public and fundraising. And I spent some time shadowing neurologists, and that's really where kind of this interest in medicine was born. I didn't take any math or science or anything ever prior to that. And then I eventually went to post back in. That eventually went to medical school at Mount Sinai, where when I did my surgical rotations, I reluctantly discovered that I really loved the operating room, and that's where I was the happiest. And I knew that I wanted it to be part of my daily life, but it was definitely, ah, a bit of a gut wrenching decision, but I've never looked back. I'm so grateful that this is how my life has ended.

spk_0:   3:40
Uh, Zara's. You become a surgeon of moving your career. Where did you develop your interest in height of care? How did you develop that?

spk_2:   3:47
So I did. My was drawn to me trauma, largely because I think it's a social disease, and because of the public health importance of it, I had always been interested in public health. I received a public health degree when I was in medical school, and so I did my critical care fellowship after my third year of residency, and it was there that I had. I think the same kind of moral distress that many of us do, where I felt like we were doing things to people and not necessarily for them, particularly around the head of extraordinary measures and life prolonging care for patients who, you know, many of us really didn't think had any chance of getting out of the intensive care unit. And I saw it too often be a failure of communication on DSO. At first I was drawn to the ethics literature, and then I was drawn to the palliative care literature, and I was heavily influenced by the work that Amazin fallen Jeff done. We're doing around that time in kind of the early mid two thousands with the American colleges are just asked for some palliative care and statement of palliative care for surgery. Ah, and just really felt that palliative care was an important piece of surgical practice that wasn't being tended. Thio and then had the good fortune of doing my trauma fellowship. Aha, Harborview Medical Center. And one of the unique things about harbor view, at least at the time, was much of the palliative care was actually being delivered by emergency medicine physicians who were dual boarded. And so there was an understanding of that FINA type of somebody who has, you know, actually, a board certification, a very procedural spread. The an award certification, hospice and palliative medicine, which is pretty unique. Um, and I had the support of Ron Mayor, who is a huge advocate for palliative care in general and particularly as it relates to trauma. And, you know, I spent a month with the Palliative care team. Attn. Harborview doing home visits during nursing home visits during hospice visits, doing impatient consults, and that was really fascinating. But then it wasn't until I became an attending here at Brigham Women's, where I was attending in the cardiac surgical. I see you and it just became so clear me that there was, ah, clinical skill set that I was missing, and that's what prompted me to become board certified in hospice and palliative medicine.

spk_0:   5:53
God, you're very much a Trailblazer in the surgical part of care front. And I think you sort of touched on some of your key national level mentors. How did you make space for this In your institution? Is your young surgeon just starting off trying to blaze a new trail? How did you make space without in the division and the department?

spk_2:   6:12
Well, first of all, I'm humbled, and there were over one thing that's being holds a Trailblazer. But I appreciate it. I

spk_0:   6:19
really what? I've read 1/2 a dozen or more papers of the person you get to be a trail.

spk_2:   6:23
Yeah, thanks very much. Agree with that? I think both. Right. Right. Maybe I just don't have enough hobbies. Yeah, I, um you know, I'm also very grateful, cause Mike Center, who is the chair of surgery at the time, who is my chair when I was a resident, and then also when I first joined the faculty brings and someone Rogers, who was my division chief, they were both very supportive of this quirk and knew that I was very passionate about, You know, at the time, I didn't think about creating a field or helping to create a field But I was very passionate about the fact that there was this gap in surgery that needed to be filled, and they were very supportive of that kind of what, at the time was a quirk of mine on my intention of building it into some kind of academic practice.

spk_1:   7:08
Zara, I'm curious. How do you feel that learning about the practice of palliative medicine changed you not only as a surgeon but also as a person?

spk_2:   7:18
I think it's a surgeon and help me understand, better understand the psychosocial aspects of my practice. Why my patients were coming to me, particularly, is a trauma acute care surgeon. Everybody comes to the story and why my patients were coming to me and what we're all of the forces that I couldn't see that we're impacting their progression or restoration of health or that we're gonna prevent that and then thinking about how I could influence those you know, pain points to improve their outcomes and recognizing that listening is an active skill. Recognizing that kind of thoughtful communication about patients and their families is therapeutic, recognizing that tending to symptoms as kind of the first step is critically important in forging that therapeutic relationship and that we're doing that you can get so much further, so much faster. I think that it really helped me. I don't practice palliative care outside of surgery. Actually, I don't attend on our palliative care service, but I use it every moment that I'm in surgery and I would include in the operating room as well. I mean, the way that I think about it, I think we all do. I don't think this is unique to me. It's just more in my in the forefront of my mind because I recognize it as a skill that I have that I've honed. But I think that we all do. We think about kind of the impact that we're having our patients, their families in their lives. I would say how it's helped me in my personal life, although I will say my husband would probably disagree that I approach things with greater curiosity and I do try to be a better listener. I am absolutely Taipei, a DHD like I am the FINA type of a surgeon and all the good and bad ways that you can imagine. But I really do try to approach things with curiosity and recognize. Recognize the value of that and try to withhold, recognize my own biases and try and withhold some of that as I listen to patients and their families. Tell me their own stories so that I can better understand how I can help them on DSO. I've I've also done that in my personal life, and I found it very helpful. I mean, actually, where I find it incredibly helpful with my 10 year old daughter, E You know, I the thoughtful pauses, all those things, all the communication strategies. They help a lot of different settings.

spk_1:   9:58
I I appreciate particularly what you said about the symptom management. I was interviewing Jeff done yesterday, and when I asked him the same question, he also mentioned that he became so much more skillful at symptom Management and also realized how important it Woz and I think about that with our patients, right. If you're just overwhelmed by abdominal pain because you haven't had a bowel movement in seven days, you can't even hear anything else. I'm saying

spk_2:   10:25
right, But

spk_1:   10:26
if I could tend to your physical symptoms first, sometimes that is a way in and a way to gain some trust.

spk_2:   10:33
Right? Right, Right, Exactly. Exactly Right? Exactly right. No. Says

spk_0:   10:38
it sounds. I was really struck by, he said. You use these scales at every moment in your practice on your surgical practice. So when you were thinking about the training of general surgery residents, should we beam or intentional about including some of these principles into general surgery? Residency, you know, Is there a baseline skill set short of board certification Hospice in spite of medicine that our residents need to graduate with? Similar? Do their baseline skill set in lab Rosco P your endoscopy or something like that,

spk_2:   11:11
Right, Right, I think. Yes. And I think there's a lot we can do. Short of having everybody being jewel certified. I think if we can approach communication and symptom management as skills, just like we do lap Rosco P, I think that would go a long way. The problem is, is that we still somehow think they're good communicators and bad communicators, that there are people who are inherently good at this and others who will never get it. We think that this is something that you just pick up along the way and I think we really need to refocus our understanding of how these skills are acquired and implemented. And so because I'm certified in hospice and palliative medicine and because Jeff Dunn is certified in hospice and palliative medicine, that doesn't mean that we're then the only people who contend to symptoms in a very aggressive, intentional way right up front. You know, right. But I'm if I'm in the emergency department, you know, a lot of times I'll try toe, you know, make sure that the patient has their pain well controlled, you know, if they need an opiate, get them an opiate, you know, get the engine to place, get all those things placed even prior to talking about going to the O. R. If there's time, because then we can have a conversation. You don't have to be, you know, board certified in hospice and palliative medicines to think about things in that way. So I do think that we need to have a frame shift in our training. Where we think about some of these things is critical skills that people need to learn, just as you say, like access in the abdomen and lepre Skippy

spk_1:   12:34
several years ago at one of my very first a. C S Clinical Congress's I Heard You You got up and said a quote that has really stuck with me And you said Just because you buy the horse doesn't mean you need to buy the whole farm. And I have repeated this so many times to patients, to families and also to many of my co workers. But I'm wondering if you can share a little bit more about your thoughts behind this statement. And if you can talk to us a little bit about the idea of surgical by in

spk_2:   13:06
So you know, I certainly Surgical Brian was coined by Karen Razzle and Gretchen Shores E. And I have had the privilege of collaborating with them on a number of papers and research projects where we've really looked very closely at surgeon patient communication in the elective setting and in the setting of high risk surgery. Whether the patient is high risk or the surgery is high risk and trying to understand this concept where you know surgeons interpret consent for surgery as consent for everything that goes along with surgical recovery, which includes, you know, all kinds of life sustaining treatments, tube strains, medications, you know, post acute care, et cetera, et cetera. And that, you know, if somebody said, Well, I want to have an operation that means that they want everything else and that's just seems inherently unfair to me. It's unfair for a number of reasons. I think the first is because it undermines the individual patient sense of autonomy. You know, just because you know, I said that I wanted to go on a first date with my husband doesn't mean I said I wanted to marry him. Ultimately I did. But it would be kind of the same illogical thinking where if we went on a date, he then thought that were spent, you know, interpret that is, you know, okay, you agreed. Absolutely everything. I think that that undermining of autonomy and agency is critically important and it's actually unethical. So that's one major piece, I think, the other major piece and I described this. This is my analogy and I don't know if it's perfect, but I have never been to China, and I would love to go to China, and somebody who's been to China could describe to me what China is like. But once I get to China, I may have a very different experience than what they describe and for patients and families who have never been to an intensive care unit who have never seen a baby on a ventilator who have never been on opiates who have never been on benzodiazepines who have never had the experience of walking with a walker who have never been to prosecute facility who have never seen a nursing home. We can describe all of these things, but really it's not until you're there that you can experience it and understand how it aligns with your own personal goals, values and priorities. And I think it is inherently unfair. Quite frankly, many of us do not have that experience as well, right? And so it's very unfair for us to just describe things and just think that because we have this relationship, the patients and families should trust us to go whole nine yards. I just I just think it's unfair for us to think that way, and we really need Thio to rethink that. I'm not sure. I mean, this will open up a whole nother can of forms that in some of these settings share decision making. It is entirely possible. So it's even for that reason that because there is always this knowledge differential, this knowledge gap that we have, that I think that we need to acknowledge that there is uncertainty that these decisions need to be iterative, that people need to have the opportunities to reconsider. And I think given the opportunity to reconsider, most patients will tend to want a pursue, aggressive, life sustaining treatment. But I do think that we should give people those opportunities. Did that answer question,

spk_1:   16:14
Rob Yes, yes, I appreciate that. And follow up to that. I'm wondering, How do you suggest that we approach this whole idea of, you know? You don't have to buy the whole farm with other surgeons who may not agree with us?

spk_2:   16:29
Yeah, that's a great question. I think you know where I found that. Effective isn't drawing some of those analogies and really going back to what is the goal of the surgery, and where do we think that the goal of the surgery remains attainable? And how does that continue to align with patients, values and priorities? I think that surgeons want to do what's right for their patients. They want to provide care that patients want. And so I think we should frame it as an opportunity, really, to continue to reassess and to reconfirm.

spk_1:   17:09
We like that. Thank you. I know as a critical care fellow, Mac, I'm sure you can agree and also has a critical care attending. I do sometimes struggle with this when I'm taking care of other surgeons. Patients in the I. C. U and I feel strongly that there wasn't really that understanding either because it wasn't discussed or just because of ah, lack of education on the part of my patients and their families. They really was no understanding of what was going to happen beyond the surgery. And I have, really, you know, as a fellow, I definitely stepped on some toes and I've learned that it's important for me to play well in the sandbox because I've learned in the end that these patients are going to leave the hospital or die, and my colleagues are still going to be there. So it's important for me to maintain relationships with them, but I've certainly had my own moral distress around watching some of these things play out and then have also been distressed. Watching the nurses have their of moral distress about this,

spk_2:   18:13
right? Right. I mean, I think if I could make a comment about that, I think there are number of things, actually, And going back to your question about what my palliative care training has taught me, it's really about curiosity. I think many of us come to this field in palliative care and in surgery, come to palliative care out of the sense of anxiety and moral distress. And quite frankly, a sense of right righteousness can impair our relationships with the people that we work with them, that we're actually trying to collaborate with an influence. And so I have in my now approaching everything is curiosity. You recognize that it's true the pages of family may have no idea what was ahead. That's nobody's fault, or maybe it is somebody's fault. But it doesn't matter now and that we really need to deal with the moment. And this is where you know, having that conversation with the surgeon and saying, You know, I'm worried that maybe they have that conversation with you, but they're thinking has changed and we need to revisit. It is it is an approach that I have found help.

spk_1:   19:13
When I asked Jeff done yesterday for some advice on how to deal with other surgeons, the very first thing he said was, Don't preach.

spk_2:   19:22
Yeah, yeah, I think

spk_1:   19:23
that's right in line with that.

spk_2:   19:24
I think that's that's exactly right.

spk_1:   19:26
Yeah, so early in your career you published a survey of general surgery residents in New England, and you found that more than 1/3 of them said they felt they were inadequately trained to discuss, withholding and withdraw of life sustaining treatments. I'm curious if you were surprised by this and whether you think these numbers have changed in the past 10 years.

spk_2:   19:51
I was surprised because I thought it would be more. And I doubt the numbers have changed in the past 10 years. Andi, it would be interesting to revisit that. I know that there have been some more recent studies that pick up on some of that, but I would doubt that that would changed much in the last 10 years. You know, one of the things that I'm I'm also struck by is how many surgeons do feel that they're equipped to have these conversations when they may not be well,

spk_1:   20:20
that's actually a very good point.

spk_2:   20:22
And I think one of the challenges for our residents is that, you know, again, this isn't taught. It's not taught in a skill bills based way, and we need to teach it in a skill based way in order for people to feel that they have competency. Actually, in order for them to actually have competency, I'm more concerned that they actually have competency, that I I don't think we've made a lot of progress in general. I think we have capitalized on a lot of interest on I think the American Board of Surgery puts the light items that palliative care is part of what all certain should know and that, you know, if you look at the HC Jamie requirements, it says the communication end of life communication is part of it. But we don't approach it in the same rigorous way. There's still a lot of opportunity to develop that

spk_0:   21:08
the question that comes up and I don't want to put you on the spot here for design an entire curriculum in one go But if

spk_2:   21:14
you just sort of

spk_0:   21:14
just say, What

spk_2:   21:15
are the what are the

spk_0:   21:16
key skills that every gentle surgeon should have on this front? Right there is the speciality trained surgeons. There's those of us in critical care who might be a little more experience and then, like what? Everybody else out in community practice or, you know, in in some specialty in college, your basketball. What? What does every general surgeon need to know about pied of care? We'll be able to practice,

spk_2:   21:37
I guess. You know, I would go back to symptoms and I would go back to the communication skills. So the symptoms, I think you know, we're fine at at assessing pain. And although you know we need to get better a chronic pain, obviously there's, ah, public health rationale for that right now as well. But we need to understand all the elements of pain, social distress, virtual distress, and we need to be able to assess chronic versus acute pain. I think we need to be able to assess nausea beyond the patient with a bowel obstruction toe, understand the importance of fatigue. I mean, once you're out in practice, the major complaint that your patients have is that they're fatigued. That's why they can't recover, that they've lost their get up and go. It takes. That's what takes people so long to recover from. Is the fatigue and the lack of appetite on these air symptoms that can be addressed either with cognitive behavioral therapies with other types of therapies with pharmacologic therapies. So understanding how to the realm of symptom management that is actually under our purview and that our patients are experiencing? I think it's important for two reasons. One. It allows us to be better clinicians. We ask better questions. We get better information. But to it better aligns us with the patient experience. Because patients are experiencing is their symptoms right? They're not experiencing how much drain output they're having. You're dancing the pain from the drain. No, we're experiencing that the social inhibition that they now feel because they don't want to go out with their Austin me. So we need to start thinking beyond what the physiologic consequences are, what we d'oh. So that would be one piece and then I think the communication pieces critically important and that, you know, again approaching things with curiosity understanding. You know, the patient experience of front. I mean, there's been a lot that's been written about this, but I think that if we can help surgeons approach these conversations, and what I mean by these conversations is understanding the goals of surgery understand the goals of care, and that is an end of life conversation. You know, um, really drill down on what is most important to patients and their families. If we can do that in a rigorous way, I think that that could be applied in Amiri out of settings and doesn't and doesn't and shouldn't just be reserved for, you know, the family meeting in the I. C U. After patients been in the ice you for 46 days. You know, that's a really

spk_0:   23:51
interesting point, and it kind of echoes in my mind something you said a couple of minutes ago, which is? His medical care gets increasingly more complex is the medical situation and surgical options become increasingly more complex? Is shared decision making even possible? You touch that a little bit a couple minutes ago. Wonder if you could expand a little bit upon that statement and then how do we teach that to our trainees who, like have had autonomy drilled into them from day one of or respect for autonomy drilled into them from day one.

spk_2:   24:18
Yeah, yeah. So I think that there is a respect for autonomy. I think there's also got to be this respect for this concept of personhood that is so prevalent in palliative care and recognizing that illness and surgery in particular strip people of their personhood and so that our concept of autonomy is compromised because we're often dealing with people who are vulnerable and so they don't have the same agency that maybe we d'oh in the same conversation because they're vulnerable. And so there's a power differential that makes a lot of this very difficult and very messy. And so how do we drill this? I mean, I think one of Vic's that drives me absolutely crazy is when I see clinicians of all stripes kind of saying, OK, here are the 10 things that we could do to you. Now you decide, because now all of a sudden, what they're doing is they're they're turning over that the decision to somebody in order to protect their autonomy. But in fact, you're not really at all because they have no idea what the consequences of those 10 things are. They don't know what the repercussions, implications experiences of those 10 things are. And so without making a recommendation, you're really kind of leaving them in a lurch. I mean, I think it's actually abandonment when we do that. So I guess the way that I would drill it into into our trainees heads it's just thinking about being on the other side of that. You know, there are some very simple, you know, kind of simple analogies that are very rough. But, you know, it's like going the car mechanic. I was tell them to take the second cheapest, whatever it is, that's fine. You know, I don't know. And so to pretend, like if my my mechanic starts explaining to me all the details of my car and then all of a sudden within two seconds, I'm gonna be able to make a very educated, well thought out decision is just unfair. So again, I think it goes back to respecting our patients, recognizing their vulnerabilities, recognizing you know what they are able to do in the moment and trying to tend to that as much as possible. Does that answer your question?

spk_0:   26:17
Yeah, it does. I think it's a one of the, you know, in fellowship. I had my attendings, you know, found herself in a similar situation and they said, Listen, you know, you can't very some of what you said. You can't expect people with limited medical background to suddenly be an expert on ventilators, dialysis, an ECMO, you know, they tell you their values, goals, priorities, and then you have to bring the medical at medical side. How do we reach those how to release those in a way that's consistent with what you want to dio, right?

spk_1:   26:47
I feel so strongly about that, too. I've heard other people talk about that. It is almost patient abandonment to just kind of throw out this list and then basically walk away and say, Well, you think about it and I'll come back. And I feel like we've all been so blessed with all this education and that part of my job is to put myself on the line and to give a recommendation.

spk_2:   27:11
I

spk_1:   27:12
think that really is a big part of my job when it's a life or death thing. Sometimes I feel like, you know, I don't want to leave my family's with this decisional burden, like I will take that decisional burden from you. And I'll tell you, if this is my mom. This is what I would do, knowing what I know about her values because the family shared them and knowing what I know about medicine, this is what I would do. I really feel it's like I'd rather have that on my soul than on their soul,

spk_2:   27:42
right? Yeah. No, I I agree. I don't know. I don't think it's fair for us to kind of put that on our patients and families. And so I feel everything. I think that's really important, Mac, is that we need to allow our trainees to understand why they're doing that right. And a lot of times the reason why we do that is because we don't want to deal with the decision ourselves, right? And so we need to name why this is hard. Why this feels bad and give our trainees and our colleagues permission to recognize their own emotion in the scenario and how that's influencing the way that they're conducting the conversation, and I think that also helps a lot

spk_0:   28:27
catch a coaching people immediately almost running two separate parallel palliative care practices, right? One for the patients of them, one for the doctors. That's

spk_2:   28:36
exactly right. Exactly. Right

spk_1:   28:39
So true. So sorry. I'm going to shift focus a little bit. I wanted to talk about your work surrounding racial disparities and end of life care. And I'm wondering what have been some of your most surprising or troublesome findings in your work in this area.

spk_2:   28:56
Yeah, I haven't. You know, I guess I would say that I haven't done a ton of work and I've done some work in this era. I haven't done the Tana bit of late in part because I'm just trying to make the case for palliative care in surgery at all. But I think that, you know what we find is that there are disparities. We haven't been able to drill down more specifically as to why they exist. But it seems that there are either patient or clinician behaviors that are driving this, and I think a lot of it is based in culture. Different groups of people have different ideas about discussing goals and values and priorities about share, decision making, about autonomy that's influenced by a whole host of things. And, you know, I don't think that we as clinicians are ever gonna be able to get it right 100% of the time, given the diversity of our patient population. But we don't have a great understanding of what our communication should include on. We don't have a great understanding of how the patient's experience and their own cultural expectations influence what the conversation should include. And so those are continued research gaps that I think need to be addressed in all of palliative care, but also in surgery, you know, I mean, I think, for example, because I am, you know, a surgeon, and I like to think of myself as somewhat of a scientist, and I like to think of myself as an educated person. I really appreciate the value of knowledge. I really appreciate the value of data, but that's not true for everybody. And it doesn't matter the color of your skin or Europe. That's that's just not true for everybody. And so again, kind of going back to a question about how palliative care has changed my approach. I no longer approach every patient situation, assuming that everybody just wants the data. And so I think that in thinking about parties, it's like where it lies is really, I think, in a very individual. I think in this build, it's a very individual level. Yes, there are structural issues, but there's still a reason on the individual level why some patients are getting palliative care, and some aren't sort

spk_0:   30:56
of opening up that research question a little bit more. Let's if you imagine you had some huge amount of money, $100 million you could fund the top five research priorities surgical palliative care that relates to trauma. But also I see you care. And also emergency dental surgery, an acute care surgery. What would you find? Where's we put the money?

spk_2:   31:17
We have Opportunity t develop that it was a research agenda in collaboration with the N I H and M P, C R C. National Institutes of Health and National Problem Care Research Council, with NBC Air See, a few years ago, I think there are three major major things. One is the efficacy trial for palliative care in surgery has still not happened. We have a lot of small trials. We did a systematic review. Um, I guess about three years ago now. And, you know, we found a number of studies that air of moderate to good quality, showing that palliative care in a lot of different domains. Ah, help surgical patients. But the efficacy trial has has really not happened yet. So I think that that's one thing you know, the temple study, and I know that, you know, Rebecca asks and others air working working towards that. One of my concerns, of course, is that those are currently in surgical oncology. And of course, you know, even if we find that works in surgical oncology, you know, if they're in G I oncology that there ask, oncologists will say, Well, that's not our patient. So I, you know, I think that

spk_0:   32:19
about 40 times

spk_2:   32:20
a little bit of a moving target. I do think that we need to do a better job. There's been a lot of data about patient report outcomes, but I think that we need to do a better job supporting qualitative research to really understand the experience of patients and families. I still think that we have no idea what happens to them after they leave the hospital and that too much of what we used to inform our decisions are based on our own personal experience and that we're still beholden to the data that we have so a lot. I do a lot of studies using Medicare data, and so we look at healthcare utilization and we look at days at home and those kinds of things. But those were really a proxy for understanding kind of what it's like to be a patient after surgery, and you still don't have a great idea of that. So I would love to think about spending more time with patients and their families to figure it out. And then I think the other thing and this is true for all of palliative care is we don't know what is the special sauce. You know, palliative care, even to those of us who are deeply invested. The field is still somewhat amorphous in that we have all of these domains. We've made domains, they're very broad. You know, when I say symptom management in communication, that could make almost anything and so really identifying, honing in on what are the aspects of palliative care that are most relevant surgical patients. Because I think in surgery, it's really not about end of life care. Obviously, that's that's important. We do take care of a lot of patients who are undergoing procedures specifically for Paley ation on. We also take care of a lot of patients who are near the end of her life. However, we also take care of a lot of seriously ill patients who are not going to die in the next year on DSO understanding how palliative care can help them live their best lives in still big knowledge gap. And then I think one thing that that's become really curious to me lately is really understanding some of these system factors. I am struck by the fact that you know, we now have papers from myself, and it's one of all and others saying that you know, surgeons understand the value of palliative care, they still don't know how to use it. They still can't get a palliative care consult that there are some real structural factors and structural barriers that are preventing us from integrating really a more patient focused approach to surgery and try to understand what some of those things are so we can remain in them. I think those are the things that I would liketo throw. Ah, couple of $100 million out of That would be great.

spk_1:   34:43
So those are a kind of speaking about all this. How do all of these ideas coalesce with your work? Is the director of the Center for Society and Public Health?

spk_2:   34:54
So I would say, is the director for the Center for Surgery and Public Health, one of the things that has been incredibly rewarding. And I think that those of us in an academic surgery find this to be the most rewarding part of our job is that I get toe, let people do what they want to dio. And so the best thing is actually seeing people pursue their own passions. And, you know, we do a lot of work in global health. We do work in trauma, we do injury prevention work. We d'oh work with the military and so you know, it's a very broad portfolio, and I've learned a lot from the other investigators. The other thing that I think has been illuminating for me is spending more time thinking about the policy impacts of some of these things and, you know, trying to make sure that the work that I'm doing has some policy and game to it. It's all great in the conclusion. If I write, you know, the the you know, this requires further study to better understand. But you know what? What are you gonna do with that? I don't know. At some point, we don't need more studies. We actually need toe change policy and figure out what levers we can pull and push to do that. So being in this role has helped me think about that. And, you know, also having Diane Meier is one of my mentors has helped me think about that too. But you know some of the work that we're doing right now, specifically around quality and quality indicators and trying to figure out how to integrate some of this in tow. Our quality measurement.

spk_1:   36:20
So I loved your 2016 JAMA Perspectives Research letter in which you detailed the difference is an end of life care intensity for various professions.

spk_2:   36:31
Oh, yeah?

spk_1:   36:32
Yeah. And found that physicians tend to list, receive less aggressive care and also are less likely to die in the hospital. And I'm wondering if either of these findings surprised you.

spk_2:   36:45
Well, you know, I'll say those were the funnies, but it was barely. It was barely. I mean, if you look I mean, it was it was only by a couple of percentage points, and that surprised me. That surprised me. So I was surprised that that the difference actually wasn't greater. Uh, interesting. But I have to say that reflecting. You know, a couple of years ago, sadly, my father died, and I'm reflecting on his experience. I'm not. He was not a physician, but I am. And reflecting on his experience, I guess I become less and less surprised because it is very hard. Thio, Um, it's hard to get off to get off the train. You know, it is very hard to get off the train and you don't necessarily want to get off the train. And I think that hope is a very, very curious thing, and it leads people in all kinds of kinds of directions, and I think we need to we need to acknowledge it, and we need to honor it. So I have been surprised. Actually, that that the difference wasn't wasn't greater. I think one of the other things that I've become more and more appreciative of doing this work and in spending time with the palliative care community in palliative care researchers is just actually how difficult home Hospice can be. And it's a lot for patients and families. And so you know, my thinking about dying outside of the hospital as a positive outcome has also shifted over time. I think that you know, there are a lot of patients where we cannot adequately manage their symptoms outside of the hospital and their families cannot take care of them. For a whole host of reasons that we need to think more about whether or not that's the problem is again, that's a proxy, right? And so what? We actually want us to figure out whether or not the patient the family had a peaceful death. I had a positive experience and acknowledging that could happen in the hospital better than it could happen at home. In some circumstances,

spk_1:   38:34
that is. One of my biggest pet peeves is overselling hospice. I think there was a great New York Times article about it a couple of months ago that I am an and actually kind of circling back to what we were talking about. One of the palliative care skills that I think if I could have my way, that all practitioners would be familiar with, not just surgical practitioners would be just a little understanding about what hospice is and what hospice isn't right. Because I've seen some conversations that surgical colleagues have tried toe have, and it's like, Okay, well, okay, well, you're going to just go to hospice. Well, you know, what does that mean? Where we receiving that hospice care? Who's actually doing the care? What does this look like? I don't think we all need to have all the details about it. But again, just in understanding that home hospice is really just guaranteeing you, I tell my family's you know you'll have a phone number that you can call, and sometimes that phone number is an absolute lifesaver and can keep you out of the emergency room. But the majority of work is going to be done either by the family or by paid caregivers,

spk_2:   39:42
right? I mean, I think the other. The other thing to that end is I would just like our clinicians, including our critical care clinicians to goto long term acute care hospitals to go to North the nets. You know, kind of this euphemism that we call everything rehab when most of it most of our patients are not going to qualify for rehab. I think all of those things tie into our lack of understanding of what happens when our patients leave the hospital. It doesn't a huge disservice because we set expectations that can't be met.

spk_1:   40:07
So true, Mac. Anything else that you'd like to add?

spk_0:   40:12
No, I I was actually just thinking about I'm glad you brought up the New York Times article because I was I literally had that conversation three days ago with a patient. We were talking about hospice, and the patient brought up that New York Times article. He really and I think it's I mean, my hope and babies are This is a question for you. It seems maybe this is also just an artifact of I live in the Pacific Northwest, but it seems that patients are becoming a little more open to the fact that you know that we don't have to do every single thing that we can do. And sometimes it's okay to transition our goals and focus on comfort in tow. Transition? The hospice? Is that just a Is that a Pacific Northwest thing? Or do you think that this is sort of beginning to penetrate into the public mindset little bit more?

spk_2:   40:53
Yeah. No, Mac, I agree with you. I think the challenge is that patients are often looking to us for permission. True? Yeah, we're looking to us for permission to do it, and we're the ones who don't give them permission to do it because we don't broach the subject because we're afraid. And and so, yes, I agree with you that I think there has been a shift because there's a greater understanding of the harms of overly aggressive treatment at the end of life for patients who are, I shouldn't say at the end of lip overly aggressive treatment for patients who are dying. But I think the challenge is is that we often don't give people permission to consider death. And we really need to do a better job of that.

spk_1:   41:35
No, Zara, as we're wrapping up. Is there anything else that you'd like to add?

spk_2:   41:41
No. You know, there's nothing on my mind immediately. I'm just so happy that you guys were doing this. And I'm very excited. Um, for what this is going to do for the field, I think it's really great.

spk_1:   41:52
Thank you so much. It's been such an honor to talk to you as Mac mentioned. I mean, I think I've read all of your articles opening time. So it's so fun toe. Just get to talk to you and hear your thoughts. And I'm so grateful for all the work you've done and all the work that you continue to do and how approachable you are. Just appreciate your time so much.

spk_2:   42:14
Well, thank you. That's very humbling and very generous. So thank you.

spk_1:   42:19
And, Mac, thanks so much for your time too. It was great chatting.

spk_0:   42:22
Oh, my gosh. Thanks for having me on this is I feel like this has been an incredibly inspiring 45 minutes from a

spk_2:   42:28
thank you both. I appreciate we're

spk_1:   42:31
gonna go out and all change the world of surgical palliative care,

spk_2:   42:34
you know, that's just keep doing it right.

spk_0:   42:36
I think I think great care. I thank you for joining us for another episode of the surgical palliative care podcast. Be sure to subscribe to stay up to date on the latest episodes. Toe. Learn more about the surgical palliative care community. Follow us on Twitter at Serge Pal care. If you'd like to get more involved with the surgical, palliative care Social media team, please reach out on Twitter or via email at surgical palliative care at gmail dot com. Lastly, take good care of yourselves and take good care of each other.