Dr. Ira Byock: National Leader in Palliative Care

#009 - Join host Dr. Red Hoffman as she interviews Dr. Ira Byock, nationally known author and speaker and the founder and chief medical officer of the Institute for Human Caring at Providence St. Joseph in Southern California.  Ira served as the president of the American Association of Hospice and Palliative Medicine as well as the Director of the Robert Wood Johnson Foundation's Promoting Excellence in End of Life Care, under which the Surgeons Palliative Care task force (now the Committee on Surgical Palliative Care) was created within the American College of Surgeons.  For those interested in the history of surgical palliative care, Ira is also known as the man who introduced surgeons Dr. Robert Milch to Dr. Geoffrey Dunn (both men went on to become leaders in the field of surgical palliative care).  Ira shares that seeing how poorly patients at the end of life were treated in his training hospital led him to develop a hospice program while still a resident physician.  He discusses that illness is fundamentally a personal issue (rather than a medical issue) and that by acknowledging this, surgeons can do their part in making certain that patients get the best care possible.  He is thoughtful, inspiring, generous with both his time and his experience, and a pure joy to talk to!

Learn more about Ira here.

Ira's books include:
The Best Care Possible: A Physician's Quest to Transform Care Through the End of Life
Dying Well: Peace and Possibilities at the End of Life
The Four Things that Matter Most

Learn more about the Surgeons Palliative Care Workgroup here (includes PDFs of over two dozen articles written about surgical palliative care and published in the Journal of the American College of Surgeons.)

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

Transcript

spk_0:   0:13
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, the Surgical Palliative Care Movement, a diverse group of surgeons dedicated to providing a high quality palliative medicine to all surgical and trauma patients. Welcome to the surgical palliative care podcast. We heal with more than steel. Hi, everyone, this is Red Hoffman. Thank you so much for joining me for another episode of the surgical palliative care podcast. My guest today is Dr Ira Byock. IRA is a well known leader in the field of palliative care. He is the author of three books and numerous articles. He is the past president of the American Association of Hospice and Palliative Medicine and a recipient of that group's Lifetime Achievement award. He's currently serves is the founder and chief medical officer of the Institute for Human Caring at Providence ST Joseph Health in Southern California. IRA, thank you so much for being here today, so appreciate your time.

spk_1:   1:52
It's such a pleasure to be with you, Red. Thanks for asking.

spk_0:   1:54
Yeah. So, Ira, as we're getting started, can you tell us a little bit about yourself? Where you grew up, where you trained and what your early career looked like?

spk_1:   2:05
Ah, sure. Ah, I grew up in the Jersey Shore before it was, you know, Ah, Joe,

spk_0:   2:12
it was the Jersey Shore. Are

spk_1:   2:14
bad TV show, right? I don't know Bruce Springsteen. I'm or identify with Danny DeVito. Who's Ah, Asbury Park Dennison of Asbury on and Jack Nicholson, one town over that. That's real jersey to me. Anyway, I decided midway through my undergraduate studies to become a doctor. I why I went to medical school quite late. Frankly, in that sense, I didn't have a career beforehand, But I certainly was struggling with figuring out what I was gonna want to do when I grew up and and I decided that I really, really wanted to be a rural family doctor. I loved general medicine, and I really want to learn it all. I wanted to you know, everything from pregnancy management and prenatal care, you know, and childbirth and neonatal care but my own, you know, fracture management, emergency medicine, reasonably simple cardiology stuff, reasonably simple surgeries, all of that, and my career path, then took me. I went to medical school in University of Colorado. I did a residency in Fresno, California, of all places, one of the really premier family practice programs. That was We're training rural family docks for, you know, kind of independent horse. A very small group. Practice was a fabulous experience. I love my residency, and during residency, frankly, was drawn in two different polls. On the one hand, I was drawn to emergency medicine and intensive care and flirted for a while. Maybe we'll come back to this with the idea of of changing residencies and and, uh, being a surgeon.

spk_0:   4:00
Welcome back to that.

spk_1:   4:02
And then, on the other hand, I was appalled by how bad care was for people who were acknowledged to be dying. And that seemed to me just kind of an odd lacuna in in what was otherwise a deeply committed and really excellent medical center in Fresno, Uh, county hospital. But academic, extraordinary care and training, but literally at this time this is 1978. I started my my internship and residency literally dying. People were put down the hall and, you know, and kept away and sort of not visited. Those descriptions are our riel and I That seemed to me not only a lapse in kind of our commitment to excellence, but somehow a social injustice. Like, when did they stop mattering like that was weird. And so I kind of just gravitated to them. I was very curious about what was going on, both in the impatient environment, but even more so, like, I did a lot of of emergency medicine during my residency, and I and I meet people with, you know, advanced cancers who were sitting in the E. R for four and five hours to get there. Tie three's refilled. You know, their timing with codings. We're using a lot of days refilled and didn't know who they're who their doctor waas like they didn't have a doctor. They just went to the cleaning up, or I I'd admit patients with rule out bowel obstruction who if you took a careful history usually having to be in Spanish, you'd you'd find out that they were simply constipated and had been for weeks because they were taking those Thai threes and not taking ah, laxatives, or I'd meet somebody in clinic. I did surgery clinics. And you, You know, I remember this one woman were picking her chart off of the little tray at the door of the surgery. See, clinic she had, you know, ah, liver full of colon cancer, down too darn near to her iliac crest. And she didn't know who her doctor was, and she hadn't been well managed and my cash. So we said I put together with a social work student at the time. Ah, little fledgling hospice program. It was really just borrowed time from Nurse on Med Surge. And And I had an oncologist who was willing to kind of pre set me in this role. Somebody from home health, somebody from the emergency department and social work discharge planning, you know, and And we every Thursday morning at seven o'clock, we convene and just run the list, and it seems simple. I mean, it was ridiculously simple, but but the fact is, we averted a lot of problems with that little program.

spk_0:   6:40
Ira, how did you know to do that? I mean, who were You were If this was, like in the seventies, like, who were your mentors of

spk_1:   6:48
the 79? Yeah, I didn't I didn't really have any I Well, I had. I mean, I I gathered them after that, you know, it just seemed like a social injustice. That's something I had to do. I had a supportive chief of family medicine, Dr John Blossom, and I was just just sort of had to do it. So let me just finish this quick sentence statement because this brings it all back and and how it shaped my career. We kept people out of the e r. We required Any resident could refer a patient to this little program was called the Esperanza care Cooperative to be followed. But the resident had to agree to see the patient back as an outpatient clinic. They didn't have to agree to readmit the patient if they ended up in the emergency department. No, no albatrosses. They were encouraged to come by if the patient was in the hospital to say hi. But all they had to do was admit, agree to see them in clinic and to refill their prescription. They're non immersion prescriptions. That's it. And if they wouldn't agree to that, we wouldn't take the patient. So we connected patients with with doctors. We made sure they weren't lost in the system. We were focused on averting crises. But what drew me in? What kind of got under my skin red was that every once in a while, not not commonly, but enough to cat. Gather my attention. I'd meet a patient. Who? Ah, you know, I'd say, Mr. Rodriguez, how are you doing today? And he was in the hospital, and we've had the talk. He knew he was dying. Ah, and he'd look up at me and Sam. Well, Doctor, how are you? Mm. Like, you know, my first response was Well, sure is. It's the more feet he's, you know, he's a little high, or it's the steroids, right? You know, he's a little euphoric, but I heard that just enough. And I and remembering I still to this day, remember of the face. I don't remember what's name really was, but I remember his face, and I and I realized later, you

spk_0:   8:54
know, that's kind of

spk_1:   8:55
disrespectful, Ira. Maybe he actually meant what he said. Right? Right. and I meet a family who came back, you know, after their mom died to see Kim, my partner in launching this little fledgling hospice program, and the family said, You know what? You know, Mom died when we heard she was not going to survive her cancer. It was the worst thing in our we could imagine. She's the center of the family. But you know, this last month has been the best time we've ever spent together. Like, What do you do with that?

spk_0:   9:26
Like, Hey, how do you

spk_1:   9:28
fit that into the continuum? Where in in the conceptual frameworks, in the language and the taxonomy, off medicine, but of psychology of human experience? Do you put that and and that that those questions changed my career, cause I realize that for my own sake, I had to explain. And remember, I was training to be a family. Dockside is really deep into cradle to grave care and family counseling, Virginia City ears, system, family systems, theories and all of that stuff like, Where do you put this? And so I went on to be a family doc for a short period of time in a rural town didn't really like the practice wasn't for me. I ended up being drawn into emergency medicine and getting boarded an emergency medicine. But along the way, wherever I was, I was always doing a little bit of, at the time hospice care along the side, trying to kind of explain to myself, but also build programs that provided people with, you know, the best care during these times. Oh, and oh, by the way, sitting on endless committees, I apparently have a unwholesome predilection for committee work. So s over time I was sitting on committees around end of life care in hospice care and and my and writing about this in 1996 summer of 1996 the Robert Wood Johnson Foundation knocked on my door. I was in Missoula, Montana, I thought and hoped that we had caught their attention with something called the Missoula Demonstration project. This community based effort to live in community with one another around illness, dying, caring, caregiving and grief rather than merely in proximity to one another. Like, what would it look like as a community if we did this? So anyhow, so Artemis J came out knocked on my door and told me about this remarkable program that the board of directors at R. W. J had and chartered to embed hospice like care into mainstream American health care. And I thought I thought it was terrific. How insightful. What a great idea. We talked for three hours, and I at the end of a long meeting, I said, Man, this is wonderful. I'll help you in any way I can. How can I be of help fully assuming that that they wanted me to sit on an advisory committee? I was about to be the president of the American Academy of Hospice and Palliative Medicine, and dying Well had been written but wasn't out yet. It was coming out the next year. Okay, And the people from our W. J. Rosemary Gibson primarily said, Weld, Ira, we're here because we'd like you to direct the program. I read. I almost fell off my chair. Honest to goodness, I was in fact, the very first thing I said to Rosemary was me. Are you kidding? You're in Missoula, Montana. Look around. You see ivy growing anywhere. You

spk_0:   12:27
know, Ira, I'm laughing because like my very next question was gonna be. How did you become the national director of this initiative?

spk_1:   12:38
I have no idea. To this day, I have no idea. Actually, you know, the next thing was, I rattled off toe Rosemary. I said, Are you kidding me? Wait a minute. There must be a short list. And I rattled off the names of half a dozen prominent doctors and said like what happened? You know, there must be a short list. What's the process? And she She looked around at her colleagues and said, Well, yes, there there was a short list, but actually, we're here to offer you the position.

spk_0:   13:04
Wow, that's that's incredible.

spk_1:   13:07
Yeah, it certainly changed my career

spk_0:   13:10
kind of around that. I want to ask you a couple questions. Basically, in all my reading and researching and preparing for these podcasts about surgical palliative care, it really seems to me that the formation of the surgeons palliative care work group, through the support of the initiative through our W J. Is really what helped to propel the surgical palliative care of movement to the next level. So I'm wondering, with all the letters of intent that you all received and read when this initiative was starting. What led you to choose to fund work by surgeons?

spk_1:   13:49
Okay, Well, um, I don't want to be glib, but it was kind of obvious that it needed to happen. Okay, The way we did have, like, 730 I think letters of intention. The first cut was 60. We winnowed it down to 60 on, then site visited 30 some programs and made grants to, I think, initially, 23 or 24. I can't remember. One of those programs was an Mosen Falls. And and Pat Murphy's a program at this surgical. I see you at the Medical College of New Jersey on Dhe. That's an amazing place, by the way. And they taught us a lot, frankly. But this notion of peer to peer work groups around specialties, specific specialty surgery being one of them, we did it. We did a number appear to peer workgroups, though that just emerged after reading 730 some odd letters of intention. All of us myself, Jeanie to it. Who was the deputy director on the people from our w J. It was very clear that there were certain themes and potential synergies and and potential collaborations and learning communities that needed to be brought together to think about at least expert opinion about how to manage certain classes of problems and patients with specific diseases and demographics. It was also clear that in addition to kind of impaneling work groups that could come up with a kind of statements of expert opinion and recommendations that recommendations for what the terrain of of a surgical extremity of ah, I'm sorry of a research agenda would look like in surgery and in neuro muscular disease, in pediatrics and in other specialties. So it was kind of a no brainer. The surgical palley of care worker was brilliant, though, and other than having the idea to bring these people together to use are convening function as the Robert Wood Johnson Foundation toe, you know, give some gravitas to them coming together and creating statements of consensus opinion. They did the work and man, oh, man, did they do great work.

spk_0:   16:07
I was just interviewing Jeff Done last week. We were obviously talking about the work group, and he was saying, You know, looking back, it's just so amazing that everything they had on their list, they actually accomplished, which is like, How often can you say that?

spk_1:   16:21
Well, you know, you work with Surgeon's done. I mean, you know, you know, it's it's a it's a pleasure. Yeah,

spk_0:   16:30
So I'm wondering, in your opinion, having worked with surgeons, What particular strengths do you think surgeons bring to the field of palliative care?

spk_1:   16:40
Mmm. So the GSD attitude, you know, getting stuff done is a big one going back to my statement that in training I was really intrigued with and kind of drawn toward surgery. It was part of the culture. Frankly, I mean, surgical culture gets a deservedly bad rap in many ways of for all the reasons I'm not going to take time to mention. But one of the things that really intrigued me and and I deeply respected was this notion that the buck stops here that we will say we will say yes to any admission, you know, in the busy safety net hospital, everybody else seemed like they could bat away an admission the surgeons kept saying Yes, even if it was just for fluid management or the burn case that really didn't need a burn unit and could have been managed elsewhere or sort of whatever they they said yes, I just like that This, you know, and frankly, some of the the best communicators in my early training, where surgeons, the people who would come sit down on the bed and have the conversation and not look at their watch because apparently surgeons don't give a damn about time and saying things like that and man like I learned a lot about being a doctor from a number of surgeons. And so I see all the problems and the will probably talk about some of this. But the surgical mentality is being fixed this and gone Zo and having trouble giving up and stopping when it's obvious and all that. But I also see a very different part of surgical culture that I've tried to internalize and, you know, still respect a lot

spk_0:   18:29
that's so lovely to hear, especially the parts about communication, because I do often feel that we get a bad rap, and certainly some of us are better than others at it. But there have been many times, especially remember is a medical student and a resident just being almost dragged around on these rounds at 89 o'clock at night because the attending surgeons still needed to go check on their patient for evening rounds and then sat and talked to the patient and the family and really invested that time.

spk_1:   18:59
That's what I remember, too.

spk_0:   19:02
So in corollary to that, I will ask another question. Where do you see that surgeons can do better?

spk_1:   19:10
So American Medicine is, is having a bit of challenges. And, uh, by the time I started training, you know, I went to medical school and 74 78 invented residency. It had already started. But back in the mid 20th century, with the evolution of specialization, which was fueled by all of this ex creasing expanding power of technology and science and path of physiology and pharmacology and surgical technique and on and on another medicine became increasingly bound to problem lists to later toe I C D codes to being medically necessary on it became increasingly and really almost solely transactional, where in the early part of 20th century it had been significantly relational and as surgeons were very much swept up into that transactional fixit model of medicine with the internist in the family, Doc's trying and the pediatrician's trying to maintain the relation a LL surgeons bought into it or were forced into it. And so, in a lot of surgical training, a lot of surgical practice these days you're there to fix a problem, to take something out, toe, reroute something. It's new, rebuild something, and that's why you're there. And if you don't have a problem, what are you here for? And frankly, it's just a little bit more of, ah, extreme in surgery. But it's that exist, even in internal medicine, in family medicine practice these days it's tragic, but it's there. So you know, surgeons often don't experience that they have the timeto have these conversations to align what we do with with what people actually would value there often, you know, time pressured, overworked and inadvertently abrupt. All of that still needs to change.

spk_0:   21:15
Yeah, I do. I like the idea of inadvertent because I I don't think it's being malicious. I think it's just not having the time to be even mindful about it.

spk_1:   21:25
I totally agree it can I stay with just for a moment with the with the positive. I've had a wonderful catbird seat for 10 years in the director's chair, if you will, of that Robert Wood Johnson Foundation promoting excellence in End of Life care project, which really you helped to spur palliative care as a discipline within this country and and within so many specialties and other national work that I've done over the years as I look across the American College of Surgeons has been a incredible force for good in all of this, repeatedly with typical clarity, acknowledging that palliative aspects of care and need to be integrated within surgical training and practice, that communication and shared decision making were essential toe quality of care. And while the implementation of those statements and recommendations eyes a work in progress, the fact that it's their unequivocally in so many publications off the College of Surgeons is really been helpful.

spk_0:   22:38
Yeah, I would, I would agree with you. I mean, my my experience, the American College of Surgeons. Every year at the Clinical Congress, there's multiple offerings around either palliative care or ethics, and and I do think the more we talk about it eventually, more people are just going to catch on. It's just constant work and constant discussion. Yeah, so I'm gonna shift gears a tiny bit. I wanted to talk about your most recent book, though I know it came out in 2013. I believe the best care possible because this was the first book that I read of yours. I was, Ah, third year surgical resident, just trying to clarify for myself what I wanted my life in my career to look like and was very interested in palliative care. And one of the things that I took away from that book was really the importance of legacy for patients and families. And, you know, my feelings are in a perfect world that legacy work can start months or years before someone dies. But often times in this day and age, especially what surgeons who are dealing with either critically ill patients or with a patient who perhaps came in well, that had an unfortunate complication. There seems to be only hours or days to think about creating a legacy around life and around what the death can look like. And so this is where sometimes I see some of my surgical colleagues fall short because I feel like the importance of just sitting with the patient and the family and telling stories and playing music like I feel like surgeons can really be a part of that legacy, but often either don't know how to do so or don't feel like they have the time to do it. But I was wondering if you could kind of just talk about that, how to create that legacy for patients and families.

spk_1:   24:30
This is a really great conversation have, and I and I'm not sure I agree with you that it's part of surgical practice. It is acknowledging it is part of surgical practice, but but I think we work in teams. And while the surgeon can redirect families, patients and families on, acknowledge what really when you think about it is it's quite obvious that there may be value in saying things that would be left unsaid and sharing memories in creating that legacy. It would be good, given the realities of surgical practice. To be ableto hand that off to to a pallet of care team or to a team that when I was at Dartmouth, we actually created a separate volunteer team program called No one alone volunteers that weren't just about dying, but they were they roamed the hospital, seeing everybody on our palliative care list and part of what they did was to sit with people. And if people wanted to record some of their family stories, they had. We had this thing called the Family Heritage Workbook, which simply asked people stories about their earlier life about their midlife and careers, and and about any special knowledge and wisdom that they would think they'd want other people in their family, including their Children and grandchildren and those they will not meet to know she's lovely. Here's my principle that I tried to reflect in the best care possible and thank you very much for reading. It is that serious illness fundamentally is not a medical condition. Serious illness is fundamentally personal, intensely so intimately. So we're and inadvertently and unintentionally train medical students and physicians in training to think of illness through the lens of the problem based model of medicine. Right? People come in with injuries and illnesses, and our job is to diagnose them and bring state of the art treatment to each component of the path of physiology or or disrupted anatomy all well and good. But the experience of illness includes the medical but is not defined by the medical for the person going through it and their family illnesses personal. When you make that frame shift as a clinician, everything for me becomes clearer because I Kenbrell in all of the diagnostics and therapeutics in service of the patient's condition and quality of life. But ultimately, I gotta remember that this is personal. So my job is not done and left unless I kind of helped them acknowledge and frame what they're experiencing within the realm of the personal in the continuity of their life, not just of their condition. Once you do that, then there's an opportunity to kind of extend your counseling guidance from the path of physiology to the realm of the personal. And most of it, frankly, you know, you don't have to be a on MSW or a psychiatrist to figure this out. It's pretty damn obvious what what's available to people to do.

spk_0:   27:48
I think sometimes I'm coming from the lens of having done a fellowship in hospice and palliative medicine and also practicing as a surgeon. But I appreciate you saying that, you know, for the quote unquote average surgeon that Yes, this doesn't need to be your job, but if you could just recognize that this needs to happen and make sure that your patient and family have that support somewhere, Then you're doing your job. Yes,

spk_1:   28:13
we work in teams, and we and sometimes they work in teams of teams. Right? And that's OK. It's not about us, right? I may. I may liketo sit down with a patient and have a cup of coffee here. And peace pie. I love therapy that could be done over pie and coffee and listen to their stories. I think it is therapeutic, but, you know, really, the clock is ticking, and I got I've got to keep moving. So it's just a challenge.

spk_0:   28:40
Yeah, that's a great reminder. I'm gonna shift a little bit again on I want to talk to you a little bit about the importance of language. So I heard you speak at end. Well, in 2018 Was that you who had the cold or that?

spk_1:   28:53
No, no, it was It was Anthony. Sure, that was money. I dubbed him the, uh, The Death Whisperer. He's He's actually a very gifted linguist and does messaging and branding. And all of this were both kind of unit polar Mannix. And we had some planting calls. Sit to my wife. You know, the biggest challenge is gonna be competing for air time with with Anthony because, like, we're both have a lot to say. And then he really got laryngitis. Oh, my gosh, that was a miracle. And I said, I I said to weave on my wife. Yes. Oh, so sorry, Anthony. Yes, great. And and it was funny, it was fun.

spk_0:   29:40
But I know you guys were speaking about language, and that's something that I've heard Diane Meyer speak a lot about as well. How do we talk about palliative care to all of the stakeholders that are involved? And so I'm wondering if you can share your thoughts about how we can use a language to convince Sword to educate both our patients and our colleagues that palliative care has something to offer them.

spk_1:   30:04
You know, communication from my perspective starts with listening. And as a physician with observing, getting a sense of what patients are I want to know are able to hear who they are. You read the best care possible. You you've heard me or read me sang risk, but But I start every interview. I'm pretty strict of myself to start every clinical interview. I think I've read your chart. I dive. Talk to Dr Jones about your current condition and why you're in the hospital. But chart doesn't tell me much about who you are as a person, so I'd like to start there, and I'm pretty strict in myself. In my fellows or residents. Start with the social history. Tell me a little bit about you. Where'd you grow up? What do you do for a living? Have you been married for all of that? It takes about five minutes. Doesn't take a long time. It begins the relationship within the context of the person's life, not just in the camp, in the context of their current hospitalization or the current complication or exacerbation of their ongoing problems. All I'm doing is a family is a social history, maybe a little bit of a family history, and I'm gonna chart it down underneath the past medical history and the medications. But starting the interview there is really helpful. I listened for the patients background, you know, their ethnicity and if we might get there to, ah, faith that's important to them. And then I'm very deliberate about trying to listen for the metaphors that they use and, to the extent ican authentically do so. Use those metaphors and talking back to them because those kind of culturally bound use of language is not hard to adopt and is really helpful. And then, as we get go to things like decision making about what of several treatment options makes more sense. I look at what is achievable physically and functionally, and then referring back to what they've told me matters most in their life. What makes sense in terms of their personal priorities. So listening more than talking, showing up and leaning forward and then trying to use their language to the extent possible. I'm really strict with myself about whenever possible using plain speak. And if I do have to use a medical term or jargon pausing to explain what what I mean by that I like of the ah definition of palliative care that cap see has come to. I think it's really very good. It's about an extra layer of service, a team based approach that provides you and your family with an extra layer of service with the goal to provide you with the best quality of life

spk_0:   32:49
I read. Thank you so much for that. It's so I'm I'm smiling so much as you're talking because, like I said, I read this book several years ago, but I feel like I must have really incorporated into my psyche because so much of what I do now is what you said. And obviously I learned it somewhere. So thank

spk_1:   33:07
you. You know, part of the starting with asking people tell me a little bit about yourself is something that man residents on rotation with us. When I was at Dartmouth and my fellows, even I really had a be strict with them. They want to jump to the H P I. You know, tell me what raise you to the hospital,

spk_0:   33:27
right? It's It's so funny because it's what I do. And people are really taken off guard like Well, what do you mean Like they want to just start talking about? Well, you know, I have this abdominal pain. I'm like, No, I just want to hear your story for five minutes and then we'll get that,

spk_1:   33:42
it makes a big difference. You know, people will say later you're the only one who ever listened to me. I don't think that's true, frankly, but I framed the relationship in the context of their life,

spk_0:   33:54
right, rather than their illness

spk_1:   33:56
rather than just their condition right

spk_0:   33:58
now. So I know that you are the founder and also serve as a chief medical officer of the Institute for Human Caring. Can you tell me a little bit about this organization

spk_1:   34:09
I left Dartmouth in, um uh, your mid 2013 to move west because my daughter and son in law were here in L. A. And just starting to have a family. And I wasn't gonna be a Skype grandfather s. So I really left for family reasons. And I took a sort of self under sabbatical for a while and did some writing and some stuff I needed to do and then wrote a three page white paper about how any health system that really believed its values and its mission and vision could thrive in the coming value based care environment, the a CEO or Obama care type environment. And that three page white paper I put it in front of some leaders within healthcare in Los Angeles. Okay, Actually got traction a few places, but the Providence Health and Service's system really just leapt at it and knew me just well enough and love the white paper and said, You know, we want you to build this here. What I described and what we're building is a way of, in a sense, spreading the knowledge, attitudes and skills that we associate with palliative care across the health system. Taking what some people call primary palliative care, communication, shared decision making, symptom surveillance and basic pain and symptom management. Ah, family support, coordination of care. I would add crisis prevention and early crisis management some of those basics and sort of just trying to embed them across the health system. And I made the strong point in my initial white paper, and we're doing it. We're demonstrating it now that there's actually a business case for goal aligned care for whole persons within the context of families and communities. This really bridges problem based care to whole person care, care of individuals to pop health, and that kind of anticipatory and yes, relation based care that gets beyond the traps of purely transactional encounter based care. You know, a latte is allowing us tow actually build these models. So this is a cost effective way to improve significantly and measurably improved quality.

spk_0:   36:37
Do you think this will be scaleable throughout other Providence organizations?

spk_1:   36:42
It already is. We are. We are actually disseminating things like we've redefined quality of serious illness, care to require a pause to document a goals of care conversation with a patient we built within our electronic health record, a place that that resides, that it can be iterated, and you can see layers of dated goals of care conversations. We've taken the sting out of doing it and finding it, but in a sense, we've We've made it required to do that. Now we haven't transformed the health system quite yet, but within the first year focused on patients with I C. U lengths of stay off five or more days. We went from zero goals of care conversations in that. In that goals of care, form and bucket in the E. H. R. To just over 30% of icy use days of five or more days, having a documented goals of care conversation in the chart. That's evidence of, you know, I would say not only practice change, but a bit of culture change that's that's going on. And it's going on in other service lines to cardiovascular oncology, hospital medicine. We focused on the I see you first because it made sense to do so. But we're doing this. We've got reliable metrics and dashboards that that support all this. Those dashboards are highly dynamic. You can look at him and you can slice and dice the data and any number of ways. So we're doing that. We're teaching people how to have these goals of care conversations, had a document them. And now, by the way, we're gonna We're gonna broaden this in surgery and working with Jimmy Chan and the Surgical Clinical Performance Group within Providence, we're now going to start rolling out Best case worst case from your our colleague Gretchen Schwartz, Ian and University of Wisconsin at Madison, which is just a brilliant tool.

spk_0:   38:38
I think one of your points that's so important is that being able to find these discussions in the E. H. R is key, you know, sometimes we have them But then there's no there's no way to find them.

spk_1:   38:50
Yeah, I learned back in my work with R W J that if you're actually gonna create change on changed patterns of practice of very busy clinicians, you have to make the right way the easy way. So we we didn't launch our goals of care initiatives before we built the infrastructure, the Elektronik health record tools. We adopted the serious Illness Conversation Guide from a tool, Rwandese Ariadne. The labs were written by Susan Block and uh and re Shelburne AKI. We developed our dashboards, we developed training programs. We contract ID with Thea Angelo Valon Days, a cp decisions videos to adopt patient and family education that linked all of it, links up and reinforces itself. Right? So we're starting to make the right way the easy way to simply say, Look, this is like, what what health care looks like in the 21st century? That's just part of hat of good health care is having these conversations, so that's part of what we're doing. We're also optimizing the palliative care workforce because specialty palate care does have a role in shifting from volume to value and and still taking very good care of seriously ill people were doing all of this. It is scalable. It's not for the faint of heart. It's still hard, but it's the work. I feel like it's the work I was born to do.

spk_0:   40:17
It sounds like a perfect job for you in sunny California, near your family. I

spk_1:   40:21
mean, anything I have two grandsons were like my B f f. So you know, I'm really happy.

spk_0:   40:28
That's awesome. So it's funny. I'm gonna ask you, looking back, what accomplishments are you most proud of? And I think you may say being a great grandfather. But I guess family, of course. But then also professionally, you've done so much, and I'm wondering what stands out to you as something that you are so proud of,

spk_1:   40:50
man. I think simply calling attention to the fact that, um, people who are seriously ill, who are acknowledged to be dying and their families still matter that well being is still possible through the very end of life. Because illness isn't medical, it's fundamentally personal. And while suffering is is far too common, and we're all far too prone to that. In fact, the phenomenon of human well being. That potential does exist through the very end of life. A lot of my writing has to do with that this notion that you can die well, not just doing it right, but dying well within oneself. That, I think is I hope has been contribution to healthcare that will continue to evolve and expand and endure from a personal perspective. Frankly, yeah, being a great grandfathers is important to me. But frankly, seeing my daughter and son in law be the most amazing parents I've ever met is probably what makes me proudest.

spk_0:   42:05
You did a good job, man. It's It's interesting when you talk about that idea of being able to be well as we're dying. I've never thought of this before, but it really helps me redefine that idea of hope because that is something that is something to hope for, right? We don't need to be hoping that we're going to live forever. We may not quote unquote beat this disease, but that we can hope for wellness, emotional, spiritual, wellness, even as we're transitioning towards death.

spk_1:   42:37
Absolutely. The first book I wrote was called Dying Well, and and it it's a play on words in a sense, you know, when you when you hear that phrase people first here Well is an adverb, you know, describing of modifying the process of dying. But it's more provocative to hear it as an adjective describing the person who was dying. Can one be, well, that book, It's Ah, it's a collection of real stories of people starts with my dad's story. But it's a collection mostly of patients that I've had the privilege of caring for, and each one of them kind of illuminates some other aspect of human well being through the end of life. And I framed this on you know, it's it's structured on a kind of human development model, very much like mad as Lower Ericsson or P R. J. That serious in terminal illness is a developmental crisis, and that crisis has various tasks associated with it that if you accomplish, you may be able to reestablish wellbeing within this inherently difficult time of life. It's not Woo. I'm always afraid I come off or that notion sounds somehow like pop psychology. This is anthropology. People do have a capacity for well being through the very end of life and illness and dying sucks. You can quote me on that. Yeah, but But it also provides us with certain opportunities to say and do the things that matter most that would be left unsaid if we died suddenly to review our lives, to reaffirm what matters most in our lives toe to do the Please forgive Mieze and I forgive use and thank you's and I love you's. What's drawn me and keeps me in this field is that I see remarkable therapeutic opportunity, and and I witnessed human well being at times not not commonly, but commonly enough that it keeps me going in people who you would you would have thought were the best you could hope for was alleviation of suffering. So the fact that we're more than our bodies and that that this potential for human well being is indeed lifelong, is, I think, the most exciting frontier in medicine still today, and frankly, I'm glad that you and your surgical car leagues are surgical colleagues are are part of this effort. It matters. It's

spk_0:   45:03
an awesome, powerful, like call the action. Can I do this? I think a lot, because I read recently with all this talk and essays and documentaries about death and dying that, you know, we do need to be careful about not romanticizing it, because certainly in the trauma world, I mean, you know, not all deaths even have potential to be good deaths, you know, Summer all holy projecting quick. But I think in my experience, because I see a lot of those when I see the opportunity tohave, even just hours, to make some sort of difference if not for the patient. But for the family, it's like that is just what draws me in because I feel very strongly my father was killed tragically, and I I feel very strongly that the legacy that's left for a family that loses their loved one tragically could be like a pretty awful legacy. And so when we have even just moments to change some of that legacy, it's just such powerful work, So sometimes the patient can't be doing that work anymore. But even if we could do it with the family, I think there's some meaning to that

spk_1:   46:07
so strongly agree. I practiced emergency medicine for about 14 years

spk_0:   46:12
that you now

spk_1:   46:13
I can tell you in those critical moments. Time is measured not in length, but in depth. Mmm. You sit down. You lean forward, you quiet the room. You can say some things. You can offer people some opportunities that matter a lot to them as well as to the family and those that they love. Who who, uh, remain alive?

spk_0:   46:37
Yeah, that's awesome. Thank you, Ira. So one more question. As we're wrapping up, I'm just wondering, is there anything that you'd like practicing surgeons, or particularly surgical residents to know about this field of palliative care

spk_1:   46:54
that we're better together, that as a as a specialty service line surgeons should draw the Palais of Care team in walk with them shoulder to shoulder. That the whole is so much more than the sum of our parts that weaken. Be teams of teams caring well for people managing their injuries or illnesses, but also giving them the best care we possibly can for their physical, emotional, social and spiritual well being. And those of their family

spk_0:   47:28
well said, That is why this man is a leader in the field of palliative care. Thank you so much, Ira. That was awesome.

spk_1:   47:37
Well, you're welcome. Thank you for including me. I so feel so privileged to be part of my surgical colleagues. It's it means a lot. So thanks

spk_0:   47:46
Thanks. 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 e mail at surgical palliative care at gmail dot com. Lastly, take good care of yourselves and take good care of each other.