A neurosurgeon’s lessons on love, loss, and compassion [PODCAST]

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“Dehumanizing patients can lead to indifference in physicians. It is a privilege to be trusted to take care of every patient we encounter, yet we can lose sight of this and begin to see our patients as a burden, or as units of work, rather than as individuals. When individual patients cease to matter, we cease to care. This is the precipice of burnout and invites mistakes and poor behavior, such as cutting corners or pushing the envelope by exposing patients to excessive risks.

Often, physicians hold themselves to unachievable standards of perfection. No surgery is ever perfect, yet we expect perfection from ourselves and from our colleagues. Partly the result of training, these unrealistic standards also interfere with emotional connection or empathy. Complications are an inevitable part of the work we do, yet physicians often lack self-compassion. Self-compassion is a crucial component of emotional flexibility; unrelenting self-criticism does not promote learning or modification of maladaptive behaviors.”

Joseph D. Stern is a neurosurgeon and author of Grief Connects Us: A Neurosurgeon’s Lessons on Love, Loss, and Compassion.

He shares his story and discusses his KevinMD article, “Emotional agility is an essential element for patients and practitioners.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Joseph Stern. He is a neurosurgeon, and he’s the author of the book Grief Connects Us: A Neurosurgeon’s Lessons on Love, Loss, and Compassion. There’s an excerpt on KevinMD from that book that’s titled “Emotional agility is an essential element for patients and practitioners.” Joseph, welcome to the show.

Joseph D. Stern: Thank you so much.

Kevin Pho: So we’ll get into your excerpt and book in a little bit, but first off, can you share your story and journey to where you are today?

Joseph D. Stern: So I’ve been practicing neurosurgery for about 25 years, and I thought that I was a compassionate and connected physician. And then I discovered what it was like to be on the receiving end of medical care, when my sister, my younger sister, Victoria, developed acute myelogenous leukemia, had a bone marrow transplant, and died less than a year later. And then after that, about a year later, her husband had a ruptured brain aneurysm and lapsed into a coma. I was his health care power of attorney, so I had to make all his medical decisions for him, which included withdrawing treatment and letting him die, orphaning their two children.

And I found, being on the receiving end of that medical care, just how extraordinarily terrifying it is to be a patient and how utterly helpless and powerless people feel. And it rocked my world and really changed how I saw my role and how I saw the impact of the medical care that I provide. So this was a transformative moment for me, and it was as if I went from seeing in black and white to suddenly seeing in color.

And it propelled me to write the book. Initially, I wrote the book, my sister had written a journal about her experiences. She was an actress, and she always envisioned that she would write a book or a play about surviving leukemia, and she didn’t. And so initially, I wanted to give her a voice. But then, as I went through this, I realized that I needed to go through my whole experience, and that’s what this book is about.

Kevin Pho: So speaking from the perspective of a physician for 25-plus years and going through that story, what would you say was the biggest unexpected thing that surprised you when you went through that experience?

Joseph D. Stern: I think just to see medical care from the standpoint of the patient, and to recognize how we say we’re compassionate, we try to be compassionate, but there’s really a compassion deficit in medical care, and that really needs to be met head-on. And we need to change how we think about medical care, how we think about making medical decisions, and how we think about communicating with patients. So that was kind of the fundamental shift.

Kevin Pho: And you talk more about that in your book, that’s titled Grief Connects Us: A Neurosurgeon’s Lessons on Love, Loss, and Compassion. One of the things that you mentioned when you were going through this experience was a compassion deficit. Tell us more about what you mean by that.

Joseph D. Stern: I think that one of the things I talk about in the excerpt that’s on your website is the need for emotional agility. I realized that I had developed emotional armor, which I was using to protect myself, but what it was doing was hindering my experiences. And I realized that I needed to let go of that emotional armor. I wanted to connect more deeply with my patients and also with myself.

But then, when you let go of the emotional armor, all of a sudden you have to think, “Well, how am I going to show up as a physician and as a surgeon? How do I flex between being defended, or trying to keep some distance so that I can operate on someone’s brain and not go to pieces, and at the same time, sit down and have a very meaningful personal conversation with them about their life expectancies, or maybe, you know, that we may have to stop, or that they may die?” So there’s a tremendous range that we need to experience emotionally as physicians and as surgeons. And I feel that in our training, we’re really not well equipped to do this. I think I’ve kind of felt that I developed this experience the hard way, by going through it.

And so one of the things I hope to do with this book is to have people consider this and start to look at this and start to think, “Well, is there a different way to do things? Can we do a better job training physicians, and can we do a better job while you’re in practice to develop greater compassion and empathy for patients?” So I think that’s kind of my mission. That’s why I wrote the book, and that’s what I want to talk to your audience about.

Kevin Pho: Well, tell me about that concept of emotional armor. And what I hear you saying is that a lot of this isn’t learned in medical school and residency, and certainly not reinforced during training. So give us an example of this emotional armor that you’re talking about that you see in physicians, and what are some of the ways that we can overcome that?

Joseph D. Stern: I think that part of becoming more compassionate is to develop self-compassion, which means an ability to forgive ourselves. We have these impossible expectations of ourselves, of perfection. You know, as a neurosurgeon, I expect myself to be perfect, and my patient is expecting me to be perfect, but that’s not an attainable goal. So how do we confront the sadness?

You know, when I was a resident, we would have mortality and morbidity conferences, and we focus on the technical and the physical, and we don’t focus on the emotional and the psychological. And we’re taught to see that that’s kind of a weakness, that we shouldn’t be doing that. And I think that’s completely wrong.

So we defend ourselves, and you do that when you start in training. And then, you know, people start with high levels of empathy when they go into medical school, and it sort of gets beaten out of you as you go through. By the end of it, you kind of have to regain that or restore that. But I think we kind of create these shells of self-protection. And the irony that I discovered is that that shell doesn’t really protect you, that the way to go through this, and to be successful as a physician and as a person, is to experience these emotions. You can’t really wall yourself off from them. If you wall yourself off from the sense of grief or failure, it’s a corrosive effect on your personal life and on your professional life. So it doesn’t work.

So I think that a willingness to go through emotional experiences, and to cry with a patient, or hold their hand, or admit failure, admit that you’ve made a mistake: We’re kind of wired or taught not to do this, but I think that’s really the only way to practice effectively and well, and that’s really the only way to connect on a profound level with your patients and with their families.

Kevin Pho: Now, take us through an example from your own story. So you described that family tragedy earlier on. Tell us specifically how that changed you. Can you give us an example of what you would have done before and what you would do now?

Joseph D. Stern: So there was a young woman. [Name removed by the editor.] She’s a very nice person. She had metastatic breast cancer to her brain, and I had been consulted to put a reservoir in her brain to be able to instill chemotherapy. So this is relatively technical. It wasn’t really a long-term relationship moment. But I went in. I found myself, when I knock at the door of a patient, I kind of go, “Well, am I going to be task-oriented, or am I going to be really present and available?”

And when I sat with her, I realized, you know, she was a mother and a wife and a teacher, and what she wanted to do was to finish the fourth-grade class year with her students. And I realized that what was really important was for her to maintain the quality of her life. This wasn’t going to cure her. This wasn’t going to reverse the course of her cancer. And I sat there with her, and I saw my sister, and I saw her fragility, and I actually just started crying.

It was a moment. It was not, I think people hear, “Oh, neurosurgeon cries,” like, “Well, I don’t want that kind of doctor.” But it was actually a profound moment of connection with her. And I think it made a difference to her. It made a difference to me.

Another example: I had a patient who was dying, a young man who’d been in a car accident, and he was dying. He had broken his neck and was paralyzed, and there was nothing we could do. And I stood with his mother in the ICU, and I reached out to her and I hugged her. And I felt that actually that connection was so much more powerful than any of the descriptive or kind of detached physician communication that I typically would have done in the past. So I felt that I actually made a big difference to her, and I felt that she helped me by reconnecting me with my own humanity.

And then what happens is you start to get into this, because you start to realize that the compassion is rewarding. It is rewarding to have these emotional connections with patients, and it’s kind of a loop that starts feeding on itself. And then you start to realize, “Well, this is a much better way to practice and a much better way to live.”

Kevin Pho: So as you know, with the increasing amount of regulation and bureaucracy in our health care system, the unit of time certainly isn’t valued. And sometimes, in order to have that emotional connection with patients, especially in a primary care setting, we often seek and want more time to spend with that patient to develop that connection. Now, given that backdrop, what are some specific ways that physicians can develop that emotional agility and develop that connection with patients with less and less time in the exam room?

Joseph D. Stern: So I think some of that is certainly external pressure, but I think some of that is also a willingness to go there, a willingness to be present. For example, it only takes 17 seconds to make an empathetic connection with a patient. And what that really takes is a willingness to be present, and to avail yourself, and to connect. And so that’s not a question of time. That’s a question of willingness and a desire to connect or not connect.

That being said, I do think that there’s a lot of external pressure. I mean, I do the electronic record, I deal with insurance companies, I deal with all those problems. And I think that one of the things I’ve noticed is that as I have developed a greater sense of the need for compassion, you start to look at health systems, and the way they behave, and the way they make decisions, and the financial pressures, and you realize that those are really not compatible with a high quality of physician-patient interaction, and those need to change. So it is something that does need to change, but I also think that compassion and empathy can be taught. Helen Riess is a professor at Harvard in psychiatry who has really shown that you can reproducibly teach greater empathy. So I think that these are things that, if people are willing or interested and realize there’s value to it, I think that they can do it.

The other thing is that if you take the time, and you probably know this in your family practice career, if you take the time to establish that deep, personal connection with a patient, that lasts your whole relationship with that patient. So sometimes it actually saves you time, because you already have this connection with a patient. You don’t have to establish it repeatedly. You have this knowledge that the patient knows that you’re there for them, and that you’re listening, and that you care. So sometimes visits are shorter because you don’t have to reestablish that each time you interact with the patient.

Kevin Pho: We’re talking to Joseph Stern. He’s a neurosurgeon, and he wrote the book Grief Connects Us: A Neurosurgeon’s Lessons on Love, Loss, and Compassion. And there’s an excerpt from that book on KevinMD titled “Emotional agility is an essential element for patients and practitioners.” What are the other main messages that you want my audience to come away with from reading the book?

Joseph D. Stern: So one of the things that I did in this book, in addition to including my sister’s voice, was I interviewed physicians and patients, and my goal is to show that this is a universal experience. I think that everybody goes through these profound moments of grief. And what we don’t do is we don’t talk to each other, and we don’t support each other. We tend to do this in private. So I feel that we need to connect more with each other, and that we need to be more comfortable discussing this and sharing these experiences.

But I interviewed four patients and four physicians, and I will tell you that each and every one of them had very similar trajectories in their own personal lives, dealing with profoundly meaningful experiences themselves, and it affected how they treated patients, how they practice, and how they live.

So I feel that what I want to do is to introduce people to the concepts through my sister and my brother-in-law, but then in the book, it’s a symphony of voices, where I let other people say that this is nothing new. This is nothing different. This was my personal experience. It happened to me, but every single patient that we see and meet in the hospital, they’re the same. You know, they’re treated as a patient. A lot of times, you take their dignity at the door. They cease to be that individual.

But when I saw my sister there, I thought, you know, here’s a patient, but nobody knows the person that she was, you know, an active, vital, engaged actress, mother. And nobody knew the little girl that I grew up with. But the thing is, every single patient that we encounter is just like that.

Kevin Pho: Now, what’s the response from physicians to your book when you tell them to be more emotionally vulnerable and emotionally agile?

Joseph D. Stern: There’s a range. You might find that there are some who don’t agree or don’t see the value to it. But one of the most extraordinary things that’s happened to me on this journey is connecting with people of a similar mindset, who realize that we need more compassion in health care, that we really need to adjust the way we do things, that we need to reinvent how we do things. And I feel that there’s a big community out there who gets it already, and that we’re at a tipping point of change. It is time to change. And that means taking some control of medical care and decision-making back from insurance and government agencies, inserting the importance and primacy of the patient in the relationship, and also adapting technology to be more helpful in that goal. You know, there are things that we could do technologically to improve patient care, or we can let it be a burden and an obstacle.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Joseph D. Stern: Let’s get together and improve health care, and let’s start by increasing our compassion and our awareness of the suffering of those that we are entrusted to treat and care for.

Kevin Pho: Joseph, thank you so much for sharing your time and insight, and thanks again for being on the show.

Joseph D. Stern: My pleasure, and thank you for what you’re doing to improve the world of practicing medicine and doctors. Thanks.

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