August 22, 2022 • 28 mins
Wait, isn't palliative care something hospice does before somebody dies? Well, yes, but that’s just part of the story: palliative care covers a whole lot of health conditions, even temporary medical health setbacks. Palliative care is like symptom relief for the emotional challenges of being alive. Doesn't that sound really interesting? Find out what it is, and why it applies to YOU in this week’s episode.
Want your questions answered on the show? To submit your questions by voicemail, call us at (323) 643-3768 or visit megandevine.co
In this episode we cover:
- What is palliative care and why should *anyone* outside of hospice care?
- Getting your colleagues to care about the emotional pain of their patients
- Dr. Red’s love letter / shout-out to nurses
- Why a skilled surgeon also needs to be a compassionate human being
- How to keep your personal losses out of your workplace (sort of)
- Why Megan hopes you’ll start seeing the whole world through a palliative care lens
Notable quotes:
“There’s no way I could have come back to this job without being under the care of an amazing trauma informed therapist. You have to do your work or there's no way you're going to avoid bringing all of your stuff back to the job. My partner's death definitely informs who I am personally and professionally, but it cannot be all about me in the room.” - Dr. Red Hoffman on the personal/professional gray area
About our guest:
Dr. Red Hoffman is a board certified trauma surgeon trained in surgical care and hospice and palliative medicine. She's one of the leading voices advocating for palliative medicine across all departments and subspecialties in medicine. Follow her on Twitter @RedMDND
Questions to Carry with you:
Where are your palliative care people? Go on an expedition to find out more!
Get in touch:
Thanks for listening to this week’s episode of Here After with Megan Devine. Tune in, subscribe, leave a review, send in your questions, and share the show with everyone you know. Together, we can make things better, even when they can’t be made right.
For more information, including clinical training and consulting, visit us at www.Megandevine.co
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Check out Megan’s best-selling books - It’s Okay That You're Not Okay and How to Carry What Can’t Be Fixed
See omnystudio.com/listener for privacy information.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
This is Here After and I'm your host, Megan Divine.
This week's show is a repeat performance. We'll be back
with season two soon enough, but for right now, enjoy
this episode and visit the back catalog of episodes too
while you're at it. This is Here After and I'm
your host, Megan Divine. Each week we tackle big questions
from therapists, doctors, and other helpful folks that let us
(00:21):
explore how to show up after life goes horribly wrong.
This week, palliative care for everyone. Wait, what isn't palliative
care something hospice does before somebody dies? Well, yes, but
that is just part of the story. Broadly speaking, palliative
care describes the stuff we do to help somebody manage
emotional pain. Sometimes that pains comes from a terminal diagnosis,
(00:43):
but it also applies to chronic illnesses, non life threatening injuries,
and even, in my opinion, grief itself. Palliative care is
like symptom relief for the emotional challenges of being alive.
Doesn't that sound really interesting? Stay tuned, everybody. We'll be
right back with my guest of surgical care specialist Dr.
Red Hoffman right after this first break. Before we get started.
(01:11):
One quick note, well, I hope you find a lot
of useful information in our time here together. This show
is not a substitute for skilled support with a licensed
mental health provider or for professional supervision related to your work.
Content warning everybody, this episode contains brief, non graphic mentions
of both suicide and terrorism. So if you listened to
(01:34):
the intro to the show today and you were like,
I don't understand any of what she just said, you
are definitely not alone. Palliative care as a term used
in the medical field, but even inside the medical industry,
most people don't know what it is. It's one of
those if you know, you know things, and if you
don't know, there's almost no reason why you should. At
(01:55):
least that is the old way of looking at things. Hopefully,
by the end of the show today you will have
a real working knowledge of what palliative care is, and
my secret hope you'll even start seeing the whole world
through a palliative care lens. You don't even have to
work in healthcare to slip on those palliative care glasses.
I really mean it when I say that palliative care
(02:15):
is for everybody, and I'm pretty sure, my guest today
would agree with that. Dr Red Hoffman is a board
certified trauma surgeon trained in surgical care and hospice and
palliative medicine. She's one of the leading voices advocating for
palliative medicine across all departments and subspecialties in medicine, and
she's the host of the Surgical Palliative Care podcast. Dr
(02:36):
Hoffman's life has been marked by sudden and often violent losses,
as we'll hear about in the show. Again disclaimer, no
graphic details are shared that we do briefly mention both
terrorism and suicide now. She and I met on Twitter,
which is usually a platform where people yell at each
other about various things. I've actually been yelling about various
things on Twitter lately. It's also, though, like a place
(02:57):
to find really lovely colleagues and potential friends who geek
out on the same things you do. At least that's
how Twitter is for me, even if I do use
it to rant about things too. So Red, welcome to
the show. I am so happy to have you here.
Before we get too deep into all of the things
that we could possibly talk about, I think it's actually
important for us to define what palliative care is so
(03:20):
really quick, Can you tell us what palliative care is
as it relates to surgery. Sure? So I think there's
two ways to look at it. One, palliative care is
an incredible specialty in that when you are trained as
a get go to a fellowship and hospice and palliative medicine.
There's like ten different specialties that feed into this fellowship.
It's like no other fellowship in the country. So you
(03:42):
can be a surgeon, a family medicine doctor, a psychiatrist,
or radiation on collegist emergency medicine doc and go complete
a palliative care fellowship. So that's why I think it's
such a fascinating specialty. So we have surgeons who practice
hospice or palliative care, but we also have this field
surgical palliative care, and that's kind of a term that
(04:04):
came up through the American College of Surgeons and Dr
Jeffrey Dunn, who I call he's the father of surgical
palliative care, and that's really palliative care specifically for surgical patients.
Part of what we offer when we're doing surgical palliative
care is a palliative surgeries. So if you have a
bowel obstruction, we might put in what's called a venting
(04:26):
G tube so that we could drain your stomach, or
we might do an intestinal bypass. Surgeries that are not
meant to cure, but that are meant to deal with
symptoms only. So that's one thing that we do is
palliative surgery. But it's not all about surgery. It's again
about symptom management, about walking the patient through any complications
(04:46):
they might have and then perhaps saying okay, we're ready
for hospice and guiding them through that again addressing the
emotional and mental component of disease processes and of dealing
with life limiting um illness says, and then also the
spiritual support. What's really cool to me about palliative care
and surgical palliative care is we're talking about there is
(05:08):
a condition here that we can't fix for you. Not
just there's no cure like terminal illness hospice, but there's
no permanent fix for this condition illness situation in your body.
What we can do is manage to mitigate the suffering
that this condition causes for you. And that like to
me that is what palliative care is. It's it's a
(05:30):
mitigation of suffering to the best of our capacity, knowing
that we can't fix what's actually wrong for you and
for me. Like little tiny sidebar before we get into
our first listener question, Like, to me, grief itself is
a palliative care condition, right, Like you can't fix grief
for somebody. You can't undead the person who's dead. You
can't restore a body back to full mobility after an
(05:51):
injury or an illness that changes that, Like, we can't
fix that central vacancy, but we can do what we
can to mitigate the suffering that comes with those kinds
of losses. So to me, you know, new specialty over here,
like grief is palliative care work. But that that as
a tangent for another day, because I feel like our
listener question for us today really touches on all the
things that we've just started talking about. So I want
(06:13):
to make sure that I get our question in before
we go too far down the fascinating rabbit hole of
you and your work and palliative surgical care. Okay, you
ready for the question? I am, all right, let's go.
It is a two part So we're gonna answer part
one first and then we're gonna get to part two.
So don't worry everybody part two. We will totally answer
it all right, Hi, Megan in Red. Sometimes I feel
(06:34):
like I'm the only one in my surgical department who
cares about the mental and emotional health of our patients.
I try to talk about palliative care with my colleagues,
like help them understand why we should talk about ways
to reduce emotional suffering, that there even is emotional suffering
related to illnesses and diagnoses and surgery. But I don't
think they get it. So I have two questions. One,
(06:56):
can you talk about ways to get your coworkers to
understand the need for palliative care or at least to
be knowledgeable about palliative care across all departments? And two,
how do you stay true to what you know when
the industry doesn't seem to care about emotional and mental health.
So I think this question here is something that a
lot of people in health care have, and actually a
(07:16):
lot of people like in the non healthcare role too.
But how do I get my colleagues to pay attention
to the emotional well being of our patients. So one,
I always think, I can't change how you're going to
treat me, right, but I can model how I want
you to treat me by treating you that way. And
so I think continuing to do what you're doing, so
doing this good work and knowing in your heart that
(07:37):
it's good work, and just continuing to model model that.
So for many years, especially in residency before I completed
a fellowship, I mean, I think people thought I was nuts,
but I just kept doing it and the patients responded well,
the families responded well. The ancillary staff I think always
the nurses and the chaplains like really saw the benefit
(07:59):
of that work, even if my teachers didn't see it,
but eventually they saw it because everyone else was seeing it.
So I think kind of just staying on that path,
you know too, For me, I'd say, I don't know
where where this person is in their career, but for me,
it was very important for me to complete additional training
to kind of give myself that legitimacy. So now people
(08:20):
do listen because I say, okay, I'm um board certified
and hospice and palliative medicine. So there's a lot of
training programs in the country. You know, there's master's degrees
for all different providers who are already engaged in healthcare.
And even just like Harvard has, you know, this online
course that goes for several weeks. So I think maybe
doing that extra training so you have that little legitimacy
(08:42):
behind you is often very useful. I love that. I mean,
one one that professional street cred right, like that legitimacy
is really really important, especially when you're bringing something sort
of new to the clinical and medical space, especially something
that has something to do with feelings, right, Like, having
that legitimacy behind you is really really helpful or can
(09:03):
be really helpful, and as you said, like it it
deepens your knowledge and your understanding so that you have
a really strong foundation for the role modeling that you're doing.
I love that spoken as a true educator, Like what
is the most effective education? While it is role modeling
the behavior that you want to see and letting the
people around you see the outcome of that behavior. Right,
(09:24):
We're all about the clinical and medical outcomes in this profession, right,
so we want to see, Oh wow, treating the human
being like a whole human being actually has some really
positive clinically significant outcomes and we make people hungry to
learn more about that. Yeah, I think that's a beautiful
way to frame them. Oh I'm sorry to interrupt, but
especially when you make your nurses happy, because those nurses
(09:47):
go and then kind of spread the word amongst the
other members of the team. And so for me, that
was like bedside nurses have a ton of moral distress
there with these sick patients, you know, twelve hours a day,
three or four days in a row. They see the
suffering in a way that physicians never do. So when
the physicians are addressing that suffering and addressing their suffering,
(10:09):
the nurses suffering as well. You also get that what
you said about street cred and then they talk about
you to the other physicians. Yeah, I think that works
as well. Yeah, I mean shouting out to the nurses.
I can hear all the nurses in the audience being like,
oh my god, you mentioned us right, Like nurses make
the world go around for real. I love that aspect
(10:31):
of it too, Like this this is showing your patients
what it's like to be treated like a real human being,
and the people around you are picking up on those skills.
The nurses are picking up on it, you know, hopefully
the other docs and the other providers are picking up
on it. The patient is also picking up on it.
And they may not know how to articulate why you're different,
(10:52):
but they know that you're different, and that has a
ripple effect out into the world. So I feel like
so much can feel wrong in our medical industry. Focusing
on those interactions, those moments, that evidence of things being
done really beautifully and skillfully, in the impact that those
interactions have, I think like those are the things that
we want to focus on and enlarge and fight for.
(11:15):
Right That is how we start changing the culture, even
in the worst of times, you know, even in the
trauma bay, in the setting of imminent death. Not always,
you know, I never want to romanticize death because sometimes
death is just ugly, but sometimes it really is just
some room for for beauty and for grace and for
(11:36):
a lot of love, even in those really horrible moments. Yeah,
I think there's always room for beauty and love and
grace inside the horror. What other time is there, and
I think there's that we don't want to conflate. I
love that you put the little asterisk next to like,
we don't want to conflate those two things, that like
looking for the beautiful things makes the horrible traumatic things. Okay,
(11:58):
that is not the equation we're talking about here. We're
talking about how do we companion these are really difficult,
terrible traumatic experiences for ourselves as providers, but also for
families and for people experiencing these things, Like we can
bring beauty and grace into those moments by paying attention
to the actual human beings in the room. I love that. Yeah, yeah, okay, everybody,
(12:21):
We're going to take a quick break. When we come back.
We were going to get into our two of that
question about how you stay true to yourself inside an
industry that doesn't seem to care. We've been talking with
Dr Red Hoffman about surgical palliative care and why everyone
(12:41):
in medicine needs to be talking about ways to manage
emotional pain. In the second half of the show, we're
talking about Dr Hoffman's personal experience and how that affects
her work. She and I jumped right into this topic,
but for context, you should know that Dr Hoffman's father
was killed in a terrorist attack in when she was
nineteen years old, and her partner died by a self
(13:01):
inflicted gunshot wound in following a traumatic brain injury sustained
in Let's get back to our conversation. So, in one
of your media appearances, you say that your dad's death
and the grief that followed has really shaped how you
think about medicine and death and grief, that in many
ways it's shaped both your career and your outlook on life.
(13:23):
The recent death of your partner by suicide also influences
not only how you see grief, but it's made you
really consider our responsibilities as care providers to really listen
to the pain we see around us. In a profession
that continues to insist that grief and really any emotional
pain should be cleared up quickly if we talk about
it at all, and insists that doctors should remain stoic
and unmoved by their work. Who We actually had a
(13:46):
good long rent about that before. But coming back to
part two of our listener question here, given all of that,
all of that like sort of industry institutional avoidance of pain,
how do you personally stay true to what you've learned
and what you know. Yeah, that's a great question. So
I always say every single shift I work, I cry.
(14:08):
One of the great things I learned in my hospite
and Pallative medicine fellowship was it's okay to cry, but
you should never be the one crying the most in
the room, which sounds like silly, but I honestly think
it's really important. So right, it's not about me, but
crying as like an emotional release valve, just like sighing.
I saw a lot too. I just let it go.
(14:29):
I learned very early on in my career, like my
first death in medical school, that if I did not
let it go, I was going to get really sick
and start acting out all over the place. So now
I just kind of let it go. So I think
that's that's one way. And the other thing is, you know,
my experience in my fields trauma and palliative care, is
that all my partners do talk about our rough days,
(14:52):
and I talk about it with like the nursing staff
and the chaplains and who's ever in the room during
a bad trauma. I mean, everyone's having feelings, and so
I just talk about it, you know, I just kind
of keep everything moving and flowing through me. And I
think because of my experiences, I don't apologize anymore. This
(15:12):
is just who I am. But I also think because
I'm a surgeon and because of my training, I also
know how to appropriately disassociate, right. I mean, that's one
thing we do in surgery that drape goes up. You
get to work in some ways. You have to just
do your job right. So sometimes that's a little challenging.
You turn it on and turn it off. But I
think because my training just taught me that it's something
(15:34):
that has come naturally to me over the years. There's
a time to feel feelings, and then there's a time
to get back to work because the patients also needs
you to be thinking clearly. Right. They want they want
a very loving doctor, and it's great to have a
loving surgeon, but they also need a clear mind that
can diagnose and treat appropriately. Yeah. I love that, And
I think you really sort of nail the the binary
(15:58):
here of like you can either be one or the other, right,
Like you can be a compassionate, present surgeon who understands emotions,
or you can be good at your job right, but
you can't do both. And I love like this, like elegant,
skillful use of compartmentalization and association, right, Like that is
a skill. Yeah, and I and I noticed, you know, certainly,
(16:20):
in this recent grief of my partner's suicide, that like
I became a little unskillful when I went back to work,
I call a little messy. And then I realized, like
I'm at work, and yes, I carry this grief, and
I think this grief has taught me so much. And
I you know, I think I was already a great
doctor and surgeon, and but maybe this made me a
(16:41):
little bit better. But it's not all about me, Like
I have to get back to work too, And so
I felt at the beginning that I kind of lost
some of my boundaries that I have worked really hard
to establish over the years. And and I noticed it
pretty quickly, and then I kind of worked with my
therapist and just did a lot of work with myself
about out. Like sometimes I like to think when I'm
(17:02):
walking into the hospital, like leave your stuff at the door.
You know, this is not me time, this is you time,
because I'm taking care of you right now. Yeah, Like
you can be informed and influenced by your personal experience.
I love that you said you weren't improved by your
partner's suicide right where it's almost like our our sphere
of understanding expands. That's not an improvement, that's just a fact.
(17:25):
Right now I have extra information to impact and influence
the work that I do and who I am in
the world and what I see. There's an essay on
an essay of yours that you where you say, I
also learned that my feelings of guilt and responsibility were
extremely common. The idea of perceived responsibility resonated deeply with
me and fed into my sense of failure. How did I,
as a board certified trauma surgeon, allow my brain in
(17:47):
your partner to die on my watch? This kind of
goes back into what you were saying about. I'm both
people when I walk through that door of the hospital,
right I am the person who lived this really intense
personal experience, and I am a provider who needs to
show up and be skillful and clearheaded and do the
work in front of me. You know, I think that's
(18:09):
very common in survivors of suicide loss to feel very
responsible for the suicide and for the actions that the
other person took. And so that's that idea of perceived responsibility.
You know what I've kind of had to come to
terms with is that I'm really only responsible for myself
and and my own behavior, and how can I improve
(18:30):
upon that over time? Like that's just a ongoing task
and lesson for me. But I do know I'm also
as I'm walking into the hospital, responsible for my patients,
and so like that idea has to just shift to
like them, Yeah, exactly is that facility of shifting, right,
what is the focus in the room? I love that
(18:51):
you said, like, uh, just don't be the one crying
the most, right, Like, don't be the one that's a
mess the most, don't be the one that is you
know in your own stuff. The It's it's really just
that shift of focus, that continuum the focus, rather than
that binary of all human or all machine. But I
think it speaks to why therapy is so important for everyone,
(19:12):
because there is no way it kind of went back
to this job without like being under the care of
like an amazing trauma informed therapist. You have to do
your work or there's no way that you're not going
to just bring all of your stuff back to the job.
And again it's like, yes, it informs my dad's death,
my partner's death, definitely inform who I am personally and professionally,
(19:33):
but it cannot be all about me in the room.
It's just it's not appropriate, you know, And sometimes I
have to remind myself it's not appropriate, but that that's
what good therapy does for someone. Good therapy. We love
good therapy, pro therapy therapy. And I like this this
isn't just like a switch that you flip to. I
think that sometimes we can get into that idea that
(19:54):
like I have to turn it off here and turn
it on over here and all of these things, and like,
this is really a community effort. This is a continuum
of care. If we go back to our discussion about
palliative care here, like your own personal life deserves palliative
care in a sense, right to have that community tending
to you and listening to you and worrying or maybe
not worrying, but like tending to your emotional, relational, spiritual
(20:17):
needs so that you can show up in the ways
that you need to show up for yourself, for others
and for the world. It's really interesting that you mentioned
that continuity of care because where I did my palliative
care fellowship, I ended up staying on as a surgeon,
and so the nursing staff knew me as a palliative
care fellow, and then you know, the next month here
(20:39):
I was as a trauma surgeon, and they were confused,
and they used to ask me all the time, what
hat are you wearing coming in as a palliative care doctor?
As a surgeon, No one asked me that anymore, because really,
when I think of palliative care, it's just this continuum
of care. I can operate on you, I can deal
with the complications, and then if at some point your
goals of care shift and we decide we really just
(21:02):
want to focus on comfort, I can like transition you
into hopefully peaceful and beautiful death. Pallid of care. Really,
in the perfect world, we call it primary pallid of
care should be woven into every medical specialty. Yeah. Amen, sister,
there's that nimble flexibility of skilled response. We had the
(21:25):
co founders of the New York's and Center for Protemplative
Care on a while ago, and Coach and Pale Ellison said, like,
we talk about work life balance all the time, but
there is one life. There is one life, and we
are our professional selves and our personal selves and our
relational selves all the time in differing. I don't know,
hydrations maybe if we want to use another silly word
(21:46):
in here, but I love that and that's really just
what you just described, right, is that everything shows up everywhere,
a real fluidity and flexibility with our skill sets and
how we respond to what's in front of us. I
love that. I love that idea of it's just where
you're putting your focus at the moment, you know. So
one last question before we close up today, what do
(22:06):
you wish other surgeons or medical providers knew about palliative care? Well, one,
I always say, you do not have to be board
certified in hospice and palliative medicine to do this good work.
You know, when I think about primary palliative care, having
the skills to do basic symptom management, to speak just
even about basic goals of care, advanced directives, knowing a
(22:29):
little bit about the Medicare hospice benefit and who qualifies,
and then really being able to say, okay, out of
my comfort zone, this person really needs a fellowship train
palliative care provider is really all you need to know.
I mean, you don't need to know much. And then too,
I think the palliative care skills are skills like anything else.
(22:49):
So you know, if you want to be a good surgeon,
you have to practice. If you want to be good
at putting in central line do you have to practice.
If you want to be good at running a family meeting,
you have to practice. And one of the best ways
to learn is just to watch other masters at work.
And so I always say, if you console palliade of carry,
should go and watch them have a family meeting and
(23:10):
you'll learn a lot. For years, all I knew was
what I learned in my fourth year medical school, and
that got me through all of residency was one month
of what I learned watching other people do what they do. Yeah,
practice is important. We're actually going to get into that
in our Questions to Carry with You at the end
of the show, But for now, I think this is
a really beautiful end note for our time here together.
(23:31):
We're gonna link to your website, to your Twitter feed
because that's where we met. But would you please tell
everybody where they can find you, your website, your podcast,
and any other information you want them to know. Sure things,
so you can find me on my website. It's Red Hoffman, MD.
Dot com. I'm also the co founder of the Surgical
Palliade of Care Society, so if you want to know
(23:51):
more about that society can look into our website at
SPC Society dot com. Can find me on Twitter at
red m d n D for Nature Pathic Doctor. And
then I also run the at surge pal Care twitter
feed where we feature a lot of research articles about
surgery and palliative care awesome. So of course I have
(24:13):
a podcast called the Surgical Palliative Care Podcast that you
can find on Apple Podcasts. So many ways to interact
with Dr red Hoffman, everybody I like. I kept thinking
that she was done with her list, but there are
so many amazing ways to connect with her, and of
course we will link to all of those in the
show notes coming up next. Everybody, your weekly questions to
carry with you and how you can send in your
(24:34):
questions for us to use on the show. Don't miss
that part, friends, We will be right back each week.
I leave you with some questions to carry with you
until we meet again. It's part of that whole This
stuff gets easier with practice thing and as Dr rod
(24:56):
Hoffman said, we both want you to practice. This week
a little research assignment. If you work in a hospital setting,
go look up your palliative care department. If you work
in health care but you're not attached to a hospital,
look up your local hospitals palliative care department. Just check
them out, like no pressure. Check them out. What are
they doing? Are there any cool or interesting workshops going on?
(25:17):
Familiarize yourself with a palliative care work going on all
around you. It's often invisible until you actually look for it,
no matter where you work in health care or nowhere
near health care. Take some time to reflect on what
palliative care really means. At its root, it's the support
and tending of emotional pain that can't easily be fixed.
(25:40):
If it can be fixed at all, What areas of
your life or the lives of the people around you
might benefit from a palliative care style approach. I would
super love to hear your responses to this week's questions
to carry with you. Palliative care as a lens on
life is a fascinating topic. I totally want to hear
(26:01):
about it. You can tag me on social media at
Refuge in Grief. Leave a review of the podcast with
something you've learned in today's show or any of the
other shows, or use the question submission form on the
website to let me know what you find. You can
do that at Megan Divine dot c O. Speaking of
Megan Divine dot c O and that question submission form,
this is your weekly reminder that I want to answer
(26:22):
your questions on the show. This show is nothing without
your questions. It is literally a Q and a show.
You can ask me anything you'd like. Bring me your
professional questions. You're I'm trying hard to be a really
good friend and I don't know how questions you're I'm
overwhelmed with the pain of the world questions and even
your I bet you don't have a good solution for
(26:42):
this one questions. I love a challenge. Let's talk it out.
Call us at three to three six four three three
seven six eight and leave a voicemail. If you missed it,
you can find the number in the show notes or
visit Megan Divine dot c O. If you'd rather send
an email, you can you that too. Write on the
website Megan Divine dot c O. We want to hear
(27:04):
from you. I want to hear from you. This show,
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(27:26):
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(27:49):
send in your questions. Want more Hereafter? Grief education doesn't
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of losses, from everyday disappointments to events that clearly divide
life into before and after. Learning how to talk about
all that without cliches or platitudes or simplistic positive posters
(28:09):
is an important skill for everyone. Find trainings, workshops, books
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in the world after something goes horribly wrong At Megan
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dot CEO for all those details. Hereafter With Megan Divine
(28:34):
is written and produced by me Megan Divine. Executive producer
is Amy Brown. Co produced by Tonya Juhas and Elizabeth Fosio,
Edited by Houston Tilly, with studio support by Chris Uron.
Music provided by Wave Crush
This is Here After and I'm your host, Megan Divine.
This week's show is a repeat performance. We'll be back
with season two soon enough, but for right now, enjoy
this episode and visit the back catalog of episodes too
while you're at it. This is Here After and I'm
your host, Megan Divine. Each week we tackle big questions
from therapists, doctors, and other helpful folks that let us
(00:21):
explore how to show up after life goes horribly wrong.
This week, palliative care for everyone. Wait, what isn't palliative
care something hospice does before somebody dies? Well, yes, but
that is just part of the story. Broadly speaking, palliative
care describes the stuff we do to help somebody manage
emotional pain. Sometimes that pains comes from a terminal diagnosis,
(00:43):
but it also applies to chronic illnesses, non life threatening injuries,
and even, in my opinion, grief itself. Palliative care is
like symptom relief for the emotional challenges of being alive.
Doesn't that sound really interesting? Stay tuned, everybody. We'll be
right back with my guest of surgical care specialist Dr.
Red Hoffman right after this first break. Before we get started.
(01:11):
One quick note, well, I hope you find a lot
of useful information in our time here together. This show
is not a substitute for skilled support with a licensed
mental health provider or for professional supervision related to your work.
Content warning everybody, this episode contains brief, non graphic mentions
of both suicide and terrorism. So if you listened to
(01:34):
the intro to the show today and you were like,
I don't understand any of what she just said, you
are definitely not alone. Palliative care as a term used
in the medical field, but even inside the medical industry,
most people don't know what it is. It's one of
those if you know, you know things, and if you
don't know, there's almost no reason why you should. At
(01:55):
least that is the old way of looking at things. Hopefully,
by the end of the show today you will have
a real working knowledge of what palliative care is, and
my secret hope you'll even start seeing the whole world
through a palliative care lens. You don't even have to
work in healthcare to slip on those palliative care glasses.
I really mean it when I say that palliative care
(02:15):
is for everybody, and I'm pretty sure, my guest today
would agree with that. Dr Red Hoffman is a board
certified trauma surgeon trained in surgical care and hospice and
palliative medicine. She's one of the leading voices advocating for
palliative medicine across all departments and subspecialties in medicine, and
she's the host of the Surgical Palliative Care podcast. Dr
(02:36):
Hoffman's life has been marked by sudden and often violent losses,
as we'll hear about in the show. Again disclaimer, no
graphic details are shared that we do briefly mention both
terrorism and suicide now. She and I met on Twitter,
which is usually a platform where people yell at each
other about various things. I've actually been yelling about various
things on Twitter lately. It's also, though, like a place
(02:57):
to find really lovely colleagues and potential friends who geek
out on the same things you do. At least that's
how Twitter is for me, even if I do use
it to rant about things too. So Red, welcome to
the show. I am so happy to have you here.
Before we get too deep into all of the things
that we could possibly talk about, I think it's actually
important for us to define what palliative care is so
(03:20):
really quick, Can you tell us what palliative care is
as it relates to surgery. Sure? So I think there's
two ways to look at it. One, palliative care is
an incredible specialty in that when you are trained as
a get go to a fellowship and hospice and palliative medicine.
There's like ten different specialties that feed into this fellowship.
It's like no other fellowship in the country. So you
(03:42):
can be a surgeon, a family medicine doctor, a psychiatrist,
or radiation on collegist emergency medicine doc and go complete
a palliative care fellowship. So that's why I think it's
such a fascinating specialty. So we have surgeons who practice
hospice or palliative care, but we also have this field
surgical palliative care, and that's kind of a term that
(04:04):
came up through the American College of Surgeons and Dr
Jeffrey Dunn, who I call he's the father of surgical
palliative care, and that's really palliative care specifically for surgical patients.
Part of what we offer when we're doing surgical palliative
care is a palliative surgeries. So if you have a
bowel obstruction, we might put in what's called a venting
(04:26):
G tube so that we could drain your stomach, or
we might do an intestinal bypass. Surgeries that are not
meant to cure, but that are meant to deal with
symptoms only. So that's one thing that we do is
palliative surgery. But it's not all about surgery. It's again
about symptom management, about walking the patient through any complications
(04:46):
they might have and then perhaps saying okay, we're ready
for hospice and guiding them through that again addressing the
emotional and mental component of disease processes and of dealing
with life limiting um illness says, and then also the
spiritual support. What's really cool to me about palliative care
and surgical palliative care is we're talking about there is
(05:08):
a condition here that we can't fix for you. Not
just there's no cure like terminal illness hospice, but there's
no permanent fix for this condition illness situation in your body.
What we can do is manage to mitigate the suffering
that this condition causes for you. And that like to
me that is what palliative care is. It's it's a
(05:30):
mitigation of suffering to the best of our capacity, knowing
that we can't fix what's actually wrong for you and
for me. Like little tiny sidebar before we get into
our first listener question, Like, to me, grief itself is
a palliative care condition, right, Like you can't fix grief
for somebody. You can't undead the person who's dead. You
can't restore a body back to full mobility after an
(05:51):
injury or an illness that changes that, Like, we can't
fix that central vacancy, but we can do what we
can to mitigate the suffering that comes with those kinds
of losses. So to me, you know, new specialty over here,
like grief is palliative care work. But that that as
a tangent for another day, because I feel like our
listener question for us today really touches on all the
things that we've just started talking about. So I want
(06:13):
to make sure that I get our question in before
we go too far down the fascinating rabbit hole of
you and your work and palliative surgical care. Okay, you
ready for the question? I am, all right, let's go.
It is a two part So we're gonna answer part
one first and then we're gonna get to part two.
So don't worry everybody part two. We will totally answer
it all right, Hi, Megan in Red. Sometimes I feel
(06:34):
like I'm the only one in my surgical department who
cares about the mental and emotional health of our patients.
I try to talk about palliative care with my colleagues,
like help them understand why we should talk about ways
to reduce emotional suffering, that there even is emotional suffering
related to illnesses and diagnoses and surgery. But I don't
think they get it. So I have two questions. One,
(06:56):
can you talk about ways to get your coworkers to
understand the need for palliative care or at least to
be knowledgeable about palliative care across all departments? And two,
how do you stay true to what you know when
the industry doesn't seem to care about emotional and mental health.
So I think this question here is something that a
lot of people in health care have, and actually a
(07:16):
lot of people like in the non healthcare role too.
But how do I get my colleagues to pay attention
to the emotional well being of our patients. So one,
I always think, I can't change how you're going to
treat me, right, but I can model how I want
you to treat me by treating you that way. And
so I think continuing to do what you're doing, so
doing this good work and knowing in your heart that
(07:37):
it's good work, and just continuing to model model that.
So for many years, especially in residency before I completed
a fellowship, I mean, I think people thought I was nuts,
but I just kept doing it and the patients responded well,
the families responded well. The ancillary staff I think always
the nurses and the chaplains like really saw the benefit
(07:59):
of that work, even if my teachers didn't see it,
but eventually they saw it because everyone else was seeing it.
So I think kind of just staying on that path,
you know too, For me, I'd say, I don't know
where where this person is in their career, but for me,
it was very important for me to complete additional training
to kind of give myself that legitimacy. So now people
(08:20):
do listen because I say, okay, I'm um board certified
and hospice and palliative medicine. So there's a lot of
training programs in the country. You know, there's master's degrees
for all different providers who are already engaged in healthcare.
And even just like Harvard has, you know, this online
course that goes for several weeks. So I think maybe
doing that extra training so you have that little legitimacy
(08:42):
behind you is often very useful. I love that. I mean,
one one that professional street cred right, like that legitimacy
is really really important, especially when you're bringing something sort
of new to the clinical and medical space, especially something
that has something to do with feelings, right, Like, having
that legitimacy behind you is really really helpful or can
(09:03):
be really helpful, and as you said, like it it
deepens your knowledge and your understanding so that you have
a really strong foundation for the role modeling that you're doing.
I love that spoken as a true educator, Like what
is the most effective education? While it is role modeling
the behavior that you want to see and letting the
people around you see the outcome of that behavior. Right,
(09:24):
We're all about the clinical and medical outcomes in this profession, right,
so we want to see, Oh wow, treating the human
being like a whole human being actually has some really
positive clinically significant outcomes and we make people hungry to
learn more about that. Yeah, I think that's a beautiful
way to frame them. Oh I'm sorry to interrupt, but
especially when you make your nurses happy, because those nurses
(09:47):
go and then kind of spread the word amongst the
other members of the team. And so for me, that
was like bedside nurses have a ton of moral distress
there with these sick patients, you know, twelve hours a day,
three or four days in a row. They see the
suffering in a way that physicians never do. So when
the physicians are addressing that suffering and addressing their suffering,
(10:09):
the nurses suffering as well. You also get that what
you said about street cred and then they talk about
you to the other physicians. Yeah, I think that works
as well. Yeah, I mean shouting out to the nurses.
I can hear all the nurses in the audience being like,
oh my god, you mentioned us right, Like nurses make
the world go around for real. I love that aspect
(10:31):
of it too, Like this this is showing your patients
what it's like to be treated like a real human being,
and the people around you are picking up on those skills.
The nurses are picking up on it, you know, hopefully
the other docs and the other providers are picking up
on it. The patient is also picking up on it.
And they may not know how to articulate why you're different,
(10:52):
but they know that you're different, and that has a
ripple effect out into the world. So I feel like
so much can feel wrong in our medical industry. Focusing
on those interactions, those moments, that evidence of things being
done really beautifully and skillfully, in the impact that those
interactions have, I think like those are the things that
we want to focus on and enlarge and fight for.
(11:15):
Right That is how we start changing the culture, even
in the worst of times, you know, even in the
trauma bay, in the setting of imminent death. Not always,
you know, I never want to romanticize death because sometimes
death is just ugly, but sometimes it really is just
some room for for beauty and for grace and for
(11:36):
a lot of love, even in those really horrible moments. Yeah,
I think there's always room for beauty and love and
grace inside the horror. What other time is there, and
I think there's that we don't want to conflate. I
love that you put the little asterisk next to like,
we don't want to conflate those two things, that like
looking for the beautiful things makes the horrible traumatic things. Okay,
(11:58):
that is not the equation we're talking about here. We're
talking about how do we companion these are really difficult,
terrible traumatic experiences for ourselves as providers, but also for
families and for people experiencing these things, Like we can
bring beauty and grace into those moments by paying attention
to the actual human beings in the room. I love that. Yeah, yeah, okay, everybody,
(12:21):
We're going to take a quick break. When we come back.
We were going to get into our two of that
question about how you stay true to yourself inside an
industry that doesn't seem to care. We've been talking with
Dr Red Hoffman about surgical palliative care and why everyone
(12:41):
in medicine needs to be talking about ways to manage
emotional pain. In the second half of the show, we're
talking about Dr Hoffman's personal experience and how that affects
her work. She and I jumped right into this topic,
but for context, you should know that Dr Hoffman's father
was killed in a terrorist attack in when she was
nineteen years old, and her partner died by a self
(13:01):
inflicted gunshot wound in following a traumatic brain injury sustained
in Let's get back to our conversation. So, in one
of your media appearances, you say that your dad's death
and the grief that followed has really shaped how you
think about medicine and death and grief, that in many
ways it's shaped both your career and your outlook on life.
(13:23):
The recent death of your partner by suicide also influences
not only how you see grief, but it's made you
really consider our responsibilities as care providers to really listen
to the pain we see around us. In a profession
that continues to insist that grief and really any emotional
pain should be cleared up quickly if we talk about
it at all, and insists that doctors should remain stoic
and unmoved by their work. Who We actually had a
(13:46):
good long rent about that before. But coming back to
part two of our listener question here, given all of that,
all of that like sort of industry institutional avoidance of pain,
how do you personally stay true to what you've learned
and what you know. Yeah, that's a great question. So
I always say every single shift I work, I cry.
(14:08):
One of the great things I learned in my hospite
and Pallative medicine fellowship was it's okay to cry, but
you should never be the one crying the most in
the room, which sounds like silly, but I honestly think
it's really important. So right, it's not about me, but
crying as like an emotional release valve, just like sighing.
I saw a lot too. I just let it go.
(14:29):
I learned very early on in my career, like my
first death in medical school, that if I did not
let it go, I was going to get really sick
and start acting out all over the place. So now
I just kind of let it go. So I think
that's that's one way. And the other thing is, you know,
my experience in my fields trauma and palliative care, is
that all my partners do talk about our rough days,
(14:52):
and I talk about it with like the nursing staff
and the chaplains and who's ever in the room during
a bad trauma. I mean, everyone's having feelings, and so
I just talk about it, you know, I just kind
of keep everything moving and flowing through me. And I
think because of my experiences, I don't apologize anymore. This
(15:12):
is just who I am. But I also think because
I'm a surgeon and because of my training, I also
know how to appropriately disassociate, right. I mean, that's one
thing we do in surgery that drape goes up. You
get to work in some ways. You have to just
do your job right. So sometimes that's a little challenging.
You turn it on and turn it off. But I
think because my training just taught me that it's something
(15:34):
that has come naturally to me over the years. There's
a time to feel feelings, and then there's a time
to get back to work because the patients also needs
you to be thinking clearly. Right. They want they want
a very loving doctor, and it's great to have a
loving surgeon, but they also need a clear mind that
can diagnose and treat appropriately. Yeah. I love that, And
I think you really sort of nail the the binary
(15:58):
here of like you can either be one or the other, right,
Like you can be a compassionate, present surgeon who understands emotions,
or you can be good at your job right, but
you can't do both. And I love like this, like elegant,
skillful use of compartmentalization and association, right, Like that is
a skill. Yeah, and I and I noticed, you know, certainly,
(16:20):
in this recent grief of my partner's suicide, that like
I became a little unskillful when I went back to work,
I call a little messy. And then I realized, like
I'm at work, and yes, I carry this grief, and
I think this grief has taught me so much. And
I you know, I think I was already a great
doctor and surgeon, and but maybe this made me a
(16:41):
little bit better. But it's not all about me, Like
I have to get back to work too, And so
I felt at the beginning that I kind of lost
some of my boundaries that I have worked really hard
to establish over the years. And and I noticed it
pretty quickly, and then I kind of worked with my
therapist and just did a lot of work with myself
about out. Like sometimes I like to think when I'm
(17:02):
walking into the hospital, like leave your stuff at the door.
You know, this is not me time, this is you time,
because I'm taking care of you right now. Yeah, Like
you can be informed and influenced by your personal experience.
I love that you said you weren't improved by your
partner's suicide right where it's almost like our our sphere
of understanding expands. That's not an improvement, that's just a fact.
(17:25):
Right now I have extra information to impact and influence
the work that I do and who I am in
the world and what I see. There's an essay on
an essay of yours that you where you say, I
also learned that my feelings of guilt and responsibility were
extremely common. The idea of perceived responsibility resonated deeply with
me and fed into my sense of failure. How did I,
as a board certified trauma surgeon, allow my brain in
(17:47):
your partner to die on my watch? This kind of
goes back into what you were saying about. I'm both
people when I walk through that door of the hospital,
right I am the person who lived this really intense
personal experience, and I am a provider who needs to
show up and be skillful and clearheaded and do the
work in front of me. You know, I think that's
(18:09):
very common in survivors of suicide loss to feel very
responsible for the suicide and for the actions that the
other person took. And so that's that idea of perceived responsibility.
You know what I've kind of had to come to
terms with is that I'm really only responsible for myself
and and my own behavior, and how can I improve
(18:30):
upon that over time? Like that's just a ongoing task
and lesson for me. But I do know I'm also
as I'm walking into the hospital, responsible for my patients,
and so like that idea has to just shift to
like them, Yeah, exactly is that facility of shifting, right,
what is the focus in the room? I love that
(18:51):
you said, like, uh, just don't be the one crying
the most, right, Like, don't be the one that's a
mess the most, don't be the one that is you
know in your own stuff. The It's it's really just
that shift of focus, that continuum the focus, rather than
that binary of all human or all machine. But I
think it speaks to why therapy is so important for everyone,
(19:12):
because there is no way it kind of went back
to this job without like being under the care of
like an amazing trauma informed therapist. You have to do
your work or there's no way that you're not going
to just bring all of your stuff back to the job.
And again it's like, yes, it informs my dad's death,
my partner's death, definitely inform who I am personally and professionally,
(19:33):
but it cannot be all about me in the room.
It's just it's not appropriate, you know, And sometimes I
have to remind myself it's not appropriate, but that that's
what good therapy does for someone. Good therapy. We love
good therapy, pro therapy therapy. And I like this this
isn't just like a switch that you flip to. I
think that sometimes we can get into that idea that
(19:54):
like I have to turn it off here and turn
it on over here and all of these things, and like,
this is really a community effort. This is a continuum
of care. If we go back to our discussion about
palliative care here, like your own personal life deserves palliative
care in a sense, right to have that community tending
to you and listening to you and worrying or maybe
not worrying, but like tending to your emotional, relational, spiritual
(20:17):
needs so that you can show up in the ways
that you need to show up for yourself, for others
and for the world. It's really interesting that you mentioned
that continuity of care because where I did my palliative
care fellowship, I ended up staying on as a surgeon,
and so the nursing staff knew me as a palliative
care fellow, and then you know, the next month here
(20:39):
I was as a trauma surgeon, and they were confused,
and they used to ask me all the time, what
hat are you wearing coming in as a palliative care doctor?
As a surgeon, No one asked me that anymore, because really,
when I think of palliative care, it's just this continuum
of care. I can operate on you, I can deal
with the complications, and then if at some point your
goals of care shift and we decide we really just
(21:02):
want to focus on comfort, I can like transition you
into hopefully peaceful and beautiful death. Pallid of care. Really,
in the perfect world, we call it primary pallid of
care should be woven into every medical specialty. Yeah. Amen, sister,
there's that nimble flexibility of skilled response. We had the
(21:25):
co founders of the New York's and Center for Protemplative
Care on a while ago, and Coach and Pale Ellison said, like,
we talk about work life balance all the time, but
there is one life. There is one life, and we
are our professional selves and our personal selves and our
relational selves all the time in differing. I don't know,
hydrations maybe if we want to use another silly word
(21:46):
in here, but I love that and that's really just
what you just described, right, is that everything shows up everywhere,
a real fluidity and flexibility with our skill sets and
how we respond to what's in front of us. I
love that. I love that idea of it's just where
you're putting your focus at the moment, you know. So
one last question before we close up today, what do
(22:06):
you wish other surgeons or medical providers knew about palliative care? Well, one,
I always say, you do not have to be board
certified in hospice and palliative medicine to do this good work.
You know, when I think about primary palliative care, having
the skills to do basic symptom management, to speak just
even about basic goals of care, advanced directives, knowing a
(22:29):
little bit about the Medicare hospice benefit and who qualifies,
and then really being able to say, okay, out of
my comfort zone, this person really needs a fellowship train
palliative care provider is really all you need to know.
I mean, you don't need to know much. And then too,
I think the palliative care skills are skills like anything else.
(22:49):
So you know, if you want to be a good surgeon,
you have to practice. If you want to be good
at putting in central line do you have to practice.
If you want to be good at running a family meeting,
you have to practice. And one of the best ways
to learn is just to watch other masters at work.
And so I always say, if you console palliade of carry,
should go and watch them have a family meeting and
(23:10):
you'll learn a lot. For years, all I knew was
what I learned in my fourth year medical school, and
that got me through all of residency was one month
of what I learned watching other people do what they do. Yeah,
practice is important. We're actually going to get into that
in our Questions to Carry with You at the end
of the show, But for now, I think this is
a really beautiful end note for our time here together.
(23:31):
We're gonna link to your website, to your Twitter feed
because that's where we met. But would you please tell
everybody where they can find you, your website, your podcast,
and any other information you want them to know. Sure things,
so you can find me on my website. It's Red Hoffman, MD.
Dot com. I'm also the co founder of the Surgical
Palliade of Care Society, so if you want to know
(23:51):
more about that society can look into our website at
SPC Society dot com. Can find me on Twitter at
red m d n D for Nature Pathic Doctor. And
then I also run the at surge pal Care twitter
feed where we feature a lot of research articles about
surgery and palliative care awesome. So of course I have
(24:13):
a podcast called the Surgical Palliative Care Podcast that you
can find on Apple Podcasts. So many ways to interact
with Dr red Hoffman, everybody I like. I kept thinking
that she was done with her list, but there are
so many amazing ways to connect with her, and of
course we will link to all of those in the
show notes coming up next. Everybody, your weekly questions to
carry with you and how you can send in your
(24:34):
questions for us to use on the show. Don't miss
that part, friends, We will be right back each week.
I leave you with some questions to carry with you
until we meet again. It's part of that whole This
stuff gets easier with practice thing and as Dr rod
(24:56):
Hoffman said, we both want you to practice. This week
a little research assignment. If you work in a hospital setting,
go look up your palliative care department. If you work
in health care but you're not attached to a hospital,
look up your local hospitals palliative care department. Just check
them out, like no pressure. Check them out. What are
they doing? Are there any cool or interesting workshops going on?
(25:17):
Familiarize yourself with a palliative care work going on all
around you. It's often invisible until you actually look for it,
no matter where you work in health care or nowhere
near health care. Take some time to reflect on what
palliative care really means. At its root, it's the support
and tending of emotional pain that can't easily be fixed.
(25:40):
If it can be fixed at all, What areas of
your life or the lives of the people around you
might benefit from a palliative care style approach. I would
super love to hear your responses to this week's questions
to carry with you. Palliative care as a lens on
life is a fascinating topic. I totally want to hear
(26:01):
about it. You can tag me on social media at
Refuge in Grief. Leave a review of the podcast with
something you've learned in today's show or any of the
other shows, or use the question submission form on the
website to let me know what you find. You can
do that at Megan Divine dot c O. Speaking of
Megan Divine dot c O and that question submission form,
this is your weekly reminder that I want to answer
(26:22):
your questions on the show. This show is nothing without
your questions. It is literally a Q and a show.
You can ask me anything you'd like. Bring me your
professional questions. You're I'm trying hard to be a really
good friend and I don't know how questions you're I'm
overwhelmed with the pain of the world questions and even
your I bet you don't have a good solution for
(26:42):
this one questions. I love a challenge. Let's talk it out.
Call us at three to three six four three three
seven six eight and leave a voicemail. If you missed it,
you can find the number in the show notes or
visit Megan Divine dot c O. If you'd rather send
an email, you can you that too. Write on the
website Megan Divine dot c O. We want to hear
(27:04):
from you. I want to hear from you. This show,
this world needs your questions. Together. We can make things
better even when we can't make them right. You know
how most people are going to scan through their podcast
app looking for a new thing to listen to, and
they're going to see the show description for Here After
(27:26):
with Megan Divine and thank God, I don't want to
talk about that stuff. Well, here's where you come in
your reviews. Let people know it really isn't all that bad.
In here we talk about heavy stuff, but it's in
the service of making things better for everyone. So everyone
needs to listen. Spread the word in your workplace, in
your social world on social media and click through or
leave a review. Subscribe to the show, download episodes, and
(27:49):
send in your questions. Want more Hereafter? Grief education doesn't
just belong to end of life issues. Life is full
of losses, from everyday disappointments to events that clearly divide
life into before and after. Learning how to talk about
all that without cliches or platitudes or simplistic positive posters
(28:09):
is an important skill for everyone. Find trainings, workshops, books
and resources for every human trying to make their way
in the world after something goes horribly wrong At Megan
Divine dot c O and a special note there is
a clinical workshop coming up on April first, then another
one on April, so be sure to check Megan Divine
dot CEO for all those details. Hereafter With Megan Divine
(28:34):
is written and produced by me Megan Divine. Executive producer
is Amy Brown. Co produced by Tonya Juhas and Elizabeth Fosio,
Edited by Houston Tilly, with studio support by Chris Uron.
Music provided by Wave Crush
Host
Megan Devine
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