6 - Brain Surgeon, Burnout in Medicine, and the American Healthcare System with Dr. Gary Simonds - Revelizations

Episode Transcript
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(00:00):
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Welcome to Revelizations, I am your host, Brian James.

(01:48):
Today's guest is Dr. Gary Simmons.
He has had an impressive, decorated four decade career in the medical field.
Not slowing down, he continues helping to shape the future minds of medicine.
He was the founding chief of neurosurgery and the neurosurgery residency program director
at the Carilion Clinic and the Virginia Tech Carilion School of Medicine until retiring

(02:10):
from clinical neurosurgery in 2020.
That's a mouthful and we're just getting started.
He remains a professor at the Virginia Tech School of Neuroscience and the Virginia Tech
Carilion School of Medicine.
He routinely presents and teaches at various national and international courses and meetings.
He has written three books on burnout and building resilience with his co-author Dr.

(02:32):
Wayne Sotile.
He has recently released his first novel, a medical psychological thriller entitled
Death's Pale Flag.
It's available through multiple retailers including Amazon.
Today we discuss his background and career in neuroscience, burnout on healthcare providers,
insurance and the healthcare system, the role AI may take in patient care and patient experience,

(02:57):
and a few other topics.
Sit back, relax, and enjoy our chat.
Thanks for listening everyone.
With me today I have Dr. Gary Simmons.
I'm very excited for you to be here and to finally sit down and have this conversation.
Thank you so much for being here.
Yeah, it's my honor Brian.

(03:17):
Tell people about yourself.
Who are you?
What do you do?
Who is Dr. Gary Simmons?
Do you just want Dr. Gary Simmons, Dr. Gary, Dr. Simmons, how would you like to be referred
to?
I generally prefer Gary.
All right, we'll stick with that.
Hey you or other epithets work perfectly well.
So whatever you need.

(03:38):
We'll start with Gary and then work from there.
Yeah.
Sounds good.
Well, I am Gary, Gary Simonds, and I guess most of my professional life I've spent as
a neurosurgeon, eventually becoming the head of a neurosurgery program at Virginia Tech.

(04:03):
And spent many years doing that, many decades, very busy surgeon.
And then, as I say, led a program of neurosurgeons and a training program.
But I got out a few years ago, the story behind that is kind of long and involved.
But since then, I've predominantly been spending time teaching undergrads, med students, senior

(04:36):
all sorts of different venues, and trying to write some books and doing some other writings.
And then also trying to reacquaint myself with my wife of 44 years, who really I neglected
for probably 42 of them or so.
Yeah, it's a really demanding field that you got into.

(04:56):
I think it's like a selfless career as far as your time and how you get to spend it.
I know that wasn't a surprise to you before you got into the medical field.
So what is it that drew you into the medical field?
Was there something you wanted to do before that and then ultimately decided on the medical
field?

(05:17):
Yeah, and I would have to say that I actually had no idea what I was getting myself into.
It's kind of interesting, back when I was an undergrad, pretty much whether you got
into med school or not was predicated on grades and MCAT scores.

(05:40):
And now there's a whole slew of other things you have to do.
You have to go show your leadership qualities and do a bunch of volunteer work.
But one of the other criteria, and do a bunch of research by the way, but one of the other
criteria now is that you should spend a lot of time somewhere in the medical realm, seeing

(06:06):
what it's like, experiencing what it's like, which of all the prerequisites makes the most
sense to me because frankly, again, I had no real idea what I was getting myself into.
And I don't think a lot of people did back in that time.
They just thought, hey, being a doctor seems pretty cool and I know you have to work hard
and study hard, but I don't think we had really any sense of how hard that was.

(06:31):
So to actually answer your question, originally I got to undergrad anticipating becoming a
minister, but was interested in science, so I was kind of a biochem and religion major
in both.
Somehow fell off the religion curve and I don't know, looked at all sorts of things

(06:57):
for a little while there.
I looked at the CIA, I looked at the FBI, I looked at becoming a fighter pilot and it
was just very much up in the air.
And ultimately, I'm not even sure how I ended up deciding on medicine, but I did.
The thing about neurosurgery, which to me is a more interesting story, at least I use

(07:20):
it as a parable for my students, is I, in med school you often go through multiple manifestations
of what you're going to become in terms of specialties and I was going to be a family
doc and then an internal medicine doc and then a cancer doc and then a general surgeon
and eventually decided on cardiothoracic surgery at the time, heart surgery, and I had that

(07:46):
all lined up.
That was what I was going to train in and that was my future and in my last month of
medical school, I saw my first brain operation and I was just, holy crap, I have got to do
that.
And that was the limit of my thinking into it.
I completely switched horses in midstream, I had to run all over the country looking

(08:11):
for somebody who would train me, looking for a program that would train me because it was
all already decided at that point and I had no idea what I was getting myself into and
you're getting yourself into just a royal crunch for many, many, many, many years.

(08:33):
But like the residency is seven years, we worked about 110 hours a week in the hospital.
We were on call every third night which meant you had no sleep every third night, you worked
the entire next day until eight, nine o'clock.
So I mean it was grueling, it was fairly brutal and as a specialty it is, but what I tell

(08:57):
people is ultimately that I can't imagine doing anything else.
Looking back, I can't imagine doing anything else.
I am so darn happy that that's what I chose.
So what I tell the undergrads and the people trying to make decisions on all this is, look,

(09:17):
I still really believe in following your heart because ultimately if you get too analytic,
I think you could end up burning out, not being very happy whatsoever with your profession.
But even if you're following your heart, I recommend you research it better than I did

(09:37):
and at least know what you're getting yourself into.
Absolutely so much information in there, just so like different career paths that you're
interested in, like I find that fascinating.
You talk about being interested in a different specialty and then ultimately just a month

(09:58):
before you're really going to start honing in on what that is or start like that intense
process, just changing it completely.
So what was that process like of when you had to go look and find another, did you just
have to find a completely different program because you're already on a different course
And so just in the last month, like you're just like, okay, who's going to take me?

(10:21):
I need to touch someone's brain in the near future.
Yeah, no, that's exactly it.
You know, usually the residency selections occur in the late winter.
So by late winter, you know where you're going, you know what you're going to do.
So I had my residency, my post med school training all set up and it was all, you start

(10:46):
with general surgery and then you go into cardiothoracic surgery.
And I had my residency all set up.
So I had to tell them, sorry guys, I changed my mind.
And then I had to run all over and literally look for anybody who might have the possibility
of an opening.

(11:06):
And I did really well in med school and had really good board scores and stuff.
So I think I was somewhat attractive to these programs.
So several really nice programs, you know, told me they'd be happy to evaluate me and
I did run out to their places and get interviewed by a bunch of people.

(11:30):
So I was out in San Francisco and Seattle and Chicago and I don't know, bounced around
a whole bunch of places looking at programs.
What made it eventually fairly easy was I had a military scholarship for medical school.
In other words, the army paid for my medical school.

(11:52):
And one option potentially was to train at Walter Reed, which had a neurosurgery program,
but they already had a resident, it was only one resident per year.
So, you know, but I got talking to the chair of the program at the time and they were looking
to increase the years of training and so they thought they could take two residents one

(12:16):
year and then flip into this longer training process.
And luckily, again, they liked me enough that they decided they would do that.
And so I ended up going to Walter Reed for my training.
Wow, that's amazing.
There's a big life lesson in there just to where you think like, oh, why even bother?

(12:40):
Like, this is their program.
They only have one person in there and their one's already got it.
Like, why am I even going to waste their time?
But yeah, you just you show up and you make a case for yourself.
And you had a whole different type of training that you would never would have had otherwise.
Yeah, I think that's a great point, by the way, Brian.
I was just recently I saw Jerry Seinfeld's graduation speech to Duke and if you've never

(13:08):
seen it, I thoroughly recommend it.
It's really good.
It's on YouTube.
But, you know, he has a few recommendations of how to get by in life.
And, you know, one of them is simply work your ass off.
And I think being willing, I think I think some of these programs got the sense that

(13:31):
I was willing to work my ass off.
And I think that attracted them.
I think they they thought, hey, you know, we can work with this guy if he's he's willing
to, you know, put in the time, put in the effort.
We can we can work with him.
It sounds like you're still working your ass off.
It sounds like someone's trying to call you into surgery right now.

(13:52):
Your phone is going off.
Oh dear, is it?
You know, it is it's it's emails.
I don't know how to turn that off, this darn thing.
OK, it sounds like are you on a Mac?
Yeah. OK, yeah, it might just be I don't know.
I wouldn't know how to do that.

(14:12):
But yeah, it's just your your alerts are constantly dinging.
You're a wanted individual.
Yeah, I I'd like to believe that.
I think it's it's just
I'm going to I'm trying to turn everything off.
Let's see. We'll see if that works better.

(14:34):
So this is fascinating to me.
You were considering a career in to be a minister.
Yes. And so what was your upbringing like to where that's
did your upbringing have any influence over that?
Like what what type of minister did you want to be?

(14:55):
Something in the Protestant line, probably, you know, Presby type.
But I know I would say
my upbringing was pretty a religious.
I don't know. I think if anything drove me into it, it was bad, bad,

(15:16):
bad luck with the opposite sex for him in some of my formative years
where, you know, I fall madly in love with some girl
and she would not reciprocate.
So prior, I was looking for looking for something to soothe me
and started, you know, reading stuff from the Bible at the time.

(15:39):
And, you know, I dabbled a little bit in the church.
But at the time, found, you know, found it very comforting and,
you know, felt there was a lot of good that could be done
through religion for people.
And I think that's what pulled me in.
But yeah, I think it was my terrible luck with the opposite sex at the time.

(16:04):
That's yeah, that's really interesting, because you have like
from what I can tell, from what I'm hearing, CIA, FBI, fighter pilot,
pastor, doctor, ultimately doctor
in a very demanding profession.
Like you said, you didn't know, but I feel like you knew to an extent.
I don't think you like from what you said, you didn't know how demanding it was.

(16:27):
Maybe you have a very service mentality
disposition.
You just seems like everything you're going to do.
Like, you know, if you're CIA, FBI, fighter pilot,
you're in service of your country.
And then with a pastor and doctor, you're in service of your fellow people.
So that's just really interesting that you you have that draw to

(16:53):
more of a selfless lifestyle of putting other people first,
because if you're in the military, you're definitely not the first person.
If you're a pastor, you have to be available to other people.
And their crisis is just constantly.
And people love to be in crisis.
And then as a doctor, you know, just life happens and you have to be there

(17:14):
to intervene in people's worst moments.
So what do you think that like, what is it about those kinds of professions
or your personality to where you really feel drawn into?
Like you have those predilections.
Yeah, I remember having a conversation, Brian, that

(17:34):
one day, I think it was while we were operating and somebody said,
oh, Dr. Simmons, what did you what what other things did you consider?
And I told him about the CIA and the FBI and the fighter pilot.
And I said, yeah, you know, I guess I vacillated between killing people
and trying to help them.

(17:56):
Hopefully, hopefully one would be kept to a minimum.
But no, I think it's a personality flaw.
I think it's a personality problem that I have that I
need to feel like I'm one of the good guys.
If that makes any sense, I just need to feel like I'm on the good side,

(18:19):
whatever that is.
And, you know, to the point of being driven to distraction about it,
I don't like the idea of of, I don't know,
of feeling like I could be looked on as not being a good person.
And so rather than altruism, I think it's a personality flaw

(18:43):
that I, you know, that I need to feel and need to be seen as one of the good guys.
So definitely I see you as one of the good guys over here.
That's that's really interesting, though, because you're.
Though you delivered a lot of bad news to people.

(19:03):
And so, you know, obviously, every time you did the best you could
and just some people, a negative outcome is inevitable.
There's nothing you could have done about it.
If someone has a traumatic brain injury, you can go in there and and do the best.
But if the brain is going to swell and just to a capacity that you can't intervene

(19:25):
and do anything like you did your best, but ultimately you have to
tell the family that I'm sorry, you know, in whatever words you want to use.
But ultimately your loved one passed away.
And so you are or can be the bad guy in that.
So were those moments hard for you when you did have to tell a family

(19:47):
of a negative outcome? Yes.
It is it is definitely something
that I think most people don't experience, thank goodness.
But it was something that was almost routine.
I worked in big trauma centers, the helicopters,

(20:08):
you know, were always coming in.
And if they weren't bringing in trauma, they were bringing in strokes
and hemorrhages and all sorts of other horrible things.
So breaking bad news was almost almost a daily thing.
And if there would be nights, you know, and particularly these things

(20:29):
always seem to happen at nights.
But there were nights that you could tell three, five, nine
families that their loved one is dead or dying or or paralyzed.
So, you know, on one level, you kind of got used to it that
you even learned, I think, from yourself and from the reactions of families.

(20:52):
You learn how to do it relatively well.
I think you also threw up a lot of defense mechanisms so that,
you know, you can't I mean, if you go and tell somebody a terrible news
and it breaks you down for the next 12 hours,
how are you going to go in and do the next operation?

(21:13):
So, you know, you had to have some sort of separation from your emotions.
And I think that was a big thing is I think I was able to divorce myself
pretty much most of the time from the emotions that were associated with it.
And I was telling somebody the other day,

(21:35):
something that I find interesting is that since I stopped doing this,
I find myself being really emotional about things.
I joke about it, but I can watch a cat food commercial.
And if it's got, you know, some sort of emotional twinge to it,
I'll feel tears in my eyes.

(21:55):
And I'm like, what the hell is that?
And I think what's happened is, you know, for for decades,
I walled off a whole section of emotional responses to the world.
And now they're just allowed out and they come to the surface much more quickly.
And it's not just not just sorrow.

(22:15):
I mean, same. I mean, I feel more joy.
I feel more happiness as well.
So now the emotions are coming.
And obviously, like you said, you did a good job of separating
that from when you're actually in your profession.
And now they're starting, you know, maybe you're making up for lost
tears now with just really touching cat commercials.

(22:38):
But how did you balance that out?
Because obviously in the medical field,
I say obvious, but it might not be too obvious.
But from what you just said, you do have to develop a thick skin, a callus,
because I believe the standard of care is OK with every patient.
You treat them like you would want your family member treated

(23:01):
like that's the type of care that you strive for.
You know, obviously, like that's going to be hard to to do
when you're working such a demanding schedule that you work.
But how do you balance that out with not living and dying with each patient?
Like, oh, my God, this is, you know, my loved one on the table.
And I need to do everything I can because I understand the repercussions

(23:25):
that if this person doesn't make it, then the ripples of how it's going
to impact their family.
And then on the other side, I was just being like, I'm a mechanic.
I see that this part needs to be replaced.
This part needs to be patched.
I'm just going to do this.
Sorry, I couldn't do anything with with this patient.
They didn't make it.

(23:46):
How do you balance between becoming too attached and becoming too cold?
Yeah, I didn't.
I didn't. I don't know if there is a, you know, if there is a well
well prescribed answer for that.
I think every every position in these positions has to figure out

(24:07):
where the balance is, because I would argue that, you know,
what I was telling you I was able to do may not be the best thing.
You know, it may be good to be touched periodically by this stuff.
It was so fast and furious at our place.
You know, I almost had to,

(24:28):
because, again, it could be crippling if you didn't.
I think there is a few things that that, you know, you can do
just because you're not deeply feeling it
and getting affected by it doesn't mean that you can't be empathetic.
So I think I definitely maintain my empathy.
I was able to convey

(24:50):
to patients and their families that I really did care about them
and that, you know, that I really wanted the best for them
and was really trying to do the best.
And my whole team was trying to do the best for them.
And I think so.
And, you know, families and patients, they're very perceptive.
If you come off as disingenuous, they they recognize that in seconds.

(25:16):
And so I think I think the empathy was real.
I don't think I was putting that on, but there was still a wall
between the empathy and allowing it to, you know,
drag me down into the depths of despair.
I think the other thing that that I tended to do was,

(25:36):
you know, everything became a a scientific, if you will, challenge.
How can I do this better?
How can I be better at this?
Not only the operations, but the diagnostics, the perioperative treatment,
and even speaking with the families and speaking with the patients,
I was always thinking and kind of self-evaluating and saying,

(26:00):
geez, you know, there are better ways to do this.
How can I do it better?
And and that may have helped, again,
create that separation when when you turned it a little bit more into a science.
But I would argue that if if you lose, you know, your humanity completely,
if you lose the empathy side of it,

(26:22):
it's not going to go well most times.
I I often challenge my students with this and say, you know,
if you if you had a big operation coming and you had your choice
between a surgeon that is known as the best in the world,
but has a terrible bedside manner, or you can have a surgeon

(26:43):
who is known to be good, but they're not the best in the world,
but has an amazing bedside manner, which one would you take?
And it's very interesting to hear their their responses.
I know which one I would take. How about you?
Oh, I'm taking the one that they're they're cold, but they know what they're doing.
Like, yeah, take care of me.

(27:04):
Do what you need to do.
And then I'll go to therapy afterwards if I need to talk about it.
See, I I kind of go the other direction again after being there.
I I kind of I still want somebody
who I feel is invested in me, really, you know,
cares about me and cares about my specific outcome.

(27:29):
So I'm thinking, yeah, I want that surgeon who's a little invested,
at least the cold calculated one.
They may be great, but, you know, I don't want to be their first big mistake.
That's a good way of put it.
I just such a tightrope to walk because obviously the
the demand of your profession is just it's so high.

(27:50):
And yeah, there's just so much there to talk about with burnout.
But I did before we get more into that, I wanted to talk about what I heard.
And I don't know if this just started out as, you know, a fake story
or a little bit of truth, and then it just spiraled into,
you know, just a complete lie, just a grandiose lie.

(28:11):
But I heard that with residents, the residency started
because the person in charge of the program was on some sort of amphetamine.
And so he could just stay up and do a tremendous amount of work
for hours upon hours.
And like that was the standard that he wanted for his students.
And so like the 72 hour residency or something evolved from that.

(28:35):
Is there any truth in that?
I frankly have not heard it.
At that, you know, as coming from one specific
situation, to be honest.
But there's certainly there are certainly all sorts of twisted motivations
in why to have a residency and how you use your residents

(28:59):
and whether you exploit them or not.
Certainly for, you know, for decades and decades is just basically cheap labor.
You know, you like I said, I was working 110 hours a week in the hospital.
And, you know, you and making dirt.
And so they're getting a lot of work out of you.

(29:21):
And, boy, you know, those 110 hours, you were working like a dog.
You you were running from one end of the hospital to the other.
Never eating, never, you know, it's just eating on the run.
And it it's it was a different world.
I would argue that that kind of total immersion,

(29:41):
that total immersion was
it built something within you.
I mean, first of all, it built a certain level of toughness.
It also just made it feel like nothing could throw you off your game.
I've been through everything.
I've seen everything.

(30:01):
I can do everything because I was there so much.
And and, you know, you didn't miss anything.
Things when things happened, you were always there.
Resonancies have gotten better.
They've gotten considerably better in terms of of how many hours
the residents can work and how hard you can work them and all that sort of thing.

(30:26):
And so it's certainly more humane.
Do we lose something?
Probably. On the other hand, hopefully we're not burning
burning them out as as much as we probably did in the past as well.
So, you know, as you say, everything's a tightrope
and you're just trying to you're trying to get the best out of

(30:47):
everything that you do.
Yeah, I've talked to my wife about this a lot because I mean,
humans are humans at the end of the day.
We need sleep, we need food, just breaks from from what we're doing.
And you can only be at attention at your best for so long.
And I know there's a definite give and take with the medical field with

(31:15):
you work longer shifts because it's better for the patient,
because then there's less handoffs.
You're you're that patient's caretaker for longer.
But with that, it seems like the negative of being overworked,
sleep deprived in some cases, I mean, that's just

(31:36):
that will lead to mistakes in of itself.
So I imagine that there is a lot of like peer review
studies of this and outcomes of patients.
And so did they just decide that it's better to have a person
who's sleep deprived, potentially sleep deprived,
working on a patient and then them just being the sole caretaker

(31:58):
rather than having multiple people who are potentially
better rested, you know, working an unheard of eight hour shift
and then coming in and treating them.
Is there is there any sort of like give or take research
where they just have concluded that, no, this is the best for patient care?
Yeah, you're you have, Brian, you have amazing questions.

(32:21):
These are great questions
with embarrassing answers in that the data on this is
is really bad, really skewed.
In fact, the major changes in residency requirements
that occurred just a couple of decades ago,
which put an 80 hour limit on on a workweek for residents

(32:45):
and all sorts of other restrictions.
It was all predicated really politically.
There was one bad outcome in New York state
that occurred that was pinned to a residence lack of sleep.
And that just took off like wildfire and became political.
And, you know, everything, all the dominoes fell from there.

(33:08):
Wasn't based on any, you know, really well done,
peer reviewed, double blinded research or anything like that.
And, you know, so research on it does come out periodically.
It's it's always a little suspect,
but it certainly favors having, you know, people get decent sleep, decent rest.

(33:31):
I will tell you, though, it's amazing what you can do with no sleep.
We and and it's it's kind of scary.
But and most of the specialties have stopped doing this.
But it's still pretty big in neurosurgery that you can be on call all night
the night before.

(33:53):
You got to forgive me.
There's a thunderstorm out there right now.
Some things are out of our control.
I can't do anything about that.
I'll just be a nice soundscape for some people.
There is a big one.
The the the the data,

(34:15):
the data will often say what people want wanted to say.
But again, it does seem to be, you know,
in favor of a little bit more common sense.
But in neurosurgery, it's not uncommon.
And I did this my whole career, but it's not uncommon to work
the full day after being on call.

(34:35):
And and so I could be up all night.
And most of the time was up all night at these trauma centers when I was on call.
And then the next day have a full slate of brain surgery.
And you kind of think about it and you're going, this is absurd.
Have the have the malpractice lawyers not figured this one out?
And and they they have begun to figure it out.

(34:58):
But it surprised me. It took so long.
So but it is it is you can do more than you think.
The human is, you know,
people are able to do much more than they think they can.
And when I talked to when I talked to undergrads
or even med students now about kind of the good old days,

(35:21):
they're like, no, nobody can do that.
You can't work for 48 straight hours.
And I said, I would tell them, listen, we would do a whole weekends at times.
We would go we would go in Friday morning at 530
and come out Monday night and work the entire weekend.
Now, you you took catnaps whenever you could.
But but, you know, you work 72 or more straight hours and you can do it.

(35:47):
Anybody can do it.
You just have to be put in a situation where you have to.
Is that ideal? Probably not.
You know, but how do you solve something like that?
Well, you need a lot more neurosurgeons around
if you want to be able to cover all that call.
You know, I like to believe, you know, outside of like business
that we're kind of doing the best we can, because ultimately hospitals

(36:10):
for the most part are money making businesses.
There's not I'd say there's more like business model hospitals
than private hospitals or, you know, like St.
Jude, like where, you know, it's more dependent on people giving money.
And so, yeah, that's another problem.
It's like, OK, well, let's fix that problem.

(36:32):
Let's make it so we don't have one neurosurgeon that's on call
and then working a shift after that.
OK, well, now you need to hire someone else
and you need to cover their shift.
OK, so we can't pay them as much.
OK, now you're disincentivizing the best person to come because like,
OK, if I'm going to be a neurosurgeon, I need to get compensated.
I'm not going to, you know, do all those years of study

(36:54):
and then not even be able to pay back my student loans.
You know, I'm still I can't do anything.
So I don't really think there's an elegant solution.
But I would, you know, it's unfortunate, like you said,
that it wasn't a bunch of peer reviewed studies that came out and like, OK,
this is science that we can't ignore,

(37:15):
that it was because of a bad outcome that got politicized.
So they changed it.
So it's nice that it's even part of the conversation
to try and make people's quality of life better in that regard.
And yeah, it's just a.
You know, it's it's a balancing of trying to figure out

(37:37):
to how to get the best people and to work the best. But
because, yeah, you can do it.
But then it brings the question of like, should you do it?
Because, like, you know, like we're humans.
And so let's just use an analogy that we have a candlestick
and the candlestick is, you know, that person is going to have that candlestick

(37:59):
regardless of what they do in their life.
And that wick is going to be the same length.
It doesn't matter.
And so you can do the tough things if you have to.
But that's going to intense the flame on the candlestick.
So the wick is going to burn quicker.
And that that can just lead to a lot of things.

(38:21):
It's not necessarily, you know, a lifespan thing.
But I think it's it's within recent history that they found out that during sleep,
our brains secrete cerebral spinal fluid over our brains and wash out
a lot of the just the byproducts of of having a brain that's

(38:43):
as metabolically demanding that we have.
And so if you're not able to get that sleep, if you're not able to go
through those cycles of getting out that waste product out of your brain,
well, then what happens?
So, Brian, are you saying I didn't have enough brainwashing in my life?
No, I just I think we're starting to see

(39:10):
just bad outcomes of of people who who live like, you know, this isn't just to
this is like any high demand profession.
So this isn't just just to doctors.
But when you're asked a lot, like you were seeing people like,
why is Alzheimer's on the increase?
And, you know, that's diet, that's exercisers lifestyle.

(39:31):
There's a lot of components to why
disease is nefarious as Alzheimer's is up.
But I believe that some of the waste product that is being washed out
of the brain when you sleep are the beta amyloids.
And I believe that is correct me if I'm wrong.
I'm definitely speaking way out of turn here, way out of information that I know.

(39:53):
But I believe like the the the beta amyloids like found in the brain are like
like that's how you get a diagnosis for Alzheimer's or no.
Well, yes and no, it's like everything in this business.
We think we we get we think we have things in the crosshairs.

(40:15):
And then it turns out that we may not as cleanly as we do.
So build a beta a beta amyloid is definitely
is something that is found in people with Alzheimer's.
And the reduction of beta amyloid may or may not help with Alzheimer's
or the beta amyloid may just be a byproduct of Alzheimer's.

(40:39):
And we really don't know yet.
We we just don't know for sure.
But, yeah, it's definitely there in the target zone.
There are all the new meds that are coming out are are oriented to it.
But ultimately, you know, ultimately,
there are fairly good studies that tell us that

(41:01):
a lot of sleep deprivation is not good for us, that overall
good mental health and mental function is
is optimized by routine,
good sleep of seven plus hours.
It is the very unusual person

(41:22):
who truly can get by on just a few hours a night.
That's a myth that, you know, there are all these people out there
who can really do great.
You know, it's interesting beyond what the Alzheimer's side
and the true physiological side.
I spent a lot of time looking at kind of the emotional impact,

(41:43):
mental and emotional impact and burnout.
And, you know, throughout most medical systems,
neurosurgeons often have the reputation of just being pricks,
you know, just being jerks.
And I really think, you know, I know a lot of neurosurgeons
and most are good people.

(42:03):
And I really think that what we're seeing is
what we're describing and what they're doing is they're
pouring all their energy into being able to hold it together
in terms of the patient care.
And then there's nothing left when it comes to just general
interactions with other hospital personnel, other doctors,

(42:27):
with frustration tolerance, for example.
And I think, you know, it's so uncommon for neurosurgeons
to be gruff and angry and snapping at everybody else.
But when they get there to the table, they are super focused,
they get the job done and then, you know, step out of that again.

(42:48):
And I think it does. It gets to what we're talking about.
What I was like kind of pointing out is like,
regardless of the motivation of becoming a doctor,
whether it is altruistic, whether it is financial,
I don't think they're, you know, unless you're like the fringe cases

(43:08):
to where you're getting into the medical field to like hurt people.
Those are the people that are taking care of you.
Those are the people that are intervening.
And your absolute worst moments,
they are there to help you see it through.
And so what I was getting at was like,

(43:30):
I would just like a system that actually takes care of those people as well,
like because so much of it is like a business model that we like to believe.
And I'm saying we and I'm talking into like a corporate structure now,
but we like to believe that we are without us.

(43:50):
This whole operation, it's going to crumble.
They cannot do it without me.
But it turns out you can be there one day and not the next.
And they don't skip a beat.
And so with that, we can kind of become a little bit more interchangeable.
And like the value of us as a human can kind of get downplayed

(44:12):
for more of, OK, what can this person provide as a business?
And and obviously you need to a hospital needs to make money
or a hospital goes out of business.
And so there's just a line that needs to be figured out.
And I would just like it if, you know, just for because one of my friends
just actually graduated from med school and he's going to PMR and he makes a joke.

(44:38):
I don't know if it's common, but plenty of money and relaxation
is what PMR stands for.
But that sounds good.
But he's going to be a rehabilitation doctor and, you know, helping people
get other interventions and hopefully get them off of pain pills,
which have been overprescribed.

(44:59):
That's like where his heart is.
And so I think that's great.
And I want him to be taken care of.
I want, you know, I want you who who is like you said, you're you're re
you're being reintroduced, re-swooning your your wife,
who you've known for who've been married to for four plus decades.

(45:20):
This is such a demanding profession.
And I would I would just like it if there is frequent
conversations of just I guess this is getting way too idealistic.
But I would just really enjoy it if like if the caretakers were.
Their health was taken into account, too, and not just

(45:43):
this is how it's always been.
This is the culture and it's working fine.
So let's just keep it this way.
I would just like conversations to be had about what we can do better.
Yeah, I mean, you're absolutely preaching to the choir.
So for the for the past, I don't know, 15 plus years,
I've done a lot of work in the burnout sphere of health care,

(46:05):
wrote three books with a colleague of mine on on burnout and health care workers
and trying to get the message out.
And it's definitely hit.
There are there are wellness measures going on almost everywhere.
And it certainly got picked up by the the academic side of it,

(46:27):
where every med school has wellness plans for the med students.
Every residency program has wellness plans and many hospital centers are as well.
But it can get, you know, it definitely it's a spectrum where on one end,
it's very genuine, they're trying everything they can,

(46:47):
except probably hiring more people and paying more money for everybody,
the nurses, the the therapist, the assistants, all that, as well as the docs.
When it comes to paying more and hiring more, that's that's always anathema.
But there, you know, there's definitely more attention to it.
And then the other end of the spectrum, there's, you know, the window dressing.

(47:10):
We're just going to. Yeah, yeah, yeah, we got a wellness program.
We checked that box.
But, you know, again, your points are very salient.
You know, I told you before, I have to be a good guy.
They just, you know, I can't stand the concept of not being on the good side.
I think this came out of, you know, my parents were in World War Two.

(47:32):
And, you know, I just have a different vision of what America was.
And we we were the good guys and we came and, you know, saved Europe
and all that sort of stuff.
And I guess I needed I needed to feel like that's the type of person I was.
Anyway, long story short.

(47:52):
So I've always worked for nonprofit systems,
quote, nonprofit systems, but they're, I don't know, 70 percent are nonprofit.
But the systems I worked for,
the thing I liked about them is they took all comers,
whether you could pay or not,

(48:13):
where I was with Virginia Tech called Corellian Clinic is in Appalachia.
And it's a big, huge system in the middle of Appalachia.
And the people are poor.
You know, it's we're not dealing with the upper crests of society
financially, and they take all comers.
And if you can pay, they're going to they're going to get you to pay.

(48:35):
If you can't, you know, it's just the way it is.
But you've got to realize, just as you're pointing out, it's still a business.
They they these big hospital systems, especially the nonprofit ones,
they they operate on these razor thin margins.
And and it takes nothing for them to flip one hundred

(48:57):
and fifty million, two hundred million in the red.
You know, just I mean, it takes nothing.
And so they they are constantly trying to figure out
how do we tighten our belts, how do we tighten our belts?
And they also are thinking, well, how do we maximize our our income?
How do we do that as well?

(49:18):
And they have to.
That's that's the business landscape that they're in.
So I you know, there are times where I would be really upset
with our administration because I felt like they weren't acting like the good guys.
But for the most part, I knew why I knew, you know,

(49:38):
they had a mission and that was to stay, you know, afloat,
because if that system went down, these people would have nothing.
This might be out of your purview, but this I think that segues
perfectly into an issue that I really have with
because what you're saying, if people can pay, they pay.
If people can't, they can't.
Well, then that means that the people can pay are paying for their share,

(50:01):
plus the share of the people who can't pay.
And that's just that's just what it is.
And so I've I've long been,
you know, on my soapbox.
I don't see myself getting off of it anytime soon.
Just about how insurances are
just an apparent conflict of interest

(50:24):
that a company who has to make money, who who are beholden
to stockholders who have to turn a profit year over year,
make more and more money.
How come they get to say what can be covered?
How come they get to say how much they'll cover, how much a procedure costs?

(50:50):
How come like we haven't done anything about that as like a nation?
Again, this is, you know, I'm getting out of your purview,
but I guess more so your experience with dealing with insurances.
But it just seems like
it would benefit a lot of people, even companies who have to pay for insurance,
that if they're just because I have to pay a certain amount of money regardless

(51:15):
to insurances or to any sort of medical invention I have until I meet
an out of pocket max.
And so monthly, I'm already paying a fee whether I use it or not.
And so why wouldn't we just switch to a system to where, OK, now we're paying
the government to take care of it or to figure out another type of insurance

(51:40):
to where you're already paying for it.
Your tax burden, how much is going to come out of your income
doesn't get impacted more so than it already is.
Maybe like a few bucks for some people, maybe less for some people.
But overall, you have more say over your health care that you get.
You know, you're not going to come to

(52:01):
you're not going to get a letter saying you've been declined
this intervention because the medical research doesn't say
it's going to improve your health.
And so it's just it's it's denied.
You can pay for it out of pocket if you want, but it's going to cost millions of dollars.
So, yeah, we're not going to pay for it, but go ahead and do that yourself.
And so I guess that's a long-winded question of of

(52:23):
is there any way to improve our insurance system, our medical system,
so that it does benefit everyone?
It benefits the hospital to where they can stay staffed properly.
They're not worried about it.
They don't have to bicker with the insurance
for every claim that they go and go back and forth.
Or I guess some of them are already pre-negotiated.

(52:45):
But to just eliminate all of that, is there is that a possibility?
For the American health care system?
So, first of all, it actually is in my purview.
I, I went ahead late in my career
and did a master's program with Dartmouth

(53:09):
in what's called health care delivery science.
And that's precisely a bunch of the stuff that we look at.
And it's a lot of what I teach now to the undergrads and the med students.
But it, you know, on one answer, and the real cynical answer is good luck.
My, the reason why I say that is

(53:35):
what I tell the students is we're a wealthy nation.
We are a sickeningly wealthy nation.
There is, you know, so much money.
And where you see it a lot is in our health care expenditures.
Why do we spend so much?
Why do we spend almost 19 percent of our gross national product on health care?

(53:57):
One answer is because we can.
We have the money, we have the resources, so we do.
Well, what that means is there is a huge amount of money
floating around in that economy, in the industry of health care.
A huge amount of money.
And whenever there's that much money involved, any of the stakeholders,

(54:20):
any of the people involved are going to fight like hell for their piece of the pie
and are going to fight like hell to keep their piece of the pie shrinking.
So every component of that industry that you can think of
is lobbying our congresspeople as hard as they can not to change the system.

(54:41):
You know, they can tinker around the edges.
They can make impassioned speeches.
They can tell us all the wonderful things that, you know, they're going to do.
But this system is probably not going to change
drastically unless we're faced with a real crisis.
You put on top of that the fact that

(55:03):
Americans aren't very tolerant of, you know, one size fits all.
They all want to be individualized, all want to be treated to the max.
We also have a hard time dealing with death and and irretrievable situations.
So we have, you know, thousands of of.

(55:27):
Terminal patients and hospital wards being kept alive for weeks
more, maybe months more than they could or should be.
We have people, you know, Americans also
are damned if they're going to be told how to take care of themselves.
So we say, oh, God, those potato chips are killing you.

(55:49):
Don't you know that?
And every time you light up that cigarette and they're like, yeah, well, screw you,
you know, and then eat the potato chips.
There are a lot of factors that combine that that
make it expensive on top of the fact that, again,
with that sort of self care behavior

(56:12):
and the lack of kind of upfront care, we tend to be a very reactive system.
You know, we don't we don't we don't head off a heart attack years ahead of time.
We wait until you're 200 pounds overweight and you have your heart attack.
And then you go into an ICU and now the care is 10 times more expensive.

(56:34):
10 times harder than it would be just to teach you
how to take care of yourself, you know, up front.
So it's it's a steep hill to to climb, to get to something different.
I personally, you know, deep down inside,
I'd love to see a universal health care system out of government,
you know, single payer, in other words.

(56:56):
But you have to accept a bunch of things.
It would not be the same.
And and eventually, ultimately,
you know, at some point you have to say,
here's where we cut it off.
Here's where we stop.
And we don't need the newest medicine.
And we don't need to keep pushing at the very end there and all that.

(57:18):
You know, at some point you have to be able to say when.
So they're tall, tall orders, Brian.
I am pessimistic.
Oh, I am, too.
I I was just wondering if it's possible for obviously everything,
almost everything is in the realm of possibilities.
I was thinking more so.

(57:40):
First of all, I feel like if like you said, there's so much money in this
and these guys are constantly lobbying the government.
And I'm not like a conspiracy theorist,
but I do believe when there's that much money involved,
trillions of dollars
that people are going to die if people start rocking the boat.

(58:02):
Like you have an idea.
I just I truly, I truly believe that.
But it's something I would love to see change.
And to me, it almost doesn't seem too difficult in a sense.
And this is where idealism is going to come in.
But like if you took away for profit insurances,
I still think like, let's keep the model that we have.

(58:24):
Let's keep choice in the kind of coverage that we have.
But maybe that wouldn't work.
I would need to think about it more.
But for for for one thing, like just get rid of the profit model,
get rid of it being publicly publicly treated,
still make tons of money, tons of money.
You can make a lot of money being a nonprofit.

(58:49):
I'm sure there's ways.
I know it almost seems like,
well, it's called nonprofit for a reason,
but you can still pay your people who are in that a lot of money
and to still incentivize a lot of people to be in that industry.
And then the cost burden of the companies
who have to pay for insurance is is crazy.

(59:10):
Like the I worked for a delivery company
and so much of the profits that they made as a company
was spent into health care.
And so I just kind of feel like, OK,
everyone wants to make money.
And once you're you're just very self-interested,

(59:30):
like you're self-preservation, self-interested,
you're willing to to to hurt other people to to make that money.
Because with I'll just say like a small little example of that,
so it doesn't sound like too crazy is every year
on the years that we got raises,

(59:51):
we were then responsible for more of our medical insurance.
So our raises would almost cancel out
with how much we had to pay for our insurance.
And so that's that's the kind of hurt that I'm talking about.
But it seems like, you know, if you're self-interested
and then you just want to make money, it seems like businesses,
like big delivery companies that have to pay,

(01:00:13):
let's say UPS, FedEx, DHL,
big companies like Wal-Mart, Home Depot,
all these companies who have such a big cost burden for health insurance.
It just seems like if they collectively and they lobbied the government
and say, hey, like, let's change this.
Like, do you think that's is that too far?

(01:00:33):
Like, you don't think that would happen?
I suppose they may have some impact.
But again, there's very strong, you know, lobbies going the other way as well.
However, I think you're also you may be hitting on something
that we may see these mega companies just taking it in their own hands
and saying, we will be providing our our health care from this point on.

(01:00:58):
We don't need health care insurance companies.
We don't need independent hospital systems and doctors.
We'll have our own.
And you work for one of these big mega systems.
You just get taken care of by our own.
And I think those days are potentially coming.
I also think AI is potentially going to have a huge impact on this

(01:01:20):
because I'm frankly shocked already that it's not happening.
But when you start talking about diagnostics and
therapeutic decisions,
computer algorithms, if they're not already, they're going to beat us
human beings.

(01:01:41):
And, you know, why would a company use
a very expensive doctor if they could take a data entry person
or a medical assistant level person to get the data,
put it into the computer and let the computer
determine the care?

(01:02:03):
And frankly, I don't even think it's that far from the day
when we wake up and we say, Alexa, I'm not feeling so well.
And Alexa says, oh, what are your symptoms?
You know, you go through it, you put your finger in a sensor
and she tells you what you got and you go down to the local Kroger
and it prints up whatever medications you want.

(01:02:24):
I don't think we're far away from any of that.
And so when the big companies, again, when the big money
catches wind that we can save, as you're saying, all this money
that's going into their health care insurance,
I am sure they're going to start saying, oh, you know,
if the outcomes are even close,

(01:02:44):
think of what we can save by getting rid of just that whole,
you know, component of the care.
Well, that's not what I wanted to hear.
That was a little more
dystopic than I thought it would be.
It doesn't have to be. It doesn't have to be.
I mean, if it can be done better, for goodness sakes, why not?

(01:03:05):
It's such a wild, wild west out there right now.
And I'll tell you, the docs aren't, you know, lily white in all of it.
One of the one of the most appalling things to me is
there are plenty of neurosurgeons out there, you know,
doing very questionable surgeries.
There are many surgeries, particularly in the spine,

(01:03:27):
that are what I would call gray.
You know, it's it's not clear how much help you can do.
And it's a spectrum.
There are spine surgeries that absolutely are going to help.
And there are spine surgeries that have very low probability to help.
And so you as a provider have to decide, you know,
where am I going to be on that spectrum?

(01:03:49):
But we definitely see plenty of neurosurgeons out there
and plenty of orthospine surgeons who are very much on that one end of the spectrum.
If you come in complaining, you're going to have a scar on your back
at some point, because it makes big money,
you know, all the way down to the individual practitioners level.

(01:04:11):
So I don't know, it's it's a wild west.
I would love to see it improved upon and maybe something like that
won't be as dystopian. Maybe it actually be better.
I like that. Yeah. Change it and flip it for me.
I was thinking more so like if we're
outsourcing to A.I.

(01:04:32):
and then there's like less money for doctors or something like that,
then it's like, OK, if we can just circumvent that that big cost,
let's circumvent it. And so I took it.
They will. Yeah, that's that's the big part, because it's, you know,
more eyes on the problem are typically better than
than just one where.

(01:04:53):
But, you know, you sent me a communication that talked about
conformational bias and anchor bias and all that sort of thing.
And, you know, we are very subject to that.
I spent so much of my time in training residents
and I still work on it with the med students and the and the undergrads
trying to trying to force critical thinking,

(01:05:16):
trying to get you unanchored from your opinion and consider other things.
And so, you know, we are far from perfect machines on all this.
And if truly, you know, computer algorithmic
learning on all this can get to a point where they can beat us

(01:05:36):
routinely and making diagnoses or are selecting the best treatments.
By all means, that's what we should do.
You know, why not?
Yeah, that's a that's a great point.
So you were mentioning how if, you know, some doctors,
if you do go in there and you complain of of

(01:06:00):
of certain pain, certain ailment, that they will just cut you open.
But let's say like that's what they say is the diagnosis.
You don't think it is.
You think like, OK, this doctor is not like that or anything,
not not even having bad intentions.

(01:06:23):
They just they've come to the conclusion that this is what it is.
And you don't necessarily think that's the same diagnosis
or that that is what you're you're suffering from.
And so obviously, like with Google and, you know,
everyone is a professional, everyone knows everything now.

(01:06:44):
And so for you as a doctor, that has to be exhausting,
absolutely exhausting, because not only did you go through all the school,
all the training, and then you have your years of experience in your profession,
seeing this exact thing and diagnosing it correctly with with other patients.

(01:07:05):
How do I communicate to you as a patient?
Just potentially like, hey, like, is it possible that it could be something else?
Like, how do we move the conversation forward?
If we're not necessarily communicating effectively as patient and doctor?
Yeah, I think it's it is really important.

(01:07:26):
I would argue actually that to me, the the best patients
were the ones who came in armed with a list of questions.
I don't know if it happens to you.
It certainly happens to me that I'll go see somebody.
And when I get out of it, I go, God darn it.
I forgot to ask the single biggest important thing that I meant to ask.

(01:07:49):
And I forgot to.
And so it was always really good when somebody came in with a list of questions,
because you you then knew what was worrying them.
And you could address specifically what was worrying them,
as opposed to creating this general picture and help, you know,
hope that you're you're covering everything for them.

(01:08:12):
I think that really helped a lot.
Yes, sometimes you had to beat down some bad information.
But I would say most patients got it when when they would say, hey, Dr.
Google says, you know, I should have my my left foot taken off for this.
And you're like, no, no, no, no, that's just wrong.

(01:08:32):
That's just plain wrong.
Most patients accepted that when.
But at least at least you heard them,
you know, you heard their concerns.
So, you know, I always I always very much
wanted the patients to come in with a lot of questions, whatever they read,
whatever their uncle Joe told them, go ahead, throw it at me

(01:08:54):
and I'll handle it as as well as I can and try to let you know.
I think when you steer into the big stuff, you know, when somebody starts,
you know, putting the scalpel on the grinding stone and
sharpening it up for you and they're saying, yeah, yeah,
we're going to put a bunch of titanium in your back or, you know,

(01:09:15):
we're going to do this operation, we're going to do that operation.
I'm a firm believer in second opinions.
I think, you know, always get a second opinion on the big stuff.
And and if the docs disagree, then first of all, you say,
well, you guys don't agree.
What do I do?
And maybe you need to get a third opinion.

(01:09:35):
You know, who knows?
But I do believe the second opinion is really important
and not the person that, you know, they don't say, oh, OK,
I'll get my partner in here and they can give you the second opinion.
You know, because there are plenty of places anymore with,
you know, big medical centers that that
you can go to as an alternative and and see what they have to say.

(01:09:59):
So I think those are some ways to do it.
But I would absolutely encourage never as a patient,
never see yourself as a pain.
You're you're paying the doc, as one of my old partners used to say,
you know, that that patient is paying me
to do the best I can for them.
And so I better do the best I can for them.

(01:10:21):
And that should be your expectation as a patient is I'm not
I shouldn't be timid.
I shouldn't be in here, you know, a frightened church mouse,
afraid to say anything or voice doubt or, you know,
ask too many questions.
Forget that. It's my body.

(01:10:41):
And I want to know, you know, what you're thinking,
why you're thinking, what are the alternatives?
And, you know, by right, the docs should be giving those.
But, you know, docs get tired.
They get they get busy and they're always rushing.
So sometimes they just forget themselves, you know, to to give you all the info

(01:11:03):
you can. I also think what we tried to do, for example,
as I tried to do a multi-tiered approach to the education of the patient.
So I made a whole bunch of videos that they could watch at home
about their their specific diseases.
I had to always try to make sure they went home with
we had a whole store load of pamphlets,

(01:11:25):
you know, that talked about specific diseases or specific treatments
and make sure that they had something in hand.
When patients would say, hey, can I record this?
I would say, by all means, you know, because, you know, as a patient, you only
you only hear a certain amount.
The more serious it is, the less you hear.

(01:11:46):
If they want to bring in their family members, by all means,
bring in their family members, the more ears, the better.
So there are many ways that you potentially can get the most out of the visit.
And but ultimately, the doc is your employee.
It's the way I look at the damn politicians is why I'm so why I hate them so much

(01:12:09):
because, you know, they're my employees and they don't behave that way.
No, that that's been long.
But that was a lot of great information without getting too personal at a loved one
who was on the bad end of
she got the covid vaccine

(01:12:30):
and she did have a bad outcome from it.
She had facial numbness.
She had I can't remember what it's called right now.
It's not cardiomyopathy.
Like, is that what it's called when your heart is cardiomyopathy? Yeah.
Yeah. So her heart was like swelling.
She literally had to sit up and to go to sleep every night.

(01:12:53):
But this was when the covid
and vaccine was unfortunately a political conversation.
And so the the doctor didn't agree with her politically.
He didn't believe that the vaccines had these side effects
that she was presenting with.
And we lived in a smaller town at the time.

(01:13:16):
And so I think we only had the option of that one doctor,
but he never diagnosed her with cardiomyopathy,
even though she was presenting with with plastic symptoms,
even though that was a reported even self professed.
The doctor said that is a side effect of the vaccine,
but he would not say that or treat her with

(01:13:38):
that she had that that diagnosis.
And so it was just really unfortunate that
just to be in that situation, to be very scared,
because with the symptoms that she was presenting with some of the doctors,
they had to rule out a stroke.
They had to rule out a brain tumor.
They had to rule out really crazy, crazy diagnosis

(01:14:03):
because of her her adverse reaction to it.
And it wasn't even like we weren't like, oh, dammit, the vaccine
or like we know, like you take something every time you take a vaccine,
every time you get a procedure done, even if it's simple as Botox.
They say, hey, you can die.
Like, that's just the reality of the situation.
And, you know, you always hope you're the one that doesn't happen to.

(01:14:25):
But yeah, just just being on that side of it,
just great hearing your inside of it.
It sounds like you you welcome the the conversation
where not every other doctor is.
So it does seem like there is a lot that you can do to advocate for yourself.
Like you said, ask the questions, come in prepared,

(01:14:45):
have multiple people come in with you, if that's what it looks like.
Just to help state your case.
And I just think that's very valuable information.
And even though, you know, we never had any interaction as a patient doctor,
I just appreciate you as a person being open to that, because you can.

(01:15:05):
Have your your ego, your pride come in and say, no, I'm right, I know.
But to just be willing, it just seems like you were willing and like, that's great.
So I guess on behalf of your patients that you listen to,
just thanks for being exceptional in that regard.
Well, again, you know, there are many, many,
many good docs out there who who do all that.

(01:15:28):
And and, you know, so I would argue that a lot of the bad docs
are burned out and need our help.
I would say that the the number of truly bad docs out there are relatively small.
They're not one tenth of a percent, but they're they're less than 10 percent.

(01:15:49):
And the grand majority of docs are out there doing their best,
but they are getting the crap beat out of them at the time.
And and so but ultimately, it's your body, you know, it's your world
that they are intervening on.
And and, you know, ultimately, we docs are paid well.

(01:16:09):
And and yes, it's hard work and yes, there's a lot of training and all that.
But, you know, at some point, we just have to we have to man or woman up and and say, yeah,
I mean, we're going to work hard and we're working hard for you.
We're not working hard for us.
But I think one of the biggest things you hit on is,

(01:16:29):
you know, again, the more serious it is, the more scared the patient is.
And the minute you're scared, the minute you're switching your brain
into a fight or flight type of mode, the less cognitive processing is going on.
And so, you know, you're not thinking as clearly as you need to.

(01:16:49):
You're not processing as clearly as you need to.
And again, it becomes important, therefore, to kind of think about your visit,
think about what you need answered, what you're concerned about, what you're worried about.
And the doctor, if they're good, they're going to ask you that.
But you're going to forget.

(01:17:10):
And so it's really important to kind of go in prepared.
The other thing that I used a lot, the more serious it was, the more visits you got
or the less sure I was of a diagnosis, the more visits you were going to get.
Because, you know, a lot of the stuff you can't figure out right away.
A lot of this stuff you can't digest right away.

(01:17:32):
And so multiple visits would also help.
You're just a fascinating individual.
And I want to talk about like the burnout and like what what caused you to get involved in that.
And then you have your own non or no fiction book of Death's Pale Flag that you've written.

(01:17:52):
There's there's so many aspects of your personality, of your career that I would just I would love to touch upon,
but just being cognizant of how much time we have left.
Like what in these last few minutes, what do you what is what is it that you want to share?
Oh, you know, first of all, again, your questions are fantastic.

(01:18:13):
Fantastic, because I guess it, you know, it feels like you agree with me.
So, you know, I'm an excellent sounding board.
No, but no, they're really probing questions and really important questions.
And I think show a lot of insight and a lot of research on your part.

(01:18:35):
So, you know, nicely done on that.
I I'm willing to go anywhere with you.
I will tell you again, we we spent a lot of time on burnout.
Even the even the novel really centers around it's about a surgeon,
a neurosurgeon who is definitely burned out and who begins to see ghosts and and goes from there and kind of devolves from there.

(01:19:04):
But so, yeah, that's where I've spent a lot of time.
How did I get involved?
I felt like my entire team was burning out and me included.
And I was trying to figure out what can we do, how can we function better?
And I happened to run into and befriend a world expert on physician burnout.

(01:19:29):
And he and I worked together for years, both on Wayne Sotile.
Yep, Dr. Wayne Sotile.
And he's just fantastic.
And he and I worked together on our team for for years and, you know,
kind of also did a lot of a mini experimentation, if you will,
and and playing around with various ideas on how we can help people.

(01:19:54):
And so it's definitely been a near and dear subject to my heart.
And as I watch these, I spent a lot of time with undergrads,
most of whom are pre-med or pre-health care.
And I'm worried that we're already burning them out even before they get to medical school,
because the demands to get into medical school are so extreme

(01:20:19):
that these kids are killing themselves at a time in their lives when they should be learning
how to socialize, how to talk to each other.
I mean, what we're talking about and how to work with your physician,
both of you better be able to communicate to a certain degree.
And particularly the physician better be a really good communicator, a good educator.

(01:20:39):
But here we have these these pre-meds, you know, they're running around doing all these things.
They they have no time to just experience what it's like to turn into an adult.
So I do worry awfully about how we're burning out all the health caregivers.
And it's obviously it's not just in medicine, it's it's in all the high demand fields.

(01:21:01):
We're in this hyper complex society and everything's going a mile a minute.
I think everybody needs some downtime periodically, needs some time for themselves,
time to enjoy life, time to take things in so they can refuel and reenergize.
You're not just worrying about it.

(01:21:22):
You've like you've said, you've written three books about it.
You've done a lot of research, a lot of thought went into this on like, how can we improve this?
Like, you know, it's an imperfect system.
I don't think there will ever be a perfect system that is just going to be a win win win

(01:21:42):
for the business, for the doctors, for the patients.
But just having that conversation and putting that thought in it is it's just it's great.
It's yeah, I just have seen the medical field, like just as a as an observer.

(01:22:02):
And it just seems like it's just so demanding.
And it's so again, people can have their reasons for it.
But ultimately, it is a self-sacrificial occupation that you get into.
And so we can point at the system.
And I think today, I'm going to talk like a previous generation person that these today's

(01:22:25):
young people, they never want to take accountability for themselves.
And obviously, like we talked about, it's an imperfect system.
But there is personal responsibility for yourself to take care of yourself.
You can't just say, hey, my my job never gets me gives me any freedom.
It's like they're overbearing, which which can all be true.

(01:22:48):
And so outside of picking a different occupation, there's not a lot of wiggle room there within
the system with how it is.
But people like you are having that conversation.
And hopefully that does gain gain, Steam? Traction?
I think I want to say traction there, gain traction.
But what is the personal responsibility for the medical student?

(01:23:11):
What is the personal responsibility for the doctor who is self-aware or is who has loved
one saying, hey, like you're changed, your your personality, you have you have no grace
at home.
Your fuse is so short.
You're displaying burnout.
What is their responsibility to try and course correct?

(01:23:33):
Yeah, what a what a fantastic point.
There's a couple of lines that I would go on with this.
One of the things we do say is that you hear from so many people in this discussion.
Yeah, they they they they they put me in this position.

(01:23:56):
They've got me into, you know, working these hours.
They've got me having to do so much in so little time.
They have put me to work with all these jerks, you know, blah, blah, blah, blah, blah, and
all of which, as you're pointing out, may be very valid.
You know, we we're in a society that that performance matters.

(01:24:17):
There's always, you know, we're always trying to produce more and do more.
One of the glories of being in the United States is one of those things where the harder
you work, the more chance you have of advancing.
But that's kind of a trap, too, right?
Where, OK, well, I don't need sleep.
I'll just keep working. Work, work, work, work, work.

(01:24:38):
But what we say is, OK, just as a little exercise, we say, OK.
Let's grant that 99 percent.
Is external, that's driving your angst, your your draining, your loss of energy,

(01:25:00):
your loss of engagement.
What's one percent?
What's one thing that you can decide to take hold of and say,
I'm going to make this better for myself or for those around me?
I'm going to tackle this one thing.
It's not going to change all of medicine.
It's not even going to change my system.

(01:25:22):
It's not maybe not even change in my department.
But but for the micro environment that I'm in, what could I do to make it,
you know, that much better and a just just taking some, as you say,
responsibility or feeling like you have some semblance of control over something

(01:25:45):
will go a long way and can often have ripples in a pond effect in the people around you.
But even kind of more important to what you were talking about,
the two starting principles that we that we advocate when we are trying to tackle burnout
and particularly when we're trying to head it off, when we're trying to build

(01:26:07):
what we would call resilience or wellness within us is what we call self-compassion and self-care.
And what I'm finding, for example, with all the pre meds is they have very little sense of themselves.
They have very little sense of who I am.
Where am I? What's my world look like?

(01:26:30):
Where? Why do I want? What do I want my world to look like?
Am I up? Am I down? What's making me feel good?
What's making me feel bad?
And we say that, you know, before you can do anything, you've got to have some sense of that.
You have to be able to sit down for a while and just think, you know, what is getting on my nerves?
What is tiring me out?

(01:26:51):
What makes me feel better?
What brings me joy?
What brings me pleasure?
But have an idea, understand yourself, what we would call self-compassion or self-awareness
or emotional intelligence about yourself and do it periodically because it changes over time.

(01:27:13):
And then the second big component is you're not going to you're not going to get anywhere
if you don't grant yourself permission to address the things that are dragging you down.
And like we said, sometimes you can't, sometimes you can't fix the system.
But there are certain things that you can address.
And even if you can't fix the system, you may be able to adjust how you respond to it.

(01:27:40):
So you may be, you know, even though the system is doing this and it's driving you crazy,
you might decide, OK, well, then I'm just going to not be part of that or I'm just not even going to worry about that
or I'm not going to sit there and bitch about it every day with my colleagues or whatever,
you know, whatever course you want to take.

(01:28:01):
So we we always say in the business of resilience building, there has to be no guilt for self-compassion and self-care.
You have to grant yourself permission to understand yourself and know what you need.
And then you have to work at it.
You have to give yourself permission to work at it for yourself.

(01:28:23):
And a lot of people have trouble with this, certainly in our industry, because we're always taught,
it's the patient, it's the patient, it's the patient, as it should be.
You know, our focus is very much on the patient, but you you're going to suck as a as a caregiver if you're all burnt out
and you can't do anything for your patient.

(01:28:46):
So take good care of yourself and then you can focus on your patients.
Yeah, some things are out of your control.
But, you know, I've been there's a study that I came across, it was a longevity study,
and someone went and interviewed a bunch of people who were over 100.

(01:29:07):
And one of the conclusions that they came to in this study was that these people who lived long were able to just roll with what life gave them.
They didn't sit and say, why, why can't this be different?
I was playing bingo the other day and I was off by one number.
Like, they don't sit and think about how things could have been.

(01:29:31):
They kind of just, OK, this is how it is.
And I'm just kind of happy to be in the experience.
And man, I'm on the other side of that spectrum.
So there's so much work that I need to do.
Yeah, because, you know, you just look and say, oh, this is how it should be.
And yeah, just what you said, you touched on it.

(01:29:53):
That happiness is a choice and you are in this system.
But you can choose how you view the system.
Like, yeah, you worked on call the prior day and you were up doing brain surgery that whole night before.
And now you have to work this following day and you can just, you know, throw all the profanity wall you want against the wall.

(01:30:14):
You can just say, woe is me.
And I would say, yeah, you say those words.
But in reality, that is going to lead you quicker to burn out on such a high demanding field.
And so just the power of of mindset is great.
And so, yeah, just so much insight in that.

(01:30:36):
I'll give you a little example.
So I worked in these trauma centers, business in a big trauma center.
Even if it's not trauma related, it feels like it always comes in at night.
And I studied it and 70 percent of our emergency calls came in between midnight and six in the morning.

(01:31:00):
70 percent. So it was real.
We always thought, oh, my God, we get killed at night.
But it was real. So throughout my career, I could not take a call from the ER,
from some poor ER doc without feeling rage, literally rage in my chest,

(01:31:24):
because I knew no matter what, I'm not going back to sleep now for a couple of hours
because either I have to go in and take care of something or I'm just going to be so pissed off that I toss and turn for the next two hours.
So one way or the other. So the minute that call came in, I'm already pissed off.
I hate the ER doc. And I tried my whole career to to step away from that response, but it was visceral.

(01:31:53):
So here I am driving into the ER each time.
And what I what I taught taught myself, thank goodness, relatively early.
But what I taught myself was, look, you do you do the patient a disservice if you come in all pissed off,
if you come in grouchy and nasty.

(01:32:15):
There's some poor patient lying on a stretcher with something that they're scared to death about.
And if you come in and you're a prick, what does that do for them?
So I taught myself, all right, every time this happens and I have to come in and see someone,
ask, you know, pretend it's a family member, pretend it's one of your sons or your mother or your wife.

(01:32:41):
How would you respond to them? How would you deal with them?
And it worked really well. By the time I would get to the ER, I would be calm.
I would be focused. I think I was very kind to the patients and, you know, answered all their questions.
And hopefully, you know, dealt with them well.
And I was able to then walk from there and go talk to the ER docs and laugh and joke with them instead of like strangle them.

(01:33:10):
But it's interesting because ultimately, I never got over that initial rage.
But I learned to manage it and soothe it, you know, through some technique that worked for me.
Yeah. And so a lot of people will just be like, this is just who I am.
I'm just, you know, you wake me up, I'm just I'm angry and this is just who I am.

(01:33:31):
Deal with it. And it's just great that like, no, you do have power.
There are certain predilections that you do have as a human that you have to overcome, but they can be overcome.
And in your type of industry or any high demand industry where other people rely on you, it's just great to to work on yourself as a person.

(01:33:57):
And, you know, idealistically, like, hey, yeah, let's let's have some of the systems change.
Let's be a little bit flexible there.
But sometimes it's an inflexible system and there's nothing you can do other than work on yourself.
So just like you said, the burnout can stem from this feeling of I am powerless.
It's going to do what it's going to do.

(01:34:18):
And I'm just along for the ride and I'm just going to get thrown around in the waves.
And, yeah, maybe you are going to get thrown around in the waves, but you learn how to navigate.
It's like, OK, waves about to crash down.
I'm going to go down, hold my breath. It's going to pass.
That one didn't get me. And then you just kind of learn to navigate that in an imperfect system.
But how much control that you have as an individual over yourself is just great.

(01:34:44):
I just I saw it firsthand. Again, it's so silly to to compare occupations at all.
But I only have my experience. But, you know, I was a disgruntled employee for a few reasons, mostly just because, you know,
I don't feel like I was getting paid enough, which is silly to say to a doctor.
But I had a co-worker who just chose joy every day. Never had a bad day.

(01:35:07):
He was the day before his sewage literally came up out of his house.
Like he had a backup. It came up.
He said there was literal fecal matter in rooms that it had no business being in there.
And he just chose joy. And I was like, man, it is a choice.
Like he he may have some some better neural wiring.

(01:35:31):
He may have like some like better genetics where he's predisposed to it.
But I think everyone is going to agree that is a crappy situation to be in.
And then, yeah, just choose joy.
And that's the end of the episode.
Gary mentioned that there were thunderstorms around him, and that's where the storm wanted us to stop.

(01:35:54):
Although I had one more question I would have liked to hear him answer, I think where it ended is a good last point to reflect on.
Out of all the choices we make, let's be intentional and make sure that one of the choices we make is to choose joy.
I don't make any promises on my end other than trying to work on that.
I really enjoyed sitting down and talking with Gary, and I hope you enjoyed listening to it, too.

(01:36:16):
Thanks for listening, everyone.
Be sure to stick around to hear the testimonial for today's sponsor.
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6 - Brain Surgeon, Burnout in Medicine, and the American Healthcare System with Dr. Gary Simonds

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.css-14f5ked{margin:0;word-break:break-word;display:-webkit-box;-webkit-box-orient:vertical;box-orient:vertical;-webkit-line-clamp:2;overflow:hidden;}6 - Brain Surgeon, Burnout in Medicine, and the American Healthcare System with Dr. Gary Simonds