The Compassion Incision: Surgery, Storytelling, and Social Justice

Podcast Intro and Guest Introduction 0:00

you've extubated and you're just like ready to leave and all your day is done and then all of a sudden the sats are dropping and all of a sudden I'm like do I need to do a craic here? Like what's gonna happen with the airway? And then it's all fine at the end and then you just go home and you're like... than the next job, which is being mom. And they don't care what you were doing. They don't understand, nor is it their job to. I don't expect them to. I don't even want them to. I want them to want me as mom.

But how do I show up as mom when I've given my all to something else? Welcome to Dr. Talks. The podcast where every episode leads to a healthier you. Join us as we navigate the world of optimal health, uncovering groundbreaking strategies to conquer chronic disease. In each episode, we'll bring you the latest insights from leading health experts, medical innovators, and wellness warriors. If you're seeking to transform your health journey, or if you're looking for answers to burning questions, you've come to the right place.

Get ready to unlock the secrets of lifelong health and vitality. This is Doctor Talks, real talk from real doctors on the issues that matter to you most. Welcome to the Too Curious MD podcast. Today, we're excited to interview and really query Farah Karapaneni. She is a doctor and endocrine surgeon in Fresno, California. She's an associate professor with UCSF Fresno, an avid writer. and wife and mother of three. And that is to put it very simply, she actually is a profound healer and really has a lot of contact and a lot of compassion for our patients.

And today we'll be talking to her about things that bring her to this space in this podcast. Welcome. How are you? Thank you. I'm good. I'm excited to be here finally to talk to you guys about this, which I think is a really important thing that you're doing. So it's really lovely.

Writing, Storytelling, and Medicine 1:58

Yeah, it's been a journey. I think we continue to meet very unique individuals with unique perspectives. Integrative medicine really brings in a lot of the different components of healing. Some things that we don't necessarily get in medical school and often are learning into things that really have an impact. And I think that is why this podcast brings in the element of story, the element of the things that we sometimes don't really pay attention to until we do. And I know you have written about this, your personal story, the stories that you encounter in your training, as well as in your current practice.

Also, your avid awareness and sense of compassion, even in difficult times. I remember in COVID, how difficult it was to really be in the operating room and the things that changed. your dedication to your family, to your kids, a mother of three and twins at the same time. And you've really come through your own personal experience and your own personal, sometimes challenges to the place that you're at currently. So thank you for being here. Yeah, I'm so excited. Thank you. I have so many questions.

There's so many realms that we can start with, but I think we can maybe start with the realm of writing and what writing means to you and how it's come to take a role in your life as a physician as well as a mom, a storyteller. What's its role in your life? Yeah, I mean, I came to writing very early. I was a very non-traditional med school applicant in that I majored in comparative literature. So writing was a big part of my undergrad major. And it was very specifically in comparative literature, like you're comparing works from two different genres or two different even languages sometimes and kind of like finding universal truths.

And when you're comparing two things, you find the comparisons and the contrasts and the stories really come to life and I focused on colonial and post-colonial literature so it was even more so about social justice a lot of times and stories are told with the vehicle of fiction but are not truly fiction and I felt like I was fighting for justice in some of those papers that I was writing and I just think writing is so powerful it's such a powerful thing to do and I brought those narratives of social justice with me everywhere.

And of course I would bring them to medicine because that was part of my path to medicine. So, you know, of course being in medicine and experiencing what we experience and not really having another outlet that really can do justice to the depth of the feelings that we experience in residency and in attending ship. And I have a surgeon father, a surgeon husband, and an OB-GYN mother and any number of like cousins. But there's still some times where I cannot find somebody to really like sit in the depths of it with me.

And that's like the perfect space for writing. Yeah, absolutely. I'm brought to, I think all three of us share the love of Abraham Berge's and you quoted it in one of your papers. I just really love how blending the medical with the literary, it's been a genre for, you know, since the beginning of whenever, you know, physicians were writing, there's a great tradition. So I feel like we're kind of following in the footsteps of that and kind of making it like a modern version of that, right? Like Chekhov and, you know, his, invention of the short story and just the fully realized characters that are our patients, right?

Just the characters of human that are just existing and some of the follies and foibles and just these complex ways in which people show up. and how that takes such a big heart, right? It takes a broad perspective, but also a big heart to kind of hold all of that. And I love that generosity about literature and how that can, when we infuse that back into medicine, I think it really does help us to humanize the spaces we're in. So I really love this. How else have you kind of brought that, you know, how have you discovered the ways in which it shows up for you in your everyday practice or in your teaching or, you know, as you're sitting around with your colleagues, you know, how do you bring that in maybe?

In the in writing specifically. Or just that perspective even, like the perspective voting gives you. Yeah, I mean, I think it's just like the humanity of understanding that everyone has a story is so important because it doesn't necessarily translate into how they show up. They might show up anxious and they might show up rude so many different ways and we can choose to respond to the rudeness or the anxiety, especially in modern medicine right now. You know, before the patient comes to a subspecialty office, a lot of things have had to happen.

And they've waited a long time, and they know something's up because they're in a surgeon's office. But it's taken a really long time to get here. And now I've given them probably 10 to 12 of my minutes is allotted for them. And expectations are actually so low. It's heartbreaking how low the expectations are in medicine right now because of how people are being treated. And so just to remember that this person exists in a sphere. They are somebody else's entire world, just like I am somebody's entire world.

And they have a story. And we're just connecting in this space and time in this one moment. And it's actually a really sacred thing. And if I don't seize that, if I let it pass, then I've missed something. And if I don't want to be a part of that, then life is too short. Just find something else you do want to be a part of. If you can't be present in this moment, in this, with this patient, with this surgery, which whatever, it's a privilege for me. And so I think it's just building that story. Like, we all have our stories.

And I think about this to my kids all the time, because, like, I read this somewhere. I was like, if you understood the reason behind a child's bad behavior, 99% of the time, it wouldn't make you angry. It would break your heart. And obviously, kids can't, like, say what's going on all the time. They can't always tell it to you. And, like, they can't wrap up their story with a bow and give it to you, you know? But you have to be able to think beyond that if you're truly gonna inhabit space and time.

And that's a gift you give yourself. I love that and how the imaginal is that muscle that we can build, right? Like reading those long novels, spending time in reverie, sitting with characters, getting inside of the skin of another character when you're reading imaginative work, I really think is a practice that, you know, when physicians ask me nowadays, what should I be doing? I'm like, read novels. I really think that is one of the ways that all three of us, I think, have arrived at this place of where humanism gets taken out of that interaction.

And you're so right in labeling it the sacred moment. If we can show up in that moment fully as ourselves, it's powerful. It's bi-directional, powerful. It has meaning in your own life as a physician. It's like, I was able to meet that moment. It was a difficult moment. Yeah, you know, and, and what's it aren't, you know, it's people don't understand that. And in the, and the, the power of like investing in that is that they will get something out of it too. Cause it's, I don't think it would drive you enough if you think it's going to be good for your patients.

I think it has to be something where you realize that you're going to get something big out of it as well. And I think that's the only way that you can actually see the value of it. It's just showing up as your authentic self everywhere that you go. Yeah, I love that. And it reminds me of what I learned from watching my dad just as a young child, a child around two physician parents who were, you know, in a new place, you know, doing the immigrant life thing, but also, and I'm sure you've, you know, seen some versions of it.

But when you see that the interactions in their lives mean something to them and how much we end up taking home, right? Physicians really end up taking everything home. It shows up in some way or the other. As a child, I got to kind of watch that and recognize how deep it goes and how hard it is to separate from that, but then it also becomes a part of your character.

Surgery, Emotion, and Bearing Witness 10:20

which is another layer of, especially because when it means something to you, when you arrive at it and you engage with it as something that really feeds your own soul. Yeah. I think I came to writing, really, I never did write as well because I was in engineering. I did not do any writing. To me, writing was very difficult and very, very extracting, very emotionally, like just, you know, expelling sometimes those emotions that you kind of really push away. I'm curious to know what were your trigger points?

What is the story and how does that story arrive in your mind and how does that feel as you extract that or even put it on the page, the story? I think it's really tricky for me to say, because most of my life is just a mess, running from one place to another. It's not like I sit down and I'm like, oh, I'm going to write this story. But I think there are certain moments that just push me to that point. And so the trigger point is whatever happened in the way it has me feeling. So it could be an unresectable tumor, the trigger point of, of just that feeling that I can't do anything.

Like the point is to do something, like that's my job and it's the point is to be perfect at it. And then there's sometimes you just can't, because if you did, you'd have a perfect resection and you'd have a dead patient. So that's obviously not gonna work. How does the surgeon reconcile those two completely disparate things? So that might lead me to like, to write something about that, because there's nothing anybody can do about it. And there's a perfectly logical explanation for it, but it doesn't change the way I feel.

Yeah, something like that. And it really goes to the ethics of caring, right? What arrives when you are in that state of it's a quagmire, you know, you've got two different discordant ideas and two different areas of dilemma, really, the dilemma of a situation and really kind of sometimes working through that, through story and through kind of that representation of what really is happening, kind of that broadening that window of what is observed. than just what we think we're seeing in that five, 15, 20 minute of that experience.

I love how people were dialogue with the self, right? You're kind of having a dialogue already, like there's a situation and it triggers something. It triggers because of the ethical stance, because of how you're seeing the conflict, you're seeing the energy being like, oh, this is exactly what I was ready to do, but now I have to stop and I have all of the stopping-ness that I need to sit with. Why am I uncomfortable with that? and exploring that and, yeah, just crystallizing it, not needing it to resolve.

Yeah. Yeah, like bearing witness, like, you know, bearing witness. And nobody, like, there's a lot of talk about, like, you know, self-compassion. You know, we want someone to, I guess, bear witness to our struggles in time. Everybody wants that, right? Like, my kids want that half the time, that, like, that they, everyone wants to be heard at the same time, you know? And so like self-compassion with Kristin Neff, I don't know if you're familiar with her work, but like the idea that you can be that person for yourself.

And for me, I feel like sometimes writing is part of that. It's just an indulgence in bearing witness to myself, because what's so hard to me about, especially not just medicine, but surgery, where the outcomes are like so fast to see, like surgery, like you know right away, is that The lows are so low, but the highs are not high. You don't experience the highs high at all. Almost nobody does. I mean, there'll be some grateful patients. Probably the best note that was ever written to me was a patient's lipoma.

And I've done a lot more complex surgeries than that. She said I saved her life and actually truly saved someone's life, but that was not the patient. Most of the time it's just like, oh yeah, no, she said it was going to be like that and it was like that. But then the lows hit you so hard. And then you're like, well, what's on the other side of this? So the 1,000 patients and there's this one. So you have to give yourself somewhere to bear witness to that. I love how you describe that, that the wins are kind of the average.

They're kind of like the everyday pattern of things. we only notice when something is really off or a pattern and then it becomes kind of like a yeah it goes deep. Yeah and then I also think why didn't I You know, I mean, I believe in God, you know, and why wasn't I so grateful for each one of those? Why didn't I celebrate the thousand times that it went well? Yeah. Why didn't I? So, like, I mean, I've thought of this, but I haven't actually done it to, like, really, like, if I walk out of the OR, those six cases went well, to just write a list of all the things that went right for that patient that day, you know, and all the things I got to be a part of that were truly a miracle.

Because, like, most of the time, I just drive in my car and just run off to the next thing I'm doing. Like, yeah. supposed to go. But like really, they really think about all the things that had to go well for everything to happen okay for those patients with the vast majority of the time it does. It is a huge blessing and I should be so grateful. I can see kind of like a ceremony at the end of every surgery where you could kind of like, just be like, we got all of these things right guys. And just do it as a team even.

Cause you know, I'll just do the next thing. You're absolutely right. And it's just the way it's structured. It's just the way our reward system is structured, but what it takes away from us in just falling into that default. Your work is to, yeah, just kind of forget the everyday miracles that are happening every single day. And for someone who truly loves their career, I feel like that can actually add to longevity too, because after a while, you know, everything becomes really routine. And then it becomes like, well, how fast can I do it?

And, you know, I can do things really fast. but then I like some days I'm like don't forget to actually enjoy it like to just savor that like you're not worried you know how to make this cut you know how to do this thing you know how to avoid that complication enjoy the process of doing it the beauty that is like how the like beginning of I forget which book maybe it was cutting for stone like the way he talks about the surgeon agape at beauty of the the anatomy in the belly like That's exactly how I feel.

But sometimes you forget to enjoy the massive privilege that it is to do what we do. That can lead to it cutting it short, because you've distilled it into something that no longer resembles the magic that it is. And isn't it amazing? Everything can look the same. The setting can be exactly the same, but something can be a sacred, right, and kind of lit from within with a certain kind of light, just like you see in some of those paintings, you know? Yeah, the position of the bedside or it can be seen as kind of like, yeah, like very grotesque or very kind of mechanical or devoid of that.

And it is what we imbue it with. It really is that kind of. It's interesting because as a surgeon, I mean, there's a different level of intimacy. You know, you see the patient first before the surgery, and then you see them in the surgery. I mean, and that access to their inner self, their body, that contact, that you know, that delicacy and the intricacy of that procedure that you've described to me before, you know, how meticulous you have to be at the same time and then even then the closure of that surgery and then the after post monitoring and the post effect and that, you know, there's such a differential arc that I think shows up in what you describe versus what, you know, as a primary care provider would be very different.

That relationship would be very much about just relational, that contact, that medication. But as a surgeon, there's that extra layer of intimacy, I think, that shows up. And I don't know how that feels for you if that comes up in your writing. Yeah, I mean, I think the issue of trust and connection feels, and of course, I don't know how it feels in any other specialty, but it feels paramount to me. The trust is paramount as a woman of color, as someone who you said that I look young. I feel like there's counts against me at times, and people will sometimes say stuff like that.

But people also within minutes will sometimes say, are you the one doing it? Because I trust you. And I think they're asking me, if I'm the one doing it because they want someone else to be doing it but they actually want to make sure it's me and they've just met me. I think that like there's something in the connection like they can tell if you care. They can tell if you have if they have your full attention with so many little details that happen in the room within seconds. Because it's not like I'm in there for very long because I just don't have that I don't have that luxury got 40 patients 8 to 4 do the math You know, it's not long and they have a resident with you So but I think as far as like in focusing on that that trust and the connection so they have to know that I care about them and I'm not there to treat their diagnosis but I'm there to make their life better and then the part about trust like can you trust me and I think that those two are obviously linked and And when it comes to, well, when it comes to writing, I mean, I think that's mostly what I focus on.

Like the connection is what leads to all the feelings that come out with building the story. How is that work in your relationship now with your husband and in the writing and then coming home and not being able to sometimes download? I can't even imagine. I mean, I think as women, we experience this quite commonly right would you agree that you come home and after a difficult day like I remember with COVID during COVID coming going to the hospital I used to think well I'm gonna die you know I'm gonna be exposed to something and I'm gonna bring something home and what's going to happen in the hospital in those early days We didn't know, you know, and that uncertainty that it was very complicated and going home with that emotion felt very, I had to tuck it away.

I had to really put it aside and say, yes, you know, things are happening, but there was no, there's no disclosure of that, that experience. And I think that happens in difficult cases and in difficult. experiences sometimes words are not enough or the emotion stays very held and for me writing was really about that and I don't know how that comes for you in that experience if there's been especially with a husband who is also a surgeon and shares sometimes those similar experiences. Yeah. I mean, me specifically like the transition between like work and home.

I think we've talked about this before. Like, how do you switch gears so fast? Such a crazy thing. Like one minute, you know, the patient's stats are dropping. Like, you know, you've, you've extubated and you're just like ready to leave and all your day is done. And then all of a sudden the stats are dropping and all of a sudden I'm like, do I need to do a crank here? Like what's going to happen with the airway? And then it's all fine at the end. And then you just go home and you're like, than the next job, which is being mom.

And they don't care what you were doing. They don't understand, nor is it their job to. I don't expect them to. I don't even want them to. I want them to want me as mom. But how do I show up as mom when I've given my all to something else? and it feels wrong. There's so many feelings associated with that. There's guilt, there's fatigue, and then there isn't a lot of reserve because there's no family around and my husband has the same story to tell. He may or may not even be home, but if he is, he'll have the same story to tell.

Trust, Time, and the Surgeon-Patient Relationship 22:00

And so where is the reserve for that? And so I think For me as far as the job itself or just like my balance, I have to be really careful about how I balance my life so that I can show up how I want to show up. And so that means like really figuring out like how many patients can I see? How many surgeries can I do in a day where I can come home and show up the way I want to show up? What do I need for exercise, like self care, like to be able to show up like this, you know, like so diet, exercise and like, like the less patients and saying no to a lot of a lot of meetings.

Like I have very few slots for meetings and. you either want the meeting with me at this time or I'm sorry and it's not going to happen and so there's a lot of no's and that means that like as far as what I thought would be like my trajectory as a surgeon like what what generally we would just aspire to you know like we're always going up and up and up and so okay there's associate professor then there's professor and then there's like well you know if I want to make an impact on a national scale then there's all this research and then there's the meetings and then the that national meetings that you would travel to and then the meetings or the committees that you would be on like as part of that.

It's just no because I can't do all that and now I'm really into a lot of social justice, mutual aid stuff in our community which is much more important to me and it's never gonna go on my resume and it's just I find a lot more meaning to it so there's just that's the end that's the trajectory for my career and it's just it's just more joy based. Yeah, there's almost a decolonizing kind of like process here, you know? Sure. Right? Like medical training has been sold in a certain way. There's this power balance and this is the one way you kind of climb, you know, up.

And we know that the playing field is completely against us, right? As women, women of color, as mothers, you know. There's just multiple ways and exactly the way you describe is like on a, on an everyday basis, there's just not enough time to be able to do it that way. But I love that when you engage in the work, authentically, anyway, in your everyday life, the work kind of becomes the way, right? It may not be being valorized or rewarded or counting towards quote unquote promotion, right? but in the depth and the horizontal growth that you're having.

And I love that, you know, social justice and narrative medicine are really just interconnected parts of, right, like, just how we understand what are the particular stories that are living through these, you know, impacts of the system that we're in and how do we describe them. There's not any random mind control trials that are going to ever you know, delineate those. It's going to be narrative work. It's going to be the storytelling of the particularities of the injustices. It's not until you know that the patient in front of you had to take two buses with three kids and a stroller that it really opens your eyes as to like what it means that they're 10 minutes late.

It really informs everything. I love that, you know, there's this kind of rebalancing, but it feels powerful. It feels, oh yeah. grounding. It's beautiful. Yeah, it is. Obviously, when you touch money to something, then it just becomes about money. And so that's what health care is. I'm there to make money. My patient's there to make the system money. And that's what we've been reduced to on a large scale. And the more we call it out, the more we can fight against it. And I think I can see different opportunities where I've had to do that, such as I don't work on Fridays.

I've blocked off Fridays. They're not for any scheduled things. It's administrative time. But I got a lot of pushback from that for, well, I go to three hospitals on Friday. I operate on Fridays. And I was like, well, I don't want to round on Saturday. And I have prayer at 1 o'clock because I'm Muslim. Not that I want to work on Friday, but I just don't want to be in the middle of a case at 1 o'clock. And if you have a bunch of hospitals going on Friday, let's work on making your life better instead of making my life as bad as yours.

You know, and then I think what kind of comes along with that though is you have to really be very good, you know, because you can't be incompetent and say that you don't want to do all that stuff. That's just not going to work. You know, so like, I think that's always been like really important is to me is like, You got to make sure you're really good at what you do. I mean, all of us should when we're dealing with patients' lives, you know? And so then I can say stuff like that. And if they don't like that, then you have to be willing to walk away, which is another very powerful thing, is being willing to walk away.

Yeah. What do you feel is missing as a professor at UCSF and in medicine right now as you see it? I always felt it was very important for residents and students to have that experience, that of contact, of patient bedside banner and that approach and that awareness. But I do see more recently that that has become diminished and that has changed and there's less contact at the bedside. But what do you feel is missing in education and training and since you train residents and students currently? Yeah, that's a great question.

I mean, I think if you ask a student or a resident that and then you ask and attending that, then you'll have very different answers, right? And I think from a resident perspective, and I totally see this, I'm guilty of this as well, is that we now that, you know, because we've monetized everything so much, productivity, productivity, productivity, like there isn't as much time to teach. And I had that when I was a resident, you know, I was like, seven, eight years ago, where you could see people were just so busy.

They were just so busy. They couldn't necessarily give you parts of the case to do because there were so many cases to do. We'd be there for hours longer than we needed to if they did that. And so that's still an issue for me in so many different ways. I don't want to spend that much more time. I can't. and then show up to the rest of my life and my patients the way that I need to, you know? In the office as well, like if the patient are scheduled, sometimes there's three patients scheduled at the same time.

And then 15 minutes later, there's another one or two. And then 15 minutes later and blah, blah, blah, and so on and so on, right? And so like how much time could you really give to a resident to go in before you and actually see this patient when they can't close anything up, you know? then then you go in you know and depending on how much they got done you got to just take it up and so so how much time does that give me with the patient you know it's a very challenging system it's all capitalism based like this these problems are capitalist I think that's probably the number one thing is that we just don't have enough time to invest in them and make money at the same time which is what we're meant to do.

But I think another issue that I feel is important is that I don't think that the trainees actually are as hands-on as they could be for whatever reason. I don't know if it's something that starts in medical school or if it's a cultural-based thing or if it's an East Coast, West Coast thing because on the East Coast it was a bit different where I trained. But I do think that they need to, residents trainees need to take a lot of ownership because it is one of the very few still like apprentice-based models that we have.

And speaking mostly of surgeries as my only experience, where it's kind of like you do have to soak it all in from seeing. And so you have to be a very active, engaged learner. And you have to think of every experience you're having as this could be my future patient, what would I do? And what do I need to extract from this situation versus just like showing up and trying not to get yelled at? or showing up and trying to figure out how to do it just so the way that attending wants it. And that's part of the culture that we as attendees need to breed too.

But I think taking ownership, these are 25 to 30 year old people. We need to be in charge of our education. But at the same time, the attendees need to give them the opportunities to try which is a fear of failure. I really think there's a real piece here that's, as an educator, I'm seeing that what we are kind of molding them into is to be, they're targeting, you know, in pre-clinicals, they're targeting a certain score. It's like, oh, you have to hit that score. It's like, okay, that's what we've just targeted into them is like study to a certain level and that's it.

Instead of studies to understand or study to communicate or even to be able to be like, what am I curious in within this, right? There's just such a kind of overwhelming use of this one way of teaching. and an evaluation that then we create these machines. Basically, we've just basically spent four years programming them this one way and then letting them go into the residency space. And I've seen this as an attending. I'm like, you're absolutely right. There's like a shutdown. There's like, oh, I'll only study what I need to know for the shelf, and that's it.

Work-Life Balance and Motherhood 31:00

And then they're like, OK, I'm done with my day. Whereas what you learn is by staying there at the bedside, by communicating, by seeing the next thing that's happening, there's a rhythm to medical care that you learn from. And when we chop it up into these little bits, and then we present it to them, and then they just swallow it, and they think, oh, I know what I'm doing now. I mean, it terrifies me to think that, you know, just so much harm that can be done from just not developing that ability to reflect an action.

You know, there's this whole idea of, in medicine, we're supposed to reflect on what we just did, think about what we did right, think about what we did wrong, and then make a plan for the next time, go, okay, I'm going to change that the next time. That's how you get better. That's how you develop this excellence. But there's such a, like, it really boggles my mind that you could be admitting a patient, you know, to your service, but you have no idea, you know, just what happened to them in the emergency room and this and that.

Like, you have no idea of what part of this patient's story you are in. I want to challenge this a little bit. I want to challenge this because I think, you know, we're talking about the system as it is right now and what it's become and the tension that you described between time and, you know, contact and, you know, experience and training and developing the residents' skills as well as your own and, you know, ensuring that it's safe. you know, then safely and the outcome is best oriented around what patient needs and recovery requires.

But I want to challenge this idea, though, of contact, you know, that patient and healer contact. Even in the five minutes, there's so much that can happen in the five minutes of just that, just listening, just that awareness, just observing and really listening even to the type of words that the patient uses. You can observe even just how their body language, where they look, how they talk, the pauses between their words, where does the voice crack, where does it sound more pained, the words that they use and what comes up.

You know, and I'm wondering if in healthcare we can do what you do for a step back after the situation and really write to that. You know, have residents and students really write a story about what they observe rather than a case report or, you know, where it's really very objective and It has to have a differential diagnosis. But really, if we just really focus on the story and describing that illness in terms of story, I wonder how that would change how the resident student would observe their experience.

Yeah, I think that's a good point. And I think there's certain, like certain places do that as part of like, it's the parallel chart, I think they call it, is that right? With narrative medicine, with the way things are, you know, I don't see this happening in a clinic, I don't know, you'd have to have like maybe half the patients that I have to maybe do this. But I think it's a really good point. And it reminds me a lot of one of my favorite doctoring poems, which is what the doctor said. I don't know if you guys are familiar with it.

Yeah, I love that one. Because it's like, this is probably being as heart wrenching as it is, it's probably being played out like in my office weekly with giving bad news. And I get it from the doctor's side, you know, but these are words that like the patient would never say to you. out of respect, right? All they'll say is thank you, like, at the end of the poem. So I wonder what someone observing that interaction would get from both sides, you know, because it's so hard to know. I think that would be a great exercise for me, then, to do, like, post-interaction.

Yeah, or write a poem or write or, you know, draw a picture or even just, you know, connect or talk about it. I think what I do think is missing also in healthcare is this time that you described, like, just stepping away and having somebody to talk to. You know, I think in terms of the training, the burnout that we're seeing is really, really a lot about that, you know, that what you're describing, the struggle between time, between pressure in doing the work and getting that done and then going home.

but also the pulls that we get, and you can really feel it, and that's very fatiguing to constantly carry. Yeah, you find that there's technological fixes that are coming down the pike that are starting to help with that, like the use of AI chart ascribing and things like that. I don't know. I don't know if you guys know of any. I haven't used anything. I don't use Dragon. I don't use anything. And I admit my notes aren't the best, but they get it done and they document. But I've heard of people using virtual assistants for documenting and for even returning calls to patients to get their more time back and AI for their notes.

When I was overseas and I had to take care of children with Down syndrome, I used to have a scribe who sat next to me and she would put in all the orders, type in all the words that she was saying. It really was such a relief in my head though at that time. I imagined a speaker being on the top and just listening in and recording the whole thing. Like, I imagined that, and I said, wow, wouldn't that be cool if there was something that was just recording, of course, you know, HIPAA compliant, and it would just record the whole experience, and then we could observe that.

I mean, you can do that in terms of videoing it, and there's so much more that you observe and you learn about yourself in that experience as well. So I think that is... I don't know, one way I think that can be implemented. Because that's what we're trying to do, right, is our attention is fragmented because we're trying to work on so many different levels. Yeah, you're doing a physical exam, you're actually communicating, you're actually doing even some differential diagnostic kind of, okay, you know, thinking as well in the moment.

There's so much happening. And then to be able to free up a part of ourselves to notice what's actually happening. through the story, right? And we know from just how people tell their stories, what quality of words they use, you know, how, what their tone is, what their body language is. I can just kind of imagine where there's just these large language models that might be able to look at a patient's story and be like, oh yeah, Here's the person of this descent and this is their genetic profile and this is where they live and this is how much we know about them and they'll just spew out a story.

What this looks like and we may be going towards that kind of space.

Medical Training, Teaching, and Reflection 37:40

So literally, I mean, describing and the use of AI and even what emerges with that collection of data and qualitative and quantitative and how it becomes its own version of something, right? That virtual... Representation, right? Like when we talk about narrative medicine and representation, when we talk about, oh yeah, it's different when you videotape somebody, it's different when you're audio, it's different when you write notes off of an encounter, and it might be different as a representation when It's been run through these large language models and those have their own biases as well.

True. And you're going to be very interesting to see. So yeah, qualitative, quantitative. Well, we've chewed up an hour here chatting about such fun stuff. Thank you so much. Yeah. Did you have anything to ask us? Any questions that you'd like to throw out there? something that comes from your curious mind. Like for future-free... I don't know. I think it's all integrated medicine and narrative medicine type of stuff. Yeah. I mean, unconsciousness, you know, I mean, they're all kind of connecting up right now.

I would say two things would be, one would be, and I'm going to forget the second one as soon as I say the first one, but like a lot of my patients have bias against or just like a barrier to paying for medical services. And I'm assuming you guys aren't insurance-based with like ketamine and things like that, right? Like if I send them to my endocrinologist friend who has lifestyle medicine certification and is extremely well qualified and they'll get more time with her and she'll be very curious about a lot of things and she'll, you'll get your money's worth.

But if it's, but she has a direct care fee, like people won't want to do that. So as someone who's interfacing between like modern medicine, but also like definitely believes in everything you guys are doing and would love to like, wouldn't, wouldn't be the one to replicate it myself. I would just refer. patients have like bias against it, like exploring that a little further and then exploring also like physicians who are not in integrative medicines, biases and barriers to becoming more curious about what is like not evidence-based medicine or what is evidence-based medicine not taught in medical school that they just don't want to be open-minded about.

Yeah, you bring up evidence-based medicine and I think, is it medicine because it's evident? I mean, do we have to, we try to prove ourselves right, prove ourselves right. And that's what we base our medical experience on. And just because it's, and that may be valid, but there's so much more. And what's not known, what's forgotten, I think, when we think about integrative medicine, we're really thinking about ancient healing practices. and how they emerged and Ayurvedic practices. There's solid evidence on that, but not really represented in our medical training and medical experience.

When we bring up evidence-based, it's definitely, I mean, I've taught in it. We've used that framework because we have to have a high degree of evidence if we're going to approach insurance companies for reimbursement and actually have these interventions. You've got to meet a certain level. Absolutely. And then I feel like that's one model that we can maybe overlay with another piece of it, which is, yeah, that holds the boundaries, right? And I love that. I'm kind of, I think, gosh, I'm forgetting Siddhartha Mukherjee had kind of like this book about just like the particularities of, there's a quote that's just avoiding, I'll look it up later.

It just kind of talks about the rules and laws of medicine. It's in his book, The Laws of Medicine. Yeah, yeah, I really recommend reading it. Some of my students who've read it, you know, residents who've read it, it's just like, you know, medicine is such a dynamic art, right? There's just so much. We're always at the edge and we're always discovering. And like you said, you know, there's all of this other bodies of knowledge that we haven't really had an ability yet to study to that degree from that materialism lens.

So yeah, kind of like, I love this question that you have of, how can we bring in the evidence and what are the different kinds of evidence is what I kind of start to think about. Or even just thinking beyond evidence-based medicine, like my patients will frequently ask me like, well, what supplements should I take for a thyroid or things like that, beyond the scope of a specialty surgeon, right? And they'll ask me, like, well, what do you think of this? And I'll say, well, I was trained in evidence-based medicine.

They didn't teach me about this, which doesn't mean it doesn't work. It just means that I don't know very much about it. And it could work as long as it doesn't have a downside, which I don't think it does, based on whatever they're showing me. Then try it and see what happens. Well, I now believe this thing about cellular health, and cellular health can be impacted by medications, by supplements, but even by emotion, even by joy. I mean, when I feel joy, I know I feel it. I can feel it in my body.

I can feel an energy. I can feel, you know, an activation. I can feel an awareness. That is in the cells too. And I've had patients who have had very significant chronic conditions and have literally willed their way through that. Willed their way. Willed their way through, I have a stage four colon cancer. patient who is active, alert, and fights for her life every single day, but with a strong sense of spirituality, a strong sense of awareness and groundedness and recognizing and really paying attention to her emotions, paying attention to her rage, paying attention, and really working with that in that mental health space.

And I think that's what sometimes heals, too, is this, you know, the internal milieu, right, and really working with that internal milieu as well as the external and bringing and uniting that external part of you and the internal part of you and really tuning to your environment. And that has an impact as well. I mean, if I have a patient who's going to have a toxic illness, diabetes, for example, and goes home to a toxic environment, of course it's going to get worse, right? But if that same patient goes to a home that's supported and guided and loved, what do you think that impact is going to have on the condition?

And this is something we don't talk about in conventional spaces. It's very simple. It's normals teach us rules and outliers teach us blogs. You know, I thought you would appreciate that as a surgeon, right? It's like the normals teach us the rules and the outliers teach us the laws. So it's like, we're always in that liminal space of, yeah, you know, things that we weren't taught in medical school because they weren't discovered when we went to medical school, right? Like my parents, when they went to medical school, DNA wasn't being taught.

Those discoveries occurred as they were graduating. And yet we took that as a basis of our understanding, right? And the same thing with the next generation of physicians who are being trained. And so it's almost like we're learning a new way of apprehending the same different thing, the same thing. Yeah. From a different lens. You also asked about the patient's pain and having that grudge feeling about pain. I think what changes that aspect, at least from what I'm seeing currently, is that time, that sense of knowing that patient, giving that patient an hour or two hours sometimes, sitting with them, listening to them, really being unconventional in your in your space, right, in yourself and doing all the same thing that you would have to do in conventional medicine, but really giving it time.

And I think that time factor is, you know, is something that patients do miss and they pay for that and recognizing that that's the quality of what they're going to be getting. Yeah, insurance isn't going to cover the extra time. I think of what patients like, there's this feeling that that health care should be free or cut mostly covered. And so I'll literally tell them like, you should go see this person because if they have a very nonspecific complaint. if you have something really like straightforward like it's hypothyroidism you just need someone to write you the levothyroxine then fine you can you know see any endocrinologist or whatever but if you've like just non-specifically feeling very fatigued and this is very different for you and nobody has found anything on the normal testings and you might need somebody to just be very curious and like that means that you should you know see someone who can ask some better questions, think outside the box.

And sometimes still patients won't do it. And I think maybe that's just something that hopefully will change with time and maybe like marketing. And I think hopefully the tide will shift from these modern models of medicine in these employed practices where everything's insurance-based. And I think that I would like to see it change and maybe I'll have more courage to go outside of my model. And then there are certain patients who need that extra time and that space and that complexity. And how amazing would it be to even envision spaces in which Both of those things are available.

You just know how to, you know, kind of, yeah, basically maneuver between the two in a, in a limber way, right? Now the way we have it is just, it's thickets. You know, it's like, oh, you want to find a therapist, you want to find a doctor, you just have to like do this and do that and go through all of those processes. I think patients are also, I think more than ever in history, better read, better informed, but also that makes them vulnerable to a lot of the marketing

Integrative Medicine, Evidence, and Bias 47:40

stuff that's happening. So the role of the physician has kind of shifted even to kind of encompass that and be alongside that, but also still be, like you said, you know, have that evidence-based mindset. so that you can help your patients decide like, yeah, you want to ignore those three things, but this one looks like it, you know, it has some good evidence behind it. So let's try that. And then here are some effects that might happen, you know, so kind of being a real guide alongside. Yeah. Well, something we've also talked about is why wait for something to really pathologize to that degree that you'd start to treat it.

Why not treat something like a thyroid condition earlier? You know, treating the health of the thyroid, not the pathology, and really focusing on what can make a thyroid more healthy. You know, how do you sleep? You know, how do you regulate your body temperature? What do you do, you know, in terms of infection? How do you, you know, help yourself? I think even just thinking through that and saying this is how also one can really, you know, there's a lot of knowledge there about these. Absolutely.

I wish we could, you know, place all of this in the teens and twenties when we really need to learn these things, when we're starting to take care of ourselves, right? Yes. We're seeing more and more of like, for example, thyroid illnesses that you brought up. When my daughter moved to the Southeast for college, she had her first bout of thyroid diabetes. And it tracked with being there and then coming back here and then going back there again, which just tells me that it's your environment. Most of our time, it's the quality of the water, it's the soil, it's what foods and things that we don't really measure.

Eating. No, which is really fascinating. And it's also a scary time where we're not sure whether to trust our environment. It's getting more and more to that point where I think that if we, in this capitalist colonial environment where everything is monetized, can we trust our water? Can we trust our food? I think there has to be a lot of education around that as well because kids these days, are they going to eat an apple or are they going to eat chips? And the chips have red dye in them, all kinds of things.

like they have so many different things and parents don't necessarily know either or they can't afford this better thing and then we're taking farmland away from people and you know like we're getting our produce not at the farmers market from our local farmer and all this kind of stuff is all connected and I think like we need to connect those dots more than ever and that's why like I think it's physicians jobs to do that. Yeah, you mentioned your work and social justice outside of the work that you do, and I disagree.

I think your work is so related to what you're doing on the outside of your teaching and surgical world is very, very much related to what shows up in your office or in the surgery. It's true. It feels disconnected because it feels like I'm working in a business at work, work, you know, because of the way it's set up. And that's such a kind of, I think, what you've just described, you know, the trust that's being eroded, like you said, in our water and our oil and our food supply, the trust in the healthcare system too, you know, kind of is following suit.

And we're all feeling that, you know, some of the ways in which our healing spaces have shifted have made all of us physicians really understand that it's not us, right? It's the way the system is set up. And also our powerlessness comes from the fact that you could see the same patient with that same diagnosis and know that this was a diagnosis related to something in the environment, for example. And there'd be not a lot there to support you in changing that in a real way for the patients in front of us.

It's happening in pockets. This ability that I think we're starting to see where physicians are reaching into environmental justice initiatives and making sure that food, fresh food is grown and patients have access to it. But those are just like, we need 100,000 of those right now. We need to get those out of the experimental phase because we know what works. I think it's also boycotting certain products that are just everywhere. I don't know if people are willing to do that for their own health or for the health of their kids.

I actually don't know if people are willing to do that. But I think it's really important. There's a few companies that make all the food that everybody's eating. And there's a lot of additives in the vast majority of those things. They're packaged goods. They're bad for the environment. They're very bad for our kids. And this is like the first generation is going to grow up entirely on such foods. And it's a grand experiment. And we see a lot more cancers, like a lot of younger folks getting a lot of cancers.

colon and breast. And that's like, you know, a lot of my colleagues are saying that they think they should change the age of the first colonoscopy to be younger because they're seeing so many more cancers now. And thyroid cancer is on the rise as well, which is a lot of that could be related to microplastics, could be related to additives in the food. And how are we going to change that? I mean, I think it's boycott. But I don't know if people are awake enough to see it and to change the way that we buy because we're just so into convenience.

It's part of the capitalist, colonialist environment. And so I think our choice for our way towards 90% of them are going to be the choices, right? Like the choices are marketed in that way, priced in that way, access to them is provided in that way that the choice is already made for you. Yeah, roll right through your own kind of behavioral economics and everything. So it really is, you know, I think physicians are at the center of this because like you said, colon cancer, everything we put in our guts ends up, right?

Breast cancer, anything that is fat soluble end up there, right? And like you said, the thyroid and the endocrine system, anything that's microplastics is up there. So it's like our bodies are telling us something. And that's the story of the body. The human corpus is speaking, and if physicians are to do a proper interpretive diagnosis, really, if we're really going to say we're making the correct diagnosis, it has to involve all of them, you know? We can't talk about any of these things by themselves.

I think that it all has to be very connected. And I think physicians need to be loud about this. We can't talk about people's health without talking about social justice. We can't talk about it without talking about decolonializing our culture. We can't talk about it without talking about anti-capitalism. And these are not popular things to say. But I can't not talk about this. Well, I think the evidence would have to come. One thing I do on intake on patients is check their CRP and I'll tell you eight out of ten patients have elevated inflammatory markers.

Just walking around with an elevated inflammatory. Obesity is an inflammatory condition and it's been shown to be inflammatory in the brain. Now we're doing brain maps so you can actually see you know, inflammatory changes in E.E. quantified E.E.G. I mean, it's there. The evidence is there. And you're right, you know, being very vocal and very, you know, sharing to that evidence, right? Because that's how it works. It makes legislative change. It really is going to take, you know, a real concerted effort, just like we got lead taken out of gasoline, right?

Like, that was a concerted effort. There are stories of exactly how this works, and it is through the storytelling connecting with the real-time evidence-based data that's coming out and then driving change, right? So I feel like I really hit this, yeah. So what are some of the advocacy programs that you're working with? How can people learn more about what you're doing? I would say like I would recommend work with local organizations.

Social Justice, Advocacy, and Community Care 55:40

So like finding common or people with like-minded attitudes and kind of form teams, you know, there's not going to be people that you necessarily live next to or people that you work with who are going to have maybe vastly different ideas of how they see the world than you do. But when you go meet up with people who are also interested in like caring for the homeless or homeless advocacy for advocating for medical patients for you know live again fresno which is one of the ones one of the organizations at fresno i work with that i really recommend when you see these folks come together you may have nothing else in common with them but you have the most important thing in common with them which is that you guys you know all want to see social justice you want to see that the people that are being kept down by systemic violence, how can I help these people?

How can I help the homeless? There are good people out there doing good work, and just be connected to them. Mutual aid is a big thing now, especially now that the government is defunding a lot of aid services. Neighbors helping neighbors is a big thing. If you have extra fruit, see if you can share it, take the food, out of, you know, our government. They're gonna, like, pull the food that they're giving kids in school now. So how can I share my extra fruit? Like, how can we grow food so we're not relying on somebody else?

We started something with just these same folks that I just came to know through this mutual aid service where instead of calling the police when you have escalation of, like, domestic violence or disputes or like a mental health issue to have like a hotline and we're taking call we're going to start this in April we're like in the process of training and like developing it now but it's just like six of us we don't know each other in any other way but our desire to help. the homeless and do these kinds of things.

We like some homelessness stuff together, but had this idea to start this hotline and like hopefully it can grow. And then if they're not calling the police, we all know that like, I don't know how many police calls, like police shootings that started with calls like this that the police came to instead of deescalating or helping because There's no other way in American society. Who do you call in situations like this? You know, if you call, you either call the ambulance or you call the police. But if you call the ambulance with a call like this, the police will also come.

And then, you know, in a larger percentage than you would think, those could end up in a shooting. And so demilitarization. All these things go together. So that's what I've been working on. And it's not enough. It's not at all enough. Not even a little bit. It almost feels like it's not even worth saying the things that I'm doing. But I do believe that feeling that it's not enough is a great way to get yourself out of doing anything at all. And so that little bit, the little, little bit, you know, those, I told you about those chickens, the chickens, the 15 chickens every two weeks with the kids from the motel families.

Like I started that in COVID every two weeks getting 15 Costco rotisserie chickens. Now those are 30. There's a fruit that goes with it. And over four years, that's more than it would have been. It's whatever number of chickens more than it would have been if I had just decided that that was a useless thing to do, you know? It all adds up. So bringing that attention, you know, you get to craft where your attention goes. I think what you're describing is anchors of attention. It's like you're taking time and you're saying, I'm going to limit certain things, I'm going to say no to things, but then what do I give that time that I got back out of the capitalist system?

You're literally like, right, you're donating your attention and you're actually, that's the worth of it because it would have, you know, had you an hourly rate, right, made money. There is an actual hourly rate that you can apply to the attention that you've given to these other projects. And, you know, we say that when things don't, you know, we devalue things when they quote unquote don't make us money, but that's also just the way we've all been kind of, you know, Like that's our psyche, because that's a movement program.

But to value things that don't make money is actually the higher good, right? Yeah, that's the only value is money, where the value actually human life. Yeah, changing that. I love that, you know, when we talk about curiosity, we talk about opening up the box and thinking out of the box and really asking those questions and really thinking about, you know, it doesn't have, it's this way, but Why is it this way and what else? And I can hear that in the work that you're doing is really just stepping out of the zone and really just saying, hey, there are other ways.

And we don't even just idea of value, right? What is value? Is it an RVU value or is it the human life value? There should be a quantified value on human life. And if we could quantify human life, then we would put value to it. Yeah. Thanks for... Wow. Thank you for your time. Thank you both as well. Thank you for tuning in to Doctor Talks. We hope today's episode has enlightened and inspired you on your path to optimal health. Each day is a new opportunity to make choices that empower your well-being.

For more insights and strategies, subscribe to our podcast and visit our website, www.doctortalks.com. Stay connected, stay healthy, and join us next time on Doctor Talks. Real talks from real doctors on the issues that matter to you most.