Chapters Transcript The Necessity of Hope: A Basic Human Need for Ourselves & Our Patients Course: Inspired MD Summit: A Professional Growth and Leadership Development CME Event for Physicians So I'm gonna end with hope there are no slides. I'm gonna talk to you um about something that I think we all intrinsically know but it's something that if we can incorporate in the in our communication with our patients and recognize that ultimately what we must always do is maintain hope and how to do that can actually improve not only our communication but ultimately the way that patients receive their recommendations and their care so let me start off by saying actually in this room. Um, and others, but in this room we have brought up patients to do something called day of patients where, um, for over 30 years I've been bringing my own patients in after the GI course and having them come and talk to the medical students usually 1 or 2nd year medical students. About what it is to have a gastrointestinal condition, talk about GI bleeding, inflammatory bowel disease, ischemic bowel, we talk about things getting caught, biliary disease, and what happens is the patients present as unknowns, so we go through the questions the medical students are all wearing the white coats they will ask questions and eventually they start coming up with a differential diagnosis which we discuss after we discuss the GI condition, go through the imaging and the pathology. The actual secret ingredient of the course occurs and that is that I asked the patients what are the things that are most important to you that you want these future doctors to know this is your opportunity let's face it, first year medical students are incredibly sensitive and they are like sponges ready to actually take in the advice that we give them as their professors but also the patients. William Osler says. Listen to your patients, they'll tell you what's wrong with them, and they are also your best teachers. So I say to the patients, what is it that you want these future doctors to have? And they say one of three things and usually all three of them just in different words they want them, they want their doctors to listen to what they're actually saying, not just to hear it but to listen. They want them to care about their outcome. They're not a case of, but a patient with that actually makes a difference. And the third thing and almost always universally is that they want hope. They want hope that by coming to see them as a patient. That their physician, the medical community is gonna give them something that can help their medical condition. They want their doctors to listen to them they want them to care about their outcome and they want hope that something's gonna be better. OK, so we've talked about listening we've talked about it in mentorship. We've talked about caring, empathy holding a hand and what it is to connect with our patients but what about hope? Can we actually always give our patients hope? Is that OK? Because what's not OK is false hope that's probably one of the worst things you could do for a patient. So when we think about what hope is, in many ways hope is one of the most. Important driving factors of human behavior. So many of us in fact unless we are um Native American indigenous to this land we've come from somewhere else our ancestors ourselves but someone came from someone else and if they came on their own accord usually to make a better life. When we have children or families or we wanna help someone, we wanna make things better we hope that their future is gonna be the best could be possibly be. Hope is one of the most important driving factors that allow us to tolerate things that might be difficult, so we hope things are better whether it's for us or for someone else like our family. So it's a very strong motivator so we take that away whether it's from us or from our patients we're really doing a very strong disservice so let's talk about the types of hopes there are when a patient comes to see us initially. They hope that whatever symptom or whatever condition they have that there's a cure for it. We find in GI a large polyp we remove that an early cancer the hope is that when surgically removed, it's curable, it's early. If we can't remove the disease or the symptom then we hope that actually we have a treatment that can minimize the symptoms can handle the chronic condition, and we hope that there might be a treatment in the future that might actually make a difference. So a clinical trial for example is a perfect example of that that maybe there's actually something in the future that doesn't exist yet that we can give you that will either help or knock out the problem. And what happens if all that doesn't exist? What happens someone really has a terminal illness they come in with widely spread metastatic pancreatic cancer or colon cancer. What hope do they have then? They'll hope for comfort um palliative care in fact uh one of our sponsors, the ACP we introduced you to Daniel's palliative care doctor but palliative care doesn't mean you're doing nothing it means you're providing comfort there's a hope for comfort there's a hope for peace there's a hope for resolution and there's a hope for presence we will be there we will help you achieve comfort and we will make sure that whatever we need to do that we will be here for you. That's actually a big hope. My point is that there's always hope. There really is always hope, and I'm happy to talk to anybody about who doesn't feel like we could provide hope. The question is what is the hope and the expectation? Expectations are so critically important. If you tell a patient who comes in in our world with an irritable bowel syndrome, we're not gonna be able to cure that, but when you say to them, I'm gonna do everything possible to help you feel better. That gives them hope. Wow, someone's here that's gonna help me. If I say to a patient, I'm gonna get rid of all your abdominal pain forever. You'll never have abdominal pain, and they go 3 weeks without abdominal pain and then they get abdominal pain in the 4th week and say, what happened? You told me I'm not gonna have any abdominal pain by saying to do everything possible to help you and they go 3 weeks without pain. That's a big success. I've now lived up to what I've told them so the hope not only has to be what's appropriate. But it has to be in a way and communicated in a way that is something that you can deliver on remember we talked about some of the techniques of what we need to do in terms of our own progress our own growth that is under promise over deliver that's like a theme at NYU by the way, under promise over deliver because you never wanna over promise your patient what you can deliver on them and you don't wanna under promise because you don't want them to feel like they're always gonna suffer you wanna be realistic. But there are real realistic things that you can give and provide hope for your patients, so I want to tell you three stories we heard about good presentation about stories. I wanna tell you 3 stories. Story #1 and story #2 concern HIV. So I did my training in the 80s when HIV became a new disease. And I was early in my career in the early 90s, um I get a call from one of my infectious disease colleagues. And my colleague called me up and said I want you to put a peg a feeding tube in the in one of our end stage AIDS patients because there's a new clinical trial on something called a protease inhibitor called Crixovan. And we feel that this might actually make a difference so that that's great. The patient comes in literally a human skeleton weeks away from death, which were the only patients by the way, that could be enrolled in these trials, and I was even sure that he'd survived the PEG procedure. Peg went in, he did well and he left with obviously all the nutrition supplementation that was gonna be required while he gets this new medication. And then I didn't hear anything. We went by, few weeks went by, month goes by. Usually if a patient expires you hear about it but I didn't hear anything and in my mind back of my mind I thought maybe I should call the doctor but I didn't want to hear that this this uh patient had had died and that the the treatment was another failure in the world of trying to find out how to control this awful disease. And then I get a call about 3 months later from the infectious disease doctor. He said, Mark, can you take out the peg? And I'm thinking to myself, we don't usually take it out, you know, just take it out yourself. The coroner takes it out. I mean, why, why does he want me? I, no, no, no, no. Pati's alive, he says, Mark, you're not gonna believe what you're about to see. And sure enough, now when you remove a peg it's just the office it it's in your in your exam room you don't have to do an endoscopy or anything in walks this handsome patient I didn't recognize he put on 35 pounds. Comes in robust, he looks healthy, and I remember saying to myself, this is a miracle, this is a miracle of modern medicine. So can you hope for miracles? Yes, can't promise miracles we can't perform miracles, but I think we can hope for miracles and I think sometimes the clinical trial can lead to a miracle. The next time I saw this patient after I removed this peg was 10 years later for a screening colonoscopy. The next time I saw this patient 10 years later for a second screening colonoscopy and I just saw him a few weeks ago because he referred his friend to have a colonoscopy and we talked about it and I said did you think you were gonna die? He said it wasn't a thought it was just we were just waiting for it and we were talking about how this was just a miracle of a new medical intervention. That literally not only saved his life but changed the whole face of how we treated patients with HIV and AIDS. Now let's face it, it's still a chronic disease. We haven't cured HIV, but we can get their viral loads to zero. We don't really think twice about it anymore, so we've seen miracles in our lifetime. Look at hepatitis C. Bob Montgomery. Got an organ transplant with hepatitis C when I was training and I see some of my, my, uh, fellows I trained with when we were training hepatitis C didn't even have a name. It wasn't A, it wasn't B, so we called it non A non B hepatitis. How many of you remember non A non-B hepatitis? Thank you. Then it got a name and then it got horrible treatment we used to give monotherapy of interferon make patients so incredibly sick and now we can get an organ with hepatitis C and just knock it out, no, no problem, save a man's life. Miracles in medicine do occur. I don't think we should take that hope away from patients. We shouldn't take that hope away from ourselves. The next story also about HIV, but it's not about having hope or seeing miracles about losing hope. So now I'm a resident. I'm on the aid service at Cornell, which I did where I did my residency just up the block and um. I'm admitting my 9th AIDS patient. Everyone was sicker than the previous one. They were young, they were in the prime of their life and they were dying such horrific deaths with horrible skin infections horrible systemic infections, and we really didn't know what to do to treat them we pump medication and antibiotics, but we knew that there was really nothing that we could do to change the outcome. And my, I remember 8 patients. There was no caps in those days there was no like someone coming in at night or sleeping. He just stayed all night as many that came in. And my 9th patient came in and I put my head down. On the desk and it was 2 in the morning. I'm the only one. I I can't do it anymore. I, I don't, I don't know how I can do it. I can't there's no hope here. How could I possibly do anything for this patient? And I remember putting my head down, looking up and you know how sometimes you just stare and there's a bulletin board there and on it was a newspaper clipping with a little thumb pack in it from Ann Landers. How many remember Ann Landers? Ann Landers and Dear Abby were sisters and they used to have an advice column. You'd write in a question, they'd write a response, and it was highlighted. So I'm just reading it, dear and Landers. Can you please tell me that story again when you're feeling hopeless about making a difference? It has something to do with a little girl and a starfish. So. How many of you know about the story with the little girl and the starfish? Few of you great because now I can teach the rest of you changed my life this this little clip changed my life when I was feeling probably the most hopeless I've ever felt as a resident. The story goes like this big storm comes by and washes up all the starfish on the seashore. There are thousands of them, maybe 10s of thousands of them. All as far as the eye goes, you could see starfish. And there's a little girl throwing starfish back in the sea. An old man comes up to her and says, little girl, what are you doing? There are thousands, tens of hundreds of thousands of starfish along the seashore. What difference can you possibly make throwing these starfish back in the water? It goes as far as the eye can see. And the little girl picks up the starfish, says it makes a difference to this one. Throws it in And I read that, I still get teary eyed thinking about it. I read that and I said, you know what? Yes. I can't cure this patient, but maybe I can make a difference. Patient at a time can make a difference. I think about that when we see things that are so I mean we see things that are so awful, so unfair, so hopeless that if we can make a difference. It does actually change the world. It helps the person it helps the family helps anybody attach one act of good deed, one act of kindness has a ripple effect that literally changes the world. I really do believe that and I think when we're part of something that's bigger than ourselves, part of a profession that is really geared to helping people when they're so vulnerable, we are all making such a big difference so we tend to forget that we tend to burn out we tend to get hopeless. But when we realized that we have seen miracles in medicine like what I told you with the first AIDS patient and even though I couldn't actually do anything for the patient that I felt was my 9th patient, I can do something being present, I'm here we're gonna do everything we can to help you and maybe there will be a miracle like the other patient down the road. So those are my two stories about hope. My third story actually has a little bit of a different twist. I'm um attending now in fact the next day I was supposed to give a talk on Hope which is very interesting. And a patient of mine comes in who is newly diagnosed with what looked like liver masses and a pancreatic mass, not we don't have the diagnosis we don't have tissue. He's in his, um, late 40s or early 50s, and, um, he gets hospitalized to have a liver biopsy percutaneously of one of these lesions. We decided to biopsy of the liver rather than the pancreas because we thought it was gonna be metastatic pancreatic cancer. And unfortunately the biopsy comes back as metastatic pancreatic cancer and I'm the one who has to give him the news so I sit down with him uh at his hospital bed. And I tell him that look um this is not a good diagnosis is a tough situation we're in. We will try with chemotherapy and let's just take this as a series of hurdles which is usually the way I break bad news, a series of steps we've actually seen a few lectures where we wanna take things one step at a time because when you look at things in big picture it's overwhelming people can deal with steps and hurdles are basically what we have to get through and you jump over one hurdle and the next and the next till you get to a finish line. And sometimes one hurdle leads to a different path than you thought you would have to go so let's just, let's just start let's start the chemotherapy let's see how you respond and let's talk again. How long do I have to live, doc? he asked. I said I actually don't know the answer to that. It could be weeks, months, maybe years, maybe 2 months from now we'll have a treatment that we don't currently have. Maybe there's a clinical trial. OK, I, I, I'll I'll start. I'll start with the chemotherapy great he actually left not quite with a smile but feeling like there was hope. I get a call probably about 6 o'clock, maybe 7 o'clock that night from the patient actually I get a page or all beepers patient needs to urgently speak to you. Though something happened not feeling well. What what happened? Complication of the biopsy. No, he says, doctor. I respect you greatly so don't take this the wrong way, but why would you lie to me? I said how did I lie to you? I said, Well, the hospitalist came in and told me the real truth that I have 2 months to live, maybe 3 months at top, and that I should get my things in order. Why would you tell me I could have months, maybe even year or years I think you said to me. I said, you know what? I'm coming over and this is not a conversation I'm on the telephone, so I come back. I actually lived across the street from the hospital in those days. It's very convenient. I go back in, I sit down. I said, Look, you might only have 2 or 3 months. I'm not saying that that's not a possible outcome, but I don't know what the future holds, and I know that if I have a term paper due 3 months from now, a night before 3 months from now, I'll be working on it. That when you put your mind on a certain time frame things usually fit that time frame and if you convince yourself that you're gonna die in 3 months, that may be what you have. But I don't want you to think that way. I want you to think that maybe there's something in the future maybe you respond and if you don't respond we could have the same conversation we're having now and maybe talk about palliative care. He felt a lot better about it and the next day I gave that talk. I was really angry about it, um. Anyway, now I know because this happened over 10 years ago, so now I know what the outcome of the patient was. He lived 2.5 years. He was an attorney. He responded remarkably to the medication and actually the, the, uh, metastatic lesions shrunk. I mean it really was an incredible response that he went back to work for I think almost 2 years he went back to work and had a really good 2 years. Then he had a really lousy few months before he passed away, but he's put in palliative care and he and I talked about this. And he said that he was so appreciative that he was given at least some hope recognizing that he did have a good outcome and I got lucky in a way that he did but you don't know when you start out and there's absolutely no reason even in the worst of scenarios to take hope away from people who are even in the worst of situation because I really really do believe there's always hope it's just what is it that we're hoping for. So I'm gonna wrap up by saying that we come together here you're all here because you wanna be better at what you do and by all of us in our profession collectively doing better we actually not only help our patients we help their families and the ripple effect of what good health means. On my Instagram account, I mean my Twitter account. My, uh, pin tweet is that a healthy person has 1000 wishes. A sick person has only one wish to be healthy. And we are entrusted in truly the most important possession that anybody has their own health. When we take away hope about what the future of that health is, I think, I think we take away everything. And my hope is that all of us collectively can do better and teach these type of skills of professional development of leadership development so that as physicians as healers we embrace kind of the human aspect. And the nonhuman aspect to accentuate what we do best which is really being present, holding a hand and giving patients hope and working together collaboratively to move the profession forward so the next generation can do even better thank you very much. So now we are, we are finished, um, instead of having QA we uh actually finished a little earlier um whoever is left from, uh, either speakers and all of you, we have a little reception outside, we can get a glass of wine, we can chat we'd love to get feedback we're gonna send you guys um forms that you can help us do better what you wanna see when we do this again. But given how many people stayed, honestly, I really appreciate that um you're also committed on a Saturday uh it it really gives a lot of hope that together we really can do better so thanks. Published February 3, 2024 Created by Related Presenters Mark Pochapin, MD View full profile
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