you you you you you you you you you you you you you you you you you you you considerations around palliative care. I do want to note that Paul's family has partnered again with the sports hub boss in 98.5 who holds the, who's your caddy classic golf tournament in honor of Paul's memory to be able to sport this educational opportunity. And this family through their dedication to disseminating Paul's message has raised over $150,000 to support our, our being together this morning. So I won't take up too much time of our guest speaker's lecture today because he has amazing things to teach us. It is great pleasure and many, many here to know Dr. Michael Landsberg otherwise known as Mike. And he, he didn't want me to say too much. So I won't tell you that he was the founding director of the Boston Adult Condental Heart Disease Program and the Pulmonary Height Protection Service at Boston Children's and Brigham and Women's. And really, and as an associate professor of medicine at Harvard Medical School, and I would say that his career has been to contribute to our, our greatly improved care of these young adults and now older adults who are living longer and longer due to the innovations that might contribute to their care. And I'll just also note that he took a step back now later in his career to think about palliative care and then decided to dive into a hospice and palliative medicine fellowship for a year. And so he spent a year as my fellow. And many other people's fellows, but I would say that the learning was entirely mutual. What we learned from Mike was, I hope, equivalent to what he learned from us. But so without any further delay, I give you Dr. Michael Landsberg. You haven't heard it yet. You don't know what it's going to be good. Brissley, a huge shout out and thank you to you all for allowing me to be here with you. Probably never before in our time in medicine in this space has the meaning of what we do and so threatened by everything that's happening in medicine, the kind of things that are asked of us. And yet at the same time, it's a hospital like this, this extensions through the real and very virtual bridges that we have that are attached to us and are close by in our distance that allows us to to innovate and to go beyond the very sum of all the component parts of who we are and give us that meaning. This has been an incredible wave to ride from me over the past number of decades with you all. I appreciate it. There are a few honors. Look, I'm an adult interventional cardiologist that I'm here at Grand Rounds for surgery and anesthesia on a bulk continue lecture. And what greater honor is it to transcend the ages, transcend hospitals to be allowed to join. I would never correct you to not go backwards, but rather to sidestep and to the honor of being house death again. What an incredible ride that was for me, how nervous I was in the process. Let me share with you a little bit. I'm going to begin with a question. I'll have a bunch of stories and hopefully we'll find some meaning together. Elena, I thank you. I thank your extended family for this opportunity. It's a huge meaning for me. We happen to be colleagues. And I learn from you. And I'm sure from your family every day. Thank you. I want to examine your world. Maybe in your world, all of your patients have sculpted bodies. They are perfectly fit. Have the leanest, most appropriate BMI. Maybe in your world when you talk to your patients, when you make recommendations, whether it be for that upcoming surgery or for that particular in my world of medicine, for a particular medication or the like, maybe every time that you make that recommendation patient to hear, rather than putting the medicine perhaps in the trash. Maybe in your world every time you talk about physical therapy after a procedure or physical fitness to have that person sort of come of age inside themselves, they do that. Maybe in your world. After every procedure that has been designed to affect some outcome, every one of your patients has that glorious outcome, drops what they're doing and shouts out, I am healed. Maybe that's your world. I don't know, in my world, it's a little bit different. This is one of our typical patients that I will share with you. We'll talk about a couple of patients and a couple of scenarios. This is not a lecture about pulmonary hypertension. It's not a discussion about that. This is a person who is a disinstitution who had a whole closed in their heart two decades later developed a devastating disease of pulmonary hypertension. This is an echo not important. What's there, it demonstrates the features of someone whose heart is failing and aching and at the time all we had to take this person who began to feel more abund was a continuous pump that attached to an indwelling catheter that was the equivalent of chemotherapy every second of every day. We transmitted a medication that went into this person's body, least so we will call her. This allowed her to transform from being bedbound to having life again, not a class one necessarily asymptomatic but pretty darn close. She had a life over a couple of decades that had true meaning, true value, and was able to do things. That's the stage that we set with me. Then something happens. Two decades into this line, into the right, into this life together, Lisa presents like this. Fairly typical Bach patients with drawn shades are on, fists is out there in a rage. If you look at a right arm tattoo on the arm, those are our patients. All right, they have their narrative. These bedbound, I have to tell you, not a story of pulmonary hypertension, but we have no idea. We do the workup, we try to figure out what's going on with Lisa, we don't know what's going on. We're facing impending doom and demise and end of life. We think about the heroics as you do, lung transplantation, heart lung transplantation. In this region, we know it doesn't happen overnight. We've got to figure out a way to prevent this inexorable decline to multi-system failure, not to talk about pulmonary hypertension. We go ahead and we do, this is a catheterization. We poke a hole, we allow some unloading of heart structures to go on. We do something heroic. How's that? You all do every day. We do something heroic, expecting an outcome. Nothing happens. And she continues on the slide. A couple of days into it, I say down on the bedside as you all do. And I say, Lisa, how you doing? And she says, I think I need to tell you something. Not sure where this conversation is heading. I say, look, it's not a confessional Lisa, you don't need to. She's not I need to tell you something. And she looks at me and she says this, what? 20 years. I tried so hard to, but I missed. I have to tell you, I hear this and I begin to assume. I tried so hard, but I missed it. I tried so hard, but I missed it. I said, I tried so hard to have a life that was filled with meaning, but I missed. I tried so hard to do all the things you told me, but I missed. I'm putting it together. And then I say, well, back off. Curiosity. And so I say what palliative care doctors and you all do, as Lisa, to tell me more. She goes, glad you asked. She goes a week before presentation to this hospital. That son of a husband of mine. I knew he was coming home late and later and later and later from work. But the realization that our lives together was coming to an end that he was cheating on me. He was seeing somebody else became real. But because that wasn't it. That wasn't it. A day before presentation, I go to the ATM. You may remember what an ATM is. You go to the ATM. I go to pull out some money. I go to check on some accounts and I see zero, zero, zero, zero, zero in every one of our accounts. That son of a bitch and she uses a different word at that point. Was gambling and everything about our future, our college educations for our kids, everything about the dreams and hopes and aspirations that we had had was gone. Was gone. And I thought to myself, she said, there goes just there it goes. And so quote, as she put it, as the beautiful wife. She comes home from work that day. He expects dinner on the table. I put dinner on the table and as he begins to eat, I go back into the kitchen. And as I go back into the kitchen, I grab the butcher knife and I come back into the room and you know what? I was going to kill him and I tried so hard. And I missed. Now that discussion was interesting because I don't know that it was just the number of days after the actual sub-tostomy. I don't know what it was, but it was that unloading and that unpacking four days after that patient turns around. This is a nice good ending story to it. And somehow things get better. No surprise to any of you. Other non-cardiovascular, non-medical occurrences, influence and shape our patients' lives and the diseases that we think by our tools that we're the only influence for. But this is not unknown to you. We specialize in that upper left hand quadrant of the physical. We get very into what we can do in the operating room, peri-operatively in the ICU's, how we can manage our patients. And we're very good at it. For cardiology, these are the symptoms that we work on and we try to master. You know what? There's a ton that goes along with those increasing symptoms over a lifetime. You're used to the apprehension, the grief, the fear, the anxiety, the loss, the pleasure, the change of cognitive function that comes with disease. And the changes in our roles in society and the many, many questions and uncertainties about who we are, what our meaning is, our faith, and what happens after. And it translates out into some total bulk of what we call suffering. No surprise. Oh, I forgot to tell you. You saw the tattoo. It's part of the title of the tattoo that this patient was had on her arms. Her narrative. I love this. It's part of Dave Matthew's song. I do like Dave Matthew's. And what was on her arm was an paraphrase. It had to disface between the tears we cry is where we find the laughter that keeps us coming back for more. And that's what I want to explore in this next half hour together, something about that timing in terms of how do we broach that space? How do we get into that space that holds the meaning, the narrative for our patients so that we can unpack that portion, not just that left up or quadrant, but the rest of what goes on in terms of the suffering and the inability for our patients. Lessons from the science and the practice of empathy. Yeah, recent fellow palliative care. I'm blessed. We're going to look at a topic called relationalism. We're going to look at certain components, what we call empathy and contrast that with sympathy, compassion and look at ourselves a bit. Let me tell you about another patient, a very real patient that came through the pack you here, came through the preoperative assessment here at this institution, came through your surgical hands. Yeah. Some of the surgeons here were involved with the patient, may bring back some memories to those of you in anesthesia as well. I'm sitting upstairs on the third, second floor in cardiology. I get a phone call from the wonderful preoperative assessment area saying, hey, Mike, get your ear in down here. Your patient is refusing surgery. Refusing surgery. Tell me more. And the wonderful anesthesiologist on the end says, I don't get it. The patient's refusing anesthesia. It'll really. Turns out this is a mid-30s year old. You know this person. I'm not going to tell you the name of this person. The identity of this is a major successful CEO of a couple of really big companies that influence your lives every day. Married couple of kids. Two prior congenital heart disease operations goes in for his third congenital heart disease operation. No stranger to this rodeo. In decades since his last surgery, I go to refuse anesthesia. They just say, come on down. And I come down and I see him. Let's call him Paul. His name is not Paul. I say Paul. How you doing? He goes, I'm not going to have it. And I say, I'm not going to have it. What do you mean? Because they want to give me opioids. And I'm not. I'm not going to be doing this. I'm not having the pain relief as they discuss. And instead of just sort of putting up the barriers, I become curious with him. I say, you know, it's interesting. Can you share with me? He says, well, you know, the world doesn't know this. My private life has been my private life. I've shielded in most of the world of who I am and what goes on. Because my last surgery, I was like seven. I don't remember it a lot. I just remember the big picture of it. Because there's a lot of time in space that's gone on since there. Because when we were teenagers, my brothers and I found my dad hanging from the rafters. He had committed suicide. That was a big deal for us. It was a huge deal for us. Left one of my brothers completely scarred. And he died of an overdose. I live with that every day. He goes, my other brother, he's in prison. My other brother is in prison. He sold. His life was affected as well. I don't know if I see him. It's just the striking dichotomy that must be clear to you all. Brother's suffering, father's suffering, patient, major CEO of a big company, multiple companies. As I said to you before, you guys know him. You would never have contemplated this. And I just look into him and I realize he's refusing surgery. We've got to get to a goal here. Somehow we're a greater understanding and I just say to him, explain to me. I see so much that is rich and successful in your life. Where do you find your strength to do all this? And I have to tell you, I had not done this with him preoperatively. What he does is he takes off a shirt. And they're emblazoned on his body. This is not a story about tattoos. But they're on his body. This is no small tattoo. This is the poem Invictus that you know from Nelson Mandela being in prison reciting this poem every day. I will take a minute. We will share the poem together if you will. I need to put it on the chaders for it. No, I don't. The poem reads what, out of the night that covers me, black is the pit from pole to pole. I think whatever gods may be from my unconcrable soul. The fill clutch of circumstance I have not wints, nor cried aloud. Under the bludgeoning of chance my head is bloody, but unbout. Beyond this place of wrath and tears lies by the horror of the shade of death. And yet the menace of the years, slyans and shelf-fine me, unafraid. It matters not how straight the gates, how charged with punishments this girl, I am the master of my fate. I am the captain of my soul. Their scar on this. There's a lot about control in this. Let's really look together and we look to preserve control. And yes, my honest, these are incredible colleagues that spoke to him about control and PCA and the ability to have control over on this the Azure. And I didn't question, we didn't go back. I guess if you want more control, he said, oh yes. You guys have an amazing job. He had a successful surgery. He's successful still out there. But the narrative lies deep and people need for us to hear their stories. Many of us in this room have spent decades in the lives of our patients. This is a little awkward one. 1970s, I'm a young to mid teenager. And I read a book that was written in 1970 by Erica Jean. People remember Erica Jean, fewer flying. Anyone remember that book, raised nods, I see nods. It was an apocalyptic, if you will. It was a radically transformative cultural book. In some ways, heightened the height of feminism. In many ways, it was the culture of our times and the changes that were going on. And for me, it epitomizes the difference between what I did for 30 years before last year and what I tried to do in fact during fellowship. Over the years and decades before, I spent a lifetime getting into the heads and the lives of my patients, deep dives over a lifetime, becoming part of their families, as you in many ways do. And last year was a trial and an understanding of what it's like to take that incredible, immediate deep dive and get out as soon as we can to let people do the incredible, necessary work that they need to while they're suffering at the greatest frequently at the ends of their lives. The story of, here, flying the first chapter has a bizarre title that I'm a little embarrassed to share with you. It is called the ziplest four-letter word that stands for fornication. And the chapter is about two people that meet on a train. They don't know each other. They know nothing about each other. They are young, mid years. They get on a train to the only people in that train compartment. And the train enters a tunnel. And in the time. They have a complete understanding of each other. They have sensed each other. They have been therapeutic to each other. And they walk away without commitment. But having done something incredible and experienced something incredible. The deepest of dives and being able to walk away. That aspect of having a relationship, being able to accomplish in that short period of time, what happened to that patient of mine in the seven or four minutes that we had in the preoperative assessment unit to be able to get into that person's head, understand and help transform, be therapeutic, and then back out and give him his space again. But I thought we'd take 30 years that we can do in a shorter period of time with something that will explore a little bit. We're going to talk about relationalism for a second. Sociologic beginnings. Those of us that remember the beginnings of humankind and studying that when we were in school and grade school, high school, college. Remember that civilization began in many places, one of which was where that white bar is, Lake Victoria, Tanzania, the old divide gorge. I remember this as a kid loving archaeology and geology and the history of mankind. Move south a little bit to where I've circled South Africa, the beginnings of early language. When people greet each other, it's not like my normal New York city speaker, hey, how you doing? How are you nice to see you? If you go to South Africa, early language, Zulu language, people would greet each other with this word, Savona. Savona, which means I see you. I don't just say hello to you. I see you. I understand. I try to understand and get into your head. I recognize you for who you are. That's the greeting. The reply back, interesting. Silent and hidden and gikolna, which means because you have seen me, I now become. I exist. There is a duality of us meeting each other, trying to quickly understand and see each other. And we define a relationship together. Sociologic underpinings of relationalism. Spiritual. My middle name is awkward. My middle name is Job. Parents have a screen to them in terms of that definition. I wanted Bruce. Does any of you know this biblical story of Job? I'm going to give you a landsburg version for a couple of minutes. Job is a story that people think of. The quote is the suffering of Job. In many ways, it's the relationalism of Job, his creator, to the unknown. Job is a man. You see here a man with a partner in his life. The kid's tremendous feels, tremendous sheep. Job has done well in life. And in the book, as it is said, there is a hierarchy. The creator is there. Creator looks down to the earth. He's his man, Job, and talks to his right hand man. Creators, right hand man, Satan, right below him. And they're talking. They say, look down at my man, Job. He's a good guy. He is. He must love me. He really loves me. And Satan looks back and says, Job doesn't really love you. Job loves you because you give him things. He doesn't love you for yourself. You give him all these wonderful sheep and grass and family. And he's happy. It's sort of a reward and love based upon your reward. And the creator says, now you're wrong. You've got a totally wrong job. The guy down there loves me for me. Like the son loves me for me. And then Satan says, let's see. Let's have a little wager on this one. It's an awkward part of what we call this monotheistic Bible. God takes on a bitch. And let's Satan do his work. And what is his work? Satan says, let's start removing things. And takes Job's children, puts them into one room, one big room, all except one, and all these many kids. The house collapses, all of his kids die. One remains and runs up to Job. Let's know of the death of his kids. Job thinks himself, you know, I must have done something wrong. I must have done something wrong. I love you God. Love you God. Satan grits his teeth. Kills all of Job's cattle. Job says, I must have done something wrong. Love you God. Get rid of all his fields, burns his fields, takes one thing away at a time after time. Job says, in the world that I understand, I must have done something wrong. Love you God. It's a one thing. So the creator, second guy, Satan gives Job with the Bible says, terrible human suffering. The disease is that you all take care of. Job gets all. Job begins to think. He says, love you God. I didn't do anything. Let's be clear, I didn't do anything. I don't get it. In my view of the world, this doesn't make sense. The creator and the Bible are really interesting. It's not this loving, compassionate, warm feeling back and forth in the creator to his man. It's about relationalism. The creator looks back at his man, Job, and says, you don't get it? Let's be clear. I don't live in your head. Not the way you think I do. Were you there with me when I'm sorry, we created the cosmos together? I don't remember you there at my side when I did it. I don't remember you there when I separated the waters from the firmament. I don't remember you there with me helping me out when I created the fish, the mammals, the reptiles. I'm sorry, you expect to know. You aren't in my head. I'm sorry, you don't know me. You don't know the work I do. You should understand what's going on with you. Job has this epiphany. Job has this sudden recognition that to try to understand what's going on with himself, he needs to have experienced what his creator has. He knows he can't do that. He replies to the creator, now my eyes, Savona. Now my eyes have seen you. I'm going to reply from the creator back as Kekona. Now you can exist again. Suddenly in the magical ways of the Bible, in these magical ways, Job has a new family created, new sheep better sheep than he had before. Better feels than he had before. Job exists again and happiness exists. You can see a suffering or you can see it as understanding and relationalism. Social underpinings of relationalism, spiritual underpinings, philosophical underpinings of relationalism. I know this is not about anesthesia. I know this is not about surgery. It's coming back there. A bunch of years ago, we had a fellow here that some of you knew by the name of Yoni Boober. Dr. Boober was amazing with us. He was the great nephew of the quite famous German philosopher Martin Boober, not of our immediate times, but within a couple of generations of us. Martin Boober is known for a philosophy that I am vowed to do. This is his greatest of works. Martin Boober is a truce of understanding. We're going to do Martin Boober in five minutes or less than five minutes. People studied Plato in their early years in college. Plato's big thing was the story to us, the way of understanding that everything on this earth is the reality. And then there's the concept of Plato called it the forms. When you wanted to understand a chair, you conceptualized something that could support you. It didn't have a definite shape or size. Maybe it did, but there was the real chairs that were out there. And then there were the forms, the concept of a chair. Boober took that idea of concept and turned it into relationalism. Boober said, look, everything that's in nature, everything that relates to people, everything that relates to our deity, has to do with both the concept of that person and the reality of that person, the concept of the deity, the reality of the deity. And all of our relationships, we can't separate the two. When I speak to Paul the front, when I speak to Stephen the front, I may be talking about a specific issue that happens. But I do it in the context of my understanding of the totality of who they are and what they've been in my life and what they can be to you all. These relations of the eye to the it, the very practical, the eye to the vow, the concept are slightly different. We need to recognize that if we're going to take deep dives with our patients. The eye to the it, the very practical, I relate to somebody. Let's go to the pre-surgical interview. I need to get a job done. Patient comes in, family comes in, I need to speak to them up front. I have a very bounded task to do. I'm going to go back to their past, my past to try to understand and get a job done. In many ways, I'm manipulating, they're manipulating me. I'm trying to change things so that we can have an occurrence happen, aligned with the way that we want to see that occurrence happen. It's very time-dependent space-dependent and it's never with my entirety. I get the job done. The eye to the vow is bigger. It's not to one particular person and specific place. I need to understand the entirety of that event. It's not bounded. It's very much understanding the past and in particular everything that's going on in the very present, my ego, my role, that's not important. It's trying to understand as a place for me and for the system and for you to grow, as always with your entirety. These relationships that we have are a combination of both that, very specific, that we need to get done, that task, and the entirety of who that person and who those people are. It's a definition of how we relate and how we have meaning to each other. That concept from Boomer mid-1800s, at the same time the art world in the mid-1800s developed a field called aesthetics. I grew out of here, New England. The history exists here in Maine. This is a painting that for a time hungered the Museum of Fine Arts. This particular artist came up with the term aesthetics and when she applied it she said, look, when I make a beautiful chair, I don't want you to just see the chair, I want you to have a sense of experiencing the chair being part of the entirety of this chair. That concept in art was translated out into medicine and into relationalism by a particular philosopher, who coined the term, I'm feeling, in feeling one feeling, which we have come to term empathy. The definition, the power of projecting one's own personality, and in so fully comprehending the object of contemplation. A theory mid-1800s. The theory becomes reality when most of you don't know readers' digest. I'm sorry, I come from a vintage. Readers' digest was the internet before the internet existed. You got all of your information. One very small, contained condensed collection of periodicals. And in the mid-1950s, readers' digest writes an article called, what is it? How's your empathy? World didn't know the term. Empathy suddenly enters the human lexicon. We begin to use the term. And you see here, it's quite interesting. It wasn't part of Thomas Lips' definition. They say the ability to appreciate the other person's feelings were, without yourself becoming so emotionally involved that your judgment is affected. We're going to talk about a few components of empathy, and it may break it there so that we can reflect a little bit together. Empathy is three components. We'll talk a little science here. An affective and understanding component of the science. A cognitive component. A processing of understanding that sense of what someone's feeling. And a behavioral reply to that understanding and that process. Let's start with the affective, trying to feel what somebody's feeling. We do this by the term called modeling. It's basically a statement that we've come from observation. People are contagious. We are contagious to each other. What does that mean? I am not. I am not a neuroscientist. Forgive me. I slept through neurology at this wonderful HMS that exists here to not tell my past professors about that. My understanding of neuroanatomy is going to be simple and I'll share it with you kind of quickly. And it just gives us an idea of where these circuitries are that help us be empathic. Back some 265 million years we lived in the age of reptiles. Reptiles did not need a lot of empathy. They had a brain stem, a cerebellum, and allowed them to run, to move, to have basic functions and to survive. As a baby, look at the memory of life as life is like. What was it? It wasn't a high empathic time. And then from 265 million years to about 200 million years ago, the age of mammals. Mammals are different. Mammals are rare they're young. Mammals need to understand. And so we develop this limbic system, this singular gyros, which gives us the ability to have parental bondage, loyalty, affiliation, to nurture, to protect, to care. We jump from mammals to really just the last few million years, when we develop this humongous neocortex, the age of apes, monkeys, and humans. And we suddenly allow ourselves to process, to be smart, to have symbolic representation, logic, mathematics, physics, technology, invention, imagination, what goes on in this room every day, that's our neocortex. But we still have the other portions of our brain. Modeling, behaviors, contagious. Look, one of the more common behaviors you guys have been so kind, not to show this behavior during most of this discussion with me. But this can change your jumps. It jumps from old to young, it jumps from one gender to another gender, and beautifully it jumps from species to species. It just, it does. We're not going to look at that. It's definitely doesn't have sound, my apologies. When you see something like this, it's impossible. I'm watching your faces. It's impossible not to suddenly have your lips turn upward when you see that smile. Okay, it's in point. Look at this. I successfully forgot the voice. So much of our behavior turns out this was a 1960s movie, a James Bond, what we call Dr. No, it's called the Dr. No effect. One saw a tarantula crawling up James Bond's arm. Suddenly everybody in the audience was going like this. And they had that same sensation is what they saw on the screen. Why are we contagious? Studies done over the past 20 to 30 years. Brain imaging studies. We're going to talk about some basic stuff. Not to remember, I want the concepts there with you about modeling. When we are touched, we put ourselves in the scanner, we look at cerebral blood flow, we have primary and secondary, sematic sensory areas in our neocardial. We sense things. The beauty is that not only when we are touched, if we watch someone being touched, the same areas light up, not to necessarily the same intensity, but we mirror the same events as if we were undergoing that sense. Same with emotions. When we experience the emotion or we feel the emotion, areas get lit up when pain occurs. When we watch pain occurring, when we feel pain, the same areas light up to a lesser extent when we feel what someone else is feeling. For example, I see some pictures, top pictures. Someone opening a door, cutting up a vegetable, a foot going near a door, a foot going near a car door. Nothing lights up in particular areas. But suddenly I transform those pictures to a hand, getting caught in the door, slicing your finger, things that you guys repair, thank you. Getting that foot caught in the door, getting that foot caught in the car door. Suddenly, areas light up in the interior, singular tires. One of those mimicry areas, those pain sensing areas, just experiencing what someone else might feel. Many of you who remember our recent present, who's statement, it was what? I feel your pain. I feel your pain. We do. We do feel other people's pain. We experience it. We run an internal model and the same areas get greater blood flow and light up just by trying to feel what someone else is feeling. Release. We're not. We don't have the sound my apologies. We experience when pain occurs. That was the scene where the ball hits them in the crotch. Everyone grabs their crotch. You and the audience tend to do the same thing. It's a mimicry because we feel what other people feel. It's interesting. These same sites, these same empathy sites. When we have degenerative diseases of our brain, we lose empathy. Top screen normal, bottom screen degenerative diseases. People study. They lose the empathic ability. Social paths. Lose those abilities to necessarily feel what other people feel. We have areas in the brain that model and mimic. We run internal models. How do we process? We process by saying, what does it feel like? Not only do I know what that feeling is, but what would it be like for that person if I were in that person's shoes to feel that feeling? Put yourself in that other person's position. Step outside of ourselves and look backwards. Turns out we have spots in our brain that do that for us. Self-location, other location. When someone's experiencing something, areas light up if we suddenly begin to think, what would it be like if I was that other person? Imagine with me person bookcase. Person goes behind the bookcase, travels very quickly. Bottom panel of the brain flow scheme. Certain areas light up. Not other areas. Suddenly person goes behind the bookcase, wingers for a while. Stays there for a while, then moves to the side. A brain suddenly begins to say, hmm, hmm. I wonder what that person is doing behind the bookcase. And why they're there? What are they seeing? And suddenly the same areas of imagining I was in somebody else's shoes begin to light up. An event occurs in a forest, the tree falls, nothing lights up. It suddenly take another event. Someone walks in front of you in a movie theater. It's not just an event. You begin to say to yourself, why did they move in front of me? What are they seeing? Then I'm not seeing. I wonder what it's like from their perspective. Same areas light up. As if that person was behind the bookshelf. It's not just about events, it's about emotions. Theory of mind. For those of us that did psychology, we've taken these tests. You look at somebody's face. You've done this. You're going to do this with me right now. You look at somebody's face from here to here and you say, hmm. I wonder what that emotion is. What is it like for that person to have this emotion? Look at this. We give you options. Is this person despondent? Shy. We're leaving excited. I'm not going to ask you the answer is despondent. But when we do that, we light up that same spot about what's it like to be in that other person's shoes. To understand what someone's feeling, to place into the context of being in that person's shoes, and then to act. The acting and what to do is trained. The behavioral response is a trained one. It's not automatic with us. And it was what all of last year was. For me, hopefully I had known some of this before, but it wouldn't practice. It was what palcare does and what you guys try to do every single day. It's trying to be curious and to remain curious. It's with different phrases that we have giving us greater depth of detail, more possibilities, simple phrases. That you all know and that use in your conversation. It is the same as what we do in our body posture to try to remain open and curious to have patients and families speak with us and feel comfortable with us. And it's a combination of different acronyms that we use that relate to sort of who we are, how we interact. When patients have a motion, we try to unpack that emotion. We stand in certain ways. We have both vocal and non vocal language that we use. And you can say Mike, this is all nice. This is wonderful touch. You feel how does this come down to practical. Turns out there are randomized control trials for putting this into place. And what happens in those trials is that, yes, patients like us better. That's kind of nice. Patients feel that we've spent more time with them. That's kind of nice and touchy. But for us in terms of the practical, patients to hear more. We work with them. We get on their level. We understand them. They do what we ask them to do much more. And that actually is what brings us meaning as clinicians. When our patients respond to what we suggest and when they feel the imperative to do because we align with their goals and their hopes, we feel better about coming in to work every day. No matter how hard it is, our lives feel better together. Knowing where to cut. That's the art of having some great hairs for giving me. No sound. Over the decades and over last year in particular. I've had this experience of the slow, incredible dive that you all have. This is the experience of last year for me. We can put that into practice in a skilled. And pathocache. This slide. Last slide that talks about. Empathy. Empathy is a trained skill allows you to both feel to process and to act. It allows us to keep diving out. We feel the patient's feel. We do something therapeutic in the process to learn what it is and is therapeutic. And then we learn how to get out. And not think that with us that's the simplest nature of things to get in and to be able to dive out. The other terms that we sometimes use in medicine and light sympathy to feel something sympathy doesn't come necessarily with action. It doesn't imply action. And so we feel and we keep it there and it noodles inside of us and it marinate there. We don't necessarily release by action. And this term compassion against feel we may want to do something but it doesn't mandate action. And so it's the action component which is one that we practice in our art's and decision art surgery every day. Action the behavioral components of sympathy. At the end of the day we went into medicine. We went into surgery. We went into anesthesia. We went into pediatrics for a reason. And so it was that relationalism that we have between ourselves and the families we take care of and the patients we take care of. And I dare say there is an art and a skill that each one of you develops. There is a bunch of basic technique that you learn. Skills that you're accounted for that you develop in the practice you become expert at. That's not what let's us come home every day and say this has been amazing and through all the paperwork through all the effort through all the power truck that we do through all the noting and charting that we do the villain that we do that gives us a sense of meaning. It's when we make change. When we have patients come back and say this was it this was exactly what I had intended for. At first screen about not my world not necessarily your world. More that we can get that patient jumping and saying I have found it to the greatest extent that I possibly can because of what you've done. That's what allows us to come home and say this has great meaning my day has been spectacular. From my lifetime here at children's hospital between children's and the brigam you've all allowed that to happen. I appreciate that. It's been a wonderful ride during that period of time it continues. I look forward to seeing how palliative care at this institution as a model which is not just about oncology but it's working with you through your patients with chronic medical and surgical diseases experience and align with the care that you give them and their hopes and their values. I'm extending that into my world of adult medicine and seeing how that translates as well. Elena I thank you and your family for the opportunity through Paul continuing through Paul and continuing through all of us. I have the ability to speak to my colleagues. I wish some of the music played for you. I'm sorry about that. I improvise a little bit at the end instead and thank you for the opportunity. Thank you all. Well, well, we have a lot to think about a lot to talk about and I'm sure Mike would welcome that opportunity. Any thoughts, reflections or questions that you'd like to share. I have a question. So you noted and had the opportunity to spend a year maybe changing from a type of approach to care that was a long term deep dive to something that allowed you to dive into relationships and then come out again. So you spent a year training in that way. What are your suggestions for folks who are not going to take that time to be able to train in that way? So star trek folks have watched star trek. And star trek is a character that's called the empath. And it's someone who has that natural ability that creator given ability that whatever planet they came from that they can feel everything that somebody else feels. Look, at the end of the day, we go back to these quadrants right there. We're not obliged. We are not obliged to own every quadrant. The winds question Dr. Wolff's question about how do we make this shallow dive. I don't know that each one of us needs to. I think we need to recognize that the leases of this world, the patient that came in for a surgery of this world that their needs are not necessarily fulfilled by the left upper quadrant. And that there are people in this is well, medicine is a team sport. We always say it, but the reality is is it is very much of a team sport in terms of our success. We have our colleagues who are great at what they do and when we invite them into our worlds to help us accomplish those goals life is so much better for us. When we feel that we are the ones that have to do everything that becomes really difficult. So Joanna, I think there are people that are naturally attracted to the space of being able to learn how to do that shallow dive when you need to do the shallow dive. Not shallow the deep dive. Thank you. But that quick deep dive. There are others of us that that's just not our gig. And if we accept it and say we tap on the shoulders of those folks that are in the far back there that are up front here in terms of healthcare or other aspects of medicine to help us achieve that goal. And not say that they're two disparate sciences. This is one total box that comes together in a beautiful fashion. I have to tell you and Craig, forgive me for pointing this out with you. I apologize. But as a fellow, I sat there in awe because I'm sorry and forgive me. I know that those of us, my daughter hated this when she came through these esteemed holes because there's the dad, there's the person. And I come to meet the incredible Dr. Lilahai who I come to know of because of tradition in surgery. And I sat there in awe as a fellow in the same conference room. And I expected to hear surgical this and surgical that. I hear this calm soothing voice with a patient and family where the family is just so threatened by the outcome of what's going to come there. And the ability to get into their head and Craig, forgive me, but it transformed me when I saw you in this practice in terms of understanding who they were. It was two minutes. It wasn't an hour. It was two minutes of what you did in terms of having that family feel comfortable knowing that you understood them and you understood what they wanted to see for their child. And it made a huge difference. It can be done by those people that have that talent. It doesn't mean you're better or worse than someone else. But to know when to use that and to know that you have that art and there are courses out here for those of us that want to learn more, we certainly can expand those horizons. Joanne, thank you for letting me expand. I'm catching you very close to the end of your day. Thank you very much for letting me be here with you guys. Have a wonderful day today. Thank you.
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