Dr. Shoshana Ungerleider is a Hospitalist turned evangelist for Palliative Care. Learn what you can be doing now to help patients in their most critical times, no matter what field of medicine you're getting into.
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Last week, I was at the Podcast Movement where I was nominated for the Academy of Podcasters Award for Best Science and Medicine podcast. And for the third year in a row, I came up short. Nevertheless, it was a blast!
Today, I have an amazing conversation with Shoshana who does her very best to change the conversation around dying. She funded Extremis, a short documentary about end of life decisions being made in an intensive care unit. It has been nominated for an Academy Award and others. Now, she's pointing her efforts towards End Well, a symposium to bring together all the best minds in the world, not only in healthcare, but also in the community and technology space – anybody that wants to help change the end of life decisions and care going on in this world. The event is taking place on December 7, 2017 in San Francisco.
[02:40] Her Interest in Becoming a Physician
Taking the nontraditional route, Shoshana realized she wanted to become a doctor way after college. Her undergrad studies ran the gamut from Fine Arts to Women Studies, Spanish, and Marine Conservation Biology. At the very end of college, she thought she would be pursuing a Doctorate in Marine Science. But she quickly realized it wasn't enough for her. She wanted to work with humans, not creatures who can't talk back to her. Not knowing what her next steps would be, she took a job all the way across the country in North Carolina. She had opportunity to work at a medical center. Three months into the process of being an intern at the medical center, she realized she wanted to go to medical school.
At 23, she found herself back in college doing undergrad courses at UNC Chapel Hill. She completed the coursework the following year and took the MCAT. It wasn't until she was 25 that she thought she had done all the work, taken the exam, applied and somebody wanted her.
There were times she thought of doing something else. She felt she had many years to continue to think about the right professional course for her. She was lucky to have great mentors that had come before her, who have also taken time off between college and medical school. It's changing now since most people take some time off or take the nontraditional route before starting medical education.
So it did cross her mind; but her biggest focus was where she's going to be happy and fulfilled in life. Despite that it took her four years off, she thought this was the right path for her. Additionally, the best advice she got was that if there's anything else you could see yourself really being happy and fulfilled in doing, do that.
Shoshana says that if you have a million interests and medicine is just one of the many and not the end all be all for you, don't go into medicine. Because there are so many factors that come along with it, such as time commitment and financial proponent. It's hard, especially for women, since you're spending seven years minimum to complete the training. That's a lot of time of your life to give up. It's worth it but she thinks you really have to be sure this is something you want to do.
For many people, having a family is something they see as a part of their future lives, if it isn't already. For women, especially, age 22-32 is prime time for people to be thinking about children and family, although it's not for everybody.
[08:25] Finding a Mentor and Asking Specific Questions
Shoshana explains there are so many points in her life where mentors played a big role. She had family friends and random connections that turned out to be wonderful mentors for her. This was when she was looking at whether medical school was the right path as well as in terms of applying and where to go. Then where to go for residency. So she had people already built into her life who were there.
Now, she stresses the widespread use of social media and the acceptance of connecting with individuals via Twitter or LinkedIn. Just send them a thoughtful note on LinkedIn. Say you're a premed and you're interested in medicine. Say you'd love to get their thoughts about XYZ. Or simply ask them a specific question hoping they'll see your message and write you back.
As a practicing physician, Shoshana has been able to connect with people she saw as complete role models whom she never thought she could reach out to. She just put herself out there. She says that if there are specific people that you want to connect with or whom you think could be helpful, reach out to them.
I want to stress what Shoshana said about asking a specific question. You have to ask the right questions to the right people. Or ask the right questions in the right places. A lot of students are going through this process and they just ask very general questions. And physicians won't respond to that. Do some home work to ask good questions to potential mentors or people you're reaching out to.
Shoshana adds that doctors and other professionals are incredibly busy. If you're writing this note to someone, know that they probably have 20 seconds or less to be reading the subject line. They're going to read the first few sentences of the message. And they're going to decide if they even want to keep reading. So be as thoughtful as you can and be prepared as you can when reaching out to somebody. Make sure you've done your research and what their background is. Your question should be something they could just easily pop on their iPhone or their computer.
[13:10] Challenges Being a Nontrad
The hardest part for Shoshana was getting through all those forms and writing those essays. This is not something unique to a nontraditional student, as everybody probably dreads the secondaries. She says there's nothing about being a nontrad that she struggled with specifically there. But it was more of an asset for her. In her interviews, she has had some life experiences so she could talk about things she had worked on, research she had done after college. She could give a clear sense of the time and effort she'd put in to make sure medicine was the right path for her which she did after college.
Mostly, she didn't enjoy medical school. She admits not being a great test taker. Where she trained, they had major exams every two weeks. And she found it really hard. She studied all the waking hours of everyday, worried about the exams. But one thing she did that really helped her was that she found herself so focused on grades. It was overwhelming. So she decided to stop checking her grades in medical school. Although she says this may not work for everyone, but this did work for her. She realized she had already achieved one goal by getting there. That was her ultimate goal – to get into medical school. The fact she made it, she just had to study and work hard in taking tests but being less focused on the actual grades. She couldn't really do more than what she was already doing, as she was working very, very hard. And that was already enough for her.
Moreover, in the clinical years in the third and fourth year for her, she loves being able to take care of patients. The second two years of training were much better for her. She found it well-suited her just being in the hospital and not so focused on the classroom.
[17:00] Choosing Which Schools to Apply To
Shoshana thinks a lot of medical schools now are radically changing their curricula or the way information is taught to either fewer years in the class or they are building in a research year potentially. They may also make the classroom material more case-based. So the context is built into what you're learning. And now with websites being readily available for all institutions, it would be much easier to research. And find out which schools are doing what kind of change around that.
For Shoshana, being a bad test taker as many students are too, she probably would have looked at places that had fewer months in the classroom. Or those that had more hands-on time either with research or getting a master's degree during medical school. Or where she can spend more time on the wards taking care of patients. That would have been a better fit for her.
That said, the institution where she trained has radically changed in the last five years in how they approach the undergraduate medical education, specifically the first two years in the classroom. Nevertheless, she believes there's a lot of variations still out there and it just takes some digging as to which schools have the right setup. It depends on what you're looking for.
[18:45] How Shoshana Would Have Created Medical Education
What Shoshana thinks should be changed in the current system is the inclusion of more case-based learning. It's helpful in the way that it helps students to remember material better because it's taught in an actual patient setting. She feels there is so much of medical school that she never used or has had to think about. And looking back, she feels it was a waste of time. And she believes a lot of people feel this way too. She also feels very strongly that medical schools need to teach a little bit on healthcare economics. She finished training with very little understanding of the healthcare system. People talk about it everyday and how it's a big issue.
And as a physician, Shoshana thinks you should be able to at least, hold a very high-level talk about it and think about it critically. Unless you've studied that in your undergrad years or are an avid reader of what's happening, it's pretty hard to fully understand that. We have such a convoluted, multi-faceted problem of healthcare. So it would have been very helpful to have some formal training and how to think about that.
Additionally, Shoshana says there are many opportunities outside of just a clinical physician taking care of patients for entrepreneurship in medicine. This is also something that is not taught. So she would probably add some components around healthcare economics and entrepreneurship. Make sure doctors are more involved in these conversations on a national level or policy level and industry. These are two areas she finds herself being very interested in now.
[21:50] Palliative Care: Does It Do Harm?
Shoshana defines palliative medicine as a fairly new medical subspecialty that focuses on quality of life for anyone facing serious illness. It can be used at any time during the course of that illness. It employs a team-based approach to caring for people. Palliative care is fantastic in that it employs a team-based approach to caring for people. Typical palliative care teams have a nurse, a social worker, maybe a chaplain, a physician, and sometimes, some other folks on the team. They work together in a much more interdisciplinary fashion than you might find in a healthcare setting. They talk about what matters most to patients who are facing life-limiting illness. And to make sure they're focused on the quality of life for as long as they have left. The field was born out of a need to bring humanity back to medicine.
Many people see palliative care as going against the Hippocratic Oath, specifically about doing no harm. They think that palliative care is sort of giving up, which does harm to patients. But in the last five or so years, palliative care has been much more widely accepted nationally. 90% of major hospitals in the country have palliative care available for patients. So things are changing; but Shoshana says we have a long way to go. What she was thought is that death is a treatment failure. Nobody wants to talk about failure. A physician's job is to cure people of their disease and you've made it. But there are times when cure is not an option. As much as we would love to see everybody well, it's not always possible. So there are times when we need to transition our focus to a comfort-based approach if people are having trouble with pain and other symptoms. Or it's about shifting our focus to quality of life.
For some people, if they know treatment is no longer working, there are other ways to support patients and families through serious illness. That can be many things like spiritual care or treatment for depression related to their illness. Sometimes it can be pain control or other symptom management. That's not to say that palliative care is only for people for whom care is not an option. Shoshana clarifies that it's really for anybody who's been diagnosed with a serious illness. But they just tend to focus a lot on people with terminal diagnoses.
In the U.S., we are so technologically advanced and Shoshana thinks the healthcare system approaches every patient thinking that we should do everything for everyone. But she says that's not always the case. That's why she found herself in palliative care because she was taking care of so many those patients. She got distressed when she realized nothing she's doing for the person is actually going to help them.
So Shoshana believes that when we talk about “doing no harm” in the Hippocratic Oath, she felt she was harming people in their last few moments or days of life. When they could have been focusing on things that mattered to them. That could be being pain-free or being with family or eating and drinking instead of having a tube down the mouth. Again, she thinks things are changing around the acceptance of palliative care but it's still a long way to go.
[27:35] Palliative Care versus Hospice
Shoshana explains that hospice is a part of palliative care. Palliative care is a long continuum. When used at its best, it's a long continuum of time that begins from the diagnosis of a serious illness all the way through until the end of life – death and even up to grief and bereavement.
Palliative care can be used for years and years. Hospice is somewhat arbitrarily relegated to the last six months of life – medicare, reimbursement, designation where patients have to be “reasonably” within the last six months of their life in order to be eligible for hospice services.
[29:15] Palliative Care Resources
In order to learn more about palliative care, Shoshana mentions several great resources such as Get Palliative Care. It contains a lot of videos and it's geared towards the general audience. It talks about what palliative care is and how it can best support people.
They also have a lecture series on UngerleiderFund.org where they host experts in palliative care to come in on a quarterly basis as they talk about various components. Also, understand that palliative care works the best when patients get an early referral. For instance, the patient has been diagnosed with late stage cancer or advanced heart disease or liver failure. There's a team that can work alongside the primary medical team to offer an extra layer of support for patients and families.
To Shoshana, it's a no-brainer. Who wouldn't want an extra layer of support from a team? This is what palliative care is all about. It's not about saying you're dying or things will be taken away from you.
[31:20] Talk About Cost and Insurance Coverage
Shoshana is not an expert on payer reimbursements. This is one area she loves to dive more deeply into. Often when patients are in the hospital and a palliative care team is called in to consult or see a patient and their family, that's covered by insurance. On the outpatient side, like in the clinic and the patient is able to drive to the doctor, this will be a slightly different reimbursement setup. But most insurance companies recognize that palliative care offers a huge value for patients not only financially, but it's just good care. Shoshana also thinks things are changing around payers being much more willing to cover these services even alongside curative treatments. So people can be undergoing chemotherapy or other expensive treatments and still benefit from palliative care.
[33:15] About The End Well Symposium
One thing Shoshana noticed is it's always the same people when she goes to these gatherings. So she would like to invite new people to this conversation. She welcomes folks outside of the realm of palliative care, like other specialties in medicine. Or more people from nursing or social work or even the spiritual care realm to get more involved in these high-level conversations.
Shoshana further shares that this is not a health care issue, but a human issue. How we live – and hopefully live well – until the very end is something that applies to all of us. So she founded this first-of-its-kind gathering called End Well. It takes place on December 7, 2017 in San Francisco. She hopes to being together the worlds of design, technology, policy, media, law, and patient advocacy – all with the goal of generating very inter-professional, human-centered innovation for the end of life experience. They're looking at how they can re-design systems and come up with new products, new services that transform the end of life experience into a much more human-centered experience.
So this is going to feel like a TED event. They will have 20 world-renowned thought leaders speaking. They will have a full day of engaging, short, highly-curated presentations. 400 attendees are expected to come from all over the world. They mirror the diversity of their speakers. It's open to the public. They'd love to have more medical students or people thinking of going to medicine. They're inviting anyone that cares about this issue as a human issue.
For more information, visit www.EndWellProject.org
[36:23] Painting a Picture of Palliative Care in the Curriculum
If Shoshana could design the perfect path for medical students and residents going through school, she would recommend palliative care to be a part of the curriculum as early as the first few years in the classroom of medical school. She would have wanted a place for more pharmacology and better understanding of medications we use around palliative care. In the third and four years where she was spending time on the wards.
It would have given her a much better foundation to think about how she can best take care of patients. For her, it wasn't until her first year of residency in internal medicine that she had any exposure to palliative care. That was her many months in the ICU taking care of very sick patients. They were not benefiting in any way from what they were doing in the ICU. Sadly, it's the default path for patients in this country. If you're sick and you need help no matter how old you are or sick you are, you will receive aggressive, invasive care even if it's not going to help you. So Shoshana felt this disconnect early on. It wasn't until she had a mentor in palliative care as a resident that she realized how amazing human-to-human conversations are with patients and families. She realized how powerful this is just as much as any procedure they do in medicine. It can be life-changing.
I think those interested in emergency medicine should listen to this whole interview a couple of times. I have a friend who won awards for helping people die. Her hospital recognized that she helps patients with their care through palliative care medicine as an ER doctor. I think this is a huge point of entry for palliative medicine if we can get these doctors to start having this conversation.
Shoshana adds this is very true for ER doctors and primary care doctors included. It's very important to take care about issues such as advanced care planning. It gets back to these core questions of – Who are you as a person? What are your goals and values for living your life? What is meaningful to you in your life? How do you share that with your family?
[42:30] Shoshana's Final Words of Wisdom
What Shoshana wishes to tell students who may also be going through the path she went through is that it's going to get better. Just push through if you can. Once you're done with medical school, that's the biggest hurdle. That was the hardest thing for her. Residency is more time-consuming and more fun. If you want to take care of patients, that's where you get to do it and really learn. After residency, the world is wide open. There are so many paths.
And for people who don't yet know what to do, the right path will present itself. Shoshana was one of those people who wasn't sure what she really wanted. And after her eight or ten weeks of internal medicine on her third year, she was sold. She never thought that would have been her path. So just be open to those opportunities and experiences.
Lastly, clinical medicine is not for everybody. If you find yourself not so interested in taking care of patients but you're in the middle of medical school, there are a million other routes you can go with your medical degree. There are industries all over the place looking for physicians to consult including pharmaceutical industry, biotech, etc. There are a ton of entrepreneur physicians out there especially in Silicon Valley.
[44:26] Shoshana on the Specialty Stories
Listen to my interview with Shoshana on the Specialty Stories episode 7 where she talked about being a hospitalist.
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