Join us for an extraordinary conversation about the intersection of compassion, innovation, and cancer care with Dr. Arif Kamal, oncologist and palliative care physician at Duke Health the first ever Chief Patient Officer at the American Cancer Society! Hosted by Nirvana Tari, Chief Patient Officer at CareYaya, and Neal K. Shah, CEO of CareYaya.
In this powerful episode, Dr. Kamal shares why he believes the most important payment coverage reform would be compensating family caregivers, reveals the privilege of witnessing bell ringing ceremonies at Hope Lodges (where cancer patients celebrate transitions with families who receive free overnight stays), and explains why the most helpful thing you can say to someone with cancer is not "I know what you're going through" but rather a tangible offer like "I'm picking up pizza Friday night, what do you want on yours?"
From his personal experience as a teenage caregiver when his mother had breast cancer in a town of fifteen thousand in Missouri to leading patient-centered innovation at a national scale, Dr. Kamal offers profound insights on why cancer has transformed from an episodic illness to a chronic condition in our lifetime (stage four colorectal cancer survival has more than doubled from two to five years), and why our support systems must evolve accordingly. Learn about the groundbreaking ACS Cares app that uses dating app technology to match newly diagnosed patients with peer navigators, provides zip code based solutions for social needs like food insecurity, and delivers tailored content recognizing that eighty percent of cancer outcomes are about the being, not just the biology.
Key insights include the hurricane analogy for advance care planning (preparing doesn't make the storm more likely to hit), why half of all cancers have modifiable risk factors we can act on today, the critical difference between transactional and relational healthcare interactions, why therapeutic presence matters more than problem solving when many of life's problems aren't solvable, and the powerful reminder that resilience is not a trait you either have or don't have but a skill you must intentionally build and maintain.
Brought to you by CareYaya, America's number one rated solution for in-home senior care, providing industry-leading quality care at the most affordable rates. CareYaya is known especially for delivering the most reliable and affordable overnight senior care and 24/7 care in many major metro areas including Atlanta, Boston, San Francisco, and Washington D.C.
This episode is essential for healthcare professionals seeking to balance clinical excellence with compassionate presence, family members caring for loved ones with serious illness who need permission to acknowledge that something can be both meaningful and hard simultaneously, pre-health students learning what it really means to be a healer beyond fixing problems, or anyone navigating the reality that someone they care about is living with cancer as a chronic condition rather than an acute crisis with a clear endpoint.
Episode Transcript:
All right, good morning and hello everybody. My name is Nirvana Tari and I'm here with The Care Plan. Today we have the one and only Dr. Arif Kamal with us and of course my wonderful co-host Neal Shah. Thanks so much for being here today. How are you? Yeah, such a pleasure. Great. I'm really excited about what we're going to talk about today. Super excited. This is actually our first in-person podcast. So I'm really, really stoked for this. A pretty cool first guest to have. Y'all already know the plan. We're going to go ahead and start with the lightning round. So tell me, Dr. Kamal, what's one thing you wish every doctor understood about patients? Well, I think about patients, you know, people are wrapped up in their own story, right? They have a story, their origins story, where their story goes through the course of serious illness, and obviously after serious illness. So I encourage every doctor I talked to about is understand someone's story, because then you'll understand their motivations, their strengths, their worries, and I think fundamentally, that's what as healers we need to do. I love it. That's a great answer. Great. And then another question, best piece of advice for talking to kids about serious illness? Yeah, don't underestimate how perceptive they are. I think for all of us who are parents or have been around little kids, kids perceive more than we might give them credit for. And so I would always over-index so that they probably know more about what's going on than you think. But to the issue of them understanding it at an age-appropriate level, that's where the work needs to be. Yeah, okay. I love that. Our biggest game changer or coolest thing in cancer care in the last five years? Yeah, so I take the concept of a cancer center. When we say center, I think largely it's been centered around the health system, the providers, and the organization. And so now the concept of centered or centered cancer care is going to be centered around a person. And what I mean by that is in their home or the place that they call home. It would have been unimaginable a couple years ago to think that ten, fifteen, even twenty percent of cancer care could be delivered in the home. We're absolutely seeing that now. That'll grow over the next five years. I love it. That's awesome. That's surprising. Okay. And then on that thread, one policy change that would transform healthcare overnight. Um, coverage, healthcare coverage, payment coverage for caregivers. Wow. That's a big one. Well, you know, it's the silent majority of people who are providing all this care, universal care across the board. And we already have a health care workforce shortage, as you guys know. And so this issue of, like, why are we not recognizing the valuable work that happens? And I think that's a pretty straightforward policy change we can't get behind. Great. Great. That's a really good one. That's going to be the tagline, honestly. Yeah, for real. So what about one helpful thing you can say to someone with cancer? I feel like this is something that a lot of people can struggle with. Well, I know what not to say is something like, I know what you're going through, or my uncle had cancer too, or all things happen for a reason. Oh, man. That's a terrible one. Yeah, yeah, because we don't know what that reason is. And two, I think there's a way to be... empathic without demonstrating that you know it all or you've been through the experience or something. And so I think curiosity is helpful in that sense. And I think lastly, I would say provide tangible offers for help. So don't just say like, hey, is there anything I can do to help you out? What you say is, hey, I'm going to go pick up a pizza on Friday night. I'm going to pick one up for you too. What do you like on it? And that's a tangible offer. And what people can do is say, well, maybe not Friday, but maybe on Saturday I could use a little help. And so you've opened up a conversation about what help could look like. That's great because there's so much decision fatigue that's going on as well. So like kind of like taking that out of it and being like, what can I do for you? And they have to think about all the things that you can do for them and just be like, I'm going to do this for you. Like how would you make it done is like a little bit. Totally. And people don't want to be a bother. You know, that's the thing is that that's sort of the paradox of being a person in need, like a patient or a caregiver. They don't want to be a bother. yeah and so giving something tangible like hey I'm about to go to you know walmart target cvs whatever and pick up some stuff for my family what could I pick up for you yeah so what you're saying is I'm already going to be there yeah you know why not it's not that much yeah it sounds like a little lift yeah that's great that's great yeah and then what's a surprising or unexpected thing that people would be surprised about you outside of medicine I think people who know me might have some predilection about where I grew up or my background or anything like that. The reality is I think a lot of the way I think about healthcare delivery and decentralization and the need for supportive care is I grew up in a town of fifteen thousand in the middle of nowhere in Missouri, in the middle of the Midwest. And so I think a lot of my perspective on what's needed is not only rooted in the people I take care of and central North Carolina, but also like what care was like when my mom had breast cancer in her town of fifteen thousand and what resources we had, what resources we wish we had and how decentralized care, virtual care or sort of more networked care helped in situations like that. Yeah. OK, great. That's super helpful for sharing. The perspective is amazing. And thank you for providing that. So you are the first ever Chief Patient Officer at the American Cancer Society. That's super, super exciting. I know it's been a while, but I still want to congratulate you. But what is the value in having a team dedicated to always thinking about the patient first? Yeah, I think there's, you know, for those of us who sit in boardrooms or, you know, have difficult discussions about how we prioritize resources and effort and work, I think it's always important to have the voice of the patient in that room whenever you're trying to solve for a complex problem. Because the reality is we all have perspectives and priorities that we each have. And so if you're sitting in a room trying to make a decision about what's best for patients and the room only has people in it that have finance backgrounds or other things, you go, well, what are we missing? So I think for ACS to have a role like this and a team like this means that regardless of whatever we're talking about, that there is the representation of the patient and that perspective in the room. And I think that's really critical. And it's a relatively new role. And I think one that I would encourage all organizations to think about is, it doesn't have to be titled this way, but who is, when you think about when you have a meeting, you've got a timekeeper and you've got an agenda person and you've got this and the follow-up action items person and all that. If you go around and say, well, who's representing the voice of the patient? And in fact, when there are competing priorities. Who's the person who's going to say, but you know what, this is still the right thing to do. Or yeah, all things being equal, let's invest in patient stuff as opposed to growing this other team that may be a little bit more indirect benefit to our mission. You know, that's, I think that's, yeah. Can you imagine how many hospitals or health insurance companies have somebody at the table that's representing a patient, you know? Yeah. That's and the lack is evident in how often care is managed. Absolutely. I'm not even gonna lie after, you know, I like researched you, learned a little bit more about you. We actually did a panel with Dr. Kamal maybe two or two months ago. Yeah. Um, and got to know you a little bit better and learn about the role. I was like, need a chief patient officer yeah yeah I would love to be said patient officer because I was like thinking about what you do and like the things that I guess that entails so you inspired that movement here at karyaya as well and now we have a chief patient officer yeah it's really kind of like yeah it's like design thinking you know like how do you design a system that all stakeholders are represented including one of the most stakeholders which is often not represented in healthcare you know kind of decision-making settings so that's that's really amazing absolutely yeah so I guess you know one moment from the past three and a half years that made you think I can't believe this is my job um there have been a lot I mean I think that um I was in the baltimore hope lodge a couple months ago our hope lodge is our program where we give last year, five hundred fifty thousand free nights to cancer patients and their caregivers who are seeking care, many of whom have to travel either large distances or even across town. But the being closer to the cancer center makes everyone feel better. Yeah. And, you know, we had this moment where I was just organically just kind of touring the lodge in Baltimore. And one of the patients took a moment to ring the bell. And we have a bell in the foyer Hope Lodges as a way to signal out loud a transition to a different phase. And for some people that might be cure, for some people that might be a treatment break, for some people that might be moving on to something else. And to witness that is such a privilege because it exemplifies in one moment why we do what we do. And what I mean by we is we who are donors and volunteers and people who support American Cancer Study, in our case, not just employees. But to see that and to witness it, I think, is such a tremendous privilege because as a physician, I have this privilege of being able to be in moments where people are celebrating, where people are crying. That's a clinical privilege that I have because that's where I'm at with people. But for them to see that as people are making this grand gesture and to see everyone around them, their family, their friends, the ACS community celebrate with them is kind of like a goosebumps pitch me moment all at the same time. Yeah, no, that's, that's, I'd say that's amazing. And thanks for mentioning that, you know, in my wife's cancer journey, the most vivid memory is the ringing of the bell after all of the chemo and all the multiple surgeries and then end of radiation. and yeah you're right that five years out you still remember you know it's like it's a very so that's cool that you get to share that moment with yeah yeah and to imagine that you know two million people will be diagnosed with cancer every year that's one every fifteen seconds um should give us pause right like that's a tremendous number But to think that mortality has gone down by nearly a third over the last thirty years or so, tells us that there are more Bells being, right? And so in some ways, the ringing of the Bell is absolutely a celebration of an individual and their family's milestones. But I think the echo, if you will, is reminding us that investments in cancer research pay off. that public health approaches to reducing, for example, smoking and cancer screening, increasing cancer screening, have real tangible population health benefits. And so I think whenever someone hears the bell, you hear multiple sounds in the ring. There's the individual, there's the population. But I also think there's a signaling that there's a ton of hope, too, because if the trend continues right, we will reduce fifty percent of mortality from cancer and you know, be able to champion that half of cancers have a modifiable risk factor. So the bell can even remind us that there's something today we can put on our plate different than we might have that might measurably reduce our risk of cancer moving forward. So I think in that bell is a ton of hope. that we can actually even over time maybe reduce the number of times that the bell has to be rung in the first place, which is pretty tremendous. I love the idea of the echo of the bell. I like the idea because I think I've only always thought about it as an individual kind of triumph, overcoming a dark period in their lives, but I haven't thought about it that way. Yeah, that's amazing. I think, hey, the idea for a next social media campaign for you guys. Bell ringing. Bell ringing. And then that's kind of like the campaign of hope. Yeah, that's really cool. That's really cool. The ripple echo effect. Yeah. I love it. So as a teenager... um, you and your family were caring for your mom through breast cancer, uh, which must've been really, really tough. And so as you experienced the healthcare system at such a young age, um, do you recall seeing things that you were like the adults were maybe missing or just seeing holes that, um, maybe only could be better seen from the perspective of someone who's younger? Yeah, I think that, um, Maya Angelou and others said it really well around this concept of people don't care as much about how much you know until they know how much you care. And I think that the words and the sentences and the moments that I remember from such a long time ago are when people were compassionate, when they were kind, when they leaned in. Because it's interesting that the democratization of information across cancer care means such that I and any of you you don't have to go to medical school to be able to access the information that one might use to make a decision right so that whereas access to the right information was the differentiator of a person who who went to medical school and did these things that really right now I think the differentiator is around compassion yeah and that when we talk about a good doctor versus a great healer, that's actually the difference people are pointing out, is the experience. More so than, oh, this person's MCAT scores were higher than this person's. But this person understands the Krebs cycle a little better than the other person. Those are things that are sort of silly examples, but at the same time, what people remember is exactly, When you walked in, did you sit down at their level and make eye contact? Did you ask about how they're doing and bring them a glass of water? Those are small moments. If they're using a wheelchair as the doctor, did you wheel them back down the hall or did they just sit there by themselves for twenty minutes? And so there's moments like that. So for our family's journey, what I take away from that was moments where there were really human centered compassion, where people went out of their way. to make us feel very supported. And then I think at the same time, opportunities, right? That we think about that things that could have gone better And for those of us who are in the profession, I would say committed to moving that ball forward. And for those of us who are, you know, access the profession in some way through journeys that are personal is understanding that it should, it should feel supported and to give ourselves permission to ask for a better experience or inquire about a better experience. Um, because we, we deserve that. Yeah. And I think that, you know, there was a time where medicine was very paternalistic and maternalistic, this idea that we were, you know, passive receivers of someone else's care or kindness. And if they weren't kind, well, you have to deal with it. Yeah. I think we're past that now, actually. I think we all deserve compassion and should be able to provide that feedback for ourselves if we're not saying it. I think, yeah, thanks for making that point. And I've been thinking a lot about that too, because did you see OpenAI demoed, you know, their new GPT-Five and one of the use cases was kind of somebody kind of like self-navigating through cancer. And I was initially thinking about, okay, how unusual that the AI company is encouraging cancer patients to kind of self-navigate. But then maybe the flip is that, that as information does become democratized and a lot of these like AI tools for better or worse, people are just gonna rely on them for more information. The empathy side of healthcare and medicine is gonna be much more emphasized. I think that's a great point. Yeah, I think it's the evolving role of, let's say, the oncologist, right? Because it might have been somewhat, confusing that an oncologist could be a chemotherapist, that their sole role is to find the right regimen and give it to you. I think that because of a lot of things that have improved in cancer care, those are really table stakes. Finding the right regimen and making sure you can get through it is like, yeah, that's, that's, but the real differentiating space is for those who can tap into someone's underlying motivations and anxieties and hopes and worries and it looks different ways. You can ask a patient like, hey, when you think about the future, what are you worried about the most? What are you hopeful for the most? What does a good day look like to you? And how can I help you achieve more of those good days? And then I think when we're not so value narrowed by assuming that someone's only goal in life is to live as long as possible at whatever cost, I think as healers, we think more broadly than that. We're curious. We will find on the other end of that rainbow that people will give us answers a lot more nuanced and sophisticated than all I want is to live longer with whatever side effects may come. Yeah, yeah. Yeah, that's a great point. Yeah, I completely agree. So I would say generally most of our audience is people who are crushing it professionally. They're in their mid forties. They're doing great. And yeah, it's great. But sometimes they avoid conversations about mortality. Sure. So what would you say one of the biggest mistakes that high performers make when it comes to serious illness planning or just kind of like thinking about potential things that could be a punch in the gut down the road? Well, I think one, to acknowledge that talking about our own mortality, our own limitations, is a hard thing. It's not a natural thing. Most people I know don't say, I would choose to talk about that as opposed to any number of other things. But the way I talk about it with my patients is I say, and you have to account for things like humans, all humans, we like to do a little bit of magical thinking. And it happens all the time. Some of us are superstitious, that can happen. But sometimes what we worry about is if we talk about a thing, it will make it come true. It happens all the time, right? This is why we – I do that too. Neil and I are in the office every day. You're like knocking on something. Why are we knocking on something? Because you're like, oh, we said it out loud. You're right. It is not a judgment. I do it too. So we start to believe that if you talk about a thing, it might make it happen. And so that's avoidance of that thing might be in our best interest. The way I talk about it with patients is pretty simple. Here in North Carolina, we have to deal with the potential for hurricanes. So we're coming up in the fall, right? It's hurricane season. So what I say to patients is this, and again, I start by creating a rapport and a trust that says, I'm here to support your goals. Let's first understand what they are, right? So I'm not gonna presuppose as I said earlier that I know what they are. So let's imagine we've established that. Now what I wanna know is, let's make a simple analogy. Let's say that the weather report was saying that there is a hurricane way off the coast, barreling towards North Carolina. Now, in that situation, it could hit. It might go to South Carolina. It might go to Florida. It might completely miss and go off into the Atlantic Ocean. But that if you knew it were coming, if you looked to your family and said, you know, if the power goes out, it'd be good for us to have some bottled water. Or if the winds were getting high and we've got these kind of older shutters, it might be good to kind of nail them down. Or we've got these tarps outside, it might be good to da-da-da-da-da. Or we park our cars under some trees, it might be good to move them out. that you take these preparatory steps but by doing that it doesn't make the hurricane more or less likely to hit yeah right yeah right it doesn't do that yeah all it does is it makes you prepare if in fact it does yeah right yeah and what you hope is it doesn't it veers off and then you've got a few extra two by fours sitting around yeah you know you got a little extra bottle of water but okay yeah And so I explain that to patients by saying like, and they're like, oh yeah, well, no, I would get ready for. And I go, well, good. Let's just get ready for the things that might come down the road. And what I do is I put that in the context of the likelihood something might happen. So if they say, you know, I've got, you know, the cancer has gone from stage one to three. So I said, well, okay, well, the thing we might be worried about is that it might do this. And so I put it in the context of these various sort of levels of risk based on where they are. I think part of that then has to do with truth telling and information sharing that is tailored to the type of information that a person wants. So I think embedded within that is asking permission. So in the hurricane analogy, someone might say, yeah, I don't watch the weather. Like if things happen, they happen. I'll, you know, I'll kind of look around and everyone's sort of panicking. I'll start doing something. That's a style. It's not my style, but that's a style. Some people might say that. Others might say, I watch the weather report every single day because I want to know if a hurricane is going to hit like California. They're like so interested in the weather that they're like all that. So I think as a healer, your job is to understand like how do people want information? How do they understand risk? And what is their understanding of it? Then I might say, you know, I might give a normalization statement if they're struggling a little bit. Like, you know, many people like you who own a place at the beach, if a hurricane were coming, might do X, Y, and Z to get ready. Does any of that sort of align with how you're thinking? And they might say, oh, the gap was the normalization stuff. They were like, oh, I didn't know that's what other people do. Oh, well, shoot, if that's what other people do, then that's what I should be doing. Others might say, no, no, I've thought about that, but I'm not like other people. Oh, well, tell me a little bit more about that. So I think embedded in that is curiosity, and I like to clearly use analogies. but I think fundamentally that's what people want is like, make it understandable for me. Yeah. Right. Yeah. I think that's very wise. You got my wheels turning. I'm thinking about so many different things right now. I'm like, okay, so I need to talk to my parents. It's like things like life insurance and stuff. A lot of people don't think about these things because they're like want to avoid their thoughts going in that direction than I might. So yeah, that's a great way to normalize and bring up the conversation. I love it. The knocking on wood thing was so spot on too. That's great. Just the human condition. Yeah, it really, really is. So actually, do you want to ask this one? Yeah. So, okay. You've got, you know, kind of an interesting background if, you know, you've got the MD, but you've also got the MBA. Sure. I guess, you know, I guess what made you go down that journey and what would you tell your younger kind of self that was in medical school or practicing, you know, kind of how healthcare and like the business of care works differently in the real world than maybe what you thought going to it on the other side? Yeah. I think that, um, I mean, I, I heard medical, I entered medical school at as part of a six-year thing. So I had this very naive, idealistic view of how healthcare should run. And by the time I was like, eighteen and a half, I was like, wait a minute. But I think that it's embracing a certain humility, which is that healthcare delivery that's high functioning is a hard thing to accomplish. And that hard problems require sophisticated solutions. And they require that you understand the processes behind them. And that really, it's easy to say that bad things happen because you have the wrong people or bad people make bad things happen. But the reality is probably not. I tend to believe, and I think most people do, in the goodness of the human spirit. I believe that everyone's trying to do their best. But if we don't make... the right thing easier to do and the hard thing harder to do, then we haven't fixed the system. And so I think if anything I learned in business school, but there's a lot of hands-on ways one can learn this too, is that it's probably more complex than you think it was. And it requires a lot of exploration and curiosity. And change happens in small ways that compound on each other. And so there's no get rich quick version of healthcare, right? What you do is you make small incremental changes and you have a guiding star, sort of a north star. And I think what I like to see when physicians are getting more involved in the process is that becomes, as I started earlier, another perspective in the room. Yeah, because I think for at least for the probably the last twenty years, many clinicians had sort of abdicated the boardroom position. Yeah. And I think what we might have lost in a little bit of that is the need for the comprehensive perspective. So we have finances perspective and legal perspective and complies with a lot of perspective, patient perspective. But to the issue of clinicians being in the room and really forecasting like where care is going. Yeah. So, you know, are we remote patient monitoring? Are we do things in the home? Are we going to do things with particular issues in mind? You really need to have all those voices in there. And I think fundamentally having clinicians and leadership positions as another seat at the table, I think, is going to always make health care better. Yeah. Yeah. And I think to that point, I think, you know, I hear often from like old school docs, you know, that, you know, that are maybe in their sixties and seventies or practiced four years ago. I think one of the biggest things is, Oh, the MBAs and the business people have taken over healthcare, you know, in the last two or three decades. So I think I, you know, I didn't realize kind of like the, the missing link there that clinicians weren't kind of participating in the boardroom. And now that's changing, you know, do you kind of, yeah. What do you think about that? You know, at kind of the next level, do you feel like it's swinging back in the other direction of like, over a long-term yo-yos between truly focused on healthcare versus focusing on the business of healthcare and then we might be you know coming off yeah extreme yeah and I think there's a bit of a false choice between you can either be a highly successful business or do lots of things that help patients I mean I think we we can think of really good examples yeah um where you know palliative care is a really good example yeah there's a really good example because it is fundamentally the care that people would want for their families that's how people as a palliative care doc have explained it to me back to me so you know oftentimes doing the right thing for people yeah can be financially advantageous to all those in the ecosystem yeah right and but it's putting it together in the right way because the intention is good and then the rest is sort of the operation and the execution and so I think when you think about you know, managing like, you know, mental health complexities. That's an example where is a, you know, can be a revenue driver for our health system, et cetera. But we recognize that, you know, for many cancer patients, for example, the reason that they go to the emergency department can have a layer of. everything from social isolation and loneliness to an actual major depressive episode or even adjustment disorder. And so that really a comprehensive assessment of someone's relationships, coping skills, their sort of support system, that in a comprehensive way, that doing that can be beneficial across the board, not just for patient and caregiver outcomes, but also in a financial sense. And I think finding the right overlap of those Venn diagrams is why you need so many perspectives in the room. And why I would emphasize having the patient's perspective in the room too. I would say that as I've served in quality roles before, it was key to me that having the patient perspective in the room, even during quality improvement projects, was really important. Which seems a little foreign because you've got systems engineers in the room and finance people and we're whiteboarding and all this stuff. and you go okay but what perspective are we missing so it's really important to have a patient in there who says you know yeah I even if you fix that it wouldn't help me yeah and you know and that's a humbling thing to go because you know you start to get into a little bit of group thing yeah yeah yeah we're super smart yeah oh my gosh like that's the most perfect thing and then you need someone you know trusted someone who can use their voice who goes and and I can tell you some of the best things accomplished in my career is when a patient was like I'm not so sure yeah right yeah I'm not so sure yeah because I think that for really high energy people and for those who are thinking through it yeah the challenge is not coming up with ten ideas yeah the challenge is finding people who can help you figure out which is the top one and which are the nine you want at this yeah Yeah. Right. Yeah. And I think patient voices, but clinician voices, caregiver voices. Yeah. Are the ones in trusted spaces are going to say, no, they're all decent. Dr. Kamal. Yeah. But like these nine are okay. This is the shining star you want to go after. Yeah. You know what the story reminds me of actually, I don't know if we've read about Amazon in the early days, but you know, kind of on the basis of building it, it was in every five, six, seven person meeting like this, there was always an empty chair. And the chair represents the customer. And it's like, if you think about how great the customer, I mean, whatever people's feelings are around Amazon, the customer experience is phenomenal even to this day. And I think it's like a embedded in the culture. Yeah. There is any meeting, there's just like a chair representing the customer and that's why everyone's here. I think that's kind of, yeah, it's an awesome philosophy. That's really cool. Yeah, I guess for people that didn't know, Dr. Kamol does specialize in palliative care as well as oncology. Yes. And the NBA, so it's multiple different things, actually. But, you know, I guess like cancer care is kind of your specialty, you would say. But really, you try and focus on quality of life. So are there lessons here that we can take away for anyone who's dealing with aging parents or maybe they're having health scares of their own right now? Yeah, I think that one is being actively engaged in communicating with the health care team about that. I think there's a lot of hesitancy for people to bring up what's on their mind. And I find that showing up in different ways. And really highly skilled clinicians will try to pull that out. But I would say to everybody that your experience is unique. And let's just say for me as a doctor, I can't fully understand what is hard for you. I can try to guess. And so I'm gonna try to ask the question, but if I forget to ask the question, I want patients and caregivers to tell me what that looks like. And so it could be something as simple as like, when you have a really tough day, What made it tough? And I think for a caregiver, their answer might be like, listen, I'm trying to work part time, take Zoom calls, pick up the kids from the bus, make sure there's enough groceries. What's the plan for dinner? And you go, oh, that's so interesting because as a clinician maybe I didn't appreciate all that yeah right and we make assumptions about people based on any number of factors and so there's a very humbling moment where someone says back to me like I don't know dr kamal how do you guys figure out what you're having for dinner and I'm like I don't know it's the like biggest like moments of like you know in our own house like she's like yeah and then the caregiver says to me well take that and then recognize that whatever the answer is, I, as the caregiver, have to prepare it, pick it up, source it, feed it to the person, clean it up, da, da, da, da, da. And you go, oh. And that's a very humbling moment. And so I think it's really important in health care today to see it as a partnership. And I think of the triad, sort of the patient, the caregiver, and the clinical team. And I think that triad is really important because they all have their unique needs and biases and understanding and how they want to be seen. And so I think that that means there should be moments where the clinical team actually talks to the caregiver by themselves and in dyad with the patient. Because there are things I've found in my own clinical practice I'm always humbled with where a caregiver will say in the room, oh, yeah, things are great. Things are fine. Yeah. And then I might find a moment where the patient steps out to get a lab done or something like that. And I might hold the caregiver back and say, how are things going? How are they going? Yeah. But I think that clinical teams have to be prepared when we ask questions like that to be able to help. Yeah. And so so it's not just the the empathy or the the step of doing the assessment, but it's also making sure from a process improvement perspective that you have a way to refer them or help them or counsel them in a way that's helpful. Because the other challenge that I know clinicians have is why would I ask about something I can't do anything about? Yeah. Right. It can seem like a bit of a fool's errand. And so that is oftentimes the reason that clinicians might not lean into something. Yeah. And so I think it's a bit of both that in the partnership, there'll be both becomes we're elucidating all these issues. So it is the imperative of the health system to try to solve them because it is compelling and common. Yeah. But if we don't ask, Patients and caregivers don't talk about it. We can't actually quantify the issue thus to make it compelling enough to create a program or hire a person or something else to try to solve that problem. Yeah. Yeah. Right. That the silence sort of the, you know, the, the silence around it only serves to help the status quo. Yeah. Right. Yeah. I think, I think that is a, you know, and it's not on the list, but I think that's a meta level insight because I've been thinking about that a lot of like, why isn't the caregiver perspective addressed enough? And I think to your point, many times the clinician will hesitate because there isn't structural caregiver support available. But I think you're right that it's a circular, that if people don't ask, there won't be a push. And we work a lot with the people at AARP. They just put out this report. Maybe you've seen it. I know they're putting it on the media, but their latest survey says that sixty three million Americans are taking care of somebody living with serious illness or disability in their family. I think it's fifteen million higher than the same thing two, three years ago. So it's like the number of caregivers across America is jumping. And, you know, oftentimes I've been in this situation myself. We obviously help a lot of caregivers and they're not kind of as much acknowledged in the healthcare system as you'd like. They're certainly not acknowledged in the payment system, you know, and I've kind of seen some inklings where, you know, they rolled out this dementia guide program, which is the first time family caregivers are getting support. And I think it's kind of still below the radar, but it's rolling out across the country over the last few months. But yeah, I've been wondering why isn't there more, but you're right. I think kind of a dilemma. People aren't asking. who at federal level is going to see the message, who at large hospitals is going to see the message. So I think some advocacy around that is pretty important. I think it's critical. That's a great point. Yeah, that's awesome. So you're also, I mean, like you're at the American Cancer Society, of course, and there's a lot of innovation that's going on there, kind of working at the intersection of patient care and technology. So tell us a little bit about what's actually happening with AI or maybe any other digital tools that are maybe advancing serious illness care, and maybe even what innovation excites you the most? Yeah. Well, one of the, you know, You have to look at sort of the environment a little bit. And technology is an enabler, right? But it's not the thing you do because it's the only thing to do. I mean, there's plenty of processes that are human-based processes in healthcare delivery and the work that we do at ACS that one could focus on. I think one of the things, though, to recognize is people want to access information and services in the ways that best make sense to them. And, you know, if you're if you're seventy with cancer, it may look one way. If you're thirty with cancer, it may look a different way. It may not, in fact. But, you know, meeting people where they are is really important. And I take my experiences from clinical care and I still continue to see patients. So I think they're my best my best focus group. Yeah. And they're the ones because many of them I've known for a long time will tell me exactly which of the nine are the bad idea and which is the good idea out of the ten, which I really appreciated. And it's super helpful. But also, like, how do we meet people where they are? I give the very simple analogy. My family is very important to me and I have two young kids. And so we think about it as a family. And I say, well, gosh, you know, where I'm at. If we are ordering pizza as a family and the apps don't work to order pizza, my kids are like, what would you do? And I said, well, when I was younger, I guess I would call. But listen, we're all friends here, so I'm not calling anybody. And I don't consider myself old. I don't consider myself young. But I think about that in the person who's thinking similarly to me, who's out there thinking about accessing a supportive service that the American Cancer Society provides. And so, you know, the same thing is, you know, for us, maybe calling the one eight hundred number is exactly what that person wants to do. Maybe going to the website, exactly what they want to do. But maybe for them, something in the app form might be the right way. Yeah. And so we launched ACS is first ever patient facing app called ACS cares. It stands for community access to resource education and support. So C-A-R-E-S. And it does three, three things. Yeah. And I, I think the world comes in three. So I was like three, three components. So the first is tailored content. And so for many people, they want their situation is unique to them and they want the right content wrapped around that. And so if they're, Forty years old, they may want to learn about fertility preservation. And if they're seventy years old, they may want to learn about retirement drawdowns and things like that and everything in between. And so we do tailored content in the app. The second, because it's a registered experience and to contrast it to cancer.org, which is about ninety million or so visitors per year. So it's the most accessed website in the world. That's great. But for people who know how to find the information for them, it's perfect. For people who want the information to come to them based on their situation, the app is a better approach. The second thing we do in the app that was really critical is recognizing that, you know, I think that for cancer outcomes, we say that maybe twenty percent is biology and eighty percent is everything else. Right. Eighty percent is the I would say sort of if twenty percent is the biology, eighty percent is the being. It is a person and their being. It is their whole sense of self. And their sense of self is driven by internal motivations and aspirations and worries and anxieties, certainly, and goals and preferences. But also their being is affected by everything around them. So their environment, their nutrition, their social support, and all these other things. So you've got a being, and this being now has to deal with its biology. that the outcomes are not divorced of the two yeah that there's an interaction obviously between the two things that are happening so to understand someone's being in their life circumstances we need to assess that and then provide them real-time solutions so what we do in acs cares is we do a health related social needs screener and then we connect them to zip code based solutions based on where they live and so the idea is you have food insecurity and you live in Durham, North Carolina, where we will find you services for you that are in your backyard. Okay, so that's sort of two. That's really cool. I'd love to. And then the third, I've been happily married for eighteen years, and so I've never in my life used a dating app, but it was so interesting. that when we were thinking about how do we connect a newly diagnosed cancer patient with someone who is like them, who can help them navigate the journey, that we would actually use the dating app type platform. The idea being that you've got you know, people searching for people and people searching for people. And then fundamentally what you would do is then say, well, what would you like to be matched on? Yeah. Right. Is it, is it age? Is it cancer? Is it where you live? Is it your veteran status, et cetera, et cetera, so that we can create these really finesse matches between the two and that they could start to chat in the app. That's so cool. And that they can move outside the app experience to meet in Starbucks if they want to and things like that. and the premise of all this is around this idea that there is this tacit knowledge yeah yeah and um you know my my clinic as as one might be able to tell I like I like to talk to my patients I think it's one of the value drivers and sometimes we're running a little bit behind yeah right and Sometimes, you know, the cafeteria might close at a particular time. And so I might be, you know, so one time I was coming out to the waiting room to talk to my patients and saying, apologies, I'm running a little bit late. And, you know, because the cafeteria hours, they might want to go get themselves some lunch. And so, you know, it was interesting to note that actually the patient, the caregiver said to me, oh, yeah, Dr. Kamal, we already know that. We already know. How do you know that? Oh, the person sitting next to me in the waiting room told me this. So this idea that there's this tacit knowledge of navigating the system that goes anywhere from like, where should I park? When is traffic really bad? When does the cafeteria close? There's all these things that people don't necessarily know to think about. And then the person next to them goes, Who are you saying? Oh, Dr. Kamal? Yeah, he's going to run about twenty minutes. Yeah, I should go now. Just tell the person at the front. Yeah, he's not going to cancel your appointment. Right. There's all the that's navigation. Yeah, that's actually a great example. Yeah, peer to peer. Peer to peer navigation. And so when we built ACS Cares, our three functions were tailored content, health related social needs and problem solving, and then peer to peer connection around navigation. And that's what the app would do. So to your question of like, how are we evolving our technologies? I think it's really thinking about and then as we think about patient facing AI and other things too, is how do we meet people where they are? Yeah. Particularly when some of the demographics are changing. Yeah. And when you think about cancer becoming more for many people, not all, but more of a chronic illness in terms of how we manage it, support it. Right. It used to be when I finished fellowship, fifteen years ago, the average survival with stage four colorectal cancer was maybe two years. Wow. Today it's four and a half, almost five years. Doubled, more than doubled. Yeah. Yeah. And so So now people are living with cancer, not so much spending a lot of time and energy of dying from cancer. Now there's still moments of loss. So that fundamentally changes the journey because whatever distress you might have in small pieces starts to compound because distress becomes a function of time. right yeah so did you say oh I don't have any financial toxicity up front because I you know have savings and a four one kbo book yeah but listen I don't care how wealthy you are if I give you cancer for twenty or thirty years yeah Absolutely deplete your resources, regardless of who you are. I could probably do that. And so when you think about distress as a function of time, it means that we have to both evolve our services that we provide. So like the American Cancer Study taking a longer view, that someone may not need to stay in a Hope Lodge today, but maybe six months or a year from now they are. What are we doing to make sure that our eligibility criteria stay up with that, et cetera? But I would say even beyond the American Cancer Society is anyone who's in this space thinking about cancer truly has a journey. And a really, you know, a classic, you know, sort of rate limiting step we look at now is even the hospice Medicare benefit, right? The hospice Medicare benefit came out in It was predicated on this idea that you could one prognosticate who's going to live six months or less. Yeah. Yeah. It was using cancer as the example. So things like dementia and aging are very complicated. And as a hospice doctor, I can tell you that's where there is a lot of nuance and experience that has to come into play. But that also at that time, cancer outcomes were black and white. In six months, you're either going to be alive or not. Yeah. And so we've actually, the innovation has introduced an area of gray, which is you can be alive and still have cancer. Yeah. And that could go on for years. Yeah. In nineteen eighty three, no one could have imagined that we could get into this place where we are now. But how wonderful it is. Yeah. But the price of innovation, if there is a cost to that innovation is we have to evolve the cancer care delivery system and all the other supportive care mechanisms around it to embrace this idea that we may live in gray and we may live in gray for years to even decades. And we need to evolve towards that. Yeah. I think first of all, awesome, amazing insight. I've actually never thought about that in our lifetime. I was born in the eighties that it's changed from cancer being like an episodic thing where it's like, liver diet, you know, a few months, a year or two tops to now a chronic thing, which is like an amazing thing. I think from an innovation perspective, but I think I like that you guys are thinking about that because the support system has to change. You know, if it's just something that is going to be binary and you're going to know within a year or two, the support system is totally different. And I think helping people treat it as a chronic thing requires different financial support, peer support. That's amazing. Yeah. I think that's one of the most interesting things that they can think of. There are several interesting things that they can think of, but that is fascinating. Well, and I think for the average person who may be listening and watching, you know, you don't have to go to medical school to make a difference in this space. I mean, that's what I encourage people to do, right, is that, you know, humans generally, we have short attention spans, and I'm not sure that social media has helped us with that generationally, right? But podcasts are healthy. Podcasts are healthy. And we want to have finality and we want to have certainty. It is the human condition. We want to put a period on something and move to the next paragraph. For many of the people we care for who are going through a cancer journey, that certainty and that finality is not going to show itself early on. And that may be actually a benefit to the innovation. But I encourage people to say, hey, you know that same time and attention you might have given to someone to check in on them? Oh, my friend just got cancer, so I've been texting her every day. I think it would just ask yourself the question, if the person still has cancer six months from now or six years from now, are they any less benefiting from you still texting them with a certain? And I think if we were all honest with each other, the answer to that is clearly no. Right. But then what are we willing as human beings to give to another person when you go, man, I would love to be their friend, get to finality and certainty in like six months and say, you're cured. Congratulations. Let's have a party and move on to the next thing. And while I hope that for people, For many people, that's not how it works out. And I think for people who are like, but how do I, I don't need an MD or an MBA, by the way, to make a difference in this space, is how do I make a difference in space? To say, you know, figure out that the thing that they may be suffering from or need in terms of help at week two is probably very similar at month two and even year two. It might have evolved, but the need for help is probably not reduced. Yeah, yeah. Right? That's true. And while the news cycle moves on and the, you know, the, they're like, oh man, that's terrible for that person. But that person can't move on because that's what they're doing. Yeah. Yeah. They're living with it. Right. They're living with it. Right. And so if they, if they're going to benefit from a pizza today, they'll probably benefit from pizza six months from now. Yeah. Yeah. Right. And I think I ask people, you know, you know, that's real empathy there is to be empathic to the idea that a journey is best help, not with having someone walking with them in only the first couple of steps. Yeah. Yeah. It is all the steps. That's super helpful. Yeah. A hundred percent. Yeah. Holy cow. No, it's totally fine. I could sit here for another hour and a half and talk to you because this is fascinating. But of course, you have to be mindful of your time as well. So I will say we maybe have time for like maybe one, potentially two more quick questions. So goodness, what do I ask? What do I ask? maybe maybe this one maybe some practical advice for our audience so um is there like a question maybe two questions that uh every forty plus year old should be asking uh their doctor right now that maybe most people haven't thought to ask yet or is there like a test that they should be asking to be ordered or do you have any advice that people can be like all right this is gonna be my next medical step Yeah, well, I think in the cancer context, I would say, you know, it's relatively new information out there that about half of cancers have a modifiable risk factor. So honestly, whether you're fourteen or twenty four or forty, I would say the same advice, which is ask your doctor, what can I be doing differently today? that could reduce my risk of let's say even a serious illness. Yeah, exactly. I think that's really important because the reason why cancer mortality has gone down by a third over the last thirty years is somewhat because our treatments have gotten better. But that's not the driving force. The driving force fundamentally has been things like HPV vaccine, record low numbers of smoking. And now the jury's still out on what vaping is going to do. But we saw that happen. uptakes in cancer screening now where we have, you know, eighty percent of women, for example, getting mammograms and things like, you know, disparities, racial disparities, for example, in mammograms are not. What happens is that that, you know, things like follow on diagnostic mammograms and biopsies and things start to become very variable based on insurance status and things, too. So I would say this and I would I would ask people to kind of, you know, even if the doctor doesn't maybe have the most nuanced answer is to use things like do other things too to find what that is I'll give you a really good example um you know eating oatmeal sounds great right and most people are like oh man they kind of admire people like I walk in with a donut you walk in with oatmeal like we're all going to make value judgments about our seating habits and that's fair to hear something that's fair no no so not bad not bad but I think that It matters because like instant oatmeal, as I was taught by my colleagues, I'm not an expert, but that instant oatmeal, for example, is not a whole grain. And the whole grain is actually what you want, right? And we know that whole grain intake reduces risk of colorectal cancer, particularly in people under the age of fifty, which we're seeing record numbers of, right? And, and pancreas cancer and some other things too. And so that the details kind of matter. And I think that cancer has gone from like, you should eat better and be active to like, now we're starting to see prescriptions and specific tailored regimen tailored to someone's risk. Yeah, like food is medicine type stuff. Food is medicine, exercise is medicine. We're also seeing people, functional medicine, we're also seeing things, the detriments of lack of social connection. It's not only the outcomes during, but even the lead up to that. Because we all know that like something feels off, maybe by yourself you're like, oh, it's nothing. But if you have a friend or a spouse or a family member, someone who's like, Arif, that doesn't sound right. Bring that up, that you can have champions to advocate for yourself. And so I think there's a lot of ways to look at serious illness from a prevention lens, too, and to think about what all of us could be doing. And as much progress as we've made, there's still one in four, one in five women who are not up to speed on their mammograms. We've got forty percent of women who have dense breast tissue on their mammograms who don't have the appropriate follow up going on. We've got colonoscopy or colon cancer screening rates at seventy five, eighty percent. So still If we filled this room right here, there would probably be two people who are not up to speed with a recommended largely insurance-covered test that time is now showing reduces mortality and stage shifting. And I think that the overall message is, because cancer used to be, in our own lifetime, used to be bad luck, bad genetics. As part of the human condition, in addition to the fact that we like to knock on things, is we don't like to talk about things we can't control. If I brought up to you nuclear proliferation treaties, we'd all be like, I don't really want to talk about that. We don't really know much about it. One. And two, what can we do? So you're like, I don't know. Should the Fed move the interest rate? I don't know. People like to talk about things they can do something about. And that's the human condition. Human condition is important. So if cancer was bad luck, bad genetics, and you go, well, what can I do about it? Then you wouldn't spend a lot of time talking to them. But if I'm telling you half of them, half of cancer diagnoses have a modifiable risk factor or a screening test, right? That changes the game. Now you have a sense of control and agency. And that fundamentally, I think, is what people want. Because one of the most common threads I hear when I'm talking to a person with serious illness is how they feel like the patient said to me the term robbed of control. right because it doesn't matter if you work in the mailroom or the ceo yeah if you get a cancer diagnosis yeah the health system now owns your schedule yeah yeah you know I can tell you where to go when to go and what yeah you get there right and so I think fundamentally in the human condition we want control over our destiny yeah yeah and I think what better message than to say you know that thing that we're all scared of well about half of those we can do something about let's get started today that's great right yeah and that's very empowering totally yeah absolutely yeah it's great do you want to ask one last question last question okay I'll do the student side you know so we have thousands of um you know healthcare students you know that are caregiving through our platform they're caring for older adults they're learning you know day-to-day what healthcare looks like you know they're helping a lot of people with serious illness whether it's dementia cancer often terminal you know If you could sit down with every pre-med student out there that's listening, nursing student, pre-physician assistant student across America, what would you want them to understand, what it means to really take care of people? That therapeutic presence is critical. And many of life's problems are not solvable. And solving them or fixing them is not you know I think that's yeah let's expand on that yeah it's very humbling because as a as a physician that's what medical school teaches you that's what medical teaching yeah yeah is that you're a problem yeah and you start to believe this idea that you can yeah if only there were enough time knowledge effort whatever that is I think that pre-professional and professional, and I think adult, when we consider the concept of adulting, I think someone really moves into a different phase of their career when they can accept the fact that they can't fix everything, but being present is a difference maker. And what I mean by that is like, you know, in my career as a palliative care doc, I believe wholeheartedly that, you know, in my professional practice, that no one dies alone, okay? Now, you'll be surprised how many people actually do for various reasons. The Norman Rockwell painting of someone having a million people in the room is wonderful. The reality in the world is that sometimes that happens, but oftentimes it doesn't. And so you find what you can do to make the difference. And so in my view, professional career, it might be, well, instead of going home at seven o'clock, this person has no one at their bedside that the nurse and I are gonna stay in that room with that person and sort of lay vigil. And I don't say that as a value judgment to anyone who doesn't do that. That's my own sort of personal style. But you're humbled at the fact that like, I can't change this for this person. But when others are walking away, there are people who walk towards. and this is not self-congratulating to me, nurses do this, social workers do this, chaplains do this all the time, that when others are walking away, you're leaning in. is a very privileged position to be in. And it's a choice that one can make because I could go home. And so I think that for those who see suffering and this large issue of serious illness, don't underestimate the power of your presence. Don't underestimate that because for many people, what they're afraid of in their journey with serious illness is not not getting better. We might presume that the only goal someone wants to have is they've got heart failure, and now they just don't want heart failure. When I have these very intimate discussions with patients about their experiences, oftentimes what they say is, I just want someone to care. I just want someone to listen. I just don't want to be alone. And it's acknowledging the fact that we can't undo the biology of what's happening here. It is not in my power and maybe not in their power to do that. But that in that moment, the last thing they want is abandonment or pity or someone's five minutes when they've given you fifteen. And so I think in that sense, we can all be healers, right? by being present, by being curious, by reaching out, by sending a text, by asking a question. And I think that there is sometimes a bit of concern that maybe we're being nosy, that we're asking the wrong questions. The thing is, people who are suffering will give a lot of grace to effort. They'll give a lot of grace to effort and say, I know you're trying. And they're like, I don't know. You've got this hard thing. I don't know how to ask you about it. I know there's no good question to ask me. Just ask me if this sucks or not. I'm like, yeah, does this suck? Yeah, it really does. And you're like, yeah. Okay. Well you want to like grab a coffee and just talk about how much this sucks. And I was like, yeah, I kind of want it. I just want to vent. Yeah. Cool. Let's do that. Yeah. And so you don't have to be a psychiatrist to professionally listen to someone vent and for them to feel better. Yeah. And so I think we all have this power. Yeah. I think we choose to use it in different ways. Yeah. And I think you, you use it and recognize people give you grace and recognize that you don't have to have the right thing to say. But in fact, silence can actually be really important. Oh, I love that. That's what I was just going to say. Or just go sit with someone, watch a movie together, and that's your contribution for that. Yeah, I think sometimes people feel this pressure of saying the right thing, saying something that'll fix it. know people get people get accused of wanting to fix it more often than they mean to but I think that same thing happens with doctors is we get caught up in the like someone gave me a problem so my job is to go fix it yeah and I think oftentimes saying you know that sounds really difficult yeah yeah absolutely sounds like you've thought through this a lot and I don't know exactly how to fix that for you I'm committed to like hearing you out and yeah you know being curious with you and If there's anything I can do, like, you know, you know, or here's some thoughts, et cetera. That while that might sound like small talk or flip it. Yeah. It's more important than most people realize. Wow. And we should use that power regularly. Yeah. I love it. That's a great, it's a great message for anyone young and old. Yeah, absolutely. Absolutely. I will apologize to our audience and say that we probably don't really have time to go through all of the questions, but just really quick, maybe for in thirty seconds. This one was interesting to me. If you could answer, you know, beyond normalization statements, are there other phrases or communication techniques you like to share? Oh, my gosh. Wait, hold on. Communication techniques you like to use to understand patients perspective, encourage them to share openly and help them feel comfortable. You kind of just went over that. Yeah. But is there something like. in particular where you're like a patient is just kind of like closed off to you. And like, is there something that's like maybe the magic word or. Yeah. Um, well, I, you know, listen, most of us have a phone. I start very simple. If, if you were to ask me what's important to me as a human being, right. And I'm like, well, I don't know what you mean. You mean like my job or blah, blah, blah. I would say, no, no, no. OK, never mind. Just show me the picture you have on your phone, like your wallpaper on your phone, right? So this is my family. This is my wife, my kids, blah, blah. So you don't have to overcomplicate this, right? So what you're asking me is like, what makes a wreath tick? What's important to them? the answer to that is two parts one is my family on this side and then the team I root for in the back right so like so but you can get a lot from that yeah right because how you spend your days is how you spend your life yeah and what's important too is what you spend your money on and what you spend your time on yeah I could tell you all kinds of things I really care about that right now like okay what do you what do you do on a saturday yeah yeah and if I were like oh man my family's the most important thing to me blah blah but on saturday I do all these other things that don't include my family well that seems strange yeah So when I'm trying to cut through that a little bit, I might ask someone, like, when you think about the future, what worries you? What are you hopeful for? What does a good day look like? And I'd be like, ah, these seem hard questions. I'm like, hey, is there a meaningful picture on your phone that you'd be willing to share with me? And tell me what that is. So this picture is my family at my sister's wedding. We're all in very traditional Indian garb. And my kids look really proud of their outfits. I could tell you how they chose their outfits, blah, blah, blah. So I tell you this story. And you're like, okay, so his family is important to him. He has a sister. So you start putting these pieces together about my life, right? That's all really valuable. And so I think we can do that with all of each other. So this idea about, you know, what is it from a patient's perspective? Sometimes even for the most difficult sort of nuts to crack, be like, hey, show me a picture that's meaningful. They'll show me a picture of their dog on a beach. What beach is that? Oh, da, da, da, da, da. It's the Florida Keys. Oh, do you like going there? I love going there. But when was the last time you went? Oh, it's been years, years, years. Oh, what's getting in the way? Well, you know, all these medical bills. I just can't afford to go. Okay. Yeah. Okay. I'm putting the story together. They can tell me what they love. They're telling me what's making their life hard. So we're putting that story together. And to them, it may look like small talk. Yeah. This is not small. Yeah. Right. But the other part of what I'm accomplishing is I'm building rapport because people, people trust in relational relationships. Yeah. And what I mean by that, right. Is if you go through the drive through and you're going to get lunch. Yeah. Okay. And you order a meal and you give them money and they give you food and you say thank you and you drive off. That's a transactional relationship. I'm not interested in that person. They're not really interested in me. Now, if it's pouring rain and I'm picking up the food and I go, man, it's really raining a ton out here. They're like, I know, right? And my car's parked all the way across the parking lot. I'm like, oh, I totally get it. Well, you know, I was looking at the weather and it looks like it's going to kind of lessen about four or five. And they're like, oh yeah, you know, I guess on the upside, I don't have to water my garden tonight. We went from a transactional interaction to a relational interaction. What makes something relational is we have something in common. And so the other thing I do with patients is let's find something in common. Now, as a physician, as a healer, you have to be really careful to not talk about yourself a lot. So when they say something like, oh, yeah, I'm going to Disney World, you don't go, oh, yeah, I've been five times. It's so cool. My favorite ride is this one. There is a slippery slope of making about yourself. And so you have to be careful about that because the story is still there. It's not yours. But I think there's a way to moderate and say, oh, do you like going to Disney? Yeah, I've gone once. Tell me more about what you like. Oh, you like that ride? I like that ride too. What do you like about there? Oh, you love heights? I love heights too. Once you understand you've established you're in a relational relationship, then you have trust. Because when you have something in common with another human being, then you trust something. Similar lived experiences, similar worries. You have these things in common. And I think commonality is fundamentally what we have to get to in medicine. Because oftentimes medicine seems quite transactional. Fill out this form. Answer these questions. I da da da. and then I'm going to leave yeah you're going to feel confused and so you know I think that finding commonalities yeah or even stating them to a normalization perspective like saying like you know I know you don't have a ton of questions you know it seems like if I were in your shoes I would be really curious about x yeah and they go well I am can I ask you about that yeah I'm like yeah ask me about that you know and if I was like you know you know the thing that would keep me up at night might be why And they're like, how did you know? I'm like, I was guessing because I'm just trying to put myself in your shoes for a minute. And they could say completely wrong. And I'm like, cool, make me right. What would I have to have said to have been right? And they're like, well, I don't worry about this, but I do worry about this. And I'm like, oh, let's talk about that. Right. So you're getting them to open up even by being wrong. Yeah. You can get them to open up. But what you're demonstrating is a curiosity in someone else's being their self. Yeah. And I think that's how we open up. Yeah, I think that's also awesome insight. Because I think a lot of times we're taught like, you know, keep it more professional, you know, etc. And I think this relational element is, you know, oftentimes de-emphasized, or actually actively discouraged, right? So I think that's, that's... Awesome bit of advice. Actually, on that note, here's a relational thing. Your last name I love because that's my middle name. That's so cute. I love that. You're like, okay, where's professional versus relational? Thanks for encouraging that because I sometimes tend to keep it very professional. There are clearly boundaries and I think it's important for people to think about. I think the other thing is you want to understand what your triggers might be before you walk in the room. And so understanding yourself is key before you can understand someone else. And so I know, as you brought up before, as being the teenage caregiver to a mom with breast cancer, I know that if I'm going to walk into a room with a woman who has breast cancer in her forties and she's got kids in the room, that I have to sort of moderate my own emotions in a slightly different way. And I think it's okay even as healers to say, like, you know, maybe I want someone else in the room with me or, you know, maybe they're better cared for by another clinician. That's a pretty rare thing to happen. But also then saying this is going to trigger something in me about my own experiences or my own thoughts or, you know, that. you know, she's got an eight year old son. I have an eight year old son. Like I'm going to see in that person, my kid. It also means there's a responsibility that to be a good healer, you have to have moments to connect with others and talk about the work itself. Yeah. And really high functioning clinicians that I admire are those who have structured debrief sessions and moments to reflect with others in safe spaces to not talk about the facts of the work, but talk about the fact that the work is difficult and actually normalizing that because both things can be true simultaneously. Something can be really worthwhile, really gratifying, and hard at the same time. In fact, medical school for me was that. It was like one of the hardest things I've ever done, and yet so meaningful. But so can caring for other people. And so for caregivers, it can be the privilege of their lifetime to give back to someone who's given to them. And yet it can be hard at the same time. And so to find places and moments and safe spaces to say, this is such a privilege, but man, this is freaking hard to do, is health. Because remember, resilience is not a trait, right? It is a skill that one builds. And it can atrophy, and it can grow. And you have to have intentionality around growing it to right-size it to the challenges that you're facing. And so if you're an eight-year-old kid like me in medical school, You've got all these, you know, you've got an attending and a resident, a fellow, and they can handle the hard stuff. And you can say, I'm just going to go home and just like, okay. But then when you become the attending, like you're the one breaking the bad news. You can't just go home or walk away. So then you find other attending physicians and others and sit in a room and go, man, that's the seventh person in their thirties or forties I've had to give bad news to in this week. Yeah. And what we can't do is say, well, yeah, that's the job you signed up for. So if you're not cut out for it, blah, blah, blah. That's a trait conversation. Or if you are good enough or not good enough to have done this and you knew what you signed up for, da, da, da, da, da. No, resilience is not a trait. It's a skill. You build it. So someone goes, hey, I think he's having a bit of a hard time because seven is a lot in a week. So let's rally around him a little bit. And let's be like, hey, you know, like, you know, tell me what was hard about that. But what was satisfying about that? You know, it was tough. but the thing is I know that I can help these people and I know they've got a lot going on and I can be a force for good. Like that's a good moment. And, but sometimes it needs outside perspective to give you that because when you're in it, it can be hard to see. And so, you know, thinking of care delivery as being sort of, I think has to be really important. And it gets away from this idea that the doctor or the clinician is they know it all, you know, resilient on their own. hard as a rock, unbreakable, unstoppable, blah, blah, blah, blah, blah. I think that is a bit of a romantic construct that is one probably never actually have been true. People are just better at hiding it maybe. But I don't think it speaks to longevity because if you want to do this in the long run, right? I mean, some of the conversations in a palliative care context I have with people are the worst days of their life, right? And what I say to people is it's like standing next to victoria falls or niagara falls right this immensely huge thing someone's worst day of their life yeah and thinking that I'm going to stand next to that and not get just a little bit wet yeah yeah you're right it's like saying that you're going to be a witness to someone else's suffering and not have some of it stick to you right yeah you're right it's not possible yeah so the question is how do you dry back off yeah and go back out there again yeah And for some people, that might be personal things, meditation, yoga, shopping, any number of things. But I think there's no way to do that without having some component of being in community. Social support is the most important thing that anyone of us could have. Well, again, this has been one of the most insightful conversations of my entire life. I could go on for another two hours. I personally appreciate it. And I will go back and answer all of your questions at home. I do apologize. Thank you for asking, but thank you so much for being here. Thank you so much. This was wonderful. Thanks everyone for being here. Take care.