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Lilly: Do you know how people say sometimes they see signs of their loved ones after they pass? I'm just really curious, what are some signs that you see?

Kate: One that's pretty obvious is rainbows. The day after she died, there was a quadruple rainbow, and she loved rainbows. So, for me, it's rainbows and sometimes skunks, which is a different story. But yeah, I call them "Janewaves." What about you?

Lilly: At the end of the funeral, there was a bunch of birds that flew over, and the weather got really warm and sunny, and I think that those are signs that I always try to pick up on.

Grief in Medicine Is Often Unseen

Hello, everyone. Welcome back to "Bundles." This is Lilly. You haven't heard from me in a while, but I'm really excited to be back, and I'm even more humbled to be here with one of my friends from med school.

We're going to have kind of a more somber conversation today. And it's not the first time we've had a conversation like this on "Bundles," and probably won't be the last, but it's something that I really wanted to talk about. I feel like it's something that we go through in school and in life, in our careers, and sometimes it's awkward and weird for other people to navigate with us. So it is nice and sad to have other people to kind of relate to when these things happen.

But I'm really privileged to be here with Kate Tyler. I'll have her introduce herself a little bit, and then I'll tell you guys a little bit more about our conversation. So, Kate, take it away.

Kate: Hi. Yeah, my name is Kate. I've known Lilly since 2020, when we started med school together, and we connected over something that is very sad, but I'm really grateful to have her in my life. I wouldn't wish this on my worst enemy, but we all feel grief, right? We'll talk about that.

Lilly: Today, I really wanted to talk about grief and what it's like to live life on both sides of the stethoscope, being a provider and a caregiver at the same time for patients who you might just know for a day or a week, and then also for your loved ones, who you've been with their whole lives or your whole life.

So I just wanted to give a disclaimer because this is kind of a difficult conversation and a raw conversation, and if you think that's too much for you this week, then feel free to listen to another conversation on "Bundles." We have lots of uplifting ones as well. I think this one can be like that, too, but it also definitely is a sensitive topic. Or maybe you've been waiting for an episode like this to see if other people feel the way you do.

So, anyway, the other disclaimer that we make on all our episodes is that our opinions are of those of ours and ours alone. So, they don't reflect our institution or anything like that. We just want to kind of share our feelings.

I invited Kate to be on this episode because I really want to emphasize the world keeps turning whether you're in school or in your career, especially in medicine. Life keeps happening, and you're kind of expected to continue navigating all those waves. And sometimes we forget that physicians are also human. They're not necessarily superhuman.

When Personal Grief and Professional Roles Collide

There's this expectation for us to keep showing up and then also making space for our grief. And I really wanted to talk about that with Kate and just hear her experience going through grief in med school and then also share a little bit of my recent grief in residency.

Kate's Loss and Grief

So, just kind of diving right in, I wanted to first start off by having Kate tell us a little bit about her loved one, their story, and all of those things that she wants you guys to know.

Kate: So when I first started my third year of med school, that was July 2022. Just to start off with, I have a son. He's now 13. I had a daughter at that time. She was 7. Her name was Jane. I started internal med, and I was on my third week, and I was at Huntsman on inpatient hematology.

And I remember my husband called me and said something about Jane being really tired. For the past week, she had some vocal changes and stuff. Because I was on hematology, I, of course, thought everything was awful. And I kept being like, "I just really wish you would have a fever," which sounds really weird, but I wanted her to be sick. I was like, "She's acting so sick, but she doesn't have a fever, and it's pretty inconsistent." I just remember being like, "I wish that she had a fever."

Anyway, I got home, and I felt like I was seeing all these signs. You know how when you're in medical school, you just feel like you're always a hypochondriac? You're always like, "Oh my god. Oh my god. Now I see this. Now I see this." I kind of felt like she was drooling a little bit and a little bit cross-eyed. And Topher just kept being like, "Okay, we've seen you do this before. Calm down."

Then I started painting her toenails. I just wanted to spend some time with her. I just felt like I needed to spend some time with her. And I started painting her toenails, and I noticed one of her toes just kept going up. And so, as a medical student, I got out my reflex hammer, and she had a very brisk upward-going response of her left foot, which is abnormal.

It was July 3rd, and I remember thinking, "Well, my resident is going to think, if I ask for tomorrow off, that I just wanted to have July 4th off," because I was supposed to be in, which is so silly now that I think about it.

But we took her in just to our local hospital. We live in Layton. They did a CT, and they couldn't find anything. I was worried about a stroke, obviously, or a brain tumor. They couldn't find anything. So they sent us home.

And then the next day, July 4th, I took the day off because we were in the emergency room for a long time. She couldn't walk straight. It escalated so fast, and it was also on and off, and I felt like I was going crazy. So we took her to Primary on July 4th, and I remember her being so sad that we couldn't watch fireworks.

And by the way, before we went, I packed scrubs because I was like, "Oh my god, Huntsman is right there. So if we stay, I could go," which is insane now, but that's also how you think as a med student. Your whole life is medicine.

We went in, and it was . . . we were in the emergency room for six hours. They kept sending in people. Sometimes she would be walking totally normally, and sometimes she wouldn't be. And I just kept pointing out, "At the end of the day, her Babinski is abnormal. So something is wrong." And everybody the whole time just kept saying, "I know what you're thinking. It's not that."

And then she got admitted for a workup, tried to figure out what's going wrong. So the 5th, a resident saw me with my scrubs, and I was like, "Well, I'm going in." They were like, "No, you aren't. What are you talking about? You've been here all night." So thank God for residents who understand life is not . . . who just kind of snap us out of that mindset.

So I guess, in my head, I kind of was thinking it was going to be something like Guillain-Barré. It didn't really fit a lot of things, but my dad has MS. So, I thought it was going to be related to that or something, especially because we had the CT, and you do a CT to rule out masses or bleeds.

And so then on the 5th, she was scheduled to have an MRI because they wanted to do a lumbar puncture. So they just wanted to double-check, as any good doctors would, that there wasn't going to be a risk for herniation.

They sent her down, and I remember my friend, who's a nurse from undergrad, came to visit me, and we were just kind of chatting. I didn't know how to react at this point. Someone came in, and they were like, "Is it okay if this person is in here?" And I was like, "Yeah, that's fine." And I remember he asked me, "Do you know why we got the MRI?" I answered it like a med student. I was like, "Yes, I do. Because we want to make sure da, da, da." And I remember honestly trying to show off for my friend, which is such a weird memory to have.

But then he said, "Okay. Well, I just wanted to let you know that we found a mass in her brainstem." And I just remember wanting to throw up, I guess. I mean, that sounds so dramatic.

Lilly: Not at all.

Kate: And so, immediately, I was like, "Oh, she has medulloblastoma." I just started picturing the next few years of my life, with all the rhetoric that we use around cancer, and pictured her fighting and getting through. I was like, "We'll get through this. It's okay." I mean, it is scary, but we'll get through this. I remember thinking it was the worst.

And then the next day, the 6th, I remember it was the 6th very clearly. I'd been waiting for that day because I was getting my Step 1 results that day. Dr. Whipple, a pediatric neuro-oncologist, came in and said he . . . It was such a long conversation, and he's an amazing doctor, and I've learned so much from him. In short, he said, "I think she has something called DIPG." And I had never heard of that. I remember being relieved it wasn't medulloblastoma, which I feel really dumb about now.

So DIPG is diffuse intrinsic pontine glioma. It's pretty rare, but it is the number one killer of all pediatric cancers because it has a 100% mortality rate within two years. And I didn't even know something like this existed.

I remember he sat with me for a second and my husband, and he said, "I've just told you your daughter probably only has two more years to live. That's really heavy." And we just sat in the silence. I don't know. I just remember the way he reiterated that, like, "I just told you this, and that sucks."

And Jane wasn't in the room at the time, obviously, but after he left, I just held my husband and cried. How do you process that? Then just mindlessly, I got on my phone, and I checked my email, and my Step 1 results had come in. It's just wild. I didn't even care. It was the most important thing. I just remember thinking it was so messed up. Literally the hour after I found out, I've been told this.

She lived another 13 months, and she died August 22nd, 2023. And then I came back to school in January. I mean, in a nutshell, that's it. I could talk about it forever, but. . .

Lilly: Thank you for sharing that. I mean, I think that the fact that you, as a med student, even were able to catch that and then not let it go says a lot. Out of everyone in the world, I feel like a mom is going to advocate the most for their kid. And so even when the scans were nonrevealing at first, I think it's a lot that you kept pushing, because clearly there was something wrong.

And even with the minimal knowledge that we have, especially starting off and being in med school, it's really challenging to be like, "No, but I saw what I saw." Or the exam, the objective data is what it is.

That's definitely something that I have been thinking a lot about in residency now, because you go from being a med student in May and then two, three months later, you're the doctor. It suddenly has more weight what your exam is or what you objectively say to an attending or a family.

It's not a light weight to have, but I realize that we should trust the teachings that we've had and be able to advocate for our patients. And exactly what you did for Jane, in an ideal utopian society, that's what we would hope every family member would be able to do for their loved one.

It's just unfortunate that we also live in a society where not everyone has the same access to the education to know what a Babinski is, or to assess for that, or to push for that. Because a lot of times you sit in the ED and the doctor tells you everything's fine and you go home, even though you have that gut mom instinct that it's not fine. Who knows how much time you gave Jane by catching that early?

Kate: I do see a lot of privilege in the system for people like me who can advocate for and are medically literate. And even then, it's still really hard.

Lilly: I think even with how much literacy we have, there's still so, so much that we can't navigate and it's so challenging.

Kate: I don't know how anybody navigates the system, honestly.

Lilly's Loss and Grief

Lilly: It's really sad, actually, because not only do Kate and I have this in common, but even the type of cancer is similar for us. My mom was diagnosed with Stage 4 glioblastoma the summer before I started medical school. So we also share brain cancer, which is terrible, in our experiences with grief.

But my mom basically started having headaches in late adulthood, which is so interesting to me now, because when I went through my family medicine rotation as a third year, every single time someone over the age of 40 showed up to the clinic and said they had this new-onset headache, every single one of my residents was like, "The first thing I think of is cancer. The first thing I think of is brain cancer. That's the first thing I want to rule out."

But my mom would complain about it to her PCP, and they didn't really do anything about it. They were like, "Drink more water, exercise, reduce your stress." I'm sure we've all heard that a million times, which I think is all great and valid advice, but a new-onset headache in an older person should be very concerning for a red flag.

At one point, my mom was like, "Do you think I should get a brain MRI?" And her doctor was like, "I mean, we can if you want to, but I don't think it's necessary." So then my mom was like, "Well, if my doctor thinks that, then I'm reassured."

And then one night she started having stroke-like symptoms and went to the emergency room, and they did imaging, and they were concerned that she had a brain tumor. So she was transferred to one of the hospitals that we actually rotate at as medical students, and they did an emergency surgery. They did a resection and sent to pathology and saw that it was glioblastoma, which we do learn about in our med school curriculum. So I was aware of what it was. However, I had learned about it before we'd even gotten to Brain and Behavior.

And then, kind of similar to Kate's story with my mom, glioblastoma does not have any kind of cure. There are palliative treatments that you can do for it, like chemo and radiation, and there are a lot of new medications that are coming out that you can try, but nothing has been verified to be curative or anything like that.

A lot of it is just kind of life-prolonging treatments to try and improve the quality of your life, because with brain cancer comes a lot of edemas or swelling in the brain, and that can cause really bad headaches and really be very debilitating for patients.

So, luckily, my generation in my family is very healthcare-oriented. And so a lot of us are pursuing higher education in medicine. I was the first person in my family that was going through medical school at the time, and my brother was in PA school, and I had a cousin in optometry school.

We all kind of put our heads together, and we were like, "Well, we're not going to accept a diagnosis of 12 to 16 months with chemo for my mom." Otherwise, she was a very healthy 58-year-old, didn't have any other illnesses, no high blood pressure, no diabetes. We just couldn't process the fact this was a terminal illness that she would pass away from.

And like I was saying earlier, even with our medical literacy, we started looking at clinical trials. And that is a whole beast of its own, trying to navigate clinicaltrials.gov. It actually makes me nauseous when I think about that website. I think it's an incredible resource, but it's also very challenging to navigate because you're just looking at all these trials across the world, across the country, and you're trying to understand all of the terminology that they use that, even as a resident now, I find challenging and have to cross-check what it means.

But we would kind of talk to her oncologist about, "What do you think of this trial? What do you think of this trial?" And sometimes they would have an opinion, and sometimes they wouldn't. And so we felt like we had to kind of take it into our own hands.

We enrolled my mom in a clinical trial in Texas, and it was the peak of the pandemic, and Houston was an epicenter of COVID. So my mom and I camped out at an Airbnb while she got a second resection done and went through chemo and radiation, and just focused on making sure she ate and went on walks.

I don't think it ever really hit me that my mom would actually pass away. You know how we think we're invincible? Sorry. Let me collect myself, Chloe. I want people to be able to understand what I'm saying. Otherwise, I'm just blubbering. But I feel like we really think we're invincible and our parents even more so because they take care of us when we're sick.

Kate: Let yourself feel it. Really quick, I can't believe that you're doing this so close. Give yourself some grace, okay?

Lilly: Thanks. It's weird because when you hear terminal illness, you kind of already start processing their death even before it happens, but you still never accept it. So I feel like I was processing the possibility of loss, but never really fully accepted it.

So I think, going back, my first thought about my mom was she spent her whole life taking care of us, and now it was our turn to step up and take care of her. And being in medicine, I don't know for other "Bundles" listeners if you feel that pressure of being that person in your family that is intertwined in the healthcare field to then be able to give answers.

As an MS 0 when this happened, I had zero answers. And then as the years went on, I felt like I had too much knowledge on something I didn't want to know anything about.

And I really resonated, Kate, with when you talked about almost feeling a sense of pride of sharing your knowledge with attendings, because I remember when I met with my mom's oncologist, he was asking me about the markers for her cancer and what was my understanding? I was explaining the methylation and the unmethylation and how my mom was going to be a good candidate for chemo. And he was like, "Oh, you know so much. I'm so impressed." My mom was so proud, and she was like, "She's going to be a doctor."

I remember feeling a sense of pride and then also feeling a sense of out-of-body experience of why do I feel pride in having this knowledge? Because I'm a medical student at the end of the day. When you're getting asked a bunch of questions, you want to have the answer. You want to show that, "I studied. I know this." It's just bizarre.

And even as a resident now, if I do share with people that I had my mom recently pass away, they're always so impressed that I'm showing up and I'm here. I was like, "I don't really have a choice, but thank you." I do appreciate the fact that I'm able to be here, too. But like I said, the world keeps turning.

So, anyway, my mom ended up going through a few clinical trials and was doing really well for two years. And then the last year, it was a bit of a challenge. And then this summer, she broke her hip because, as we know, with cancer and being on chronic steroids, you're at risk for osteoporosis.

She never really, truly recovered from that, and her cancer spread to her spinal cord and started to shut down her body. And unfortunately, my mom passed away on October 10th of this year, which sounds kind of like a while ago, because it's two months, but it also feels like it was yesterday.

What Colleagues and Institutions Can Do to Support Healing

But I do think navigating my mom's care really taught me a lot about the things that I love and I hate about medicine. And one thing that really stood out to me was I was on my sub-I, which is where you spend a month during your third year specializing in whatever field you're going into. For me, I had to do neurology and internal medicine when I applied to neurology.

I was on my sub-I, and my mom's health was declining. She was having seizures and was in the ICU. And I had to navigate trying to get time off to go visit her during this time where you're supposed to be at your peak performance to get letters of recommendation for residency and all these things.

I remember at one point, I was on the phone with one of her care team members, and they were giving me an update. It was in the middle of rounds, and I was in the hallway. I just kind of went behind one of the little hallway doors, and I stood there, and I was crying after I hung up. I was trying to collect myself because I still had three patients to present. And it was really bizarre knowing I was caring for other people while I also was really struggling.

I've had some really amazing residents and attendings who have really shown up for me. I think some people who experience grief really know just to be there or to comfort and that there's not always something that you have to say.

But I think other people, because maybe we're around it so much and it doesn't immediately impact us, they don't really know how to act. And to be perfectly honest, I've had some experiences where it's almost awkward and weird to be in my grief.

I always think it's so bizarre because I think these other residents or these other attendings or whoever it is around me, we all chose to go into healthcare because we really care about taking care of people. But then when you have a person in front of you, you just don't know how to act because you have this veil of professionalism that you show to a patient in a room. Then you walk out and you just go about your day.

But when it's someone you know and you work with and you see every day, you don't really know how to humanize them, if that makes any sense.

I remember thinking how awkward I felt being in my grief on this rotation. There was one lady who I'll never forget. She's an aide, so she'll do the one-to-one supervisions on patients and stuff, or she'll do vitals. She was walking by and saw me crying, and she told me to come sit down. We sat down, and everyone in my team was in the patient room.

And she was like, "I know you're going through something really tough right now." And then she hugged me, and she was like, "You just need a mom's hug right now." I didn't know her at all, and she was like, "I know it's someone close to you. Is it your parent?" and I just nodded. She kept hugging me and sat with me. And she was like, "You need to go. You need to go be with them."

And then after a few minutes, she was like, "Are you okay?" I was like, "Yeah. Thank you." And she left and went back to work. I just thought how interesting it was that of all these people who are so educated and literate and have so many experiences taking care of patients and being around grief and pain, the person who comforted me was someone who doesn't have as much of those intimate conversations with patients about their care or palliative medicine.

They don't go through conferences and educational seminars about how have these conversations. They're not trained to do it. They just know how to do it. You know what I mean? You just have that bone in your body where you're able to do that.

I remember being like, "Wow, I wish that more people around me were able to do that." It stuck with me, and I think now when I hear of other people's grief, I don't want to be that awkward person who doesn't know how to just give someone a hug or sit with them or embrace the grief.

Kate: I really hate the metrics we use. And you look at the timeline and you're like, "I should be fine." When you said it's been two months, that's no time. That's no time. You're going to be feeling this and more for a long time.

I think, especially being trained in medicine, we get so stuck on these numbers and these time periods and stuff. I have felt like, "I'm doing things very wrong based on these numbers. How am I not meeting these milestones of grief that we've set up for normal grief?"

Lilly: The five stages.

Kate: That just makes everything so much worse. So first of all, never apologize for crying. I do too. It's easy for me to say, but I totally relate to that feeling of being like, "I'm too much."

And in fact, you said something about people being impressed, and that is something I struggle with.

One thing that's super important that I want to put in bold is grief is not logical. We're trained to be very logical people, very systematic problem-solvers. Med school kind of disassembles you and turns you into a problem-solving machine. And then suddenly I'm faced with an unsolvable problem, and it feels really cruel in a way that, in hindsight, seems unnecessarily cruel.

I hate it when people are impressed, and I also need them to be impressed at the same time. It's not logical.

That's just to say that there's no right way to behave. And some people come at me with . . . I've been told, "Oh my god, that's my worst nightmare." And I'm like, "Yeah, mine too, and I'm living it."

Sometimes I get the impression that people are surprised I'm even still alive, and I'm like, "Yo, same." But what else am I going to do? You would, too.

You talk a lot about showing up. And for me, I'm not sure if I have actually learned how to still show up. It's different for me because I don't have a job. Everybody says med school is a job, but it feels very different.

To be honest, I don't think the system necessarily teaches us. I think we're all indoctrinated to not show up if we're going to be a burden. And I don't know how to change that. I think a lot of it has to do with productivity. The things we value most is let's get people in, get people out, make money, solve those problems. And when you're grieving, for me, it feels like I went back and I was like, "Oh, you guys are all living in a world where all these things matter."

This sounds really arrogant, but I don't mean it to sound arrogant. It's just it feels like everyone is playing by different rules. And I'm like, "Oh, you're here in this world where hierarchy matters, where productivity matters. And I am living in this world now where I'm just trying to survive and make human connections," and that's not really rewarded. You know what I mean?

Lilly: Yeah.

Finding Support in Shared Experiences

Kate: I don't think grief is rewarded, which is hard because it makes me want to push down my grief. But I also feel like I'm a better person, and I'm honoring Jane more when I'm grieving her.

One thing that I've noticed is that everybody goes through this. Yes, mine was my daughter, and we could get into comparative grief, but that's useless, because at the heart of things, I've seen the faces of ÑÇÖÞ×ÔοÊÓƵren of 95-year-olds, and I'm like, "I know exactly what you're feeling." And the world doesn't talk about it. The world doesn't prepare you, because having an existential crisis isn't productive.

Well, there are two things that every single person in the whole world does, and it's they're born and then they die. And we don't ever talk about death, not in a real meaningful way.

So when Jane was diagnosed, Child Life came up to me, and I said, "How do I talk to her about this?" And they said, "Well, obviously there are certain ways you can go about it. But for us, we like to be honest because she is going to know she's dying at some point." They said the most important thing is we want her to not be scared about dying.

And I remember thinking, "How am I supposed to make her not scared of dying when the number one thing I'm afraid of is dying?" I think it's everyone's greatest fear, and I think that us not talking about it just makes it so much worse, and it makes it feel so much bigger.

Physicians who have confronted their own fears about death, you can sense it. It's a difference between . . . I always talk about the subtle difference between pity and empathy. It feels different.

Lilly: As you were talking, I was thinking when it comes to the performative nature of medicine, we all want to come across as empathetic. What med student, what resident, what attending is going to tell you that they don't want to practice empathy? But I don't think you learn that in a classroom.

I don't know if it's just the lived experiences of really getting to know a patient and having a meaningful conversation with them, not just running through the checklist in your head of what you need to get information-wise to come up with a diagnosis.

But I have noticed, with some people that I feel like I can turn to, it's really sad and unfortunate, but it's people who have gone through grief.

When my mom was in the ICU, I called two attendings, and one of them was someone who I met on the interview trail. I'm not even in her residency program. I didn't end up going to the institution, but I really, really connected with her on my interview day, and I knew she would understand my grief because she had experienced something similar.

I felt like when I talked to her, she was able to comfort me in a sense of, "Someone else has walked the same path before me. I'm not the first one, I'm not the last one, and I don't have to go through it alone."

And then another one was an attending from my home institution who had had a very similar experience to us and was able to sit with me in my grief.

And so it's sad, but I think other people who have experienced grief . . . and we all will experience grief. I'm sure everyone who's listening to this episode knows one person, someone that they love, someone that they care about. And like you said, Kate, we need to have a better way of preparing for these kinds of conversations and having that instilled in our practice.

I don't have a good answer as to how to do that, because when I sit through sessions where they teach us about it, it just doesn't really resonate. But then when I'm in the room with a palliative care doc and I watch them talk to the family and sit there, I'm like, "Yeah, this is different."

Obviously, there are always so many excuses of, "We don't have the time. We don't have the time to be in a patient room for that long." But when my mom was at the last hospital she was at, the neuro-oncologist sat in the family room with us, this big conference room that's horrible. You all sit at a table, and you click through all the MRI scans to kind of visualize what's happening. And he sat in that room with us for three hours.

I have never in my life seen a physician sit for three hours in one spot and over and over again answer questions and sit there with us and tell us, "I don't know. I don't know what she'll pass from first. Here are the things that could happen. Here's what I'm worried about."

And I think being able to sit through that and process that was something I'll never forget. But I also know that's not the norm that every single person can do, because at the end of the day, people do have families and lives outside the hospital, and I can't expect caregivers to be able to do that.

And so I really struggle with navigating this part of my life. Now that I'm a resident and I'm a little bit more . . . or I think I feel at least a little more responsible for what happens with my patients, whereas when I was a med student, I thought, "Okay, I'm signing out. I still have my senior. I still have the intern. I still have the attending. If I miss something, they'll catch it." Which is definitely still the case as an intern, for sure. There are lots of checks and balances.

But I had a patient at the VA that I was taking care of during my first year, and it was a very similar story to my mom. The daughter was asking all of the right questions and had all the right concerns. And this kind of dives into the next thing I wanted to talk about, which was my icks with going through grief and things that I just can't tolerate anymore now that I'm on the other side of the stethoscope.

I feel like sometimes you get this really positive experience with someone being in healthcare, like Kate was saying, where you feel like there's that sense of respect and they know that you understand enough that they really want to take the time to make sure that we're all on the same page.

But there's also this other side to medicine. I don't know if you've experienced this yet. There's almost this frustration with a family member who is literate or has enough exposure to the medical field to have an opinion and questions and wants answers to things.

And like I said earlier, I think all of our patients should be like that. They should ask these hard-hitting questions. We should be able to have those meaningful conversations with them.

But at the end of the day, whether it's educational or cultural, sometimes not every patient's family is going to feel comfortable or know what questions to ask. At least from my culture, there's so much respect for doctors that you don't really question what they say. You just follow what they say. If they say, "Do this," you just do it and you don't question what that means or what that's going to look like.

But I think when there's someone who's a nurse or a resident or a physician or someone who's involved in healthcare and has enough information to ask the right questions, I do notice that sometimes the care team will get frustrated and be like, "Ugh, she has so many questions for me," or, "Ugh, they have so many questions," or, "Oh, they want to talk to me again," or things like that.

When I was on the other side of that, I was in the hospital with my mom, she got really tachypneic and was having a difficult time breathing. And her nurse was on a lunch break. I ran into the hallway and was trying to get a nurse to come see her. They came in and assessed her, and they thought she was in pain. So they gave her some morphine. And then five minutes later, it all started happening again.

The intern in me was lighting up, sparking up. I was like, "This is a rapid. This is a rapid waiting to happen." For those of you who are in your first couple years of med school, you might not have experienced this yet. But for those of you who are in your third and fourth years, you may have already been to a rapid, which is basically where they call . . . not really a code, but they call response to try and get people there quickly.

So someone could have low blood pressure. It might be a concern for a seizure. They might be suddenly altered or had a fall. And you just need people to get there quick, someone to assess, someone to get labs, someone to check their EKG. It's just meant to kind of get people there quickly to try and figure out what's going on.

I ran back into the hallway, and I grabbed the nurse that was at the front desk, and I was like, "You need to come into the room right now. My mom needs to be put on oxygen."

And they came into the room, and they were like, "Oh, she's satting well. We don't think she needs oxygen." I was like, "No, she's tachypneic to the 40s. Put her on nasal cannula." And I was starting a rapid on my mom at a hospital I didn't even work at. I was like, "You need to put her on nasal cannula." And they were kind of dismissing me.

Then eventually, a minute later, the provider taking care of her came into the room. And within a second of walking in the room, they were like, "Get the non-rebreather." And that's when I knew this was a rapid.

Then the rapid team got called, and they came in, and they kind of started running the show. I sat in the hallway, and I just thought . . . I've been to a couple as an intern where we just kind of go through the computer and do a little exam and kind of watch our seniors lead the show. So, as a baby intern, I was terrified to think that the first rapid I triggered was on my mom.

But at the same time, it reminded me, "I have these skills. I have this knowledge to be able to do that, and a lot of other people don't." The lady that was in the room with my mom, the other patient, thought my mom was snoring because she was so tachypneic. It sounded like snoring.

So it's just really interesting because we have that privilege and that access to know those skills. And I'm sure, on the other side, people were getting frustrated with me because I was demanding things or I was asking for things, and I was frustrated.

I noticed sometimes the neuro residents that would see my mom in the morning wouldn't do a neuro exam on her because they would kind of be nervous around me. It was awkward and it was weird, and I was like, "I don't know anything either. We're all just figuring this out together."

And then on the other side, I would hear people get frustrated, whether it was someone that consulted on my patient or the team I was on, that felt like, "Oh, this person asks a lot of questions," or, "Oh, they're difficult to talk to," or, "Oh, they have unrealistic expectations." I was like, "In an ideal world, wouldn't all of our patients ask these questions? And wouldn't they all at least have enough knowledge to be able to try and figure out what's going on for their loved one?"

And now when I know that someone in the patient room is in healthcare, in medicine, I obviously ask them, "How much do you want me to explain to you with medical jargon? How much do you want me to explain to you in a different way?"

Typically, some of the people, kind of like us, want to show that they have the skills and the knowledge, and they're like, "No, you can use the medical jargon. I know what an SVT is." And then others want me to dumb it down for them, which is how I felt when I was on the other side. I was like, "Dumb it down for me. I am not an oncologist."

But I always have to remind myself to take a step back and be like, "Well, I want them to advocate because they know the patient better than I do," and to remind the team around me, "This is the person who knows them best," and try and get rid of that weird culture in medicine where we're nervous about family members who ask too many questions or know too much or read through the chart and see the labs in the morning. Why is that a bad thing? I don't understand.

Kate: I have had so many of those experiences being labeled difficult. "The patient's mom is difficult." And then it was hard for me to convey because I just wanted to understand fully the reasoning behind my options before I made a decision.

Yeah, sometimes I'd go in circles. And sometimes when you're making the hardest decisions of your life, you're going to go in circles, but in an ideal world, we wouldn't feel rushed. It would be so lovely if we could get in the culture of medicine just refusing to rush on some of our patients.

And I found myself doing that a lot as a medical student. But when I'm not rushing as a medical student, I just look like I'm being lazy. You know what I mean?

All of us have met an attending that we want to be like, and we've met an attending that we're like, "What happened to you? And why are you in this?" I would like to think all of us start medicine with that same, "I want to help people, da, da, da." And the truth is that the system kind of beats it out of you a little bit.

You and I both, even though we have these experiences, are going to have days where we're someone's awful story. You know what I mean?

One of my icks that when we're rounding, sometimes I'm like, "You do know people can hear what you're saying right outside the door, right?" When people are kind of eye rolling and being like, "Ugh, the patient's daughter da, da, da."

We all want to vent. Again, emotions aren't very logical, and you just want to say something nasty about someone because maybe you've had a bad day or maybe they made you late to something because they were asking you too many questions or whatever. Don't do that right outside the door. It drives me insane.

I'm okay with people doing that in general because I think we need to let off a lot of steam. And a lot of times, it's not about that person. It's about us trying to survive in a place that doesn't make us feel like we are being the best version of ourselves that we can be. But don't do it right outside the patient's door, please.

Lilly: Agreed. That also makes me think of how many institutions use the phrase, "Oh, I have a bunch of rocks on my list," or, "There's a rock on this list," or, "I can't get rid of my rocks." And for those of you who are as horrified as I am, that basically is when we reference a patient who's been there for a long time and isn't moving on from the hospital, whether they're having a hard time figuring out disposition of where that patient will go, or no one can really figure out exactly what's going on, or there's social stuff going on, but you refer to them as rocks.

Kind of talking about digestible things, I have gotten to the point where I kind of just pick that as my hill to die on some days and I'll be like, "I don't like that term." I just say it. "I don't like that term. I don't like talking about patients as rocks. I get what you're saying, but let's just say, 'My long-term patient,' or, 'My patient that we know well.' We really don't need to call them a rock because that just completely dehumanizes them."

And I think it immediately makes you more dismissive of what happened to them overnight or what complaints they have or what's going on with their care. It's a small thing I think we can do culturally to . . .

Kate: It's probably harder for medical students. I tend to die on hills as a medical student, and I think it really gets me in trouble. I don't read my evals. And it's not a humility thing. It's just, unfortunately, my life experience has made me an expert on areas that a lot of people don't have to learn until they're a lot older. And I'm not really afraid of an attending like I used to be, but I respect them.

Lilly: One thing I always get feedback on is that I have really good soft skills, which used to be such an honor for me as a med student. I was like, "Oh, yes, I have soft skills." And then you kind of break down what that means, and now I'm like, "I don't know how I feel about soft skills being used to reference the fact that I'll sit and chat with the patient, or get to know them, or have a good relationship with them and know how to navigate conversations with them." I think those are hard skills.

I think it's easy to research a diagnosis and go on UpToDate or read a research paper and be like, "This is what I think the diagnosis is. This is what UpToDate says is the treatment. Here's the exact dose of the medication I want to give," and then I can go chat with the pharmacist on the duration of the medication. I don't think that's the challenging part.

I think the challenging part is when you're sitting in a room with a patient, and they ask you a really hard question that you can't answer by googling it or putting it into UpToDate. Those are the parts where you could line up a beautiful plan that was algorithmy . . . Algorithmic? How is that said?

Kate: Algorithm? I don't know.

Lilly: Is that a word? I'm making up a word. But let's say an algorithm shoots you down to exactly what to do, and then you present it to the patient and they're not game for it. I think, at that point, everyone can go down the arrows of figuring out what they want to do if we have the time and the resource, right?

But when you're able to sit in a room and have a meaningful conversation with a patient that makes them feel invested enough in their care that they want to be on board with that plan, or that they tell you, "No, I actually want to do this," and you're able to make that happen for them, I don't really think those are soft skills. Those are really challenging things that a lot of people can't do because they get frustrated or they don't have the time or they don't have the patience for it.

And as I've gone through intern year, I feel like I've gotten a lot better at being efficient, seeing all my patients on time, knowing what plans I want to do and what meds I want to give them, and where I think they'll go after they're in the hospital.

But now I've noticed I don't have the time to get to know my patients as well and to have those patient-centered conversations with them that used to be referenced as soft skills. Now sometimes I depend on my med students to be able to build that rapport with them. And that's really unfortunate, and I need to figure out how to get in a good medium of those two things.

It is interesting what we choose to emphasize when some things can be researched and others are just skills you need to work on that you can't just blow off as a soft skill. I don't know.

Learning to Hold Space for Grief as Physicians

Kate: It's the human side of medicine, and I hate . . . I don't know why I hate it. I don't like it when people say "the human side of medicine." But most of the time, patients won't just listen to what you say unless they have a relationship with you anyway. You know what I mean? If they feel like you care, it honestly makes the biggest difference.

I think there is an art to delivering hard truths. It's a hard skill because the way you feel afterwards . . . I mean, ultimately, it's always horrible once you find out a loved one is dying. But there's a difference between finding out from a very cold standpoint and not a cold standpoint. It makes something already so difficult a little bit easier if you can perfect those "soft skills."

If the goal of medicine is to ease suffering, that eases suffering in a way that nothing else can. It's being a human in a room with someone after you tell them, "I can't fix your problem."

Also, I do think all medicine is palliative care. We're all going to die. When Jane was in the PICU for the last time, we kept getting told by PICU doctors, "Considering her diagnosis, do you really want to . . ." And I'm not saying fight, fight, fight, but what I'm saying is we're all going to die. Everything we do is palliative.

I have seen so many really practically good physicians bounce off even just a hint of a palliative care conversation. They just want to forward it to palliative care. And I'm like, "But this should be a conversation we're all capable of having in little bites before it gets there, because that will soften the blow."

Lilly: I totally agree with that. My mom, each time she presented to an emergency room that wasn't familiar with her, the first thing they would say is, "Have you guys considered talking to palliative care?" And I would be like, "Everything we do for my mom is palliative care." I almost felt like I was telling them, "This is a terminal cancer, and everything we do for her is palliative."

And even from day one, when we started chemo and radiation, it was in the sense of palliative care. So it's not a new thing we need to consider.

I really like the way you're phrasing it, because yeah, everyone will experience death. That's the one certainty in life.

And thinking of that in the way that we care for people, even small things. When we're treating someone who's of an older age and saying, "Hey, I want you to take this medication four times a day," and they can barely remember how to get to their doctor's appointments or something, how can I expect this patient to successfully take this medication at home four times a day?

A lot of times, you think, "Well, that's what the algorithm says," and just send it down the list. But I really like how you phrased that, and I should think of that more in my practice outside of just people who have terminal cancer.

And when you mentioned the ICU, it's interesting because that's where things can change so quickly. When you talk about time pressures, that's the time where you wished that you did have more time.

I remember constantly thinking, "Are they pushing us to make the decision because they need the bed for someone else?" And that was a huge stressor on me because I was thinking, "Are these doctors giving us all the information because they genuinely think there's no hope, or is it because they're just trying to keep the gears going on their unit and they have other sick people?" Which is valid. You do have other sick people who really need a bed. And with staffing and everything else, that is something that comes into play.

But if we were to have these types of conversations early on in care and continue to have them, then maybe it wouldn't be as scary when we have to make those decisions.

And I love the idea of a required palliative care rotation because you learn so much that really influences even just the way that you talk to patients, but also how you target those goals.

For me, going into neuro, I feel like so much of neuro is tied to palliative, and it's something that I need to be really good at.

One thing that I thought was interesting, when we kind of go back to advocating for patients and palliative care, is a lot of people would tell me how amazing it was that my mom lived four years past her diagnosis, basically hinting that we should be so grateful for the time that we had with her, that a lot of people don't get that time, and it's just a miracle.

I'd have to kind of remind them my mom lived this long. Yes, she's a fighter. And yes, a lot of it could be a miracle. But also, a lot of it was the fact that we pushed and we fought and we got her every possible care we could and found clinical trials that she qualified for and made sure she had good community and good support. It wasn't just magic.

Kate: Yeah, you have the trauma to show for that. You do carry that. It is hard when people write it off. And also, for anyone listening, never call for a grieving person to be grateful. They know they should be, but they don't want to be sometimes. Don't point out why they should be grateful. It won't make them feel better.

I once said to Lily I got pretty decent at a neuro exam from all of this, and I've learned a lot of lessons. And yes, I am grateful for all these lessons I've learned. And yes, I do think, in a lot of ways, I'm going to be a better doctor. I would give it all back just to have Jane.

I do see the silver linings of this horrible, horrible experience, but never for one second think that someone who has lost someone dear to them will accept those things as a replacement. I have to tell myself these things to keep going day in, day out, and to give myself motivation. But nothing would compare to just having her.

Lilly: People say, "This experience is going to make you a better doctor," and the jaded part of me is like, "Well, I wish I wasn't a doctor because I couldn't even save my mom."

Kate: Just know that it's a very steep cost that they didn't choose to pay.

Lilly: Yeah. I think that's a beautiful note to also wrap up this episode.

For anyone on "Bundles" that's listening and is going through your own grief, I hope that this episode made you feel a little less lonely in your corner of the world, because I definitely do. I'm so appreciative to Kate for spending her time with us today and sharing her story and keeping Jane's memory alive in everything that she does.

I do think we're going to be really great doctors, despite everything we've gone through. And I like to think that each patient we care for and made that time for will be a reflection of the care that we hoped our loved one would get. That keeps me going.

I hope you all find something that can ground you as well, because this is a long path. It's challenging, and it's okay to feel all the emotions, and it's okay to cry. That's something I have to keep reminding myself about. We're not superhuman, but we're just doing our best.

Anyway, I hope you guys all enjoyed this episode, just going through all of the ebbs and flows of grief and things we can work on. As always, there's so much to do in the world, but hopefully there's something that you picked out of here that you can take with you.

And I really wanted to dedicate this episode to Jane Tyler and my mom, Alia Kanishka, and the huge impact they had on everyone around them. I want to dedicate this to everyone who's listening who also is experiencing loss or has lost someone.

Otherwise, you all can keep up with us on our Instagram and our website. I hope you guys all subscribe and chat with us. Leave us a comment. Let us know what you think and how you navigate your grief and what we can do and how we can build better community.