E68 Red Hoffman on Writing and Surgical Palliative Care

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Chad Ball  00:12

Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad Ball. We’ve had the absolute privilege of chatting with some amazing Canadian as well as international guests over the past year. While the topics have been brought in range, whether clinical, social or political, our aims for the podcast continue to remain the same. We hope to inspire discussion, creativity, scholarly research and career development in all Canadian surgeons. We hope you enjoy our second season as we continue to highlight some incredible guests, deliver detailed masterclass sessions on a myriad of clinical topics and introduce some fresh new features such as debate and companion formats. We hope you relish the podcast as much as we do.

Ameer Farooq  01:13

One of the major drivers for many surgeons to pursue surgery is the idea that they can tangibly and physically cure someone of their disease. What is clear, however, once one starts surgical training is that often what we do as surgeons is guide someone through the end of their life and help them make the best choices for them. Dr. Melissa “Red” Hoffman is a dual board-certified palliative care physician and trauma surgeon in Chapel Hill, North Carolina. Dr. Hoffman spoke to us on this episode on her career, her writing and her passion, palliative surgical care. Be sure to check out her own podcast, the Surgical Palliative Care podcast. Links, as always, are in the show notes.

Chad Ball  01:55

I was wondering out of the gate if you could tell us about where you grew up and what your training pathway was.

Melissa Red Hoffman  02:00

Sure thing I grew up in, born in Brooklyn, raised in New Jersey, and for most of my life, I thought that I’d grow up and be a writer. And then after my father died, I got very interested in social work so I thought they’d be a social worker and eventually kind of found my way to medicine. But my initial path in medicine was actually as a naturopathic physician, so I spent five years studying naturopathic medicine, and got a naturopathic doctorate degree. And during my training, I actually spent some time in India in a truly integrated hospital studying homeopathy. Yeah, it was awesome. And that was the first time that I was in surgery. And you know, in India, it was crazy. I was in Mumbai, and it was this crazy hospital where the OR was like a 100 degrees like a burn OR rather than the OR’s we are used to where it’s freezing all the time that we wore flip flops in the OR. And that was where I first saw my very first surgery and I was really hooked and I thought oh my god, I think I’ve made a terrible mistake. I want to be a surgeon. And so I came back to the States I finished naturopathic school, I actually worked as a medical assistant for two years for a surgeon and then kind of started on the journey of allopathic medical school and surgical residency and then more training in surgical critical care and hospice and palliative medicine. So I’ve been a student for the majority of my adult life is the end of that story.

Ameer Farooq  03:36

Well such a fantastic background. And and clearly a lot of those influences still lost to this day in and make you the person that you are today. Certainly your your passion for writing still persists and continues to permeate all the things that you do. And I had the pleasure to read one of your pieces recently, in preparation for this, which was the JAMA piece, which was actually for our listeners voted as the top 40 pieces in the last or the last decade. Is that right?

Melissa Red Hoffman  04:08

Yeah, yeah.

Ameer Farooq  04:09

And it’s a beautiful piece. That’s called The Sound of Silence when there are no words. And it’s a moving piece where you talk about your father being killed by a terrorist in Egypt. Can you talk about how that early experience shaped your path through life?

Melissa Red Hoffman  04:26

Sure, sure. It’s funny, I was actually I was actually thinking of that piece the other day, because I saw on Facebook, that someone I know professionally suffered a horrible loss. And so many of the hundreds of comments and so many of the comments were there are no words. And that was something that really touched me when I was going through this experience though. I think at the beginning there were no words that I had to express my feelings. So I was 19 years old and you know, like many 19 years old, 19 year old people I was in a community that didn’t necessarily know how to talk about their feelings, that’s, you know, challenging when you’re a teenager or a young adult. And so I just struggled so much with what I was feeling on the inside. And that really, for me, ended up I really ended up summarizing a lot of my feelings and that’s really how I ended up going to naturopathic medical school because I was sick for years after my father died and found some relief and through integrative medicine. Over the years, I really got interested in other people’s suffering because I was noticing that my patients’ families, so though I’m very tuned into my patients, I’m particularly tended to my patients’ families were also like struggling as their family members were being sick or dying, they were struggling to find those words, and they were struggling to find someone to listen to them. And so I really got interested in holding space for those feelings or holding space for that silence. So that was certainly I think my I mean, my father’s death, just really, I think just one gave me a real appreciation for life, but really just gave me an appreciation for other people’s sadness that I think I just never would have had. And I feel, I always feel so grateful. I’m one of those people that believes like, I mean, who knows why that happened. It was bad luck, bad timing, but there, there is a certain like madness to the universe as well. And I really do feel, I feel blessed that I was able to take that experience and make the best out of it.

Ameer Farooq  06:40

It takes so much courage to tell that story and to write that story and send it to a journal like JAMA. So I’m so impressed that you’re you’re able to do that and to express it so beautifully. And I wonder how much that sort of search for words and search for meaning has permeated what you do, because, you know, in some senses, end of life care, which we’re going to talk a lot about today on the podcast and is clearly your life’s work is about kind of finding the words to communicate with people and to understand what gives them meaning at a really critical point in their life. Can you talk a little bit about that? Like how is your journey as a writer, perhaps helped you to become a better palliative care physician and maybe vice versa?

Melissa Red Hoffman  07:26

That’s a great question. What I think my experience as a writer, and I noticed, one of your questions that I thought was really interesting is how does that experience as a writer in that experience as a surgeon work as well, and I was reflecting on that, sorry to steal your thunder, if you’re gonna ask me that. But I was reflecting on how, when I write, like, I love to just have silence and space in my head to let these ideas form and so you know, I’ll have this idea and then over the next couple of days, or a couple weeks, it will slowly form in my head. And then finally, I’ll sit down and, and write it. And, um, you know, that just kind of takes time and space. And so I love that idea of time and space. Because time and space are really I think like so important. In the practice of good, really good medicine, I mean a good palliative care but really of good medicine, you know, the idea of sitting down where I work there’s like a new tower in our hospital and in every room, there’s like a chair near the that’s just kind of like hooked up near the door that you can take so there’s always a chair and I always use it to just sit down with the patients and their families and just to be quiet and and listen and to give them that time to think and breathe and cry and just be. So to me the process of writing and the process of listening and the process of doctoring, they’re in some ways all the same thing. The problem becomes right we’re also busy and there’s never there’s never enough time and so you really have to be or I have to be really thoughtful and mindful about how do I carve that out of a busy day and you know sometimes that means staying late or sometimes that means putting off those challenging visits until the end of the day when there’s like you know surgeries are done and all the paperwork is done and then I can just go and sit with someone for half an hour and not feel rushed.

Chad Ball  09:27

That’s a that’s a beautiful description and probably something that we should all strive towards that you know, every day there’s there’s no question we have to put the patient I think at the at the center of of what we’re doing always and remember their experience, you know, and some of those rushed moments certainly matters. If we shift gears a little bit and and I’d love to hear your thoughts on the mergence of palliative care and surgery in general. You know, we both do trauma surgery and I also do HPV surgery, and certainly the there’s not a day that goes by I would say, despite discussing the process of dying or death that’s just happened, where I wish I didn’t have your skill set as a palliative care doc. How does does one of those jobs inform the other? And how do you use it on a daily basis?

Melissa Red Hoffman  10:19

Well, one, I think a lot of people don’t realize that, you know, the term palliative care was actually coined by a surgeon, a Canadian surgeon, no less, Dr. Balfour Mount, who was a urologic oncologist. So I always say that surgeons have like deep palliative care routes. And I don’t think that many of us realize that. I think the other thing about surgery is, we are all we know that our patients suffer, even our patients who do well, I think being in the hospital and undergoing surgery or undergoing a stay in the ICU, there is so much suffering inherent in that. And I’ll often tell patients, when this suffering is a means to an end, when it’s going to lead to saving a life or improving our quality of life, that’s great. The problem becomes when this suffering, will, I’ll say to what ends, you know, when the suffering is just never ending and the outcome is not what the patient or the family would have hoped for, then what do we do about it? And so, for me, you know, people have asked me, well, you know, don’t you get confused, like if you’re wearing one hat or the other, but to me, a good a good surgeon, you know, kind of stands by their patient in the preoperative period, in the operative period, obviously, and then that post operative period, regardless of what it will bring. Because that’s kind of the covenant that we make with not only our patients, but with their families as well, that we are going to stand with you. And so again, while it takes a great amount of time sometimes and a great amount of emotional energy, that sometimes it’s hard to kind of summon at the end of a long day, or especially at the end of a long day in the operating room. That’s kind of the promise that I feel like we made with our patients. And, you know, while I think it’s nice to have training in hospice and palliative medicine, I mean, there’s 80 surgeons in the United States who are board certified in hospice and palliative medicine. But there are certainly hundreds of surgeons who I think do good primary palliative care with their patients, because it’s just very patient centered work that I really feel like anyone can do with just a little bit of training.

Chad Ball  12:37

That’s so interesting that there’s 80 board certified, sort of double-boarded folks that that’s, that’s remarkable, you know, probably the rest of us, maybe don’t use, you know, you you folks as the 80 probably enough, I mean, I really think we can learn so much more from from all of you.

Melissa Red Hoffman  12:59

And one thing that I always say is like, the best way to learn is that when you are consulting the palliative care team, if you could just, I mean, I’ll tell my trainees this a lot like go to the family meeting and watch what they do. Because for many years, I mean, my first introduction to palliative care was as a fourth year medical student at OHSU in Portland, Oregon. And then when I went to residency, we didn’t have a palliative care team and so the patient suffered greatly and I did a lot of what would be considered primary palliative care really just based on that month long training and some of the reading that I’ve done so I feel like there’s a lot to learn just from watching other skilled communicators lead a family meeting or have a goals of care discussion or have a discussion about code status and you know, it’s like you might not be perfect but I mean none of us are perfect so it doesn’t matter you know, I think if you are coming from a good place I have found families to be and patients to be quite forgiving when your hearts in the right place.

Ameer Farooq  14:02

We sort of dive right into the the topic which is your life’s passion and you’re and you’re clearly something that you’re getting good at and and have made an objective of trying to spread it which is palliative surgical care. And you actually mentioned you in you have a great interview on your own podcast with Dr. Balfour Mount on the origins of palliative care, but for our listeners, how would you define palliative surgical care? And what does that mean to you?

Melissa Red Hoffman  14:32

So I’m going to read the definition so and we call it surgical palliative care. And so this is the definition from Dr. Geoffrey Dunn so. Well, you know, Dr. Balfour Mount coined the term palliative care and he’s kind of he’s considered the father of palliative care palliative medicine in North America. I call Dr. Geoffrey Dunn, the father of surgical palliative care because he really brought that idea of surgical palliative care to the masses starting in the late 1990s and he defined surgical palliative care as the attention to suffering in all of its manifestations, so physical, emotional, psychosocial and spiritual of the patient and the family under surgical care. So a very simple definition. And basically what it means to me is that we are as surgical palliative care providers, we’re not interested in just the physical manifestations of pain and suffering, but we’re really tuned into our patients and their families as people and we’re there to minister that to them kind of throughout their surgical journey.

Chad Ball  15:45

That’s, I love that definition. To be honest, I had never heard it, you know what one of the things you said that that took me back was, was how we model ourselves or how we actually deliver these conversations and engage in these conversations. And it’s amazing as a surgical trainee. To your point, you know, watching different folks, whether it’s an HPV surgeon, whether it’s a formal palliative care expert, the different styles and the different deliveries with which you see, not only from clinician to clinician, but also really almost from patient to patient. And my observation, I remember thinking very early on of some of these really good communicators was that, you know, as you’d expect, now, there’s so much experience the, the, their ability to shift gears, almost even the cadence of their language could change, depending on who they were talking to, like, it’s really quite an artistic and beautiful skill.

Melissa Red Hoffman  16:40

Yeah, I will say, you know, my experience as a palliative care fellow, that was one of the most challenging years of my life. I mean, after years of surgical training, and then doing a surgical critical care fellowship, I was just feeling challenged in such a different in such a different way, the feedback was so much more personal, and in some ways, so finely tuned in. So really that communication style, like we would have discussions on because I have a very loud voice, especially when I’m talking about something I’m excited about, you know, how do we kind of lower the volume of our voice. One of my attendings used to say, you know, be the smallest person in the room, this is not about you at all. You know, I’ve got a lot of feedback around, I tend to, like, if I’m, like, my resting face is more like a resting smile face, that’s just my face. And I remember what some of the feedback I got was, like, well, that smiles just like really inappropriate during this hard family meeting. You know, it’s my face, right. But, um, it did really make me I just really appreciated all that was just that, you know, the I came in thinking, like, I’m so good at this. And then I realized, Oh my God, I have so much to learn. And, you know, I had several times where my program director who was just so great, you know, he would really say, like, I’m just sensing, like, you’re very surgical today, you know, like, very rushed. And just like, you know, how we are when we’re rounding, like, we’re just keen to go, go, go, we got to get all this stuff done before 7.30. And he just kind of tells me to, like, slow it down, like, you know, you don’t have anywhere to go, you’re not in a rush. And so, you know, I would say today, I always think like, if my attendings from palliative care saw me, you know, what would they think because really, I think, in many ways, I, I still act very much like a surgeon, because the majority of palliative care that I do is, as a surgeon, you know, like, my main job is a surgeon. And so I’m fitting this into my busy surgical day. But I still always do sit down, I’m a big fan of touching, you know, I’d love to touch people’s feet for some reason, but you know, like, either holding on to their hands or their feet or sitting on their bed, like making some sort of human contact, because I think especially now, in this last year, our patients are so lonely, you know, they’re so starved for can physical connect, because they’re not with their family. Yeah. And so I think that’s become even even more important, and then just really trying to get the family on the speakerphone. And so they can be a part of the conversation as well and be a part of a lot of this difficult decision making.

Ameer Farooq  19:31

Can you unpack for us a little bit more? What was different about the training that you did in palliative care? And what did that teach you that was different than what you already do? You know, you get the sense that a lot of surgeons now I think, talk about palliative care and talk about end of life discussions. And really, that’s something that’s part of our zeitgeist, you know, I think of Atul Gawande’s book, Being Mortal and what that’s done for the conversation, both inside medicine and surgery and outside of it. Do you think, like, what were the things that you learn that you weren’t expecting to learn? Or the things that we you just found that we weren’t doing well? And what are the things that you think that surgeons in general could improve on?

Melissa Red Hoffman  20:13

So one thing I learned is like how to shut the blank up. And so, you know, I think, I don’t know if it’s in Atul Gawande’s book, or I read somewhere, you know, that, like, we doctors tend to interrupt their patients within the first like, 16 seconds or something. I really learned how to shut my mouth, and just let the patients or families talk. Now, that is something that takes time, right. So again, as busy surgeons, we don’t always have that time, it’s sometimes as palliative care provider, you’ll leave an hour for the meeting. And so you really do have time for patients and families to just really get it out however long, you know, whether that’s five minutes or seven minutes, you know, at some point, they stopped talking, but then I also learned the power of, so not just like shutting the blank out, but that that power of silence because that silence can become very uncomfortable. But in that silence, then like the real emotions emerge, so just kind of sitting there, and then eventually they’ll start talking more or start crying, or start filling that space. So if I jump in and fill that space, then I’m, I’m really denying the patient or the family that opportunity to go deeper. So that was something that I hadn’t really thought a lot about, you know, we think about like listening and active listening, but really just like sitting in that deep, oftentimes very uncomfortable, and awkward silence to see what comes up. And it is like, it’s incredible, what kind of bubbles up on the surface for people. And then just I think I just learned to ask a lot of good questions that tend to work for everybody, you know, are in many situations. So one of the questions I love to ask is, you know, if your family member was in this meeting with us right now, rather than like, intubated and sedated in the ICU, what would they say? And so like inviting that fan, that patient and their spirit into the room, even if they’re intubated and sedated, in the ICU, it really is incredible, because people will just like shout out, oh, they’d say, like, you know, get this off from me or get me the hell out of here. Like it really gives a voice to that person. And so like, that’s one of the the tricks that I use to like get, you know, families get so concerned that I’m not making the right decision. Well, really, you know, we’re inviting you to please speak on behalf of your loved one, what would they say if they were here. And sometimes the families don’t want to hear what they would say, because the loved one would sometimes say I don’t want to do this. And the family member wants them to keep moving because of course, they’re human. And they don’t want to they don’t want to lose their loved one. They don’t want their loved one to die. But it’s, it’s just I love that question. I just get the most remarkable answers.

Amir Farooq  23:13

And one of the things that I reflected on after reading Being Mortal, and actually Atul Gawande came to our class while I was doing my MPH in Boston, and one of the things he is he’s a fantastic guy and just riveting person to listen to. But one of the things that I have wondered about, there are a couple of things. You know, one is in true Gawande fashion, he came up with a checklist. And so I’m curious if you have a similar checklist that you use when you’re actually trying to approach this situation? Or is it much more fluid or organic, and you kind of try to tailor it, as Dr. Ball said, tailor it to the, to the person that you’re speaking with?

Melissa Red Hoffman  23:50

I think another thing I learned in my palliative care fellowship is really not to have an agenda. So if you’re going into a meeting, and you’re like, I gotta get a code status. I mean, a lot of times that’s like, doomed to fail. You know what I mean? Because there’s many people who don’t want to talk about that right now. And it’s, you know, certainly there’s some times where it’s, you know, say a sick emergency general surgery patient in the middle of the night that has to has peritonitis and has to go the operating room, I mean, that you kind of, I feel obligated, and I want to have that discussion right away. But you know, when we have time, if someone’s like a trauma patient, the ICU, you know, they’re going to have this prolonged stay. And you can just kind of tell it’s not going to end well say that, you know, I don’t always have to get a code status on the first on the first go around. So kind of, for me, I try not to have an agenda. And I can tell I can like, it’s not like I always can, like manage that because I am thinking recently I was in the trauma bay and like I had such an agenda. And not only did I want a code status like I wanted this family to make this person Do Not Resuscitate. I mean like I really had strong feelings, like it’s not, you know, it’s not about me. And I can tell that I was kind of I was pushing it a little bit. And I could tell that the family members trying to was really just kind of shutting down. And I honestly don’t blame them. I mean, what do we get from that, then we’re never going to revisit the discussion. If we, if I go in without an agenda, I bring it up, you know, they shut me down that I want to talk about it right now. Well, I didn’t burn any bridges. And then the day later, just kind of come back and talk some more and maybe revisit it, say, remember what we talked about? And so I really don’t have I really don’t have a checklist. I have certain questions that I always ask because I think they helped me kind of get at who is this patient? I love asking, you know, tell me about the last six months of so and so’s life? What was it like? Because it’s very easy for someone to say, Oh, you know, mom was doing fine. Well, you know, what, what are the last six months been? Like, tell me what a typical day’s been like, and then you realize, you know, mom hadn’t gotten out of bed in weeks. Yeah, she’s, quote unquote, fine, but she’s really not doing anything at all. And so that kind of helps us establish like a baseline functional status, which I think is always good for, you know, sometimes we’re just kind of blind to our own suffering and to the suffering of those around us. So I think it’s good to kind of have people say that and then and then reflect it back to them. Well, this is where mom is. And I mean, the reality is, you know, we’re probably never gonna get her back to here. And after a long, prolonged hospitalization, or a surgery or trauma, I mean, the likelihood of even getting to 75% of that is sometimes, you know, highly unlikely. So what would mom think of that? And? That again, no, I don’t have a I don’t have a checklist.

Amir Farooq  26:51

To me, that makes a lot of sense. The other thing that I have often struggled with, and Dr. Ball and I have had lots of discussions about this, is that, you know, in some ways, what we’re trying to do with these end of life discussions and, and Palliative care is really have people confront reality that we’re not used to thinking about, and this is why this is why I brought up the your essay, right at the beginning is because I do think, you know, in some ways having to deal with, you know, your own mortality or a close family member’s mortality, makes you think about this issue differently. But, you know, one of the things that’s so challenging about this is that we have to have this discussion about something that nobody wants to talk about, and none of us are really in touch with, it’s not something that we we think about, you know, you know, if you if you talk about, you know, your your end of life, when you’re healthy people say, Oh, well, that’s kind of a more of a discussion, even though it’s not really it’s, it’s sort of a way of embracing life in some ways, and in a way of thinking and enjoying your own life to the fullest possible, you know, even if you’re healthy. And it becomes even more important when you’re when you’re really in a difficult situation. So I’m, I’m curious how how your experience has been with trying to, in some ways combat a cultural challenge, which is sort of endemic in, in the Western world and in modern reality.

Melissa Red Hoffman  28:13

So so one thing that I do is, and I talked about this a little bit in my essay, but I think like the power of sharing stories is like, pretty incredible. So, you know, with my older patients, I’ll always ask, Are you married? And a lot of them are widowed. And so then I’ll say, oh, how long were you married for? How old was your wife when she died? You know, was she sick? Like, I really enquire about that, that depth. I mean, like, I always tell my patients, like everyone has an expiration date. I mean, we’re all going there. And so I don’t, I just don’t shy away from it. Because people will often say that, you know what I have. It is amazing. When when people are in the hospital, I don’t know, I’m sure you guys have noticed this too. But it’s like it brings up everyone’s other deaths. You know, so many family members will be like crying about Oh, my brother died last year, or my mother died 15 years ago, like it brings up all their stuff. And instead of ignoring it, I’ll kind of dig into it a little bit. Well, oh my god, how old was your brother? What did he die from? Like, you know, do you often ask, like, do you dream about him? So kind of just like normalizing deaths in gen like in general. And then, you know, it’s hard to talk to a patient, especially a sick patient that you know, is, you know, you get that sense, right? We all have that doctor sense that these this patient really may die. It’s hard to ask a patient how they’re feeling when they’re so close to death, I have found that the majority of people when you ask them, they have been thinking about their mortality, they might not be talking about it. They might not have like, formed a lot of coherent thoughts. They might not have like the most graceful words but you know, people know when time is short, it’s it’s quite remarkable. It’s like, the reality is though that we don’t like hold any space for people to even talk about it. So you know, when someone’s sick, it’s like, so many families have said to me, God, I wish I talked to mom about this, but I didn’t want to hurt her feelings, or I didn’t want to make her anxious. And, you know, me mom at mom’s bedside. And like, you know, the majority, not all of them. I mean, sometimes it’s challenging when people are not really realizing how close they are to death, but the majority of people know. And yet, we don’t really invite them or hold space to talk about it. So I tried to hold a lot of space and ask like, very honest questions, like, do you feel scared? Or what do you think happens? Or when I’m at a patient’s bedside, you know, say, when we’re doing like a terminal excavation, I always ask the families like, who’s waiting for them on the other side, you know, to kind of like conjure up all the spirits in the room. And that is also a great question, because then they start talking about all their dead family members. And it brings a lot of joy and like love into the room and really could feel all these spirits, like just waiting to invite this patient. So the, it sounds a little woowoo. But I really do believe that like, you know, just waiting to welcome this patient, I always tell our families like, you know, they’re just going out with a ton of love. And they’re just going to be met with a ton of love. And so I just try to keep talking like I just, that’s where I have a hard time being quiet sometimes. But I just try to keep moving the conversation, keep normalizing everything like yes, this person is dying. Yes, you’re dying. Yes, we need to talk about this. And yes, all these other people have died. And we’re just going to keep telling these stories and keep conjuring up these memories and keep kind of calling on our ancestors to help us. And and to me, I think that brings people a lot of peace. I mean, I get lovely feedback from families that they they just feel like, okay, this is the best way, you know, no one’s happy about how what happened. But this is the best way that it could have happened.

Chad Ball  32:05

I think I’m running out of income. I’m writing all of these tricks and tips down that you’re giving us in our audience that can’t thank you enough, like, unbelievable, yeah, it’s great.

Melissa Red Hoffman  32:15

I just want to say like just like to not be scared, like I realized early on, like, the patients are looking to us as physicians to set the stage. You know, I remember when I was like a second year resident, I just totally, like, I still remember this man, I just totally connected with this man who had you know, children, like my age are a little younger, I think actually, he was like, my, his children were a little younger. And he was like my dad’s age when he died. So I was like, very connected to this man. And he I was telling him, he had like stage four cancer. And I said, like, how are you doing? or How are you feeling? And he’s like, well, I don’t know, like, I’ve never gone through this before, you know. And I realized, like, our patients are really looking at us to be the guides, you know, and, you know, how many times have you been at the bedside of someone, like, who’s been dying, and the family members are just standing there, like, they don’t know that they can touch their family members on like, come on, gather around, let’s like love on this person and touch them and hug them and kiss them and put on some music. Like, they just they just don’t know, they don’t know, because they’ve maybe never done it before. And so it’s really, it’s up to us to normalize all that and to really set the stage and that’s really the beginning of legacy, right, because the patient’s going to die regardless, but we’re really in charge of how the family is going to that’s the beginning of their processing of death. And we can really help them have kind of a good way forward and hopefully avoid this complicated grief that a lot of us, unfortunately, struggle with.

Chad Ball  33:53

Oh, that’s, that’s beautifully and poetically said and, you know, it makes me reflect on on my own personal experience, which, you know, just briefly was that my dad died quite young when I was in Atlanta training as a fellow. And it was interesting, because he was a, an ex professional hockey player who came from a farm and was a very salt of the earth kind of dude. And I would have bet, you know, a million dollars times, you know, infinitely essentially that when his day came, he would have died very much like a salt of the earth guy sort of saying, Oh, well, this is this part of life. Here we go. But he didn’t he actually he was in what happened very quickly over a couple of months, unexpectedly, but he railed against it. He was not happy. He felt he was too young. And then all the other things that I’m sure you see every day. But that for me, that was a really good lesson to what you’re talking about with you with your example. Yeah, we don’t know how we would actually behave until we’re in those situations and we shouldn’t make the assumption or project in any way from our experiences, whether it’s job based or whether it’s just life based. And that we understand without asking some of these questions.

Melissa Red Hoffman  35:03

Right.

Chad Ball  35:04

Very well said, the other thing I wanted to sort of dig down in with you is about, just over a decade ago, we published a paper that looked at, I think it surveyed just over 500 clinicians and in terms of how they look at end of life care in severely injured patients. And it was an international study, all five continents, all different types of trauma related physicians. And it’s interesting because that, that that manuscript, that project was spurred by a bunch of us as Canadians, entering the US over about a five year period doing trauma and critical care fellowships, and sensing a palpable difference in terms of how these two different cultures and countries looked at end of life care. And I’m, I’m curious what your what your thoughts are on, on, you know, Ameer kind of touched on it a little bit there, but culture and country and religion, sort of differences globally, and probably the most high profile, maybe the most high profile example, recently in this country in Canada has to do with medical assisted death and dying, you know, that there’s now a federal law that that says we have to engage in this and have structures and systems in place to, to not necessarily promote it, but but to do it with some sort of, you know, elegance and hopefully, grace. I was curious what your thoughts are on all of that?

Melissa Red Hoffman  36:30

Well, so I just want to clarify that’s for the entire country that you guys have that.

Chad Ball  36:36

Yeah, you betcha. It’s a it’s a federal law. Yeah.

Melissa Red Hoffman  36:39

That’s awesome. You know, in the United States, I think there’s about eight states where physician assisted suicide is is currently legal. You know, I think that religion certainly plays a great role in a lot of decisions that are made in this country. And so and I certainly see it in the south, there’s a there’s a lot of, and I’m Jewish, so I can’t really even speak to it. But I just feel like there’s a lot of religious beliefs that certainly rail against physician assisted suicide the same way that they would rail against some abortion today. But what I have found is that faith kind of works both ways. Like, because they’re the same people who really have this strong faith in God and will pray for a miracle, I find that a lot of people have just a lot of comforting in their religion and God and feel like they know where their loved one is going. And so I tend to really try to support that idea and promote it, you know, I have found that say, for me working in the south, now, my language around death and dying has really, I’ve just kind of adopted the language that’s around me. And to me, it still feels, you know, it’s not the language I was brought up with, in New Jersey, it’s not the language, I would speak on the west coast. But, um, you know, to me, it’s all the same. Like, I really feel like we’re all you know, whoever you’re praying to, I mean,  it’s all we’re, we’re looking for that same sense of comfort and support. And so I find myself kind of using that language of, say, like Southern Baptist and that sort of thing. That’s what a lot of our patients are down there and talking a lot about God in a way that I wouldn’t necessarily have talked about before. And, and just kind of reminding our families that because this is what they believe, and I love this idea, too, is that these patients will die and be fully healed. And so I think that’s a great comfort for people. And so I echo it all the time, you know, your loved one is not going to suffer anymore, they’re going to be fully healed. I say all the time that, you know, it’s us who’s left behind, that’s going to be suffering, they’re going to just go off into this eternal grace, basically. So that’s how I kind of found my way of that. That’s how I just kind of dealt with being in a, say, in an environment that’s not really native to me, but I still managed to make it work.

Ameer Farooq  39:22

That’s, I think, a beautiful reflection on on this whole process and the real challenges of dealing with different cultures. I didn’t want to touch briefly on your own podcast, and I’m curious what made you want to start that podcast in particular, and what have you sort of learned along the way from doing it? You know, I’m curious what feedback people have given you and and talk to you about and things like that.

Melissa Red Hoffman  39:47

So, a little over a year ago at the in October 2019, yes, at the American College of Surgeons Clinical Congress, the committee on surgical palliative care was meeting and we were talking about how we really had no the the whole movement of surgical palliative care really didn’t have any sort of online or social media presence. And so I initially started the Twitter account @Surgpallcare. And then from that just started daydreaming about okay, well, how do I, you know, I reflected a lot about when I started becoming interested in palliative care as a young surgical trainee, I really didn’t have anywhere to turn, the American College of Surgeons had one online PDF that is called Surgical Palliative Care Resonance Guide that was coedited by Dr. Dunn and that kind of became my Bible. I mean, that was like the one thing that I could use, but and I certainly knew names like Dr. Geoffrey Dunn, and Dr. Anne Mosenthal, and Dr. Zara Cooper, but didn’t necessarily feel empowered at that time to be reaching out to them. And and so I felt like well, how do we how do we make it so that this next generation of surgeons that like you said, I think, you know, I think more and more people and more and more surgeons are starting to consider talking about death and dying and suffering as part of their practice. And so how do I support this next generation of surgeons coming up, and you know, like many people, I love listening to podcasts. And I also felt very strongly Dr. Dunn has been a great, he’s like, like our historian, like he’s written a lot about the history of surgical palliative care. But I was like, man, a lot of these people are old, you know, like Dr. Mount, is in his 80s. And if we don’t record these people, they’re going to die. And we’re going to be so sad that we don’t have their stories so that we can look back on them. And so I just felt really motivated like this needs to happen. And I had the time and the energy and so mike, this is going to happen now. You know, I was very blessed to have Dr. Balfour Mount is my first guest. I mean, I don’t think you can get any better. And then Dr. Geoffrey Dunn, really, he’s become a great mentor and friend of mine. And you know, his Rolodex is like way, way deep. And so he’s basically introduced me to a lot of people that I never would have been able to contact to agree to be on the podcast. And then I kind of I got some advice from the folks who run the GeriPal podcast. And they kind of told me, you know, cast a wide net, like, don’t just focus on surgeons and on physicians. And so then I started saying, alright, well, I need to have some nurses on and some I just interviewed a pharmacist that hasn’t come out yet. And so I’m looking at other people who aren’t surgeons like someone like Diane Meier, Ira Byock, who are just giants in the field of palliative care, but have really I mean, Dr. Byock, he really supported the surgical palliative care movement from the very beginning back in the late 90s. And so getting to talk to them and hearing what they thought surgeons brought to the field, and also how surgeons might improve their communication. So I thought that was just really fascinating to get that input from them.

Ameer Farooq  43:17

Do you ever get the sense that now surgeons, because you’re making them sort of sort of aware that there are ways of doing this better. Do you get the sense sometimes that surgeons, maybe are more scared to do their own sort of end of life care, and are now referring everything to the, to the palliative care team? And instead of really engaging with that, themselves? And And certainly, you know, one of the challenges, as you pointed out, is that we really don’t have time. And so I’m curious, you know, what has been the feedback from surgeons listening to this. Has it been that, you know, you’ve made me a lot better, I’m going to try and do this for myself, or is it that you know, maybe I’m not the right person to do this? And sort of what what are your thoughts on that?

Melissa Red Hoffman  43:59

So I think the feedback is mixed. Part of it depends on what field of surgery someone is in. So when I think of an acute care surgeon like myself, you know, splitting time between the ICU and trauma floor and emergency general surgery, you know, when I’m in the ICU, I mean, that kind of the whole the general vibe of the ICU and kind of the rhythm of the ICU, that you’re really in the ICU and not often in the operating room, it really lends itself to doing a lot of your own palliative care. And so there I tried to do a lot of it. However, even for myself, even if I might want to, there are certain times when you can’t so one is, you know, if your service is overflowing, you just can’t. Two, I’m always mindful of who’s following me in the ICU because if I’m starting something that I sense, it’s gonna last like weeks rather than days, I will get the palliative care team involved because that continuity of care is really hard. You know, I have several partners who are very, very skilled at palliative care and several for like, they’re just not as interested. And so, you know, I really look to see who’s coming next. And if they’re going to want to continue to engage on that level. And then lastly, when we do our own primary palliative care, we have to remember that, you know, one of the, I think selling points about palliative care is that it’s an interdisciplinary team, right. So you have the physician, you’ll have a nurse, you’ll have an advanced practice provider, maybe you’ll have a licensed clinical social worker, you can have a chaplain, if you’re lucky, you’ll have a pharmacist. Well, when I’m doing my own palliative care, you only have me. So it really depends on how much support the patient and the family and then the nurse needs. And I’ve talked about this before, there have been several cases, I there’s several cases that I’m thinking of where we’ve had young people with high spinal cord injuries, and like, I myself am so overwhelmed by the the suffering that the patient, the family are going through, like I find myself to be not very effective yet in those situations, but then the nurse is suffering and the family is suffering, and there’s just no way that one person can address all that suffering. And so for those kind of challenging cases, I will get the palliative care team involved because they have a little more of the resources that are needed to take care of the family to take care of the nurse, and of course, to take care of the patient.

Ameer Farooq  46:30

Yeah, there’s, there’s a lot of emotional burden that you have to take on if if you’re suddenly the point person. And I’m sure you’ve become that for your colleagues, both in your own institution and, and nationally, you know, it is not easy necessarily to keep on doing that day in and day out. And so how do you support yourself in that work?

Melissa Red Hoffman  46:51

Yeah, so one, I’m just super mindful about what my, like how full my bucket feels, basically, and on the days where it just doesn’t feel full, and I might have some stuff going on in my own life, then I’ll just consult palliative care team. And I very lucky, I work at the hospital where I did my palliative care fellowship. So I feel very comfortable just saying, like, I’m just, I’m just going through it today, or I’m just like, overwhelmed, either professionally or personally. And I just like I’m so sorry to consult you, but I just like I can’t do this today, you know, I’m very honest. And then I feel, you know, I’m young in my career, but older in years, and I have like, now it feels like a lifetime. But you know, over two decades of like, good self care that’s just like programmed into me. So you know, thankfully, I know how to sleep well, I know how to drink a lot of water, I know how to eat well, I know how to move my body almost every day. And so I know how to, like maintain a really good equilibrium. And then I think, um, you know, I’m not the type of person or surgeon that just pretend that I know everything. I’m very I have no poker face, I’m very free with my emotions, and I just don’t try to hide what I’m feeling. And so I don’t waste a lot of energy trying to convince myself or you that I’m okay. Like, if I’m going through something, I just kind of talk about it, and then you know, then it’s out and I don’t have to deal with it. And so I’m not not holding on to that idea of what a physician or a surgeon is, like supposed to look like I think gives me a nice sense of freedom to just kind of move through my day and move through my life with a little more like emotional freedom.

Ameer Farooq  48:37

I hope we can all aspire to have that level of insight, because it’s certainly not easy. And sometimes it takes a moment for you to kind of step back and say, woah, what’s what’s going on? What What do you say to the people who perhaps don’t recognize or don’t feel that that is an important skill for them to have in terms of end-of-life care and, and palliative surgical care? You know, we all know those people who are a bit brusque and perhaps don’t think that that this is, you know, what they need to be spending their time doing and you know, their time is better spent better spent operating and curing people that they can cure. So how do you approach that colleague or that surgeon who who maybe doesn’t see the value the same way that you do?

Melissa Red Hoffman  49:21

Well, I think that everyone has their own skill set like I mean, I’m meant to do this but there I can think of people who are like just meant to be in the OR for like 15 hours a day and that’s probably the person I’d want operating on me if I had pancreatic cancer. So what I would just say to them is just you know, we all need as an as adults to recognize our strengths and our weaknesses and if that you know, if communication is your quote unquote, weakness or if this kind of goal setting and end-of-life discussion is not really what you want to do, then can you please just recognize it and then consult the palliative care team because what stinks is these people who are not really great communicators, but who then won’t counsel the palliative care team and so the patient’s suffering and they have no one to talk to. But um, I mean, there’s certainly people who are either too busy or just not engaged on on that particular level. And I think that, that’s fine, but then I strongly suggest like, Whoa, I know. And it’s not about saying, I know you’re not good at this. It’s more like I know you’re super busy and your plate’s super full. Do you mind if we just console palliative care on this patient? Because I really feel like they need that extra layer of support. And in kind of just leave it at that.

Chad Ball  50:38

That’s a beautiful way to interact with that scenario. And you know, I’m, I’m, I should say, we’re not certainly unique in in Calgary, but, boy oh boy, we have some pretty great relationships with our palliative care folks, both on the oncology side, as well as on the trauma side, and we’re grateful.

Melissa Red Hoffman  50:58

Yeah, health care teams are amazing. And and, you know, and that does speak to the other thing about palliative care teams, the, you know, there’s not enough palliative care physicians in the world. I mean, we know that when you look at the fellowship training spots every year, and so we do have to remember that they are a limited resource. So I do think that yes, while I can forgive that surgeon who is, you know, really meant to just be in the operating room, and doesn’t want to engage at the same time consulting someone like consulting palliative care to establish a code status is not appropriate, no, you are operating on the person, you establish the code status, you know, now it gets hectic and they have, like, all these unforeseen complications and all that I of course, 100% understand consulting, palliative care, but we just have to remember that this team is a very, very limited resource, and we have to use them wisely. And I think that we’ve been seeing that so much in the last year throughout the world that like, there’s only so much of the palliative care team to go around with all this death and suffering that that’s happening. And so we all kind of have to step up. And, you know, a lot of times it’s it’s doesn’t have to be this long drawn out discussion. Like a lot of times again, as I was saying, people kind of know what’s going on in their bodies, if we can hold a little space, and a little time for them to just talk like, a lot of times people can really tell you what, what they need, if we just ask some of those very pointed questions.

Chad Ball  52:36

Yeah, that’s again, beautifully said you know, there’s no question you’re exactly right that nobody should show up in an operating room for a classic intersection or a Whipple without having had that discussion in a in a tempered calm, you know, quite potentially beautiful way in clinic before they they arrived for sure. I guess most importantly, we can’t thank you enough for being on the podcast today. You’re amazing what you contribute is amazing. And you’re changing the world clearly of surgery and beyond by doing what you do. So I hope you never stopped. The last question that we always ask almost everybody is if you were to go backwards in time and give your younger self, maybe some some advice that the experience stage self knows now well, what would that be? What would you tell yourself?

Melissa Red Hoffman  53:33

Ah, I’d say girl, you’re enough. Keep shining bright, keep showing up. And I used to have a hard time showing up just like show up. That’s where the magic happens. I have found that in my life. So much like so much magic has happened for me in the last couple years. Because I’ve just shown up, I’ve just invited myself to the table. And then once you’re there, people just assume you’re supposed to be there. And then I wish I wish I knew that when I was younger, I was always just so anxious, didn’t want to step on toes felt shy and you just got to push through it, you know, so I would I think that’s what I’d say. And then there used to be a lot of angst around me in residency wearing glitter eyeshadow, which I never stopped wearing. So I tell myself, it’s okay to wear glitter eyeshadow, you’re going to be just fine.

Ameer Farooq  54:33

You’ve been listening to Cold steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So feel free to email us at podcast.cjs@gmail.com or connect with us on Twitter @CanJSurg. Thanks again.