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Surgical Palliative Care: A Podcast with Red Hoffman



The cross-over episode is an American tradition that is near and dear to my heart.   My childhood is filled with special moments that brought some of my very favorite characters together.  Alf crossed over with Gilligan's Island.  The Fresh Prince of Bel Air crossed over with The Jeffersons. Mork and Mindy crossed with Happy Days and Laverne and Shirley at the same time.  To honor this wonderful tradition, GeriPal is crossing over with the Surgical Palliative Care Podcast for this weeks podcast!


The Surgical Palliative Care Podcast is hosted by Dr. Melissa "Red" Hoffman.  Red is both an acute care surgeon and hospice and palliative medicine physician in North Carolina.  She has been podcasting since this beginning of this year and my goodness she has been quite busy in doing so. Her podcast featured some of the founders and the leaders of the surgical palliative care community, including Dr. Balfour Mount (the father of Palliative Care in North America), Robert Milch, Zara Cooper, and Diane Meier.   That's an amazing lineup.

We also welcome Joe Lin as a co-host for this topic.  Joe is a surgery resident and palliative care fellow at UCSF.   We talk to both Joe and Red about
  • How they got interested in the intersection of surgery and palliative care
  • How the culture of surgery and palliative care differ (and the misconceptions that both fields have of each other)
  • What the day in the life of a surgical palliative care physician looks like
  • A recent article in JAMA Surgery titled "Palliative Care and End-of-Life Outcomes following High-Risk Surgery"
  • What palliative care skills all surgeons should have (primary palliative care)
  • And lots of other topics!
So take a listen and check out Red's Surgical Palliative Care Podcast.



  


You can also find us on Youtube!

 

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TRANSCRIPT

Eric: Welcome to the GeriPal ... Wait, this is not just the GeriPal podcast. This is a combined-

Alex: GeriPal and the Surgical Palliative Care Podcast.

Eric: With Red Hoffman.

Alex: With Red Hoffman. Red Hoffman is an acute care surgeon in North Carolina and host of the Surgical Palliative Care Podcast. Welcome to your own podcast and our podcast, Red.

Red: Thank you for having me. I'm so excited to be here.

Eric: Thank you for having us on your podcast. Look at that.

Alex: How about that?

Red: Thank you.

Eric: This is a GeriPal first.

Red: Awesome. Thank you, guys.

Alex: We have Joe Lin in studio here. Joe is a UCSF resident in surgery, who is also right now completing his palliative care fellowship. You've been on the GeriPal podcast before, right, Joe?

Joe: I have.

Alex: Welcome back as a guest and guest host.

Eric: So we're going to be talking about surgical care, but before we do, we always have a song request. Red, do you have a song request for Alex?

Red: I do, Alex. I would love if you could play me Africa by Toto.

Alex: Why?

Red: Well, this is one of the two songs that my dead father comes to visit me with on the radio. So I thought it was appropriate given today's topic.

Red: And that is meant to be a happy thought, not a morbid thought.

Alex: Yeah.

Eric: Do you want the Toto version or the Weezer version?

Alex: They're kind of the same.

Red: The Weezer version is great too, but they sound very similar to me.

Alex: They do. I was like why did they cover it if they're just going to karaoke the same song?

Eric: It's the exact same song.

Red: Because it's so great to sing, that's why.

Eric: You know a funny thing about Africa? So my car loads my songs up for me. Every time I start my car and my phone gets on the Bluetooth, it plays Africa every single time.

Eric: Because it's "A" and we are so sick of that song. [laughter]

Alex: So you know this song. Eric and Joe will be joining in on this song, join in on the chorus. Here we go. (singing)

Eric: (singing)

Joe: (singing)

Red: You guys rock. Thank you.

Eric: No, despite actually hearing that song on a multiday basis, I actually still have no idea what the words are. I thought it was I catched some rays down in Africa, but it's I blessed some rains down in-

Alex: I blessed the rains down in Africa.

Eric: Rains, yeah.

Red: Oh, I thought they were catching waves down in Africa. [laughter]

Red: Whatever, it sounded great to me. Thank you.

Eric: That's great. Joe, what'd you think they were saying?

Joe: I was reading the lyrics. [laughter]

Alex: Well, a topic of today is surgery in palliative care. We often like to start this podcast by talking with both of you about what got you interested in this area. As you note in the introduction to your podcast, Red, there are like, what, 79 surgeons trained in surgery and palliative care. I wonder, starting with you, Red, if you could tell us a little bit about your journey and why you became interested in these two, to some people, seemingly disparate topics.

Red: Sure. Unfortunately, my dad was actually killed 26 years ago now, and it really changed the trajectory of my life. In the end, it made me extremely interested in trauma, which is what I ended up pursuing, but also really interested in grief and the isolation that can come when something tragic and unexpected happens.

Red: I was very lucky. I went to medical school in OHSU in Portland, Oregon. Oregon's the birthplace of Death with Dignity. It's where the POLST form was born. And so, palliative care was just well-integrated into my medical school training. So I ended up developing these dual interests that eventually I was able to pursue.

Eric: How about you, Joe?

Joe: I started to get interested in medical school, there was a well-integrated geriatrics and palliative care course in our undergrad education, and then clinically fell in love with surgery. Then coming to residency here, I was having such a fantastic training and really loved everything I was doing, but just felt like there was this piece missing of having both the time and the training to address that aspect of our patient's care. And so, the pieces just fell into place for me to do this fellowship, and it's been great.

Alex: I love this. Normally we interview internists, researchers, and they give us 10-minute answers and we have to interrupt them and cut them down. Surgeons, surgeons.

Eric: That's the point.

Alex: Concise stories. Very concise stories. [laughter]

Red: Got to keep moving forward.

Alex: Right. I'm interested to hear from both of you what it's like to train in palliative care. Now, Joe, you're doing this now in the midst of your surgical residency. What do your co-residents think about this? Then we'll turn to Red after hearing from you, Joe.

Joe: I think a lot of my ... Pretty much universally my co-residents are super supportive and think that makes a lot of sense, and I think, in some ways, wish a little bit that they could have time to do this sort of thing, too. It's definitely very different, though. I think whereas all my co-residents are going to lab or doing clinical research type stuff, I'm still going to work and on the pager. But the work itself is actually incredible and really rewarding.

Eric: Was there a shift at all, going from the surgical pace to more of the palliative care pace of things, or was it just natural, like it felt the same?

Joe: It definitely shifts in the pace and timing and stuff. I mean certainly not starting the day at 5:30.

Red: Bonus. [laughter]

Joe: 6:15 [laugher]. But a lot of it, I think, is the same. In surgery, we're working with really super sick patients all the time, with really complex symptom management and psychosocial needs. And so, a lot of that was very similar. I think the difference was just having the time to address a lot of those things, and then also the multidisciplinary team to support me as both a learner and a provider for those patients.

Alex: And, Red, how about you? As I understood, you did surgery first then palliative care.

Red: That's correct. I did surgery then surgical critical care and then a fellowship in palliative care.

Alex: And then palliative care. How was it to train in palliative care after coming out of all of that surgical training?

Red: Well, in some ways, some of the feedback was even more painful. It's very common in surgery to hear that you suck basically constantly. But you don't take that so personally. But in palliative care, some of the feedback I got was very personal. For instance, I tend to have a resting smile face, like I just have a natural smile on my face, and the feedback I got was that, "That smile seems inappropriate during these family meetings." I was like, "That's my face." I was not sure what to do with that feedback.

Red: The pace was certainly slower, and sometimes actually my attendings, who were lovely and great and very supportive of my being a surgeon and wanting to go back to being a surgeon, they would just say like, "We're just sensing the surgeon in you today. Slow it down, settle in. You don't have to be in a rush. Here you really have the time to just sit and be." So I learned a lot. I came in thinking I was so great at communication, and I was humbled by how much I had to learn.

Red: Then one more thing, as Joe said, that support of that interdisciplinary team, it was just incredible to be around, for the patients and really for myself, too. I've really tried to take that and tried to bring that back into surgery a little bit. It's like now I'm really tuned into, well, this is my team and I need to take care of everyone else now. I need to make sure that the nurses are feeling okay as well and that my residents feel cared for. So I feel like I learned a lot about how to be a good team leader.

Eric: So what does that actually look like, to be somebody trained in both? Surgical palliative care, is that a palliative care specialist or a surgeon who's a palliative care specialist working with palliative care teams? Is that a palliative care specialist who does surgery? What is surgical palliative care?

Red: Well, as far as how that manifests in life for these 79 or 80 people who are currently board-certified, all of my colleagues, everyone has a different career path. So for me, I work full time as an acute care surgeon. I do a ton of primary palliative care. Then I pick up some hospice shifts on the side.

Eric: And a podcast.

Red: That's right, and I have a Surgical Palliative Care Podcast on the other side. I have one friend who does palliative care and have time for surgery. I have another friend who doesn't operate at all anymore and just does palliative care. So it looks very different for everybody.

Eric: When we think about palliative care in surgery going together, do we have any data around surgical palliative care or palliative care for surgery patients, a separate kind of now let's focus on the patients?

Red: Well, that seems like a good intro into an article we just read. Do you want to talk about it?

Eric: Yeah. Do you like that leading question?

Alex: That's good. The article is titled Palliative Care and End-of-Life Outcomes Following High-Risk Surgery. It's by Maria Yefimova, who is a nurse researcher at the VA Palo Alto. It was published in JAMA Surgery recently.

Alex: Briefly, what they did is say this is conducted in the VA healthcare system. This was a retrospective study, meaning they looked back at people who'd had high-risk surgeries, and had palliative care consults within 30 days before or after surgery or not, and outcomes. They looked at family reported ratings of care, communication, and support.

Alex: My read of this is that palliative consultation, I mean I'm interested to hear what stood out to both of you. Maybe I should start there. What stood out to you, maybe we'll go to you first, Joe, about their findings here in this study?

Joe: One thing, I guess I was maybe more pleasantly surprised by there's a fairly high proportions ... I guess from a pessimistic view. The proportion of people who actually got palliative care consultations, about a third, to me actually was like, "Oh, that seems not bad."

Alex: A third of all decedents, decedents.

Alex: Of the ones who died, about 30% had a palliative care consultation.

Eric: Yeah, I think that shows a lot of what's ... So this is the VA, and the VA has been doing palliative care for a long time. There's a very big push to get palliative care. That number does seem also a little high too, so I wonder does it include folks who also transitioned to the hospice unit. But it's remarkable that a third of patients sought palliative care in that time frame.

Red: But I would say what was a bit disappointing were all these people ended up dying, and yet less than 6% of them had a palliative care consult before surgery. And so, it does beg the question were these surgeries in line with their goals of care? So that's where I see room for improvement.

Eric: Yeah. Do you think there's a role for palliative care before high-risk surgeries?

Red: Well, the world that I work in, trauma and emergency general surgery, that would be considered a luxury, and we don't often get that. Although I do feel that surgeons should be doing their own primary palliative care, and so that we should be having discussions beforehand to make sure that we're giving goal-concordant care to our patients.

Red: But for a lot of these surgeries, they were high-risk surgeries, but they were not all emergent surgeries. And so, for these patients, obviously, I think, the people who died, most of them, they had four or more comorbidities. I mean these were high-risk surgeries and high-risk patients, and so, yes, I would like to see palliative care be involved beforehand.

Red: But another point that it makes in this paper is that we didn't pick up if the surgeons were doing their own primary palliative care, which I do feel like a lot of surgeons are probably having some sort of discussions with their patients, but you can't pick that up in a retrospective chart review.

Eric: Do you feel like in training programs, there's a lot of palliative care being taught to surgeons?

Red: Joe, what do you think? You're in training.

Joe: Right now, no, but we're working on it. I have another research here next year, and I think a big part of what I'm going to be doing is trying to integrate what I'm learning in the palliative care fellowship into our surgery training program.

Red: I'll tell you, I think I had absolutely no palliative care training in my institution, and we didn't even have a palliative care team. So there was a lot of patient suffering and then also resident suffering, because we didn't necessarily have the skills to address the patient's suffering.

Eric: The one reason I really like this study is if I think back to 10, 15 years ago, we were just building evidence bases around palliative care. A lot of it was focused on cancer and working with oncologists. Because we didn't have a lot of studies showing benefit, it felt like it was an uphill battle. I don't think I can think of one randomized control trial in surgical patients doing palliative care. And so, this really gives us some evidence, at least for decedents, that their outcomes were actually better as far as the care provided through this brief family member survey.

Red: It's an outcome that matters because the patient died and who's left? It's the family, and they are left with this legacy. And so, this matters. I mean, yes, I certainly think it's important to look at 30-day and 90-day mortality in these high-risk schools surgeries as well, but the fact that we're looking at the people that are left behind. To me, that's so much of what palliative care is about. We're caring for the patient, but we're really also providing care to the family.

Eric: When we think about training for surgeons, what do you think the most important parts of primary palliative for a surgeon is?

Red: For me, when I think of primary palliative care skills, I think of being able to conduct a family meeting, being able to have a good goals of care discussion, being able to discuss code status, having some basic understanding of symptom management, which, as Joe pointed out, I mean we do a lot of that as surgeons.

Red: And, lastly, having some understanding of hospice, that there's a difference between palliative care and hospice, who qualifies, and more importantly for me is where is this hospice care going to be given, because I've seen many surgeons walk in the room, like, "All right. Well, go to hospice." Well, what in the world does that mean? So having some understanding of how to negotiate the hospice system. So I think those five skills, if I could have my way.

Eric: Yeah, the other question I have is we have every intern on medicine rotate with our palliative care service. It's not for very long, it's just for a week. Should we be doing similar things with surgical interns? Either of you can respond to that.

Joe: Well, I think this whole year has been great for me, but I can see definitely how a shorter course would be really great. I think if we could make it work with scheduling, that'd be fantastic.

Eric: Red, what do you think?

Red: Well, I would love it. At OHSU, Karen Brazell, she has all the interns rotate for a month on the palliative care team. At my institution, I wanted to make that happen, but I think the palliative care team feels overwhelmed, so that we have to get buy-in from them as well, because it's a whole another group of learners. Though I tried to explain to them that surgery residents were some of the hardest working people in the hospital and will probably write a lot of great notes for you and get it done. But I understand that it puts a burden on a team that's already working so hard and is already stretched thin. To have a whole another group of learners on the team is challenging.

Eric: I also feel, though, a lot of this is about relationship-building. A lot of the early stuff between palliative care services and in oncology services was about relationship-building. I feel like the relationship-building between surgery and palliative care, there's a lot of room to grow there, for both sides to learn about each other's cultures.

Alex: Right. It's one of the reasons that the consult rate was so low. I mean on the one end, as Joe says, oh, 30% is better than expected. On the other hand, as Red pointed out, it was like 5.6% before surgery. We can do better. A lot of these patients were older and sicker and they ended up dying.

Alex: You're absolutely right. The people who we rotate with now, those interns, they go on to be chief residents and then they go on to be attendings. We have really strong relationships with them because we've known them for years. Whereas we don't have that same sort of developing relationship with the surgery residents.

Red: It's actually really interesting. It's a good way for me to think about selling it back to the palliative care team. In the end, it's a consult-based team. If you want more consults, get to know these people young and they will consult you.

Eric: Yeah. Going from surgery to palliative care, we talked a little bit about misconceptions about palliative care from the surgical standpoint, like what is palliative care, what's hospice, what can hospice do. Were there misconceptions about surgery that you saw from palliative care providers or surgeons?

Red: I think we've earned some of our reputation that we have in the hospital for being a bit short with people sometimes and not having great communication skills. What I found, though, is that sometimes there's a little bit of a lack of understanding of how deeply the surgeon is connected to their patient, especially after they operate on them. There have been studies that have shown once people have operated on people, they tend to overestimate the likelihood of them surviving. It just clouds our judgment.

Red: And so, I think it's just difficult to understand what it's like to truly take someone's life, especially someone's life that may have been previously healthy, into your own hands and then perhaps have a devastating complication. Then the palliative care team's getting involved. So I found myself just doing some education around that.

Red: The other thing I found was it's hard if you're not a surgeon to really understand what the typical course of a surgical patient is. When you think of something like a Whipple, I mean as a surgeon I think not if you're going to have a complication. It's what complication are you going to have.

Red: So we have perhaps sometimes, as surgeons, a higher threshold for our patients suffering, because not that we want them to suffer but we know that this is just going to be this long, rocky course that still might end up well. Sometimes we just get lost in that and we can't see the forest for the trees and that sort of thing.

Red: But I did find that even as a learner, as a palliative care fellow, people are coming to me and saying, "Well, explain, how does this work?" or, "What are we expecting here?" So there was a lot of relationship building there for me.

Eric: Yeah. I loved having Joe on our service as somebody who's in the middle of surgical training, because one day he drew up on the board what do efferent/afferent loops look like for post-Whipple patients, because I had no idea what people were talking about.

Red: Yeah.

Eric: Just that collaboration and that relationship ... Did I even get that right. Is it post-efferent?

Joe: Yeah.

Eric: See, I learned something.

Red: You got it.

Alex: Joe, any thoughts from you about perceptions of palliative care from within surgery?

Joe: It's a spectrum, I think. I think a lot of surgeons, like Red was saying, either knowingly or unknowingly are doing a lot of palliative care, primary palliative care, themselves, navigating difficult medical decisions with families. But, yeah, in speaking with, at least here, different attendings, there's different levels of willingness to involve another team and what they feel like decisions regarding surgical diseases that just falls under the purview of the surgeon-patient partnership.

Joe: For example, one attending told me that he just doesn't like calling palliative care. He knows that they can help, but he feels like when he has to call them it's because he has nothing left to offer. He can't do anything else for the patient. And so, it's almost like a demoralization for him to call another team to help.

Alex: Yeah, it's like a sense of defeat or loss or regret.

Joe: Exactly.

Alex: Yeah, rather than a wonderful partnership for a patient who's seriously ill, who may have a variety of different outcomes including death, but also including return to function and survival.

Red: Sometimes it makes me wish ... In some of these situations, I don't practice in a place like in an ICU where there's automatic triggers. But sometimes you can see where an automatic trigger like if a surgical patient has been in the ICU for 30 days, which is a long ICU stay, postoperatively, then we're going to just call palliative care, because again sometimes I feel like the surgeons are, "Okay, this is going to be this long, rocky course." But, I don't know, 30 days in the ICU is a long time, and I've watched people suffer for months.

Red: As an ICU fellow, I was watching people suffer for months, and the surgeon was just not comfortable getting palliative care involved. Sometimes I wish we could just say, "Well, this is what's going to happen because it's the best for the patient and, again, for the family, too," the family is suffering. Sometimes the nurse is really suffering, too. And so, just for the whole team, that we can just have another layer of support.

Alex: Yeah, interesting you should bring up 30 days. Can we talk about that? There's a perception within palliative care that some surgeons are reluctant to consult palliative care because they're concerned about their 30-day mortality rates. In some surgeries, these are publicly reported or that their quality ratings depend upon the survival of patients past a certain date. Thoughts from you as surgeons about that perception.

Red: It's hard for me because I work in a surgical field that we're not really looking at that per se because so many of our patients are coming in so ill. I just would say I feel for those surgeons. I just feel for them and I think ... I just recently was talking to Dr. Zara Cooper about this. We were just talking in general about when you're starting to feel judgmental and like, oh, the surgeons just don't want the patients to die within 30 days, to really step back and try to adopt a sense of curiosity. Rather than just assuming the worst, like really what's behind that.

Red: If it's really about these reported outcomes, then I just have a sense that there are some suffering from the surgeon behind that as well. And so, I feel for them. So just kind of at least coming from a place of curiosity and trying to assume the best.

Red: I mean do some people think like that? I'm sure they do. But I really don't think that the majority of surgeons are walking around like that. I really think if surgeons don't want to consult palliative care, it's because they have a false belief that the palliative care team's going to come in and kill their patient, "kill" their patient, and convince them to go to hospice, and that the surgeons have really put their heart and their soul into this patient. They really believe that they could help them and they don't want to "give up".

Red: Now is that right? Not all the time. Is that associated with patient and family suffering? Yes. But, again, just trying to understand where they're coming from, that they got into this field for the same reason as us. We all want to help people. It just comes out in weird ways sometimes.

Red: I guess it goes back to what you said, Eric. It's all about building these relationships. We're certainly not going to build them by assuming the worst in people.

Eric: Yeah. It just reminds me is that when we do often get consult on surgical patients, it's when things have gone really, really bad. So our viewpoint also may be clouded. The truth may be somewhere in the middle. We don't know enough about these ... What does the natural course look like after a lot of these different types of surgeries?

Eric: It's up to us too to learn from our colleagues in palliative care. Is this abnormal? Is this normal? Should we be expecting this? Because I feel like we are to blame too for a lot of the poor interactions between the two fields.

Red: How so? I'm just curious. How would you ...

Alex: This is great, Red Hoffman taking over the host role. [laughter]

Eric: Yeah, okay. Pass on the mic. [laughter]

Alex: Love it.

Red: The surgeon in me is being bossy.

Eric: Yeah, I think sometimes we can come in with sometimes a too negative outlook as far as prognosis without actually first learning about what does the natural history ... What does the course look like after the surgery? I feel like where we are right now with surgery is where we were 15 years ago with oncology. 15 years ago, we got consults when things got really, really bad and the oncologist felt like there's nothing more that they could do. Everything we just said about the surgeon, that's where we were like 15 years ago.

Eric: Now we're in a place where when people are getting diagnosed with advanced cancer, we are just being consulted on those folks while they're still getting treatment. I feel like studies like the one we've just talked about are things that we need to show that working together, learning from each other, and, just like with oncology, learning, "Oh no. We expect these rocky points during this type of chemotherapy. These are the people that are going to get better. These are the symptoms that we should worry about."

Eric: I don't feel like we're having those conversations with surgeons. I don't feel like we're learning from surgeons about that. I certainly learned a lot when Joe was on our service and building that relationship.

Alex: It's great. I wanted to come back to the study, just to note that received palliative care consultation because there is a punch line here.

Eric: There's a punch line.

Alex: Was associated with better ratings of overall end-of-life care, communication, and support as reported by patients of families who died within 90 days of high-risk surgery. So in this retrospective study, families reported greater satisfaction with care and better end-of-life outcomes for persons who died after high-risk surgery and received palliative care consultation compared to those who did not.

Eric: Yeah, and after adjusting for a bunch of things, like the type of surgery. So it was a really interesting study. Again, we need a [inaudible 00:30:44] study, or an ENABLE study on surgical palliative care.

Alex: Right, right. Early palliative care at the time of diagnosis of serious surgical illness.

Eric: Yeah.

Red: Joe, I'm seeing what's going to happen for your research next year. This is great.

Eric: I think Joe's interested in education.

Joe: I might need more than a year for that.

Alex: I wanted to ask about what are the opportunity what other opportunities do you see for growth between the fields of palliative care and surgery? Are there particular domains? Surgery is, of course, heterogeneous. We should say, of course, that surgeons are heterogeneous. Some are trained in palliative care, some have no familiarity with it, whatsoever. What are the major opportunities for growth here in terms of the field of surgical palliative care?

Alex: It seems like the surgeons that I know who most understand palliative care the best, who are most interested in it tend to be trauma. We've got Red, we have Zara Cooper, both trauma surgeons, or vascular surgeons. Their patients are really chronically ill, they have severe vascular disease, and their trajectories are generally ... They may be able to fix this or that, open this pipe or that pipe for a period of time.

Alex: But, in general, a lot of body parts are slowly disappearing over time. This leads to tremendous suffering for patients with severe vascular disease, and vascular surgeons seem to be quite attuned to that. Are there other areas where there are opportunities for more growth? I know, for example, here we are rarely consulted by the cardiovascular surgeons. Interested in your thoughts on that. Joe, you want to take that one first? He's like, "Oh boy. I don't know about that."

Joe: No, I think there's definitely ... In terms of specialty, bi-specialty, a lot of room for growth beyond what's been the services that are more typically involved with palliative care. I think, for example, all the other oncologic surgeries and that we right now don't typically see. I think also end-stage liver disease has a very complex role with palliative care because it's very much like surgery or death for those patients. I think there's a big role for palliative care there.

Joe: I think, like we were saying earlier too, aside from just approaching by specialty, also integrating into training, I think, would be important. I think that medical schools are already doing a better job of teaching students about this. I was exposed early on, and so I think the residents are the next step of integrating palliative care resurgence.

Alex: Red, thoughts from you?

Red: Yeah, sure. I mean I think transplant surgery, I think that would lend itself so well. I mean I could be mistaken, but I don't know if anyone who's a transplant surgeon, who's also boarded in hospice and palliative medicine, and then, as Joe said, the surgical oncologist.

Red: Then I think another way to perhaps integrate is there's some departments of surgery that during their M&M, there's discussion around palliative care topics. But I think integrating the palliative care team into our M&M, if they were actually involved in the patient, I think would be so useful.

Red: Again, it's an ask on the palliative care team to be coming to another meeting in a room full of surgeons. But I think when we're talking about developing relationships, that's just the way to get it done, because I have been in M&Ms where we're discussing a patient death and I'm hearing the surgeon say, "Well, palliative care came and then they took over. then my patient's on hospice," and I don't know. But to hear that other, "Well, this is what I saw with my palliative care eyes when I walked in the room."

Red: I've certainly, when I'm wearing both hats, when I'm the ICU doctor, I'm doing a lot of palliative care, not only on my own patients but sometimes I'm getting drawn into the other surgical subspecialty patients that I'm caring for in the ICU, and I have been accused of convincing the family to withdraw care. And that's not assuming the best of the palliative care team or of me as a palliative care doctor. So it would be so nice to be able to have that very frank and open discussion in the context of an M&M I think is always worthwhile.

Alex: I love that idea, actually going to surgical M&Ms.

Red: You can really learn how surgeons think when you're sitting in the M&M. So it would just be a really nice insight into the surgical psyche for the palliative care team.

Eric: Yeah, and the language and the culture of surgical teams. I got one more question for you? Why a surgical palliative care podcast?

Red: Well, for me, when I was a younger resident thinking about this field, I didn't have any mentors. I started just Googling and I found Dr. Geoffrey Dunn and Dr. Anne Mosenthal, who have become my great mentors, really two giants in the field of surgery and palliative care.

Red: But I felt like, one, I really wanted to learn more about my roots. So I got to interview Dr. Balfour Mount, who's a surgeon. I mean I didn't know when I got interested in this that a surgeon was the person who coined the term palliative care. So I wanted to celebrate the founders of my field. Then, two, to get, for me, other surgeons interested in this field and talking about it and seeing what the possibilities are.

Red: Again, I'm not expecting anyone ... I think it's great that some people are doing a fellowship. The vast majority of surgeons are not going to do a fellowship. But if we can just all realize what our part is in doing some primary palliative care for our patients, I think it would be amazing.

Red: Then, lastly, I get to talk to all these amazing people, because when you have a podcast, everyone wants to talk. So I've gotten to talk to such incredible people.

Eric: I think it is absolutely ... I love your first podcast with Balfour Mount. That is amazing. It's such a really lovely podcast to listen to, at least for all the GeriPal listeners. For your podcast, who haven't listened to it, listen to that first episode. It's just really remarkable. And listen to the rest of them, too.

Red: Thank you. I really appreciate your support on this. Yes, Bal was just such an incredible man to talk to. One thing I've realized in speaking with some of the other older folks in the field of surgical palliative care, they all have the same language. It's really just this shared genetic makeup of being a surgeon, but also really being invested in everything that happens at the bedside.

Red: Multiple people have said, yes, what we do in the operating room is amazing and incredible, but there's so much that takes place at night after everything's done, when you're just sitting at the bedside holding the patient's hand, talking to their family. That's what we're about as well.

Eric: I want to thank you for joining us, and I guess for us joining you, for this combined podcast.

Alex: Did we just thank ourselves? [laughter]

Eric: I just thanked myself, giving myself a pat on the back.

Alex: Thank you, Joe, as well. Thank you, Red.

Eric: But before we leave, maybe we can get a little bit more Africa.

Alex: A little bit more of Africa.

Eric: Catching some waves.

Red: And some rays.

Alex: (singing)

Eric: (singing)

Joe: (singing)

Eric: I'd catch some waves. Red, a big thank you.

Red: That'll make my whole week.

Eric: Big, big thank you. To all of our combined listeners, thank you very much for joining us.

Alex: Thank you to Archstone Foundation.

Eric: Goodnight, everybody.

Alex: Bye.



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