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The Baylor College of Medicine Resonance Podcast is a student-run podcast aimed at showcasing the science at Baylor through the eyes of young professionals. Each episode is written and recorded by students who have a passion for research and the medical community. Guests on the show include both clinical and basic science research faculty who are experts in their fields. We hope that whoever listens in gains new insight into the exciting world of biomedical research.
My name is Race. I'm a 1st year medical student at Baylor College of Medicine. And today, I'm gonna be interviewing doctor Agarwal. Doctor Agarwal is an assistant professor at Baylor College of Medicine. She's a palliative medicine physician in the hematology oncology department at the Den l Duncan Comprehensive Cancer Center.
Speaker 1:Instead of telling you how she ended up at Baylor, something she'll talk about herself in this episode, I wanted to talk about my experience following her around for a day in her clinic. I'd worked in hospice before, so I sort of thought I'd know what to expect. Conversations on futility, overwhelming patient suffering, families in denial, difficult, and generally not so fun conversations. In short, I was expecting palliative medicine to center around death and dying. I could not have been more wrong.
Speaker 1:Of course, there were difficult conversations, but more than that, I remember doctor Agarwal making her patients laugh, her patients making us laugh, and figuring out a way to manage a patient's pain well enough so that she and her husband could set sail on a cruise together the next week. I was in such disbelief that I even asked her if that day was some sort of outrageous outlier. Doctor Agarwal admitted that there were certainly highs and lows in her work, but this was a pretty typical day. This experience is one of the many reasons I'm excited to interview her today. But before that, a little background on palliative medicine.
Speaker 1:Hospice and palliative medicine is defined by the double AMC as a subspecialty seeking to reduce the burden of serious illness by supporting the best quality of life throughout the course of a disease and by managing factors that contribute to the suffering of the patient and the patient's family. For much of medicine's history, all we were capable of really was palliative medicine. The Egyptians and Sumerians were known to use the bark of the willow tree to treat fever and pain. Medieval medicine involved ointments and salves made of wormwood and crop leak and were boiled in brass kettles. Things more closely resembling Harry Potter potions glasses than what we'd call medicine today.
Speaker 1:Nonetheless, many of these medicines work to relieve the pain and suffering of their patients, even though they may not have treated the underlying disease. The active compound in those willow trees the Egyptians and Sumerians used was salicin, which was metabolized into salicylic acid, and that turns out to be the main component in aspirin. Then came Pasteur's germ theory and Lister's antiseptic, which paved the path for the rest of the medical revolution and what we would more closely recognize as medicine today. Surgery boomed, antibiotics were born, vaccines were administered. But then around the sixties seventies, people began to wonder if our pursuit of curative medicine had perhaps lost sight of the value of palliative medicine.
Speaker 1:So the hospice and palliative care movement was reignited. By 1980, hospice care was covered by Medicare. By the nineties, it was designated as its own specialty. And by 2,000, it was gaining widespread recognition in the US. And then in 2010, a paper out of the New England Journal of Medicine clearly demonstrated that hospice and palliative care was more than an existential service for patients at the end of life.
Speaker 1:This paper showed that not only does palliative care integrated with oncological care improve patients' quality of life, but that it also increases length of life and decreased cost of care. One of my favorite quotes about palliative and hospice medicine is by doctor Atul Gawande when he said, if this were a drug, this would be a multibillion dollar blockbuster, and the FDA would put it on ultra expedited approval. But instead, it was just having these conversations. And with that, I'd like to welcome doctor Agarwal. Howdy, doctor Agarwal.
Speaker 1:Thank you so much for joining us. I'd like to start off with the classic introductory questions. How'd you end up here today from hometown to college to medical school to Baylor, And how did you choose palliative medicine?
Speaker 2:Oh, man. How did I end up here? Well, to be honest, I had no idea I was going to be a physician, let alone a palliative care physician. I used to wanna be a cashier as a kid as I really loved math. I was raised in Sugar Land, Texas, not too far from here, brought up in a big fat Indian family who emigrated in the early eighties, all eventually creating their own businesses.
Speaker 2:I had the one family who did not actively wish for their kids to go into medicine. But I loved math and science, so medicine seemed like the thing to pursue. I went to college at WashU where everyone was pre med. And despite the whole look to your right, look to your left, only one of you will finish pre med, And I was between 2 very smart Asian guys. Somehow, I came out still pre med.
Speaker 2:Afterwards, I wanted to spend a year in India working at a women's shelter, but tensions got heated between India and Pakistan for, like, the umpteenth time. And my parents were like, nope. We don't feel comfortable with you going. And this was like the middle of senior year. So, I had to scrap my plans and try to figure out something else.
Speaker 2:Given that I wasn't really completely sold on medicine and my parents were telling me, are you really sure you wanna waste your good years in medical school? I did a year in Philadelphia where I took medical school classes
Speaker 1:to see if this was really what
Speaker 2:I was interested in. And that's where this path started making sense. I went to Texas A&M for medical school, where not only did I meet the love of my life, but I also felt like I had a system rooting for my success. And I thrived and my love for medicine and patient care grew. I followed my husband to Georgetown University for internal medicine residency thinking I wanted to be an oncologist.
Speaker 2:Then my 1st month came along and I was in the medical ICU, and I fell in love with that field as well. So fast forward to 2nd year of residency, I had a mid residency life crisis not knowing what I wanted to do. Oncology versus critical care. And I realized what they have in common. Very sick patients who need not only medical life prolonging interventions, but also a hand to hold, more conversations, and more of a focus on their quality of life.
Speaker 2:I realized I really loved being in the room talking to patients when other people were stepping away. I did a palliative care rotation, and I believe it only took about 2 hours for me to be like, yep. These are my kind of people and I really love this work. I will never forget tweaking someone's medications, seeing them the next day, and they had tears of happiness saying they couldn't remember the last time they slept through the night without pain waking them up. I was like, man, this feels awesome.
Speaker 2:I wanna feel like this every day. Prior to that, I had never felt that, you know, that kind of warm and fuzzy feeling when I got somebody's blood pressure down. Feeling when I got somebody's blood pressure down. Their symptoms is what I really cared about and brought me so much joy and wanted me, you know, made me wanna come to work every day. I then went on to complete my hospice and palliative medicine fellowship at MD Anderson Cancer Center, And I eventually made my way to Baylor where somehow I got very lucky and I got the opportunity to create a palliative care clinic and inpatient service dedicated to the care of patients with cancer.
Speaker 2:We're embedded within the medical oncology clinic where I get to see patients alongside their oncologists to provide really good coordinated care. It's just the best job ever.
Speaker 1:And so was the deal that you follow your husband to Georgetown and then he'd follow you to Baylor?
Speaker 2:Oh, you know it. I have a big, fat family in Houston, and I knew once we got there, we wouldn't be going anywhere else. So, that was the agreement. I followed him for residency. He followed me for a fellowship.
Speaker 2:But I didn't tell him what my plans were all along. Now he's stuck here. Now he loves it.
Speaker 1:And so I gave the AAMC's definition of hospice and palliative medicine, but I was wondering if you could give us, doctor Agarwal's official or unofficial definition of what you do.
Speaker 2:So I practice in palliative care. I am boarded in both hospice and palliative medicine. But day to day, I practice in palliative medicine. Palliative care is a specialty focused on quality of life for patients with serious illnesses. We help support patients through the course of their illness, get a better understanding of what they value in their health care so we can advocate for them.
Speaker 2:We help set appropriate expectations, and we also try to help their primary caregivers as the patients aren't going through this disease alone, but rather with their whole village. Hospice, on the other hand, is provided when the patient has an illness where their physician says, I wouldn't be surprised if this patient passes away within 6 months, And, no further disease modifying treatments are being pursued. So, they focus on allowing nature to take its course while providing comfort and minimizing suffering. This is usually like a multidisciplinary team who comes to the patient's home to provide that kind of care. So, there are different things.
Speaker 2:Hospice, you could kind of consider it like the tail end of palliative care, but palliative care itself is a broader scope, and can be integrated at any point in the disease's trajectory. A typical week for me is split about half and half between inpatient service and clinic. And, you know, like I said before, I get to work alongside our awesome oncologists in providing coordinated care to our patients. And in the hospital, oftentimes, we're dealing with acute symptom crises, cancer related complications, and sometimes even having very difficult conversations about this huge life change that they've gone through and what lies ahead. While in the clinic, we are able to sit with the patient, discuss what everything means, what their hopes are, what's stopping them from being able to live their lives the way they want, and what we can do about it.
Speaker 2:I really do think here at Baylor, we've got this unique service where we get to follow our patients from the clinic to the hospital and back, and we really provide excellent continuity of care.
Speaker 1:And so in medical school, we're taught about the ubiquity of uncertainty and the necessity for a good physician to be able to navigate it. What does uncertainty in your specialty look like, and how have you learned to navigate it?
Speaker 2:So my specialty is fraught with uncertainty. It's very humbling, and I think it keeps us grounded as physicians. The way I navigate it is by simply acknowledging it. It's oftentimes the elephant in the room and it's okay, even as physicians, to say, I don't know. I too often tell my patients that I'm not God.
Speaker 2:I don't pretend to be God and I have no crystal ball. All I can do is present evidence based medicine. But they're a person. They're not a statistic. I will share those statistics if they want to know that.
Speaker 2:But other than that, I can't see into the future. Even when asked to give a prognosis, I say minutes to hours, hours to days, days to weeks, weeks to months, etcetera. I often say, I worry that they may not survive the night or I wouldn't be surprised, but I will never say things in certain terms because, again, I can't see into the future. Some of my patients joke with me saying, Yeah, yeah, I know. You're a physician.
Speaker 2:You're never gonna say anything with certain terms. And I say, yeah. That's true. We don't know. We have no idea.
Speaker 2:And we're constantly surprised by people, both for the better and for the worse.
Speaker 1:You talked a little bit about how you manage it, and I was wondering how you think your patients manage it. Like, you just kinda you just used an example of humor in saying like, oh, I get it. But what sort of coping styles have you seen in your patients?
Speaker 2:Yeah. So, you know, they say when it comes to coping, the way you cope with something is the way you've coped with things all your life. And so, every person is different and their life experiences really dictate that. So, usually with patients, one of our, you know, mottos that we talk about is taking things one day at a time. And it's something that we say very often and they repeat that back too because for a lot of them that's how they feel like they are taking things is one day at a time.
Speaker 2:I have some patients who say, hey. If I'm awake and I'm alive and, you know, I'm doing okay for the most part, it's gonna be a great day. And so it really is one day at a time given that kind of uncertainty. You know, we try to provide the tools that they need to cope in a healthy way but coping is extremely complex. One thing I wish all of our patients had access to, which we're actually actively working on, is having access to a psychologist because I do think every one of our patients could benefit from that.
Speaker 2:And I'm really happy to say in a few months we're gonna have our own psychologist who is able to see, you know, any of our patients who have those needs. But they can only do so much. I can't change family dynamics. I can't change the experiences they've had about losing another loved one to cancer in the way that they deal with it. But I can try to just be there for them, let them feel like they have a safe space where they can talk about things.
Speaker 2:I do think, you know, it's a really humbling position to be in where people can do, people can share how vulnerable, they feel. And some of their deepest darkest fears that they don't talk to other people about. They don't talk to their own family about for fear of how they may take it. And so I do think we we are very lucky that we get to have this kind of sacred relationship with our patients. And it's important to take that seriously and do whatever you can to support them.
Speaker 1:Mhmm. I might be biased because I'm such a fan of palliative care, but, it's really evident that relationship, you know, people call medicine a science and an art. And whenever you talk about that sacred relationship and having those that, no man's land conversation with these patients, that becomes really clear.
Speaker 2:Yeah. So actually, you know, when I was in residency, especially my intern year, there were times where with certain physicians, I felt like we had one conversation outside the patient's room and then we would go in and say something somewhat different where we didn't talk about our concerns and when it was like, come on, you can do it type of thing. And I would be like, but we just talked out there about how the chances of response are so low and what? There's just this disconnect. And the patients are looking to us, to give them the best treatments possible but oftentimes to also be, you know, transparent and honest about things.
Speaker 2:Why would we ever recommend something we didn't think would could potentially help? And yet, very often, we do that because we don't know what else to do. And so, I think that this kind of relationship we have, we have with patients is, is something not to take lightly and really, it's so important. I always tell all my patients, I can't speak for other people, but for me, you will always get honesty and transparency as much as you want. Because everyone, you know, they take information differently.
Speaker 1:Mhmm. One of my favorite scenes from a movie called Interstellar, have you seen it Mhmm. With Matthew McConaughey?
Speaker 2:Yeah.
Speaker 1:You know the robot? It's, like, SARS or VARS or something.
Speaker 2:I don't remember the robot's name.
Speaker 1:It has well, it has an honesty setting. And throughout the movie, it changes from, like, you know, whenever I think he reduces the honesty setting because he gets tired of the robot, like, saying all this really dark stuff. And I think he also has a humor setting or something like that. And so I I feel like being in your position, you you modulate your
Speaker 2:Oh, absolutely.
Speaker 1:Your settings.
Speaker 2:Absolutely. Like, there are times where when I'm working with a resident, I'll be like, look, they understand the severity of their disease. Every time I see them, I don't have to sit there and be like, you know you have a stage 4 cancer and this is what this means. You you don't need to beat them over the head with what is going on. Most of your patients have a very clear understanding.
Speaker 2:And once you've established that they do understand things, you move on. You talk about what makes, you know, what helps them have a good day and what their every day is like. And you don't have to keep beating them over the head with it. You talk about, where did you go on date night recently? Do you have restaurant recommendations?
Speaker 2:I had a patient who loved telling me about the massages she would get around town and fun Korean spas. Wanna talk about those things.
Speaker 1:That that sort of leads into another question that I have about, the language surrounding your specialty. How do you understand how do you, yeah, how do you understand and deal with language? Like, he's a fighter. Don't give up on me. We'll do everything it takes.
Speaker 1:We'll beat this.
Speaker 2:I think I hear this in some capacity probably almost every day but here's the thing, my patients are super tough. They give it their all and we don't give up on them. I remind our patients and especially their family members, because usually the language is coming from the family members, that this is a disease happening to them. There is some that's in their control. Compliance with treatments, appointments, relaying to us their symptoms, staying active, nutrition to a certain degree, you know, not smoking, but then there's a lot that's not in their control.
Speaker 2:The way the cancer responds to the treatment, for example, it's not in their control. It's not really even in our control. As the medical team, we use our expertise to give them the best treatments for that patient, balancing between efficacy and quality of life. And then after that, time will tell. We'll always be there for the patient, walk with them, provide with them you know, provide them the best care possible, and remind them that the cancer does not define who they are.
Speaker 2:If the cancer does not respond the way we hope, the patient hasn't failed. They've not given up, but rather the treatments have failed them. We're also limited by the treatments we know of and clinical trials that are available to us. If we run out of cancer modifying treatment options or if the risks outweigh the benefits, it's because we haven't come as far as we would like in medicine. So I tell people, there's no doubt that they're extremely strong.
Speaker 2:No one thinks that they're giving up. And we're absolutely, you know, gonna do everything we can to help, get through this, but we are also limited. And not everything's in our control and not everything is in our poor patient's control. So, reminding them that this person is not cancer. This they're a person and cancer is happening to them.
Speaker 2:I think that can be really helpful for trying to kind of separate the 2. But I never refute them when they say those things because I think I would feel the same way if I were them.
Speaker 1:How how's it been dealing with, we talked about patients, but how's it dealing with family members? How how does that experience vary?
Speaker 2:So I really do think, especially when dealing with a disease like cancer, your support system can make or break your experience. I feel so horrible for the for the patient to have no family or friends here. Whether that's they've immigrated from another country, or, you know, they've lost touch with people or we've had patients who have lost all of the closest people, around to them to other illnesses and oftentimes to cancers. It is so difficult to go through this journey, whether it's your calendar being full of appointments, simple things like transportation, feeling so weak, feeling so terrible, you feel like you can't drive, getting sedated on medications and you can't drive, how much gas costs, and you're already hemorrhaging money by having to meet all your deductibles and co pays. And and all of our patients pretty much meet their deductibles in January.
Speaker 2:Like, having cancer is a very expensive disease. You can't work. Very commonly, people aren't able to work as they go through through diseases and trying to keep your insurance during that time can be really difficult. I mean, all of these things. And if you have nobody to help you with these things, to make you a meal when it's really hard for you to go to the grocery store, get the food, make something, you know, stand for that long and do these things.
Speaker 2:I mean, it's it's so, so difficult. Family can be extremely family or friends, whatever your support system really can can I truly mean it when I say they can make or break your experience. They can provide you so much support in terms of all of these other things that we mentioned that can be in your control. Making it to your appointments, staying on top of your nutrition, motivating you to get out of bed and walk around, things like that. Now, of course, family has its pros and cons.
Speaker 2:We've had where, you know, a family member said, oh, don't take any chemo. That stuff is gonna kill you. And then a person's, you know, condition has declined significantly, when that could have been avoided by, you know, by other types of treatments. Or the person at church who tells you to take the worm medication as they know this person whose cancer was cured by this and they convince you not to do those things. We've also had family members who are convinced that doctors have a silver bullet for cancer, but we just refuse to give it because we'll be out of business.
Speaker 2:And I've actually, probably just this year alone had this conversation at least 3 or 4 times with different people about how if we had the cure to cancer and we were just sitting on it, wouldn't we at least give it to our family and friends, the people that we love? And does it really make sense that we would keep it from people? I try to remind them that, you know, going into medicine is a very difficult thing. You don't just do it on a whim. The vast majority of people in medicine are in it for the right reasons.
Speaker 2:They wanna help people. So if we had something that could actually cure cancer, why wouldn't we be acting on it? You know? And unfortunately, misinformation spreads very quickly, especially through things like social media. And there are so many people who will comment on do this, do that, do this, do that.
Speaker 2:And I do try to I try to help be that person who's like, okay. Tell me all the things that you're hearing. Let's go through things 1 by 1. I try not to refute it right from the beginning, but we talk about what's the evidence behind what they're saying? Is it gonna drain all your money?
Speaker 2:How can this be an adjunct to your treatments? And so very commonly, we end up talking about, you know, herbal supplements. We've recently been talking about marijuana a lot, other drugs, vitamins, etcetera. And so I try to make sure that the family feels that they're being heard because they're always coming from a good place where they're, like, they want to help. But sometimes you have to balance that with, you know, the actual science part behind
Speaker 1:it. Mhmm. Sonia, you brought up that I ignorantly haven't really given a lot of thought of, and it deserves an entire conversation of its own, is the employer based structure of health insurance and how so many people who are getting treatment for cancer lose their jobs. And so that means so many of them are gonna lose their insurance.
Speaker 2:Yeah. Actually, just this morning, I was seeing, someone in the hospital who had just started concurrent chemo and radiation and when you start radiation, you need to continue all your treatments. And it's, for her, it's 6 weeks of radiation And she was going to be starting her chemotherapy this week, and she comes to check-in. And she gets told your insurance plan was terminated. This is how much chemo's gonna cost out of pocket.
Speaker 2:Doesn't we don't even know how much radiation's gonna cost, but that's gonna be, what, another five and a half weeks of treatment. And it had to do with the fact that when she got diagnosed, she had to stop working, and then she went on her husband's plan, and then her husband's had to leave that job in order for it to be something a little bit more flexible such that he could be there for his wife. So now she doesn't have health insurance. She's already started 3 treatments of radiation. You can't go a long period without just having to kind of discard those 3 treatments.
Speaker 2:And, also, time is of the essence. At the moment, she has a potentially curable disease. But now because of this, I don't know what's gonna happen. So I'm frantically calling her oncologist. We're trying to figure out a plan.
Speaker 2:We've got social work on the phone. We're trying to figure out, can she apply for Medicaid? Can we go through the can we go through Harris County? And the thing is all of these things take time. And I don't know what's gonna happen to the cancer in the meantime.
Speaker 2:And on top of that, we started her on treatment. We started her on, you know, we started her on radiation and it was, like, all for naught. I feel terrible for her. It's it's a horrible system. It it really is.
Speaker 2:And, unfortunately, those of a lower socioeconomic status are absolutely, are absolutely hit harder. Luckily, in Harris County, we have an awesome system but we get so many patients from Montgomery County, Fort Bend County, all these other places that don't have, these kinds of resources for those patients.
Speaker 1:That's one thing I didn't know about, Harris County before coming here was how good of a job it does of taking care of its own, but that doesn't mean that people aren't left falling through the cracks here.
Speaker 2:Yeah. Absolutely.
Speaker 1:So I'm gonna pivot a little bit. And I was wondering how in a world that values curative treatment so much, how do you help manage expectations of treatment with the reality of mortality and that not all treatment can be curative?
Speaker 2:So that's a really good question. It's it's really tough. Now, because I work alongside our oncologists, I I get to cheat a little bit by having someone else normally tell them, before I do. Our oncologists are really they're incredible for many different reasons. Aside from being truly experts in their field, I love that they set expectations from the beginning.
Speaker 2:They sit down, they have a long, you know, chat with patients as to what does this mean. And compared to other oncology groups I've worked with in the past, they're much more, they're much more just kinda forthright about, hey, this is what the goal of treatment is, If it's curable or incurable. And I've heard the language that they use and I do think that they try to use layman language and make it such that the patient and the family understand things. So, I mean, I really try my best to kind of talk to them about, hey, this is what we know of this disease as of, you know, 2023. Medicine's constantly evolving, but we don't have cures for everything.
Speaker 2:You know, for example, from what we know of stage 4 pancreatic cancer at this point in time, we don't have a cure. So we talk about how I wish we had a cure, but we don't at this point in time. If that ever changes, you'll be the first to know. But we have treatments that we can provide with the hope of living longer and with a good quality of life. And so, again, I think it's really important to be upfront about the expectations of treatments, but in a compassionate way.
Speaker 2:You don't just say, hey, this is terminal. You're never gonna be cured. You're gonna die. Nobody you should never talk to a patient that way. But you reassure them that you're gonna do everything you can to help them, but that may evolve.
Speaker 2:What that means may evolve over time. But at this point in time, we don't have something that we can say, hey, this is gonna cure this. But we do have other treatments that we that will hopefully give you a longer life, but without sacrificing your quality of life.
Speaker 1:I wanted to know what the what your favorite part of your job is and then what your least favorite part of your job is.
Speaker 2:Oh, my the best part, that's a very easy question. My patients. They're just the best. I mean, you got a you got a little taste of them the other day. My patients are the absolute best.
Speaker 2:Whether it's, you know, busting a pancreas pinata with a patient or, you know, talking about Korean massages, I mean, they're just they're the best. They have the best outlook on life. It's all about the it's all about the small things. And when you sit there and you talk to them, you're like, man, my problems are so tiny. I need to stop whining.
Speaker 2:Like, I've got it really good. And getting to just talk to them about what they value is so refreshing. It's really incredible. The hardest part is seeing them suffer and seeing their family suffer and feeling like you can only do so much. Of course, losing them is always very hard too.
Speaker 2:I've had, so many patients become such a regular part of my life. And I'm talking to them monthly, sometimes even weekly for years, that when they're gone, it hurts so much. It does feel like some does feel empty. Seeing their family, especially their little kids, left behind to grieve this amazing person is just the worst. Seeing the kind of devastation that's left behind.
Speaker 2:What I hope, though, is we can help prepare them as much as you can possibly be prepared for something like this and that we can get them the resources they need to to try to cope in a healthy way. But it's always so hard.
Speaker 1:Mhmm. I know you mentioned that, initiative y'all are doing with getting a psychologist on y'all's team. Do you consider talking to the family and preparing them by having conversations with them part of your job?
Speaker 2:I do think it's a part of my job. You know, I'm a big proponent of painting a picture. And we talk about best case scenario, worst case scenario, and thinking about those different things. In general, in medicine, we do a very good job of hoping and praying for the best, but we do a terrible job of preparing for the rest. And so, that's what we really try to talk to patients about is, this is what I hope and pray happens, that this cancer is gonna respond beautifully, that we're gonna see this.
Speaker 2:Your pain's gonna be less. You're gonna feel more like yourself. You're gonna get to go on that trip to Paris, etcetera. But let's also talk about what if we don't get what we want, whether that's now or further down the line. Talk to me about what's important to you.
Speaker 2:It's important that you have those conversations with your family about what if we don't get what we want such that they've heard it from you. Because oftentimes complications happen and then you can't make your own decisions returning to family. And if they've never heard it from you, that's a really hard thing to try to have to come up with all these decisions on your own. I tell them, I hope you never, you know, I hope your family never has to use that information. But if they do, they've heard it from you.
Speaker 2:And my husband and I, I mean, he's pulling critical care. I do this. And so we see unexpected things happen all the time to also young people with little kids like us. So we've had multiple conversations about, you know, what if this horrible thing happens? You know?
Speaker 2:I want you to remarry. This is what I'd want to happen to the kids. You know? At what point are you okay with a trach and peg and all these other things? And we're both bawling.
Speaker 2:We're sitting in our cars just crying. But at the same time, I hope he never has to use use that information, but he's heard it from me. Then you move on, right? We have that conversation. We don't talk about that every day.
Speaker 2:We rarely ever talk about it. Then we focus on the living and we focus on the here and now and how we can just try to enjoy things, you know, to the best of our capacity.
Speaker 1:Mhmm. Yeah. Advance directives, is a pretty serious, issue for public health right now. I think most Americans die without an advance directive.
Speaker 2:Which is absolutely crazy. It takes such a short period of time to complete them. I think I give this spiel to every single patient and probably every trainee as well that I'm like, have you done your medical power of attorney? Do you know your parents would be your medical power of attorney right now? Is that who you would want?
Speaker 2:It's very important to do them and there's some basic ones. Of course, selfishly, as a physician, I care a lot about a medical power of attorney such that I'm always talking to the right person. But that's a really simple thing to do and I tell people it's just like car insurance. You hope you never have to use it but you get it just in case. Same thing with advance directives.
Speaker 2:You hope you never have to use them, but you've got it just in case. Have you completed your advanced directives? I have. Okay. Good job.
Speaker 1:The super simple one, Paige.
Speaker 2:The super simple one. Okay.
Speaker 1:Yeah. Going back to your favorite part of your job, I remember, at the end of the day, I asked you if that was some sort of outlier of a day because I was so impressed by the people that I had met. Like, that one patient
Speaker 2:I know exactly what you're
Speaker 1:talking about. She had me rolling. I was about to fall off my chair. This patient was so funny. And then the super sweet patient that, we talked about, you talked about, making it possible so that she and her husband could, go on the cruise from Galveston, and they were so sweet.
Speaker 1:I was so impressed.
Speaker 2:The sweetest. I'm telling you, my patients are just the best. Actually, with that patient, we bond over our love for Trader Joe's and Costco and we talk about the seasonal items. I mean, it's just, who can do this in their job? It's really the best.
Speaker 2:And one thing I commonly hear is that they appreciate that they feel human in our clinic. They don't feel like a disease process or lungs or kidneys or whatnot. They feel like we're treating them like humans which is what we are constantly reminding them of is, you are human. You are not this cancer. But, yeah, my patients are are really the best.
Speaker 2:Yeah.
Speaker 1:So this is, this next question is a bit of background, and then the question comes at the end. So one study in the New England Journal of Medicine took 2 groups of patients treated, or being treated for metastatic non small cell lung cancer and scheduled only one group for palliative care visits. In this study, palliative care resulted in a significant reduction to be on chemo in the last 2 weeks 3 months of life, more time spent at home, less time spent in the hospital, a decrease in the likelihood of dying in the hospital, less suffering, lower rates of anxiety and depression, lower costs, and a 25% longer survival. Considering these metrics, why do you think palliative care is still underutilized? And how do you think we can go about bridging the gap between people who would benefit from palliative measures and those not receiving it?
Speaker 2:I wish all of those things could be on a billboard and, like, put in front of every medical institution. I think that while we've come really far, there's still a lot of misunderstanding about what palliative care is. You know, it's often confused with end of life care or hospice, even by many physicians. I mean, oftentimes when I tell people what my job is, you know, the response is, that must be so sad. And it's you obviously don't understand what palliative care is.
Speaker 2:But people just equate it to end of life care. And so, I really think it comes down to kind of education. I'm really happy to see so many medical schools and residencies exposing trainees to palliative care because this will influence what they know of the field and therefore utilize them. So when I joined Baylor, I will say our oncology group is, you know, on the younger side, but all of them have had exposure to palliative care, in their training at some point. So they actually understand what we do, and therefore, they utilize us in that capacity.
Speaker 2:They're not like, oh, this patient is actively dying. Now I need you. They're like, hey. This person is symptomatic or this person has a disease I can't cure and they're really suffering in their quality of life. I do think that their prognosis is years.
Speaker 2:And I'm like, yes. We should absolutely that's absolutely appropriate for us to see that patient. But it's also often misunderstood by medical, institutions, again, as end of life care. It's a vital service for our patients with serious illnesses and requires, you know, investment by medical institutions. Given the fact that we don't do procedures and instead we spend just a lot of time with patients, we don't generate a lot of revenue.
Speaker 2:Insurance doesn't really reimburse well for time spent with patients. They reimburse well for things you do to the patient. And so, it does make it harder for institutions to prioritize it. They also because they think of us as end of life care, they tend to utilize them really only in the hospital when it's equally important, if not more important, that we're also in the clinics, helping people even when they're not in a crisis. As we generate more data showing the value of palliative care, I really hope it becomes more available to patients.
Speaker 1:Now we just need to rely on the insurance companies to
Speaker 2:I know.
Speaker 1:Change their reimbursement.
Speaker 2:That's not gonna happen. That's not gonna happen.
Speaker 1:Have you seen a change? You talk about your team, but have you seen a change in your career on the perception and utilization of palliative care?
Speaker 2:Yeah. I I really have. You know, I mean, I went into medical school not knowing what palliative care was. I think maybe I even went into residency not really understanding what palliative care was. Not that I came from a big medical family, but still, I, you know, was highly educated and I didn't know.
Speaker 2:And so in residency, when I actually got some exposure to it and then really, of course, immerse myself in it in fellowship, I had a much, better appreciation for the scope of the field. And so, in my first job right out of fellowship, I was working at Memorial Hermann in the Heights. It was pure inpatient and there were very few physicians who actually, you know, consulted us early. And for the most part, it was ICU physicians or, you know, sometimes even dispo. Like, this person's been here for 3 months.
Speaker 2:We don't know what else to do. Let's consult palliative care. And then I came here and it was like, great, you're here. I just got this, you know, new consult and this person has a new diagnosis of pancreatic cancer. I think it'd be great to get you involved right now.
Speaker 2:And it was a world of difference. It was it was so, so nice to see that. Even in the hospital now, it's pretty rare for me to get consulted, you know, more than a few days into the person being here. It's usually in the ER they're calling being like, Hey, I think they would benefit from seeing you at some point. It's really nice to see that change.
Speaker 2:Again, we still have a long ways to go because a lot of people still think what we do is end of life care. But I'll say, especially in the oncology world, given awesome data like what you just presented, there is more of a focus on integrating palliative care early.
Speaker 1:Mhmm. And, how do you think we can change the conversation around end of life care so that it's not, so it doesn't get the reputation of end of life care.
Speaker 2:So that's a hard one because I do think even a lot of people, when they hear the word hospice even, they think, oh, this is a place you go to die. It's not a particular place. You're not going there to die. It's oftentimes dying patients are referred to hospice. And so, you could call it in a sense a self fulfilling prophecy, but it's not where you go, somebody hangs a morphine drip, which is what a lot of people still think it is.
Speaker 2:There's a lot of mistrust there. But during my fellowship, I actually got to work with hospice companies and go to people's houses and see what they provide. And it was really eye opening. And thanks to that experience, I get to talk to patients more about what they do We're at the whole team of people, nurses, social worker, chaplain, aids, and then there's usually a team physician. And they go and check-in on you and check-in on your whole family.
Speaker 2:How are you feeling? How's it going? What do you need to help care for your loved one? Do you need a hospital bed? Do you need oxygen?
Speaker 2:Do you need medications? Everything comes delivered to them such that families aren't having to run around town. They can send aids out to help with bathing, things like that to take away some of the stress of providing round the clock care that that is put on families. And they're also there to provide counseling. So that's my favorite part is actually the grief counseling that they provide.
Speaker 2:All hospices, after the person has passed away, provides free grief counseling for at least a year to family. We can't ever get that with anything else. I mean, even when people pass away in the hospital, I mean, it just feels like that's it. There's no closure. You know?
Speaker 2:I had my uncle pass away in the hospital from COVID, and his family is out of the country, couldn't come here. And so I was at his bedside when we, when we kind of withdrew the kind of artificial life support and allowed him to pass naturally. And when I left, it was a very weird feeling. I was like, wait. That's it?
Speaker 2:But that's it? I'm just gonna now leave and get into my car and drive home? This can't just be it. There was zero closure. There was nobody calling in to check-in aside from my family but there wasn't there was there was nobody looking out for me other than my family.
Speaker 2:And I feel like that's just wrong. That's just wrong. It's the end of someone's life. There should be something more than that. And hospice provides that.
Speaker 2:Whether you're on their service for 1 minute or you've been on their service for 3 years, they're there to help provide that kind of counseling.
Speaker 1:So now one of my last questions, it's another long one. One of my favorite books is Being Mortal by Atul Gawande. And in this book, he reckons with the question of how we can live a good life up to the very end. Doctor Gawande is a big fan of checklists, so one of the topics of the book is a checklist for any physician to put in their pocket to help them have these conversations about end of life care. At the top of the list is, what does a good day look like for you, and what would you not be willing to sacrifice in the course of your treatment?
Speaker 1:I was wondering if you wouldn't mind putting on the patient's hat and answering these questions yourself.
Speaker 2:You know, there's a reason why I feel a lot more comfortable on the physician side rather than the patient side. So what does a good day look like? Well, honestly, the answer to this has changed depending on what stage of life I'm in and that it'll keep changing. Currently, a good day looks like hanging out with my husband and 2 kids, maybe dancing around the house, you know, ideally enjoying some good food together. But that's pretty much about it.
Speaker 2:I wouldn't be willing to sacrifice large chunks of time away from my family or my disease stopping my children from living their lives. You know, I really think I would wanna do whatever I can to watch my kids go through milestones. I never thought I would be the type of person who would even consider trach, peg, all of that type of stuff. But, I think, with having little kids and I want to see their milestones so badly, that I think I would think a lot more about these things than I would have before having kids. It's definitely changed, my outlook on that.
Speaker 2:But I would also never want their lives to stop. I wouldn't want to do anything that would, you know, prevent them from being all that they can be because of what I was going through. I'm okay with stopping my husband's life, but but not my but not my kids' lives.
Speaker 1:That's awesome. Thank you for sharing. So as a final question, I wanted to ask you for a recommendation. So what's a good book, movie, or any form of media that you've consumed recently and have enjoyed?
Speaker 2:Wait. Do we actually do things outside of work? No. Just kidding. I think I I tend to gravitate towards very light and airy media given the gravity of the work that I do.
Speaker 2:I really honestly rarely watch anything that's, like, serious or very sad. I'm all about the rom coms and I I think it's a nice escape, from the realities of my work every day. But I did, on a vacation recently read Lessons in Chemistry by Bonnie Garmas. Highly recommend that book, especially if you are a female, in medicine. But that one's a a really, really great book.
Speaker 1:Right on. I was recently recommended, Scrubs.
Speaker 2:Oh, Scrubs is so good, the show? Yes. Oh, Scrubs is amazing. Now I've seen Scrubs, like, multiple times. It's probably the closest medicine show to actually how medicine is.
Speaker 2:But that's a I think that's a really great show because it shows people working hard but also coping in the ways that they know, which includes a lot of humor and appletinis and yeah, and the bromances that you develop with your colleagues because you're in it together. You're going through, a really hard thing together. So, that's a great show. Definitely recommend that one.
Speaker 1:Every every physician who's recommended that or even watched part of it, they're always they the one thing they always say is that it's the most accurate.
Speaker 2:Oh, yeah. No doubt about that. I think my my parents recently have been watching, to, like, New Amsterdam or something like that. And they were like, is this what it's like? And I was like, I haven't even seen it, but I could tell you this is not what my job is like.
Speaker 1:And, actually, it was my ethics facilitator, doctor Hopinot, who's surgical oncologist. I love doctor Gynock.
Speaker 2:I love doctor Hopinot. Yeah.
Speaker 1:And and we were talking about end of life care and what it means to extubate somebody. And, somebody was talking about it somebody was saying that, kind of being flippant about the idea of extubating somebody and removing that life support. And she was like, actually, that's, you know, every patient that I have had to do that sort of I've had that sort of interaction with, like, they stay with you. And she brought up one of the episodes where I think through the throughout the episode, the people who died on their ward followed them around. I've only finished season 1, so I haven't actually seen the episode.
Speaker 1:But
Speaker 2:No. It's it's true. And I think that, you know, unfortunately, as you go through more and more years of medicine, you feel bad that you can't necessarily remember every single person. But there are many people who just stay with you. So, you know, I had, my 1st year of residency Christmas Eve night.
Speaker 2:I was working in the ICU and I had a really horrible, scenario where I was a young guy who pretty much had signs of brain herniation and was on all forms of life support. And and it was a holiday and there was no attending in house and I had to have kind of a goals of care conversations before I knew I wanted to do palliative care. I had to have a kind of a goals of care conversation 3 AM Christmas morning, and I had to call his parents in. And we had to have that really hard conversation. And, actually, it was his father who brought up to me how kind of crazy the whole end of life is, especially in the hospital where he said, so what, we just turn off the machines, get our parking ticket validated, and leave?
Speaker 2:As if our son never existed. And of course, I started bawling. And that was also a good lesson, you know, to try to hold in your tears as much as you can while talking to family and allowed them to cry and be there for them. But that was my Christmas morning. I just thought about this family and how this is how they're going to remember Christmas every year.
Speaker 2:Every year on Christmas, we do Christmas big in our house. I mean, I pour one out for him. And it's been, you know, almost 10 years now and I will never forget that. And I have many patients who are like that. I have one oncologist for all of his patients whenever they pass.
Speaker 2:He puts it on his calendar for 1 year from now. So he remembers to call that family on their 1 year, death anniversary to check-in on them. I mean, we all have different ways that we kind of cope with it. But, yeah, we're human. You can't just let these things just kind of slide off your back.
Speaker 2:And that's a good thing. The fact that, you know, these people stay with you, means you care. And Doctor. Hope knows amazing. And so I'm not surprised that that those things matter.
Speaker 2:And we, I mean, she's seen me cry. I've seen her cry. We we feel things about our patients.
Speaker 1:So lessons in chemistry
Speaker 2:Lessons in chemistry. For
Speaker 1:the book.
Speaker 2:Highly recommend.
Speaker 1:And scrubs for the TV show.
Speaker 2:I think it's actually number 1 on Amazon right now. So for its genre.
Speaker 1:Well, doctor Agarwal, that's all I have for you today. Thank you so much for coming.
Speaker 2:No. Thank you guys so much for having me.