https://youtubetranscript.com/?v=u1-1h6hr2k4
Welcome everyone to another Voices with Raveki. I’m here with Rucham Modi. I’m looking forward to talking to him. He reached out to me and we’ve had a previous off-camera conversation and he wanted to get in some in-depth discussion with me. And so Rucham, why don’t you introduce yourself and tell us a little bit about yourself and why you reached out to me and how your work and my work intersect. Yes, I just want to say again, thank you for having me. I’ve been a big fan of your work, trying to keep up with it. It’s very intellectually dense. But I think what you’re trying to do, which is provide society at large and all of us, especially in the last couple of years with the pandemic, dealing with challenges of meaning and crafting understanding out of the events, both internally and externally, is super important. My name is Rucham Modi. I’m a gastroenterologist here in Los Angeles. And yeah, I was on faculty at Keck School of Medicine for many years before I transitioned to an affiliate faculty role where I focus on two sort of areas of interest. One clinically is on colon cancer screening and prevention and creating systems of care that can reach out to underserved populations that have historically been excluded from sort of preventative health and public health measures. And then I’m part of the Health Systems Science Research Lab at the Gair Institute at USC, which is focused on not only quality improvement, but healthcare policy and advocacy work to sort of revamp our system of care, which in America, for those that don’t know, is still largely fee for service and not really focused on quality, throughput more than outcomes. And so that’s kind of been my area of interest. And personally, it’s also been a very difficult time as a provider, you know, trying to deal with the dramatic upheaval in our healthcare system, especially in the last couple of years. And I was in the ICU, you know, March of 2020. And they’re on in as well as on the floors and in the clinics taking care of patients. For those that don’t know, since I’m an intestinal liver doctor, most of my patients are critically ill, they’re bleeding, they need endoscopies and stuff like that. So I reached out to you because I was definitely looking for guidance and someone to make sense of the sheer amount of just chaos that’s going on. And I have increasingly become more interested in advocating for people who are in frontline and healthcare and healing professions, because there is a massive amount of underappreciated struggle, either before the pandemic, but accelerated because of these crises with meaning and a challenge of how to handle the modern machinery of medicine and healthcare versus this sort of science of healing and taking care of people and the art of healing people, which is what got us into this field. And that schism is getting larger and that is creating a meaning gap for people, for respiratory therapists, to physicians, to nurses, to occupational health experts, to people who are social workers. And I hear this from a variety of providers. And I thought, like, well, your work would definitely be very relevant and illuminating to physician and clinician burnout, which is, I think, going to be probably the biggest long-term complication of the pandemic, is just providers struggling to not only handle the clinical workload, but to craft some sense of what does this all mean? I mean, we all went through very unique interpretations of a collective trauma. And that has, I think, still not fully been dissected and discussed and reintegrated into our individual and collective experiences. And I think we aren’t trained to do that. We aren’t trained to have that kind of reflective experience. I remember, and I’ve told this story before, I remember the first time I lost a patient as a physician out of med school as an intern. And, you know, there was definitely a sense of this is unfortunate. But then it was on to the next one. You know, you have 20 other patients that are critically ill when you’re in the hospital. And there wasn’t a sense of like, we need to process this and give especially younger clinicians who are still learning the science and the art of taking care of other people time to integrate this into what this means as providers, citizens, humans, people going through this human journey. And I see that being a real problem. And then as a last comment, I will say in my field of intestinal liver disease, we are increasingly seeing the immediacy of these deaths of despair, which is Angus Deaton of Prince was commenting on. I am seeing opioid epidemics leading to intestinal issues, hepatitis, liver cirrhosis, alcohol use and abuse, intravenous drug use leading to viral spread of diseases, mental health challenges implicating in gut health. So this is directly a clinical phenomenon as much as it is sort of a social and human and psychological one. And I think these are sort of the challenges that we’re struggling with because you can’t medicalize a lot of this stuff. I mean, the root problem is a lack of meaning. It’s a lack of being able to contextualize, interpret, you know, all the sheer rawness of what has happened in the last couple of years. And as our society becomes sicker, more comorbid, dealing with more health issues in a society, at least in America, that has got a fraying social fabric and, you know, this sort of post-God sort of society, I think people are sort of struggling and they look to physicians and health care professionals. But we aren’t necessarily equipped to answer those questions and it becomes sort of a difficult sort of time. The last comment I know I’m sounding off as the first question is that physicians are not allowed to speak on this publicly because if there’s any implication that they are mentally and emotionally struggling too much with all of what I’ve just referenced, then that becomes, well, can you even do your job? Every hospital, clinic, credentialing forum privileges to even take care of patients in any health care setting, you are screened, rightfully so, for any of these things. Do you have any mental health issues that would limit your ability to sort of take care of providers or for patients? As a result, I know a lot of providers that have to secretly handle these issues in the shadows, stealing, not steal, I don’t mean that literally, but getting off label use of antidepressants without seeing a clinician in a traditional setting because they don’t want that labeled on their medical chart. Like in between patient, do you mind, I need a little Prozac, do you mind writing me a script, but a friend that you know or a colleague. And so there is also that added level of like not being able to disclose any of it, which is tragically ironic given the nature of the work that physicians do, which is trying to heal people through their difficult moments. And so it sort of brings back the physician heal thyself. We aren’t allowed to because if it ever becomes dramatically, if it ever becomes that clinically significant, then your livelihood and your ability to take care of patients could be in jeopardy. In fact, there was a there was a New York Times op-ed, I think earlier this year and about June, I’ll send you the link outlining this very thing where physicians and clinicians are getting depressed, hyperanxious, they’re confused, rightfully so, given what’s going on, but they aren’t able to safely and without stigma and without financial and legal blowback, easily access supportive care. And so that is adding to this sort of this is driving down this sort of phenomenon of physicians struggling to make meaning, struggling to make sense, emotionally heal. They aren’t able to get those communities that you so reference where you can make meaning together because you can’t talk about it. You have to be behind closed walls or after hours or in between these little nooks and crannies of the day to sort of take care of your own issues on the side. Increasingly, while our services are commoditized as sort of factory physicians. And so this has become, I think, a series of issues that have stacked upon themselves and compounded what has already been sort of difficult time. So you see five hundred thousand nurses in the United States who have already retired early and or left the field since the pandemic occurred. And that’s only going to increase. And then a number of surveys that have cited at least at least two thirds of physicians in most studies are actively thinking about retiring early, leaving and or would also not recommend this field to their children. You can see, I mean, that that is a massive problem. And I’m not as familiar with the Canadian data. And obviously, the health care system is very different there. But I have friends that work in Canadian health care facilities and they’re reporting anecdotally, at least very similar challenges. And so I thought, you know, who better than yourself to at least provide some guidance to people who are like trying to make meaning out of this? And I had a friend, a physician who shall remain named, who just called me last week as a last comment. And he’s tired. He’s so career and ex essentially burnt out. And he says, I love medicine, but I hate health care. And there are so many physicians, especially mid career or early career, that still have 20, 30, 40 plus years potentially in this industry that are at a crossroads. You know, I don’t know how to handle this because this is not at all the system of care that I thought I was going to be inheriting to take care of patients. And they don’t know how to re identify themselves because, you know, I’m not going to compare physicians versus like other professionals. But I will say that for physicians, that decision about yes, no, do I want to become a physician or a nurse practitioner? That was made very early in life for the vast majority of people. There are people who are in a different field and they had some important issue that transitioned them in their life to going into a different area. But the vast majority of physicians were the ones playing with stethoscopes when they were two and, you know, dressed up as doctor. Like that was something that was a central part of how they view themselves as a person and how they view the world and what their role in the world is. So for them to be in their mid to late 30s or mid to late 40s, certainly not knowing how to navigate all this. This is a crisis of meaning here. This is not simply, oh, they’re working me too hard because physicians are accustomed to working hard. And I often tell people, you know, do this thought experiment if you were doing something that you truly loved and you felt supported by the larger political economic system of health care to do that. But you were working still 80 hours a week. You might be truly exhausted at the end of the week, but would you be burnt out? And most people that I talk to in health care say no. I would not be burnt out if I felt I was equipped to handle the modern milieu. What lack of a better term of health care? I would be really, really tired, but I wouldn’t be burnt out. And I think the reason that burnout is more of a problem as opposed to just sheer fatigue, although that is one too, is a lack of meaning, a lack of not being able to do the work that we came into this field wanting to do that we dedicated our lives to do. And I don’t think clinicians are able to navigate that and you can’t talk about it. And now and when you talk to people outside of health care, you know, when you even intimate that you might want to leave the field or you’re struggling with all this, like, but you you spent so much time, you’ve dedicated your whole life. Why would you even think about anything else? And it’s like, well, you don’t seem to understand. Like, it’s precisely because I have dedicated so much time and I care about the work that I do that it’s tragic that a lot of colleagues of mine and friends are thinking about stepping away. And so hopefully you’ll be able to fix this in the next 40 minutes or whatever. At least provide some guidance, because I know I’ve talked to a few people, you know, I said, look, I’m going to be talking with this esteemed professor who’s done a tremendous amount of work on sort of crafting meaning through a variety of cognitive sciences, sort of, you know, psychological lenses. And they’re very interested because this this this this is not in the consciousness of the average health care provider, because none of this is sort of discussed. You know, we’re body technicians at this point. We’re not healers. We’re not we have encounters with consumers of health care. There’s this lexicon of the market that has overtaken U.S. health care to the extreme. And even the languaging of all this is it’s messing with our ability to think clearly about this. So that’s that’s kind of in broad strokes, kind of what brought me to you, which I’m very excited and privileged to even sit here with you virtually and what got me interested in your work. And and yeah, that’s kind of where we would start. Well, thank you, Ruch. So that was that was quite eloquent and well articulated. Just want to make sure I’ve got some of the salient features, those are sort of intersecting factors. One is and you’re right, burnout is not the same thing as fatigue. Burnout is a meaning issue. And you’re right to articulate. So so there the the the meaning is not there in the medical profession, at least for many practitioners. And so that is becoming. As meaning often does, it is is becoming a an existential and mental health issue. So that’s one thing. And then that’s intersecting with the fact that there’s a general meaning crisis and the deaths of despair are going up. And so while that’s putting more pressure and giving you more sort of in the face of in your faces, you’re having to face despair and you have to face the fact that you’re going to have to face these lives that are being consumed by self deceptive, self destructive behavior. The medical profession is now. Existentially and mentally burnt out, so it doesn’t have terrific resources of meaning in life by which it could confront this challenge. And in order to try and confront it, presumably there might need to be right practices for the cultivation of meaning and wisdom, but you’re not allowed to bring those up because those are quickly assimilated into mental health issues that signify that you’re no longer competent to be a physician. Is that basically a good explanation of the problem? Yeah, absolutely. Absolutely. And I would add the sort of the the shift in identity. I mean, physicians are generally very impact oriented. They want tools to be able to affect change in a very particular way. And it’s profoundly unsettling when you’re not able to do that because you’re not able to spend enough time with provider or with patients or they have social determinants of their health problems that you would just don’t have the tools to address. That’s a despair. This general despair that you so eloquently talked about in a lot of your work is one of that that that is not separate from what’s happening in the clinic room. Yeah. And so we can provide pharmaceuticals and various other tools, imaging, etc. But we’re not blind to the fact that this is grossly inadequate given the scale of this problem. Right. But many times it’s the E.R. physician or nurse or it’s the primary care doctor. So unfortunate to have one that starts picking up on these sentinel events that clue us in that there’s this larger social phenomenon. And then we start hearing experts such as yourself and these other scholars bringing this to our attention. And that that becomes a challenge. So I think there’s a sense of professional and personal impotency. But we can’t address this in the way that we are accustomed to addressing diabetes or high blood pressure. Right. And that sense of undermined agency and futility then exacerbates your issues. I mean, all of you collectively, your issues about why am I doing this? What? Why? How do I matter? How am I making a difference? And what’s the point of it all kind of thing becomes pervasive, I take it. Absolutely. Yeah. I mean, I think that’s exactly I mean, that’s a good breakdown of the core, you know, essential issues here. And I. You know, I’m I’m desperate and fascinated and excited and anxious all at the same time to kind of hear like what what kind of, you know, insights or directions you can kind of point us out, because I know that it’s going to take a number of successive conversations with multiple leaders to kind of address this. I’m just excited that we’re having this conversation because again, it’s not something that’s easy to talk about in formal medical settings. And like this, in my opinion, again, I’m just one person. This is the central medical issue of facing clinicians. Right. You’ll never see this on a conference agenda, with the exception of a few maybe select medical associations. This is rarely discussed in any meaningful sense. And the overtures that are given by hospital administrators or medical society bodies are do more yoga wellness Wednesdays where you get an email newsletter of like, you know, fairly perfunctory and quotidian sort of minor individual things that you can do, you know, to sort of relieve this stress burden when the the thousand foot perspective is that clearly this is a systematic and social issue. But the burden is on you. Well, if you’re not taking time for self care, well, then clearly that’s the solution to all this, not these social factors that we’re all privy to that we can’t talk about. And so, you know, now the burden is on us. There’s some implication that we’re falling short. Like we shouldn’t be so burnt out if we only meditated more for 20 more minutes every day on top of the laundry list of all the things we have to do. That would that would, of course, solve it. So then there’s a sense of like. Not being able to be heard and validated when we’re speaking out about these issues on the rare moments when we are able to speak out. And, you know, I give people in societies and institutions the benefit of the doubt, but there is a sense of like. A little bit of gaslighting involved, you know, we’re not able to get validation for what we’re discussing, you know, and that ends up being itself. A challenge, you know, so I see that like there’s this vicious cycle then, right, the societal thing. And then you you’re required to respond to it, but you really don’t have the tools to respond to it. And yet you’re not allowed to acknowledge that you can’t really respond to it. And it’s taking a heavy toll on your spirit in a profound way. Now, you mentioned that this was exacerbated by covid, but this trend had started long before covid. When do you think like, do you have a sense of when it changed and when it shifted? Like if we could get an understanding of the bit of the well, the etiology of it, like, do you have a sense of what there was a turn? You said there’s been and I think this was very telling and I want to slow down around it. There’s been a sense of a change in identity. And you mentioned that when did that shift happen and when did it become pronounced? You know, I think that’s a that’s a difficult question. If I had to point to sort of a time period, I would say probably the Nixon administration, probably or around the sort of late 70s, early 80s. When managed care and I’m referencing just the United States sort of phenomenon here, obviously, we could do a discussion of comparative health systems later. But when managed care ended up being a central player, you know, and for those that don’t know managed care, private health care organizations and insurance firms that are tasked with providing a risk pool of patients that they cover with insurance services, but therefore they have to then pay hospitals and providers for their clinical services. When that became a central stakeholder and the delivery of health care, then suddenly then suddenly and I don’t blame them initially for wanting to do this, cost containment and shareholder value ended up becoming the central maxims by which they would reimburse for care. And when you shift the incentives and how care is delivered, that fundamentally reshapes how care is even imagined in the first place. And that was when the lexicon of the market became right for the central. When that happened, then you suddenly had the only metric that truly matters, even to this day in most health care facilities in the United States, whether it’s the clinic down the street or quaternary medical institution associated with the university is throughput. It’s speed. You know, it’s what we call the RVU, sort of this revenue value unit. It’s how fast you can do care, how large of a volume of care that can be done. It isn’t necessarily for the most part, quality of care or more humanistic sort of ideals. So I always joke with people, you know, I guess I went to provider school, not medical school, because that’s the only term that is used to describe me as a provider. And patients are not patients. They’re consumers. Well, we have a medical encounter. And when I first heard that term, I was like, you know, spies have encounters with other spies in like, you know, shadowy parking garage. I mean, clinicians and doctors should not be having encounters with patients. And I’m not opposed to sort of the need for business savvy in health care. Obviously, when it’s a ballooning budget, we have to be very critical about how dollars are used. But that was so extreme that physician services ended up being accurately commoditized. And when you’re a commodity, then you’re bought and sold under the moniker of various health care organizations that package physician services. So then you had a drop in physician autonomy. You had the rise of this sort of factory model of care. The only metric that was ever really of value was throughput and the speed at which you could see patients. And that led to a dramatic shift away from alternate models of care. And even now in the last 10, 15 years, when valued base care, you know, which is theoretically at least supposed to be more quality driven, that still has got a long ways to go before that’s taken root. So to answer your question, I would actually point back to probably a number of decades ago when this became an issue. And then probably starting in the early to mid 90s, you had a massive wave of consolidation in most major urban metropolises of health care organizations. Now that ended up not working with that has now resurfaced. So in most major U.S. cities, cities, physicians typically have probably no more than five employers, probably much less than that. Like, you know, you look at cities like Rochester, you know, in Minnesota, you have two employers, that’s it. So when physicians have no ability to sort of interact with patients aside from major medical machineries, then it becomes much more difficult to advocate for patients in the way that you want, because you’re told what to do on a schedule. You’re told what to do in terms of people that have nonclinical interests or shareholder values, you know, at stake here. And there needs to be a balance. But there has been such a shift towards. The expense of physicians and patients in the name of, you know, financial quarter one, you know, balance sheets, profits and losses that you end up having sort of such a asymmetry in terms of being able to take care of privations. And so and this and the sneaky thing was. It wasn’t as if there was a discussion of like, oh, this managed care sort of volume based sort of approach, which is fee for service, that that’s going to reconceptualize how we view physicians at your core. And that was not known to us at the time. Right. And that is exactly what has happened now. And now that that is the precedent, it’s very hard to get that back. And so that would be what I would sort of point to the pandemic has led to some unique issues, but that was definitely. The central factor. Yeah. OK, so there’s a lot going on there. So the first thing is like, so, yeah, there’s a fundamental change in the conceptual vocabulary and then that changes identities, the identities of both the actors and of their actions. And then that undermines meaning for the physicians. And yet they’re being expected to be sort of resources of meaning in some way to all these people who are coming in, experiencing the meaning crisis and meaning scarcity. So one thing is it sounds like the shift was a very much a shift that represents sort of a fundamental kind of modal confusion that what that fundamental change is. And fundamentally, and there’s other people, Han is talking about this when he talks about the Burnout Society and other things like that. There’s a reconceptualization of health and then there’s a reconceptualization of what it is to provide health or health care. And so like the first thing, we’ll try some of these ideas on and see if they work. One is, you know, from notion of a modal confusion that what we’re doing is we’re using the having mode where we’re supposed to be relating to a transformation of a person. And that should be a being thing, a being event, a becoming event. You’re you’re transforming a person in a fundamental way, and that should be inherently valuable. And therefore, it should be from the being mode. But everything is now in the having mode. And you said it’s commodified. And so the sense of. I think you said like impact or the sense of connecting to people as entities that are inherently valuable has been undermined because you put in a frame in which they are not treated as entities that are inherently valuable. Is that part of it? Right. Does that land for you? Does that sort of make sense? Yeah, I mean, I would say that, you know. Health care for a lot of physicians was to be a sacrament and now it’s purely a contract. And when that happens, that does. Shift the identities of not just the clinician, but of the patient. Yes, yes. Actually, no one include either of us in. And I think a lot of patients, especially older ones, who still have an idea of this sort of Marcus Welby, the old school physician that’s going to connect to you. And that’s a good expectation to have get abruptly put on notice. No, this is in fact not what you get. And so then they get upset at providers not realizing that the reason you only have 10 minutes with your doctor is not because of our choice. That was a system that has been put upon us as well. Right. So we’re sort of bonded into this sort of decaying binary system. Yeah. And the reality is, unfortunately or fortunately, we’re all going to need health care in some format. Yeah. And so this is not something that can be ignored. I mean, if you’re lucky and you’re an upstanding citizen, you may never really need a lawyer, for example, aside from like wills or basic financial or legal planning. But it’s going to be hard unless you’re exceedingly lucky that you’ll ever go through most of your life without needing health care services. And so this ends up being something that consumes both of us, but suffices neither in terms of their meaning needs. You know, I wouldn’t even know how to code that in a chart somewhere when someone is having a meaning issue that I feel is directly pertinent to their health care. Right. Right. Like that, it cannot be coded if there’s no ICD 10 code. ICD 10 is the billing system of nomenclature that is attached to medical claims so that they can be reimbursed. Then it doesn’t exist. OK, so this and what do you do about it? This then moves to the deeper issue, the deeper issue of the conceptualization of health, which seems to be I’m going to forgive me. I’m just trying here. Right. It seems to be sort of a reduction of mechanically oriented suffering. And then what we’re trying to do is get rid of how this machine is not operating properly. And then once we can do that, we’re done with the person. And so health has been disconnected from well-being and meaning is itself not considered an important aspect of health unless it shows up in a breakdown of the machinery of cognition or something like that. Is that yes. I think that’s exactly it. I mean, until it gets to the point where someone has a quantifiable mental health issue, it’s largely ignored. Right. And no way to address it. And so part of the problem is right there used to be there used to be institutions that dealt with meaning issues for people. There was religious institutions and then there used to be sort of semi religious institutions around therapy. But therapy is also being like psychotherapy is also being driven into this model. And the churches and the temples and the mosques and the and the sanghas are no are by and large not meeting this. And so it sounds like that means that everything is now being funneled into the medical system that is precisely being designed to not deal with this issue. That’s exactly it. And I think that this might be branching a little bit, but I think that. You know, people have to put their faith in something, otherwise they wouldn’t get out of bed. And I think some people put it in technology, as you know, or Western medicine. A lot of people go into alternate routes. I don’t think it’s in a I don’t think it’s a coincidence. And you’ve spoken much more deeply about this than I than I have. That psychedelics and plant based medicines have a consciousness changing element to them at their core as their essence. I don’t think it’s an accident that is taking off now. People are searching for this. Oh, definitely. We don’t have a collective experience that brings that into their reality. Yeah. Right. So we’ve lost the ancient meaning of health, which was connected to wholeness and wholeness is typically understood, you know, in the ancient traditions. It’s associated with well-being. You’re trying to write. You’re trying to live a fulfilled life, a life in which the whole person has come to fruition in some fashion. So. What. What like what do you do? What do you think? Is preventing. The ability to like. Let me try this very carefully. There is a lot of good. Philosophical theory, because we are talking about moral issues and meaning issues and a lot of good science separating meaning from mental health and from physiological malfunction. And. Why is that information not getting in to the medical field? Like because. Yeah, a good. My initial response when you said, well, the doctors can’t talk about it, I would want to say, well, why not? But there’s a big difference between facing issues of meaning and existential connection and being debilitated in your ability to, you know, do your profession. Like, I mean, you’re trading. Well, in one sense, you’re not. But you’re at least you’re meeting people that are suffering deaths of despair. That’s the meaning is a separate issue, at least to some significant degree from physiological malfunction or from, you know, serious mental disorder. That this is, you know, it’s not controversial to say that. I mean, it might be controversial where you want to draw the boundaries. So I’m finding out, I guess I want to understand why does all of this information not permeate into the medical profession? I mean, that’s a that’s a very challenging and excellent question. I mean, if I had to guess, I think one is. It may be fairly salient to experts such as yourself. This whole body of work that’s multidisciplinary, it really isn’t in health care. This is there. There are very few lectures. I didn’t get a single lecture in med school on these larger issues of meaning making. Now, I definitely had clinician leaders and attendings that, you know, at the bedside teach me some of this, but that was entirely at their choice. And these were clinical pearls that were given epitomically if there was a patient that merited that discussion. There was no systematic education about this. So that’s that’s number one. I think number two is that some physicians have accepted the reconceptualization of what they do. Most have not, but many have taken it on like, you know, it’s not uncommon that some physicians will say that there was a whole Twitter discussion about this literally like a week ago. Physicians shouldn’t be in the business of handling these larger issues. We are, in fact, just body technicians. When medicine was very close to tied to the roots of shamanism, you know, in the village community thousands of years ago, and there wasn’t really much medically that could be done beyond plant based germinism, aspirin. Yes, we could understand that, you know, healing and spirituality were distinctly tied along with questions of meaning. Now we have too many things that we can offer medically for patients that are rooted in biochemistry and genetics and all the other sciences. And so some people have increasingly argued, and I think we have accepted as a class of professionals as de facto that I guess this is just what it is, that this is all that we do and that we really shouldn’t be expressing ourselves beyond this. And I point to the third factor. Look at some of the two central things. At least again, I’m again, maybe arrogantly from an American perspective, but I’ve seen similar challenges in other countries. Look at sex and death. These are birth and having a child, having sex and then passing the two central issues physically, at least as well as mentally, emotionally and meaning why the most potentially meeting leading events in people’s lives. We treat them and we are asked to treat them as professionals, as purely medical events and nothing more. And that has led to a gross problem in being able to address these things. In America, we have a society that denies death. Yes. You obviously know extensively about that. Ernest Becker’s book was fantastic in that regard. And his whole thing was what you have done, you know, world leading research and discussion on this sort of symbolic meaning making nature and the biological one. We don’t talk about it in health care. Most physicians, unless they’re oncologists or deal with cancer a lot, like I do in intestinal diseases, or they’re a palliative care doctor, they aren’t trained to handle these larger issues and they’re uncomfortable. So we are sorely ill equipped and we are not encouraged to handle that discussion. And then look at the flip side when there’s a birth, which is usually a joyous thing and the discussions around sex equally vitriolic. Now, there’s more discussion about that hyper politicized, but at the same time, a lack of respecting the humanity of other individuals, just like the dying person in front of you that’s passing. That’s a pronouncement medically. OK, no pulse, no breathing, no neurological reflexes. That is a purely medical thing. No, that was a person that is a person that is passing that has a whole constellation of other things attached to that. But we aren’t given the opportunity to get into some of that. And so with these two central pillars of human existence, I mean, just look at the news like we have a massive problem of million people have died as a result of the covid pandemic in this country alone and millions more across the world. People argue actively is the covid pandemic even real or not in some communities? Are these numbers real or are they fake? We still haven’t had a real come to. Sort of public mourning, aside from a couple of speeches about all this death. I mean, a million people have died in the last two years. Millions more have been permanently ill with long covid and other long term health complications. You think that we would all take a time out and pause and like, let’s let’s bring in some experts such as yourself and let’s let’s make sense of this. No, it’s off to business as usual. And then look at the discussions that we’re having about conception and birth. And obviously, with political events in this country, that has gone on to record levels of extremism and vitriol on both sides. So I think that, you know, in a healthier medical industry or biomedical industrial complex, physicians would be equipped and given the opportunity to be able to bring some sanity into these discussions and then be able to pass the baton, proverbially speaking, to someone such as yourself and say, look, we’re dealing with some difficult things right now. Let’s bring in some experts who have dedicated their lives to understanding how to make meaning so that this isn’t so scary for you, that this isn’t as confusing and that you are then equipped with the skills to find out how you can make meaning of this. But that that hasn’t happened. And I think it’s all these issues come together. And I think most physicians. Have this sense of like there’s a splinter in their mind. They’re like in a dream, they’re trying to wake up from like something is fundamentally off about how we’re doing care. Right. They aren’t able to verbalize it because they don’t have the cognitive knowledge, they don’t have the lexicon. And so they burn out and then they wonder why they’re burning out. There’s some obvious risk factors, but then there’s some non-obvious ones. And so that that was to a certain degree my journey as well. And but then I came across a lot of your work and some of your call. I was like, yes, this is a meaning issue. And this is the discussion that’s not happening, even though this is the 800 pound grill in the room. And it’s now leading to people not wanting to be in the health care field. And I’m truly worried for at least the American public. And I’m sure in other countries like you’re just not going to have enough caretakers. And if you do, they’re not going to be fully engaged there. No, no. So you don’t want a white coat. You want a person there in front of you, crafting an experience with you to guide you through whatever health question you have that you can then take to your community and then elaborate from there. That that isn’t really happening. And unfortunately, I don’t see that happening anytime soon. So that was a meandering answer to your question. No, it’s a good answer. And I appreciate the passion and the commitment. I do know of a couple of instances or more where psychiatrists have actually recommended my series to some of their patients because they’ve realized that their patients are encountering an issue of meaning rather than, you know, you standard models of depression or anxiety or things like that. I’m wondering. I mean, this is a delicate question. And if you like. I’ll ask it and you can you can decide how specific or nonspecific you want to be. But are the deaths of despair creeping into the medical profession itself? Are nurses and doctors moving towards this? Yes. Yeah, I mean, I cite the statistic that I mean, roughly. About four to five hundred physicians alone every year in the U.S. commit suicide. And there was actually that’s basically a med school graduating class every year, every year, and an average physician, depending on the nature of your specialty, will have probably about a patient panel of probably anywhere from one to three thousand patients. So you do the math there and then those are communities that. You know, are bereft along with the family members of the people that commit suicide. So that that’s one. And then I don’t know the statistics on nursing. In fact, there was an E.R. physician who committed suicide at the height of the pandemic in New York. And Joe Biden, you know, the current U.S. president, passed a small measure, but it was a nice overture, a lot under her name and maybe an executive order sort of trying to emphasize the need for federal support and resources directed to clinicians. So this absolutely has permeated. There are definitely rates of substance abuse, not just burnout, professional lack of satisfaction and mental health challenges that are creeping in. Into the into the into the well-being of, you know, the whole cohort of allied health professionals. And it’s it’s become a real challenge. And the health care industry writ large is concerned with like, well, who’s going to see all these patients, who’s going to get through all this billing, who’s going to do all this charting? The central question is like, why are the healers not feeling healed and supported themselves? Yeah. And what does that speak to the larger mission or lack thereof of what we’re trying to do? And it’s only in the last few moments of this pandemic where I at least I get the sense that some organizations are finally starting to realize just how deep this problem goes. Because, you know, at least in the U.S., we have sort of a sort of a complacency to crisis model of reaction to things like it has to get to a crisis level before anything would even be done about anything. Otherwise, we’re completely complacent. And that’s obviously not a great way of handling things. And I think that it may take the bottom to fall out before before we start having, you know, real issues here. So this is another vicious cycle. The health professionals are driven into being body technicians. And then because they’re body technicians, a great number of them suffer a crisis of meaning. And then, right, that is that it can lead to deaths of despair. And so they are incapable as a profession of actually addressing the issues of the way addressing the way their inattention to meaning is actually eating away at the very profession itself. Absolutely. I think that’s in fact, absolutely it. So we talk about like physician reimbursement, autonomy, how you deliver the care. But I think at the root of it, those are all spokes off the central hub, which is this meaning. Yeah, yeah, yeah. And I think there is a long history of physician authors from Oliver Sacks to William Carlos Williams and other individuals and physicians and characters of literature, death of Ivan Ilyich and all these sorts of artistic antecedents, if you will. But there really hasn’t for the most part in the modern era. There aren’t these people both within the health care community and outside of it. That that are able to sort of work and engage in these sorts of issues. And I think part of it is also the media environment. I mean, we are oversaturated with just, you know, social media, entertainment, so many things competing for our attention as life is getting busier for everyone. Yes, generalized that it becomes hard for, you know, those prophets in the desert to get their voice transmitted. I mean, I was sort of like when I came across your YouTube series, I was like, how is it that I’ve not come across as before? Because I’m certainly not an expert in any of the areas that you are in. But I’m sort of at least interested general on these topics. But this this just didn’t the algorithm didn’t feed it to me. And I didn’t even think that there would be. I honestly was surprised that anyone would take this level of time and attention at length over like 50 episodes to provide this to the public. I mean, that’s an enormous amount of effort. And I can just congratulate you so much for that. That is that is not something that would naturally occur that I would think an expert or anybody would really do. That just seems like such a huge boulder to push. But you pushed it. And I think that kind of work needs to be transmitted further. It’s just sort of. When you come across something like that, you’re like, of course, like, of course, something like this is needed, you know, where people can help us craft meaning. But before I knew about it, I didn’t really even know what I was looking for. Right. Right. And that is part of the connection problem with people who may have guidance and insight and counsel, such as yourself versus people that desperately need it. And because this is so shrouded in all the issues we sort of elaborated on, that connection is not easy to make, you know. Right. Right. That’s very well said. I mean, is part of the problem. That. Medicine has progressively. Crafted its identity as a science and art and distinct, like you said, from any connection to a religious framework, right, because it’s smacks of shamanism or superstition or magic. And so the right and and so. Any attempt to start talking about these is sort of thought these issues is thought of sort of pulled itself away from. I think so. And I think that that’s an excellent point. And I think I think that under wrote some of the controversies, at least in this country, about recommendations for the covid pandemic. Obviously, we had such intense controversy about masking. Who should mask when, especially with school kids? When can school kids go back to school in person versus doing lectures, views, zoom, you know, when should there be public mandates on this, the vaccines? Now, I think that there were some notable missteps by public health bodies in the United States. But what I can do is at least say that there was an attempt, however, unsuccessful at times to at least ground some of those recommendations based on studies and data and science. But this is a fascinating pandemic. It was a novel virus. Public health research, research, research, research, research, research, virus. Public health research is dramatically harder to conduct, especially in real time. Yeah. Versus traditional biomedical research, which is why the solid, the most solid evidence basis for our interventions came with the the antivirals and the and the vaccines, because that had been developed for decades, really. The other issues was where the controversy occurred. So to your point, I think that a lot of public health bodies would have garnered more credibility with the American public if they said, look, we do have data for this recommendation about elementary school kids masking or not masking. But we understand that this is also, to a certain degree, a values and meaning based recommendation. Yes, yes, yes. You know, and when parents are like, look, I’m worried that my child may not socially develop and that that social connection is important for them to be able to grow, that they were summarily dismissed as being sort of not relevant. And I thought that was not the message that needed to be sent. We needed to be able to say it’s OK to make recommendations that are based on things that are not purely public health or medical, because obviously the art of judgment and discretion has to come in. But I think there was a fear on part of medical authorities that if we do that and we open those gates, exactly what you just cited is going to be occurring that, well, then all of our recommendations are going to be dismissed. None of it is valid. It’s completely unscientific. And I understand that fear when we had some, frankly, pretty awful conspiracy theories. Yeah, yeah. Not the least by the former president about some of this stuff. You know, and so, you know, how do you raise your children? What kind of communities should be existing in an era of pandemic? I mean, this is something that our society is ill equipped to address. So there’s been a hundred years since this has happened. Now, if you look at the history of societies, which you know better than me, the presence of pathogens and germs have always been a central feature in all these societies. But we have been fortunate in the modern era that that isn’t the case. So when it came to those larger questions, we in the medical field didn’t really honor those questions. And there’s exactly we didn’t want to be felt like we were being pulled back to your point. But when we made that central error, we lost credibility. And then that is when we had massive politicization and the lack of agreement. And that ended up the very enterprise of responding to responding to the pandemic started breaking down. And that was a meaning question that I don’t think we addressed at all. Yeah. And the conspiracy theories were emerging precisely because of the meaning issue and the domicile that people were experiencing. They were they were articulating it poorly. And then that, like you said, that made everybody no, no pure science. And then they created a meaning vacuum. And then the whole thing was doing this on itself. I agree with this dipole system here. Yeah. Yeah. And I think that that is probably for me. And this may be an inarticulate way of saying that was probably one of the big takeaways just writ large from your work when I was going through the series, as much as I could pick up, because obviously I this is not my area. So I was like Googling every other term you said, like trying to keep pace. But I mean, it occurred to me that. People will regularly violate their values in order to meet their needs. And the central need that you’ve pointed to is a need for meaning. That is a hardcore, yes, central humanistic thing that is part of our existence. Yeah, we don’t have a society and we certainly don’t have a health care delivery system, for lack of a better term, that honors that. And yet this is supposed to be the most human of all professions. And that is now come to a crescendo with all these sorts of challenges. And we’re just totally bewildered. And we’re having fallout, fallout of patients, fallout of doctors, fallout of nurses, the general public is like not sure what to make of it. And the center is starting to collapse. And to your point, nature doesn’t like it back. We need a new system to kind of take that place that is better. And I don’t see a larger movement as of yet. Maybe in Canada, it’s a little bit different of that system kind of coming into place. And that is a problem. And I think that I don’t know how that plays out. I really don’t. So during the during COVID with my colleague and good, very good friend, Dan Schiappi, we read Camus, the plague together, where you get exactly the opposite. Right. There’s very there’s I mean, they’re doing what they can. But it’s clear that right. The plague is going to overtake them. They have to quarantine. They’re doing everything. And it was so pertinent because the whole point of the novel is is to, first of all, get people to like step back and, you know, and the main one of the main characters is a doctor. And, you know, he’s basically a stoic figure in the midst of this. And then there’s other important figures helping him. And one of the figures, Tareu, it’s very much this one of my almost a personal slogan for me. He said, I want to learn how to be a saint without God. That’s the whole problem I’m up against these days. Yeah, they they took they took this issue. They took this issue of people facing a pandemic. Well, Camus took it, I should say. And he makes the whole existential issue the central thing, because the point he is actually making, of course, is that we are always, in a sense, in a pandemic, because we’re always mortal. We’re always facing this. And if we try and remove, right, the the the the treating of the ill from the fact that we are also in deeply moment by moment mortal, then we’re we are dehumanizing ourselves. And so it’s the way in which the heroes relentlessly will. They will not let go of their humanity in the midst of the pandemic that I found such a contrast to what was going on in sort of the public space and the government led space, which which. Brings up the issue of. Do you think it is? And you already alluded to this. Do you think it is that. The medical profession really. I’m going to say this very boldly, really is not dealing with life and death anymore, it doesn’t really. I don’t mean life just as metabolism, I mean, life, right, right. You know, bio, not just Zoe, right. And like you said, there’s the whole attempt to deny that death hat right is there and to treat it almost. I don’t know, almost as a background phenomenon or not acknowledged, as you said, how these two things are. Only. Livable for human beings if they’re invested with some kind of meaning like. And so. What would it take like what is needed is is like it, I mean, this is going to be a ridiculous proposal, but like do we do we need to get people in the health care reading this kind of literature, thinking more philosophically, getting into deeper discussions about you know, what makes a life worth living, why is death and mortality so challenging for human beings, how do we process it? I mean, there’s a lot of literature out there on this. And again, it doesn’t have to be new agey or woo woo. But it can be like really careful reflection, like the main character, like he’s basically a stoic. He’s an existential stoic hero. That’s like, is that I mean, that to me, that’s a great work of literature. And one of the things you could ask is, well, is that how the doctors should have been behaving during the pandemic, should they have been exemplars of people who are facing these challenging realities? And if not, then who should they be turning to in order to find the exemplification? Yeah, I actually don’t think it’s ridiculous at all. I mean, I was fortunate to take a couple of classes as an undergrad in the literature of medicine and the sociology of medicine. I mean, I was a bioethics major in college, so I had a lot of sort of amateur philosophy training, but yeah, most most colleges and certainly med schools don’t really regularly offer that now that’s changing. In the modern era, you’ll have a couple of lectures or even a whole class as an elective, but I do think that this is going to be. Requisite, and the thing is, is that. When you’re early in your training in medical school and certainly probably once you graduate, you’re rarely put in the position, if ever, where you’re the sole provider of care for someone that is critically ill. And usually not always, but they’re not going to put you in the ICU, the first year of medical school to shadow senior doctors. I mean, they may usually start an ambulatory clinic where the patients may have chronic health issues, but they’re not dramatically ill. And then they kind of graduate you up as intuition might dictate so that you can kind of develop those skills. And that would be the opportunity where you could start having a sort of a curriculum built in. Yes. Where you could have these kinds of exposure. But the flip side is. The return on investment to use a medical business language will not be immediate. If you’re a first year medical student, unless you’ve lost someone personally or you’ve had some close ties to death, all these discussions that I think are central that are needed about the philosophy and the central challenges of what is a good life and therefore what is a good death, that may not have an immediate return in terms of relevance for a number of years. So I think the value proposition of this kind of work needs to be made. Now, if you’re already in the trenches or you’re already later in your career and you’re dealing with this, I think when someone hears about like the work you’re doing, they’re going to get it like that. It’s bringing to words something they’ve known in the background of their mind, but they couldn’t verbalize. But earlier in training, you may need to explicate a little bit more distinctly like this is why this is important, because you’re going to be facing down the road challenges may not be a plague. It may not be a pandemic or these skills and funds of knowledge are going to be directly relevant and that this is a skill as is doctoring. Like you’re not going to just read Death of Ivanilic or the Plague or learn some stoic philosophy and like, oh, you’re set like, no, this is a discipline. Yeah. And you’re going to have to develop this skill and it’s going to be no less relevant than listening to heart sounds to make sure there’s no murmur or whatever. And like that needs to be built in. Yes. Into that kind of curriculum, you know, during during the Hellenistic period when there was there was domicide and a mean crisis in the Hellenistic world, a new metaphor emerged for the philosopher. The philosopher was the physician of the soul. But now, right, we it looks like we need to go the reverse. We need to get the physicians to to to remember that that function of healing, healing the soul and not just healing the body. I’m wondering. Yeah, I’m wondering what that would mean. I mean, it sounds like. You’re right. I don’t think you’d get this just by reading. That’s just propositional. You need you need all the other kinds of knowing. You know, there would need to be, you know, an ecology of practices that physicians individually and collectively were participating in on a regular basis in order to address some of the deep deficits that you pointed out so eloquently. And there would need to be time and opportunity to do that, which would be hard because inevitably, unless someone is very dedicated to this, that that would take away some time from patient care, like if your clinic or your workload is stacked from like and most physicians are working at least 60 hours a week, if not, yeah, yeah, yeah. Including their own families and other things they got to do. You would need to take time away from that so they could process some of this. I mean, hearing you talk, it reminded me. It’s not uncommon that I’ll log into a chart on the computer for a patient that I had previously seen, but no longer actively taken care of. And then I’ll get a pop up. You are now entering the chart of a deceased patient admitted to the hospital and they had sepsis, which is a severe infection or a heart attack or what have you, and and the health care system is so disconnected. Most of the physicians, unless you were immediately taking care of the patient at the time of death, you will not get notified of that, but it’ll be this sort of benign pop up. And it’s like, oh, this is such a such a microcosm of this larger issue. Like we’re not even notifying the community of providers that one of their patients just passed and you don’t get it unless you happen to look in the chart and it’s one of like 10 alerts that you get just to log into the computer. And I was like, wow, that is. That is exactly the problem. The most central event in someone’s life, arguably, is when they pass. And this is treated as a non-event that doesn’t even merit discussion. And you’re lucky if you even hear about it, let alone having an ecology of practices where you can really get into this. And I’m not suggesting every patient that’s critically ill with every provider needs this whole thing. But I think a regular part of someone’s practice, especially if you’re in certain fields, you know, like oncology, cancer care or whatnot, this would be particularly relevant. And I think that there is a need for that. Yeah, yeah, yeah, yeah. That makes that makes really that’s a very good point. I guess what you’re saying, though, the problem is initially you’re not going to see the benefits of this, you’re only going to see it long term where, you know, the the the unacknowledged depression and anxiety and, you know, forms of addiction and deaths of despair that are chewing away at the medical and the quiet quitting. There’s a lot of exactly a great. Yes. Right. And so where we, you know, you. This is this this this requires leadership because the market is not oriented towards these long term goals of meaning. And right. And so we should like we need this is where political leadership has to, you know, really take a stand and say, no, no, no. Right. If we if we keep doing these short term measures, we’re actually sacrificing our health care system long term. The doctors are going to be overwhelmed by the disease that they’re trying to treat, but not properly trained or prepared to treat. I 100 percent agree. And. You know, for a lot of your listeners that are well versed in the work that you do, it may seem obvious that this is clearly needed, but this for the most part really isn’t spoken of in any real length. I mean, there’ll be a class here or there. I’m not saying there’s no discussion on it, but as a regular part of certainly practicing physicians, certainly not. And the example I give is I remember when I took an astronomy class or I had a lecture in high school and we were looking at the stars at night with a telescope. And for the life of me, I struggled to see the big and the little dipper and all the other constellations that were out there. And someone had to kind of almost point it out and they took a picture book and like this is what it’s supposed to do. You see it there and orient your tell. And I, for whatever reason, really struggled to see the pattern. Once it was pointed out to me and I practiced it, I was like, oh, now I can’t help but see it. Right. When I look at the night sky and I’m in like the right part of the country and whatever. And it’s sort of like that. There’s this whole constellation of experts in cognitive science and philosophy and sociology and artists and literatures and philosophers, like all that have dedicated in their own disciplines or cross-disciplinary to making meaning and learning the skill set of how to create that meaning that has been established for thousands. I mean, this has been the work of civilization. All that has been disconnected from the core of medicine. And so it seems obvious to a lot of your listeners. It really is. We are the people looking out. We don’t really see the Big Dipper. And now this wave of suffering is not only overtaking our patients, it’s pushing people who are good people out of the field. And it almost have to be like a variety of not only political leaders, but thought leaders, yeah, yes, to the attention and maybe even frankly, dumbing it down a little bit because we don’t have the bandwidth to go deep into like, you know, the pre-Hellenistic roots of all this sort of stuff. But like at least as an intro, be like, look, there’s a body of knowledge that’s been created by a variety of people that can really help you. And let’s create some classic examples practically that make it relevant for people who are taking care of patients. This is why this is relevant for you and you don’t need to wait until there is a real crisis with one of your patients or when you’re really dealing with this stuff, if you see how useful this is, I think you’re going to see a lot of people naturally gravitate towards this much earlier in this training. And I know that the modern medical students of the current generation that reach out to me for guidance and mentorship and application help and whatnot, they’re on this on a level that I was at even. And I had some exposure to this. Part of it has become the pandemic because they’re like, you know, 20 year old kids, 22, 23, 24, for the most part, they’re ready to go into medical school. But they’re seeing all this. And they’re like, wow, what a not going to cost on your pocket, but what a disaster. Some of these elements of the pandemic response has been and they don’t want to repeat the same mistakes and nor should they. And they’re reaching out and they’re way savvier about some of this stuff. So I think that’s my hope is that they’re going to be much more receptive and engage, willing to engage on the work that you and other leaders in this area have done. And that that gives me an ability to feel slightly less anxious about this and that the future can actually be redeemed for good. Well, I work with somebody specifically who is like, you know, doing Ph.D. in medicine and going into being a physician. But she is deeply interested in the issues around the meeting crisis and awakening from the meeting crisis for exactly the reasons you’re talking about. So it sounds like it’s a matter of encouraging. And educating this most recent generation so that they can make it. Accepted that physicians in general can talk about this and seek the kind of training of skills and virtues that are needed in order to tip the balance back the right way again. So we’re not like the way you’ve described it, we’re in this sort of death spiral. And we’ve got to get out of this. You know, I it sounds fairly soon or the system is going to be irretrievable. It’s we’re going to you know, there’s a point where systems like that, you pass the knee in the curve and then you can’t intervene in them anymore. You just have like the the Western Roman Empire just falls. Right. There’s a kind of thing. I mean, I think the only reason that there has been more of an issue than there already has been is that we still have an influx of medical applicants. I mean, medical applications increased by like almost 20 percent in the first year and a half of the pandemic because they called it the Anthony Fauci effect because people wanted to sort of mimic this sort of physician hero conception. Again, a question of meaning like this is how I’m going to do my job. Yes, I don’t know. Is that one of the reasons Dr. Fauci is so loud in most but not all circles is is how exemplar but how much of an outlier he is. That is not an opportunity afforded to most patients or most young physicians. But the other thing is that you still have record numbers of applications. And then depending on immigration policy, you have foreign trained physicians coming in. So the system is like, well, we can turn out more doctors. It’ll take a long time. But like we have an influx. So we don’t really care if the current physicians are spewing out with all these meaning related health issues. Now, when the influx of new providers drops, then you’re going to start really seeing systems start panicking like, oh, we should have been paying attention to this a lot earlier. Yeah. Ruch, this has been very educational for me. I hope I was helpful back to you because you were certainly teaching me a lot. This is great. I love talking to people that can kind of. Take my verbal diarrhea and kind of really make it centralized. And I I would just encourage you and all of your colleagues that are in this area. There is a huge class of people around the world. I know I’ve referenced America quite a bit, but they’re in health care professions and not just Finnish physicians, but allied health professionals writ large that are dealing with this issue with a few educators who are not in health care that I’ve talked to, you know, teaching at various levels. Obviously, you know, teaching much better than me. I’m hearing somewhat similar stories, like people who are in these central social service fields. This is a huge area where meaning is is not theoretical. This meaning challenge, this is very, very relevant. So I encourage everyone to see how you could help those who are trying to help others, because I think there would be a lot of avenues for for integration, for the work that you all do with the people that could really hear it. Yeah, that seems like a very good place to end it with that call to action. So I wanted to thank you very much for coming. For those of you who are watching this, I’m also going to go on Russia’s podcast and try and get this message out. So I’m looking forward to that. Thank you so much. Thank you for having me, Professor. It’s been a real pleasure. Please call me, John, and thank you very much. All right. Thank you.