Episode 13: The Human Experience in Healthcare

Cara Lunsford (00:58.491)
Perfect. All right. Well, it's nice to have you. I know we chatted a while back and had such a nice conversation. And then I was like, you have got to come on and talk to this audience because you've got some awesome stuff to talk about, especially like the art of medicine.

Rob McDermid (01:17.446)
Well, thank you. You know, I'm really looking forward to having this conversation with you. We started a long time ago, but today's going to be a lot of fun.

Cara Lunsford (01:25.019)
Yeah, it's gonna be great. So Rob, Dr. Rob, I'd love for you to tell me just a little bit about yourself, a little bio so that the audience knows who you are and what you do and maybe a little bit of how you came to be really fascinated more, I think, by the art of medicine.

Rob McDermid (01:55.046)
Sure. So my name is Rob McDermid. I'm a intensive care physician at a hospital in British Columbia, Canada called Surrey Memorial Hospital. I did my training quite a long time ago. I trained in Edmonton, Alberta to be a respirologist and intensivist. And I finished my training back in 2003. I also did a fellowship in cardiac ultrasound.

because I felt that that was going to be a very important part of critical care in the future. And I had the good fortune of being part of the early development of a critical care ultrasound for very sick patients. Since 2003, I've been practicing as an intensivist. And how I kind of fell into this is it was often on holiday when people heard that I was effectively a life support specialist. What my job entails is,

putting people who are very sick on machines and using machines and technology to keep them alive when their bodies would otherwise die. And so people don't often get to see death and dying in their lives other than maybe a partner, maybe a parent, and certainly not more than a couple of times. But over my career, the statistics show that about one in six people in the ICU die. And that means that...

When I'm looking after 15 to 20 patients a week, I see death quite frequently. And I don't know if that makes me an expert, but it gives me familiarity with the process of dying. And it's allowed me to be with families in a way that most people don't get to be. So this closeness to death and this closeness to bridging the gap between life and death means that I have this opportunity to connect with people in a way that a lot of other people don't.

And so when I was on holiday, you know, people would ask me about my job and I'd say, you know, I'm an ICU doctor and the people would be like, so what does that mean? And I say, well, you know, one of the things that I see a lot of is, is death and dying and people stop. I have to just don't know, actually know how to approach it. And then they start asking little questions about what does that, what does that mean? Like, so what is it like? And how can you do that? And, and to me, I've found that what.

Rob McDermid (04:16.454)
the conversation around death and dying is a doorway into what matters to people. When you're dealing with a limited time for yourself or with other people that you care about, things become really clear really quickly. And so I had this great opportunity to connect with people, with families, and I felt that that was really where the value was. Because what I've come to learn is also that I don't have...

the tools or the skill to save life all the time, right? It's a lot of what happens in the ICU is the determinants of whether someone will live or die are there long before I get to see them. But what I can have a very powerful impact on is the journey that people take and the experience that they have while the events of their illness unfold. Certainly my goal is to try to help people survive.

But what I can have a very powerful impact on is how that experience unfolds. And so I've taken to understand that there's a lot of uncertainty in medicine, even though we call it a science, and that the art part of it, which is the creating an emotional experience that is safe and caring and satisfying as well as safe, is really important for people. If I can't affect the outcome,

I can affect the journey and you can turn this really horrible, difficult experience that people are having into something that is a transcendent legacy that they remember forever in a way that allows them to have post -traumatic growth. It's always traumatic, but sometimes you can grow from it because you've had an experience that allows you to integrate the experience into your life. So that's how I came to it. And I also have the good fortune of being a hospital administrator. I was the medical director for a pretty large hospital, 600 bed hospital for six years.

And I tried to embrace that art part of medicine as part of my practice. And now I have another administrative position where I'm in charge of a medical advisory committee for a health authority of about 2 million people. So my role is to provide advice to the CEO of the organization and the board of directors about how do we do medicine? How do we practice medicine in a way that is safe, compassionate, effective, and all that? So it's a lovely.

Rob McDermid (06:38.534)
opportunity for me to speak what I believe. And I think one of the things that we're missing in medicine right now is a focus on that experience. I think that art part, and we'll talk a little bit more about that I'm sure, but the art part of medicine is what really, that's what people really want. You can't not deal with the science stuff. You can't be a quack, right? You have to be good technically at what you do. But if you don't do the art part, people don't feel cared for, then...

Cara Lunsford (07:00.635)
Right.

Rob McDermid (07:07.526)
you're not doing your job, right? We're in a healing specialty. We're in a caring specialty, both you and I. And if we don't do that caring part, then the technical stuff doesn't land. So that's how I got to where I am.

Cara Lunsford (07:17.851)
Absolutely.

I love it. It's something that if you have, like what you said, if you've worked in end of life, in death and dying, you know that I have as well. So I worked in pediatric oncology most of my career. I would even venture to say all of my career because I have had even home patients, private patients clear up until...

very recently. So for 17 years. So it's it's a hundred percent about

having that that part cannot, it cannot not exist. Because I would venture to say that there is no healing, there is no wellness really. When you don't incorporate that into your practice. And I don't think people I don't think we

I don't think we look at it as much as we should be looking at it about how somebody does when they have that kind of support. They have that type of caring. They have people that are in the room, sitting down with them, taking time, holding space, doing all of these things that really do affect the outcome of their disease.

Cara Lunsford (08:55.355)
And a hundred percent, right? It's like, and like you said so beautifully, the outcome of their disease may be death, but the quality of that journey, the quality of that passing is heavily dependent on the practitioners who embrace this art.

Rob McDermid (08:55.846)
100 %

Cara Lunsford (09:21.595)
And so I'm so curious, like, as you've worked as a hospital administrator, how have you seen adoption of this or the rollout of this? Because I'm sure other administrators, other people are listening to this podcast and they're going, we need more of that in our hospital. We need more of that support. We need a chief medical officer that supports that.

Rob McDermid (09:53.286)
You know, there's a couple of things that come to mind when you ask that question. The first is that we struggle in medicine for a couple of reasons. One, we pretend to deal with certainty, right? We want to predict what's going to happen. We want to know who's coming to the hospital. We want to know what they've got. We want to know what tests they're going to be necessary. We want certainty about, and then we want certainty of outcome. One of the challenges with certainty is that,

It doesn't leave a lot of room for hope. If you know what's going to happen, there's nothing to hope for. If you know what's not going to happen, there's also nothing to hope for. It's the uncertainty that actually brings into the equation the possibility of something that you aren't confident of. And that's where hope, that's the well from which hope springs, in my opinion. Now, the real challenge is that with certainty, there's another very powerful motivator, which is efficiency.

And being efficient in healthcare is important because we know it's hard to get in to see practitioners sometimes. In Canada, we're having a lot of problems with that right now because of human resource shortages and doctor shortages. But I think the focus on efficiency means that people are rushing. And if we know that, what we know very clearly from the data is that if people are task oriented and hurried, it's not that they're not compassionate.

It's that their ability to be aware of suffering, of things that they're not focused on, is very limited. And so it's not that they're willfully ignoring people when they're busy. It's that they actually, it doesn't even enter their consciousness because they're not paying attention to the signs that someone might need attention, right? Themselves. They're not paying attention to the signals that say, hey, I need to pause here.

because I'm being held accountable for X, Y, and Z. These are the tasks that I need to finish. And so to come back to your question, what have I seen? I've seen it be very difficult to embed in terms of an organizational practice. What it really is, in my opinion, is a way of being. And so the only way to create that is really through modeling, role modeling. So you have to, at the top,

Rob McDermid (12:14.11)
be demonstrating this ability to pause. And then you have to build the infrastructure around it that allows those pauses to happen when they're most important. Now, the downside is you don't want your doctor spending eight hours with you when you don't need it, and two, there's a whole bunch of other patients waiting. But to be able to create the space for the pause when it's necessary, I think is super important. And in fact, if we don't do that,

I think medicine in general is at risk because what people come to the hospital for, what people go to healthcare for is to be cared for, right? There's some legislation in Canada where they, if I'm not mistaken, I hope it's changed. I haven't looked at the legislation for a while, but it refers to people who work in our profession as health professionals. They've actually omitted the word care, right? Which is shocking. We're not healthcare professionals, we're health professionals.

So I thought to myself, wow, like if our legislation missed that part, then how do we change the infrastructure and the incentives and the remuneration and all of that stuff that obviously matters, but is really peripheral. We're supposed to be doing this stuff to enable the care that's necessary. And yet we haven't really built the right structure to do it. I am hopeful because I'm not certain. Yeah. I know.

Cara Lunsford (13:32.667)
That's so profound, by the way. That's so profound. I mean, the fact that you were like, they took out the word care. I mean, that's...

Rob McDermid (13:41.222)
I don't know if they took it out or if they never included it, right? Either way, it's still like mind boggling. So I think that one of the most important thing that I think we can do is model the behavior, right? And so people with some positional authority need to say, hey, paying attention to what matters to patients is important for our providers to do. And I think the things that we hold people accountable for,

showing up to meetings, doing charting, all these things are very important. But when there is a patient needs, somehow we need to give people a pass. As long as they're not socially loafing, right? You're not avoiding work that's necessary by saying, I'm gonna spend it with my patient, right? Looking after the patient is the work and all of these other things are supposed to be empowering the healthcare professionals to be able to do that work. So in my opinion, I think one of the big things we have to do with...

every intervention in healthcare is figure out when we do something, how do we drive more time to the patient's bedside? If we can drive more time for providers to be able to be at the patient's bedside, then we'll win because the being at the bedside is the thing that actually allows people to make connections and to have that experience of being cared for and for caring for people. So that's how I see it.

Cara Lunsford (15:02.171)
Yeah, that's how we address so much of what we talk about on a regular basis, which is moral injury. Moral injury really is like when you, and I've said this ad nauseum on this podcast, so any listeners are gonna be like, we know what it is. But for anyone who hasn't listened before, that when you cannot do the job that you signed up to do,

And you can't do it safely. You can't do it ethically. You can't do it morally. You know, you that you are, you're up against all of these things and you can't take care of yourself. And so you can't take care of other people. It, it, it is something that will strip away at your soul. And I, I do feel like.

When your administrators, when your managers or your directors or whoever it is shows that they care about you, then you can then do the job that you signed up to do, which is to care for other people. I mean, you signed up for that. That's why you're doing the job that you're doing. Nobody goes into nursing or to be a physician.

because they love sitting in front of a computer and charting and like that's not what we signed up for. We understand that's part of the job, but if it becomes all of the job and none of it is what makes you feel like you're making a difference in the world or making a difference in the lives of people, then there's no sustainability.

you will continue to see nurses leave and physicians leave and, and, and that's going to continue to happen. And I do, I feel like there's things that could be done that are, they're not hard things to do. Like I used to say, okay, at the beginning of my shift, I'm going to sit down with my patient. I'm just going to sit. I'm either going to sit on their bed and sit in the chair next to them, but I'm going to sit.

Cara Lunsford (17:28.635)
down. And even if I just spend a few minutes, it doesn't have to be hours. If I spent a few minutes at the beginning of the shift, showing that I'm taking an interest in you as a human being, you as a person to learn a little bit about you to learn how was your night? Or when are you thinking, you know, what are you thinking is going to unfold today? Or

What would you like to see happen today? And what kind of goals are you trying to meet? You know, do you have family at home for when you are discharged? Let's talk a little bit about that. Like what's the support that you have or don't have? Taking an interest, but sitting down, not hovering over people, not standing over them and looking like you're ready to turn around and walk out the door. So.

I mean, do you feel like Rob that there's some things like some easy lift things that you implement on a daily basis or have throughout your career that you feel like maybe seem like small things or don't take a lot of time, but have a big impact?

Rob McDermid (18:47.814)
Absolutely. So I do a few little things in my practice. Whenever I'm talking to someone, I either sit or lean against a wall. It creates the, I'll say illusion. It's not an illusion. Like it creates the impression that I have all the time in the world, right? I want to appear approachable. I want to appear like I'm committed completely. So I assume some kind of relaxed posture intentionally. I allow people to call me by my first name.

I mean, I've been doing medicine a long time. And so if someone doesn't recognize my positional authority, I actually don't care anymore. It's like, I remember a patient that I was looking after who I had his wife in the room while we were putting him on life support. And I had some trainees with me. And so because I had trainees, I was supervising. But I was sitting in the back of the room watching everything going on. And I was talking with his wife. And...

just chatting about what was happening. I had a resident with me who was physically very large, he was about 6 '5", and he was like 230, 240 pounds, so just a giant of a person. And I had another trainee who had very gray hair, and even though I'm 52, I don't have much gray hair and I don't color, it's just fortunate for me right now. So I looked like the youngest person in the room. And the...

woman looked at me while I was, and she was just chatting with me about her husband. We actually put him on life support, but just before we put him on life support, I excused myself for a moment because he said, I'm so cold. And I went and got him a warm blanket from a blanket warmer. And I kind of tucked him in while we were getting ready to put him on life support. And for me, that was actually one of the most meaningful things I did all day because I actually did something that was caring for him. But after we'd finished putting him on life support,

his wife turned to me and said, you know, that was a really nice thing that you did. And, you know, I really appreciate you getting him the blanket. When are you going to be a real doctor? Right? When do you get to be a real doctor? So she thought I was a medical student or something. I don't know what she thought it was. But but I said, I hate to break it to you, but I'm actually the doctor in charge of all of this care. And she said, What? And I said,

Rob McDermid (21:07.91)
I'll tell you something else. I'm actually the medical director of this entire hospital. I never tell people that, but I thought it was so funny that she thought I was a medical student. And so I actually shared that I was the medical director for the hospital at the same time. She said, you get out of here. And it was so funny to have that experience of doing this thing that his wife felt was insignificant from a medical standpoint. But in my opinion, it was actually the pivotal thing that made him feel comfortable while we were doing all of this other stuff and resonated with her.

as a person watching the care being delivered. Right? It was that moment of, it was a bit of an unusual experience of the thing that I thought was necessary was the thing that was completely non -medical. It was a very serious situation, but it wasn't even perceived as part of medicine, which I thought was very, it was satisfying to do, but I thought, wow, like,

These are the things that we need to incorporate. We need to consider the person that we're doing this stuff to and shift it from doing it to them to doing it for them and with them. So I really believe in that kind of dialogue. I think that that's one of the things I always ask. I look to see if they're cold. I take a relaxed posture. I try to get a warm blanket. Sometimes I buy people in the ICU. We don't often have people that aren't intubated. So they're almost always on a ventilator. But if someone's able to swallow, which sometimes they aren't,

and doesn't have a tube in, I often ask them if they want a cup of tea or a cup of coffee or something to eat if the meal trays have gone by. And I'll go down to our Starbucks or second cup or whatever, and I'll go buy them something to eat if the meal trays have gone by because it's something kind of generous to do and it makes me feel good and they feel like they're being cared for. So I make that a part of my routine practice. And then the other things that I do in my routine practice are,

when when you're admitted to an intensive care unit your family goes through an emotional roller coaster and you know not a lot of doctors do this but i feel like families need a lot of communication right not everybody has time to speak to families every day but if a family is in the room i always assuming you know

Rob McDermid (23:30.726)
My day isn't getting completely blown out of the water by people who are extraordinarily sick and if my attention isn't being forcibly dragged elsewhere, if I see a family in the room, I always acknowledge them. So I give them just one or two minutes of my time because they are waiting for some kind of sign from their doctor that things are okay or not okay. It's just this emotional roller coaster. And so I make it a practice that if the family is in the room, I say, hello.

If I don't have time, I actually say, I'm sorry, I don't have time to talk, but today's going okay, right? And I'll talk with you tomorrow. And that practice of actually just touching base briefly to say, hey, I see you there. I understand how stressful this is for you. And I want to give you information. All you need to know is that today I'm not worried or I'm less worried than it was yesterday. And that's usually enough to carry things forward.

I do put a lot of time in with families upfront because one of my jobs is to engender a relationship. I have to create a relationship with people very quickly when they meet me. It's a very serious situation that they find themselves in and I have to create a relationship with them for them to be able to trust me to do the things that are required for their loved ones. Up to and including allowing them to die comfortably. And I have to build that rapport very quickly. So three things I need to do. Yeah.

Cara Lunsford (24:54.331)
Yes.

Rob McDermid (24:55.43)
It's amazing, the three things you need to do is you need to be honest, reliable, competent, and then the catalyst for building that, being trustworthy, is that you're compassionate. So that's the practice of me going into the room, me being available, me being reliable, following up on what I say I'm going to do, and just being accessible. And so sometimes the first name helps, other times people just want to refer to me as doctor, that's okay. I always try to address some kind of physical need in the room.

And I acknowledge what the person needs and what the family needs to the best of my ability, trying to create time and space for that.

Cara Lunsford (25:34.331)
Yeah. And all of those things don't have to take a long time. Like to your point, it's like that can all be done in minutes. It really in minutes. And so I know sometimes I hear nurses, I hear doctors say, you know, I just don't have time. I just don't, I just don't have time. And I understand I've worked at the bedside. I know what it's like when you're short staffed, when you're trying to, you know,

Rob McDermid (25:43.814)
Absolutely.

Cara Lunsford (26:03.995)
check the boxes, trying to just get the things done. You're like, okay, this person needs to go to CT. This person, I need to get these meds in. I, you know, this person, these orders need to be signed and this person's going to be discharged. And I have an admit mission coming later. And I know that the ED is going to call me. And there's all these things that are happening all at the same time. And, but at the same time, what I have tried to impress upon even nurses that I have precepted.

is I'm like, you won't believe how many call bells you will save yourself when you go in early. If you go in early and establish this early that, you know, I'm here, I've got you, I've got a lot of stuff to do today, but don't worry, I know exactly what's happening in your care and let's take a second, let's review.

Rob McDermid (26:44.55)
Yes, yes.

Cara Lunsford (26:59.163)
what your night was like and what you want to do today, which only sometimes takes just a few minutes. And I will tell you, it brings down the level of anxiety in those patients and in those family members, because sometimes it's not even the patient that's ringing the call bell. It's the family that's ringing it. So, you know, kind of establishing that at the beginning of your shift.

Rob McDermid (27:16.838)
Yeah. Yeah.

Cara Lunsford (27:25.147)
can save you so much time throughout 12 hours if you're a nurse or if you're a doctor just being paged to the room again. So I really, I'm hoping that people take away from like what you just said, all of these things that are what I would consider to be like low lifts. They're a low lift and, but they mean so much.

Rob McDermid (27:33.19)
Yes, yeah.

Cara Lunsford (27:56.075)
And you and I are both friends with Michael. I've interviewed him before on the podcast and, and we've talked about how, how you have to establish these intimate relationships very quickly. And it, it comes from a sense of vulnerability. There's like, if they're in a really vulnerable situation and.

you come in and you don't have some element of vulnerability too, it's very hard to meet people where they are, to establish that. Like they've been maybe sitting in the same clothes for like three days, haven't showered, you know, holding vigil over the bedside or something like that. And, and, and, you know, to come in and to just be,

kind of humble in a way, but also carry with you a sense of, like you mentioned, being very competent. They can trust in you, you carry this with you, but at the same time, you try to come down and meet them where they are.

Rob McDermid (29:15.046)
Totally, totally. So one of the things that I hear a lot of people say is, and there's a great Ted talk on it by, I think she's an Irish philosopher named Enora O 'Neill. She says, we don't need to build trust, right? Trust, you can't build something that someone else gives you, right? So rather than building trust, she says we need to earn trust by behaving in a way that is trustworthy.

And so it really puts the onus on us rather than me trying to convince someone to trust me. All I have to do is a behavior, which is behave in a way that is worthy of someone else's trust and they will automatically trust you. Right? So you have to be sincere in it, obviously. And like I said, the three elements are the competency, reliability and honesty. And it's not about being nice. It's about being kind. Right? Sometimes you have to share really difficult things and being nice actually.

puts a veneer over top of it that actually interferes with what needs to happen. Sometimes we need to say very difficult things, but we say difficult things in a way that doesn't compound suffering. So by being kind in the way that we express things. And I also agree with you, meeting people where they are, you have to acknowledge that there's positional authority. This isn't one of the big differences between medicine and the retail industry.

Is that that people don't really have a choice they have a choice sometimes of which hospital they go to but They get the nurse that they're assigned they get the doctor that's there if it's an emergency They they have limited choice and certainly they're not choosing to be sick almost ever right so the reality is is that there's a power differential and if we don't acknowledge the power differential and put our place ourselves in a position of being

accessible and available and thoughtful, then patients won't trust us because they're trusting us with their most precious resource, their lives, right, and their well -being. So I totally agree with you that we need to be able to, and it's not really come down to their level, it's be at the same place as they are, meet them where they are. And if they haven't had a shower, sometimes I know it's like, you know what?

Rob McDermid (31:38.534)
you need to be able to look after you, right? And you say, if you need some time to just go and have something to eat, shower, clean up, because you feel like you need to, I'm here, right? We'll look after the patient. I'll make sure I keep an eye on your husband, on your son, on your daughter, on the person that's in the bed. It's really, for me, and you're probably getting this impression, and you know this from your experience in critical care, that I'm dealing with families.

as much as I'm dealing with patients. It's almost like a pediatric experience where the family is really a very important part of the overall care team. You can't look after the patient in a very effective way unless you understand the context in which you're looking after them. And that means knowing the people in the room, which are the family members. Most of my patients are unconscious and on ventilators and on life support. So I don't get to engage with them. When I do, I really enjoy it because then I get to...

you know, engage with the person that's actually experiencing the physical and emotional suffering and see if I can do something about that. But the family experiences it temporally and emotionally. And they also have their physical needs start to be a little bit peeled back, like they don't sleep, they don't eat, they don't get to look after themselves. Jobs are obviously, people don't always get time off from work, there's financial stresses, all of those things.

And so I'm meeting them in this place where it's super, super stressful. And what they need to know is I've got their back, right? And I've got their loved ones back. And once someone trusts me to do what's right, my job becomes so easy, right? It may be hard, but the stuff may be hard to do, but the journey becomes so much easier to navigate. And that's when the outcome becomes obviously very important, but a little bit less, the focus shifts from the outcome.

Cara Lunsford (33:05.019)
Yep.

Rob McDermid (33:34.022)
to the journey. So if someone is going to die, we can make sure that the experience is solid and that the family trusts that I'm doing the right thing, even if the outcome isn't what they hope for. And I also need to know that I'm doing the right things. So it's restorative for me to have that experience because the moral injury that you talked about is alleviated in a big way when you are doing what you feel is morally right for someone, even when the person doesn't survive.

Cara Lunsford (33:35.899)
Yeah.

Rob McDermid (34:03.302)
And so that experience is very restorative for people. I think the pandemic showed us that when you weren't with patients, because you were wearing all the crap that we had to put on all the PPE, people died from loneliness and healthcare workers burnt out because the stuff that mattered, the being with people was peeled away. We weren't allowed to, we couldn't do it. So it was so hard to communicate with people, so hard to be with patients, it was so hard to be with families. Families weren't allowed in the room. And...

Cara Lunsford (34:07.707)
Yeah.

Rob McDermid (34:33.094)
I think that that experience really shattered a lot of the foundation of healthcare. Somehow we've got to reclaim that. And I think we are clawing our way back to the older ways of being, but with a new framing. We're not going back, we're moving forward, but recognizing the value of what we used to do pre -pandemic actually made a big difference. Holding someone's hand, being with them quietly saves lives.

There is no question in my mind that art part that we talked about that you mentioned, it saves people's lives because they relax, they don't fight, they don't get agitated. They start concentrating on the healing aspect of what is necessary for them to do. They sleep, they eat, they exercise, they trust their healthcare team. And hopefully they end up having, you know, restoration. Their bodies have the capacity.

to heal from the terrible thing that happened to them, whatever that might be.

Cara Lunsford (35:34.779)
When you can get people to, when you can inspire them to all row in the same direction with you. And that means the families, the patient, the healthcare staff, because just getting everybody kind of on board and rowing in the same direction. And if they can't row in the same direction at the very least, they just pull up their oar.

Rob McDermid (36:01.478)
Yeah, they don't roll against you. Yeah. Yeah. Yeah.

Cara Lunsford (36:01.947)
They don't dig it in, they don't go the other way. They don't, you know, it's like at the very least if you can get them to just lift the oar and just be like, look, you know, and because to what you were saying is this is a point in their lives and these patients' lives and these families' lives that they just have no control. And I don't know many people.

that are comfortable being out of control. You know, there's maybe Gandhi. I don't know. Maybe there's like Buddha or something. I don't know. Like, it's just like, you know, these... But most people, you really have to be, yes, you really have to be superhuman in order to...

Rob McDermid (36:42.31)
Yeah.

Yeah.

Rob McDermid (36:52.006)
You have to be superhuman, I think. You have to be superhuman. Yeah.

Cara Lunsford (36:59.515)
really be comfortable with the discomfort. And so, you know, it's just about A, I think, you know, you said this beautifully, it's like just saying out loud to people. Like sometimes like there's this assumption, right? That, well, they know that I know that this is so hard. I'm like, no, do they though?

You know, so sometimes just saying, and I used to do this too, with families, I'd say, you know, how many other kids do you have at home? And then they'd say, you know, I have, I have three kids and, you know, and not only do I have three kids, but my mother lives with us and, you know, she's disabled. And, and so, you know, I, I just, but I can't leave the bedside. I mean, I can't just can't leave. I mean, what am I going to do? Leave my, my child who has cancer.

So I have some neighbors that have been helping me out and I've got some church people that have been helping me out. But I don't know how long that's gonna last. And all it took was me just asking a question. Because now they know that I'm making, I'm putting things together. So do you work from home or are you the sole caregiver? Do you, is...

the is the is the do you have another parent who helps or you know, are you both working outside the home? You know, it's like you just start to take an interest in their life. And you start to show that it is not lost on you that they are having to juggle a lot of other things aside from the fact that this person who is the most in person.

person in their life probably or at least close to it is battling something that could be life or death and that everything else kind of has to take you know take a backseat but it doesn't mean that it's not weighing enormously on them and so I think there's a little bit of of that of like don't just make an assumption or don't

Rob McDermid (39:00.742)
Absolutely.

Cara Lunsford (39:19.963)
You know, like make sure you ask, even though you're like, God, if I ask these questions, you know, the patient's going to go on and on and I'm not going to be able to get out of the room and I don't know what I'm going to be, you know, it's like, I understand. Like sometimes you don't know, you know, how far that's, that's going to go, but there are ways of being able to say, this is super important information that you're sharing. And I think we probably need to bring in a few different elements of the healthcare team so that we can help provide a really holistic approach.

for you and the patient and your family. And so this is going to go on my list of things that I'm going to focus on today.

Rob McDermid (39:58.246)
Yeah, I mean, you've obviously got lots of experience with managing teams. And that's a lot of what we do, right, is managing teams, making sure the right people have the right information. Having a family completely unload on you and then being responsible for managing that information packet is actually quite challenging. And you want the other team members involved because they have skills that I don't have.

There's two things that came to mind. I want to use your line, getting comfortable being uncomfortable. It's such a great line. I'm going to steal that. That's OK, because it's absolutely what we need to be, being comfortable in situations where we are uncomfortable. Just being able to tolerate that discomfort in a way that doesn't derail us is a super, super useful skill.

Cara Lunsford (40:32.283)
You can have it.

Rob McDermid (40:48.518)
The other thing that I've always been very mindful of in my practice is that your experience and my experience of the suffering that we see is very different, right? Your experience of suffering with a patient is a 12 hour shift or an eight hour shift, depending on where you're working, but you're dealing with the suffering of a single person and you can't escape it. One of the things that doctors have the luxury of is, you know, I might see a patient, if I spend a long time with a patient, it's 20 to 25 minutes, like that's a lot.

long time with a critically ill patient to spend with a family just chatting about things. I might be doing things that take a lot longer in terms of the technical stuff, but to talk with someone for 20 minutes, that's, you know, people say that's unheard of, right? So I think that my experience of a patient suffering in terms of his temporal length, like 20 minutes versus 12 hours, that is completely different experience. And I can't imagine what it would like.

be like for a nurse at the bedside to not have the physician who is in charge of the care plan not acknowledge the suffering. So one of the things that I'm very mindful of is to make sure that I'm supporting the rest of my team in being able to manage the suffering. And you spoke about having everybody rowing in the same direction, making sure that if the team members are experiencing moral distress or having trouble with the care plan, knowing that I'm supporting them.

in their journey of illness as well, because they're having this vicarious suffering of watching someone who is in their charge have pain, have suffering, emotionally go through an emotionally very traumatic experience and the family as well. Right. So by supporting my team in their journey, then you can help the family heal even more effectively because you really, you appear to be a unified,

like part of a greater whole. I think that's also very important from an administrative standpoint. You really want to create this impression of continuity. And there's kind of three experiences of continuity when we're talking about care. There's this kind of relational continuity, where you have a person that you know is your nurse or your doctor, so the relationships exist over time. You have informational continuity, where you're taking the stuff from the past,

Rob McDermid (43:10.694)
and you're bringing it into the present so that you can try to plan for the future. And then there's this managerial continuity, which sometimes health care doesn't do very well. The feeling like all of the component parts are part of a greater machine or of an initiative or of a practice that is moving forward in a cohesive way. You can tease apart those three elements when you look at how continuity of care works.

And that's one of the things that I try to focus on. In an emergency department, you really are talking about relational continuity because the person needs to feel safe. When you're having transitions of care, you're looking for informational continuity because when you go from one team to another, you fracture the relationship and you have to actually have information being carried forward so it feels like there's still something connecting the two. And when someone shows up and says, I don't even know why I'm here, right? You break down the managerial quality, continuity of care. So if you feel like the...

elements of the care, the left hand doesn't know what the right hand's doing, it's really traumatizing for people. So I try to make sure that we create this impression that there is continuity on those three levels, the relational, the informational, and the managerial continuity, because I know it's going to break down on one of the three at some point, right? And if we can rely on the other two to say, hey, hey, no, we did know this, we just, you know, we had to catch up because there was this transfer of care. I'm trying to catch up with all of the information. I'm your doctor. And again,

Cara Lunsford (44:12.923)
yeah.

Rob McDermid (44:35.878)
being accessible and being available and being trustworthy means that patients will excuse those follies that you have, those little, I'll call them mistakes, even though they're not necessarily mistakes, but those gaps, we'll say, is probably the best way to describe them. The gaps in continuity that may or may not have any impact on the outcome, but have a huge impact on the journey and on the experience of care that we were talking about at the very beginning.

So I think that those things.

Cara Lunsford (45:05.499)
Yeah, people will latch on. People will definitely latch on to something that is then suddenly making them question or feel unsafe. It's like, it doesn't take much to shatter the confidence. And I...

Rob McDermid (45:26.31)
No, no, to shatter the confidence.

Cara Lunsford (45:34.523)
I am kind of fascinated by AI and what AI is gonna bring to the table for healthcare over time because one of the things that I think would be fantastic is if it's like, hey, give me like two to three sentences about this patient's healthcare history before I walk into the room that I can refer to that will help to create confidence in my ability to provide care. And...

Rob McDermid (46:02.598)
Totally. Yeah.

Cara Lunsford (46:03.739)
And can you imagine it like spits out for you? It's like Mr. So -and -so, you know, had, you know, had, has had four surgeries over the past, you know, six years, you know, and is, you know, is currently struggling with congestive heart failure. And, you know, has a wife who is his, you know, his power of attorney, something like that, durable power of attorney.

Rob McDermid (46:28.39)
Yeah, absolutely. Yeah. And there's actually a project going on in my health authority where we were working with an AI company and some big data organizations to create AI enabled discharge summaries. So that's basically the same thing. Obviously, the challenge is going to be garbage in, garbage out.

And if you're being told to put glue on pizza and like the things I was just saying in the news about the Google AI, I don't know how we don't want it to be hallucinating. So we have to be very careful about how it's used and the integrity of the data source. But on the flip side, I do think that there is the ability to summarize data that is put in front of them, maybe very, very beneficial from an

Cara Lunsford (47:08.571)
the integrity.

Rob McDermid (47:22.662)
The AI maybe allow us to synthesize information very quickly into a snapshot that gives us a starting point for how to engage with somebody in a more meaningful way. I'm kind of excited about that, to be perfectly honest, because I think that one of the challenges is now, where do we pay attention? It's the amount of information, not information, the amount of data that we have on people is monumental, right? And the...

The biggest part of my job is actually sifting the data for the information, trying to filter the noise from the signal. And so I want to know what the signal is, what is important to pay attention to in this really complex patient. If there's something that critical care is really good at, it's trying to get to the things that matter from a data standpoint. It's probably the most data -rich environment in the hospital, and yet the vast majority of it. Some of them say, well, what do you think of this? And I often say, I ignore it. No, I haven't ignored it.

I'm incorporating it into a plan. I feel that is of lower relevance than this other data. I never ignore anything, but you have to be able to put it into a hierarchy of what is really important, what's mission critical right now, and what are the other things that matter a little bit less, but are still important contexts.

Cara Lunsford (48:35.483)
Yeah, establishing confidence and being able to just break through something very quickly so that you can do the other things, so that you can get to the art of medicine is so wonderful. And I know I've probably said this before, but when I was precepting nurses and they had not ever done something, they'd never put an NG tube in or they had never placed a Foley or this was their first time putting in an IV or something like that.

Rob McDermid (48:45.35)
Mm -hmm. Mm -hmm.

Cara Lunsford (49:05.295)
there were things where they'd be like, well, what if the patient asked me if I know how to do this and if I'm good at it and how many times have I done it or this and that? And so I would say, this is what you say. You say, you wouldn't believe how many times I've done this.

Rob McDermid (49:27.398)
I would hate to have to tell you, I would hate to have to tell you how many times I've done this.

Cara Lunsford (49:28.571)
And that's your answer.

many times I've done this, you wouldn't believe it. And then you just do it. So, you know, you just, you create, you're not lying. You know, you're not lying, but you are instilling confidence and what you said earlier, you know, being competent, because that's what people want. They want somebody who at least has the illusion of being competent, you know.

not in an unsafe way, but that they carry themselves and they, you know, you don't want to be like, I don't know, you know, shaking and being like, you know, I have to, you know, it's like, that's not gonna, it's never gonna work. They're gonna be like, I need another nurse, I need another doctor.

Rob McDermid (50:14.822)
Yeah, yeah, absolutely. And you know, you're very accurate in saying that it's not the illusion at all, but the way you carry yourself is very important. I've got this idea that I would love to work with somebody on and I haven't found the right partner. If you're interested. So it's medicine as performance art, right? And so if you think about art,

as being, I've thought about this a lot. And we have this dichotomy of art versus science. The science is the technical stuff, right? The data and the information. And we say that the art is the emotional stuff, the soft stuff that is really important. And old clinicians will be like, it's all about clinical judgment. What we know very clearly is that if you rely on clinical judgment, standardization of stuff that should be standard, we can design therapies.

that are much more effective if we take some of the clinical judgment out of it. So at a population level, we can actually save more lives if we follow the science. Now, medicine isn't science. It's a whole bunch of experiments involving a single person. So we don't do science in the traditional sense because we're not going to be able to predict the future with science. What we're doing is science and medicine is always retrospective.

I do something and I see if it worked rather than I'm doing something because this is going to be the outcome. So I think that there's a really interesting book called How Doctors Think by a woman named Katherine Montgomery. And she says that the dichotomy, it's a false dichotomy, art versus science. She said, what it actually is is practical reasoning. And I think that's a very true statement. The science.

is the foundation, right? We take science and it informs our practice. The art inspires our practice and compassion motivates our practice. And so I actually think that the importance of the art part is that it inspires us to do the things that are hard, but we do the hard things with technical expertise. I think that coming back to the thing that I wanted to ask you and what I haven't found someone to do is I think the art part is really important.

Cara Lunsford (52:23.579)
Mm -hmm.

Rob McDermid (52:31.718)
Right? Because it's an experience that people have. You can have the technical quality, but the experiential quality drives a lot of the outcomes that we want to see. Do people believe in, in the state in Canada, for example, universal public health care, right? If they don't have, using an analogy from Michael, if you don't have a whole bunch of rabid fans for it, you know, you're going to become irrelevant, right? We've got to have people who are loyal to the idea of medicine.

This is because it's meeting their needs is actually surprising them. And so when I approach patients, one of the things that I want to do is surprise them with kindness. They don't expect to be treated kindly. They expect to be treated competently. You're never going to get pat on the back for having a safe hospital, right? But if you surprise someone by doing something kind of like, Hey, I didn't expect that, right? He got me a cup of coffee, right? Or any, and you layer that on top of technical expertise, then you get people are like, damn, you know, I, this, this healthcare system actually works.

And so I think that if you come back to the idea of medicine as performance art, something that we can take from lawyer, from actors and from, from the movie industry is that acting isn't fake behavior, right? Acting real, like good acting is authentic behavior in a manufactured environment. And so treating medicine almost as if you're on stage. So when you show up, what role am I playing? It's not, Hey, I'm going to pretend to be compassionate here.

It's what is my job? Who am I supposed to be? How am I supposed to interact? What's my goal? And then how do I wanna make, how do I behave in a way that allows people to feel what I want them to feel? And so I think things like improv classes and some acting classes for healthcare professionals would actually do a lot because you hear about doctors who are technically expert and they have zero bedside manner. I think bedside manner is performance art, right? And it's not, like I said, fake behavior. It's not performative.

Cara Lunsford (54:04.059)
Yep.

Cara Lunsford (54:25.115)
Mm -hmm.

Rob McDermid (54:28.646)
It's, who am I being when I'm in the room? Yeah, totally, totally.

Cara Lunsford (54:30.171)
But you also need to be convincing. You need to be convincing. I mean, it needs to be convincing. And, and, and some of that is that you are, if you talk to people who are good actors, they will say that they had to tap into something inside of them that allowed them to relate in some way or to convey a certain feeling. And to, so.

Some of it is that like, if you're gonna walk into this room and the role that you're gonna play in this moment is that you are going to play the role of the advocate. You're gonna be the advocate in this role, you know? And so you have to then look back on a time in your life where someone was an advocate for you.

And how did that feel? And what did they do? And how did they behave? And so that you can channel those same qualities and so that you can do those same things. But it is like to what you're saying is like it is that is performative, but it is not, it's not that it's not authentic. It's still authentic.

Rob McDermid (55:45.926)
Yes.

Cara Lunsford (55:48.091)
It's just that you have had to get in touch with something in yourself in order to show that authenticity to someone else, which then does come across as convincing. They do feel convinced that you are this person, you are the advocate, you are the spiritual healer or whatever you are in the moment.

Rob McDermid (56:09.19)
Mm -hmm.

Cara Lunsford (56:16.667)
Being a chameleon, people have asked me like over my career, they're like, how do you just, you seem to just go into these different scenarios and kind of assimilate to where you're going. And maybe it's someone's house, maybe it's a patient's room, but it is, I think like being willing to kind of.

pause, take notice of your surroundings. How also like how do you what are you picking up on? What are you feeling in there? Does this seem tense? Are people not talking to each other? Is no one smiling? Are people all looking at their phones? Are they all distracted? You know, like you have to look and then read the room.

And that does kind of inform how you're going to the role you're going to play. And you kind of have to be able to do this rather quickly.

Rob McDermid (57:27.174)
Absolutely. And if you want to be effective, you need to be able to, like you said before, meet people where they are. And if where they are, and by reading the room, you then figure out, okay, how do I shift the behavior? What behavior do I need to embody to shift the way they're feeling to the way I hope that they need or the way that I believe they need to feel in order to process this situation most effectively. So I think there's some real value in being

Cara Lunsford (57:54.267)
Yes.

Rob McDermid (57:57.03)
very self -aware when you walk into a room, being aware of your environment. And that comes back to something that you mentioned a long time ago, that we talked about a long time ago already, was that there needs to be time and space for that. So if you're going into the room task -oriented, you don't have that open awareness of what's going on. And that's when you create catastrophe for yourself that ends up being, you know, you end up spending hours trying to undo the damage by unintentional communication.

Someone told me you never don't communicate. The question is whether you're communicating intentionally or unintentionally, right? So when you show up in a room, are you communicating intentionally or is everyone around you just collateral damage? So by being very intentional with the way you're behaving and being very clear on your goal. And then the third part is being courageous.

and not being self -conscious about, am I doing the right thing? You have to know what you're doing. You have to be confident. You don't need to be overconfident, and you don't need to be certain. In fact, I think certainty is very problematic, because I'm not certain of anything. I can be quite confident in something, but once I'm certain, I'm almost invariably wrong. Almost invariably wrong. So, yeah.

Cara Lunsford (59:14.107)
Yes, absolutely true. I have learned that when people, yeah, certain and wrong. I know that always used to happen for me when people are like, how long does my father have? And I'm like, you know, I don't have a crystal ball. And that is what I know. And I know that every time I think I have an idea,

Rob McDermid (59:19.046)
If I'm certain about something, it's that. Every time I'm certain, I'm wrong.

Cara Lunsford (59:42.107)
of when someone is going to pass, they usually prove me wrong. They usually hang on longer than I thought, or they'll leave sooner than I thought. And, you know, there's things that I can show you, there's things that I can look to, to indicate that the body is going through certain transitions. Whether their skin is modeling or their extremities are becoming cold, or there's, you know, there's just things that you can start to see very,

Rob McDermid (59:45.158)
Hmm. Hmm.

Cara Lunsford (01:00:11.707)
objectively that can start to lead you in a certain way, but you know, it's okay to not be certain and sometimes people are a lot more they trust you a lot more when you this goes back to what you said earlier honesty just being honest and saying I know how important it is that you know when this is gonna happen and You want to be here?

You don't want to miss it. You don't want to leave to go to the bathroom and something happens and or you just decide you're going to leave for the night. And that's when they end up, you know, passing. I know that it's really important and I wish that I could give you more specificity in this. But unfortunately, people go when they're going to go. And and there isn't a way for us to truly know.

when that's gonna happen. And when you can do it with a sense of like saying out loud what you think they're thinking, because if you've been doing it long enough, you know what people are thinking. You do. Yeah, you've been around the block a minute, like you know, like you're like, okay, like they, you know, they're afraid that if they go to the bathroom or if they get up and go downstairs to the cafeteria and get some food,

Rob McDermid (01:01:25.606)
Yeah. Yeah.

Rob McDermid (01:01:31.014)
Yeah.

Cara Lunsford (01:01:40.443)
you know, that this is going to be the moment that they're going to miss it. They weren't going to be there for their last breath. And so you instill some sort of confidence that they're going to go when they feel ready to go. And, and sometimes that is when we're not in the room and that's okay too. It's hard for you because you want to be here, but this is, this is how it works. You know, this is how.

Rob McDermid (01:01:41.158)
They're gonna miss it. Yeah.

Cara Lunsford (01:02:10.203)
This is how death and dying unfolds sometimes, and sometimes they can't do it when you're here. And yeah.

Rob McDermid (01:02:15.782)
Yeah. And I think what I was going to say is one of the things that I find very interesting is that when, when I, the few times in my life when I've been certain, I have been wrong, but people don't believe you. They want to, they want certainty, but when you give them certainty, they don't actually believe you. And when you're human about it, right, then they actually are much more trusting because

when you say this is what's going to happen, they're like, Dr. McDermott, you said this was gonna happen and it didn't happen and I knew, right? So I usually say, here's my best guess. This is how I see it happening based on my experience. But coming back to the idea of certainty and hope, I had this experience one time that I had a patient who came to me after a cardiac arrest and he had this advanced directive on his chart.

that he didn't want to be resuscitated. He was a 65 year old guy, was pretty healthy, he had cancer, but he had a not for resuscitation. And he had what's called a pulmonary embolus. I know you know what that is, but for your listeners, it's a blood clot that goes to the lungs and it stopped his heart. And in response to that, the team in the hospital actually overrode his advance directive saying not to resuscitate him because he had a whole bunch of family there.

who said even though he didn't want it, his sister was flying home from Africa and her plane had just touched down and he would want to see her. So they overrode his advanced directive and I thought, okay. And the hospital where it happened didn't have an ICU. So I was getting a phone call to say, hey, we've got this patient who was it not for resuscitation who we just resuscitated and now we need to transfer him to you.

because his family overrode his, and I thought, my God, this is like, this is all bad. This is all bad.

Rob McDermid (01:04:15.494)
So I accepted him in transfer because I wanted to help the family come to terms with it. And it was just not the right time. Now that the traumatic experience had already happened, now it was time to manage it. And so he showed up on my doorstep in the ICU and I talked to his family and I said, I know he had an advanced directive. I know there's a family member that's on their way. What you don't need to do is worry about the process. We will manage the process. And I said, tell me a little bit about, about.

Why, you know, about him? Like, I'm taking over his care now and I don't, I need to know who he is. And that's how I actually open a lot of my conversations. Like I get them to tell me about the person that's in the bed because that shows that I'm interested and I am interested. And that information helps me decide how am I going to manage all the technical stuff? But they said, you know, he's had cancer and he never wanted to be put on life support. I was like, okay. So has he, you know,

What did he do for a living? And they said, what do you mean? And I said, well, before he got sick. And they said, he's still working. I was like, hm, OK. What did he like to do for fun? They said, he likes to golf. I said, does he do nine or 18 holes? What does he like to do? I don't golf, but I just ask questions about it. And I said, when he golfs on the golf course, does he use a golf cart? And they're like,

No, no, he walks 18 holes. He does it every Sunday. And I was like, that's odd. And I thought, does he have any pain? And they said, no, he has no pain. And I was like, why didn't he want to be resuscitated? Like, pardon my ignorance, but he had no pain. He's still working. He still enjoys life. Like, is his quality of life okay? And they're like, yeah, it's great. And I said, so why didn't he want to be resuscitated? And they said, well, because when his mom got sick,

He was put on life support and they asked him if they could remove the life support. They asked him for his permission to remove the life support and put the burden of responsibility on him to decide to stop treating her. And he told us that he never wanted us to be put in that situation. So he never wanted to even entertain the idea of being put on life support, even though this guy had a great quality of life, pain -free and had cancer that was actually causing no symptoms. So I thought, my God, like, okay.

Rob McDermid (01:06:40.678)
So now, now we're in a different situation. And I thought to myself, okay, so this guy has a bad brain injury because he's now had a cardiac arrest. He's unconscious. The family's coming and everybody is talking about not, you know, it's time, it's time for him to die. So, I ended up telling the family that the, the, the person that came from overseas landed and came to the room. She said, I believe.

Cara Lunsford (01:06:44.475)
Yeah.

Rob McDermid (01:07:10.694)
in miracles and.

He's going to live. And I said.

Rob McDermid (01:07:20.07)
I have no way of knowing how this is going to play out. This is what I see. I have a lot of information that suggests that he is going to not be all right. And I am going to take him off the life support because those were part of his wishes. And right now things look pretty bleak. I said, but one thing I'm going to be very careful of is I'm not going to create a self -fulfilling prophecy. I'm not going to sedate him into oblivion.

One of the things that he wanted and you want as a family, and I'd learned this when talking to them, that they wanted to be able to see if they could talk to him, right? Or at least share with him. So I said, I will give him something for pain so that he doesn't suffer, but I will not end his life with medication. And I just don't feel comfortable with that. And I never have felt comfortable with that. I allow the body to take its natural course and I am very good at relieving suffering, but I don't end people's lives with medication. It's against the ethical principles that we practice under.

So the family, I said, we're going to do this at three o 'clock. And so the family ended up going down for a cup of coffee. And at five to three, before they got back, he kind of opened his eyes and was a little bit, you know, he was a bit agitated. He started coughing. He had a breathing tube in his throat. And so he started coughing and freaking out. And I thought to myself, no, if I don't take this tube out right now, even though I've negotiated with the family that I'm going to do it in five minutes and they're not here, he's going to have to be resedated. And then,

I'm not going to be able to do the thing that I said I was going to do. So I pulled his tube out 45 seconds before they walked in the room. And so I shattered the trust that I had with the family by acting in what I thought was his best interest because they said, you said you were going to wait for us to be here. They walked in as we'd pulled the tube out. And so I thought, this is all bad. So the whole situation was, was completely chaos. But I said, no, we had to do it. I had to make a decision in his interest to follow.

his wishes and then allow you to have the experience that you wanted. And the timing didn't happen. That was the certainty part of things. And I said, now we're just gonna watch and wait. And he didn't die. He ended up breathing okay. And we moved him off to a palliative care ward. And a couple of days later, actually connected with the family and they were very grateful. Once the anxiety of the moment settled down.

Rob McDermid (01:09:45.862)
They were very grateful that I'd done what I did and they said they understood and they were glad that I did the extubation when I did because they were able to, you know, at least be with him a little bit. Went up three days later and started to rouse a little bit and he was kind of in and out of consciousness. And then they're like, okay, well, he's been sick for in hospital for a week. We're going to move him home. And as it turned out,

about seven or eight months later, a home care nurse showed up at his house to give him a bath. And door opened and she said, hi, I'm here to give Mr. Smith a bath. And he looked at me and he said, you're very young and pretty, but I think I can manage a shower on my own. That was seven years ago. The guy's still alive. I get a Christmas card every year. He completely blew my mind in terms of everything that I'd anticipated. He actually, he's back working, he's golfing, he's like,

I was completely wrong, right? And so the reason I tell you this story was that I was certain he was going to die, but I didn't create a self -fulfilling prophecy of ensuring that he died. And what I allowed myself and allowed him to do was be surprised by something that I didn't expect. That was positive, that I couldn't have predicted. And so by allowing the uncertainty to be there,

His sister, who came from overseas, was totally right. She believed in miracles, and I have an operational definition of a miracle. It's something that I didn't expect, that I can't explain, that people generally agree is pretty darn good. So it doesn't have to be religious, but I've seen that all the time. Could I anticipate this happening? Not a chance. Did I allow it to unfold? 100%. If I can take any credit for it, it was for not being certain.

and being comfortable, being uncomfortable, as you so eloquently said, and allowing the journey to unfold in the way it needed to unfold in a way that ultimately was good. And the irony in it for me was that if I hadn't been so comfortable with the uncertainty, I would have said, damn, like, the guy lived when I was certain he was going to die. Like, why would I ever want to be so certain that...

Rob McDermid (01:12:06.726)
a good outcome becomes something that is actually embarrassing for me, right? It was, or becomes something that I'm trying to fight against. So by allowing myself that opportunity to be uncertain and to embrace the moment, I was pleasantly surprised by something that I didn't expect that the family appreciated and I was wrong, but I wasn't in error. I was in error, but I wasn't wrong, pardon me. So my prediction didn't come true and I want to be wrong.

Cara Lunsford (01:12:31.419)
Yeah.

Rob McDermid (01:12:33.542)
I don't want my patients to die. I want them to survive and have a good quality of life. So if I'm wrong when I say that someone is very likely to die, fantastic, fantastic. And that's what I try to push onto families is this idea that your job is to be hopeful. And we'll just see how this plays out.

Cara Lunsford (01:12:50.427)
Yeah, that was just, well, what a beautiful story. I was just literally like on the edge of my seat. I was like, what is going to happen to this guy? You know, I could not.

Rob McDermid (01:12:59.662)
I couldn't believe it. I honestly couldn't believe it. I couldn't believe it.

Cara Lunsford (01:13:05.147)
I can't believe it either. I mean, like, and I've, I've kind of seen some stuff too, where I was like, I didn't know that was going to happen, you know, like, and, and it's like you said, you're, of course you're pleasantly surprised and the more you see, the more humble I think you are willing or able to be.

Rob McDermid (01:13:13.83)
Totally.

Cara Lunsford (01:13:30.619)
because you don't wanna be in one of those situations. It's super uncomfortable to be in a situation where you were like doubled down on something and you're like, look, I'm gonna muscle you into believing or just submitting to this because in some way,

you know, I need to get you to a place of acceptance or I need you to understand what is happening so that I can, you know, move forward. And, and probably some of the best stuff in my career has been some of the most surprising. and, and it really has now probably put me into a position where I will.

Rob McDermid (01:14:01.766)
Yeah, yeah.

Cara Lunsford (01:14:27.515)
I will help people get to a place of comfort, right? Like I, it used to be really hard for me to watch a family struggle. And there was an element of suffering involved when I would watch parents whose child was at the end of their disease. And everything had really shut down at that point.

And so it's hard and sometimes I'd say, you know what, I'll be honest with you. Sometimes I medicate for the patient and sometimes I medicate for you. And it's because you're having a hard time seeing these gasps of air, the sagging breathing, this, you know, some of the stuff that is relatively difficult to watch at length.

And so I'm going to give some stuff that I think is going to help with air hunger. I'm going to give a little bit more atavan, you know, to help with a level of disconnection so that I can say, look, you know what, your child, this is a physical thing that's happening right now, but they are not, I have given enough medication at this point that they're not feeling any of this. This is just, this is, this is mechanical.

Rob McDermid (01:15:43.046)
There's discomfort, but there's no suffering. Yeah.

Cara Lunsford (01:15:46.395)
This is mechanical breathing. This is something that's happening from the brain stem. This is, you know, like this is not them struggling. This is just mechanical. And this is going to have to, and especially with children, because children's bodies are strong. Their hearts are strong. Their bodies are strong. Their life force is strong. And so it takes time sometimes for them to transition.

And that is a really, really hard thing. And over my 17 years of doing this, it's probably only been in the last...

five to seven years that I have felt like I was able to get to a point where I'm like, okay, now I feel like I can just help and hold space for the family and I can help them get through this because we have to let the body go and the body is going to take its time. And now I just have to shift my focus over to them. And now I'm caring for them. And it's...

It's a challenge. It's not easy. But this, again, goes back to the art of medicine because at that point, I'm not really doing anything medical anymore.

Rob McDermid (01:17:08.454)
Yeah, it's that sitting with people.

Cara Lunsford (01:17:09.883)
I had a family, yeah, I had a family just recently say to me, I got called to a house. A friend of mine called me to a house and said, my friend's longtime boyfriend is dying. He's been on hospice for a period of time. He was in a lot of denial, didn't wanna take the medication, didn't wanna take the morphine, didn't wanna take anything.

His girlfriend was trying to convince him to take it. He didn't want to take it. And now he is unresponsive at this point. He's on the couch and he's kind of like in a compromised position and he's unresponsive and my friend is freaking out. She said, could you go? And she just happened to not be too far from me. Like, you know, probably about a couple of miles away. So it was like a Sunday morning. I walked in. Sure enough, this guy is like,

practically hanging off of the couch, one foot kind of like hanging off. You could tell that someone had tried to adjust him, but he was heavy. And so I came in and I was like, first, we're gonna get him comfortable. Then I'm gonna sit down and we're gonna, we'll talk about what's happening. But first, we're gonna get him to a place of comfort. Okay? And so, you know, I...

showed her I'm like, okay, you're gonna do this, I'm gonna do that, we're gonna move him and this is how we're gonna move him and we moved him and we propped him and we did the whole thing. And then I sat down on the couch next to her. And apparently I, you know, take this is what I do, I take my shoes off. It's a thing. I don't know. I've done it for a long time. Not in the hospital. Let's be clear. Let's be clear. This is in home environments only. But I take my shoes off.

Rob McDermid (01:19:00.742)
Yeah. Yeah.

Cara Lunsford (01:19:08.315)
It's like a grounding thing for me and I will oftentimes sit cross -legged. And, and so we went in and we, we just started talking, you know, at this point, there's not anything that I'm doing for him. He's, he's out, you know, he's, he's breathing, you know, he's apnic, but he's, he's breathing and it's just time. Like, this is just time at this point. And so I sat with her and it was like a, probably a couple hours and then.

finally, like he took his last breath and you know, she was there and, and a sister had come and now she was there. And we called the hospice nurse. She was on her way. And then I was just like, okay, the hospice nurse came and I was like, okay, you're in good hands. She's going to take care of everything from here. And if you need anything, you know, feel free to let me know. And I left and a while later,

she reached out to a friend of mine, the friend who had called me and said, she literally verbatim was able to tell my friend everything I had said in that moment. Like she literally, I was like, yeah, that is something I would say. yeah, that's, that sounds, yep, that sounds like me. Like he was, she was like literally like she had hung on to every single word I had said. She even,

said she came in, she took her shoes off, she was sitting cross -legged on the couch, she knew everything. She painted the picture for my friend. And I was like, you know, because that is, that's what matters to people. They hang on to that stuff. Yeah, totally.

Rob McDermid (01:20:42.79)
Well.

Rob McDermid (01:20:51.142)
being totally present. You're totally present. Sounds like it was just...

Cara Lunsford (01:20:57.595)
Yeah, totally present. Yeah.

Rob McDermid (01:20:58.054)
Sounds like you were totally present. And that's, that's what I think is so great about the precious gift that both of us have in looking after people that if you, once you've done it for enough time, the technical stuff gets pretty easy. And I won't say it's, it's not simple, but it's straightforward. It's the presence and the being able to do it with your eyes closed if you have to.

that having that skill to be able to do the technical part while paying attention to all of the stuff that's going on around you so that you can manage the environment and make it a safe space for people while you're doing this really difficult thing that people freak out about. It's understandable that they freak out. It's scary. But to be able to have the confidence to say, here's what we're going to do first, and then we're going to do this, and then we're going to talk. I mean, that's just absolutely beautiful. And what I hope to embody when I'm with patients.

just like, like you sound like you did there. That's a beautiful story.

Cara Lunsford (01:21:59.867)
well, it's not even close to your story. The guy that was alive all these years later. I'm like, what?

Rob McDermid (01:22:09.734)
I know I got a Christmas card this year from him in December, 2023. Like it's seven years. And I thought to myself, my God. And they always say, here's another year and we're so grateful to you. And I think to myself, like I didn't do anything here. All I did was take his tube out and he did all the hard work, but you're giving me all the credit. So it's amazing. It's, you know, it's, yeah.

Cara Lunsford (01:22:27.323)
No wonder you're not like, you're like, I can't help people die, I'm sorry, because there's a guy who's still alive seven years later and I can't do it.

Rob McDermid (01:22:34.47)
I've told this story so many times and it's like, it's mind blowing. And the reason I find it so important is the thing that I've found and what I think your story really emphasized for me is this idea that there's so much stuff to do in medicine, right? And it's at that moment when there's no more stuff left to do that you just have to sit and be present with the suffering. And I had that experience.

I did a TED talk a couple of years ago, and in my TEDx talk I actually talk about watching a person die. And it was in the moment of sitting with them while they died and not having anything left to do other than be present that I truly felt like a physician, like a doctor. That's when I understood what it meant.

to be a doctor. It's not the science stuff. It's not distracting myself with tasks like, you know, flicking the IVs or adjusting oxygen tubing or trying to give a medication. It is just being there and holding a hand and being present with the suffering, shouldering a little bit of that burden and allowing people around you to know that things will be okay. Even though they're not okay, they will be okay. One phrase that I've heard a lot is,

things happen for a reason.

Maybe, but I'm not so sure. I'm not so sure. I've seen a lot of really bad things happen to some really good people. But what I am sure of is that people make meaning out of difficult situations. Right? And it's not the meaning that is inherently present in an event. It's how you interpret it in the context of your life and what you do with that experience that is where the meaning comes from. And I think that's a lot more powerful, to be honest.

Rob McDermid (01:24:25.99)
how you create an environment for people to make their own meaning out of a situation that is traumatic allows them to create some kind of transcendent legacy from a traumatic experience. The death of a child, your experience with dying children, very different than my experience with dying adults, dying parents. Most of the time, my parents are older than I see. With the toxic drug crisis in Canada and in BC, I do think that we are seeing more children die. And so, death of a parent, you're losing your past.

death of a child, you're losing your future. That's a very different consequence for someone. And so for me, being able to take this thing that is extremely traumatic and allow someone to see the beauty that might be in it, even though it's extremely difficult, and then take that little kernel of something beautiful and carry that forward with them into a legacy that they can tell, a story that they can tell about how this unfolded.

in a way that allows them not to be devastated by it. That's where I get the most value for myself. And it's what makes me want to get up and go back to work every day. If I can find that little thing that allows someone to just flip the switch and say, this horrible thing, maybe just a little less horrible than I thought it was because now they're comfortable or now they're not suffering or their pain has been eased or people care or something, right? It's looking for that little thing that flips the switch.

Cara Lunsford (01:25:52.859)
Yeah. And, and, you know, I just, I don't want to keep you too much longer, but I was like, this made me think of something and now I have to say it. Now I have to say it to you. Okay. So I was just talking to, a long time friend of mine and this was probably about, gosh, six years ago or so.

Rob McDermid (01:26:01.766)
Sure, absolutely.

Cara Lunsford (01:26:22.267)
I had a couple of margaritas at our friend Mike's house and got challenged by some spicy margaritas, got challenged by his niece to do a cartwheel. And so Ella was like, you could do a cartwheel with me. I was like, I can do a cartwheel. And so I tried to one -up it and I tried to do a roundoff.

Rob McDermid (01:26:27.206)
Spacey Margaritas.

Rob McDermid (01:26:49.861)
Go!

Cara Lunsford (01:26:50.523)
which I should not have done at almost 40. But at the time I was almost 40. So I was like, I broke my ankle, my right ankle. yeah, yeah. In fact, Lanny was like, he heard the sound, the crack, the whole thing. I mean, he was like, what was that sound? And I'm like, that was my ankle. And I just kind of like, I just crumpled to the floor.

Rob McDermid (01:27:00.934)
no!

Rob McDermid (01:27:14.982)
That would be bones. That would be bones.

Cara Lunsford (01:27:19.035)
And it was St. Patrick's Day. And so my wife takes me home and I like, you know, I try to medicate myself and then work and end up in the hospital. Anyway, whole thing. Fast forward. I now have a cast on my right foot and so I can't drive a car. So I had to take a lift to take my son to school. Okay. Which I would not normally have been doing. I would have driven. So I take a lift to school.

And when I come out from dropping him off, I of course then have to call another lift to leave. So I'm now I'm standing out in front of the school when I would not normally be standing out in front of the school, but here I am standing there because I'm waiting for a lift. My friend whose daughter who has optic pathole glioma went to the same school as my son. She has lost most of her sight because of it. And she was running back in because

Sophie had dropped her water bottle. And so here we are, we meet, we see each other and we meet. And I'm like, hey, how are you? What's going on? And she's like, my gosh. She's like, well, she goes long story short, but I'm in the middle of trying to do these clinical trial things. And I had a lab set up for...

Sophie's tumor and they were gonna give me some of the tumor and I was gonna take it to this lab and we were gonna do some clinical trials and some testing and stuff like that and the lab fell through. She's like, you don't happen to know anybody who owns a lab, do you? Or runs a lab. I said, that's really weird that you say that because actually I do know somebody who runs the lab at UCLA. Let me see if I can connect you, it's Dr. Jewett. So I send a message to Dr. Jewett.

And ping, she pings me right back and says, of course, I'd be happy to help. And I said, my gosh, there you go. I was like, and there you go. I don't know what's going to happen, but there you have it. Flash forward seven years. They are actually now saving lives. The attending who used to be at CHLA, Dr. Finley, who is world renowned for headstart therapy for brain tumors.

Cara Lunsford (01:29:38.075)
is now going to be her medical director as of yesterday. They are literally starting to, the very things that they discovered in that lab all those years ago and then apparently when she started her business and she did not know she started it on St. Patrick's Day two years ago.

Rob McDermid (01:29:58.278)
Really?

Cara Lunsford (01:29:59.675)
And it just so happened that the start of her business was on the very same day that I broke my ankle six years ago, which put me smack dab right where I was supposed to be, I guess.

and now look at everything that unfolded. So it's like, yeah, you don't know. You don't know how things are gonna.

Rob McDermid (01:30:16.23)
That's crazy.

Rob McDermid (01:30:22.406)
And that's the beauty of uncertainty, right? And things aren't inherently good or bad either, right? They're just, they just are. And we will see, right? We will see how they turn out. I think that, yeah, I think it's really important that we try not to pass judgment too often on whether something qualifies as good or bad because it's all in the eye of the beholder. And the things that you take away from something,

Cara Lunsford (01:30:28.891)
They just are.

how they unfold.

Rob McDermid (01:30:51.334)
the learnings that you have. I think there's a quote, and I wish I could remember who said it, but the world favors the opportunity. Fortune favors those who spend their lives preparing for it. So I think being prepared for opportunities, being open and aware, and being compassionate and thoughtful, that's the kind of message that we want to spread. That's the societal message that we want to share.

with all of the chaos that's in the world right now, maybe at least healthcare can be a last vestige of decency because we're dealing with suffering in such an acute way. And that's one of the things that I would love to see is if at least we can be kind and compassionate in healthcare, maybe some of the polarization and rhetoric that we see in society will abate a little bit. It's an uphill battle. It's an uphill battle for sure. But if we don't...

maintain it in healthcare, I don't know where it's going to stay. I don't know where it's, hospice maybe, but I consider hospice part of that healthcare spectrum. If we don't do it in the caring specialties, in the caring professions, then it runs the risk of disappearing completely. So in my administrative role, I think we have to be absolutely laser focused. You look after the people that are looking after the people, right? If we can treat each other with kindness and compassion as an organization.

Cara Lunsford (01:32:15.419)
Yep.

Rob McDermid (01:32:18.022)
then our care providers, our healthcare providers, will actually look after people in a way that is compassionate, and then maybe that message will spread to the rest of society. I think we're at a tipping point right now. Yeah.

Cara Lunsford (01:32:27.963)
And it does. Yeah, and it does. It absolutely does. And I think it's, it is our duty. It's our responsibility. We have to do it. If we don't do it, it's, it's, it is, I think, going to be lost in some capacity. And so me too.

Rob McDermid (01:32:45.062)
I'm very hopeful. I'm very hopeful that we can do it because I think that every time I go to work, every interaction is an opportunity to improve someone else's life just slightly. And that's the approach I try to take with conversations. Even when my pager goes off, my phone rings, I'm like, It's like, deep breath, hello. Right? It's just, I don't want that carryover of stress to...

Contaminate the next interaction I have with someone it's a new interaction. I have to remember who I am who what role I'm playing and Set people up for success be compassionate it may be relentlessly compassionate so

Cara Lunsford (01:33:27.515)
Absolutely. Absolutely. Rob, you're one of my favorite people.

Rob McDermid (01:33:32.262)
Well, I love talking to you. I love talking to you.

Cara Lunsford (01:33:37.339)
I love talking to you too. I know. Mike always says, he's like, he's like, Dr. Rob, Dr. Rob said this and Dr. Rob said that. And I was like, that's because Dr. Rob is awesome.

Rob McDermid (01:33:46.566)
Ha ha.

Rob McDermid (01:33:50.374)
Well, you're very, very flattering and I love talking with you. This has been a huge privilege to be part of your podcast. I would love to come back again sometime and talk about other things. It's a lovely experience. Thank you for making it a safe space for me. Yeah, thank you for making it a safe space for me to talk.

Cara Lunsford (01:33:54.875)
Cara Lunsford (01:33:59.355)
Thank you so much. Absolutely. Well, thank you so much, Rob. Of course. Of course. All right. Have a wonderful, wonderful weekend and I'll talk with you soon.

Rob McDermid (01:34:15.494)
Okay, you take care.

Cara Lunsford (01:34:17.563)
Bye Rob.

Rob McDermid (01:34:18.534)
Bye bye.