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Beyond the Exam Room: Physicians as Advocates · Health Ethics Podcast

• 0:08
  Speaker 1: Welcome to Health Ethics, a series of conversations with leading
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  Speaker 1: experts about ethical considerations associated with health and healthcare, both
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  Speaker 1: locally and globally. I am Brian Pilkington, Professor of Bioethics
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  Speaker 1: in the Department of Medical Sciences at the Hackensack Meridan
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  Speaker 1: School of Medicine. This series, like its predecessor, which focused
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  Speaker 1: on the COVID nineteen pandemic, relies on the idea that
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  Speaker 1: challenging ethical issues are best addressed by folks from diverse
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  Speaker 1: backgrounds practically reasoning together, and complements the Health Ethics series
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  Speaker 1: with its panel of leading experts from medicine, nursing, politics, economics, philosophy,
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  Speaker 1: and the law. Thank you and enjoy the episode.
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  Speaker 2: In today's episode, I speak with doctor Larry Rosen about
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  Speaker 2: advocacy and medicine and what ethics demands of physicians. Doctor
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  Speaker 2: Larry Rosen is an integrative pediatrician and founder of the
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  Speaker 2: Whole Child Center, one of the country's first integrative and
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  Speaker 2: ecologically sustainable primary care pediatric practices. He's appointed as Associate
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  Speaker 2: Professor and Pediatrics at the Hackensack Meridine School of Medicine
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  Speaker 2: and serves as Assistant Director of the Human Dimension Course
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  Speaker 2: and co chair of the Environmental Health Working Group. He
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  Speaker 2: is a founding member and former chair of the AAP
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  Speaker 2: Section on Integrative Medicine and a recipient of the AAP's
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  Speaker 2: Pioneer in Integrative Medicine Award. Additionally, doctor Rosen teaches yoga
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  Speaker 2: and meditation to medical students and faculty.
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  Speaker 3: Larry, thanks again for being here, really really appreciated. What
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  Speaker 3: we're really thinking through today is advocacy and physician advocacy.
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  Speaker 3: See so, from your perspective, what is advocacy? How do
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  Speaker 3: you think about advocacy?
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  Speaker 4: Me, advocacy starts with action, you know. I think it's
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  Speaker 4: one of those things you know when you see it.
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  Speaker 4: But I think what we forget sometimes is it's not
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  Speaker 4: just a theory. It's really about what are those actions
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  Speaker 4: that support the person or the idea that you are
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  Speaker 4: creating the action for. So, in terms of physician advocacy,
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  Speaker 4: the way that I think about it is you are
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  Speaker 4: supporting or even I would argue, defending a public health
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  Speaker 4: initiative or policy, and that can be on a patient
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  Speaker 4: level or on a much larger level.
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  Speaker 3: That's a helpful frame and it sort of fits in
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  Speaker 3: line with a lot of conversations that folks who listen
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  Speaker 3: to the podcast will be familiar with in terms of
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  Speaker 3: patient centered care, physician considerations and obligations focused on the
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  Speaker 3: patients and framing it broadly right, this is what many
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  Speaker 3: many professionals do. These are the altruism obligations that lots
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  Speaker 3: of different professionals have. For physicians, it's toward patients. You
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  Speaker 3: mentioned population health, which I think raises a really interesting question,
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  Speaker 3: which is if physicians are advocating for their patients, is
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  Speaker 3: it different to advocate for the patient in front of
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  Speaker 3: you the kind of care that you offer when I
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  Speaker 3: show up with my kids to your office and right,
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  Speaker 3: my daughter has some issue and you're going to treat
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  Speaker 3: that or treat her as opposed to thinking more broadly
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  Speaker 3: about advocacy physicians might engage in to help all sorts
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  Speaker 3: of folks right in the broader patient class.
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  Speaker 4: Yes, I think that most physicians and patients are very
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  Speaker 4: comfortable with the idea that I am your doctor advocating
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  Speaker 4: for some specific health thing for you in front of me,
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  Speaker 4: or in my case as a pediatrician, your child, you know,
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  Speaker 4: for a certain way they're going to eat, or we
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  Speaker 4: even think about behavioral health interventions, and we're very comfortable
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  Speaker 4: with that role. I think that's been pretty well established.
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  Speaker 4: I think where things start to get not even controversial,
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  Speaker 4: but curious and interesting is about if we take it
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  Speaker 4: to the metso or a macro level. You know, is
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  Speaker 4: it my moral obligation as a physician to advocate for
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  Speaker 4: policy change, for political change on a you know, real
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  Speaker 4: structural level. If I believe that this has tremendous health consequences,
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  Speaker 4: is that not part of my role as a physician.
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  Speaker 3: So what's the I mean that that is the question, right,
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  Speaker 3: and that's how you framed it, really really well.
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  Speaker 5: So what's the answer.
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  Speaker 4: Yes, the answer yeah, I mean I'm coming at this
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  Speaker 4: from a perspective of I do believe that we have
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  Speaker 4: an ethical obligation to speak up and defend public health.
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  Speaker 4: I think that that So that's the short answer. The
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  Speaker 4: more complicated answer is really around I certainly have a
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  Speaker 4: certain set of values and beliefs, right, and so I
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  Speaker 4: can think of examples historically to start with, you know,
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  Speaker 4: there have been pediatricians who looked around and said, my
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  Speaker 4: patients are being poisoned by leading the environment. Right. They
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  Speaker 4: look at gasoline, and they look at paint. I'm talking
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  Speaker 4: about the fifties and the sixties, you know when this
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  Speaker 4: was controversial, right, and we think now, like, of course,
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  Speaker 4: how did anybody think that was a good idea? But
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  Speaker 4: there are lots of examples. You want to think about tobacco, smoke,
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  Speaker 4: you want to think about asbestos. We can go back
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  Speaker 4: and back, right, But if I think about the pediatricians
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  Speaker 4: who stood up. You know Philandrigan, who was a hero
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  Speaker 4: and a mentor of mine, who is the guy who
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  Speaker 4: really went to Congress and said, we have to get
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  Speaker 4: the lead out of these things that are poisoning our kids.
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  Speaker 4: If it wasn't for him, you know, we saw the
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  Speaker 4: average lead level and kids drop precipitously and exponentially because
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  Speaker 4: of his work testifying in front of Congress to move
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  Speaker 4: industry that way. It took decades, but that happened and
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  Speaker 4: we have much better health outcomes today. Doctor Moehana, who
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  Speaker 4: is in a Flint, Michigan crisis right a more recent example.
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  Speaker 4: But if she didn't take the example of her own
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  Speaker 4: patients in her practice and said this is there's something
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  Speaker 4: wrong going on here my practice, I wonder if this
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  Speaker 4: is a bigger issue, and then take that and build out,
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  Speaker 4: we would continue to have social and structural problems poisoning
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  Speaker 4: kids on a huge scale. So I think that those
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  Speaker 4: are just two of many examples of history where if
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  Speaker 4: they didn't follow their values in their alignment, we would
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  Speaker 4: not have the same public health outcome. I think where
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  Speaker 4: it can get tricky is if my health beliefs or
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  Speaker 4: my alignment with my values is not the standard of
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  Speaker 4: care or it doesn't match up. And we can get
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  Speaker 4: into this with environmental health and other things as well.
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  Speaker 5: We should and we will. I mean, but so the lobbying.
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  Speaker 3: Cases, right, the sort of that you just described, are
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  Speaker 3: excellent examples of advocacy and they're also instances of activism.
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  Speaker 3: So it seems like, I mean, we have these two
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  Speaker 3: different I mean, maybe there's a paradigm shift now, but
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  Speaker 3: we have, at least in my mind, we have these
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  Speaker 3: two different ideas. I show again, show with my kid
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  Speaker 3: to see you, and you might advocate that insurance covers
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  Speaker 3: something that they might not, or you might you know,
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  Speaker 3: work in some way with the school to try to
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  Speaker 3: get some sort of special exception for something given health concerns.
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  Speaker 5: Or something like that.
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  Speaker 3: Those sort of individual interactions impact patients and I see
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  Speaker 3: how they align well with what physicians do generally showing
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  Speaker 3: up to Congress arguing that, you know, we are making
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  Speaker 3: folks aware of problems with lead paint. The historical cases
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  Speaker 3: are helpful or right or tobacco smoke gaessline, whatever that
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  Speaker 3: may be. That also seems in line with what you
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  Speaker 3: all are supposed to be doing because you're helping patients
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  Speaker 3: in particular, you're care for patients, but lots of them,
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  Speaker 3: and so that makes sense to me. But there are
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  Speaker 3: folks who will push back and say that the latter thing,
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  Speaker 3: you know, the incence of activism goes beyond what physicians
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  Speaker 3: should do. They should just be treating patients in the clinic.
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  Speaker 3: Any thoughts for the dissenter, right, a kind dissenter? No, no, no,
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  Speaker 3: doctor doesn't stay in the office, right, don't get into
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  Speaker 3: my politics. I mean, what makes you think that the
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  Speaker 3: sort of broader notion of advocacy or the second notion
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  Speaker 3: of advocacy really does fit what the physicians should be doing.
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  Speaker 4: There are definitely people who will say, stay in your lane.
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  Speaker 4: You know, that's where you should be. You know, you
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  Speaker 4: are a physician in your office and you see patients.
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  Speaker 4: I do want to make the point I think for
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  Speaker 4: those students who are listening, and for physicians in general,
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  Speaker 4: I think if you say, at the end of the day, look,
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  Speaker 4: it's just not my wheelhouse to go and speak in
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  Speaker 4: front of a school board or testify in front of
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  Speaker 4: the state legislature, that's fine. I think doing the work
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  Speaker 4: of advocacy for that one patient in my exam room
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  Speaker 4: is enough. I think that's enough. I want to make
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  Speaker 4: that clear. That is patient centered care, treating the patient
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  Speaker 4: in front of you. However, the pushback that I would
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  Speaker 4: give to the stay in the lane people is if
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  Speaker 4: you think about who is the most trusted health expert
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  Speaker 4: in the room, in any room, it's going to be
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  Speaker 4: a physician. I would argue that you know, on and
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  Speaker 4: on and on and so if a physician has the
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  Speaker 4: knowledge and is the trusted party, which generally, if you
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  Speaker 4: look at surveys, public surveys, even in twenty twenty five,
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  Speaker 4: the number one trusted source of health information is your
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  Speaker 4: primary care doctor. Across political lines, across geographic lines, it
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  Speaker 4: doesn't matter, which is really interesting concept, right. So if
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  Speaker 4: I am that person who better to counsel, to advocate,
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  Speaker 4: to speak up on behalf of health policy. Right, that's
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  Speaker 4: the lane is health. We are actually health experts, and
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  Speaker 4: so it's a choice I get to make as a physician.
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  Speaker 4: I believe, I don't think it's outside of my lane.
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  Speaker 4: But if I decide I feel so passionate about a
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  Speaker 4: health issue and I am an expert in that area,
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  Speaker 4: I'm offering my counsel to ten patients or one hundred
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  Speaker 4: patients or one thousand patients, depending on the scale. But
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  Speaker 4: that's no different in terms of my I believe ethical
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  Speaker 4: and moral obligation and my expertise. I think that that's
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  Speaker 4: strong ground to stand on.
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  Speaker 3: The arguments persuasive, I think, and is also in line
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  Speaker 3: with and this is another sort of air in your wheelhouse.
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  Speaker 3: Is also in line with increased work, increasing acceptance and
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  Speaker 3: understanding of the determinants of health. And once we start
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  Speaker 3: thinking deeply about the determinants of health, my two cents,
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  Speaker 3: some of the clinic lines, right, that start blurring a bit.
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  Speaker 5: And so it's I mean's.
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  Speaker 3: So that's a pursuas of argument for the And you said,
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  Speaker 3: you know, just caring for the advocating for the patient
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  Speaker 3: in front of you is sufficient. Let's think about that
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  Speaker 3: a little bit. More and physicians of a million things
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  Speaker 3: going on for the students. I mean, I'm not looking
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  Speaker 3: to heep anything more on them. But if you have
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  Speaker 3: an opportunity to advocate for something which helps folks, I
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  Speaker 3: mean not one, not two, but one hundred, as opposed
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  Speaker 3: to however many can see in a day, you don't
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  Speaker 3: have to. But do you think that future physicians should
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  Speaker 3: be encouraged to do this?
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  Speaker 4: Yes? I do. Yeah. So when I say it's enough,
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  Speaker 4: I think that people are just wired differently and have
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  Speaker 4: enough going on. And it may even be you know,
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  Speaker 4: when you're thirty years old. You know. I know for
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  Speaker 4: me personally, when I was starting in practice, it was
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  Speaker 4: enough just to figure out how to manage my practice,
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  Speaker 4: see my patients, spend some time with my family, you know,
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  Speaker 4: all that stuff. As you grow in your field, in
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  Speaker 4: your expertise and your comfort level. I do think it's
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  Speaker 4: an important pieces. I think it's an important part of
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  Speaker 4: being a physician, part of our identity, and I think
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  Speaker 4: that it offers some antidote to burn out. Interestingly, I
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  Speaker 4: think that when you think about how challenging it is
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  Speaker 4: to be a physician and the challenges that we have,
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  Speaker 4: if you can reconnect to the purpose, to the reason
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  Speaker 4: you went into medicine in the first place. Some of
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  Speaker 4: that has to do with this passion to make change, right,
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  Speaker 4: to be changing. So the way that you define health,
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  Speaker 4: which is how we define it at Hackensack at our
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  Speaker 4: medical school, health is not just a behavioral determinant of
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  Speaker 4: health or just a biological So, if I'm truly caring
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  Speaker 4: for my patients, I am thinking about structural determinants, I
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  Speaker 4: am thinking about political determinants, I am thinking about social
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  Speaker 4: determinants and environmental That is all part of health to me.
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  Speaker 4: So I do need to consider that in my advocacy
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  Speaker 4: work as well.
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  Speaker 3: If future physicians are sort of more engaged in advocacy
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  Speaker 3: in light of this right, so they find the arguments
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  Speaker 3: persuasive again, adopt the determinants of health, and they want
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  Speaker 3: to help their patients in whatever means they're able to do.
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  Speaker 3: You have any recommendations, suggestions, problems you've run into about
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  Speaker 3: doing that in a climate And I think you alluded
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  Speaker 3: to this earlier, where there might be different sets of
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  Speaker 3: values that are operative. So and I imagine there are
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  Speaker 3: instances where patients you know, wanted to keep smoking or
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  Speaker 3: something like that. And just thought maybe that wasn't sort
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  Speaker 3: of that's not something that really you all should have
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  Speaker 3: been having a conversation. Or maybe it's about food, deserts
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  Speaker 3: and other challenges and interacting with another kind of organization
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  Speaker 3: to change things such as your patients are in better places.
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  Speaker 3: Or and this may adds a huge question. This goes
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  Speaker 3: back to your point about physicians being the most trusted
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  Speaker 3: health expert in the room. What about an acclimate where
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  Speaker 3: they're just very different understandings of expertise and it seems
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  Speaker 3: like folks are seems like folks are offering descriptions of
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  Speaker 3: health which just don't really fit medical science or I mean,
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  Speaker 3: so any recommendations for future physicians as they run into
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  Speaker 3: obstacles in this kind of advocacy.
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  Speaker 4: Yes, I think while today's landscape is different in terms
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  Speaker 4: of where information comes from, and we can get into,
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  Speaker 4: you know, how how you h leverage, how you address misinformation, disinformation,
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  Speaker 4: all that stuff, I think the good news for students
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  Speaker 4: and young physicians is this, it's still about patient centered care.
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  Speaker 4: So if you come to see me and you are
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  Speaker 4: short of breath and you have a fever, that might
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  Speaker 4: not be the best time to start talking about how
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  Speaker 4: I feel about the impact of climate on your health.
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  Speaker 4: Right that that might maybe for that visit you're in.
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  Speaker 4: You know, I'm in the emergency department and you're having
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  Speaker 4: a heart attack, God forbid. That's like, that's a different
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  Speaker 4: time for a conversation. But particularly in primary care where
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  Speaker 4: you have a sustained relationship, I'm going to have that
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  Speaker 4: conversation with you and figure out, you know, what is
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  Speaker 4: most important to you my patient, you know, for this visit.
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  Speaker 4: And there are opportunities to start to bring in conversations.
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  Speaker 4: So smoking is one example. Right where are you on
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  Speaker 4: the readiness scale? You know, we talk about this with
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  Speaker 4: our students, are motivational interviewing and health coaching. It's the
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  Speaker 4: same with a lot of these other issues. So I
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  Speaker 4: can have the same conversation of about air quality and
• 15:01
  Speaker 4: your asthma. And the reasons for that are why when
• 15:04
  Speaker 4: I have kids coming in with seasonal allergies all day long,
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  Speaker 4: every day now, much more so than five years ago,
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  Speaker 4: I have a lot of kids will say why is that?
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  Speaker 4: Or the parents will ask why is this happening to everybody?
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  Speaker 4: I know, Well, there's an opportunity for a conversation around change.
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  Speaker 4: You know, start to think about and again, this is
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  Speaker 4: one of my areas of passion around sustainability and climate.
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  Speaker 4: But you can apply this around a lot of different areas.
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  Speaker 4: So advocacy for a lot of physicians con center on
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  Speaker 4: access to healthcare, you know, access to medications, access to treatments.
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  Speaker 4: I know I kind of sidestepped your question about the
• 15:38
  Speaker 4: sort of controversial areas, but I still think we're humans
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  Speaker 4: having a conversation, right, and so wherever we fall on
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  Speaker 4: the political spectrum of the belief spectrum, I'll be honest,
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  Speaker 4: it's the same way I have conversations with my patients
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  Speaker 4: about vaccines, which I know you've already covered in another podcast,
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  Speaker 4: so we're not going to spend all our time on that,
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  Speaker 4: but it's the same way we have conversations.
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  Speaker 3: I mean, I love the sort of the framework of
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  Speaker 3: this is how humans have conversations and have at it.
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  Speaker 3: If you want to add to the sort of knowledge
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  Speaker 3: base around around vaccines, I mean, it raises maybe a
• 16:12
  Speaker 3: potential sort of in and of itself. It's just it's
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  Speaker 3: an interesting thing to think about relative to both physicians
• 16:21
  Speaker 3: and patients, but also patients and other patients. Right, So
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  Speaker 3: I mean we've touched on expertise, we've touched on sort
• 16:27
  Speaker 3: of the challenge of misinformation and disinformation.
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  Speaker 5: I mean, you raise these these.
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  Speaker 3: Prospects, but lots of times bioethicists think or act as
• 16:36
  Speaker 3: if you know, we have health folks, right, physicians, nurses,
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  Speaker 3: other health experts, and you all are experts in health,
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  Speaker 3: but patients show up with their own set of values.
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  Speaker 3: And I think the world is messier than just sort
• 16:49
  Speaker 3: of that sharp division. Once you start talking about environmental
• 16:54
  Speaker 3: concerns and we'll go full bore and sustainabilities into sustainability
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  Speaker 3: against another one of your wheelhouses shortly, But once we
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  Speaker 3: start talking about vaccines or anything which might impact another patient,
• 17:06
  Speaker 3: how should physicians think about the patient in front of
• 17:10
  Speaker 3: them and then the patient. I mean we don't know
• 17:11
  Speaker 3: if to even go full public health in the waiting room, right,
• 17:14
  Speaker 3: I mean, do you have obligations to a second or
• 17:17
  Speaker 3: third patient which impact you in seeing your first patient?
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  Speaker 3: Should you change someone's mind who is either smoking a
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  Speaker 3: lot sixteen feet from the school or whatever the cutoff is,
• 17:30
  Speaker 3: or who thinks recycling is a joke and constantly right?
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  Speaker 5: I mean, yeah, how do you think about that? I mean,
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  Speaker 5: that's another big human question.
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  Speaker 4: Yeah, and I think the answer is yes. I think
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  Speaker 4: I have a responsibility if I and again I'm keeping
• 17:44
  Speaker 4: this to examples that I think are really well understood
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  Speaker 4: and stand the test of time. If I have a
• 17:49
  Speaker 4: grand parent who is smoking in the house that smoke,
• 17:54
  Speaker 4: there is credible scientific evidence that that smoking impacts the
• 17:58
  Speaker 4: health of the other people in the home. I can
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  Speaker 4: apply the same model to other behaviors and other strategies.
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  Speaker 4: So whether it's infectious diseases and how they spread, whether
• 18:11
  Speaker 4: it's the impact of a behavior I have. If I
• 18:13
  Speaker 4: carry out a certain thing and it impacts your health,
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  Speaker 4: I do think that that's part of the counseling. I
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  Speaker 4: also think we can walk and chew them at the
• 18:21
  Speaker 4: same time. I think it is possible to address the
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  Speaker 4: individual patients concerns, needs, weighing, risks and benefits, readiness scale, consent,
• 18:31
  Speaker 4: all that stuff with the lens of public health the
• 18:34
  Speaker 4: greater good. Right, if you think about the greater good,
• 18:38
  Speaker 4: I do think that that is an inherent ethical principle
• 18:42
  Speaker 4: that all physicians suld think about it. And when we
• 18:44
  Speaker 4: think about public health, the decisions that we make, the
• 18:47
  Speaker 4: recommendations we make are generally for the greater good. I know,
• 18:51
  Speaker 4: there's going to be some disagreement about the level of
• 18:53
  Speaker 4: scientific evidence behind certain things, and when should societies come out,
• 18:58
  Speaker 4: like when should the you know, American Medical Association or
• 19:02
  Speaker 4: the American Academy of Piatrics proclaim that this is a
• 19:06
  Speaker 4: policy now right? These are big decisions, you know. I
• 19:08
  Speaker 4: do think how I choose to live my life in
• 19:12
  Speaker 4: terms of health certainly has an impact on the other
• 19:15
  Speaker 4: humans around me.
• 19:16
  Speaker 3: Yeah, goog And so the walk in chew gum analogy
• 19:19
  Speaker 3: is helpful. So it sounds like you're acting both for
• 19:22
  Speaker 3: the interests of the patient you're seeing in front of
• 19:24
  Speaker 3: you and also with an eye.
• 19:25
  Speaker 5: To other patients.
• 19:26
  Speaker 3: It's not as though you're saying, look, Brian, you, I mean,
• 19:30
  Speaker 3: you really got to stop smoking, or you really have
• 19:32
  Speaker 3: to stop eating so much pizza, or you really have
• 19:34
  Speaker 3: to do X, Y and Z it'll be better for you.
• 19:36
  Speaker 3: But really, look at all these other people that you're
• 19:39
  Speaker 3: negatively impacting. I mean, it's it's sort of that causal
• 19:43
  Speaker 3: flow that I think is interesting because if we were
• 19:45
  Speaker 3: to accept that causal flow, then there's a lot of
• 19:48
  Speaker 3: things you might good physicians might be strongly inclined to
• 19:54
  Speaker 3: push me to for the benefit of public health. And
• 19:56
  Speaker 3: that goes back to the values difference and all that.
• 19:59
  Speaker 3: And so since we've touched on it, and we'll a
• 20:02
  Speaker 3: loupe back to some medical students sort of holistic considerations.
• 20:06
  Speaker 3: But since we've touched on it, sustainability, I mean, you
• 20:10
  Speaker 3: are a huge advocate for sustainability, You're a leader in
• 20:14
  Speaker 3: this space. Do you think all physicians should be working
• 20:17
  Speaker 3: more towards the sustainable future? And if so, I'm guessing
• 20:21
  Speaker 3: the answer is yes. If so, what might that.
• 20:24
  Speaker 4: Mean if you are someone who cares about the health
• 20:26
  Speaker 4: of people? Yes, you do, because I can't make I
• 20:30
  Speaker 4: can't think of a greater determinant of health globally worldwide
• 20:35
  Speaker 4: than environmental determinants of health. So it's estimated that about
• 20:39
  Speaker 4: a quarter of all deaths globally or due to environmental determinists,
• 20:44
  Speaker 4: and climate is probably the major trigger of that for
• 20:48
  Speaker 4: human health issues. Today we'll stop. So because I'm a
• 20:52
  Speaker 4: physician and I care about, you know, ameliorating suffering and
• 20:56
  Speaker 4: promoting health, I think it's a critical need. So not
• 20:58
  Speaker 4: only is it probably one of the greatest drivers of health,
• 21:02
  Speaker 4: it's something we as physicians have some control over and
• 21:05
  Speaker 4: so some people may scratch their head and say, well,
• 21:07
  Speaker 4: if I recycle in my office, how much of a
• 21:10
  Speaker 4: difference does that make? I would argue it helps. But
• 21:13
  Speaker 4: healthcare as an industry is one of the greatest contributors
• 21:18
  Speaker 4: to environmental ills, if you will, and so we as
• 21:24
  Speaker 4: a profession have an obligation and an opportunity to act unsustainability.
• 21:29
  Speaker 4: And even if it's only in quotes our own institutions,
• 21:33
  Speaker 4: that would make a tremendous impact, huge scale. Six to
• 21:36
  Speaker 4: eight percent of US emissions come from healthcare industry. So
• 21:40
  Speaker 4: the choice of not only how I operate my hospital
• 21:43
  Speaker 4: and my health network or my clinic and with the
• 21:45
  Speaker 4: whole child center where I work that I started. One
• 21:49
  Speaker 4: of our mission statements was around ecologically sustainable health care.
• 21:53
  Speaker 4: Why did I do that? Because I want to be
• 21:56
  Speaker 4: I want to walk the walk. I want to be
• 21:57
  Speaker 4: a role model for the kids that walk in the
• 21:59
  Speaker 4: door and say, look, you can come to a space
• 22:02
  Speaker 4: where you can see how we practice this. What paint
• 22:06
  Speaker 4: do I use in the walls? What ceiling tiles do
• 22:08
  Speaker 4: I use? The built environment? Do I recycle? Yes? Do
• 22:11
  Speaker 4: we have green plants in our space? Yes? And there's
• 22:14
  Speaker 4: do we take back on us medication for proper recycling. Yes,
• 22:18
  Speaker 4: you know, these are all things that families can come
• 22:21
  Speaker 4: in here and see and we can roll model. And
• 22:23
  Speaker 4: also I can use it as a teaching point. Also,
• 22:26
  Speaker 4: I get to now work in a space that is
• 22:28
  Speaker 4: healthy and I'm contributing to positive sustainability, not contributing to
• 22:33
  Speaker 4: the environmental ills. And I think we can do that
• 22:36
  Speaker 4: on scale. So I think that that plus are as
• 22:39
  Speaker 4: we've talked about, plus our opportunity to work with families
• 22:43
  Speaker 4: and patients, and some of whom run large corporations are
• 22:47
  Speaker 4: in big industries that have an impact or purchasing power,
• 22:50
  Speaker 4: et cetera. So there's lots of opportunity, and I think
• 22:53
  Speaker 4: it's hard to make an argument there's a greater opportunity
• 22:57
  Speaker 4: to promote health.
• 22:58
  Speaker 5: That's really helpful.
• 22:59
  Speaker 3: And I appreciate that you run up the whole Child Center
• 23:01
  Speaker 3: because I wanted a couple questions sort of for the
• 23:04
  Speaker 3: future physicians, and they tie to that.
• 23:07
  Speaker 5: One is how likely do you think it is?
• 23:10
  Speaker 3: And if this is to Crystal Bally, then just just
• 23:12
  Speaker 3: punt that physician's writ large will embrace the importance of
• 23:18
  Speaker 3: sustainability in light of the impact that climate considerations have
• 23:23
  Speaker 3: on health. And I was thinking about the whole, the
• 23:26
  Speaker 3: whole child center through this question because I'm curious if
• 23:30
  Speaker 3: someone who I don't know open minded the right time,
• 23:32
  Speaker 3: but engages engages the health of patients holistically and integratively.
• 23:37
  Speaker 3: I mean, are there folks like you who are just
• 23:40
  Speaker 3: more open to sort of seeing this and pushing in
• 23:43
  Speaker 3: this direction than maybe other folks, than other physicians might be.
• 23:48
  Speaker 5: So do you think it's likely?
• 23:49
  Speaker 4: Yeah, And it's happening, you know. And I think if
• 23:51
  Speaker 4: I compare thirty years ago when I started in practice
• 23:54
  Speaker 4: to now, the changes have been have been amazing to
• 23:57
  Speaker 4: witness and see. And so now we have many many
• 24:01
  Speaker 4: physicians across the country who are involved in these efforts,
• 24:04
  Speaker 4: spanning across all disciplines surgery, medicine, pediatrics, emergency, you know,
• 24:10
  Speaker 4: all the above. Every professional society in the United States
• 24:14
  Speaker 4: of all of these disciplines is addressing sustainability within their
• 24:19
  Speaker 4: own profession. From anesthesiologists and surgeons and operating rooms and
• 24:24
  Speaker 4: materials that we use or single use plastics, et cetera.
• 24:27
  Speaker 4: Two primary care docs like myself who are thinking about
• 24:31
  Speaker 4: the way that we build and run our practices. So
• 24:34
  Speaker 4: This is definitely a movement, It's definitely happening. They're professional
• 24:37
  Speaker 4: organizations that are, i think doing a really good job
• 24:41
  Speaker 4: today of connecting the dots between policy and health really
• 24:46
  Speaker 4: what we call health in all policies. So again, it's
• 24:49
  Speaker 4: a very comfortable place for me to be if somebody says,
• 24:52
  Speaker 4: what's your advice or what's your counsel on this policy
• 24:55
  Speaker 4: as it relates to health. You know, I'm not an economist.
• 24:59
  Speaker 4: You know my opinions, but that's not my you know,
• 25:02
  Speaker 4: that's not my doctorate, right, but I can certainly tell you, hey,
• 25:05
  Speaker 4: this is what I see in my patients, this is
• 25:08
  Speaker 4: what we're seeing in our community, this is the impact
• 25:11
  Speaker 4: this is having, and this is how this policy is
• 25:13
  Speaker 4: going to impact the health of our community. That's something
• 25:16
  Speaker 4: we can do and I'm definitely seeing that happen, and
• 25:19
  Speaker 4: we're seeing the students come in already advocates already doing
• 25:24
  Speaker 4: this work in many causes, in many areas. And you know,
• 25:27
  Speaker 4: my thing might be around climate and environment, someone else
• 25:30
  Speaker 4: may be about whatever name your you know, one hundred
• 25:33
  Speaker 4: other issues. We're just what we say to the students
• 25:37
  Speaker 4: is try to align your passion with activism and a
• 25:41
  Speaker 4: skill set that we can teach you. We can teach
• 25:44
  Speaker 4: you skills, we can teach you competencies so that when
• 25:46
  Speaker 4: you graduate medical school, not only do you feel that
• 25:50
  Speaker 4: you have a moral obligation, now you have a skill set.
• 25:52
  Speaker 3: This is great, and you sort of guess my question,
• 25:54
  Speaker 3: what advice do we have or do you have for students?
• 25:57
  Speaker 3: So let me add a layer to it. You mentioned
• 25:59
  Speaker 3: that some of these kinds of engagements, which at least
• 26:02
  Speaker 3: bears out anecdotal experiences and conversations that I've had with
• 26:04
  Speaker 3: students as well. But some of these sort of the
• 26:08
  Speaker 3: advocacy and activism experiences helps with burnout, right, and maybe
• 26:12
  Speaker 3: it helps physicians or this is really what I got
• 26:15
  Speaker 3: into medicine to do. Any advice guides things you've run
• 26:20
  Speaker 3: into in light of the current landscape when maybe and
• 26:24
  Speaker 3: maybe this is wrong, but maybe future physicians are going
• 26:28
  Speaker 3: to bump into more challenges when they pick up the
• 26:31
  Speaker 3: phone for or when they go to advocate for things
• 26:34
  Speaker 3: that seem to be in their lane. Right, So you
• 26:36
  Speaker 3: met you're a health expert when purported health experts say
• 26:43
  Speaker 3: radically different things than you might, and I mean, so
• 26:47
  Speaker 3: how I mean the big philosophical question is how do
• 26:50
  Speaker 3: we live with moral disagreement? But how do future physicians
• 26:54
  Speaker 3: avoid burnout engage in advocacy for what it is that
• 26:58
  Speaker 3: they deeply care about, what they're past sho't about in
• 27:01
  Speaker 3: a landscape where it seems like expertise, expertise is not
• 27:05
  Speaker 3: taken us seriously.
• 27:06
  Speaker 4: These are challenges, you know, and I think that because
• 27:09
  Speaker 4: there are challenges, we just need new language and new
• 27:11
  Speaker 4: ways of dealing with them. You know, if we're dealing
• 27:14
  Speaker 4: in a you know, super high tech, fast speed world
• 27:17
  Speaker 4: where information comes from many, many sources, I think we
• 27:20
  Speaker 4: have to develop skill sets about recognizing where does information
• 27:23
  Speaker 4: come from. Should I, as a physician speak to my
• 27:26
  Speaker 4: patients in the exam room about take, you know, take
• 27:31
  Speaker 4: a look at their social feed on their phone. If
• 27:34
  Speaker 4: I have a sixteen year old and I say, look,
• 27:37
  Speaker 4: show me where you're getting your health information from. Sew
• 27:40
  Speaker 4: me the TikTok feeds, show me the instruct you know,
• 27:42
  Speaker 4: and then say, okay, let's have a discussion about the
• 27:46
  Speaker 4: credibility of those sources. You know, this is really granular
• 27:49
  Speaker 4: kind of stuff. Should we be doing that as physicians?
• 27:52
  Speaker 4: You can make an argument that that is where you're
• 27:55
  Speaker 4: going to have an impact in health, right, and so
• 27:58
  Speaker 4: I think there's new skills. I think that's part of
• 28:01
  Speaker 4: the thing. I don't think we should shy away from
• 28:03
  Speaker 4: it because of that. I mean, I think, you know,
• 28:04
  Speaker 4: there was a time where people put their ear up
• 28:07
  Speaker 4: to someone's chest and listen to their heart, and someone
• 28:09
  Speaker 4: invented a stethoscope, you know, and on and on and on,
• 28:13
  Speaker 4: and we can definitely get into AI and technology, but
• 28:15
  Speaker 4: I think there's a way to have some sort of
• 28:18
  Speaker 4: I tech high touch conversations that doesn't get rid of
• 28:21
  Speaker 4: the humanity piece. You can feel passionate and you can
• 28:24
  Speaker 4: feel purpose at the same time, you know there's burnout
• 28:28
  Speaker 4: can happen, or disempowerment can happen when you feel really passionate,
• 28:31
  Speaker 4: but there's no avenue, there's no way out. You keep
• 28:34
  Speaker 4: meeting roadblocks. I think that there are a lot of opportunities.
• 28:37
  Speaker 4: I've never had anyone in policy say to me, a
• 28:41
  Speaker 4: lawyer or a legislator, executive branch person say to me,
• 28:45
  Speaker 4: I don't want to listen to you. You know, if
• 28:47
  Speaker 4: I'm a physician, whatever, I may have a different political perspective.
• 28:51
  Speaker 4: If I have something to offer, people are still respectful,
• 28:56
  Speaker 4: you know, in those spaces by and large, regardless of
• 28:59
  Speaker 4: perspective and opinion. And I think civil discourse is part
• 29:03
  Speaker 4: of a skill set that we are teaching our students,
• 29:06
  Speaker 4: and they're gonna have to learn. That's just that's part
• 29:08
  Speaker 4: of being the doctor today.
• 29:11
  Speaker 3: I mean the great answer, and I mean I for one,
• 29:15
  Speaker 3: appreciate the granularity and sort of the physician as teacher
• 29:21
  Speaker 3: of critical thinking, critical information reasoning skills, if that's what
• 29:25
  Speaker 3: you need to do in order to help your patients
• 29:27
  Speaker 3: understand what they can do best to care for their health.
• 29:30
  Speaker 3: Since you mentioned AI, I think there's an interesting consideration
• 29:35
  Speaker 3: relative to advocacy, I mean as a as a leader
• 29:38
  Speaker 3: in the human dimension course as well. Right, I mean
• 29:40
  Speaker 3: the which I think lots of folks will listen to
• 29:42
  Speaker 3: the podcast will be familiar with. You're keeping in mind humanity,
• 29:45
  Speaker 3: you're taking seriously health and sustainability, and then you're talking
• 29:49
  Speaker 3: about the sort of high tech, high touch piece. There's
• 29:52
  Speaker 3: phenomenal promise for artificial intelligence and healthcare and health and
• 29:56
  Speaker 3: bettering folks, and like there's riots some ethical challenges, but
• 30:00
  Speaker 3: and large things move very fast and with great potential.
• 30:03
  Speaker 3: It also takes a great deal of energy, and there
• 30:06
  Speaker 3: are other folks who are being impacted depending where the
• 30:10
  Speaker 3: data form is and this kind of thing. So any
• 30:13
  Speaker 3: preliminary thoughts as I see the clock and sort of
• 30:16
  Speaker 3: running a long time, any thoughts on sort of how
• 30:19
  Speaker 3: folks working in the healthcare space interested in AI can
• 30:23
  Speaker 3: keep an eye on sustainability.
• 30:26
  Speaker 4: Yeah, I mean it's certainly the energy used question. You
• 30:28
  Speaker 4: know about these huge you know, data server farms and
• 30:31
  Speaker 4: how much energy we're using. That is a I am
• 30:34
  Speaker 4: deeply concerned about that, and I'm a student of history,
• 30:38
  Speaker 4: you know. I think back I was at MIT back
• 30:41
  Speaker 4: in the nineteen eighties and these same conversations were happening
• 30:45
  Speaker 4: sort of post Cold War around nuclear disarmament, nuclear fuel,
• 30:49
  Speaker 4: you know, same kinds of things, high risk, high reward,
• 30:53
  Speaker 4: really you know, very deep philosophical questions about should we
• 30:57
  Speaker 4: be doing this at all? But maybe there's potential great
• 31:00
  Speaker 4: benefits in humanity versus harm. It's the same conversations, and
• 31:05
  Speaker 4: each time, I think, unfortunately we we we don't think
• 31:10
  Speaker 4: enough ahead of time about the humanism aspects before the
• 31:14
  Speaker 4: technology has been released and out and it's in its
• 31:17
  Speaker 4: way beyond beta testing. You know, where we are a
• 31:20
  Speaker 4: living experiment for these things and they happen. I just
• 31:26
  Speaker 4: I've been encouraged by the conversations that I'm hearing about
• 31:29
  Speaker 4: how we can leverage the technology so that we actually
• 31:33
  Speaker 4: can focus more on the humanistic aspects of medicine and again,
• 31:37
  Speaker 4: bottom line, improve health and reduce suffering, you know. And
• 31:41
  Speaker 4: I think if we can keep our eye on the
• 31:43
  Speaker 4: ball with that, I think we can do both things.
• 31:45
  Speaker 3: A good into and a feature I love, which you
• 31:47
  Speaker 3: know I will love about that kind of approach is
• 31:50
  Speaker 3: I mean, it's just rife with interesting philosophical conversations. And
• 31:54
  Speaker 3: to notice these kinds of questions around AI and sustainability
• 31:59
  Speaker 3: as another set of questions in a broader sort of
• 32:02
  Speaker 3: human conversation.
• 32:04
  Speaker 5: I think that's exactly right.
• 32:05
  Speaker 3: And you've heard me on this too, But a reason
• 32:07
  Speaker 3: that I think all medical students should take a bit
• 32:09
  Speaker 3: of philosophy. I think these things sort of come together
• 32:11
  Speaker 3: really nicely. So let me get you out on one
• 32:15
  Speaker 3: last thing. Any final word of well, I guess twofold.
• 32:19
  Speaker 3: Any final word of advice for future physicians who are
• 32:23
  Speaker 3: noticing the world and interested in advocating for the health
• 32:27
  Speaker 3: of their patients broadly, well, so I'll leave there and
• 32:31
  Speaker 3: then I'll give you one more question. So advice to
• 32:34
  Speaker 3: future physicians.
• 32:35
  Speaker 4: Yeah, I think that two things. Once you find your
• 32:38
  Speaker 4: passion and you know what you're passionate about, work on
• 32:41
  Speaker 4: your skills. There are concrete skills. And the cool thing
• 32:44
  Speaker 4: is the skills that make you a good physician also
• 32:48
  Speaker 4: make you a good advocate. Meaning how you message. You know,
• 32:52
  Speaker 4: how do we talk to our patients is the same
• 32:54
  Speaker 4: way we can structure ways that we create messages that
• 32:57
  Speaker 4: are framed well, that are meaning that are evidence based.
• 33:02
  Speaker 4: There are skills that you can learn and be taught,
• 33:05
  Speaker 4: whether you're already a physician and you're doing you know,
• 33:07
  Speaker 4: CME work, or we're teaching you as medical students. I
• 33:11
  Speaker 4: think that there are some key skills about understanding civics.
• 33:15
  Speaker 4: You know, how does the government actually work or not work?
• 33:18
  Speaker 4: You know, these are things and if you're frustrated on
• 33:21
  Speaker 4: a federal or national level today, then think about on
• 33:25
  Speaker 4: the state level or the subnational level. You know, there
• 33:27
  Speaker 4: are many places. It could be your kid's school, your
• 33:31
  Speaker 4: local community. You know that is just as valuable and important.
• 33:36
  Speaker 4: So focus on the skills and then get out there
• 33:40
  Speaker 4: and start doing it.
• 33:41
  Speaker 3: All right, And the final question what is next for you?
• 33:44
  Speaker 3: So is there a new research paper you're working on.
• 33:47
  Speaker 3: Is there a new section of human dimension you're excited
• 33:49
  Speaker 3: about For folks were interested in sustainability in your perspective
• 33:53
  Speaker 3: in medicine, what can they look out for in the future.
• 33:57
  Speaker 4: Yeah, I'm really excited about what we're doing in the
• 34:00
  Speaker 4: Dimension program at the medical school. To pick up on
• 34:03
  Speaker 4: what I was just speaking to a sort of our
• 34:06
  Speaker 4: theme for the years around advocacy skill building, and we're
• 34:09
  Speaker 4: doing that both from the undergraduate medical student level through
• 34:13
  Speaker 4: residency GMEY, through faculty development, and so we're really breaking
• 34:17
  Speaker 4: down the sort of the things like when you graduate
• 34:20
  Speaker 4: medical school, what are the core competencies you should have
• 34:22
  Speaker 4: in this area to be you know, just like you
• 34:25
  Speaker 4: would to examine patients or treat them right. And so
• 34:28
  Speaker 4: that is an area of research and the practice that
• 34:31
  Speaker 4: we are actively involved in and it encompasses everything. So again,
• 34:38
  Speaker 4: you know, I'm going to continue to work on sustainability
• 34:41
  Speaker 4: and the health network level. There's a lot of support
• 34:44
  Speaker 4: there for some students and stuff, some faculty they have
• 34:47
  Speaker 4: other things, but these skills cross, you know, all interest
• 34:51
  Speaker 4: and so I'm deeply interested in doing that, and it
• 34:55
  Speaker 4: is again, I'll say this again, it is a strong
• 34:58
  Speaker 4: antidote to burn out and disempowerment, which at this time,
• 35:02
  Speaker 4: you know, when we're seeing all time high rates of
• 35:05
  Speaker 4: people leaving the fields or getting frustrated. It's a way
• 35:09
  Speaker 4: to reconnect to why we went into this in the
• 35:11
  Speaker 4: first place. So personally I'm excited about it and professionally
• 35:14
  Speaker 4: I'm excited to see where we go.
• 35:16
  Speaker 5: Larie, thank you so much for joining me. It's been
• 35:18
  Speaker 5: really great to chat.
• 35:20
  Speaker 4: Thanks for having me.
• 35:22
  Speaker 1: This podcast series is a production of the Health Ethics Lab,
• 35:25
  Speaker 1: and I am grateful to colleagues in the Department of
• 35:27
  Speaker 1: Medical Sciences, the IHS Library, and the Hackensack I'm ready
• 35:31
  Speaker 1: in the School of Medicine for making this collaboration possible.
• 35:34
  Speaker 1: To learn more about our work or to engage with
• 35:36
  Speaker 1: the series content, reach out to me Brian Pilkington at
• 35:40
  Speaker 1: Brian dot Pilkington at hmh N dot org.