Listening to Dr Matthew Tyler mull over the intricacies of conversations between doctors and patients always gives me hope. How do we figure out when to say yes or no to treatment? How do we create conversations that navigate these waters with honesty and grace? How do doctors break bad news, and how do patients prepare to hear whatever is going to be said? Plus – what’s “the surprise question”? (Hint: it’s a way of getting at your life expectancy.) This is a wide-ranging conversation with seeds that I hope will bear fruit in your future.

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Transcript:

Diane Hullet: Hi, I’m Diane Hullet and you’re listening to the Best Life, Best Death Podcast. Today I’ve got a wonderful repeat guest, Dr. Matthew Tyler. And Dr. Tyler and I talked way back on Best Life, Best Death number 128. And we had a great conversation about how to train your doctor. And so welcome back, Matthew.

Dr Matthew Tyler: Great to be back. Thanks for having me. 

Diane Hullet: Yeah. I’m excited because, you know, Matthew’s on Instagram. I follow him there. He’s got these wonderful. really short little videos and sometimes pretty funny skits. And a lot of times he’s in a plaid shirt in his car and they’re just very pragmatic. I always appreciate what you bring to the conversation because I think, you know, you’ve got relevancy as a doctor, but the way that you approach it is really through the lens of how can I help patients.

train their doctor. And it’s just a great, it’s just a great platform. 

Dr Matthew Tyler: Thank you. It’s been a, it’s a little, I call it my little experiment and it’s been, it’s been a fun experiment. So I’m glad they’re landing with you. 

Diane Hullet: Yeah. Yeah. I think they totally land. So Matthew and I were kind of kicking around subjects to talk about because there’s so many different ways to dive into this field.

And you know, we just, we sort of said, well, let’s, let’s kind of talk about communication and let’s talk about paperwork and you know, how do those two things dovetail when a patient comes to a doctor, whether palliative care or oncology or internal medicine, how does communication and paperwork kind of play together.

Dr Matthew Tyler: Right. And just as a quick recap of my, my origin story, so to speak, the whole how to train your doctor platform sort of born of this observation that I had at the bedside when I would be seeing a family or a patient as a palliative care physician consult. And as I do at every consult, I would ask them, Hey, what, what questions do you have?

And very, very often the response would be, I don’t even know what I should be asking right now, because Being in the hospital, being sick with something serious is very overwhelming, um, at the very least emotionally overwhelming. But then to think about all the complicated medical decisions you need to make and how to weigh the risks and benefits.

It often takes a medically trained person to weave through that, and so you just, you don’t know what you don’t know. So I wanted to build a platform where I could slowly start to give little pearls and educational nuggets for folks to better understand what questions they ought to be asking, how to think about serious illness, whether that’s cancer or dementia or heart failure, so they could feel more empowered, uh, with what’s going on, what to ask, and just feel like they have a better grip on how to move forward.

Diane Hullet: This idea of like how to be a more empowered patient, that’s really your bottom line. 

Dr Matthew Tyler: Yeah, and I think from a practical standpoint, the communication piece, like what to ask, how to ask it, when to ask it, um, at the bedside, in the clinic, that’s, that’s a big piece of kind of owning your healthcare plan, as is the paperwork that you may need to, to back up your wishes, your preferences, things that you’re going to need to do to some degree in advance.

And, um, again, you don’t know what you don’t know. So I try to cover those things. Uh, so that way you can feel reassured that you’ve done everything that you can do and no matter, no matter how much you’ve done, there’s always going to be this sort of unsettled feeling that you’re not doing everything.

And my hope is that once you’ve got your ducks in a row, we can kind of work on normalizing that sense of unease knowing that yes, you have, you have done everything and this is This is hard and it’s normal to feel a little anxious about that even when you’ve done everything. 

Diane Hullet: Yeah, yeah. We, we talk about a lot about advanced directives and how, you know, you’ve got to fill out your advanced directive and it’s, it helps you think through what you want and it helps doctors understand what your wishes are.

I’m actually struck as I say that by, it is a big piece of it is you yourself thinking about what you yourself want. And there is something about filling out an advanced directive paperwork that really is about facing your mortality on some level and thinking through different scenarios. What would you want?

But I always tell people the paper is just a piece of paper and far more important is the conversation you have with your medical. medical durable power of attorney. Am I saying that right? Medical MPDOA, I don’t know. It’s one of these acronyms, but the person who is your healthcare proxy, the person who will speak for you when you cannot speak, and I can’t emphasize that enough because I think people forget that.

I don’t know. There’s some statistic. It’s like 80 percent of us or 90 percent of us will be in a situation at some point where we cannot speak for ourselves. So who is that person? And do they understand what’s behind the little black and white check boxes on your advanced directive? What, what’s your experience with all that or your thoughts on it?

Dr Matthew Tyler: I think that’s well said that any advanced directive is going to be fairly vague in the language about your actual health care preferences and like on the front line as a doctor who is interpreting these advanced directives day in and day out for people who become sick enough to be in the hospital and where their advanced directives have become relevant.

You’re exactly right that a lot of what we’re doing is interpreting. Uh, we’re trying to interpret the wishes that are written down and bouncing those off of the person who is now speaking for you and putting that in the context of what’s going on with your medical situation to try to figure out what do we actually do with this.

And the advanced directive itself is a general guide. It’s a guide, but the conversations you’ve had with that person who is stepping up on your behalf are so much more important because there’s, there’s context there subtext there that requires. A deeper knowledge of who you are as a person and what’s important to you than any piece of paper is going to do.

Diane Hullet: You had a great video on Instagram recently about CPR. Let’s let’s kind of use that as an example. Like, so I say in my advanced directive, don’t want CPR or I do want CPR. How does that play out? What is the point of CPR? 

Dr Matthew Tyler: Yeah. So, uh, so CPR, um, chest compressions, when, when your heart stops. This, uh. This is a very interesting one when it comes to advanced care planning, and I think highlights the, the limits of advanced directives themselves, and I say that because most people, most of the time, when it comes to any medical intervention, whether that’s the chest compressions involved in CPR, or a ventilator, life support, Most everyone tells me more or less, Hey, doc, you know, if this is going to work, if it’s going to help me get better, sure, go for it.

But if it’s not going to help me get better, then I think I’d rather just die comfortably in that case. And the problem is, in most instances of advanced care planning, when we think about the traditional model of you sitting down at the kitchen table to talk to your family about your wishes, typically before you necessarily know what you will die from, it’s very difficult.

Difficult to make a sweeping statement about whether or not you’d want CPR because CPR was invented for sudden cardiac arrest. It was a perioperative procedure invented for folks who had a bad reaction to anesthesia, went into a bad heart rhythm and we needed a way to Um, and CPR still shines when someone’s heart stops unexpectedly, or as we say, when your heart is the first thing to stop, not the last thing to stop.

Uh, and I really don’t, I really don’t encourage people to talk about whether or not to withhold TPR until there’s some general idea of, you What you will die from if you have a life limiting illness and you have a sense of how this is going to play out, then I think we can start to talk about that upstream to that though.

I, I don’t think it’s particularly helpful. Um, unless there’s some very like specific, serious context that makes it relevant for you. Um, so the, the context is everything. And once, once you’ve got the context, there’s in the, in palliative medicine, we start to distinguish within advanced care planning and.

serious illness conversations. Because once you’re sick enough that things like CPR are relevant, you can make an argument that’s not, not that advanced anymore. It’s more of like, how are we going to approach the situation that we are now in? Um, and the advance in that case is in advance of you losing the ability to voice your wishes, but not so much in advance of a hypothetical illness if there’s one at play now.

Um, but getting back to that CPR video, that one was, um, very hotly debated because the context of that video. Um, was driven by the frequent observation that when a doctor is talking to a patient about CPR, uh, versus the do not resuscitate order to not initiate CPR. If the doctor thinks CPR is a bad idea, uh, very often they will invoke the breaking of ribs and we’ll say, you know, we’re gonna, we don’t want to break your grandma’s ribs and they’re going to be in a lot of pain and yada, yada, yada.

And um, I really don’t like this approach. I, I think it is, uh, I think it’s coercive, because it’s true, if someone is, if someone is very frail and old, uh, yes, it is true that they will likely suffer broken ribs in a CPR attempt. However, I, I look at it from the risks and benefits point of view. If, if CPR would actually work, we wouldn’t care about the broken ribs, right?

If CPR were a pathway towards recovering and going back to living independently at home. No one would care about the rib breaking thing. Um, but the point is that it wouldn’t work and you may also break ribs, but it’s, it’s a downside that far outweighs the upside, but we Often skip that part. We often skip the part where we say it just it wouldn’t work.

And that’s why we’re not recommending it. But we still have this CPR is a very weird topic in in health care because it’s the only invasive medical intervention where we’re just sort of like lay it at the patient’s feet and say, do you want it or not? And it tends to not be couched in a recommendation like any other surgery would be, any other procedure would be.

It’s got this weird place in our, in our culture right now where it’s sort of like, you get this invasive procedure automatically, whether or not there’s a medical indication for it. And it does create this weird dance around like trying to, the doctor trying to like sort of passively convince you to like say no to it, even if they have a medical opinion.

And my take on it is that. We should be sharing our medical opinion and um, the rib breaking thing is really, I think, a excuse to not have the harder conversation that this person’s likely near the end of their life and if their heart stops, it’s probably because they’re dying of something irreversible.

Let’s focus on what we, ought to be doing in that situation rather than what we ought not to be doing. 

Diane Hullet: Right, right. Like you, you give the example of when a football player drops on the field of a sudden heart attack, this is a totally appropriate intervention. And nobody’s worried about the ribs breaking.

But in the case of grandma in the hospital and trying to decide what to do, it isn’t really about the ribs breaking. It’s about that grandma’s It’s having failure of multiple levels and the heart stopping is one piece of that failure. So yeah, it’s um, it’s, it is interesting how we focus on that and how much, you know, you said it when you said the context is everything.

So is it me and I’m 59 years old, I’m in a car accident or have a heart event. I want CPR. But what’s the context when I’m now 85 and other things are problematic, then how does that all change? And again, who can speak for me? Because maybe I’m not totally in my right mind for whatever reason. So who’s my person who understands the pros and cons of an intervention such as CPR, right?

Dr Matthew Tyler: Right, right. Yeah. CPR is a great intervention. When your heart is the first thing to stop the last thing. Right. 

Diane Hullet: Yeah, well, so this connection of paperwork and communication in order to be an empowered patient is, is a really interesting one. And I, I like you, you talked earlier, I think before we hit record, we were kind of talking about just how it’s this dance of context and, um, Doctors being better at communication.

And, you know, you said a great thing about how doctors are humans and it’s awkward for them to break bad news. It’s awkward for them to have difficult conversations. How do you think we could improve that for the medical field? Is there like, do doctors take communication training or is there a way to, uh, put that upstream in medical schools somehow?

Dr Matthew Tyler: Yeah. Um, great question. And it depends on who you ask. And this is, this is a point of, of contention and pushback that I received too, because some, some doctors feel very strongly that they get good communication training. I, I disagree with that take. I’d say by and large, We, we don’t get serious illness communication training.

Typically, we get very basic crash course through just how to talk to a patient about their situation and to take a history. And there’s some communication involved in that. As serious as we tend to get when we talk about, What’s the general, like, standard medical training? We all get this same module in Breaking Bad News, and usually there’s a standardized patient involved, and there’s this very, like, formulaic way we go through the delivery of bad news.

Diane Hullet: What’s a standardized patient? 

Dr Matthew Tyler: A standardized patient is a patient actor who is given a script. and they have some fabricated illness and they’re like very clear things that they have been prompted to say or not say based on what the student doctor says or doesn’t say. Uh, so it’s our way of practicing the clinical encounter in a safe environment where there’s not an actual sick person’s life, life on the line.

And, and so that, that breaking bad news, um, follows this, um, tried and true model called SPIKES, uh, which is an acronym for setting the scene, understanding the patient’s perspective on what’s going on, asking for an invitation to share the news, then sharing the, the knowledge of which is the bad news, then navigating the emotion, and then summarizing situation and, and next steps.

And it’s been around for a very, very long time. And that tends to be as serious of the training as we get. And we don’t really have any sort of standardized training in medical schools across the country about what do we, what do we do next? How do we navigate the decisions we make after the breaking of bad news?

And that’s where programs like VitalTalk, because I have to give a shout out to VitalTalk, um, uh, who have sort of taken the baton. And started training people on how to have like really like nitty gritty, high stakes, high emotion, serious illness conversations, uh, with the same precision and training and coaching and feedback as you would get from an attending surgeon to a surgeon in training, uh, with, with the same, the same mindset that these conversations are the same as wielding a scalpel, you have to have a fine, precise touch.

You have to, you have to train for it if you want to do it well and guide patients through very highly emotionally charged, very difficult decisions in a way that they feel like they’re on the right path for them. 

Diane Hullet: That’s fantastic. That’s, that sounds like an amazing way to deepen as a physician, deepen your understanding and your relationship to this communication.

Dr Matthew Tyler: It’s the vital talk is a great training. It’s it’s fantastic. It’s becoming more and more the standard within palliative care fellowship training. Um, still not, not a requirement, but a lot of programs are using it at this point. Um, it’s, it’s not part of medical school across the board. And, and that really is the problem that there’s doctors working with patients who have a serious illness.

Um, and, and those doctors all the time, regardless of specialty, whether you’re a generalist, a family doctor, OBGYN, or oncologist. You’re working with people who have some serious issues all the time, and you often need to make some high stakes decisions without necessarily the training to do that in a way that’s really patient centered and that incorporates the context of the situation with the patient values and the trade offs they’re willing to make.

Most people just emulate whatever their attendings did when they were in training and sometimes You’ve got a great attending who just is a great communicator and you do what they do and things work out fine and sometimes you don’t have that that role model to work from and you sort of have to make it up as you go and sometimes that works out okay and other times it doesn’t but this is too big of a deal to just like leave it to chance and that’s why I’m such a big fan of VitalTalk and why I’ve gone through their training and why I’ll sing their praises uh pro bono as the day is uh because I think we do need to get to a point where we’re really Putting a greater focus on high stakes communication.

Beyond the breaking bad news into the what do we do with that? How do we work through this together as a team with the doctor and patient? 

Diane Hullet: I’m, yeah, I’m so struck by that. It, you know, as a doctor, you don’t know who you’re walking into a room with. I mean, you, the, the range of people you see, the range of their understanding of what’s happening to them or their family support or their, uh, sense of, uh, you know, everything about their life and what they bring, their level of education, their economic class and how that plays into their relationship with a doctor.

You know, you’re walking in to this soup. Not knowing what the soup is going to be like until you start interacting. And then you have to just be so quick on your feet to respond to all those variables in the most heart centered way. And from a medical perspective. So it’s just, wow. I really am so moved by the complexities of the work you do.

Dr Matthew Tyler: Yeah, there is a, there’s a fair amount of improv involved in, in these conversations to be able to just. And read the room and kind of follow that energy and navigate all those dynamics. 

Diane Hullet: Navigate it all. You had another great little post that I love that was the surprise question. Let’s throw that out there for the listeners.

Dr Matthew Tyler: Yeah. So the surprise question refers to a way of getting at your life expectancy. Uh, and we, we use this a lot in the medical research, um, involved in prognostication since, uh, doctors to this day, we’re still. We’re still kind of bad at predicting your life expectancy. And one of the ways we’ve tried to get closer to the truth of how long you have to live is a surprise question.

And the way that works is you ask the doctor, would you be surprised if this person died sometime in the next six months to 12 months, something like that. And the idea is if the idea is the doctor’s more comfortable Saying yes or no to that as opposed to the more direct question of how long do you think this person has to live?

That said the surprise question is still it’s still got a bit mixed results on how on how accurate it is I think both both questions are tricky and that they’re both prone to optimism bias Which doctors, uh, doctors are prone to the same biases as the rest of humanity, and optimism bias is a big one.

Like, we, we, we want to be wrong, we want things to go better than they often do. Uh, so much so that, like, we truly believe, we believe that it’s not, it’s not the same thing as obscuring the truth or, or lying to patients. It’s that most doctors truly believe that. believe deeply that you’re going to do better than, than you do because of that optimism bias.

So the surprise question tries to get around that by asking it in a more indirect way. Literature is a bit mixed on how, how effective it is. Uh, but what I find interesting about the surprise question is that as, as a patient or as a caregiver, I think that’s one more tool to have in your toolkit. If, if you feel very strongly about having as much information about your life expectancy as possible.

And. You’ve asked your doctor. How long do you think I have to live and they’ve given you some like vague answer Like I don’t have a crystal ball I think of the surprise question is just another way to ask the question that might get you closer to the truth So if you’ve asked your doctor, hey, like how long do you think I have and they say I don’t know you might ask Well, like would you be surprised if I was here next year?

And they, they might feel more comfortable answering a yes or no with that. It’s not necessarily more accurate, um, but it may, it may still give you more helpful information as you think about how to plan your year, how to plan your medical preferences, what to say yes or no to when it comes to interventions.

And I think also positions yourself to your doctor as someone who clearly wants the truth and as a way of signaling to your doctor, like as you get more information, as you change your mind, like, just like, can you let me know, I just, this is important for me to know. 

Diane Hullet: Yeah. Yeah. What, what do you see as a, as a palliative care doctor when somebody kind of faces that directly?

What, what’s the impact for people with that? If, if the doctor says, yep, probably I would be surprised if you were here in six months and they, they kind of grapple with that. What changes do you see in the way people are living? 

Dr Matthew Tyler: It’s a good question. In a situation like that, often. Often the very practical question at hand when we’re asking the surprise question is how seriously should I be thinking about hospice care?

Uh, because it really comes down to the very emotionally challenging question of what medical interventions do I want to leave on the table? Or at least the feeling that you are leaving more good time on the table by transitioning to hospice care. Um, prior to the very clear transition to the actively dying phase of those last days.

When some of that question tends to melt away, but at that point, you’ve, you’ve left a lot of good hospice care on the table if you wait to the last days of your dying. So I think for most people that are asking these questions to try to get at the fact of like, how much should I really be chasing more chemotherapy or how much should I be chasing the surgery?

Next time I get sick enough to require a hospital level care, should I be calling 911 or should I be calling a hospice nurse in that situation? I think it’s really more of helping people, you know, make some practical decisions when they’re at a fork in the road that would prompt them to really be wondering about their time.

Diane Hullet: Speaking of hospice and longtime people in hospice, let’s talk about Jimmy Carter. Cause we’re talking here in early October of 2024 and Jimmy Carter’s just turned a hundred. 

Dr Matthew Tyler: Yeah. Happy birthday. Right. 

Diane Hullet: Happy birthday. And how long has he been in hospice now? 

Dr Matthew Tyler: 19 months. 

Diane Hullet: So how does that work? Because hospice is typically said to be, you know, six months or less to live.

How does it work that someone is in for that long? 

Dr Matthew Tyler: Another good question. So from a nuts and bolts standpoint to enter hospice in the first place, a doctor needs to review your situation and certify that their medical opinion. They believe that if your illness runs its expected, normal, natural course, that your time is likely less than six months.

Uh, and that’s more common knowledge. The lesser known piece of hospice is that once you’re in hospice, every two to three months, it depends on how long you’ve been in hospice, uh, that hospice doctor is going over your situation again and re reviewing it. And looking at how you’ve changed over the subsequent two to three months and they need to recertify that based on your current situation, they still believe that your prognosis is less than six months.

So it’s always measured against six months. You don’t, the timeline doesn’t shrink once you’re in hospice care, but the burden of proof kind of goes up as, as you’re in hospice longer. And as the doctor is certifying your case, they need to write their clinical narrative as we call it, which is a summary of the changes that you’ve made.

experienced over the last certification period. And by changes, these are things like, have you been losing weight? Have you become less conscious? Are you sleeping more? Functionally changed in some way that would indicate that your disease is still running along its normal course. Because sometimes diseases don’t run their normal course.

Sometimes people get better. Um, other times people just don’t get worse. Other times people are getting worse, but they’re getting worse more slowly than we thought they would. And so the recertification period is trying to like differentiate between those three pathways. Like, is this just, uh, is this someone that is kind of recovered against our expectations?

And maybe we should be thinking about a discharge from hospice and resume, you know, resume normal health care. Um, or is this person steadied out and maybe we just need to discharge from hospice temporarily until there’s another client. Or is this person just steadily declining and yeah, they can stay in hospice and, and here’s why I think that.

Otherwise, Medicare is going to come back and say, hey, like, how do you, how do you justify your prediction if this person hasn’t changed in the past three months? Uh, so that’s, that’s really what this is about is just being, um, good stewards of Medicare, aka taxpayer dollars. So Jimmy Carter’s situation is, is interesting and I want to be careful about not reading too much into it because I’m not his hospice doctor.

But there was that comment that his family made in the press release that he’s, the quote was somewhere along the lines of he’s been more or less the same over the past year. And again, I don’t want to read too much into that because it’s a press release and you know, what we’re telling the public versus what’s going on.

You know, there’s, there’s probably some discrepancy there. Um, but I think it’s important to know that in general, if, if you literally been the same for a year straight. Most of the time you’re going to get discharged from hospice, because that’s, that’s sort of getting into Medicare fraud territory. Um, because then it gets harder to justify why you think that way.

life expectancy of six months or less if the person hasn’t changed at all. So I suspect he actually has changed and they may be referring to more of his mood or his consciousness, you know, some specific measure of who we call Jimmy Carter. Whereas his overall clinical situation has continued to march forward in a way that justifies ongoing hospice eligibility.

Diane Hullet: Right. That makes sense. Again, 

Dr Matthew Tyler: all, yeah, all speculation. 

Diane Hullet: Probably more of a press release than anything else. I actually think it’s a terrific example, too, of how going on hospice can actually stabilize you and extend your life. It can actually be a real benefit, not to mention the care and support you get as a family in the hospice.

Hospice team stepping in. So I, I’m such a huge fan of early hospice for people and you know, the fact that many times people end up on hospice in the last two weeks of life is just, it’s not enough to get the benefit of hospice and the support from hospice and the team in place to stabilize you. And often with hospice, people do live longer.

I don’t know the stats on that, but I think they stabilize and have a good quality of life for their remaining time, which is. I, I, which is what I’d like to see, right? 

Dr Matthew Tyler: And it certainly is consistent with what most people tell me, which is that if they are clearly dying, their doctor thinks we can’t fix this, they, they want to be comfortable.

They want to be a family. They want to be at home by and large. I do think most people, most of the time will reach this point in their lives where when it comes to like the traditionally default health care that we deliver in times of illness, there is sort of a less is more truthiness. That again depends on the specifics of your situation.

But I think it’s sort of the benefits of hospice are both sides of the coin of, yes, the actual hospice support you get is great. I also think there’s the flip side benefit of just not being in a hospital and not being exposed to the germs there, the crazy schedules that we put people through, like waking them up at four in the morning to draw their blood, being surrounded by strangers.

Uh, being pumped full of fluids and medications that, you know, as you get older, have diminishing returns and oftentimes can flip over from diminishing returns to active arms. Um, I, I think there’s that dual benefit of just sort of protecting oneself from unhelpful to harmful interventions and replacing that with just, you know.

TLC. 

Diane Hullet: TLC. Oh, that’s so well said. Well, thank you so much, Dr. Tyler, Dr. Matthew Tyler, how to train your doctor. I really appreciate your time. And I think this is going to end up being episode number 165. So that’s kind of cool. And, um, last time we talked was number 128. So it’s great to see you again and hear your thoughts on these, uh, you know, various topics.

We’ve kind of been wide ranging from. paperwork to hospice, but I think it’s all really good food for thought for listeners to just have another perspective from a doctor’s point of view. 

Dr Matthew Tyler: Well, thank you. I always love riffing with you. Always happy to come back. 

Diane Hullet: It’s all good. Couple of Midwesterners riffing on a Thursday morning here,

Well, thanks again. You can find out more about Matthew’s work at How To Train Your doctor.com, and as always, you can find out about the work I do at Best Life. Best death.com. Thanks for listening.