Welcome back to the Healing Pain Podcast with Nicole Piemonte, PhD
As always, it’s an honor and a pleasure to be spending this time with you. Before we begin, there are a couple of thank yous as we move forward. I wanted to thank OPTP Products for hosting me on their webinar, which was on September 16th. I conducted a webinar for them on mindfulness and acceptance-based approaches for the treatment of chronic pain. Also, I talked about some information from my latest book, Radical Relief, which you can find on their website as well. Thank you for all the great people at OPTP. Make sure you check them out on their website, which is OPTP.com.
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Confronting Suffering And Vulnerability In Healthcare Education With Nicole Piemonte, PhD
On October 21st, I’ll be giving a two-hour session on mindfulness and acceptance-based approaches for the treatment of chronic pain at the New York Physical Therapy Association Annual Conference. I hope to see you there. I also want to thank the NYPTA for inviting me. Finally, you can catch me and our guest in this episode at The 2021 Educational Leadership Conference in Atlanta, Georgia. The Excellence in Physical Therapy Education Conference highlights excellence in physical therapy, as well as innovation. It’s a collaborative effort by the APTA Academy of Education and the American Council of Physical Therapy.
If you’re a PT or PT educator and you’re going to be at the 2021 ELC Conference, make sure to visit me and my colleague. We’re presenting a session called Mindfulness and Acceptance-based Interventions in Physical Therapy Education. It’s time to address the cycle of distress using evidence-based practice. Also, if you’re attending the conference, make sure to catch the keynote by our guest, Dr. Nicole Piemonte. It’s on Friday, October 22nd at 8:00 AM. She’ll be speaking about cultivating the habits of the heart of patient care, including compassion, vulnerability and imagination.
Let me tell you about Dr. Nicole Piemonte before we begin. She is the Assistant Dean for Student Affairs and a faculty member in the Department of Medical Humanities at Creighton University School of Medicine. She earned her PhD in Medical Humanities, where she focused on Philosophy and Medical Ethics. Her teaching and research focus on incorporating the humanities into medical education in order to cultivate future practitioners who are tuned to suffering, vulnerability and social justice.
In this episode, we discuss the benefits of confronting suffering and vulnerability, both in healthcare education, as well as its impact on patient outcomes. Once again, I want to thank the New York Physical Therapy Association and the Educational Leadership Conference for inviting me to speak. It’s a great honor. I look forward to meeting all of you and without further ado, let’s begin. Let’s meet Dr. Nicole.
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Nicole, welcome to this episode of the show. It’s great to have you here.
Thank you, Joe. Thanks for having me. How are you doing?
I’m doing good. I’m glad we got a chance to connect. I’ve been trying to connect with you for a while now. I’m excited to talk with you. The topic of suffering is one that people are living with chronic pain and the practitioners who treat them are intimately aware of. I know a lot of your work focuses on it. When I read through your bio, these words jumped out at me. That is the role and the interest you have in training healthcare providers and raising awareness on suffering, vulnerability, and even social justice are all such important topics nowadays. How did you become interested in those topics even before they’ve seemed to become popular in the stratosphere nowadays?
It’s a personal journey for me. When I was a senior in college, my mom was diagnosed with advanced ovarian cancer. I chose to stay home in those later college years and commute to take care of her. I became her primary caregiver. She lived for about two and a half years with an intense illness experience that was traumatic for me, her and our family in a lot of ways. She was a nurse but we still were navigating the world of medicine, not knowing or understanding fully what that meant. When I was a young Master’s student, she died between my first and second years.
As she was spending some of her last days in the hospital, a physician came in and offered her either a 4th or 5th line chemotherapy treatment like this is the next thing that we do. We thought, “I guess we’re going to do this.” A few hours later, a palliative care doctor came in. I had never even heard of palliative medicine and talked about making her comfortable and transitioning to hospice. My mom cried and said she was relieved to not be fighting anymore. She was eager to go home so we could spend the next weeks or months together. She ended up dying six hours later in the hospital. She should never have died in the hospital. I knew something went wrong. What went wrong that an oncologist was willing to offer her another chemotherapy treatment and she was even going to live another 24 hours? I spent time in my Master’s program, which was in Communication and Advocacy at the time.
I was studying Health Communication. I was enrolled in a course on Mother-Daughter Communication and Cancer and she died three weeks before that course started. I thought, “I can’t take this course. It’s going to be too traumatic,” but I had a supportive professor who encouraged me to take it and to process through some of my experiences. What I learned in that course and in my subsequent work was that it wasn’t necessarily a moral failing of my mom’s physicians to not have those hard conversations about prognosis and end of life much earlier in her illness trajectory. It was a dynamic we had created where they were trying to protect us and I’m trying to protect my mom. No one’s protecting each other by ignoring these conversations.
I learned that we do a very poor job in healthcare education talking about death and dying. Teaching our future practitioners to talk about suffering, vulnerability, end of life, hard conversations about heartbreak, loss and illness. I went on a journey and got my PhD in Medical Humanities to focus on how we can do better, and how we can cultivate future practitioners who’ve got the moral courage to walk into the inevitable, suffering and death that’s all around them. Also, to normalize it and help better equip them to have those conversations so that what happened with my mom and me, which I still see all the time, might start happening less often. That’s the long story of where I got to where I am now.
I’ve received emails all the time from people with pain. One of the fears that happened a couple of years ago was when opioids started to be placed under the microscope. People started being tapered aggressively off of opioids. I would get emails from people near the end of their life. It’s a tough place for those people to be in because they’re not the ones who shouldn’t receive compassionate care at the end of life. There are lots of overlaps with your story and how it coincides with aspects of what’s happening in the chronic pain world. Suffering can be an existential crisis for some people. It’s something that can endure for years at a time. Can you explain to us or define what suffering or extensional suffering means?
I do like the definition that Eric Cassell came up with way back in the early ’80s. He’s a physician writing about the differences between pain and suffering, which for a long time hadn’t been distinguished in the literature. Biological pain or pathophysiological pain was conflated with suffering. According to Cassell, suffering is a threat to the disintegration of the self. It’s the deconstruction of my roles and identity. If I’m dealing with chronic pain or facing the end of my life, what does that mean for me as a mother, a daughter, a professor, a father, a son or a brother?
When we got this threat to my way of being in the world, as I once knew it, a breakdown of the way I make meaning in the world suddenly is completely disrupted by the fact that my body no longer works the way it did before. As we know, our bodies are our life. We can’t live without living in a body. When there’s that breakdown, there’s suffering. The questions of meaning, being, purpose, who am I, and how do I get on in the world? To me, that suffering. Medicine and healthcare have struggled so long with being able to sit with those questions, and even think through satisfactory answers to those questions.
I love that response because it brings together the mind and the body. We talk a lot about a biopsychosocial model, especially with regard to chronic pain treatment. A lot of times, people hear that and they discover the psychological or social aspects of pain. They’re important but the pain is, in fact, that embodied experience. We can’t forget about the body, as you mentioned, how the body impacts our self-identification or self-realization. Chronic pain and trauma are all embodied experiences that we have. A lot of what you’re saying is bringing all of that together in healthcare, which is definitely not where we are. We’re starting to move in that direction but for hundreds of years, we have lived in a dualistic system.
You’re right and it’s so important to talk about that because science and technology matter. I want clinicians who know the biological and physical functioning of my body to be sure, but it’s necessary and insufficient. There’s something more. Understanding the embodied experience, which is a philosophical question, is also needed in addition to knowing the biomechanics of my body.
People say we’re spiritual beings having a physical identity or a physical presence. I always say, “We are human beings on this planet. We are in some ways identified with the body and how our body functions or has challenges functioning affects us.” How do we begin to confront the idea of suffering? I think healthcare education is your focus. It’s talked about in the mental health curriculum. It exists there but as you trickle down to the other health professionals, it starts to slowly get pushed out. How do we start to educate all healthcare professionals on the impact of suffering and vulnerability in healthcare education?
There is this deeper sense that we need to be in touch with our own vulnerability and our own suffering in order to approach the suffering of the other. Recognizing that if I’m a Physician or a Physical Therapist or Occupational Therapist, I’m only one step away from being the patient in front of me. I am them. I can be them at any moment. We don’t do a good job at recognizing our own potential for suffering and our own potential for vulnerability. Encouraging, reflecting and getting future healthcare professionals to be in tune with that is the start, not in some morbid or morose way but recognizing their own potential for suffering because they are human beings who are embodied. The other is always bringing to bear the lived experience of illness, which is necessary to be a good clinician.
For instance, a good physician will shape her treatment plan around knowing what the illness or injury means to that person. OTs or occupational therapists are good at this in a lot of ways. When they have a patient, if the patient doesn’t want to learn how to write a letter again, but they do want to learn how to pick up their grandchild or help her tie her shoes again, that’s what the OT is going to focus on. They are going to focus on what brings meaning back to that patient’s life.
We can focus similarly in all the health professions on remembering that, in a lot of ways, the alleviation of suffering is restoring meaning and purpose. Even if that’s a patient who’s dying, we could have a team that focuses on what brings the most meaning to this person in the limited time that they have left. It’s probably not to die in the hospital but to die in a place that they would want to be with their families. Getting our future health professionals to see the why of what they do, and that healing is so much more than fixing or curing the physical body. Healing is about alleviating suffering. Suffering comes from the destruction of someone’s identity and meaning. We could participate in rebuilding that meaning for patients.
Do you think the evolution of evidence-based medicine has taken some of that meaning out of health care? We’re focused now on the proper protocol, what intervention, what works and what population. Back when I went to PT school in 1995, there was a lot more talk about physical therapy being an art, as well as a science. I always thought it’s embedded in that art is a lot of the things that you’re talking about, the soft skills. Have we lost that with evidence-based medicine?
I feel like there are two questions within that question. One, evidence-based medicine is important. I am glad that it exists. There is some rigor behind some things that we need but when it comes to the clinician and patient, gut feeling and intuition matter. Some anecdotal experience matters. You have to take into account some of the nuances and intricacies of human connection that evidence-based medicine can’t capture.
I like to think about the art and science of physical therapy or the art and science of medicine. It’s not that there is science I use sometimes, then I throw art in when I need to use some art or that it is only soft skills. It seems to me that when we mean the art and science of medicine or healthcare, it’s always already both at the same time. It’s a practice and it involves emotions, gut feelings and science. We’re trying our best to put all of that together in some gestalt to do the right thing for the person in front of us.
A lot of times, those aren’t even soft skills because, in order to get the right diagnosis and the right treatment plan, I use intuition and connection. It then helps me be a better clinician in a hard science way. It’s not only bedside manner that we’re talking about or compassionate or being nice, but that being a good clinician requires a human connection.
I know a lot of your work focuses on implementing this into the curricula of different health professionals. How have you started to do that and where have you seen the most success?
Fortunately, I am at Creighton University, which is a Jesuit private medical school. The benefits of that are the Jesuits are very into personal and professional development, character formation, reflection, and the liberal arts. My background in the Medical Humanities has been fully and warmly accepted by Jesuit education and by the leadership. Some of the struggles we have in medical education, for instance, is if leadership hasn’t bought into the benefit of something like the Medical Humanities. Using philosophy, history, literature, social science, anthropology, art to think about medicine, that’s the Medical Humanities.
If leadership hasn’t bought in, you’re probably not going to get a lot of space in the curriculum. It’s then a tacked-on experience or extracurricular. For our students, it’s required. Right after you and I are done talking, Joe, I’m going downstairs to teach my first-year medical students about Medical Humanities. That’s the course where we talk about suffering, death and dying, the patient-clinician relationship. We talk about social justice, trauma as a social determinant, all of these deep questions, and it’s required for them. Writing reflections is required for them. This is not to force them to have to do something. Maybe it is in some ways, but it communicates that this is as important as your Renal class or your Respiratory class. It’s done well when it is fully integrated.
When our students learn their Neuroscience course, for instance, they’re learning the basic science of that. They’re also down in the clinical skills lab learning their neuro exam. In their Medical Humanities section, we’re talking about the lived experience of someone who’s trying to make a life after a traumatic brain injury. What is it like to make a life after a serious stroke or devastating or traumatic injury? They’re learning about the neuroscience of the brain at the same time that they’re learning about the lived experience of some of these neuro issues. It’s blended together in such a way that I hope they can’t see where science ends and the humanities begin because this is what it means to be in Medicine.
It’s a little bit of my belief that we avoid this in healthcare. We avoid it because it’s hard to see the dollars and cents that are attached to it right away. It may impact productivity. There is a scope of practice questions about talking things like this with patients. Maybe this falls in the realm of mental health or a psychologist and we refer out for that, which lands into our siloed discussions. What are some of your thoughts about that?
I have lots of thoughts about that. I don’t want to be Pollyanna-ish and think that everybody should be having these intense conversations when a primary care clinician has fifteen minutes to see someone. I am someone who thinks that human connection can happen quickly and doesn’t have to be a very long-drawn-out existential discussion. It could happen over multiple visits. I also deeply believe in interdisciplinary and interprofessional teams where people can work collaboratively to address these very complex issues. Those things are important.
Someone who’s engaged in the Medical Humanities always has to be engaged in the critical Medical Humanities. At the same time that I’m trying to help students determine that these topics matter and connecting with their patients is critical, I’m also helping them see that they need to demand more from this system. The system should not be about dollars and cents, and profit-driven. Part of being a good future clinician is advocating for a system that is not demoralizing to both patients and healthcare professionals. The critical Medical Humanities get them to see the power and the politics that are at play, and help them muster the courage and gain the voice to say that things ought to be other than what they are. That’s how we’re going to provide good care to our patients.
These are transdisciplinary skills that everyone can benefit from. The word transdisciplinary is not used often. Oftentimes, it’s interdisciplinary. Transdisciplinary means that providers, whether you’re working under the same roof or providers in the same community or the same environment have similar skills, similar goals and objectives when working with patients. It exists in physical rehabilitation, pain care and mental health. These are all important topics that you’re bringing in. We can make connections easily to how this helps patient outcomes, and how it helps someone’s physical, emotional and mental health. How does it help providers in their daily occupation?
I’m someone who doesn’t believe that burnout happens because of compassion fatigue. Often, we hear this, “If I saw the suffering of my patients and answer these deep questions and engaged in these difficult conversations as I advocate for, then I’m going to get burned out.” They’ll have compassion fatigue. Sure, I do think that there are deeply empathic people among us who are wrecked by other people’s suffering. I don’t think that, by and large, that’s what’s going on in healthcare. My sense of what’s going on is that rote factory-like interactions with patients after patients, void of human connection.
To me, that’s what’s leading to burnout. It’s not connecting with patients deeply. If we can advocate for these changes in healthcare education and in the healthcare system that help people see vulnerability and suffering, walk into it and connect with others, I think that brings meaning, purpose, sustainability and protection against burnout in the way that the system now undermines all of that. That’s what I think is leading to burnout.
This is where mindfulness and acceptance-based skills come in because they train people on these essential skills that you’re talking about.
Yes, and mindfulness and recognizing when someone is powerless to change the situation. Also, that it’s not overwhelming and exhausting, that they can’t take this person’s suffering away, and being mindful that there are limits to what people can offer one another. You’re not always going to be able to fix and cure and rescue everyone.
Is mindfulness somewhat a part of what you’re teaching in the curricula because you’re at a Jesuit University? People think mindfulness is a Buddhist technique or component of Buddhism, but it exists in every major religion and spiritual practice across the globe.
Yes, it does. Where we are, we start every meeting with my colleagues with a reflection. As I alluded to before, our students are required to write a reflection. It ends up being about every other week for the first two years. They have to write a five-page reflective paper at the end of their Humanities and Ethics experience in the first year. Written reflection, verbal and dialogical reflection, small group learning, and grappling with these big questions are part of everything that we do. I always tell the students when they enter the first-year class, “Buckle up. You’re going to be doing a lot of reflecting,” because we are committed to their development as people more than just future physicians.
How much of your personal experience do you bring into your work knowing that it precipitated a lot out of your course of study, your PhD work, and the work you implemented into the curricula? It must be important to you and meaningful knowing that part of your mom’s story is wrapped up in that.
I draw on it at times when I teach students about having end-of-life conversations. We do a simulation on their fourth year where we have standardized patients that students need to navigate end-of-life conversation with them. I draw on my own experience and why it’s important. My mom died when I was 23 and nine years later, my dad had advanced stomach cancer. He died while I was in this role in creating this curriculum for these students, and went through the whole experience all over again.
Even though at that time, I had a wealth of research and knowledge, I still couldn’t even navigate that situation the way that I wanted. It gets so hard when the people you love are facing the end of their life. I do draw on it in some of my scholarships. Sometimes when I’m teaching the students, I am more than willing to share my own vulnerability and then towing that line of not making it about me and making sure it’s focused on these students to grapple with these questions for themselves. Many of our students haven’t had this experience. I’m always trying to find that balance of drawing on it when it makes sense. Also, letting students come to their own conclusions without feeling like they’re obligated to agree with me because I’ve been through something like this.
It’s great that you model this for new medical student residents because going into the health professions in general, we’re not allowed to be vulnerable. We’re expected to know the answers. We’re expected to have all the answers to every patient’s problem. Suffering is a big responsibility for practitioners to take on day after day for people.
It’s so much. Part of recognizing that has led to us developing Schwartz rounds at our hospital. For those of you who haven’t heard of it, I encourage you to look it up. It’s part of the Schwartz Center and it’s a conference where we get a panel of folks together and we try to get an interdisciplinary panel. We’ve had physicians, OTs, PTs and ultrasonographers. We’ve had some of our cafeteria and food services folks on our panel. They talk about what it’s like to be in a hospital or caring for patients, being in a hospital during a pandemic, and what care looks like.
We rightfully have focused a lot on patient stories. The Schwartz rounds get the caregivers to talk about their stories. What does it feel like to take care of patients? The point is for the panel to tell their story so that the folks in the audience feel comfortable sharing their story. It’s about solidarity, connection, vulnerability, and articulating the things that people are experiencing every day and remain silent about in the hospital and healthcare, and trying to normalize it. That’s my goal. In medical education and the hospital, how do we normalize the human condition and talking about the things we’re all seeing and thinking about and never saying out loud.
There’s a lot of what we’re talking about in this episode, which you can find in Nicole’s first book. It’s called Afflicted: How Vulnerability Can Heal Medical Education and Practice. That’s 2018. It’s MIT press. You can find that online. She has a second book about to come out. It’s called Death and Dying, which was released on September 7th, 2021. Can you give us a little insight into that second book?
That second book was written with a palliative care doctor and looking at our own experiences. Shawn Abreu was looking at his experience being trained as a medical student and resident. He was struggling with dying patients when finally confronted with them in residency training and thinking, “No one trained me to acknowledge this.” I was writing as a medical educator and some of my scholarship but also the lived experience of taking care of my dad.
We wrote that book while my dad was sick and while he was dying. After he died, we’re going, “We’ve had all this experience in end-of-life care and still the medical system grabs you up into its wheels and churns you along.” If you can’t stop the train, you’re going to get intervention after intervention, even as people with expertise in end-of-life care. We were looking at how did we get here in medicine? How did we avoid vulnerability, suffering and dying for so long that the default mode of medicine is to intervene? Intervene in ways that can cause harm than advocating for ways that we could change end-of-life care. That one is written more of a lay-educated audience and less academic. I’m excited about that one.
Both of Nicole’s books have great overlaps with chronic pain and chronic disease. If you’re interested, make sure to check them out. The first book is called Afflicted: How Vulnerability Can Heal Medical Education and Practice and the second book is called Death and Dying. I want to thank Nicole for joining us on the show. It’s been a pleasure talking to you about the topic of existential suffering. Please let everyone know how they can learn more about you and follow your work.
If people want to follow some of my work, I am on LinkedIn and Twitter with the handle @NicolePiemonte. Also, I started a new Instagram page it’s @Meaning.In.Medicine. I want to use that as a platform to share some of my thoughts that might not ever make their way into any formal publication. Also, to have conversations with folks interested in some of the things that we’ve been talking about because they’re important. We need to normalize it. Maybe social media is the place where we could start talking about these things. We’d love to engage with folks on Instagram in that way.
Our followers are very active on social media. I’m going to ask all of you to take a screenshot of this episode on your phone and share it out onto Instagram and tag me at DrJoeTatta.com and you can tag Nicole at @Meaning.In.Medicine. We’ll make sure to be social and talk back to you. I want to thank Nicole for joining us. As I mentioned, please share that and tag us on Instagram or whatever social account you’re on, whether it’s Facebook or Twitter or LinkedIn. Both of us are active on there. We’ll see you soon.
Thanks so much, Joe.
Important Links:
- Radical Relief
- OPTP.com
- NYPTA
- APTA Academy of Education
- American Council of Physical Therapy
- Dr. Nicole Piemonte
- Afflicted: How Vulnerability Can Heal Medical Education and Practice
- Death and Dying
- LinkedIn – Nicole Piemonte
- Twitter – Nicole Piemonte
- @Meaning.In.Medicine – Nicole Piemonte Instagram
- Instagram – Dr. Joe Tatta
- Facebook – Dr. Joe Tatta
- Twitter – Dr. Joe Tatta
- LinkedIn – Dr. Joe Tatta
About Nicole Piemonte, PhD
Nicole Piemonte, PhD, is the Assistant Dean for Student Affairs and a faculty member in the Department of Medical Humanities at Creighton University School of Medicine, Phoenix Regional Campus. She also holds the Peekie Nash Carpenter Endowed Chair in Medicine at Creighton University. Nicole received her PhD in Medical Humanities from The University of Texas Medical Branch where she studied continental philosophy, medical ethics, literature and medicine, and medical pedagogy. Her current teaching and research focus on incorporating the humanities into medical education in order to cultivate future physicians who are attuned to suffering, mortality, vulnerability, and social justice. At Creighton, she designed and leads the medical humanities curriculum that is embedded throughout the four years of medical students’ training, and she also co-directs, develops courses, and teaches in the Masters of Medical Humanities program. Her first book, “ Afflicted: How Vulnerability Can Heal Medical Education and Practice,” was published in January 2018 with The MIT Press, and her second book with The MIT Press, “Death and Dying,” will be released on September 7, 2021.
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