8.1 - Therapeutic Presence

In this episode, we hear about Keri Brenner's journey to medicine and why she finds Therapeutic Presence so vital to her work as a Psychiatrist and Palliative care physician. We'll also learn how this simple practice can transform all our interactions as well as some practical tips for bringing therapeutic presence into our own lives.

49 minutes • Published Jul 01, 2025 • Download • Transcript

Transcript

[Intro music]

Hi and welcome to the Hippocratic Society Podcast. This podcast is a project of the Hippocratic Society.

In the podcast we aim to reflect on deeper questions in medicine, all with the aim of rediscovering the ideals that brought us to medicine in the first place in order to better serve our patients and colleagues.

Thank you for joining us and we look forward to engaging with you through this podcast.

Hi and welcome back. I'm joined today by Dr. John Rhee and Dr. Carrie Brenner.

Dr. Rhee is a board certified neurologist, neuro-oncologist and palliative care specialist at Dana-Farber Cancer Institute and instructor of Neurology at Harvard Medical School.

He co founded the Hippocratic Society and serves as its executive director.

Dr. Brenner is a clinical Associate professor of Medicine at Stanford University.

She practices palliative care and psychiatry and her clinical work includes inpatient palliative care consultations at Stanford.

She completed her adult psychiatry residency at Mass General Hospital and her palliative care fellowship at Harvard.

She has served on the University of Notre Dame Board of Trustees and was awarded funding through Harvard's Radcliffe Institute for advanced study in 2019.

In her personal life, Dr. Brenner enjoys the beautiful outdoors of Northern California with her husband and four children.

Thank you so much for joining us today, Dr. Brenner. We're excited to have you.

Thanks Michael. Thanks for that wonderful introduction. I'm just so inspired by the Hippocratic Society mission in cultivating this culture of virtue and in response to our call to medicine. And it's also been an honor to be on the board of the Hippocratic Society, which is such a laudable initiative and movement.

Absolutely. And I don't know where we would be without all the help and input that you've put into the Hippocratic Society. So thank you.

So today we wanted to talk about therapeutic presence. And As I understand, Dr. Brenner, this has been pretty vital to your own personal journey into medicine and in your life in general.

So I'd love to start out with just your story. What drew you to the concept of therapeutic presence?

Yes, Michael, my origin story for my magnetism to therapeutic presence today actually began over 20 years ago when I was really magnetized to the mission and the life work of Mother Teresa and her sister's work in Kolkata, India.

And my 21st birthday was actually my very first day volunteering at Mother Teresa's Home for the Dying in Kolkata, India. And the work that we did was that we would go out into the slums of the city and find people who had been abandoned by their families,

oftentimes for medical reasons.

And we would bring them into Mother Teresa's home for the dying and be present to them,

giving them real comfort, focused care, often in the final hours, days,

weeks of their life.

And that first time that I did this really privileged volunteer work,

I was such an ambitious volunteer. I brought like whole boxes of supplies with me, and I had this box abundance of energy to do, do, do.

And the irony is that that summer when I arrived, there were actually plenty of volunteers.

Her home for the dying was super saturated with volunteers. And so although I came to do instead, I actually learned how to be.

Because every day when I showed up and Kali got in her home for the dying, the sisters would turn to me and say,

carrie, I want you to sit next to this patient. And oftentimes it was a patient that was in the active phases of their final chapter of life.

And I would ask the sisters, well, what should I do for them? And the sisters would say, carrie, be with them,

be present, accompany them,

be attentive to their plight.

And those moments throughout that summer and the subsequent times I returned to Calcutta, India,

were just utterly transformative to my life,

entirely expanding my worldview,

because it really taught me the sense of the immaterial poverty that exists even within our well resourced countries. And this is an insight that Mother Teresa shared very frequently,

that the immaterial poverty is the greatest of all.

This experience of feeling abandoned,

isolated, lonely,

the disordinate desire, spiritual empowerment, impoverishment, dysfunctional relationships, this is the darkness that we feel called to give a light to in that darkness. And Mother Teresa saw that even in our well resourced areas like the United States.

And so that actually drew me to discern a life of academic medicine where thinking about the world of ideas,

existentially, how we shape those ideas, and how that shapes culture and society and could be a way to tend to this immaterial poverty through this avenue of therapeutic presence.

Thank you. That was very beautiful. I. I'm always struck by Mother Teresa, anything she says. So I can't even imagine what it must have been like to be in the work, doing the work that her sisters were doing.

That sounds amazing. So walk me through, if you wouldn't mind, a little bit more about how that translated into your journey as a physician and what sort of how that theme carried on throughout your professional life.

Yes. So I was. When I did pre med at the University of Notre Dame as an undergrad, I was also simultaneously a philosophy major. So go Irish.

And I was actually then drawn to Yale Medical School because of the opportunity to do a thesis while I was also a medical student.

And that gave me a really spacious curriculum to explore phenomenological personalism and the doctor patient relationship. And what I learned through writing that thesis is that there was this distinct chasm that exists within medicine, this chasm between the biomedical model that we're trained in, that the physicians conceptualize disease processes in versus the way illness is actually experienced as a lived reality by the patient.

And those life worlds are often so separate.

And so how do we begin to bridge this gap, to expand our worldview as physicians to be more attentive to the suffering and illness of another. And I used a lot of phenomenological personalism to explore the ways that we could consider doing that through our relationality,

receptivity and presence to others marching forward, you know, I then voyaged into psychiatry residency and palliative care fellowship. And this work that we're so privileged to do in serious illness care,

it offers to me, I always have this image of like getting a backstage pass into the most sacred spaces of patients lives,

this space that we inhabit with patients in these crucible moments where they're really on the threshold of this liminal space of sort of life into death.

And we then are privileged to bear witness to some of these raw elements of life itself. Meaning, purpose,

regret, fear, love, connection, transcendence.

And that's the privileged space that we get to inhabit as clinicians caring for patients with serious illness.

Again, thank you, Carrie. That was really profound. I love how it's so clear. The initial draw into medicine from working with the Sisters continues to be what you do with your day to day practice of medicine.

Very consistent at the very least. But seriously.

Yeah,

I definitely carried those seeds that were planted now over 20 years ago. Definitely just continue to bear fruit and flourish in all of these multidimensional ways, even today.

Yeah,

absolutely.

So why don't we start off talking a bit more about therapeutic presence and this theme that has been so instrumental in your physicianhood.

So what is therapeutic presence exactly? I know we presence kind of gets thrown around a lot and.

Yeah, what exactly is it? Therapeutic presence.

Yeah, therapeutic presence is this intentionality being attuned in an embodied way when we're being with another person,

offering that sort of emotional, moral, existential, relational holding amidst somebody's suffering.

So therapeutic presence really calls for our full attention without distraction, to foster that sort of trust, connection and healing. It's person centered.

Healing is through the Relationship itself. So before we act,

being called to be with is therapeutic presence. And I think, Michael, a lot about,

you know, throughout our medical training, we're trained so often on how to think and how to treat, but we're rarely taught on how to be.

And I'll never forget my first day of internship year at Mass General Hospital and this faculty lecture shared this insight that just left honestly this indelible mark within me that continues to flourish today.

She looked at all of us in her first day of internship year and she said, as physicians,

as healers, your very self is the primary instrument of healing first and foremost. Your being is the median of the medicine. So it really opened me up to the sense that my very self as embodied, relational, morally grounded, that's the first and most enduring medicine that I can offer,

and that's indispensable and essential to the healing process that we offer within medicine.

And I am just, you know, years later now into practice so awestruck by the evidence that supports the therapeutic alliance. As a psychiatrist, we see this in the psychotherapy literature where we know that the quality of the therapeutic alliance itself has been shown to often be more essential than the specific psychotherapeutic techniques being utilized.

So the therapeutic alliance actually transcends the specific technique employed, whether it's CBT or ACT or dbt.

It's the connection.

And we actually see similar associations and signals and in the medical literature with serious illness care. You know, there's an interesting study that I recently read about cancer patients.

And when cancer patients experience a strong therapeutic alliance with their oncologists,

it actually results in them having enhanced well being and better quality of life metrics. And so this, this evidence that we're seeing in the literature is really inspiring.

Yeah, I think one thing that I've been thinking a lot about Carrie recently is this idea that how we can be present, perhaps in my patient population of patients who have cognitive deterioration and perhaps also towards the end of life,

I would say oftentimes are sleeping the most of the time or perhaps are minimally conscious,

and how that aspect of therapeutic presence is perhaps the most important thing that we could do with patients at that time. I also think about that in my hospice rotation as a palliative care fellow, how there may be patients who were sed or just asleep or also unconscious, and how we as clinicians can still sit by their bedside holding their hand,

just being with them,

and how that itself, perhaps is that aspect of healing for that patient in that moment and how oftentimes, because we have this aspect of we have to do and not be that sometimes we feel uncomfortable with patients who have cognitive impairment or patients who we are not interacting with cognitively.

And that we think that therefore there's nothing that we can do for them. And so we often don't even address them directly. We might address like their caregiver instead and forget that it is also this, like, presence, this relationship, the relationality with the patient that's so important.

I think just like one additional anecdote is,

I recently had to do a calls of care conversation with a patient who is deaf.

And I think that that was a new challenge for me. But it really brought into focus this idea of presence because you had to be so intentional about who was speaking and be very intentional about taking turns speaking so that it could be then translated by the ASL interpreter.

And the sense in which we were also pacing there,

I felt was very unique.

But then also just the dynamic of the body language that was like so important in the communication where there were some barriers in terms of perhaps speech and understanding being or reminding me of just like also being more in that space.

Yes. And John, you're making me think of just so many different micro moments where we can model this way of being and the intrinsic dignity of the other, even when faculties fray and get diminished within a patient.

You know, a couple practices that I've learned along the way is the simple act of just simply asking, who is this patient as a person? Tell me about who they were and what was important to them before they got sick and even in their everyday life now, what brings them enjoyment and meaning and being able to weave that more panoramic view of their personhood and into the conversation when we're with them,

when we're honoring them, and when we're talking to their families.

And that depth of personalism really allows us to maintain the intrinsic dignity of their worth.

And I think you're also bringing up, John, something I hope we can chat about more today, which is there's the verbal and the non verbal dimensions of how we're with people and the nonverbal is just as important and often under recognized or a blind spot in our training.

So it seems to me that part of this aspect of presence,

an essential part almost, you might say, is getting to know the person and being yourself,

being like we, like you were saying, but also knowing them and understanding their being,

the fact of understanding their personhood and getting to know them almost connects your being and their being together in a more intentional way, which I think was really beautiful. And the fact that all the aspects of their personhood affect directly how you can treat them.

Like John was saying, this patient who is deaf,

completely different interaction than someone who can hear fine.

So if we could break down this concept of therapeutic presence a bit more. I know you were already going into some of the tips or ideas of what that actually looks like, but what does it mean to be really.

Yes, I'd love to just sort of double click and zoom in on a couple of these key components of therapeutic presence.

Two that stand out to me, Michael,

are attunement and the holding environment,

which I think are two key concepts.

First, with attunement,

that's in a being, as you talked about, Michael, being allowing our being to be in sync with the patient. So having an actual congruence through our emotional tone,

our pacing,

our presence, a deep attention, a relational focus,

as opposed to thinking about the encounter as tasks or goals to be done, as opposed to an objectification of the encounter or the other.

So it's this purposeful practice of awareness and focused attention, a deeper listening, that's attunement. It's a kind of resonant presence. And I am enthralled by the findings that solidify and crystallize attunement that we have within the medical literature.

Like our very neurobiology affirms this.

We know now about mirror neurons,

our mimetic nature as beings,

physiological synchrony in doctor patient interactions, that synchrony and alignment that happens when we're attuned to a patient. These studies that show the synchrony of our heart rates beginning to align, our movements,

the respirations that we take actually being in harmony with one another.

And the studies actually show that when we have that level of attunement, that mutual engagement that patients have, reduced pain scores in the encounter and also increased trust.

So these non verbal dimensions which you were mentioning before John, and alluding to, they really enhance that therapeutic alliance.

And then there's the holding environment.

So the holding environment is a concept that was written about by Donald Winnicott, who is a British pediatrician and psychoanalyst back in the 20th century.

And he talked about the holding environment as this relational space in which a person feels really emotionally held and seen and where they can express their vulnerabilities,

they can express their fears without a fear of abandonment or judgment.

And what Winnicott noticed is this actually begins in our infancy when a caregiver responds to the distress cues from an infant.

And when an infant is Held in being attended to, the infant then internalizes that tolerance and ability to hold the distress in a way that when they then grow older and develop,

they can have more adaptive coping mechanisms and a deeper groundedness in their interior life.

And what we found now, and our group has written about, is that this is quite analogous in the doctor patient relationship, this therapeutic holding environment. When we offer that that kind of consistent, grounded, attuned presence,

it actually is a container for the vast array of emotions and fears that patients experience with serious ill.

And it leads to more adaptive coping within our patients when we create that holding space for them.

Terry, as you're talking, I'm just reflecting on the fact that last night I came back from a full day of clinic where there were a lot of serious illness conversations, goals of care conversations,

and then also some pretty young patients that I saw,

which just also is like a tough place to hold,

you know, all the distress. And then came back to also a couple conversations that I had to have with mentees that also required a lot of, like, emotional energy.

And then even now,

trying to, like, really hold attention, because I also want to, in this act, active being right now, to respond thoughtfully to the things that you're saying.

Recognize often that in those moments there's all these things that creep into one's mind, right, because you come directly from stressful moments or things that have happened, or just like a thousand things on your mind and how to be kind of aware of that, but then be able to step into a space where you can be truly attuned,

truly hold that environment for the patient and wondering, both with your psychiatry training, but also your palliative care training,

if you have any thoughts about that. Because I think that it's probably something also that a lot of trainees and physicians think about this idea of how we can do that and be truly present when then there are also many other things that are also happening in our, like,

own lives and our personal lives and that we bring to the patient encounters.

Yes, I think that's a. That's really an insightful question, John. And I, I often have this image of how do I.

How do I traverse and carry the bustling activity of medicine through a contemplative gaze?

How do I have a contemplative gaze amidst all the activities that I'm doing and holding?

I got to actually practice this firsthand for a couple years because I was in the convent,

discerning to be a religious sister myself for two and a half years.

So during that two and a half years, of discernment, of becoming a religious sister potentially. I spent about six to eight hours a day meditating and praying and practicing this life of contemplation.

And eventually I discerned that I was called to marriage. And now I'm 10 years into marriage and we have four joyful,

boisterous young children.

But it was, it was really,

I still carried those practices within me amidst the bustling activity of medicine. This sense of having a contemplative heart and an inner calm,

of silent, focused attention and receptivity.

And there's a couple. So that that comes from my own interior life. It doesn't take two and a half years in the convent though to develop it, I promise.

One concept that I teach a lot to my students is a distinction between suppression versus repression.

In medicine, we're often what's tacit and implicit between in our culture and medicine is to repress.

You see a tough case, you've got a lot going on, just shove it under the rug unconsciously, kind of pretend it never happened. Versus suppression is a more adaptive coping response where we acknowledge in our mind, wow,

that's really tough or triggering or that's heavy to hold.

I'm going to put this in a box and I'm going to put that box on the shelf knowing that when I have a moment later tonight to phone a friend, to reach out to a colleague, to reach out to my social worker,

I can open that box again and process it in a way that's healthy and constructive and productive.

So I'm not burying things within me. And I think that that's a really important distinction for us to be more conscious of in terms of our own coping as physicians and our own countertransference, which we can talk about today a little bit more.

Countertransference, meaning the concept of knowing our own reactions,

associations,

feelings that come up when we're with another encounter transference Freud first wrote about, you know, over a hundred years ago.

It's still alive and active today. It's normative, it's in almost all of our interactions.

So the more we can actually bring what's unconscious to the conscious, foregone to have a self awareness and reflective capacity.

The more we can have our own sustainability and well being and also reduce kind of implicit bias and enhance inclusivity within our practices.

I think one thing that I feel like is so important to highlight there is that is this return then like making sure that you do return back to the box and that therefore one needs to make sure that you are setting aside time in order to return back to it and therefore grow in that reflective practice.

Because I think that oftentimes in our culture where time is so pressured and there is a tendency towards efficiency and also again, like doing rather than being that. I think that a lot of people, or I've just noticed in medicine too, that there is a devaluing therefore of that time of being with those emotions or those kind of things that we witness of suffering in the hospital and that there is a necessity for coming back to that.

Or else we can become kind of cold or too removed from our patients or as a kind of subconscious way of dealing with the suffering that we encounter.

And to build off of that insight, John,

I really want to emphasize that this does not take.

You don't have to be a Buddhist monk to do that. Well, it can truly be micro moments literally weaved within our everyday life.

And ideally it's that seamlessly integrated and woven where the more what Freud said is what we can't say we do.

So if we can't verbalize it or have a self awareness to something that's in the dark unconscious aspects of our mind, well, it will come out at some point in aberrant behaviors where we might stave off seeing that patient and maybe not see them till the end of the day or have a messianic complex and come in and give two,

three hours for a family meeting when it should have been one hour.

And so the more that we can even just verbalize to a trusted friend, a colleague within ourselves a bit of the spectrum of our reactions and emotions that we experience as we're facing the sufferings of others,

the healthier our processes can become.

And I think as physicians, as attendings, I try to model that for a lot of my trainees where when we leave a patient's room,

I might just be really honest and say, gosh, I felt so helpless and hopeless sitting in that family meeting today. What came up within you?

Before we talk about sort of the cognitive elements of the case or all of the details and technicalities of what we're going to do, I first do a check in with how was there being in that meeting or in that encounter and really model the whole spectrum and gamut of acceptable emotions that I can feel bored and distracted with a patient or angry or helpless too,

even when I'm 10 years into practice myself.

I know Michael probably wants to move on with the podcast, but I just like there's like another thing that I just want to explore there and get your thoughts on Carrie if that's okay.

Which is another just point that I've been reflecting on, which I imagine a lot of people who listen to this podcast also often think about, which is this distinction between the emotions that surge up within us that sometimes can be bad.

Right. Like in the sense that like sometimes, you know, for example, yesterday I was talking with a patient who basically everything I said he negatively reframed, like to the max.

But it was. I went to Florida, but it was terrible because it was like snowy or like it was cold and that's not what I wanted. And so then we actually worked on, I pointed it out to him and then we were actually able to work on it and he was like,

decided to keep a gratitude journal. And anyway, it ended up being like a great,

great discussion.

And it reminded me of how these emotions can also drive us towards things that are harmful within us.

Yet at the same time,

ultimately the will is about that intersection of those senses that we're bringing, you know, and recognizing in ourself and the intellect and how that kind of comes together in the heart.

And ultimately it's like in the heart that we decide and also activate our will towards the good and the beautiful and in some sense is where the real acts of kind of goodness come from.

And I was just wondering if you had any thoughts about kind of those. Yeah, like those negative perhaps emotions. Should we think about that differently from that kind of heart of the will and how you conceptualize that also as like a psychiatrist, but somebody interested in philosophy.

Yes. I like this Thomistic distinction that you're making right now.

First to point out within the emotional landscape of our lives,

I try to encourage the initial emotional reaction is neither good or bad. It just is to have sort of a non judgmental curiosity about our emotions. Because that example that you so eloquently described,

the man who was really stuck in negativity,

your own experience of that projective identification of the negativity onto you was essentially a key that unlocked a formulation of what might have been going on within his inner core struggle.

And that was. That's so illuminative.

And so I think your ability to see that how emotions have an infectious nature to them and they can be contagious and projected onto our feelings in the room. And then to use that as an insight to recognize his core struggle and to utilize your will so the will to transcend above mere sort of animalistic affective states,

to choose love, to choose his ultimate well being and his ultimate good of the healing that you're seeking and Aiming for us as provider. That's sort of that next level and philosophical distinction I think, that you're pointing out through that lens.

John,

thank you guys so much, and thank you for allowing me to execute my dictatorial regime and move this podcast along.

I did try to aware. Be aware of my urgency to move the podcast along and reframe that to a positive being moment. But anyway,

this is seriously beautiful.

But at the same time, as has been kind of suggested within medicine, this seems sort of countercultural, even something that's not very talked about as much. So why is this so unique and maybe why is it not talked about as much?

And what is so core to medicine that this touches on that is so striking?

Yes, I notice within medicine,

we have inherited this contemporary cultural trend that promotes this fallacious notion that we're just atomized individuals,

this expressive individualism,

you know, totally autonomous entities. The patients are autonomous. We are, you know, these.

This sense that we are providers that connotes sort of a transactional,

reductionistic, utilitarian element of the encounter with a patient.

That's what we inherit from our secular culture and contemporary culture.

And what therapeutic presence offers is an antidote to that trend.

It's a therapeutic presence aligns with our nature,

our anthropology of actual embodiment of our essential nature as humans, that we're in relationship to one another,

that our lived reality is relational in itself, and we have a dependence on one another and thinking about dependent, rational animals, to quote Alasdair MacIntyre, My favorite philosophy professor from my time at Notre Dame.

And this is categorically different and distinct than that mentality of being a provider, that sort of transactional, reductionistic mindset. Because instead, when we think about therapeutic presence and this anthropology of embodiment, we become healers,

healers where we are aiming toward that end, where medicine becomes a moral practice, toward the good of the patient's health and their healing.

And that's actualized first and foremost in the relational context itself in these encounters as persons.

Thank you. That was very beautiful. And I can see the influence of Carter Snead as well, or I guess Car Snead, being influenced by Alasdair MacIntyre from his,

yeah, virtues of embodied embodiment and expressive individualism. We had him on the podcast a couple episodes ago. And very, very beautiful anthropology to inform the medical practice, bioethics, law, and everything in between.

Michael, what really captivates me is the empiric evidence that bolsters those philosophical observations and claims, because there is this relational quality to being a healer. And I love the work of Harvey Chochinov in Canada, who's a very dear friend and colleague of mine.

And Harvey has empirically studied patients at the end of life for decades. And one of his longitudinal qualitative studies looked at patients and their subjective sense of their dignity. So their ability to see their own intrinsic dignity.

And what he discovered is that patients ability to see their own intrinsic dignity was actually shaped by how they perceived they were being seen and treated by their clinicians and caregivers.

So what they saw reflected was how they were perceived. If others, if their clinicians and caregivers saw them and treated them as whole persons,

as a person in the room, rather than reductionistically as a patient with disease,

then they actually were able to better understand and be illuminated to their dignity.

And so we see this relational dimension into the quality of being a healer when we're present in that way through therapeutic presence of medicine.

I think one thing that it also brings up to mind is this idea that I was also thinking about yesterday in clinic,

which is we often think about, or we've talked about it in prior podcasts with Brewer, and then this idea or framework of physician as healer, teacher, which we're both very familiar with in academic medicine, but this third dimension of philosopher or thinker.

And also this idea that Brewer and I were also talking about in one of our Hippocratic Society meetings about even the word physician being at the root,

having the word physics in it, and so trying to, or just trying to discover the nature of things and how things are.

And just brings to mind this idea of the fact that oftentimes as physicians, we think about the healer aspect,

also touch on the teaching aspect, but rarely think about the philosophy aspect,

and that the philosophy actually does inform how we are treating our patients, because there are a lot of moral questions there.

And I was talking with one person and without giving too much away, so I'll be kind of talk about it more in generalities, but was just telling me about his struggles with anxiety and how he had been talking with the therapist.

The therapist in his meetings with her just kept coming back to this, like, trying to discover whether his anxiety was from the result of any poor relationships he had with his prior relationship with family or whatever.

And he was like,

no, I just. I feel like my family loves me. That's not the issue.

But then it's. It brings to light, I think, this sense of which that itself is kind of a philosophical approach of what that person sees as the root causes of this person's anxiety, and also therefore Their understanding of how perhaps things are rooted only in past traumas or unconscious traumas,

and rather seeing potentially a different frame that understands the person in perhaps a different light, like we're talking about in terms of embodiment, in terms of relationality or dependency,

and how important that is, therefore, or that we are all informed by a certain type of philosophy when we are approaching our patients. And to touch on this idea,

Carrie, I wonder of how perhaps physicians might be a little bit allergic to the word philosophy,

but perhaps how important it is in the care of our patients and therefore requires a deeper dive, or at least an exploration into questions about how we think about the person or suffering or things like that which we are trying to do in the Hippocratic Society.

Absolutely. Because I think that what you're touching upon here, John, too, is our teleology within medicine.

And we need a teleology and a shared mission and shared aims and cohesive collective orientation as to who we are, what we're about, and what we're aiming for,

or else it potentially erodes and disintegrates or gets quite distorted along the way.

Thank you both for those responses. And I love that comment about philosophy and physicians being somewhat allergic to that, because just the other day I was in a meeting with an advisor who was,

yeah, advising me about different options about going into possibly bioethics. And I mentioned a passion for philosophy. And she said, oh, maybe I want to be careful about going down that road.

You might not ever get out.

So it's funny, it's sort of a buzzword that is one of the negative ones.

Anyway, so moving on towards, yeah, from this philosophy and anthropology that informs medicine and informs therapeutic presence and makes it so core to medicine,

what are some more ideas that we can actually bring this into the hustle and bustle of daily medicine? As you were saying, Carrie, I know we've already talked about a lot, but what are some concrete ideas where we can actually practice this amidst all of our worries?

Yes, a lot of trainees will ask me this question,

like, how do. What are some first steps that I can take to actualize this process? And one of the most foundational concepts I teach to trainees and throughout serious illness care is how to use formulation.

Now, formulation is from the psychotherapeutic world, but it applies a lot into our everyday work in serious illness care. Formulation is basically a working hypothesis about a patient's core, core inner struggle and coping style.

It helps guide us to be more attuned and therapeutically present in a personalized way to attend to the patient in a very personalized,

person centered way.

So when we utilize this within medicine,

it can really have some meaningful effects. I'm thinking about the vast arrays as to why a patient might feel stuck, let's say, making a medical decision.

You know, we often see this in serious illness care where patients have a critical medical decision before them and they're taking a long time to make that decision and they're stuck.

It might be that the formulation is that they're an engineer. We have a lot of those here in Silicon Valley, these engineer types. And maybe they need more data to make a better decision.

Maybe they have a mistrust in medicine. Maybe there was an oversight or a breach in their care that resulted in an error and they mistrust medicine itself.

Or maybe it's another formulation. Like they're the kind of person that feels a heavy amount of guilt of the responsibility of a decision or worried about making a wrong decision.

So there are a variety of reasons beneath the surface as to why a patient might feel stuck. Let's say the formulation figuring out that why that core inner struggle that then becomes our compass to help guide our therapeutic presence and our approach.

Because if it's the engineer, I might actually get out the bilirubin trends and show them those trends, or show them the creatinine trends or the latest imaging.

If it's mistrust the second patient that I mentioned, maybe I give them greater agency and autonomy over the decision.

If it's somebody who feels completely burdened and overwhelmed by the guilt of making maybe a wrong decision,

maybe I dig deeper and get to know their core values in a way where then I can make a tailored recommendation on their behalf to relieve them of that guilt and relinquish that from them.

So understanding this why beneath the surface and the patient's core inner struggle allows us to really customize how we're going to be therapeutically present.

That was really beautiful. And I love how that also comes back to this idea of self awareness where you're almost having basically an other awareness, where the formulation of the other is reflects exactly the self awareness that you already have.

So that therapeutic presence is again, just bringing in that being where you are fully being, you're understanding their being, and together you're just in the present moment and everything is just around this truth, rather than any sort of facade that are, that are being put on by either you or some sort of something that's not coming up in their reactions explicitly in their subconscious.

Yes. And Michael,

I Often explain to my trainees and when I'm teaching this concept that this is not about being overly sentimental or sappy in any way and it's also not about taking more time.

Often utilizing these types of techniques saves us time. You know, I had a case a few months ago where the patient was a 30 year old man, Division 1 athlete, his parent was a Division 1 coach, his dad was,

and they were livid at the care that they were receiving. They were infuriated about the disease process of its gastric cancer and they actually got really angry when we used our typical palliative care approach of open ended questions.

In my formulation of that patient of that 30 year old with gastric cancer was he's a division one athlete, he was in college.

He needs to know that I am on my A game, that I'm going to show up competent, confident, a top performer on their behalf.

So when I came into the room every day, that's the kind of presence that I had with him. I didn't ask a lot of open ended, overly sentimental, emotive questions.

Instead I came in and I had a clear plan and I showed that level of competence and competence that they needed to be responsive to the way that they coped best.

And this is very different, Michael, than, you know, 90% of the time when I'm with patients, I had this, this little portable stool that I carry with me all throughout the hospital because we see the therapeutic benefits of when we just sit down next to patients at the bedside.

In fact,

there's a lot of evidence that validates that patient's perception is that the quality of the visit is better.

They perceive that the physician spent almost 40% more time than they actually did when they sit down versus stand up.

And so I carry the stool with me all the time throughout the hospital to sit and to be present and to have that non verbal type of attunement to a patient's needs.

And now it's been awesome to see the prolific effect of this intervention because within our palliative care team we now have about 10 of these portable stools. So it's like a whole fleet of stools that are throughout the hospital.

But it shows how when you have this kind of rapport,

this non verbal synchrony of even the unspoken of what's unsaid in terms of our presence and attentiveness and attunement to the patient, that satisfaction rates of patients are higher.

Patients often even have a better understanding of their condition cognitively.

I think one thing just to Reflect on that, Carrie, is this idea that I had a student rotating me with me yesterday in clinic and had a challenging, perhaps visit with a patient where it was kind of unclear what the patient wanted from the visit and seemed to be asking for things that were just like,

not in my ability to give in terms of information and decisions.

And ultimately we ended up having like a really great. It ended up being a really great visit.

And partially it was because she had all these, like, concerns of neurologic side effects to various medications and basically wanted me to fix a lot of those side effects. But then as I was just trying to be, and I just listened to her,

what I realized was behind all of that was that she didn't feel like validated by her bringing it up to other clinicians who would say, like, oh, that's not a side effect of that medication.

And so kind of insinuating that it was all in her head.

Now I think that there is some, like, mood issues playing into what was happening there. And at the same time,

this student and I were discussing after the visit of what was I coming for or what was coming forth from like, what she witnessed there.

And we talked about this idea of pulling away, in a certain sense from evidence based medicine. Because there's this tendency to put everything into like boxes of evidence. And if it doesn't fit that and then it must be that the patient is wrong or like, you know, it's not.

It's just something that's in that patient's head.

And this idea of like seeing the individual in front of us. And the reality is like, at some point I also like feel like any patient can have whatever side effect they want in the sense that, like, I mean, all these drugs go through so many different metabolism, there's like no way we can actually know.

Even if it's super rare and it's not on the box. And even if it's on the box, it's like that's from just like some trial of a set number of patients.

And so this openness to the patient experience and also validating to that person as an individual the fact that they are going through this. And that actually was like, what opened the door to us having this conversation about the fact that, like, you know, I actually think it could be related to that.

But ultimately this drug is helping your cancer. And so now the discussion then is more about, like, I acknowledge your side effect and what can we do about that in terms of it's helping your cancer.

So we have to find this balance of what Are the side effects that are acceptable and perhaps which ones are not acceptable and how can you also find a way to live with that?

And so just this idea of this individual, the approach to the individual that you were talking about, especially with that athlete patient,

and that we can't. There might be an approach that works in the majority of cases or perhaps in a treatment plan that works in the majority of cases, but part of treating another human person is that that person is uni,

an individual. And that we shouldn't be also swept up by this culture of like only using evidence or kind of going down certain lines, because that's like the way that evidence works.

Don, you're reminding me that it's not about perfection, it's about connection.

It's not about perfection, it's about connection. And that striking example that you just gave shows your ability to have this sort of therapeutic humility,

to be therapeutically present,

to enter into the lived experience of illness as that woman experienced it through the side effect burdens of her lived reality. And that therapeutic humility is such a critical component to therapeutic presence because it acknowledges the limits of medicine,

our own limits as individuals. It allows space for the mystery of the complexity of medicine,

the acknowledgement of the unknowns and listening with this kind of reverence and curiosity and a non judgmental stance where you really demonstrated there a way of inhabiting the space of her experience without presumption,

with a desire to know and to learn more deeply. And that's the essence of that therapeutic humility, which is it just a core component of this concept of being therapeutically present.

I really love that reflection, Carrie, because I think it also draws back on the thoughts of Alasdair MacIntyre and Carter Snead and the virtues of acknowledged embodiment and humility as one of the core virtues there.

And so I think that is very beautiful and so true.

And if I can sort of in a way tie everything together, if I were to put all of this into one word, that wasn't presence.

I think a lot of what you guys have been talking about has been,

can be described by understanding,

which I think some would say is the beginning of charity and love. And so understanding yourself, understanding others,

and using that to be present to the patient and be with them as much as possible.

And so as we wrap up here,

if there was one thing that you could say to every student or clinician about therapeutic presence, what would you say?

I'd like to echo, it's not about perfection,

it's about connection.

To let your being your very being be the medicine itself first and foremost that our very presence is therapeutic to patients.

And I would love to invite everyone listening to just consider even one commitment, one takeaway. I know we talked about just a whole spectrum of topics, but maybe one thing that you'd like to do different in your being with a patient as you go through training and encounter people in this clinical ecosystem tomorrow,

next week, next month.

So thank you so much, Michael. Then John, this has been just such an honor and privilege to be in this space with you. And thanks for your therapeutic presence with me for us to have this very illuminative conversation together.

Yeah, thank you so much for being here, Carrie, and we so appreciate the wisdom that you also shared with us today and also are excited for you to continue helping us build this Hippocratic Society of network of physicians, informing others in this practice and pursuit of good medicine.

Thank you so much, Carrie. We really appreciate it and are very much formed by the wisdom that you shared today.

So again, well, great to be here. I definitely experienced the generativity of this group.

Very glad to hear it and thank you again. And we will see you all next time on the Hippocratic Society Podcast.

Thank you very much for joining and reflecting with us today.

Keep up with new episodes by subscribing to the Hippocratic Society Podcast.

For more information on the Hippocratic Society,

visit us at hipsoc.org. The Hippocratic Society is a 501(c)(3) and depends on the generous support of its listeners.

And as always, we'll see you next time on the Hippocratic Society Podcast.

Loading...

0:00 / 0:00

Loading...

0:00 / 0:00