• Read Dr. Chochinov’s article, The Secret Is Out.
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Joe Sanok 00:00:00  Are you a mental health practice owner juggling the complexities of running your practice? Meet at mirror, a CRM and operation software solution designed to simplify your day to day workflows and streamline your operations. Admire makes managing your practice easier by simplifying referral management, client onboarding and communication, and other essential tasks with customizable workflows, email templates, and automation tools. It helps you run your group practice more efficiently. Plus, it integrates seamlessly with your email platform, website, and EHR system, bringing everything together in one place to save you time and reduce errors. Ready to transform the way you work? Visit mirror to learn more. That's ad irr. To learn more, you can sign up for a free 30 day trial or schedule your free demo today. Admission. This is the practice of the Practice podcast with Joe Sestak. Session number 1195. Welcome to the practice of the Practice podcast. I am Joe, your host, and we are here 3 or 4 times a week helping you build a thriving private practice you absolutely love.

Joe Sanok 00:01:29  We have been digging into all sorts of issues, both clinical and business, throughout this year, and today is going to be a great day. We have Doctor Harvey Max with us, who is a distinguished professor of psychiatry at the University of Manitoba and a senior scientist at Cancer Care Manitoba Research Institute. His research in palliative care has resulted in more than 350 career publications broaching diverse topics such as depression, quality of life, suicide, vulnerability, spirituality and existential distress. He's also led a large program of research on dignity within the health care setting, which includes the development and study of dignity therapy. He's the co-founder of the Canadian Virtual Hospice, co-editor of the Handbook of Psychiatry and Palliative Medicine from Oxford University Press, and his latest book is entitled Dignity and Care The Human Side of Medicine, published by Oxford University Press. He's an officer in the Order of Canada and an inductee into the Canadian Medical Hall of Fame. I am so excited to have you on the show today. Harvey.

Dr. Harvey Max Chochinov 00:02:37  Thanks, Joe.

Joe Sanok 00:02:38  Yeah, well, we're we're talking about dignity in care.

Joe Sanok 00:02:42  Now, is this something that kind of throughout your career has been a focus, or was that something that you kind of discovered along the way?

Dr. Harvey Max Chochinov 00:02:49  It certainly wasn't there at the outset. I mean, at the outset, being a psychiatrist, I was interested in the early parts of my career, looking at things that were more kind of typically, quote unquote, psychiatric. So, we studied things like depression, desire for death, will to live, anxiety, hopelessness. but at a certain point in time, in exploring what I would refer to as kind of this experiential landscape of end of life care, we discovered that there were things that were, pressing, but yet in some ways kind of ephemeral, in terms of their influence on patient experience. And that's when we started to enter into the area of, of dignity. and the, the clue that that was important was looking at the Benelux countries. The experience reported by Dutch physicians, is that the most frequent reason why patients had sought assistance with hastening death was because of a lost sense of dignity.

Dr. Harvey Max Chochinov 00:03:59  Now that goes back like 30 years or, you know, plus 30 years. but at the time, there was no empirical work on dignity. And we said, well, you know, if dignity is worth dying for, dignity is worth studying. And so we embarked on a large programme of research, you know, following that particular path.

Joe Sanok 00:04:17  Now, just so we're all on the same page with terminology. How do you define dignity when it comes to working with clients and patients.

Dr. Harvey Max Chochinov 00:04:25  Well I mean, you know, I mean the question really kind of addresses, you know, why the research was important in the first place. People define dignity in a whole variety of ways. I mean, the dictionary definition of dignity is the idea of being deserving of honor, respect or esteem. we started to explore it by sitting down with patients who were near the end of life to find out what it meant when it worked, when it didn't work. And I guess two critical things that came out of that from the quantitative studies.

Dr. Harvey Max Chochinov 00:05:00  What we reported is that the single most ardent predictor of sense of dignity in a large cohort of dying patients was this idea of how they perceived themselves to be seen, in other words. And for me, that was actually rather an epiphany. in other words, what it means is that patients, at least metaphorically, even though this is driven by empirical data, metaphorically, are looking in the eye of the health care provider for an image or a reflection that will affirm their sense of self, their sense of personhood. So so that's the first piece of my answer. The next piece of my answer, really, again, goes back to qualitative data that we got from patients. And there we published a an empirical model of dignity in the terminally ill. And what that model shows is the various different sources of distress S that can affect someone's sense of dignity. So you know it. And they, as you would expect, can include physical dimensions of experience in the throes of a life limiting condition. It can include external things to the individual.

Dr. Harvey Max Chochinov 00:06:12  So things like social support and privacy concerns. And then the most kind of nuanced thing that we reported within that model is something that we call the dignity conserving repertoire, which really is about the the spiritual, the psychological wiring of that individual. So things like hope and feelings of, meaningful roles and spirituality. So and it's not a hierarchical model, which means that for different people, different elements from within that model will influence their sense of dignity. So at the end of the day, when you're sitting down with a patient, you need to find out from them what are the things that are most profound in shaping their experience.

Joe Sanok 00:06:59  I know sometimes in research, the research is kind of naming what's already there and saying, okay, we haven't really classified this, but this is what we're observing. And then other times the research is kind of pushing the envelope forward and saying, these are emerging models that maybe we haven't named as much. When you think about, kind of dignity therapy, first, I guess, do you agree with that? You can always disagree with me.

Joe Sanok 00:07:26  if you, would add something to kind of how research is, is conducted in your mind. but if those models are where you would say we would land, where does Dignity Therapy kind of fall in regards to emerging, ways of doing therapy versus kind of naming things that maybe were part of the human experience already?

Dr. Harvey Max Chochinov 00:07:44  So, I mean, what I would say is this, I mean, when you I mean, intuitively we have a sense of what dignity might mean. but the problem is with intuition is that, you know, it may or may not be kind of, you know, borne out based on, experience with patients, when we, produce the model. And again, this is based on input of patients who are nearing end of life. As you point out, I mean, many of the things in that model are things that you would predict would have an influence on, on sense of dignity. So things like pain, for example, good symptom management, you know, good social support, all of those things you would say, well, I might have predicted that those would have some influence on sense of dignity.

Dr. Harvey Max Chochinov 00:08:31  But what also happened is that there were some things that appeared in that model that we might not have previously expected. And one of the things that came out, and this is a segue to responding to your comment about dignity therapy. One of the things that came out of our model was the idea that for patients, generativity turned out to be an important issue. And by generativity I mean that for some patients, the assault on dignity is the sense that who they are will not have some ripple effect beyond this life. In other words, this idea of, you know, so what what did it all amount to? What did life mean? What was the meaning of my having been here? And so that led us to develop a therapeutic innovation that we have coined dignity therapy, which is now the most studied psychological intervention and palliative care. There are, you know, over 100 papers collectively in the medical literature and about 12 systematic reviews. And dignity therapy is a way of, with the help of a trained therapist, guiding a patient towards creating a legacy or a generativity document.

Dr. Harvey Max Chochinov 00:09:43  So this is a conversation that we train therapists to elicit from patients with life threatening, life limiting conditions. Those conversations are recorded, transcribed, edited, and then returned to the patient so that they can share it with the people in their lives who matter.

Joe Sanok 00:10:04  Now, what kind of shifts has this led to? in regards to how psychiatrists, therapists, other medical professionals are maybe approaching end of life or, other conversations or, treatment within dignity.

Dr. Harvey Max Chochinov 00:10:19  Well, I.

Dr. Harvey Max Chochinov 00:10:20  Would say, I mean, the effect hopefully that it's had and, and hopefully continues to have and one can only hope that you know, that effect will will grow is, a heightened sensitivity to the importance of these things when it comes to patient care. in other words, I mean, much of what we are trained to do with patients is very much in the realm of the transactional. You know, the thing we do to the patient. You know, we we give people drugs, we do surgery, we radiate. So we we perform various different tasks or interventions.

Dr. Harvey Max Chochinov 00:10:58  And those transactional tasks we begin to think of as being, in their totality, what medicine has to offer, what my work hopefully has done in the work of, of others, of course, in, in this particular lane is to say that there are other facets of medical care that aren't within the realm of the transactional, but really within the realm of the relational. And to operate in that lane, you need to understand something about personhood. You need to understand not only what the person has, but who that individual is. And so I'm beginning to see that kind of mentality, certainly in palliative care being seen as, you know, part and parcel of holistic, comprehensive palliative care, maybe in some ways kind of operationalizing the kind of work that Dame Cicely Saunders suggested palliative care ought to embrace. At the outset, when she founded the modern hospice movement and said, you matter because you are you. Well, it turns out, I mean, you matter because you are you, not only because of the ailment that you have that brings you to medical attention, but you matter because because you are you based on who you are as an individual.

Dr. Harvey Max Chochinov 00:12:22  So much of my work over the certainly over the last decade has really been focusing on this whole notion of personhood and really alerting health care providers about the importance of eliciting personhood if you're going to be providing person centered care.

Joe Sanok 00:12:49  Listen, I didn't take insurance in my counseling practice because I had no idea how to handle it. The process of accepting insurance outside of a group practice can be tough, but most people looking for mental health care want to use their benefits to pay for sessions. If you're like me and you feel a little scared about taking insurance, or you just want to make it easier on yourself and you're interested in seeing clients through insurance, alma can help. They make it easy to get credentialed with major insurance plans at enhanced reimbursement rates. They also handle all the paperwork from eligibility checks to claim submission and guaranteed payment within two weeks. Plus, when you join Alma, you'll get access to time saving tools for intake scheduling, treatment plans, progress notes and more in their included platform. It's going to make it so much easier for your team, so you can spend less time on administrative work and more time offering great care to your clients.

Joe Sanok 00:13:43  Visit. Hello, alma. That's. Hello, all. To get started. I think that, you know, just as we think about the things that we all learned in graduate school and then the development of, of different approaches, sometimes it's easy to, to miss, you know, this emerging research or emerging best practices. what what for you are are people that are staying at the cutting edge of this. What are they doing regularly to help stay clinically relevant in regards to as they're thinking about these issues? And maybe even if you want to dig into, just some of, of what this therapy and this modality looks like practically, we'd love to hear kind of what that looks like practically as well.

Dr. Harvey Max Chochinov 00:14:29  Well, I mean, the details of dignity therapy are, you know, kind of like out there, certainly available in the literature and available online. I mean, the description of it in sort of a thumbnail sketch is that, you know, patients are engaged in this brief conversation, and are asked about things, and there's a kind of a framework of questions that we have that's elicits, you know, core issues around personhood and particularly things that they would want known that they would want remembered.

Dr. Harvey Max Chochinov 00:15:02  So some facets of it are biographical. You know, the particular vignettes from your life that you feel were formative or that you would want no one remembered. And some of them are more kind of emotionally evocative and have to do with things that you've learned. the things that you would want remembered or known lessons you would want to convey, specific wishes or hopes that you might have for individuals that you are about to leave behind. so that conversation is organic. again, we trained therapists and have done so for decades now from around the world to be able to elicit those conversations and to know how to take those transcriptions and to make them into a into a legacy document that can then be given to that individual to share with their loved ones. And those documents, you know, can have multigenerational effects. But I think even more broadly, I mean, the practice of dignity and care is not something that is just for, you know, selected patients who feel that they need to do something about generativity, dignity and care is really an approach for all health care providers to understand that to be a health care provider means more than being a human body mechanic.

Dr. Harvey Max Chochinov 00:16:29  It means being a healer. And to embrace that role means to be attentive not just to the physical, but to the psychosocial, the spiritual, the existential. And to do that, at a minimum, one needs to ask. And, you know, we've we've done studies on, you know, what we call the patient dignity question? What do we need to know about you as a person in order to take the best care of you possible? We know that that can be the stem of a brief conversation. And we have had these conversations with with hundreds. And now there are thousands of patients who have participated in this in studies that have taken place around the world. And what is we've shown in our results is that this enhances a sense of connectedness, a feeling of being respected, of being heard. And for healthcare providers, it even increases job satisfaction and therefore perhaps may mitigate against sort of the stance of becoming very kind of robotic and disengaged from the human pathos of what's happening in a clinical encounter and therefore may be something that actually prevents burnout.

Joe Sanok 00:17:44  Yeah, I think that that's fascinating to see kind of how it's being implemented and can I how people are enacting it. for, for your own, personal habits. You know, for me, I always love when there's researchers and experts that have studied something deeply. I think it's impossible for it not to affect our lives personally. For you personally. Like, how does this how do you live differently because of the research you've discovered? Or how do you think differently about the world? Or are there habits that you do quarterly or weekly or annually that that impact you because of this research that you've done?

Dr. Harvey Max Chochinov 00:18:22  That's that's a hard question. I mean, I feel like, you know, the research in some ways, you know, has affirmed things that, you know, hopefully at some point in my life I would have discovered and, and I think with age, we all eventually do discover and that is that, we are all, vulnerable. you know, that all of us, you know, Encounter issues in our life that can be overwhelming.

Dr. Harvey Max Chochinov 00:18:50  And that, into my mind, is kind of not so much a reflection of personal weakness. It is a reflection of the human condition. You know, that, you know, vulnerability is really kind of woven into the DNA of of the human experience. And so I think that I, I carry that with me and see people through a lens that understands that. The other thing that I think that I've learned and I've and I've actually written about this over the last few years, something that I call the platinum rule. Intuitively, when we are trying to determine, I mean, what might be in the best interests of someone, you know, what treatment might they need, what's the best approach in this situation? Or even interpersonally, you know, like, so what do I think this person, you know, might need for me at this time? The the intuition is the golden rule to say, you know, we we, we use ourselves as a gauge or as a barometer for what that person might need.

Dr. Harvey Max Chochinov 00:19:52  And what I've come to realize is that as a as important as that approach is as kind of giving us a starting point. The fact is that it still means that we are imposing this external standard on what somebody else might be feeling or thinking or needing. And so the platinum rule, which I've written about, really says, doing unto patients as they would want done unto themselves. In other words, being mindful that all of us bring a particular perspective that is shaped by the way that we were raised, the society in which we were born. And that is going to create certain biases or taints our outlook in ways that may be discordant with the patient's lived experience. And so that is another, I think, lesson that I've learned along the way that I've been writing about. And, and hopefully I would think would be an important element of, you know, the whole dialogue that we have certainly in, in this country about EDI, equity, diversity, inclusiveness. I think to be mindful of that, first and foremost, we need to be aware that our own lens, our own gaze, is shaped in ways that we may not even be aware of.

Dr. Harvey Max Chochinov 00:21:19  So we need to, I think, heighten our alertness to the fact that we are seeing things, in a way that is shaped by, the fact that we have a particular outlook. But the important outlook, of course, is for the patient and the way this makes certainly I mean, it makes, has implications in a whole variety of ways, but certainly one very practical way in palliative care, where, you know, sometimes you can no longer elicit what the patient might want. The correct question to the son or daughter or spouse who's sitting at the bedside of their now uncommunicative loved one is not. What would you like us to do? But if we could bring your person back into this room the way they were a week ago or a month ago, what is it that they would want? And I would say that is a platinum standard and that is raising the bar on person centered care.

Joe Sanok 00:22:15  Yeah. I love that idea of looking back a couple of months and thinking through, you know, what would that have look like if we had had some of these conversations or you know, if they were thinking through it with them.

Joe Sanok 00:22:25  you know, the, the last question I always ask and I swear these, these interviews have gone by so quickly. but the final question I always ask is, if every private practitioner in the world were listening right now, what would you want them to know?

Dr. Harvey Max Chochinov 00:22:42  Well, I mean, two thoughts come to mind. One is the title of an article that I published years ago, and the title of that article is The Secret is Out. Patients are people with feelings that matter. So that's the first thing I would like people to think about. And and maybe the last thing, just given the limitations of time, I was asked to give a speech to our incoming medical students this year, their white coat ceremony, and amongst the many other things that I said to them was this patients won't care what you know until they know that you care.

Joe Sanok 00:23:18  It's so important. Harvey, if people want to follow your work, if they, want to learn more about what you're studying and what you're researching, where should we send them?

Dr. Harvey Max Chochinov 00:23:27  dignity and care.

Dr. Harvey Max Chochinov 00:23:29  Or they can follow me on Twitter at. Or LinkedIn. Harvey. Max.

Joe Sanok 00:23:38  And we will link to all of that in the show notes also. Harvey, thank you so much for being on the practice of the Practice podcast.

Dr. Harvey Max Chochinov 00:23:43  Thanks, Joe. My pleasure.

Joe Sanok 00:23:52  We'll take some action as you listen to this show. As you look back, you know, if we had our future of series and before that we also had our Better Brains series. So all sorts of really interesting discussions. Then we talked about the future of trust. We talked about how veterans can recover from moral injury. We talked about trauma and vagal theory and what it takes to actually make change that matters. So all sorts of really interesting shows we've done in the last month or so. So go back, check out some of those shows. Also, we couldn't do the show without our sponsors. Thank you so much to alma for being our sponsor today. You know, I wish alma had been around when I had my private practice.

Joe Sanok 00:24:33  I had no idea what I was doing. That's why I didn't take insurance. But if alma had been there, I would have. And there's no reason that as a clinician, you should be spending hours on paperwork to bill for insurance or not knowing for sure that you'll get reimbursed for sessions with your clients. If you're interested in seeing clients through insurance but don't want to navigate the process of paperwork on your own. Alma can help. They make it easy to get credentialed with major insurance plans at enhanced reimbursement rates, and a guaranteed payment within two weeks. Visit. Hello, alma. That's. Hello, alma, to get started. Thank you so much for letting me into your ears and into your brain. Have a great day. I'll talk to you soon. Special thanks to the band. Silence is sexy for that intro music. And this podcast is designed to provide accurate and authoritative information in regard to the subject matter covered. It is given with the understanding that neither the host, the producers, the publishers or guests are rendering legal, accounting, clinical or other professional information.

Joe Sanok 00:25:36  If you want a professional, you should find one.