EP. 60: THRIVING AFTER CANCER

WITH TARA SANFT

May 3

WITH TARA SANFT, MD

The Director of the Survivorship Clinic at Yale Cancer Center shares how she helps patients thrive after cancer — even after the cancer treatment has ended.

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Episode Summary

When we hear about people with cancer, the stories often end when the treatments end—either the battle has been won and the cancer cured, or in more tragic circumstances, the cancer takes the patient's life. But for patients who survive, that's not where the story ends. Cancer has fundamentally transformed their lives. How are they to make sense of the existentially threatening experience they have gone through? That's where cancer survivorship comes in. Joining us in this episode is Dr. Tara Sanft, director of the survivorship clinic at Yale Cancer Center, where she helps patients thrive after cancer. Dr. Sanft is also a breast oncologist and the Chief Patient Experience Officer at Smilow Cancer Hospital. In this episode, we discuss the importance of cancer survivorship, how Dr. Sanft navigates the emotional challenges of her work, and what all clinicians can do to better support patients through difficult times.

Tara Sanft, MD is board certified in both medical oncology and hospice and palliative medicine. As the Chief Patient Experience Officer at Smilow Cancer Hospital, she works to improve care especially where the provider and patient experience overlaps. As a breast oncologist, Dr. Sanft has a busy practice and enjoys taking care of women with newly diagnosed breast cancer. She is the director of the Yale Survivorship Clinic, one of the nation’s only multi-disciplinary clinics specializing in cancer survivorship, and Chair of the NCCN Survivorship Guidelines. Her research focuses on healthy lifestyles and quality of life after cancer.
In this episode, you will hear about:
• How the death of a family member influenced Dr. Sanft’s decision to go into medicine - 2:04
• Why Dr. Sanft’s decided to focus on palliative care - 6:02
• Reflections on how communication and building relationships are key to palliative care - 14:20
• A discussion of cultivating sacred moments in medicine - 19:53
• The purpose of a cancer survivorship clinic - 26:02
• A discussion of the most challenging aspects of Dr. Sanft’s practice - 33:35
• How Dr. Sanft shoulders the emotional toll of her work - 36:30
• Dr. Sanft’s duties as the Chief Patient Experience Officer at her hospital - 40:25
• How to create culture change in medicine - 43:17
• Dr. Sanft’s advice to clinicians on how to better foster self-compassion and create effective healthcare teams - 48:18
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives, those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] When we hear stories of people with cancer, their stories often end when the treatments end and either the battle has been won and the cancer cured, or in more tragic circumstances, the cancer takes the patient's life. But for many patients who have survived, that's not where the story ends. Cancer has fundamentally transformed their lives. How can they reintegrate with their social connections? How are they to make sense of the existentially threatening experience they have gone through? That's where cancer survivorship comes in. Joining us in this episode is Dr. Tara Sanft, director of the survivorship clinic at Yale Cancer Center, where she helps patients thrive after cancer. In addition, Dr. Sanft is a breast oncologist and the chief patient experience officer at Smilow Cancer Hospital. In this episode, we discuss the importance of cancer survivorship, how Dr. Sanft navigates the emotional challenges of her work, and what all clinicians can do to better support patients through difficult times. Tara, thank you so much for taking the time to join us and welcome to the show.
Tara Sanft: [00:02:02] Thanks for having me.
Tyler Johnson: [00:02:04] Can you start out by just telling us your origin story? How did you get into medicine? What did your path look like?
Tara Sanft: [00:02:12] I grew up in Iowa and my father worked for Winnebago Industries and my mother was a psychiatric nurse in the outpatient setting. Sort of functioned like a nurse practitioner. Back in the day, and she really found her job very fulfilling. So she would talk to me as a child that you could do anything you want. And she felt that practicing medicine was really special. And so in her generation, she was not encouraged to pursue a career in medicine as a medical doctor, but instead through a nurse nursing school. And she suggested, though, that I could be anything, even a doctor. And so that seed was planted very early. And then when I was 11, her brother died of pancreas cancer. So my uncle, he was 32 at the time and I was 11. And I realized now that that had a profound impact, not just on my family, but on me and my. My connection to. Oncology to palliative care and to supporting people during really serious illness.
Tyler Johnson: [00:03:23] And so, tell us a little bit about that. You know, it's so interesting. We've talked with a number of people on the program over time who have some experience in their young life that has a really formative impact in terms of leading them to become a doctor. But it's also so interesting that what I imagine was, you know, especially when when your uncle was so young at the time of diagnosis, had to be a tragic and very difficult And I imagine as a child, very confusing event in your life. How was it that that operated to make you then want to go into medicine?
Tara Sanft: [00:03:59] It's interesting because what I remember is just snippets from like back seats of a car, you know, of conversation happening in the front. And and I remember profoundly that there was just great sadness that at this time there wasn't great treatments. There was nothing much that could be done. He had two little kids, and my uncle was the life of the party. He was the comedian at the barbecue who was always having us laughing with funny stories like kids included. And so there was this profound sadness that this was coming. And yet when he passed away in his home in hospice, everyone felt like that was very beautiful. And I remember. Being drawn to that, to that ability to support a family in their most, most serious time of suffering and giving them comfort through something that's inevitable and didn't know all of this at 11. All I knew is I could be anything, including a doctor. And so I fast forwarded. I was I loved school. I loved science. And I went into medical school. And it probably wasn't until my intern year when I rotated on oncology. And was on call in the middle of the night having to talk to patients about either transferring to the ICU or focusing on their comfort on the floor, that it all kind of clicked for me. And I, I felt that deep connection to these patients at their toughest times of deciding what to do next. And I finally felt like I was finding my calling and that I it was it made me feel very fulfilled to be a part of that, regardless of what they chose, whether to go to the ICU or to stay on the floor and focus on comfort, I felt always fulfilled after being a part and bearing witness to that and helping to facilitate those decisions.
Henry Bair: [00:06:02] So one of the things I've come to recognize is how important palliative care is. I, for one, didn't really understand the nuances of what palliative care entailed until about halfway through medical school, and I think that's true for most people. In fact, I think it's not uncommon for someone to make it through all of their medical training and still not really be able to define the scope of palliative care. You, on the other hand, had a very early exposure to palliative care. Can you tell us your subsequent journey in palliative care and how you eventually came to specialize in this area of medicine?
Tara Sanft: [00:06:38] Yeah. So I would say that the decision to pursue hospice and palliative medicine came first and it was pretty much on that oncology rotation as an intern. And it was the recognition that the palliative care specialists were often called in at end of life. And so they got to be a part of those serious discussions routinely. In thinking about what parts of palliative medicine and hospice and palliative medicine did I love the most? It was the care of cancer patients. A lot of hospice and palliative medicine deals with symptom management and in particular sometimes chronic pain management, which we now know there's a word for the opioid crisis. But back when I was training, that wasn't recognized, but it did not. That part of the specialty didn't feel particularly fulfilling to treat patients pain with a with medications that didn't always result in mean it never resulted in resolution of their pain. So I really focused in on the the practice of the conversation and really witnessing what people were going through in their life. And that tended to be a lot in the cancer care world. So the decision to pursue oncology. And hospice and palliative medicine together came out of those desires and passions to be with patients that drain those serious times.
Tyler Johnson: [00:08:12] And just to be clear for our listeners who may be in the middle of the river, so to speak. So you did medical school, then you did an internal medicine residency, and then which thing came next?
Tara Sanft: [00:08:24] That's right. I did medical school at the Medical College of Wisconsin. I did internal medicine residency at Northwestern. And at that time, Northwestern had a combined fellowship in medical oncology and hospice and palliative medicine. So I did them combined. It was one of the only programs in the nation and it was fantastic training and and positioned me to have many choices when I graduated for the different job markets that I was interested in. And so I talked to interested students all the time now in that who still want to pursue that kind of training. And there were many, many options. But I ended up here and I can go into how I practice palliative medicine today in the world of cancer survivorship. But it's right exactly where I feel like I need to be.
Tyler Johnson: [00:09:14] So I think it would be helpful for us, You know, just to give a little bit of background before I ask you this question. Right? So as a I'm a medical oncologist and so I practice at the Stanford Cancer Center, and it used to be the case. I lament the fact that this no longer is, but it used to be the case that we had a palliative care team that was embedded in this little room right down the hall from the team room where I practice. Right. And from my vantage point, it's a tragedy that that then changed because when they lived there, we were talking to them all the time. Right. I mean, it was like that walk down the hall for any patient who had either serious symptomatic concerns, as you mentioned, but especially for those who were approaching the end of life or facing really difficult either existential questions or treatment related questions about whether to undergo some big, heavy, aggressive treatment that also carried with it a lot of risks and that kind of thing. We were really the relationship between the medical oncology team and the palliative care team was was very, very strong and it still is. But now they're in a different building, which I think is really unfortunate. And then I should also mention that there has been an enormous amount of research over the last 15 years demonstrating that if you are a medical oncologist practicing without the proactive assistance of palliative care partners, you are practicing suboptimal care, right? So there's tons of data demonstrating that that collaboration with the palliative care team leads to better quality of life.
Tyler Johnson: [00:10:54] And in many sort of what some people incorrectly assume are softer measures, better care. But then there are also even some like there's a famous study from Jennifer Temel indicating that it even in some cases leads to longer life. Now, you know exactly why it can be debated, but the point is just to say that it's incredibly that partnership is incredibly important. But then we have really interesting people like you who are both of the things. Right. And, you know, like it's sort of like trying to imagine somebody who both does the cancer surgery and the chemotherapy after the cancer surgery or whatever. Right. So I guess talk us through a little bit. First of all, just what's it like to have both of those training backgrounds? And then also, so what do you do with it? Like what what does your daily life look like as somebody who lives in the very narrow overlap between those two circles?
Tara Sanft: [00:11:50] So I would say that it's a privilege to have gone through both sets of training. I could not imagine myself practicing medicine without having the skill sets that I gained through palliative medicine training in my oncology practice. Not to say that you have to have that, you certainly don't, but to me it makes my life richer. And in my world now, the way I use my palliative care is through the survivorship clinic that I run and talking to patients about their experience and what it was like for them and what to expect going forward is. All of the things that drew me to palliative medicine. And it's and these are serious discussions. It just happens to be that many of these patients are not at the end of their life. So it's really palliative care for those patients who are entering into surveillance. And it still manifests with, you know, sometimes debilitating fear of recurrence, a long list of side effects that needs to be managed and first needs to be believed and then managed. Um, and then, you know, how to get some semblance of your life that you had before back in terms of your physical abilities, how to maybe even become healthier than you were before.
Tara Sanft: [00:13:08] Because we know in adults changing behavior is very hard, but that cancer can be a teachable moment. So it's again, it's just a privilege to work with this population. And I happen to also treat breast cancer in my active cancer clinic. So they tend to enjoy very long survival. By and large, not everyone, but it's a population that does very well. And so they there's a lot of survivors there. Not all of my patients are facing long term survivorship. They're they're also facing end of life. And and to me, I do engage with palliative care, even though I'm a palliative care physician, because I think that talking to them separately can often bring about other issues that you might not want to disclose to your oncologist who's signing treatment plans for you. Um, but I do feel like. That those patients who I see through to the end of their life, it's a really strong bond that I do not take for granted. And I think my palliative training has helped me develop those relationships in a way that's really fulfilling to me and hopefully also to the patients.
Henry Bair: [00:14:20] You know, earlier you talked about what drew you to palliative care in large part Was the conversation. Right, as opposed to I mean, the comfort care and the symptom management is just as important. But for you, you really honed in on some of the relationship building. That sounds a little bit abstract, I think, especially for someone who hasn't seen it right. If it's someone who is not affiliated with the medical profession or still early in their training, they have no idea what palliative care is. And they think having conversations with patients, that seems like something that all good doctors should do. I'm wondering if you can share a specific example or a story that illustrates the unique work that you do and the unique skill set you're able to bring.
Tara Sanft: [00:14:59] Yeah. Guess as it relates to communication, it does sound really easy. And many of us are drawn to the field of oncology, for instance, because we enjoy communicating with patients at this time in their life. I will say that I thought I was a really good communicator going into my fellowships, and I probably I mean, there were no complaints, but there are some very specific skills that we need to, I think, be taught and then practice in order to. Optimize the conditions so that there is room for these what I call sacred moments, these moments of interconnection. That make time stand still and that you walk away feeling like, wow, I was just part of a really. Moving discussion. And. And that is and I have had more of that since I have become more of a communication expert or trained. Trained in communication skills. And my my life mission now is to really talk about this in a more open way so that we can refocus on the importance of this, you know, the EMR and all these other pressures on us to see a lot of patients every day. Sometimes these basics get missed. And so what does it actually mean? I mean, the first step is to build trust with your patient. And you cannot do this without building rapport, understanding who the patient is in some way as a human being, something about them, and then really listening to their story. And think that certain communication skills have helped me do that throughout my career. And guess one example that comes to mind? This is a survivorship example, but I could probably think of one if you wanted something from that group.
Tara Sanft: [00:16:56] But this was in the pandemic, a lovely patient in my breast cancer clinic who was, you know, unfortunately not responding to her fourth or fifth line treatment and. She wasn't doing well. She was having a lot of symptoms. And we had talked a little bit about what she might want at the end of her life. But she was young and she had a young child and really wasn't ready. To let go of all of that in her life. And there was a day when she was becoming so symptomatic that she was going to need to be admitted to the hospital and this would have. She wouldn't have been able to be discharged like it was very close to the end of her life. And so we were talking about this and I talked to her on the phone and we started to talk about, okay, so. Here's the options. We can call in the hospice team. They can come in and assess you. We can enroll you. And the goal would be to keep you at home. Or you can come in through the emergency room. You'll be admitted, and we can try to do all these things in the hospital setting. And at the time of COVID, there were no visitors know. So that was really unattractive for so many reasons. And there was a moment of silence there. And I just let the silence go. And she started to ask me, well, what would staying home be like? And we talked a little bit and I said, Tell me more.
Tara Sanft: [00:18:20] Like, what are you thinking? And and she said that she looked around the room and she was all of a sudden realizing this life that she has had living with breast cancer for 12 years in the metastatic setting and how rich it has been, and that she looked back at a picture in her room of her son and her husband and her and in like a photo shoot when he was a baby. And they had like worn matching outfits. And that at that moment and that Mother's Day photo shoot, it was 12 years earlier. She wasn't sure if that would be her last Mother's Day. In looking at this and she's realizing that she's had 12 years to be her son's mother. And it's been a good life. And maybe there would be some things she would do differently. But she's really. Grateful and celebrating all the things that she's been through. And, you know, it's hard to describe this and do this story justice with how I'm describing it to you. But but trust me when I say that the power of listening and just being curious and not rushing, what's it going to be? Are you going to stay home or are you going to the emergency room? And just letting the conversation evolve was sacred to me and was so meaningful in a way that obviously it's right on the top of mind. I wrote it down. I've thought about this patient so many times and and those are the conversations that keep me coming back to do this work over and over again.
Tyler Johnson: [00:19:53] I'm so struck by that story for multiple reasons. One of them is because the more that we have talked to people on the program and the more that I've reflected on my own medical practice, the more it has become clear to me. So you've used multiple times the word sacred. And one of the things that has become clear to me is that if you look at any religious tradition, a large driver, I think of the religious impulse in humans is a need to discover a way to grapple with our own mortality. Right. It's the recognition that none of us is going to live forever, at least in this current form, and to try to figure out what does that mean for while we are alive and how? How do we grapple with that knowledge and how can that knowledge transform us? And I think that in many ways a lot of what religious traditions do is they try to kind of alchemize the knowledge of our own mortality to make some kind of meaning out of it. Yet it is also the case that in Western society we have, at least in so-called developed countries, that we have largely cordoned off death, right? It's a thing that happens to other people in other places that we don't really want to think about very much. And if it's depicted at all, often in popular cinema and whatever, it's depicted in a way that is kind of crass and dismissive, right? It's Marvel movies with hundreds of people being blown up and you don't even notice because you're focused on, you know, Captain America saving the Day or whatever. All of which is just to say that one of the ways that being an oncologist has transformed me, even as a person who is already religious, is that it just fixes my own mortality in front of my face in an unavoidable way.
Tyler Johnson: [00:21:55] And in a sense, when I resonate so much with that story that you were just telling because I almost feel like I have been. Burdened with this responsibility to run out and evangelize to everybody who will listen how different your life is. If you recognize that you're not going to live forever. Right. Because when I take care of patients who are dying, then all of a sudden it's like I wake up from it's like I've been sleepwalking and I wake up and say, Oh my gosh, everything right? The the color that leaves turn in the fall or the way that a cookie tastes in your mouth, or the sound of children laughing on the playground at recess or whatever. There is this this indescribable sweetness to life that you were describing that your patient had come to recognize. But because we get to have these intimate conversations with these people, we have the opportunity. And then when I feel like, you know, of course, being not as smart as I should be, I have all these opportunities and then don't remember them the way that I should, right? But I feel like what I should be doing is running around to everybody I know saying, Oh my gosh, do you realize what a gift this life is? Right? Do you realize how much beauty and sweetness and of course, also suffering and sorrow. And I mean, that's obviously wrapped up in all of this. Right. But but it's it it is just such like once you have accompanied a patient as they walk that path, I feel like if you let it, it will never let you be the same.
Tara Sanft: [00:23:30] Yeah. And I should call out the sacred moments. Term is not mine. There's actually a recent article in the Journal of General Internal Medicine by Martha Quinn out of Michigan talking about hospitalized patients and sacred moments reported both by the provider and the patient. And that resonated with me. And I thought, this is where it's at. Like, this is what we do all day, every day, is we cultivate these sacred moments and the word sacred. To me, it's that sense of awe and wonder at maybe it's how are how is this person continuing to smile and crack jokes in the face of such a heavy topic? Or, wow, I mean, sometimes it's it's how does this person have the courage to leave an abusive relationship? And it has really nothing to do with their cancer or, you know, sharing these intimate details about their family that I think. Thank you so much for trusting me with this. Or maybe it's disclosing that. They have a drinking problem. Mean there's like there's so many things that doctors are privileged to not just at the end of life. Think throughout the spectrum of human existence. But it's that sense of awe like, wow.
Tara Sanft: [00:24:49] I It's. I'm so lucky to be a part of this. That is what keeps me coming back for more. And and I think I have the sweet spot of it in oncology and also this palliative medicine training and communication training that. But I agree with you that I feel this urge to say, listen, we as a medical community, we need more of that. And and we need to remove as much barrier to creating those atmospheres as possible. So not only just having the time to listen and understanding the value of curiosity for these patient stories, but also how many checkboxes do we have to have? Can we minimize the time in front of the computer screen? Can we call on our teammates to share in some of not only the sharing but the bureaucracy sharing so that we collectively can experience more of those? They can even be joyful moments. I don't know if Joyful resonates as much in our work, but these really special times, I think. More of that, more of that and less of the stuff that takes us away is what I would hope to create in the culture of medicine going forward.
Henry Bair: [00:26:02] Well, thank you so much for for sharing all of that. That was beautiful. You've alluded to your work at the survivorship clinic numerous times now, but we haven't actually talked about what that is. And I think I'd be curious to hear more about what kinds of patients you see and what that work entails in general.
Tyler Johnson: [00:26:23] Can I just say one thing as a preface to those remarks? I think this is especially important precisely because I think that most people don't even know that's a thing, right? And not only do they not know that it's a thing, but they think they know it wouldn't need to be a thing. Right? Because often the the metaphor, which I know is this is being sort of questioned now, but often the metaphor for cancer is one of a battle. Right? And so if you get to the part where you're ready to go to the survivorship, it's like clinic. It's like the battle is won. It's over, right? You celebrate and you march off in victory and you're all done. So what in the heck do you need a clinic for after the battle is already won? Like, what's that for?
Tara Sanft: [00:27:04] Yeah. Any survivor hearing this is going to be like, Oh, my. Oh, boy. Like that. I mean, I think by and large, the generations that came before us, I mean, it was the real fight. And if they could get you to live through this terrible disease, which we had terrible treatments for, then you're lucky to be alive And like, let's move on to the next person. Right? And I think we are we needed that in the generations preceding us. And thank goodness we were to this point now where many patients can have multiple treatment options, live with cancer as a chronic disease in some circumstances. And and for some they go through the treatments and then that is it. It's like a little bit of a blip. And survivorship does not resonate with everyone. Don't like it's it can be very disruptive to people who don't identify as a survivor or see a lot of problems with that term. So always try to recognize that my dad's a survivor. He's never once called himself that or even like he would never come to my clinic because it wasn't a big deal to him. He got, you know, his prostate was removed and that's the end of it. But there's other people who. To send them off back into their life. We're sending them off as a completely different person as they came into us. And so the survivorship clinic is a multidisciplinary clinic aimed at really meeting the patients where they're at at that point in their recovery and understanding their needs. And we have so we have, myself, the medical director, there's a physician's assistant who's a specialist in survivorship care, a social worker, a physical therapist and a dietitian. And we refer out to tons and tons of supportive services.
Tara Sanft: [00:28:53] But the idea is to really meet the patient where they're at, to understand what their goals are. So we ask them, just open ended, what's your top two concerns coming in today? And we try to tailor the discussion to that and then how do we make it so that we're helping you meet your goals, either by getting back to the gym or maybe starting in a gym or. Well, lots of patients have questions about their weight, weight gain, weight loss, weight maintenance or what to eat. What supplements should I take to prevent my cancer? Right. What do we endorse as a medical community for supplement use? There's a lot of discussion around that. And then, of course, fear of cancer recurrence. And it doesn't it's kind of regardless of your stage. So we think, oh, it's not a big deal. You had early stage cancer, but it is a big deal to these patients. And and how do they cope with that now? So it's like palliative care. It is palliative care. It's and it's supportive. The the whole person. And what I've learned after doing this for ten years, so many things from my multidisciplinary partners but it's a lot of this stuff needs to be moved into the diagnostic phase so that we don't end up with a completely different person at the end of treatment than when they walked in. We need to. So it really needs to be renamed as like the patient experience in my mind and which is what I'm doing now. But it's it's care of the whole person, not just the disease, but their spiritual, emotional, physical and mental life as well.
Tyler Johnson: [00:30:33] Yeah. You know, I recall as you're recounting all of that, that when I was an oncology fellow here, we had a sort of internally published Oncology Fellows handbook with chapters that were written by each of the faculty members about, you know, the very different various different aspects of being an oncologist. And so most of the chapters were each about a different kind of cancer. But there was one chapter that was about sort of just about oncology drugs in general, and it was called something like "Disabling Therapeutics and Potentially Fatal Remedies," right? Because because as an oncologist, that's the weird reality of what you do, right? I mean, this is getting to be somewhat less true in the era of immunotherapy and so-called directed therapies and whatever. But even there, there's still some resonance to it. But especially if you're talking about old fashioned cytotoxic chemotherapy drugs, really what they are is carefully titrated poisons. I mean, pretty much literally. Right. Honest to goodness, if you have certain kinds of hematologic cancer, we give you a carefully titrated dose of the active ingredient in mustard gas. Right. Like that's literally what it is. And in my world, I take care of patients with GI cancer. We give a medicine called oxaliplatin all the time that I know has a not insignificant risk of causing lifelong neuropathy that at best can be very frustrating and difficult for patients and in some cases can be disabling, leaves them unable to walk or unable to use their fingers for fine motor movements or whatever.
Tyler Johnson: [00:32:10] Right. And to, you know, to the point we try to have discussions with patients about the risks and benefits of the therapies that they're getting. But of course, most people, when faced with cancer, say, you know, whatever you need to do, doc, you've got to get rid of the cancer. Right? Which makes sense in a sense. But then it does leave people afterwards who have lingering long term problems that we don't have great answers for, and not to mention the existential questions about what does it mean to get a, you know, a surveillance scan or what does it mean to get my PSA checked or what does it mean to get, you know, whatever the thing is, it's or, you know, every time you're back creeks for five years after you have breast cancer, you wonder if it's your bone metastasis that you've been fearing or whatever. Right? Like, it's just it's a it's a very heavy load in a way that I think, to your point, used to be totally ignored. Now it's a little bit more top of mind, but I still don't think that we have great tools or training, most of us, for what to do with it.
Tara Sanft: [00:33:04] Yes. And that's where the field of palliative medicine, supportive oncology and think the approach to patient experience, just needs to be even more amplified. We we can't we have the treatments we have and they are what they are. And can we welcome patients into our care and say, no matter what, we're going to walk with you through this and we're going to believe what you say and think of ways that we might be able to maintain your health and address the issues that come up in a proactive way so that think, by and large, human beings understand that we can't make these treatments nontoxic, but can we create a culture of care that makes them at least feel seen and heard and understood?
Henry Bair: [00:33:55] So, you know, when I listen to so much of what you've said, I'm struck by a lot of the the hope and the optimism, general positivity that you see in some of these very challenging moments. At the same time, I recognize that that can't be 100% of the case. Right? I'm sure. I'm sure there are patients who, you know, don't do well, who don't respond well, who who are frustrated with everything that's going on. And I'd be curious to hear about what some of the most challenging aspects of your work are and how you navigate those challenges. Yeah.
Tara Sanft: [00:34:33] Thank you. You know, I think so. You're talking about patients who might be aren't responding to anything. And I have a patients like that. I have some right now that unfortunately, whatever we've tried has done very little to slow the progression of cancer. I don't find those cases particularly difficult because, again, I lean into the relationship with this patient and we're trying to do it together. And by and large, we are on the same page trying to fight the cancer. And and we're devastated and disappointed when each treatment doesn't work. But but that relationship is very important to me and keeps we keep going. I find what frustrates me more than that, or the burden of what we do is more in the tasks that take you away from the bedside. So it's really fun to be in clinic or very fulfilling. And there's lots of these special moments of interconnection. I if I could walk away at the end of the day and move on to the next clinic day, that would be amazing. But then I have to make sure I've documented all the things that we talked about and don't do that in the middle of the visit, by and large, because I find that to be I cannot multitask and type what we talked about and still be talking to the patient. It's hard for me to do that. So I find the culture of medicine, the stuff that takes us away from the face to face encounters very. Can be very frustrating and you have to build in some rest time and recharge time and vacation time and find other venues to. Get fulfillment. Because if I was in clinic all day, every day, I'd be writing my notes all night, every night and on the weekends. And that would be a no go for my patient, for my patients and my family.
Henry Bair: [00:36:30] So, you know, we talked earlier about how our culture doesn't like to think about mortality and death, because for a lot of people, these can be upsetting things to think about. And so I can imagine someone looking at the work you do and say, I could never do that. It's it's too much emotionally, I wouldn't be able to handle it. Are there moments when you experience something like that? It's like the emotional toll of your daily work gets too much to shoulder. And if so, what do you do about that?
Tara Sanft: [00:37:05] There have been a few times in my career where it's been... A lot. And I can think of one example in particular. I was on the inpatient unit several years ago. I was in breast cancer clinic. The day before I was supposed to be in survivorship on this particular day and a close friend and colleague was admitted under my care. And it was a serious situation. He had a GI cancer and he was bleeding. And we had known about this for a few days. We were trying hard to reverse the bleeding and on the morning on this morning, started to vomit blood. And again, it was. Right away on rounds. I was called into the room. We had a deep friendship prior to this and and he was actively bleeding and we were trying to have a conversation about going into the intensive care unit. We're staying on the floor. And we had initially decided to go to the intensive care unit. And as I was sitting there again, allowing for some silence and. And just being present. He said, What will this do? What is this going to do? And, you know, we had been talking a little bit about the seriousness of his disease over the course of his admission. And and ultimately, then he decided not to go to the intensive care unit and that he was going to stay on the floor and we were going to focus on his comfort and let his family be there. And he wouldn't be on a breathing machine. And arguably they weren't going to reverse the bleeding that day. We haven't been able to we hadn't been able to do it anyway at all.
Tara Sanft: [00:38:50] This was going to be the this was going to be the thing that ended his life. And I remember that was a very emotional and that wasn't the time that it was too much. It was when I walked out of that room and I got a phone call from someone saying, Hey, we haven't seen you in survivorship clinic much. Sort of implying like where you're out of sight, out of mind, you're not working that hard. And I sort of lost it because I had felt very like, I can't be now. Also at survivorship clinic, I've just witnessed my friend dying and making that decision with him to not be on artificial life support. And that was hard. I told the person who called me like, I can't, I cannot do this. You know, I tried to be open and transparent with my feelings at that moment. And I think that message was heard. And I tried to take care of myself and be very gentle that day and think back to that time. And I was exhausted. I had little kids at home. I felt very responsible for the health of my friend who was admitted. And that helpless feeling of not being able to reverse this terrible thing. So I have a lot of compassion for myself at that. You know, looking back. But in that moment, it was a lot. There was a lot going on and it was too much. And fortunately those big days only happen a few times in my in the last, you know, 14 years of practice now. So.
Henry Bair: [00:40:25] Thank you for opening up and sharing that with us. One of the things that you've mentioned earlier several times is the patient experience, and I'd love to know more about what exactly you mean by that. And I know that you are the chief patient experience officer of the Cancer Hospital. Can you tell us more about what that work actually entails and what your mission is?
Tara Sanft: [00:40:49] I told someone or someone introduced me once with this title and he said, Oh, just imagine a bunch of patient complaints that you're dealing with all day, every day. I guess I could see how people might think it's that, but fortunately I've been able to shape what this role is. I was the first patient experience officer for our cancer hospital, and why I wanted this title was to really focus on where the patient and provider experiences overlap. Again, mostly in the world of communication. When when complaints happen, it's mostly around the way things are communicated or the lack of communication. And, you know, we as doctors feel very badly when either someone communicates with us in a very negative way or complains about our communication when we think. That we're doing our best, right? We by and large, every day we are all doing our best. So really that work focuses on these. Logistics and nitty gritty of communication to try to maximize the chances that the communication will be a positive one or at least neutral and minimize negative communication experiences. And specifically, you know, we we have initiatives where we're trying to address communication about wait times.
Tara Sanft: [00:42:12] So weightings is somewhat inevitable. In oncology, we run a little bit behind, but how do we communicate about that weight? What can we do for patients to make that weight less uncomfortable? So those are things that are very important to me, and it's a place where the provider and the patient experience really overlaps. You know, there's a lot of complaints that come in about the parking garage, but we there's only so much we can do. We can't do anything about that. We don't even own our parking garage. So it's really focusing on a huge umbrella of things that patient experience entails is focusing on those things that we can control and the way that we treat ourselves each other and then the patients. So we focus a lot also about on how do we treat ourselves and each other and when do we recognize when the culture is one that needs to be more optimistic, more supportive, more positive? Can if we create a culture like that, will our work be more fulfilling? And that's really the type of stuff that I like to talk about and think about.
Henry Bair: [00:43:17] Culture change is just about the most difficult thing, and I think even more so in medicine, because I feel like physicians generally like to do what they've been doing for a long time. It's hard to change. So how do you try to shape that conversation, that cultural conversation? Yeah.
Tara Sanft: [00:43:34] I just was reading something recently that culture is conversation. So the you can say we are we are a culture of excellence. But if people are, you know, talking, venting about each other in the hallways, like that's your culture, right? There's the declared culture and then there's the real life culture. And what I've realized is if culture is conversations, then we have to start bringing up some of these topics that have maybe never been talked about before in order to get the conversation started. So, for instance, like just a few years ago, we were talking about vacations. We'd never once talked about how any of us approach our vacation life. Who covers for you? How do you are you checking your in basket or not? How do you. Who's who? Who do you sign out to? How many vacation weeks do you take? Are you able to take a vacation? Do you feel guilty when you're on vacation? And so sometimes just starting the conversation. Again can at least get people thinking like, yeah, maybe I do deserve a few weeks if if other people are taking. You know, four weeks off a year. Maybe I should plan ahead for that. And think sometimes sharing these stories make us feel less isolated and start the conversations that make the culture one of. Silence about all of this too. Like, yeah, no need. You know, we talked about this. Everyone needs a vacation. This is what we value here. We need that time. We have to have it. I mean, is this universal to to the cancer center that the culture has changed on this? Like, of course not. It's so slow as what you've talked about. But I do think bringing up these topics and really giving them some. Attention and understanding the perceptions of what's happening and people's real lived experiences is one way to start culture change. And then of course, leadership has to endorse this too. But it's hard to deny that taking time for yourself and your family is important now.
Henry Bair: [00:45:40] Yeah, it's hard to imagine another line of work where you don't talk about like what you do after work we do outside of work. How do you unwind? What do you take vacations? It's it's pretty remarkable. Yeah, well.
Tara Sanft: [00:45:55] Because we're not human. We're super human. We've been held up in regards to the society that we are heroes. I mean, it says that on our banners, heroes work here. So of course, you don't need to go to the bathroom or eat or sleep, much less like take your kids to Disney because you're a superhuman. And I think we honestly we've there's a little disservice to us in that regard. We are really just humans trying to take care of other humans and we really need to. Foster our human selves so that we can continue this work. Otherwise, we will resign or go into industry or retire early like we've seen in the great resignation since the pandemic. So we need we have to change this culture. It's the only sustainable, sustainable path forward.
Henry Bair: [00:46:48] Yeah, Yeah. We've been talking to several other guests recently about the epidemic of burnout. Everyone focuses on different aspects of it. You know, some people talk about the lack of that sacred space that we you know, we mentioned earlier in this conversation. Other people talk about the excessive administrative burden that doctors have to face. And then you're bringing in this other perspective about the way that doctors see themselves is actually exacerbating the problem and sort of pushing them in a direction that maybe is not so healthy for physicians. So I think it's really important that you are bringing this to light.
Tara Sanft: [00:47:23] Yeah. And certainly, you know, the system itself needs to take responsibility for the culture that it's contributed to. It's to their advantage for us to see extra patients all the time in service to the patients, right to be that superhero. And it can feel really good to give that. But I think we need to start understanding that our workforce is the most valuable thing that we have in medicine. And if they're not healthy, then it's going to be hard to keep the patients healthy. So it's not just in the individual to make sure they take a vacation. It's in the institution to create that culture and force those what we know from other sectors of society to be healthy, smart, actually profit generating practices like allowing your your employees to take time off to reset and recharge.
Henry Bair: [00:48:18] So what the last few moments we have here, I'd love to ask you about some advice you have for trainees and young clinicians. We've talked so much about your lifelong mission on better communication. What advice, what concrete specific advice do you have for clinicians working anywhere in medicine really, like not just in oncology, obviously, but any specialty? What specific advice do you have that they can apply today when they step into clinic about being better at at working towards that relationship with the patient they're caring for?
Tara Sanft: [00:48:52] Yeah, to me. So first of all, if you're in medicine and you're practicing medicine, you've already arrived to some standard of excellence to get into your training program. And I'm talking to doctors and physician's assistants and advanced practice nurses and nurses. Like it's these are, again, competitive fields that you have to meet certain requirements. With all of that is can be this inner talk about what is what is excellence and how you need to meet certain metrics to be excellent. And so I would challenge listeners to really take a step back and try to believe that you deserve to be here, that you've earned your place here and now. Is that critical self-talk serving you or is it maybe getting in your way? And and I'm specifically talking about self-compassion. And if there's one thing I think we could do better as as a medical culture, it's to be more compassionate towards ourselves. We give away our compassion to patients all the time. But what do we really say to ourselves when we're less than perfect again? We're humans, so we are less than perfect. And how do we nurture that and understand that in the moment to ourselves first? And and I think that's number one. Number two, you work with your team way more than you're in the room with your patients. So how how do the messages we send the team either written or verbal or, by the way, we roll our eyes or don't ask them about their lives? Like, can we sit with our team and give them the same attention and care and compassion that we give our patients? I think that the days go better for me when I'm with a team that I feel knows me and I know them and we understand each other. So those are two pretty concrete things to think and learn about self-compassion and then really think about how our compassion to our patients could be applied to our team.
Henry Bair: [00:51:01] Well, with that, we want to thank you again for your time, Tara. This was an enlightening conversation. So thank you for all the insights and the stories you've shared with all of us.
Tara Sanft: [00:51:10] It's my pleasure to be here. I think you guys are doing great work and thank you for inviting me to be a guest.
Henry Bair: [00:51:17] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.thedoctorsart.com. If you enjoyed the episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:51:36] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:51:50] I'm Henry Bair.
Tyler Johnson: [00:51:50] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.