Healing Begins With Feeling

[Intro melody into roundtable discussion.]

Juan Carlos: And welcome to the Baylor College of Medicine Resonance podcast. I am one of your hosts Juan Carlos Ramirez. 

Emily: I am your other host, Emily Xiao. 

Juan Carlos: Emily is also the lead writer for this episode. And today, we will be hearing from Dr. Niraj Mehta, on the value of humanity and Medicine, improving medical education, and the Art of healing.

Emily: Dr. Niraj Mehta is an associate professor at Baylor College of Medicine and has been a hospitalist at Ben Taub for more than 10 years. He completed his entire medical education and training at the University of Texas Health Science Center Houston. He was a full-time educator at the Lyndon B Johnson hospital for two decades where he received multiple teaching awards before transferring to Ben Taub hospital where he founded the birthday program and the physician-led physical exam rounds. Dr. Mehta is also the author of his memoir, entitled “Hopes and Fears, Dreams and Tears” in which he details his journey and lessons learned through medical school, residency, and life as an attending. 

Juan Carlos: Sounds amazing. I know when you, when you, when you mentioned Dr. Mehta, immediately I got a flashback to one of my like probably one of my fondest memories of internal medicine when he was leading those physician-led physical exam rounds and just I was just thrown away, I'm sorry, blown away by just like his grace and just how careful he was and how well-mannered the physical exam went and the patient was at ease in the learning experience and I felt like we were in this surrounded by his aura, you know.  

Emily: He definitely has some gravitas and I think we all felt it –(laughs)–. Patients felt it, and it's definitely an educational experience like no other that I've had. 

Juan Carlos: Yeah, so I guess when I, when I wonder like why you, I don't I guess I don't wonder, why you chose Dr. Mehta. But is there anything that sort of stood out to you?

Emily: I just think since we have an audience that has so many pre-medical students and medical students, it's so important to hear from a voice that really emphasizes the power that medical students have to be the first line advocates for their patients and to really be the future of medicine and to create new programs and create the future of medicine that they want to see. And I think no one really embodies that and practices by that more than Dr. Mehta. 

Juan Carlos: Yeah. It's like I think I uh, so I didn't do the birthday thing, but when I was reading through the, you know, the pre-Roundtable outline, I saw the cupcake man.

Emily: Yeah, so whoever happened to be on a service, which I was fortunate enough to do for three weeks, whenever there was birthday, he would get the entire and we would get we all sign a card, we would go get cupcakes or a piece of cake and we get a balloon and we would just go around the hospital to everyone who had a birthday and, you know, give him the cards, give them the balloon and the cupcake, and we would sing to them. And it was just, I mean incredible because who does that? No one does that in the hospital. It's such a really depressing place for so many of the patients. And their faces really would just light up, like they were so overjoyed. So many of them would cry, just tears of joy. There's always those few who are kind of just like, just waking up and we're like, what's going on? 
An incredible experience for everyone. 

Juan Carlos: That sounds very inspiring and very touching. I've never heard of anyone going that extra mile, right? For the patient. 

Emily: Yeah, which is kind of sad almost that this is, you know, such an exceptional thing. Out of the norm. But hopefully by amplifying, you know, the fact that projects like this to exist. It can motivate other people to start their own projects. 

Juan Carlos: That's very cool and I can't wait to hear it from Dr. Mehta. And I also did not know he was an author. 

Emily: Yeah, so he wrote this Memoir. That's just about, you know, his journey throughout his medical training and he gave us all a copy of it. When we finished our, you know, really long stint with him at Ben Taub, and, you know, I was reading it. He's very funny. There's a lot of poems, just a lot of stories, personal anecdotes, and I thought I'd be something really interesting to talk about as well. 

Juan Carlos: Yeah, that would be very interested. I'm looking forward to, to reading it, and if you haven't already, make sure you pick yourself up a copy of, of his “Hopes and Fears, Dreams and Tears” And I guess, without further ado, let’s have a conversation with this very inspiring individual. 

Emily: Yeah, let’s get into it. 

[Interlude Melody]

Emily: Thank you Dr. Mehta for joining us today, it’s a pleasure to have you.

Dr. Mehta: Thank you. Glad to be here uou you guys. 

Emily: Can you start by telling us more about yourself and how you chose to pursue internal medicine? 

Dr. Mehta: Sure. I grew up in Houston, Texas. You'll pick up from the Texas drawl pretty easily. Spent my whole life here since I was a little kid and wanted to be a high school English teacher, but that was a difficult conversation with Asian parents in the early 80s, and like almost all other kids back then, Math and Science was the standard outlet, and one thing led to another and I was interested in education and helping people. And here we are. 

Emily: Wonderful. And something I’ve noticed about your background is that you’ve pretty much practiced entirely within the Harris Health System, is there a reason that you chose this particular environment to practice in?

Dr. Mehta: Well, I think that we come from different backgrounds and when were exposed to different Hospital Systems throughout our medical school and residency training, we tend to have a kinship towards a particular institution or hospital. And for me, personally, it was Harris Health and wanting to take care of those that I felt had so much to give to this world, but in terms of health care, they had limited resources and I didn't want their outcomes to be affected simply based on the fact that they were in Harris's Health. Not by choice, but I actually wanted to be by choice to be able to say I'm proud of the care that I give at Harris Health. And that's why I chose to work within that system. 

Emily: Yeah absolutely, and I was just going to ask you about all these wonderful initiatives that you’ve pioneered within the Harris Health System both for the benefit of our patients and our medical students. The first being the physician-led physical exam rounds that we all do during our internal medicine core clerkship. Could you start by just telling us a bit about what those physical exam rounds are? And what inspired you to start that program? 

Dr. Mehta: Sure. So, I think that we have so much technology now that when we take care of patients, a lot of times the information that we get on a patient is on what the cat scan showed, what a consult team opinion may be, what an echocardiogram may show, and I felt that slowly but surely, we were losing the touch of spending time with individual patients. And the value of cost-effective diagnostics where I felt that physical exam rounds would add a valuable tool to taking care of patients. And a few years back I had to medical students on my service, Nathan and Evan, Nathan's actually going to be a GI fellow here at Ben Taub and at the end of the rotation, they really enjoyed the amount of time that we were spending at the bedside. And they wanted to formalize measuring a before-and-after initiative related to physical exam rounds. And then we were able to move forward from that using the JAMA Rational Exam Series as well as the Stanford 25 Model. And what I try to emphasize the most is not only measurable outcomes, in terms of cost-effective Diagnosticsdiagnostics, but what our learners and our patients get a sense of, with the time that's spent at the bedside, the sense of touch and the sense of healing powers that my doctor is spending time with me. And so far. It's been very exciting. 

Emily: Definitely. I think it says a lot that when you were leading these rounds it would take up a good amount of the patient’s time. You had pretty big groups of students with you. The fact that the patients were always willing to let all of us learn and be a part of our educational journey, I think really shows how much it meant to them as well. The investment into their care. 

Dr. Mehta: Yeah, absolutely. And I think that, you know, I try to teach my learners that the, the closest line of defense that we have to humanity and empathy and taking care of patients, is our medical students. And I hope that’s an art that never gets lost with all the technological advances, which we clearly need, but you're absolutely right. Our patients have been heavily involved and are very very appreciative. 

Emily: Yeah definitely. And speaking of all the technological advances in our education, what are some ways you wish modern day medical education could be different? Or gaps in our education that you see?

Dr. Mehta: Well, I think that the first and fundamental change that we need to have is to be able to ask our individual learners what do you think is working and what do you think are effective ways that we could improve what we're actually doing. A lot of times with medical education, we've been doing the same thing over a long period of time and/or the second aspect of medical education, that becomes difficult, is that we do a lot of theoretical teaching. Writing essays, classroom work, but we don't reflect on how that actually affects outcome at the bedside. And I think if perhaps we even asked, not only our medical students, but asked our patients because we're an academic institution, what would you suggest would be different in the way that your doctor spent time with you and otherwise. I think that that would be highly effective because we have all these surveys but how we actually measure patient satisfaction, I still think it's one of those holy Grails that you can almost gear, surveys, and questions to ask what you want to hear in return, but it's not necessarily the best way to measure a patient’s success to what their anticipated outcome should have been yeah. 

Emily: Yeah absolutely, I think that makes sense and should be common practice that if you want to best serve a population you have to ask that population how to best serve them. So, I mean, I think that makes complete sense and something that you've already sort of addressed, is the importance of that human connection in medicine. And something that I've heard you say a lot throughout my time working with you is that “Healing begins with feeling”. And so, I'm wondering what sort of experiences you had that led you to that motto. 

Dr. Mehta: Well, I think it started off with the idea of… I had a medical student back in 1998. If you remember the late 90s people were wearing these wristbands, “WWJD, what would Jesus do?”. And I actually wrote up an editorial and it was WWJD but J. Stood for Jason, who was my medical student at the time. And we had a very difficult patient, who had a complicated medical history, who required an amputation. And I'd spent over 90 minutes at the bedside trying to explain everything in detail to the patient and trying to obviously understand his point of view that amputation is no small task. And at the end of 90 minutes, he turned to Jason and he said, “well doc, what do you think I should do?” And I thought that Jason was going to collapse from heart rate variability thinking that perhaps he had overstepped his boundaries, but I couldn't have been more proud of him and it made me realize how important it is spending time. And when I brought Jason into my office and I said, “Jason, you know, he obviously trusts you more than the rest of us. What are you doing differently than the rest of us?” And he's the one who said, well, “Dr. Mehta, I do these things because I just simply think it's the right thing to do. I just feel it.” And that's sort of where I came in with the idea of healing begins with feeling. And a lot of times our medical students and residents, look up to faculty and so do patients. But I equally believe that it's a bi-directional street of education and that we learn equally from our students. And more importantly, from our patients who end up being our teachers, over the long haul. 

Emily: Yeah absolutely. And I guess on the flip side, have you had any experiences that challenged the conviction to empathy? Any really difficult patients or difficult scenarios when you kind of question how emotionally involved you are with patients? 

Dr. Mehta: Oh, absolutely. I think they're we deal with that every single day. I think the distinction that we have to make in time is the difference between lack of empathy versus professional disconnect. And in the field that we have all chosen to pursue. We do have to have some degree of professional disconnect. An act and to try to best understand what are the barriers to why we respectfully agree to disagree with each other, and then to learn from each other and be able to move forward. But I think that if we don't do that and we create this hierarchical structure of well, “I am the physician and therefore I‘m right. And you are the patient and therefore perhaps you don't understand with your cliche, Google MD degree. What's In your best interest”, then I don't really think that we change outcomes over the long haul. 

Emily: So how do you recommend balancing that professional disconnectc  enough with, you know, having that intimate therapeutic relationship with your patients, where do you draw that line?

Dr. Mehta: I think part of it comes from being able to have other avenues of decompression and asking others in the team structure, your medical students, your interns your residents, what their opinions of the individual situations are in terms of what's happening and then being able to take a step back and literally having a coach per say, being able to evaluate the situation at hand and telling you that perhaps in this situation, you're a bit too close and you need to take a step back. And I think it's hard to do when you're emotionally connected to taking care of individual patients and learners. You almost have to have a neutral party being able to provide you some feedback. 

Emily: Yeah absolutely. Something else I wanted to talk to you about was one of your other initiatives. You founded and led the Cupcake Man Project since I believe 2014. Can you tell us a little more about what inspired you to create that project and what that project is? 

Dr. Mehta: Sure. So, as you mentioned earlier, I've been privileged to have spent my medical school residency and faculty career all within the umbrella of the Harris Health system. And the first thing that we were taught when I was an intern back in 1993 by our upper-level resident, was on our paper charts to look at the patient's date of birth. And the reason we were doing that was not to celebrate their birthday, but we were looking to see when the patient may turn 65 years old, because there's limitations within Harris Health with diagnostics and therapeutics that we could provide but perhaps if they had Medicare or secondary insurance that were getting ready to kick in then we could change their outcome over the long haul. Well as it happened, when I was a third-year resident I was randomly looking at the chart having been taught that and it happened to be my patients birthday on that day. So, I don't know what got a hold of me, but I went to the cafeteria and just got a cupcake and brought him a cupcake to the bedside and said, happy birthday, and he said, “doc, aren't you going to sing?” And I got emotional the nurse, got emotional. Uh, back in the day, there were four patients to a room separated by a curtain. Other patients started to sing, and we sang Happy Birthday. And then as I started off, as junior faculty and 96 at LBJ, within the UT system and Harris health, I used to celebrate patients, birthdays individually on my services, but those were few and far between. And when I came to Ben Taub, I had a Eureka moment as part of my Baylor Master Teacher project to say, what do we all have in common regardless of our Political political affiliations or religious beliefs, our ethnicity, our backgrounds and it was the fact that we all celebrate birthdays. And I started to wonder how many patients were actually celebrating their birthdays in the hospital and how lonely it must be during such a difficult time to celebrate birthdays, especially if you're alone. And as we did a retrospective analysis and move forward, I started to measure out the idea of measuring empathy and could empathy be taught or was it somewhat just in you or not. And we started to look at the data from that and it moved forward from looking at the Cupcake Man Project and celebrating birthdays. 

Emily: Yeah, when I was on your service and you had us go running around the hospital with balloons and cards and cupcakes

Dr. Mehta: Yeah

Emily: It was such a positive experience. I love seeing the variety of reactions we got from patients. Some crying and filled with joy, other sitting uncomfortably not really knowing where to look or what to do

Dr. Mehta: Yeah –(laughs)–

Emily: But I think it's a very, very humanizing experience for both the patient and for us. Because for the patient that's such an isolating and sad experience to be in the hospital on their birthday by themselves. And for us, I think it's so easy to start to forget that the patients are real people. They're not just charts. And so celebrating a birthday with them, I think this is such a great way of- a great reminder for everyone that you know, we're all real people with these real feelings.

Dr. Mehta: No, absolutely, you know Osler said over 100 years ago, “It's more important to know what type of a patient has a disease than what type of a disease a patient has”, and the Cupcake Man Project is a reflection of really understanding an individual patient. We've celebrated over 1800 birthdays now at Ben Taub. And all birthdays are special, but the two that stand out the most in my memories is what I call the “book end” birthdays. One on the happy end and one on the sad end. On one end we celebrate a birthday where the mom is holding a baby in her hands and they both are celebrating a birthday together because she just delivered six hours earlier and that was amazing. And on the other hand, we look at every individual chart and make sure that we get patient and/or family permissions, and the situations are appropriate to celebrating birthdays. And on the other end of the book end we had a birthday where the family was waiting to turn off the ventilator on an ICU patient until it was his birthday. And to this day, I still keep in contact with that family and, you know, we couldn't hold back the tears on that day. As we got the family permission and saying, happy birthdays and exchange hugs, but yeah, it's been a very, very special and meaningful project for us. 

Emily: So this project has obviously been an enormous success, I'm wondering though, if to start this project, you encountered any obstacles. Did anyone fight back when you're trying to do this? 

Dr. Mehta: Yeah, it's funny that you ask that. So, when I started the proposal submission for the project, you know, there's a lot of moving parts. We had to get key stakeholders on board and when there's different institutions involved, it's always challenging. And in this particular instance, we not only had Baylor College of Medicine. We had Harris Health then within the umbrella of Harris Health specifically at we had Ben Taub hospital. In addition to that, we had to look at getting different parts of the project on board, which included Epic, which included the ability to have inclusion/exclusion criteria to be running the computer system every single day as busy as the Epic department is, to be able to say, we need a list by 3, a.m. every day of every single birthday in the hospital. We had to get Dietary on board to be able to say are there dietary restrictions obviously at Ben Taub we have a lot of patients with diabetes and other health restrictions. And then the logistics of helium birthday balloons and making the birthday card. So yeah, there was a lot of different moving parts and initially there was a lot of push back, the whole project took almost two and a half years to get from beginning to end off the ground. But when we finally told Administration that it would cost around two dollars and twenty cents per patient, they were on board from the beginning. And now that we've been doing it for almost seven years, the vendors cover the costs that of the cupcakes. We make all the birthday cards as part of the group building in-house with the patient relations department at Ben Taub. And we simply pay for the helium tank and the balloons. So, the current project cost is less than 30 cents a patient. 

Emily: Wow. I mean that's Incredible, I think we're all so fortunate that things were able to work out so well with all of your hard work and the hard work of everyone else involved with the project. So as someone who has now led created these two successful hospital-based projects. Do you have any advice for up-and-coming med students or young attendings of residents who want to start project of their own? 

Dr. Mehta: I think my biggest advice to medical students and Junior faculty is you know, you be you. Let the institutions and the world adapt to the individual gifts that you're going to bring to that particular institution. And that absolutely there are going to be barriers and challenges along the way but that if you're a square peg, you just need to look a little bit harder to find other square pegs instead of trying to find it fit yourself into that proverbial round hole, but it's doable. 

Emily: Yeah, absolutely. I think that you’re proof of that, that you can make it happen if you work hard enough and you really believe in the mission. Something that I wanted to loop back to that you mentioned a bit a go is the idea of empathy, and if it's something that sort of innate, or that's something that can be taught. In your Memoir, entitled “Hopes and Fears, Dreams and Tears” you have a poem in there that's entitled, “If” and I just wanted to read a brief excerpt from it. It goes, 
“if you could see through my eyes, you would not see diabetic retinopathy. But a grandfather 
who cannot see a baseball game with hisas  grandson. If you could hear what I hear, you would not hear aortic stenosis, but a woman who can no longer enjoy working in her garden. You think you see yet you are blind. Do you see what you have become? A cynical self-absorbed arrogant pawn... Hippocrates cried a tear today.”
I thought that the imagery and the language and that piece was incredibly powerful and something that really stuck out to me was I think the idea of cynicism and medicine as being something that's inevitable. Like no matter how pure your intentions are at the start, someday, you're going to become a jaded attending, you know, 30 years down the road. Do you think that there's truth to that statement or do you think that it's possible to really preserve that sort of like innocence and empathy throughout your medical journey?

Dr. Mehta: So I think it's a great question. I think there's truth to that statement and both ways, which is that. Yeah, along your journey, you are going to become jaded and you're going to become cynical, but I think that you will come full circle. For me, it was having my medical students and then more importantly, my two young daughters were grown up now, constantly reminding me that I wasn't all that I thought I was. And to keep me, well-grounded. And I think that, yeah, there is hope for medicine. And as I mentioned earlier, our closest line to everything that's wonderful and well in the field of medicine is medical students. And I try to tell my medical students every single day. Don't let us try to beat that out of you. And try to resist that and try to push back. Along the way, the things that you value and that you're chasing that you think are gonna define you and make you happy are not what's going to sustain you 30 years down the line. And the examples that are use is the MCAT score. The SAT scores at one time in our lives we thought it was a center of our world and now, we kind of just sort of reflect on it in passing. And I think what we will remember 30 years after you finish your medical school are those special patient encounters that you had at times difficult at times challenging, but that really will define you. Not the awards of the accolades that you're going together along the way.

Emily: Definitely. And speaking of the first line of defense being medical students, what are things that we can all do to build that empathy in that first line of defense? How we train that, cultivate that?

Dr. Mehta: I think the best way to train and cultivate that is to spend time with your patients. Just like if  any of us have kids, nieces, nephews or otherwise, what we value in any relationship this time that's spent. And that's something that doesn't require a lot. For a busy clinician or medical student who's always trying to multitask, get ready for board exams, getting ready to apply for residency programs or otherwise. It always feels like time is that most valuable asset. But if you sit down and spend time with your patients, you will actually understand how important it is for them to heal and the healing power of time and that sense of touch that we briefly mentioned earlier. And I think that that would be a very valuable asset. And to answer your question in terms of what could we do to cultivate some of those habits, it's basically surround ourselves with other square pegs who truly believe in that. And if we surround ourselves with people of equal value systems, we can't help but become what those other reflections are. 

Emily: Yeah, I couldn't agree with you more on that. I think it's really, really easy to have that sort of empathy and propensity for emotion with patients to kind of get discouraged really easily and really early on in our medical journey, you know. I personally had experiences where I express and empathetic statement towards the patient and had someone, you know, make a comment about how “you're not going to feel that way and five years” or “wait till you're at my age, you're not going to feel that way anymore.” And I think there's so much that all of us can do to just say words of encouragement instead and words of praise when students and other young learners are trying to build and train that empathy at all stages. 

Dr. Mehta: You know, I think you're absolutely right. And I think sometimes we forget what a stamp we put on our medical students and even our on our patients, with our words and our actions. And that they are constantly at times early on in their careers especially our students trying to emulate those behaviors. And once some of those imprintings happen, it's very, very hard to change that. And I think that's why it's very, very important to lead by action and by words and be role models. And as I mentioned earlier to also realize that it's bi-directional that we are as faculty members are constantly learning from our students and that our patients are our biggest teachers.

Emily: Definitely. So given all this conversation about what we can do differently to improve our education, to create better initiatives, to cultivate empathy in the future…what do you envision for the future of medicine? What do you hope to see happen in the future? 

Dr. Mehta: Well, what I hope to see is that in terms of the broad brush stroke of physicians, the physicians that I think are our biggest role models are the physicians who are out-patient based or clinic-based who are primary care physicians because as busy and as so-called unrewarding their job description may be and how difficult their situations may be with the high patient load, every single day. They are really spending time to learn each and individual patient and cultivate relationships over time. What I would hope is there for the future is that we have less of a disconnect between what we consider to be the inpatient world of medicine, the so-called sexy world of medicine 

All: –(laughs)–

Dr. Mehta: versus the outpatient grunt world of medicine. The difference between the subspecialty world of medicine versus the so-called gatekeeper world of medicine. And I think every single physician matters, just like every single life matters in terms of patient care. And I think that if we all work towards a team concept, then we can always perhaps aim to cure. But more importantly, aspire to heal and never forget that power of healing. 

Emily: And that's a future that I would love to see. So I think our time is slowly drawing to an end. Are there any parting words or words of wisdom that you want to leave our listeners with? 

Dr. Mehta: I would simply say that each one of us is here with a purpose and each one of us is unique and special in our own way. And I hope that in the field of medicine, if you’re a learner that you will never ever let a faculty member or someone else tell you otherwise. And if you are a patient that you would remind your healers of the extremely difficult and challenging job that he, or she has. But to be thankful to them, and then give them those bits of encouragement that all of us need so much.

Emily: Absolutely. Well, thank you so much again Dr. Mehta for taking the time to join us today. This was a fascinating discussion. I think all of our listeners will be able to take something meaningful away, and it's been a pleasure having you today. Thank you. 

Dr. Mehta: Thank you. It’s been my pleasure. Thank you very much. 

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