Why Palliative Care Means so Much to Dr. Tim Corbin, Ep. 11

A Life & Death Conversation with Dr. Bob Uslander

Dr. Tim Corbin joins the Integrated MD Care team. He shares his experiences as the Director of Palliative Care at Scripps Health and why working with terminally ill patients is so meaningful to him. Note: A Life and Death Conversation is produced for the ear. The optimal experience will come from listening to it. We provide the transcript as a way to easily navigate to a particular section and for those who would like to follow along using the text. We strongly encourage you to listen to the audio which allows you to hear the full emotional impact of the show. A combination of speech recognition software and human transcribers generates transcripts which may contain errors. The corresponding audio should be checked before quoting in print. Transcript Dr. Bob: Welcome back to A Life And Death Conversation. I'm Dr. Bob Uslander, and I'm here today with my good friend, Dr. Tim Corbin, who has recently joined the ranks of Integrated MD Care after working for many years in various capacities as a hospitalist, a palliative care and hospice physician. Tim, I'm excited to have you on the show, and I'm excited to have you as part of our team, Tim. Dr. Corbin: It's good to be here. It's been a journey to get here, and it's a really exciting future for me. Dr. Bob: Well, we've been talking about working together for quite a while now, and timing is everything. Just so listeners are up to speed on you and what you bring to our team, tell me a little bit about your background, your training, and the work that you've been doing up until now. Dr. Corbin: Sure. Well, I'm internal medicine trained through my residency and became board certified in internal medicine. I went into private practice for a few years. I had the romantic vision of being able to take care of my patient completely in my office at home, in the hospital. I realize in the changes of healthcare that that just wasn't practical. It became more difficult at that time to make a living doing that, believe it or not, with insurance changes, and the evolution of HMOs, and all those sorts of things. What I really loved, being in the hospital, taking care of patients who were facing more serious illness and ultimately became a hospitalist as that movement was developing, so spent over 10 years being a hospitalist and taking care of patients in the hospital. But all along I've been doing hospice medicine. There was just a part of me that identified with patients, and I saw that need, and it was very meaningful work, so always a percentage of my practice evolved around caring for patients on hospice and at home. Palliative care became one of the fastest growing specialties in medicine, you know, kind of in the last 10 years. Having done hospital-based medicine as well as hospice work, I was in a position to really gravitate towards that, and it really spoke to the style of medicine that I like to practice, and I again saw a huge need, and so began developing really hospital-based palliative medicine services, and started one in 2008, and then ultimately became the director of the palliative care service at Scripps Health for four or five years. Dr. Bob: It seems like you were in a really well positioned for palliative medicine, being internal medicine trained, having all that experience in the hospital, working with hospice. I think, like me, what you recognized was there's a gap, right? Dr. Corbin: Absolutely. Dr. Bob: There's a gap between treating people aggressively in the hospital and then sending them off to hospice, where the entire focus is comfort and essentially waiting until the end of life. There's this big gap there, where people still need more care. Dr. Corbin: Having done so much care at home, I think I would see in the hospital what patients were often missing. You know, they were receiving their care in the hospital setting, and I always thought about the possibilities of doing some of this at home, where patients prefer to be and can be more comfortable if we had the abilities to do that. That was clearly a huge gap that's been improving, but in my careers, that was a huge gap for families and patients, so I recognized that pretty early on. I always used to joke that hospital medicine, you know, being a hospitalist and internist, strengthened my care, caring for patients at the end of life, but the opposite was true. Me doing hospice medicine and caring for so many patients when they were dying really strengthened my ability to be a better doctor upstream, as an internist, seeing patients in a hospital or even in a clinic setting. Dr. Bob: So, can you expand on that a little bit? Why is that? What do you think that results from? Dr. Corbin: I think for myself, if I'm effective as a palliative care physician, I'm guiding patients through the process of end of life, if patients and families don't recognize that there was a possible issue that could have caused more pain, or suffering, or difficulty, but I've been able to help guide that that never becomes and issue, because I have kind of a prospective insight about what may be coming, and so part of it is a skill of anticipating when we may not have good outcomes or beneficial care and not providing care that doesn't provide that. The way you set what beneficial care is and what quality is is really having those conversations with patients and families so that you gear your care towards what best supports them as a patient and a person. Dr. Bob: Yeah. What they want, what their goals are. Dr. Corbin: What they want. Dr. Bob: It's so true. I think that most physicians who don't take care of people who are dying or who don't see them in their homes, the traditional office-based physician, really have no idea what those challenges are and what's happening with people once they're no longer able to come to their office. I don't fault them for it, but there's a certain amount of ignorance or just lack of experience. They can't anticipate it, which if they can't anticipate it, they can't do anything about it. ` Dr. Corbin: You can take a history and a social history and ask patients, but when you're in the home, and you see for yourself, you see aspects that will affect patients' medical care. Now we're getting in the realm of talking about the social issues and the emotional issues, even spiritual issues. You go in a house, and you can tell a lot about what's important to a patient, and you can immediately identify conflicts and what we're doing medically that don't align with that. Dr. Bob: Right. That don't support that. Sure. Dr. Corbin: In fact, many times I would say, "You know, let me come see you at home next week," and patients laugh out loud, or they're taken aback. They say, "Well, I can come see you in your office." I say, "No. I really want to come see you at home," because I anticipate that later I will need to come to their home–in a fair amount of time–but also, again, it gives me that insight, and there's something about being in a home environment, where you break down some barriers of trust. You can be open with each other to really talk about what's most important. I had a very elderly patient who had a lot of medical issues going on. I thought I was going to her home to talk about that, but her cat kept bothering us while we were trying to have our interview. What it came down to, one of her biggest stressors was, "What's going to happen to my cat? Who's going to take care of my cat?" These things were affecting her ability to make medical decisions about what she wanted and what choices she wanted because she was worried about who's going to help take care of her cat. Dr. Bob: If she were coming into your office, she probably wouldn't feel like that was worth your time, right, to bring that issue up. Dr. Corbin: Right. If I were really an astute clinician, I'd notice the cat hair on her maybe, and I would be able to ask those questions, but I'm usually not that good. Dr. Bob: The second part of that is that someone who's in the patient's home may see the cat, and the cat may come up in conversation, but they wouldn't really be so perceptive or be so concerned about that dynamic, so it's not just the fact that you're there. It's also the fact of who you are. Dr. Corbin: Too often what we see as important to physicians and clinicians is medically based. It's disease based. We don't often think about the social dynamic of patients and how that may affect their health and their decision making. I think that is so true in the hospital setting because patients become institutionalized. I mean, you're giving up your freedom in many aspects, because you become a patient, and you become a patient within a hospital that has certain processes, and rules, and you don't have access to your home. This is something that is tolerated, obviously, by many patients, and we give amazing care, but when you start having patients who that's not really the most appropriate place for them to be, then we have to start creating better solutions than using the hospital as a way to kind of take care of patients who really don't want to be there or don't need to be there. Dr. Bob: Right, or don't need to be there, or it's detrimental for them to be there. Let's segue into that. We'll go back and talk more about what you're doing now because you've made a shift, and you're no longer in that position of running the palliative care and hospice program at Scripps Health, much to many people's dismay over there and joy on our side. But I wanted us to talk a bit about the hospital experience, the gaps that people experience, the challenges, because me, having my experience of being an ER doc for so many years, seeing people coming in various states and conditions, you as a hospitalist, palliative care physician, hospice physician, I think we're in a unique position to help people understand some of the challenges and risks that they face when they are in the hospital dealing with complex illnesses. You can I could spend hours, and hopefully, we will, talking about the different challenges and gaps that people face and ways to help avoid being harmed by them. Well, let's spend a little time focusing on what happens in the hospital, what doesn't happen in the hospital, what happens when people are preparing to be discharged, and where are the gaps, and what can people do to help prevent any further turmoil or challenge? I mean, you mentioned when you're in the hospital, you're in an institution, right? You're in their territory, so you lose some of your freedoms. I think that people who work in the hospitals, they lose sight of that. I mean, they're busy. Everyone's working hard. No one's lollygagging around, for the most part. I will make generalizations. In general, I think that people in healthcare really do care. They really want to do the job, and they really want to take good care of people, so it's less of a personal personality issue, and I think more of an institutional system problem, that we just don't have enough staff. We don't have enough people to provide the kind of personalized, supportive care that people are looking for and need, and that's largely a financial issue, right? I mean, what's your perspective on that, having spent so much time in the hospital? Why don't people feel, in general, like they're well cared for? Or do you think that they do? Dr. Corbin: I think in many cases they do, and in many cases, they don't. I think one of my family members, in their personal experience, made a comment that in the hospital they felt like they were a cog in a wheel, where there's this path of workup, and diagnosis, and treatment that is on a course of, you know, kind of standard medical treatment that, again, a patient gets put into. A patient's in a bed. The physicians discuss having, "Well, we need to get a CT scan." It's ordered, and all of a sudden someone shows up to the patient, and they're whisking them to the radiology, and the patient doesn't understand why. When you sign yourself up in a hospital, you're signing yourself up and agreeing to the treatment that needs to be done for your particular issue. As physicians and clinicians, we're trained to treat that condition. You know, there's kind of a process and an algorithm to that, to a certain extent, and we don't often go off course. To not do something could risk missing a diagnosis or risk of there being downstream harm, and physicians are very sensitive to that, whether it's from the standpoint of malpractice or not providing a standard of care. The standard of care becomes doing everything, which is not always appropriate. It's not always beneficial care. I tell you, patients often recognize that, and they understand that and are willing to take that risk, if you will, so there becomes this disconnect between what the treating teams are doing and what the patients really want. The patients, it's not that they don't want to be hospitalized. They may say, "You know, I'm weaker at home. I'm 90 years old, but my quality of life's pretty good, so I don't mind coming in and getting treated for pneumonia, but I'm not really up for getting a bunch of CT scans and being poked and prodded and this sort of thing," so where is that balance? In many ways, it's the physician's job to cure and to treat fully, but we're not always taught how not to do everything, so I think patients need to recognize that. There are many times patients bring up the fact and want to have this conversation. So, in the last 10 year, palliative care teams have developed in the hospitals, which are multidisciplinary teams made up of physicians, and nurses, and social workers, and even chaplains to really address patients' emotional, social, spiritual needs, as well as their physical needs, but really it developed as a support team to help support patients with serious illness through the hospitalization, which is kind of crazy when you think about it. Our technology and ability to treat patients is so, you know, high tech and the ability to keep patients going and keep patients alive is so extended that we need support teams to help- Dr. Bob: To protect them. Dr. Corbin: ... to help fend off, you know ... It's kind of like the ability to turn off your cellphone and ways for patients to connect with you. It's very interesting when you start thinking about the ... I always joke that I hope I don't have a job as a palliative care doc one day because that means that our healthcare system is treating patients with the values and the principles of palliative care that we don't need specialists in palliative care to do this. I think we'll always need our expertise and specialty, but there's so much work to be done in that realm of taking care of patients holistically. Dr. Bob: So, a huge issue that we touched on is that when people are in the hospital, sometimes the care is appropriate, and then there are times when it just goes beyond what they would want or might seem necessary because that's just the way it's done. My sense is that it's the path of least resistance. A person is in the hospital. They've got a condition. Something else might be identified. Then they get a consult with the kidney specialist, and they get a consult by the cardiologist, and a consult by the infectious disease guy, and the pulmonologist. Everybody gets a piece of this patient. Everybody gets paid, but everyone's ordering the tests that they feel are appropriate, potentially the treatments that they feel appropriate, and then before you know it, there are six different physicians treating the patient, and they're now a week into it, and they've been tested and treated way beyond they may have ever wanted, because those conversations are not happening. Dr. Corbin: Let's think about each of those physicians who are seeing those patients, who are amazing clinicians, really good docs, want the best for the patients, want the best outcomes, so intentions are all perfect and good, but in today the chances that any one of those physicians has a long-term relationship with that patient is almost zero. We now have sub-specialists, who do nothing but round in the hospital for their group. We used to have just hospitalists. Now we have cardiologists that are hospitalists. We have GI docs that are hospitalists. We have neurologists that ... when you get admitted to a hospital, you have this new team taking care of you, and no one has had that relationship over time. If you, as a patient, have defined what is most important to you and what your true goals are for your life, what gives you dignity and respect, and how you want your life to go as you become sicker, no one has appreciation for that. That's one reason we have palliative care teams, because we sit there for three hours and try to understand this, so we can affect what we decide to do with patients. If you don't have those conversations, as my family said, you become a cog in a wheel, where we're going to treat whatever's going on as we do everybody, and there are tremendous pressures to then get you out of the hospital. You know, we always want a shorter length of stay. Dr. Bob: We do everything- Dr. Corbin: When I first started as a hospitalist, patients stayed in the hospital five or six days. Now it's down to below four days, three days average length of stay. Tremendous pressure to see patients, make a diagnosis, start treatment, and then get out of the hospital. So, you don't have the luxury of time to sit there and think about what you want, or you don't want, because people are coming up to you constantly saying, "We need to do this next and this next." So, it can be completely overwhelming. Families and patients get in a crisis mode. You know, I tell families and patients, "It's really not a good place, in a hospital, to be making life or death decisions, when you're in a crisis mode, where you're emotionally stressed. You haven't been sleeping well. Family's flying in from out of town everywhere, and you're being asked to make decisions that hugely impact what your future is going to look like. You really need to try to have these conversations earlier." Dr. Bob: Very critical information, the timing of that, when you do it, but a lot of times it's not being done. Dr. Corbin: Absolutely. Dr. Bob: So, we now find people who are facing this. They're in the hospital. They're being asked or kind of demanded to make a decision about what's next for them, which may mean going home with certain treatments. It may mean going home and being in hospice. It may mean going to a nursing facility. But they're being pressured, because of what you were just describing, where there's pressure on the physicians to discharge patients and get them out of the hospital quicker, which in some cases is appropriate, but it puts this new sense of time pressure on families to make decisions, and they're getting it from the hospital discharge planners, and the case managers, and now the doctors. So, what do you do? Dr. Corbin: Yeah. You started this conversation talking about gaps in care. I think the gaps are that, you know, our healthcare system's kind of in silos. You see your primary doctor. You go to specialists. When you're in the hospital, you have your hospital team. When you leave the hospital, you may go to a facility, like a skilled nursing facility, which has its own team. So, the patient needs to speak for themselves. We talk about healthcare now should be more patient-centered and family-centered, where the patient should have the autonomy in decision making to make decisions that are best for them, but they're constantly facing a new team. I once looked at social workers' touches on a patient who had cancer very early in their diagnosis all the way through to the end of their life, and they had five different social workers over the course of like a two year period. You know, they had a social worker, outpatient oncology social worker. They had a home health social worker. They had a social worker in the hospital. The palliative care team had seen them eventually, and they had their own social worker. When they ultimately went home on hospice, they had a different social worker. So, you can see that families and patients sometimes complain about having to tell their story again, because they're constantly having to tell their story again– Dr. Bob: Over, and over, and over. Dr. Corbin: ... and reiterate what's most important to them. You know? It's almost like telling my story fatigue. They just get tired of that. So, there are the gaps where there's not that support. Dr. Bob: The continuous support, the continuity. Dr. Corbin: And often it's about explaining to families and patients what their options are and how to be prepared for those things. It's much easier to do it when you have a little bit of time and space. It's very hard when you're told, "You need to figure this out within two days, because they're being discharged in two days, and we need to know if they're going to a skilled nursing, or are they going to go home with more support, or whatever the case may be." Then patients often, depending on what kind of support they need, they may ... For example, hospice, which is by definition for someone whose prognosis is estimated to be less than six months of life. With that, you get a hospice service, and you get kind of this comprehensive care that's paid for through a hospice benefit. It's great support. You have 24-hour care for nurses, a triage available. They can come to the home as needed. Medicines are often delivered to the patient. You have a social worker, physician's visit, do home visits. I mean, it's an amazing program, but it's for the more very end of life. I see a lot of patients who are kind of really I wouldn't say pushed, but one of the options is to go to hospice when maybe it's questionable whether they may qualify. It's questionable whether that's what they truly want. They're not maybe ready for that, but they get the support because everything else is breaking down, that they're kind of pushed towards that, and then patients get better because there's not another alternative. The alternative home is often home health, which doesn't give the same amount of support. If patients' preferences are to get home, one of the huge gaps is enabling patients to get home with the kind of support they need. By default, if we don't have that, they have to go to a skilled nursing facility many find it very difficult to participate, but they're supposed to participate with a certain amount of therapy. They prefer to be at home. You look at a healthcare system that's looking at ways to be more cost-effective and to give beneficial care. You know, you have a situation where patients prefer to be home. That's where they want to be, yet there's no infrastructure to support that, yet it's inexpensive care when you compare it to a skilled nursing facility, or you compare it to going back in the hospital, and yet we haven't, as a healthcare system, figured that out yet. There have been improvements there, but it's a gap. It's a problem. Dr. Bob: Yeah. I think one of the reasons that it continues is because the people who are making the recommendations and facilitating the discharge, physicians, discharge planners, case managers, they have a hard time thinking outside the box. They're looking at what is the most efficient. They're looking at multiple factors. They're looking at what's in the best interest of the patient, what's going to allow them to get the patient out most efficiently because they have pressure to discharge the patients, and then what they're familiar with. How do you facilitate it? Unfortunately, what's in the best interest of the patient or what's most aligned with the patient's goals and values drops down the list of priorities, and people, patients, and families don't know to question it. They don't question the doctor. When the doctor says, "You need to go to a nursing home," well, that's where you need to be, but many times, as we both know, that's really not what's in the best interest of the patient or the family, and so everyone continues to struggle. Dr. Corbin: We should always question, as patients and families, if possible, just not question, but understand. If I'm going through a test or if I'm being sent somewhere, you know, why? What's the purpose, and what is the outcome, and what's the endpoint? What is my goal? I often tell patient and families, "Let's understand who you are as a person, as a patient. What's most important to you? What gives you the quality of life and meaning? And let's align the medical care we provide and the support we give with those goals." It's approaching the patient from a completely different perspective than what we're really taught in medical school, which is really disease based, you know, history and physical, if you will. Diane Meier, who's a leader in palliative care, had a quote. I don't know her exact words, but basically, she said, "You know, palliative care is about matching patients' goals with the medical care we provide." Dr. Bob: It needs to be driven by that, and it's not. And patients still, especially the older patients that we get to take care of, they're intimidated. They don't feel empowered to question what's going on. They may, in some cases, and sometimes there's a family member who will stand up and advocate, but too seldom does that happen. We, I think you and I recognize these gaps. We're working towards trying to fill them in our way, in our community, but what I'd like to do is to give a couple of, I guess action items, a couple of things that people can do to take away from this discussion when they have a patient, a family member, or themselves admitted to the hospital who is then going to be discharged. What are the couple of things that we would recommend that people could do? I'll start by saying, in general, if possible, you should never allow a family member to be in the hospital alone. Whatever needs to happen. And I know it's not always easy. It can be very challenging. Sometimes it's costly, but when a person is in the hospital, they are sometimes sedated. There's the potential for medication errors. I had just a patient who was a 31-year-old woman, who was on pain medication for an intestinal disorder that made it so that she couldn't eat anything. She was being fed through feedings going through her veins. She got an infection. She was hospitalized. A well-meaning nurse, but a relatively new nurse, instead of giving her five milligrams of Methadone, gave her 50 milligrams of Methadone, which is a huge, potentially fatal error. Those types of things happen all the time. It's not just the errors. It's the feelings of loneliness, of isolation, of needing to get somebody to come in and help you get to the bathroom, to understand what the doctors are saying when they come in on their rounds, which could be whenever. People need advocates, and I will never allow a family member of mine to be in the hospital at any point without somebody there to advocate for them, so I would strongly encourage people to find a family member, friend, or even if you have to to pay someone to be there with you. Dr. Corbin: Yeah. I would agree with that. You know, things in the hospital happen fast. We used to round as a team once a day, get all our tests, round the next day. Now we're rounding multiple times a day on a patient. You'll round, get some tests. You'll round again in the afternoon. Things happen quickly, so for a family to get real-time information is challenging if you're not there. I also tell families, "You know your loved one best. What are you seeing?" Subtle confusion or changes in their cognitive abilities, which is very common when you're hospitalized, particularly when you're older, may be missed by someone who doesn't know the patient. If you treat that early, you can kind of help prevent some of that, so there are lots of reasons to have an advocate for a patient there, for sure. That's one of the risks of hospitalization. I mean, it's well documented, medical errors, and hopefully, there's been an improvement in protocols, but the reality is is that, again, you're institutionalized. There are processes, and as much as there are checks and balances to avoid mistakes, mistakes can happen that can cause harm. It's been well discussed in medicine as an issue in our healthcare system, as well as infection risks, and often hospitalization tends to lead to more treatment. One thing leads to another, so you have to define what your purpose is in the hospitalization. You may know this. What an ER doc told me once, "As soon as a patient comes into the ER, the first question I have, 'Am I sending them home, or am I admitting them?'" I mean, that's the first question they ask. You know, as a hospitalist, I would say, "Okay. When am I discharging this patient?" It was all about the discharge. It's, "What do we need to do to get the patient out?" That doesn't mean we're not concentrating on treating, but there's such pressure to get patients out. So, another thing of having someone be there with the patient, be an advocate, is really advocating for what the vision of the patient needs to be in transitioning out of the hospital, back home or wherever that might be. Dr. Bob: Right. You alluded to this, the experience and the perspective of an emergency physician, and I think another tip for people is really thinking about whether you need to go to the emergency room or not. Give some serious consideration to that, because when an elderly person or a person with complex illness ends up in the emergency room, it's far easier to admit them to the hospital than to discharge them. Whether that's in their best interest or will ultimately result in improvement, or the opposite becomes kind of secondary. Speaking from the perspective of a physician who worked in the ER for 20 years, when an ill or elderly person comes in, ideally we could assess what's going on, determine what needs to happen, and determine if we can safely allow them to go home, which is where they'd rather be, and in many cases that's the safest and best thing for them. But because that takes more time, energy, and puts more risk on us as a physician, the path of least resistance is to call the hospitalist and say, "I've got a 95-year-old who's maybe got a touch of pneumonia and a little fever," and they might fight you, because they don't want to do another admission, but you're going to push that. Then you're going to order all the tests and order all the x-rays to cover yourself. So, there are times when we pick up things, and that kind of a workup and approach is valuable, but there are many times when it's not. Dr. Corbin: Another thing for patient families to realize, is that most physician offices are open from 8:00 to 5:00, but it's often 9:00 to 4:00 or something like that. After hours, and weekends, there's more chance that you're going to have an issue off hours than you are during regular business hours. Our human bodies function or not function 24/7. But one question for patients and families is, "What do I do after hours or on weekends if I have a medical problem?" Unfortunately, by default, if there's an issue after hours, and if you have any kind of significant medical history with advanced illness, no one's going to take the chance that something is missed–so they say, "Go to the emergency room," or, "Go to Urgent Care." That's just what we do. We impact our emergency rooms. It's very expensive care. Most of the time, if you have significant illness, the ER doc's going to feel uncomfortable sending you home, because they don't know you, and it's complicated, and so you end up getting admitted. As a hospitalist, I felt I did a lot of admissions, which were unnecessary. If someone was there to coordinate care at home, and kind of have an oversight, and there was that plan of what to do if it was after hours. That's amazing thing of your service with integrated MD care is that someone who has that layers of care, you know, all this is kind of planned out, and you have that support, and patients are really satisfied because you're not just ... Patients aren't just being sent back to the emergency room, and you get, again, into that cog wheel of treatment, where many patients don't want to be, which is another point. One of the risks of hospitalization is when you go, the medical records, you know, your history, what's been done, there are often duplicated care. You get more imaging tests, and you get more workup that you don't really need. I really advocate for patients and families to take a medical history and have that with them. If you come with a full binder, no one's going to look at it or read it, so it needs to be kind of done by someone with some medical knowledge to very succinctly put the diagnosis and what treatment's been done, so it's well understood, because- Dr. Bob: A summary. Dr. Corbin: We just reinvent the wheel. Again, this new team takes over, and they're kind of obligated to do the workup, and it's probably, in many cases, already done. It doesn't seem like a big deal, until you're in that seat, or you find those tests to be very difficult to get through. You know, to go through an MRI, if you've ever had an MRI, it's not a fun experience. I've had one, generally young and healthy, and it was really tough. Imagine if you're in pain, or have more advances illness, or if you're elderly going through these tests. We don't think about it. We think to go to the hospital; you just do what you need to do. You get these tests, but we don't understand kind of sometimes the physical and emotional toll that that takes on you. Dr. Bob: It's very easy to order the tests, right? It's very easy to order an MRI, or a scan, or another blood test, but even just getting blood drawn, these people, the folks, they're sick. They feel horrible. Dr. Corbin: I used to challenge my ... I used to come in as an attending, whether I had residents or teaching. It was like day number seven of hospitalization, and they had the same blood panel every single day. I'm thinking, "What are you going to see in this blood test that may change what we're doing in management?" I mean, we get in this protocol where we stop thinking critically, and we just start treating patients as a process, and- Dr. Bob: Yeah. And a commodity. Dr. Corbin: It's easy to do. You referenced it earlier, about how when you work in that environment, it's comfortable to you. You know it. When you're not in it, it's over. I remember the first time as a medical student I walked into an intensive care unit. I kind of stood back, and it was just kind of a, "Wow." It was kind of overwhelming. Well, you know, when I was a resident, and I spent a whole month being an attending resident in the ICU, after that month it was ... Even after a month it became pretty routine, and all those bells, and whistles, and machines, and tubes, and everything else became kid of normal, which is kind of scary when you think about it, but you've just kind of normalize to that. We always have to back up and understand it. That's what's so hard to have these conversations with patients and families, to really get them to understand what things may look like as they make different choices about their treatment. I say, "There's no right or wrong answer about the treatment." I think patients need to understand their choices and make the decisions that are best for them, and then we try to support them in that decision. I think to have a good history available with you, be prepared with what your true goals are downstream, so you can share that information with physicians and teams, if you change different healthcare settings, and then really having someone that can really coordinate that care for you. If there's someone in the family that can't do it, and you have the means to have someone else or hire someone to help coordinate that care, just like having someone be with you in the hospital, there's no doubt you're going to get better care. Dr. Bob: Yeah. That's critical. Unfortunately, I think once you're in the hospital, it's hard for outsiders to come in. You might have that. So, for me, we do this high level of in-home care and become very intimately connected with our patients and our families. We do a great job of keeping them out of the hospital, because we are available 24/7, and we address things as they come up, and we really try to encourage people to not just rush to the hospital. In general, we're pretty successful at that, but sometimes people end up in the hospital. Even though I have this very intimate relationship and the patients want me and my team to be engaged, the hospital doesn't want that. They don't want outsiders coming in, and it's very difficult to get much information. I'm able to communicate with the hospitalists with some effort, but you can't coordinate anything. It's very difficult to influence the care that's happening, so you have to be able to work with the families, to spend some time with the patients, and allow them to become self-advocating as much as possible. Then get them the heck out the hospital as quick as possible, right? Let's talk for a moment about palliative care, because it really can add a lot of value to the experience for people in the hospital and save them from some future struggles and help guide things more in alignment with their values and wishes. Is palliative care available for every patient in the hospital, or how does somebody get a palliative care team to work with them and support them? Dr. Corbin: That's a very good question. Palliative care, first off, is really available to any patient at any time in their medical illness. It's a whole-person, holistic approach to care, where we address patients' physical needs, but also, as I mentioned, emotional, social, and even spiritual concerns, and try to align our care with what their true goals are for themselves, knowing that those goals may change with time. So it's a fluid situation. But it's really having those conversations and supporting those patients in that goal. It's a team approach, so it's a physician, and a nurse, and a social worker, and often a chaplain, and also maybe sometimes ancillary services as well, so it's a team approach as well. There's a lot of talk the last year that unfortunately palliative care, someone gets palliative care by chance. We know that palliative care is beneficial. We know it enhances the quality of life. We know patients like it. There's less caregiver stress. There's better end of life experience in death when that time ultimately comes. Patients can tolerate their medical treatments better when they have palliative care involved. We know all the outcomes look really good. Palliative care across the board is inaccessible to all patients in every care setting, and so it becomes who do you know? It's, "Oh. Well, I know my neighbor's Dr. Corbin, who does palliative care. Maybe you can call him," and so, oh, I get involved. It's kind of word of mouth and by chance, which is fortunate. Hopefully, in the future, we get palliative care across the spectrum. Palliative care started in a hospital setting, and now over 70% of hospitals in the country have some sort of palliative care team. For example, Scripps Health has palliative care team at all five or their campus and hospitals. So, patients in the hospital can request palliative care consultation. Usually, it's up to the attending physician, whether that's the specialist or the hospitalist, to request a palliative care consult. Dr. Bob: Can a patient or family request a consult? Dr. Corbin: It depends on the hospital. For example, at one of my hospitals, where I started the palliative care team, we made it so anybody could request a palliative care consult, family, the patient. It doesn't have to be from a physician. In that setting, we sent a nurse in to really evaluate the situation, to see what was happening, and then to talk to the attending physician and say, "Can palliative care ...?" But it was a real challenge, in the beginning, getting in the door. Dr. Bob: I would imagine. Dr. Corbin: In many ways, we're seen as a threat, or we do another layer of care that then can be seen as getting more complicated, but the reality is is that we're working through all these issues that really are not discussed. So, that's in the hospital. Most hospitals have palliative care, so if there's a desire to have palliative care if you ask. Often you can look online or read about the hospital, and they advertise their palliative program. The big gap is outpatient palliative care, so what happens to the patient when they go home? If they go to a skilled nursing facility, most likely they don't have palliative care. If you go home, most likely you're not going to have home palliative care, although there are some programs that exist now. There are different levels of what that means. So, if you've seen one home palliative program, you've probably seen one home palliative home program in terms of structure. Some are just nurse-driven. Some are just physician-driven. Dr. Bob: Or physician assistant, but none of them have figured out the model so that they can really deliver. Dr. Corbin: And the barrier's really been about reimbursement, who can pay for that. Unfortunately, that hasn't been figured out. There are trends now with private insurances, as well as possibly even Medicare, starting to pay for kind of more home palliative kind of bundle payments towards that, which will hopefully gain more access. Dr. Bob: Apparently Medi-Cal, which is the California Medicaid program, as of January 1st, is now paying for some version, some form of palliative care. Dr. Corbin: I know Blue Shield of California is paying for home palliative services for some of their patients they identify that need that. So, the other is outpatient palliative care in clinics. Now that's the third tier, so it's been kind of hospital-based, an attempt to do more home-based palliative care, and now actually doing even farther upstream where patients in a clinic setting can get palliative care has been pretty rare. I started an outpatient palliative care clinic at Scripps, which we ran in a radiation oncology center, which is a great setting, and I saw patients in the clinic just to kind of see patients kind of farther upstream. The powerful thing of that is that we were having these conversations not in the hospital when you're in the crisis mode. Because what happens? You can have all of this great plan and this great conversation in the hospital and know what you want to do, but as soon as the patient leaves the hospital, it all falls apart, because there's not the infrastructure or process to support it. You go back into the same process of delivering medical care that we do, which is going to your primary office, going to your specialist, and after hours, if you don't have availability, you go back to the hospital. How do you break that cycle? Dr. Bob: Your family was trying to figure out how to find the right resources for you. Dr. Corbin: So, seeing patients in a clinic upstream is extremely powerful. I would encourage patients with any non-curable illness, whether that's heart failure, or early dementia, or Parkinson's Disease, or an advanced stage cancer,–even if you're getting full treatment, you expect to get treatment, your illness will hopefully be well controlled for years to come–still you should have a palliative care type conversation with a physician or a team that understands the longterm vision. One, you start to have conversations that you don't want to have in crisis mode, or you don't want to have way down a couple of years from now when you're being admitted to the hospital. That's not the right time to have these conversations, to really, truly know what you want. It also relieves this burden. It's always the elephant in the room, you know, what do I truly want, and having these conversations. Frankly, having conversations about death, and what it may look like, and what your preferences are if you do that, it's not threatening when you do. If you do it when death is a real possibility– Dr. Bob: Death is looming. Right? Dr. Corbin: ... it's incredibly frightening and overwhelming. Dr. Bob: For everybody, including the physicians. Dr. Corbin: Including the physicians, so by fault, we don't have that conversation. So, the patients that can have these conversations, and they want ... Studies suggest that patients want to have these conversations. Dr. Bob: And experience would confirm that. Dr. Corbin: We just don't do a good job, as physicians or clinicians, having those conversations. We just don't want to have the conversation. Palliative care in the hospital, there is some in the outpatient clinic. For myself now, I have two days a week where I do outpatient palliative care, where I can see patients in a clinic setting. I'm working within an oncology group, but I'm open to more than just oncology, so if patients know about me, they can come and see me. The purpose is to say, "Hey. What's going on medically? What's going on in your life? Where are your stressors?" You know, I ask patients, "How do you feel your quality of life is? What is your distress? How are you sleeping? How are you eating? What are you eating? How is your nutrition? All of these are things that we generally don't talk about with patients. But it's all about how can we identify things that are important to you? I had a younger patient, with advanced cancer who, after a long conversation, two things in her life were missing. One, the ability to still do yoga, and two, she had some experience with acupuncture, and she was interested in trying that again, but she was kind of bummed that she tired and couldn't do yoga anymore. Through connections, and friends, and again, palliative care by chance, I called a couple of friends, and one goes once a week now to help her do restorative yoga, and another goes once a week to do acupuncture. She's just thrilled. She's thriving. Her tumor markers are decreasing. She's responding to her chemotherapy. Her sense of wellness is much better than what it was before. She has hope. She's confident. She's living with her cancer better. I guarantee you in a normal healthcare environment, that would never come up. If she didn't seek palliative care, no one would ever have the conversation about setting her up with home yoga or acupuncture. It just doesn't happen. Dr. Bob: It sounds like a great concept. I kind of wish I had thought of that. Dr. Corbin: And you did. You know, what you do, the services that you can provide through integrated MD care, for example, the music therapy or aromatherapy, or massage therapy, or acupuncture, many patients don't think about that being important, but it's incredible how that can help you tolerate treatment better, reduce stress, take away some of the fears that you have. Ultimately we're deciding what are you afraid of. Is it what's coming tomorrow? Do you make up a story in your mind of what your future's going to look like, or you make decisions based on that fear, or you have conversations about that? Do you understand the facts medically, from a physician and have someone who can tell you, "This is most likely what will happen, and there's evidence to support that,"? And you get rid of this stuff we make up that scares us, and then you start to trust yourself. You start to trust life to give you what you need, and patients start to respond to treatment and can tolerate things at a whole other level. Dr. Bob: If those things that would enhance your life, and those people, and those therapies are presented to you and through trusted sources, and you open yourself up to them, I've seen, as you are expressing, I've seen tremendous, tremendous transformations in people. I've seen people, who had a prognosis of a month, and they were being told that they've got a month or six weeks to live, open themselves to receiving these therapies and ultimately live for a year and a half with an incredible quality of life. The reason for that, it's multifactorial. Part of it is the actual therapeutic benefit. A lot of it is just this connection that happens with life through other people, who are there to reach into your spiritual being, to help bring out the joy. So, that's a powerful, powerful thing that there's really no way to really put any kind of value on. Dr. Corbin: It's really taking your life back from whatever disease you're dealing with. You think about it, you know, you're whole day. I saw a patient yesterday who wanted to come to my clinic, but he said, "You know, but every single day I have a doctor's appointment for the next two weeks. I don't know if I want to come see ..." I mean, your life revolves around testing, and diagnosis, and treatment, and you lose the things that were important to you, like yoga and massage therapy that you used to do. Dr. Bob: Or time with your grandchildren, or time at the beach. Dr. Corbin: Or time to read or whatever. So, if we can challenge patients to make space for that and to remain who they are as a person through their treatment, it's invaluable. You know, unfortunately, I was never taught that in medical school. We're not taught how to take care of that aspect of patients. It's been, you know, over 20 years since I've done that. I think the medical education system has responded to that in many ways, and it's getting better, but the reality is is that we don't ... We talked about this earlier. I'm taught how to do a history and physical, and the things that I ask in my social history, like, "Do you smoke? Do you drink?" You know, those sorts of things, but I'm not taught, "What is most important to you? How is your stress level now? How is your nutrition?" We just don't ask those questions. Dr. Bob: Yeah. Certainly not, "Where do you want to be when you die? Who do you want to be around you?" Because for me, and for you as well, the idea is starting with the end in mind. If you can get people to share what that experience, how they would like that experience to be, it tells you a lot about who they are, and then you can help to guide all the care that happens. Dr. Corbin: That conversation intertwines a lot of spiritual, religious, philosophy, all of these things, right? But it's not about that conversation. I mean, I can have a very religious person or a very spiritual person who still hasn't truly thought about the way they want their end of life to look like. Sometimes who I think might be the most religious or spiritual person struggles the most with that decision, because they haven't thought about it in the context of that. No matter what your belief system is, no matter what your support system is, if you're challenged to think about it, it's an exercise we should all do. Dr. Bob: And people will often spend a lot of time thinking about how it should be for others and what they're comfortable with, and what they believe. But it's very difficult for many people to actually go down that path and take it to the point of imagining and trying to identify what's most important for them at the time of their death. Dr. Corbin: So, we've covered a lot. Dr. Bob: Yup. Always. Dr. Corbin: We've touched on a lot of issues. I think, hopefully, this is really valuable for people to get some real, heartfelt discussion from physicians who have been right in the fray. Right? I feel like we have a kinship here. We both love medicine. We both love medical people. We have a lot of respect for the passion, and the heart, and the compassion of healthcare providers. We're sensitive to the fact that they are often working in environments that don't allow them to practice optimally, and it gets very frustrating and discouraging. We see how wonderful the medical technology is and what it can do for people, and at the same time, we see how that has created this propensity to use that technology, and wield it un-responsibly, and neglect sometimes what's really and truly most important to people which can be to encourage them to take a different path. Dr. Bob: We have a lot of experience. Hopefully, we've shared some things for people to think about, and I think we're going to have lots of opportunities to continue exploring, discussing the pros, the cons, the good, the bad, but I'm excited, because we, in our practice, get to fill the gaps. Dr. Corbin: Absolutely. Dr. Bob: That's why we started Integrated MD Care. That's why we're doing this podcast. That's why we're doing a lot of the things is we're responding, we're taking a risk, right? Dr. Corbin: Absolutely. Dr. Bob: We're stepping outside the norm, and we're facing some folks who don't quite understand what we're doing, how we're doing it, or why we're doing it, but I think we're both committed to the process and to serving people at the highest level. Dr. Corbin: Absolutely. I agree. At the end of the day, we need to listen to the patient, keep the patient in the middle, provide patients with the best quality and beneficial care, and that really comes from talking to the patient and understanding what gives them the most value. That's what it's all about. Then we need to help continue to push our healthcare system to give the infrastructure to support patients with that. It's really exciting to see the work that you've been doing, and the outcomes that you've had with patients and families and really helping patients be able to transcend those gaps to get the perfect alignment of care that they deserve. You know? And making it not about palliative care by chance or this type of care by chance, because someone happens to know you, but really hoping things like this podcast will start to trickle out there, so patients are aware of what is available. Hopefully, we'll push the expectations higher, and our healthcare system will start responding to that. Dr. Bob: Yeah. That's our goal. Dr. Corbin: Look forward to it. Dr. Bob: In the meantime, we're doing it, and we're letting people pay for it, to recognize the value that they receive. The non-profit foundation that's just been created, Integrated Life Care Foundation, will help to provide funding for people to receive this level of care when they don't have the resources to do it. I'd like to now officially welcome you to the Integrated MD Care team, as one of the providing physicians and one of the leaders of this movement. Dr. Corbin: I look forward to it. A lot of work to be done. Dr. Bob: Absolutely. Thanks for coming on the show, and we'll be connecting again soon.