Outworker
Stories of healing, personal development, and inner work. Founded on the idea that the relationship with oneself is the most important to develop, but the easiest to neglect, Outworker shares conversations aimed at helping you develop that relationship.
Outworker
#067 - Dr. Ronald Epstein - Why Mindfulness Is The Key To Healing In Modern Medicine
Dr. Ronald Epstein shares how decades in medicine and mindfulness taught him that self-awareness is the foundation of healing—not just for doctors, but for patients, too. He explores why detachment is often mistaken for professionalism, how curiosity fuels care, and how moments of presence—even during medical crises—can restore humanity. Along the way, he reflects on medicine’s discomfort with the word suffering, and how naming it can be the first step toward real healing. From the limits of cure to the reach of healing, and from meditative breath to medical crisis, this conversation examines the soul of medicine and the path to becoming a truly mindful physician—one who listens more deeply, connects more fully, and ultimately cares more humanely.
Timestamps:
00:00 Relationship With Self
06:24 Medical School Isn't Intellectually Demanding
10:46 Dr. Epstein's Impactful Med School Experience
17:07 Medicine & Mindfulness
24:30 Detachment Between Physicians & Patients
32:26 Impact Of Personalized Care On Physical Health
37:35 Curiosity Having A Negative Connotation In Medicine
42:34 Philosophy On Emptiness
46:54 Suffering Is Off Limits In The Medical Space
57:10 Certain Practices Still Seen As Radical
59:01 Who's Actually In Charge Of Changing The Medical System?
1:04:03 What Individuals Need To Do To Get The Best Care
1:08:54 Connect With Dr. Ronald Epstein
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What’s up outworkers. Dr. Ronald Epstein shares how decades in medicine and mindfulness taught him that self-awareness is the foundation of healing—not just for doctors, but for patients, too. He explores why detachment is often mistaken for professionalism, how curiosity fuels care, and how moments of presence—even during medical crises—can restore humanity. Along the way, he reflects on medicine’s discomfort with the word suffering, and how naming it can be the first step toward real healing. From the limits of cure to the reach of healing, and from meditative breath to medical crisis, this conversation examines the soul of medicine and the path to becoming a truly mindful physician—one who listens more deeply, connects more fully, and ultimately cares more humanely.
Tim Doyle (00:06.189)
The guiding idea for this show is that the relationship with oneself is the most important to develop, but the easiest to neglect. And I always use that as the North star for the people that I want to have on the show and talk with and always just living up to that ideal of having conversations that I really believe are helping people develop that relationship with themselves. you have a very, very
similar belief system when it comes to the medical system and how doctors can become much better doctors and you believe if doctors need to understand their patients better, they need to start by understanding themselves better. When did you first believe or when did you first begin to have an appreciation for this idea?
Ron (01:02.67)
boy, I think it really evolved as I was considering medicine for a career because I had long valued the value of knowing oneself, even as a teenager. was something that I thought was important and I sought out friends who also thought that was important.
became interested in psychology and meditation and various other ways of travel, I mean, various other ways of getting to know oneself in various contexts. So I think it kind of evolved with me. then in my, I didn't take a very straight path to medical school. So the first thing that I did seriously during my teenage years and in
in college was music. And it's kind of implicit in music. If you don't know yourself, you can't express yourself. So there is, you know, it's kind of part of the education of musicians is to not understand your feelings by naming them and analyzing them, but being in touch with them. And that just taking a purely rational approach to life is rather impoverished.
And so.
And I would say I wasn't ripe for considering medicine until I had spent time at a Zen monastery, until I spent time hitchhiking around the world. Just things, I spent time driving a taxi cab in Manhattan at night. mean, just these kind of worldly experiences that whether they're pleasant or unpleasant, they certainly help you develop an appreciation for the complexity of the world. So I...
Ron (03:02.72)
I started medical school at age 25. Most people started at age 21, 22. So those extra years for me were really important.
Tim Doyle (03:14.061)
Yeah, your core makeup really isn't a doctor. You have a very diverse background and a very diverse set of experiences and you're really a creative at heart. And you've talked about how those sentiments really manifested when you did get to med school where it felt like that environment felt very unnatural for you. How did you navigate that entire experience?
Ron (03:41.256)
I'd like to just make a small corrective in terms of what you said. It didn't take me long to fully inhabit the role of being a doctor. So I do feel that I do inhabit that for better and for worse. mean, are, but not long, I would say five or 10 years after finishing my training. I don't see that as a long time. But I think that...
I think contrary to popular belief, medical school is not, it's cognitively demanding and it's exhausting, but it's not terribly intellectually demanding or emotionally demanding unless you want it to be. you know, I just think it's possible at least during the initial parts of medical school to the classroom parts is to not be very,
deeply in touch with suffering. Of course, when you hit the wards in the hospital and all that, then suffering is kind of staring you in the face. But I think it's possible.
But I think because, and I don't say that I'm alone in this. I mean, I had classmates who had done really diverse and interesting things prior to medical school. And some people who hadn't, who just seemed to have a kind of innate wisdom about the human condition. But I think it's that wisdom that you bring with you to medical school that's pretty important. Because now I think things are better. But when I was a medical student, there wasn't...
at least in the core culture of medical school, there was a lot of knowledge, but not a real lot of wisdom. And you kind of had to seek it out. It wasn't made accessible. There were plenty of wise clinicians and researchers that I worked with, but finding that was difficult. There wasn't a path. So I think part of it is you have to know what you're looking for to find it.
Tim Doyle (05:51.597)
Any ideas for why you think that's the case, where it's not naturally set up to be intellectually demanding as well?
Ron (05:58.062)
Well, there's a lot to remember. There are a lot of words to learn and there's a lot of procedure to learn. So, you know, the curriculum could easily get crowded with the technological and informational aspects. And again, I'm talking about the 1980s, which I think was the 70s, you know, probably when that was...
maybe at its worst because technology was exploding so rapidly. And we didn't have access to things like computers and smartphones and everything had to be committed, read on paper and committed to memory. And I think the things have actually gotten better in that regard because we do have those mind extenders, those things that can help us not have to remember.
every single bone and its attachments in the body. you can say, people just say, well, look it up if you need it, or if you become an orthopedist, you'll need it. If you become a neurologist, you might not. But I think that was that, and also there was a time of incredible biomedical reductionism. There was a sense that if we only knew the molecular basis of everything, we could cure everything.
I'm kind of parodying it, but I think there was really that mentality. And of course, we've learned otherwise that life is a bit more complicated than that.
Tim Doyle (07:30.477)
Has the medical system, has the med school curriculum evolved at all to include more subjective courses in academia where, okay, we're focusing more so on ideas and thinking rather than simply just information or largely speaking, do you think it's still a lot of the same?
Ron (07:51.79)
I would say both, that there's a lot of the same and a lot of things that are really pretty remarkably different. And that was part of my impetus to go into teaching and research was to try to make things different. And so, some of the mentors I have were really pioneers in that domain of really studying the human dimension of medicine. It almost sounds like ridiculous to say the human dimension because
medicines about humans, but that was a real reaction to the biological reductionism, which really tended to focus more on molecules and cells and organs rather than whole human beings. And so I do think it's changed. For example, medical schools all teach something about communication skills. They all teach something about ethics. They all have some programs that
talk that helps students navigate just how to sustain themselves in a career in medicine, how not to burn out, how to develop joy and passion for what they do. So I think that has changed. And in a way, I feel honored to have been part of that change. And also, I think the timing was right because there were a number of people
with similar kind of restlessness and passion when I started doing the work that I do.
Tim Doyle (09:28.269)
You had a core experience in your third year at Harvard Med that really set you on the trajectory for exploring a lot of the ideas that we've begun to talk about here. Can you talk to me about that experience?
Ron (09:43.788)
Are you talking about the one in the operating room? Yeah, OK. There were actually several. so that was a real awakening for me. Surgery was one of my first rotations during the third year. Third year is the clinical year where you spend time in the hospital. And so there I was, a naive medical student, never having been in a surgical setting before. And I was all eyes and ears.
Tim Doyle (09:45.89)
Yes.
Ron (10:14.597)
I subsequently learned that the questions that medical students ask are often some of the best ones because they don't have assumptions about the way things should be. So I was kind of in that eyes and ears space and I was in the operating room with a urologist, a surgeon who does surgery on kidneys. And this was, the patient was a young man, probably 18 or so, 20.
who had developed testicular cancer. And testicular cancer tends to spread to the lymph nodes that are in the back of the abdomen near the kidney. And so this surgeon was very carefully kind of had the belly open and was removing all the lymph nodes that he could find to see if they contained any cancer. And that was the treatment at the time. Now,
with MRI scanners, you don't have to do that all the time, but that was the treatment. And it's very delicate work. And so he was dissecting around one kidney and finished and then went to the other side. So we switched sides of the table so he could see the other kidney. And I was opposite him so I could see the kidney he had just dissected. And I noticed that it was beginning to turn blue. Now, kidneys are normally pink, healthy tissue.
and blue generally isn't very good. It means the blood supply is cut off or something bad is happening. And that much I knew as a medical student that pink was good and blue was bad. I mean, that's kind of basic. But what I didn't know were the rules of decorum in the operating room, which I violated. I said to the doctor, know, gee, I'm noticing that that kidney that you just worked on is looking a bit bluish.
I don't remember the exact words he said, but it was something like, up, Which I can kind of relate to. Here's this guy, Harvard surgeon, very experienced, well known. So I didn't fall until I wasn't falling into line. But I noticed that the kidney was beginning to turn a dusky purple after a while. And so I mentioned something to the scrub nurse next to me.
Tim Doyle (12:16.109)
Fall in line.
Ron (12:33.998)
who could also see that, and she was an experienced nurse, and who then mentioned it to the intern, who was the surgeon's assistant, who was standing next to the surgeon, who then mentioned it to the surgeon. And again, those words I couldn't exactly hear, but then the surgeon, like, he turned a color of white and became obviously agitated and upset and tried to untwist the kidney because it probably had twisted itself and cut off the blood supply.
unsuccessfully and I'm called in a vascular surgeon urgently to try to open up the blood vessel which after a period of time which seemed like hours which was probably just you know 45 minutes or an hour finally restored blood flow to the kidney and I felt somewhat culpable in not kind of speaking up more loudly and sooner.
So the next day on rounds, I was with that same surgeon and the intern. And the surgeon explained to the patient and his mother who were in the hospital room that an unavoidable complication had occurred. And I was really struck with the word unavoidable. And
You know, what it raised for me were several things. One is that we see the world as we are, not the world as it is. And I'm not the first to say that, you know. And that surgeon was seeing the world in terms of inevitability and lack of culpability, or at least he was projecting that. I was seeing the world through a missed opportunity,
evaded responsibility, and also a sense of guilt and complicity on my own part. I ultimately spoke to the chief of surgery because I myself wasn't sleeping at night because of this. And he assured me that I had done everything right, I had done nothing wrong, and that he personally would speak to that surgeon. I never knew the outcome, nor did I have the right to know the outcome, but...
Ron (14:59.0)
But for me, it was a real awakening in terms of how you see the world. He was really unwilling to acknowledge that something that he had probably done hundreds of times before had gone wrong. And, and.
So that, you know, it was also an era in which probably the worship of physicians is kind of putting them on a pedestal was much more common than it is now. I think doctors have kind of fallen into their place a little bit more and maybe in the public eye, you know, anyway, that's debatable issue, but nonetheless, it...
Tim Doyle (15:44.362)
That's interesting. Do you mean from the sense of like can do no wrong basically?
Ron (15:48.256)
Exactly, exactly. Yeah. And of course, now there's suspicion. There's probably too much suspicion. So there has to be some kind of balance. But it was also a lesson to me that if I'm going to really do my job, I have to be willing to look frankly at a situation and see the possibility of my making a really pretty embarrassing mistake or a really pretty devastating mistake happening on my watch.
and having the emotional fortitude to accept that that mistake had happened and still maintain the ability to function.
Tim Doyle (16:29.859)
So at that time, did you already have a strong sense and understanding of these concepts of mindfulness and mindlessness, or was that kind of like you kept progressing in your career, kept understanding more, and then it was more of a reflective process for you?
Ron (16:46.796)
I had a sense of what it was like to feel self-aware because I had a meditation practice and also I think I was just kind of a reflective person. But contextualizing that awareness into the role of a physician was something that I had to grow into.
The word mindfulness really was not part of the lexicon in those days. I actually met John Cavits in when I was a first year medical student in 1980. And he was just starting his clinic and hadn't written his books and or maybe had written one book, but, you know, it really hadn't taken off. And so it was really in the 90s that the word mindfulness really entered the public lexicon, but was still
far outside the medical lexicon. But in my training after medical school, I was fortunate to come to Rochester, New York, which had a very psychosocially oriented family medicine training program. And in the process of all that, I came across the work of
a person named Michael Ballant, who was a psychoanalyst who worked a lot with general practitioners in England in the 1950s and 60s, who really explored a lot of this terrain. And then also because of the orientation of some of my teachers when I was a resident, the role of one's own family of origin, shaping one's values and one's psyche was really prominent in my training here. So that...
idea that of knowing yourself in order to be a better physician, to be a better person, I had assimilated by the time I finished my training and started writing about it. I started writing about it, you know, when I, shortly after finishing residency and then I thought about how do you teach people, how do you help people take that journey of, in a way that feels safe,
Ron (19:09.738)
and relevant. So it's one thing to go off to a monastery and do meditation and build your sense of self that way or sense of place in the world. But medical practice is not a monastery. You're always with people and you're with people in the most intense and often most unpleasant moments of their lives.
And so, and you're working not by yourself, but you're working in teams that if they're not functioning, then people won't get the care they need. So it's a highly socially charged environment. And the question of how do you bring that sense of self-awareness and mindfulness into an environment like that was really the challenge that I had to.
stumble through or muddle through. So I'll just tell you one thing that I might not have mentioned in my book that, do you know what a code is? It's when someone's heart stops and they try to resuscitate them, do CPR. And whenever you see television depictions of codes, like most often people survive, right? And they're up and happy after. That doesn't happen most of the time. Most of the time people die during codes.
Tim Doyle (20:19.853)
Good.
Ron (20:33.364)
As they're dying, people become more and more upset. And often, the code itself can be rather chaotic. People yelling at each other, who's in charge? And so one of my aspirations as a resident was to try to, when I was leading codes, to try to create codes that were as calm as possible, that were.
where people were really listening to one another and working together like a smoothly oiled machine. And I realized the only way I could do that was to cultivate that sense of calm in myself first. So rather than having my blood pressure go up when I entered a code room, I would just like take a breath and say, okay, now here's a really wonderful challenge that I have, regardless of what outcome there is.
I want to have create, it's almost like theater, kind of create an event where everyone is actually singing the same tune and reading off the same script, engaging in what I later called shared mind, where people are kind of walking in sync with one another, kind of attuned to one another. And actually I would say I achieved that some of the time. But the first step, the third discovery for me was
The first step was taking my own pulse and kind of being aware, yes, this is life threatening. This is very real. There's no pretending that this will always go well. This could be devastating. are family waiting outside the room. There's nothing more stressful than this. Just totally accepting that and then saying, okay, now how do I move forward through that swamp?
Tim Doyle (22:24.801)
I love that. It's like you took a common event that would be a trigger and you just turned it on its head to work in your favor. And I had Dr. Ellen Langer on my show recently. I know you, you, you reference her. And one of my favorite ideas that she talks about how is that there's bad events don't exist. They're just events. And then it's our reaction to those events that, you know, in our perception of those events that make them stressful or in your case,
Ron (22:35.88)
OK, yeah.
Tim Doyle (22:54.627)
turning it into a dance or kind of a fun experience.
Ron (22:58.542)
Well, I wouldn't say fun. mean, this is someone whose life's on the line. But I would say it's a sense of I did the best I can. And I was really present and I wasn't phoning it in. So, you know, I think it's a little Pollyannaish to say that death isn't bad. mean, and but I would say the process and also my reaction to it.
are things that we can control. I Victor Frankl, who wrote about his experiences in the concentration camp, really talked about how he kept his own sense of values and sanity during what unimaginably horrible circumstances. And so...
I think there are lots of different pathways to that, but I think that that's an aspiration that I would want to share with people who I teach and who I interact with.
Tim Doyle (24:05.421)
Getting deeper into patient-physician relations, I mean, one of the most common things that you hear nowadays, and it's almost like it's a given or a necessity in the medical space, is that sense of detachment between physician and patient, where it's like, hey, this is just kind of what needs to happen for doctors to be able to manage this type of work.
Do you think that that's just been the natural evolution of the medical system? Or do you think that's been like a conscious design of like, hey, this is what you need to do to do this job.
Ron (24:46.966)
Ron (24:51.606)
I think that, I mean, the word equanimity comes to mind for me, not a kind of cold hearted equanimity, but I would say a warm equanimity of, and it's kind of a radical acceptance of the way that things are. So, you know, I've taken care of children who were dying of brain tumors. I mean, as a parent and a grandparent, I can't imagine anything worse, right?
But if I were to fall apart in my taking care of a distressed child and family, it would really do them no good. So...
So sometimes I have to park, not park my feelings, but park my reactions. And I can say, yes, I am feeling devastated by the circumstance and I can be a comforting presence to this patient and family. So there is a detachment there, okay? There is...
Tim Doyle (25:46.777)
Mm.
Tim Doyle (26:03.608)
Yeah.
Ron (26:05.998)
There is a sense of, excuse me for a second, I just have to silence my phone.
Tim Doyle (26:15.033)
But you are allowing yourself you're saying I guess to feel that stimulus like you're allowing yourself to feel the weight of the moment the weight of the moment, but creating that little sense of gap I guess between the stimulus and the response.
Ron (26:16.621)
Right.
Ron (26:20.952)
Yeah.
Ron (26:30.604)
Yeah, yeah, I mean, you know, that, and so I think part of creating that pause between stimulus and response is actually being aware of the stimulus. But I would say on a personal level, I need to filter it. I need to be aware of it, but not let it go into full bloom.
or at least not in that moment. And also it depends how quickly those stimuli come in succession. I think we all have a limit. I think we all have a need to protect ourselves to some degree. I mean in life in general, but I think also in our work as doctors. I think the unhealthy detachment comes from a couple of sources.
One is what I would call cognitive or intellectual detachment. I think I tell a story in the book about a woman that I cared for when I was a medical student who had a rare kind of cancer called hairy cell leukemia. It's because the cells look like it kind of fuzzy around the edges. And in the 1980s, that was one of the first diseases to be understood on a molecular level, just which gene.
And so this patient was very fascinating to the team that was taking care of her. But given that I had some responsibility for her, I went in and talked to her. I noticed there were no greeting cards on her desk. I noticed whenever I went to see her, she was alone. She didn't have any visitors. There were no flowers in the room, no evidence that someone cared about her. I also noticed that she was in pain, although she was not personally a person to complain. I had to ask.
And that sense of isolation, pain, loneliness and abandonment was totally lost on the clinical team because they were really interested in this fascinating disease. So it was not that they were emotionally overwhelmed, it's just they had the wrong focus or they had a narrow focus. And so I kind of brought it to their attention. I said, when I went on rounds with her by myself in the afternoon, she told me that she was in pain and her pain wasn't well.
Ron (28:55.182)
They were very happy to control her pain and express concern and were apathetic, but it just escaped their attention. The second kind of detachment, I think is a little bit more, well, it's just different. I'll give you again that example of that child with a brain tumor.
I can easily imagine when I had children that age and that because of identification, it would be so overwhelming for me to experience vicariously, to take in vicariously the experience of that child's parents, but I just would feel a need to avoid the patient.
to not go in their room, to not have to talk to the parents, to appear as they might say professional, know, stand up straight, coat, asking questions about symptoms, but not really asking questions about how are you really feeling, because not wanting to take that in. And that kind of...
know, feeling that emotional resonance and then saying, no, I don't want to experience that. And therefore I'm going to take a step back. I'm going to remove myself from that situation. That's a kind of a distancing empathy. I'm feeling empathic feelings, but I want to get rid of them. I want to get them out of my psyche. And I think that's really damaging also in a different way.
Tim Doyle (30:46.603)
I mean, that's really tough to navigate because I feel like what could potentially happen is just the distancing just incrementally starts to go a little bit further and a little bit further and then a little bit further. And it's tough to play that game of where you're supposed to just stay and have that detachment, but also be present.
Ron (31:00.504)
Yeah, right.
Ron (31:13.218)
Yeah, no, it's, mean, I'm a palliative care doctor, which means I take care of people at the end of life. And when I'm called to do a consultation, I keep in the back of my mind that there are always four patients to consider. There's the person in the bed, that's their family and their social circle. There's the referring team, there are the oncology team or the nephrology or the cardiology team that asked me to see the patient who also might be
really distressed and not know what to do. And then there's me, right? There's how this situation is knowing at me. And I never know when approaching that new consultation where the greatest distress is going to lie. Is it gonna lie on the clinical team, the family, the patient, or is it gonna be me? And so...
I find that helpful in the sense that I'm surprised if I don't sleep well one night or if the team seems to be insistent that I fix something that's unfixable. I think that broader perspective of, know, what's my job as a doctor is really helpful. It's not just the person in the bed.
Tim Doyle (32:38.211)
think another interesting component to add to this conversation as well and bringing Dr. Alan Langer back into the mix. Another thing that I find really interesting about her beliefs and her research is that she believes that chronic stress is at the core of all diseases, sicknesses and illnesses. Would be interested to know your thoughts on that as well. But where my mind goes to is like, yes, we need to have that sense of
personalization and presence so you can make patients feel comfortable and take that stress away as much as you possibly can. It's not so much about just, you know, a better experience within the medical system, but from that lens, you could also say, and Dr. Allen Langer's lines is like, well, we also need to do this to mitigate stress as much as we possibly can because there could have physiological.
ramifications as well. What are your thoughts on that?
Ron (33:43.31)
Let me answer with a story. A number of years ago, I woke up at five in the morning with very bad abdominal pain and went to the emergency room. And the care that I got in the emergency room was technically very good. Things happened in a timely manner. They gave me the medications that I needed for the pain. They sent me for all the right tests.
Tim Doyle (33:47.107)
Love stories.
Ron (34:12.536)
the diagnosis they made was as correct as it could be in the emergency room.
But the, and I was clearly worried because as a doctor, you have advantages and disadvantages when you get sick. And one of the disadvantages is that all of the really bad things that you learned about in medical school suddenly reappear in your memory. So I was going through the 450 causes of abdominal pain and of course started with the worst ones. So I was clearly anxious.
The one memory that's the clearest in my mind is when the transport guy, the guy kind of wheels the stretcher from one place to another, was wheeling me from the emergency room to the CT scanner so I could have an x-ray.
And at one point in that trajectory, he, and actually just, if you've never seen the world lying on your back on a stretcher going through a hospital corridor, it's not a very pleasant way to see the world. I wouldn't recommend it. It's kind of very disorienting and disarming. So, but at one point in that trajectory, he stopped the gurney, walked around to where he could make eye contact and just asked, you know, how are you doing?
Tim Doyle (35:17.081)
Hahaha.
Ron (35:34.904)
Okay, four words. And I suddenly kind of felt myself relaxed. I said, yes, here's a human who's actually making a connection. And just another story. I unfortunately needed to have prostate surgery because of the depredations of aging. it's not a pleasant.
Tim Doyle (35:41.049)
Mm.
Ron (36:04.878)
undertaking. And so you wake up with a catheter, which was a novel experience for me, which I hope never to repeat. the surgeon who previously had been really kind of cool and somewhat detached and kind of all business, walked in the room and said that the surgery went well. And he kind of pointed to the catheter there and said, and that thing
I know it's inhumane, but you need it for a few days. And it was just like my heart opened to him. These little things that you can do to humanize what could otherwise be, for lack of a better word, mean, unpleasant is saying it mildly. It's kind of humiliating.
Tim Doyle (36:36.44)
Mm.
Tim Doyle (36:43.469)
Yeah.
Ron (36:58.618)
disempowering. I mean, you can go through the whole lexicon of things that people experience when they encounter the medical system. But we often forget, as healthcare practitioners, just how awful it is and disorienting it is when you're a patient, how out of control you feel. And just a little bit of that, just, and it takes three seconds to...
Tim Doyle (37:26.819)
Yeah, just acknowledging the reality of the situation. Yeah. Yeah, because the... Yeah, the exact opposite is what makes it worse. Like the shying away from it and the reactionary components of it are just like, okay, now we're gonna just take this for what it is. Another component that I find really interesting is...
Ron (37:27.906)
just acknowledging the humanness of the other person.
Ron (37:44.812)
Right.
Tim Doyle (37:55.981)
your take on curiosity and how generally speaking within society, curiosity is seen as a very positive thing. Be curious. Can you talk to me about how that's overlooked in the medical space and even within med school, how it's a negative connotation?
Ron (38:15.488)
Ron (38:19.351)
I
You know, it's kind of interesting.
I think good clinicians and good researchers are always curious. I mean, it's really a precondition because you see something, you think you understand it, you open your mind to the possibility that you don't really understand it, and then feel some kind of impetus to need to understand better. And that's really kind of the... So it's this process of perception.
and then allowing yourself to feel uncomfortable and then having in the back of your mind that there is the possibility of wonder. so I think that that's how new drugs get invented. That's how new diseases get named and described.
And that's also how you provide personalized care. So for example, as a family doctor, I took care of a lot of people with diabetes. Diabetes is a very, very difficult disease to live with. You have to keep to a diet, you have to keep to a regimen, you can't enjoy some of the same things that your friends do. You have to take medications that sometimes don't make you feel any better and actually may make you feel a little bit worse.
Ron (39:54.872)
People generally feel better when their blood sugar's on the high side. And so when you lower it, they don't always feel so good. And so after a while in practice, I kind of felt like I kind of had assimilated all that I could about the medications to treat diabetes, the types of diabetes.
Ron (40:22.99)
But the thing that really kept me interested in taking care of patients over time, because I would take care of people for years and decades, sometimes with diabetes that was not very well under control.
is trying to understand, well, who is this person with diabetes and why aren't things going the way they should? And then I'll discover that this woman with diabetes has six children, two have to be gluten-free, one's a vegetarian by choice, she's on a limited budget, her husband isn't working, the grocery store is a long drive, and it suddenly makes sense why she is not eating the things that she...
should be. And then that helps me then create a more reasonable treatment plan for her, with her, I should say. And then I have this kind of aha moment. yeah. This is what's really interesting about this woman. Her type 2 diabetes is kind of right out of the textbooks like everyone else's in some ways, but her life isn't.
And so curiosity about people's lives and what makes them tick and what they're skilled at and what they're not skilled at, what their strengths are, that then becomes the really interesting part of primary care practice. And so that if you don't have that kind of curiosity to know people as people, then you begin to burn out. It becomes uninteresting. It becomes tedious.
So
Ron (42:07.948)
I think it's really, really hard to be curious when you're angry. And I know that feeling of something, know, prescribe a medication, the patient comes back three months later and you notice in their medical record it's not been refilled. And you think, hmm, what's going on? And they say, I'm taking my pill every day, but they should have run out a month ago. And so, you know.
It's hard not to be annoyed or frustrated. But if you can cultivate this capacity for curiosity and say, gee, know, this seems like a perfectly reasonable person. Why is there this disconnect? Maybe they want to maintain a positive self-image with me. Maybe they have an embarrassing problem that they have trouble talking about. So that curiosity about people when I'm
angry or upset or I think that's the challenge. So going from furious to curious.
Tim Doyle (43:13.753)
I like that.
bring another term into the mix here and to further display how you have more than simply just a medical mind but more of a philosophical and very meditative mind. What is the philosophy on emptiness?
Ron (43:34.126)
Wow. Okay. You know, I think
Ron (43:46.894)
I can give you an intellectual answer.
Tim Doyle (43:51.351)
I love those types of answers.
Ron (43:53.026)
But well, when you think of important questions.
When you think of simple questions, often they have an answer. But important questions usually have more than one side. There are more than one way of seeing the situation or the question that you're.
And so.
People now talk a lot about mindset. So you don't have a rigid mindset, a flexible mindset.
I think the idea of emptiness is, can you imagine having no mindset?
Ron (44:41.036)
that is being able to.
Ron (44:48.81)
in a fluid and consistent way.
when perceiving something.
also seeing in it that the perception itself is a creation of your own mind.
So there's a lot of talk about, for example, how would you define a chair? Just simple things like that. How do you know that that chair is a chair? Well, people will say, it has four legs. Well, could there be a three-legged chair? Could there be a no-legged chair? Could there be something else with four legs that isn't a chair? I mean, you kind of go on and on, and then you kind of realize that the assumptions that you'd made about this chairness.
begin to fall away. And now imagine taking that same view of your own.
Tim Doyle (45:48.409)
Mm.
Ron (45:48.982)
I'm a stubborn person, I'm a kind person, I'm a perceptive person, I'm an evil person. You're just whatever those things are, the more you begin to experience those deeply, you realize that, well, it might be almost true, but it's not quite so. And so it's that not quietness is how I...
There was a second century Indian philosopher named Agarjuna. And he was asked questions like, you know, does God exist, for example? And he would say, basically, you know, make an argument that God exists. He would make a second argument that God doesn't exist. He would make a third argument that God both exists and doesn't exist.
and then would make a fourth argument that God neither exists nor doesn't exist. And he would hold that all of those would be true or possessed some, or the truth would be the ability to assimilate those radically divergent worldviews.
Now this doesn't mean that you don't have opinions, okay? But it means the capacity to engage with the world with a kind of not quite so mentality.
Tim Doyle (47:25.549)
I had on a guest, great conversation, but there was one line that he said that stuck with me the most. He said, you know, the card is known for the idea. I think therefore I am. He goes, I live by the opposite of that, which is I don't think therefore I am. And I thought that was really, really fascinating. And to bring another idea into the mix.
And like you, we've been talking about how within the medical space, especially in med school, it can be very information heavy rather than a focus on ideas. And one component within the medical space that you would say is a given is the idea and the specific word suffering, but you've shown that suffering within the medical space and specifically the word suffering.
really doesn't have a space. Can you talk more about that?
Ron (48:31.382)
Ron (48:34.734)
Boy, you're asking good questions. Again, I will tell you a story. In 2005, I was asked to write a monograph for the National Cancer Institute, it's part of National Institutes of Health, to create an agenda on improving communication in cancer settings. This was emerging from an era when patients first weren't told their diagnosis, then
were kind of given a treatment plan without their input. And they were really trying to, I think it was actually a very enlightened project of trying to help patients but be more involved in their care and fulfill an ethical mandate that they'd be informed and be involved in decision making. So I wrote the monograph with a close colleague. And
And I wanted the tagline of the monograph to be improving care and reducing suffering. And they objected to the word suffering. They thought that quality of life would be OK. One person said health-related quality of life. But I was really pretty insistent.
Tim Doyle (49:47.833)
Fascinating.
Ron (50:03.756)
And the argument I made was, have you known someone with cancer? And they all said yes. And I said, do they suffer? Yes. mean, was kind of, what's wrong with the word? And so it finally stuck, but it was really, it was kind of the first reaction was we don't use that word. And.
Tim Doyle (50:16.686)
You
Ron (50:32.782)
They were also objected to end of life because they talked about cancer survivorship as kind of the end, as the end game for people with cancer. But I said, well, what about people who don't? And do we need to help them and their families during their, the terminal phase of their illness? And again, there was huge debate and you know, what should seem obvious now, nearly 20 years later.
But the mindset was that medicine wasn't about suffering as much as it was about curing. so I'm not the first to say this. It's been a long history of people writing about suffering in medicine. I don't know if you ever had Eric Cassell on your show when he was alive, but he was a notable figure in that domain. But...
Tim Doyle (51:30.093)
I did not but I was I was about to bring him up. So great segue because you reference him in your writing and I think it was really fascinating because before you referenced him, I was like, why isn't suffering talked about and then you reference how he said or he described suffering as a holistic experience and the thought that came into my mind I was like, all right, bingo, then that makes perfect sense within the medical space because it seems like there's a harsh delineate
Ron (51:33.612)
Yeah. Yeah. Yeah.
Tim Doyle (51:59.949)
delineation now between what we know as conventional medicine and what we know as holistic medicine. And you reference an article of Eric's about how he stresses that in the medical community, the central obligation of healers is to address suffering, not just cured disease or relieve pain. Where do you think those two paths start to divide or
Are they already separate right from the start when we're talking about curing and suffering?
Ron (52:36.674)
I think we've made huge progress in that regard.
Ron (52:44.382)
I really think that the misplaced optimism of the 1980s has really faded, that people know that serious illness and chronic disease is part of the human condition. And I think that's what led to and was further accelerated by the palliative care movement. So I think that...
I think that divide was described by Plato in one of his dialogues, I think it was laws where he, it was framed as a political, in politically incorrect term because he talked about the care of freemen and the care of slaves and doctors who attended to those who were rushed and just prescribed treatments.
and didn't really get to know their patients as people. And on the other hand, those who were more privileged got to be known as full human beings.
So that idea of separation between cure and just being the dispensary and also being a healer, I think was really embedded. And there are similar quotes, probably a little more politically correct from the Yellow Emperor's classic, which was the Chinese classic of medicine written about the same time as Plato. So that idea that just providing the right potion is not the answer.
Not the full answer. I think that's a pretty old idea. I think the divide really happened historically with the ascendance of the church in the Middle Ages because healing was then assumed as a spiritual practice and therefore the province of priests, whereas offering medications and doing surgery was a lay proposition.
Tim Doyle (54:38.969)
interesting.
Ron (54:46.85)
that was the province. And actually, think, you know, again, I don't know my medieval history very well, but I think that for doctors, physicians in those days to assume that healing role might've even been considered heresy. So I'm sure they did and found other ways to talk about it. I'm sure there've always been people who have, but I think that reinforced some of that schism and made it.
harder to, and then I think that the scientific revolution in the late 19th century had accelerated in the 1960s and 70s, which kind of produced this promise that we don't need to heal people, we can cure them. I think that also was something that, you know, added some fuel to that fire.
Tim Doyle (55:40.931)
That's really, really interesting. So would you put healing in that same group then that that really isn't a word that is used for my own personal experiences within the medical system? It was always, you know, recovery cure, not so much healing. What are your thoughts there?
Ron (56:00.034)
Well, I don't know. think good doctors do both. I think they've always done both and may not name it as such. I think that surgeon who the urologist who did my prostate operation wouldn't call his statement about the catheter that I mentioned. He wouldn't have called that healing. But it was. It really was. And so.
Tim Doyle (56:04.236)
Yep.
Ron (56:27.808)
I don't think that the holistic health movement embodies healing necessarily any better than traditional medicine. Because some practitioners do and some don't. I trained as an acupuncturist at one point. Some of them were just incredibly mechanical. They might as well have been a surgeon. you come in, they put in the needles, you sit there for 20 minutes and they pick them out and you're done.
I don't think there's anything more holistic or less holistic than any medical tradition than any other. I just think of what it's your capacity of bringing your own humanness to that practice. And every branch of medicine, regardless, if it's Chinese medicine or Ayurveda or Reiki or mind-body things, meditation, all of them involve the human domain and really at their best.
Tim Doyle (57:08.793)
Mm. Mm.
Ron (57:28.022)
are both healing and curing activities.
Tim Doyle (57:38.135)
Yeah, I really like that. Do you think?
Just to parse that out a little bit more, do you think that healing involves curing as well, but not necessarily the other way around? can you cure without healing?
Ron (57:55.01)
You can remove a tumor in a totally cold, impersonal way. Imagine a surgeon who never meets the patient except when they're anesthetized. If you've got a kidney tumor, they can take out the kidney or just take out the tumor and you no longer have the cancer. It's not gonna spread, it's not gonna kill you and you go and live your life. I think it's certainly possible.
I think it's also the opposite that's possible and it happens all the time of people with terminal illnesses feeling a sense of healing and wholeness even though they know that they're not going to live very long.
Tim Doyle (58:32.057)
Hmm. Yeah. Really, really interesting. I like that.
Ron (58:35.532)
That's what I try to do as a palliative care doctor.
Tim Doyle (58:39.469)
Yeah, that's great. Use the phrase a few times in your book, radical, until recently when talking about different practices or programs that have helped doctors connect better or just bring more humanity to medicine. Are there things that you still see that you think are very, very beneficial but still stay in that camp of being viewed as radical?
Ron (59:10.797)
Ron (59:15.054)
question is radical to whom?
I think it's a question of degree and a question of focus. I think medicine now is very misaligned in lots of ways, mostly due to the corporatization of medicine and transforming it from a relational sphere to a transactional sphere, often having to do with money and throughput.
Ron (59:49.848)
Paradoxically, I think that has in some ways, in some circles, united healthcare workers to find a greater sense of purpose and meaning of their work because they know they're not being provided by the institutions they work for. Some leave, some get burned out and leave, but some use this as an impetus to say, this is not.
the value, this is not the reason I went to medical school, this is not the reason I became a doctor or became a nurse. And then head on a path of exploration and learning. So, I mean, that's a whole other discussion about just how the public sphere and also healthcare financing has influenced all of this because it is a huge influence and not always a healthy one.
Tim Doyle (01:00:46.435)
We throw around the phrase, you know, the medical system all the time. I mean, I've used it, you know, constantly throughout this conversation. But I think part of the reason why we do that is because we really don't know who's actually responsible for these types of things or like leading the charge for change. Like within politics, you know, within the American system of politics with all the problems that we have.
we at least still have, you know, political parties and public officials that we can at least point to and be like, Hey, like, you know, what are you doing to try to help us within the medical system? Like I said, we just reference the medical system. So like, where do you see change for that occurring or like, where are people supposed to like, look to for like, Hey, like, what are you doing to improve things or bring these practices that will really
help people to the surface.
Ron (01:01:48.753)
Ron (01:01:52.246)
I'll just say it has to come from the bottom up and top down and the willingness of people to make themselves just visible. And part of the reason I wrote a book was because I wanted to be visible to people who weren't necessarily in my medical bubble. And I would say it succeeded. I mean, I've had many conversations, really interesting conversations with people I otherwise would never have met. And...
and feel that it's one way of having an impact.
I think there are a lot of individual voices out there in terms of humanizing medicine. There's Atul Gawande, there's Abraham Verghese. These are public figures who've written a number of books and are real medical humanists and also have been in leadership positions.
I think that...
Ron (01:02:55.456)
organizationally, I wish that healthcare, I when you talk about health system, the health system, there is no health system in the US. It's a cluster of independent and partially independent organizations that are constituted of very different kinds of people. So it's not a monolith. It's, and,
It's not even a cruise ship, it's a flotilla and they're not all going the same direction. It's really chaos. And so I think it's that chaos that when you encounter, when you enter, when you're seeking healthcare or getting healthcare, you don't see the depth and severity of that level of disorganization.
What you see is how people treat you at the surface. And as a healthcare practitioner, you have some glimpses of that because of what insurers will pay for, but they won't.
Tim Doyle (01:03:55.298)
Mm.
Ron (01:04:09.002)
And if you're asking who's leading the charge and who's in charge of the healthcare system, my answer would be nobody. And if you talk to people at the top saying, know, people with very important jobs, you know, the head of very large healthcare systems, kind of multi-billion dollar enterprises, the head of Harvard Medical School, I mean, you can ask them how much autonomy they feel they have in terms of changing things.
And it's not a lot. And then if you ask, well, who is in charge of this whole thing? They might point their fingers at each other, but no one actually feels that they're in charge. So I think that's part of what we're feeling as some of that we're feeling in encountering health care. And I don't have a coherent answer to you for that.
Tim Doyle (01:04:46.211)
Haha
Ron (01:05:06.144)
other than if we have enough voices raising alarm, occasionally some organizations actually do get it right. And then even more miraculously, sometimes the organizations learn from one another. And that has happened. That has happened. I'm not completely a pessimist, but if you kind of think of it as a chaotic enterprise,
that is occasionally self organizing, but often not. That's kind of how I see the world that I inhabit in medicine. And again, it allows me not to blame any one individual or any one organization. We're all muddling through the same swamp and it's really difficult to navigate.
Tim Doyle (01:05:49.966)
Yeah.
Tim Doyle (01:06:00.127)
Yeah. And a final point on that and to turn the table here, because for the majority, if not all of this conversation, it's just been focused on the medical system and mostly physicians and how they relate to patients. But I'm a big believer and I've experienced it myself. It's like, and like you were saying right there, how nobody feels like they are in charge or creating change.
And in my mind, if I'm an individual, when I hear that, like, yes, it's easy to just point the finger and blame, like, all the medical systems terrible, like, I can't, you know, get the proper care that I need. When I hear that it's like, okay, individuals truly need to take their well being into their own control. So are there any thoughts or ideas on that or what patients or individuals should be doing to
truly getting the care that they need because you can also flip it in terms of like relationships. You know how you said doctors need to have a good relationship with themselves to have a good relationship with patients. Well, I would say that the other side of that is true as well. It's like people need to have a good relationship with themselves to have strong relations within the medical space or whatever it may be.
Ron (01:07:23.95)
With one caveat, people, it's not a symmetrical relationship. People come to medical care because they're feeling vulnerable and because they're scared, they're feeling disempowered. So to put the burden of solely on patients, I think is unfair. But I think there are things you can do. The first thing is don't go to the doctor alone. If it's something
at all serious, bring someone you trust and love with you because you're not gonna be able to hear everything and someone else will, they can help you that. So come prepared with a list of questions that are the most important ones and start with the most important one first. Don't leave it for last. So often patients will come in, they'll say, well, how often do I have to take this medication? And oh, by the way, I've got a hangnail.
And then finally, when the visit's about over, they'll say, by the way, doc, do you think I could die from this? Or I've been having this pain in my chest, should I worry about it? So start with the most important question first. Consider your doctor a colleague, a collaborator, a friend in a kind of
professional sense, your medical friend, your... And so start with that mindset, saying that here's someone... I mean, everyone goes into medicine to help people in some way. I mean, it's too hard of a path if you just wanted to make money. It's just not a good choice, right? Go into banking, go into something else. It's just...
Ron (01:09:24.802)
Be willing when you ask those important questions to listen to the answer. Be willing to state when you don't understand something, because doctors often tend to lecture, they tend to use jargon, various other things. So I think those kind of guidelines, none of that is new, but I think it's the...
It's having, I guess having a certain openness and relational mentality that I think is gonna be helpful. And also recognize that doctors are under time pressure. It's something that nobody likes, but that's why kind of get, do the most important things, say the most important thing first.
Tim Doyle (01:10:22.541)
Love that. And I'm a big believer because like we were talking about, the medical system used to be very, you know, personally based. And I think to a large degree it still is, but room for improvement. And I'm a big believer of like, if something used to be like something, then we can get back to that.
Ron (01:10:41.612)
Well, I don't, I lived through the so-called good old days and they weren't that good. Okay. I wouldn't over glorify the past. We did, there was less time pressure. That was one thing I would say, but there were other big problems. And so I think it remains a collective effort.
Tim Doyle (01:10:50.819)
Hahaha
Tim Doyle (01:11:10.105)
but we'll take the good stuff from the past and try to bring it with us and we'll leave the bad stuff behind. Ron, really love talking with you today. Where could, if the people are curious, where could people see more of the work that you do and the stuff that you talk about?
Ron (01:11:12.898)
There, there we go. There you go.
Ron (01:11:25.69)
I do have a website. It's my name. It's RonaldEvstein.com. So there's other stuff there. And also there's a contact form if you want to contact me.
Tim Doyle (01:11:36.363)
Awesome. Great talking with you today.
Ron (01:11:38.146)
Great, thank you very much for inviting me.
