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A Physician-writer On Stories And Conversation As Essential Medicine For Patients At The End Of Life

Jeffrey Millstein | September 16,2019 

In her memoir That Good Night: Life and Medicine in the Eleventh Hour, Sunita Puri takes us along on her journey as a first-generation American to becoming a physician, and then choosing to specialize in palliative care. She writes about the rewards she finds in caring for seriously ill patients, often at the end of their lives, when they may reveal what matters most to them.

The book is also a tribute to her close-knit family. Her mother, who overcame great adversity to attend medical school in Mumbai and went on to a successful career as an anesthesiologist, inspired her daughter’s interest in medicine. Yet, as Puri writes, it was hard for her mother to understand at first why she would set aside a more prestigious specialty in favor of palliative care, a relatively young field.

Now the medical director of palliative care at Keck Medical Center at the University of Southern California, Puri will be in Philadelphia on Sept. 28 as keynote speaker at The Inquirer’s “Telling Your Health Story” conference for health-care providers and patients who write about their experiences.

I recently spoke with her about her writing process, her message, and what she hopes it will achieve for both patients and her fellow physicians.

In the excerpt from your book The Inquirer is featuring, you speak of becoming an “accidental linguist,” referencing the layers of meaning in the words used to discuss illness. Can you tell us more about that phrase?

I was always linguistically oriented as a child and was drawn to stories and writing. Growing up in a home in which sharing stories is part of our culture and the way we relate to each other, I was naturally drawn to a medical sub-specialty focused on stories and conversations. But the importance of clear communication in medicine is something that for me was an evolving realization in my training. I may know science, but if I cannot translate this “foreign” language for my patients, then I will be less able to empower them with health information they need to make the right choices about their care.

A pivotal experience for me in my training was one particular patient with diabetes and kidney disease who was struggling to understand how eating sweets might further damage his kidneys. It was difficult for him to grasp the danger of something as comforting as sugar, so I had to learn to explain it in a way that helped him to understand diabetes as I do.

Effective communication has been especially important in my practice of palliative medicine, when I must translate high-stakes information about disease, treatment, and the limits of medicine while also attending to the emotional and spiritual needs of patients and families.

You make very effective use of dialogue in the book. As a fellow physician-writer, I found it very instructive in showing what may or may not work in our conversations with patients. Was that your main intention?
I wrote this book, in part, in order to write the book that I wish I had when I was going through my training. I wanted to model how conversations, both in medicine and in life, can go very well and can also go very badly. I wanted to offer not only doctors but also everyone in the general public useful language for contemplating and discussing mortality, dignity, suffering, and illness. The dialogue was a way of inviting readers urgently into the scenes I vividly remember, so that they might experience the challenges, rewards, and importance of these conversations. My goal was to humanize both patients and physicians, both of whom struggle to have honest discussions about serious illness, while also showing it is entirely possible to take on these discussions in a productive and meaningful way.

Family features heavily in the book. Did exploring and reflecting on your own family dynamics help you learn to better manage difficult conversations with your patients’ families?
Coming from a close family, I have a strong appreciation for the complexity of family dynamics and how they can play a role in the response to illness. Even though my family and I share a lot with each other, I have learned to respect the fact that some topics are simply “off limits.” Early in my training, I clung to a fantasy that serious or terminal illness would help resolve old conflicts and bring a family closer together and that, as a physician, I would bear witness to that. But I’ve also seen the opposite — that illness can deepen long-standing conflicts. I’ve learned to accept that most family dynamics don’t change immensely. Although I cannot necessarily fix a personal dynamic, I can try to navigate it to find agreeable solutions that are in the patient’s best interest, while also ensuring that the family feels well-supported and cared for amid the stress they are experiencing.

What is the most important message that you hope readers take away from your book?
My biggest hope was to write a beautiful book about what it means to live well with knowledge of our mortality, and to take on this weighty topic via stories that read like a novel. I wanted readers to consider that death and illness — which we generally avoid thinking about — invite us to contemplate what we value most about our lives, and what brings us meaning and fulfillment. In its own way, our own impermanence is a profound gift, particularly if we can start to peel away the fear and denial that we yoke to death. If the book can help readers to contemplate the interrelatedness of life and death, and to take on essential conversations about what they want for themselves both in life and in death, then I’d be over the moon.

Jeffrey Millstein is a primary-care physician and medical director for patient experience–regional practices of Penn Medicine. He will address the issue of telling stories with respect for patients at The Inquirer’s “Telling Your Health Story” event on Sept. 28. For tickets: