My Experiments With Truth
Date Published: December 11, 2019
Oncologist Gabriel Sara, MD, is a maniac about the truth. Whether delivering a tough diagnosis, or sharing his feelings with colleagues, he refuses to sugarcoat. It's a lesson he learned as a medical intern in war-torn Beirut, where the truth was a matter of life and death, and over the years it's become central to his practice. On this episode, Dr. Sara talks about how he uses radical honesty to build trust, empathy, and resilience.
Dr. Sara is Medical Director of the Chemotherapy Infusion Suite and Executive Director of the Patient Services Initiative at Mount Sinai West.
You're listening to Road to Resilience. I'm Jon Earle. In the video, there's a man lying face up on an operating table. A blue cloth covers his face and upper torso, except for a square of exposed skin on his sternum. The man is nervous. He grips the hand of a woman out of frame. The cloth blocks his view of what's about to happen to him. The doctor, dressed in a white coat, shuttles back and forth to his instrument tray. He moves confidently, preparing the needle and then the instrument he'll use to extract the marrow from the man's sternum, which he'll later test for leukemia. It looks as scary as it sounds, but the atmosphere in the room isn't grim or somber. Instead, the operating room is full of singing.
[VIDEO CLIP STARTS] 00:41
I can feel you screwing something in there. I don't want to see but I can feel a little bit.
Dr. Gabriel Sara: 00:59
It might hurt now.
Oh, great. Thank you so much. Halelu— aaahh.
Dr. Gabriel Sara: 01:04
Do you feel it?
A little bit!
Dr. Gabriel Sara: 01:07
But not much!
Dr. Gabriel Sara: 01:10
I think it's better.
Dr. Gabriel Sara: 01:11
Very good. Great job!
[VIDEO CLIP ENDS] 01:13
The doctor in the clip is Gabriel Sara. He's an oncologist at Mount Sinai West, where he serves as Medical Director of the Chemotherapy Infusion Suite. Dr. Sara grew up in Lebanon. He cut his teeth in medicine during the country's long civil war. And along the way, he developed a style of medicine — or really of being — that I find fascinating. Dr. Sara is all love, zero BS. He's brutally honest with his patients, but he also cries with them. He's no nonsense, but he's also into feelings and deep listening. In our conversation, Dr. Sara talks about the experiences that shaped his philosophy of radical honesty. And he explains how telling the truth helps him and his patients to be resilient, even at the end of life. Dr. Sara, welcome to the podcast!
Dr. Gabriel Sara: 02:03
So you have a mug, and it says, "Don't sugarcoat it," if I'm not mistaken. Can you tell me a little bit about that mug?
Dr. Gabriel Sara: 02:12
So basically this mug is a mug I keep on my desk, and basically what it says is, "Honesty is better than sugarcoated BS." And I can tell you, patients love it. They sit down, and while I'm talking, they realize that I'm being honest, they look at each other and say, "Well, it's written on the mug, you know!" [laughs] And then many pull their phone out and take a picture of it. And they tell me, "I love that." So I leave it on my desk because I think it gives them a flavor of what they're going to have when they talk with me. I really mean what is written on that mug. And I mean everything I say to them, and they know that. And once they know that you will never betray them, they will go everywhere with you. It will transform your experience as a doctor and as a patient.
And we're going to talk all about it. But I want to start from the very beginning. I know you grew up in Lebanon.
Dr. Gabriel Sara: 03:10
And when we spoke, you told me that you grew up in a family of people who did not BS each other.
Dr. Gabriel Sara: 03:16
Yeah. I feel very blessed that I have a father and a mother who are both totally honest, truthful, no attitude, no issues with being honest, and never hiding anything from anybody. So we grew up this way. And at home we never lied to each other, which is an amazing thing retrospectively because for me it was normal. But I realized how much around me there's a different level of honesty. People actually can be honest a little bit or a lot or 50 percent, 70 percent. In my family it was 150 percent.
That sounds like it would cause chaos in a family.
Dr. Gabriel Sara: 03:59
Yeah. Which was great. When you grow up this way, you feel good about yourself and you're never ashamed to do whatever you believe you should do.
You went through a very intense experience as a young person. You lived in Beirut during the civil war.
Dr. Gabriel Sara: 04:19
Tell me a little bit about your experience during the war and how it kind of shaped you as a person.
Dr. Gabriel Sara: 04:26
The war, the kind of war we lived — which I hope you will never experience in your life. Even if you see movies, there's no way you can get the feeling of what it is when you are sitting in your room and then a bombshell enters your room or the room next door, or sniper fires comes and hit the desk next to your shoulder. When you have your neighbor that is brought to your emergency room half-dead, and friends come to the hospital wounded with blood all over. So these kinds of things.
You were a medical student at the time?
Dr. Gabriel Sara: 05:04
I was actually an intern. We were in the OR and we were operating nonstop, 24/7. And our surgeons were amazing people, the strength they had, the courage. And during the bombing they would be operating calmly and teaching us what should be done. So we were interns helping them, but they were performing surgery.
When we spoke you told me stories about riding a motorcycle through the streets of war-torn Beirut. And you told me a story about playing guitar in a bomb shelter.
Dr. Gabriel Sara: 05:42
Yeah. So at some point, for about almost a hundred days, my hospital was under siege. There was daily bombings. Sometimes we had one bomb every 30 seconds falling on us for several hours. And so we had a basement which we transformed into a shelter. So it's untenable, obviously. So I would play guitar. What else could we do? We are stuck inside that room waiting to die maybe. So everybody would start singing with me and even dancing while the building was trembling because I think it kept a lot of people sane. It took our mind off being scared to have fun.
What songs would you play?
Dr. Gabriel Sara: 06:27
I played the Beatles. I played all kinds.
Any one in particular? What would you play when you the bombs are coming down?
Dr. Gabriel Sara: 06:37
"La Bamba!" That's the one that would put everybody at ease?
Dr. Gabriel Sara: 06:41
This one, everybody starts getting excited. Everybody knows the song, you know? Yeah.
It sounds like "Apocalypse Now." Have you seen the film?
Dr. Gabriel Sara: 06:50
No, I haven't. I haven't, but I heard about it.
It's the absurdity and the music and the culture, with violence and bombing, and it's those things in one place.
Dr. Gabriel Sara: 07:00
Being able to be calm under fire and being able to tell the truth. Were those the main lessons that you take away from that experience of being in Beirut?
Dr. Gabriel Sara: 07:13
So when you experience these things, you're basically facing death straight in the face. And when you face it many times, and when the people around you are facing the same thing, you realize that the war doesn't allow anyone to BS around. Because there's no room. There's no time. You could die tomorrow. You could die tonight. And that certainly made me become familiar with death. I've seen so many people dying before even becoming an oncologist that I think that somewhere it made me comfortable talking about death, dealing with death, helping patients die peacefully and families accepting their deaths.
What is the next milestone in your story of truth telling?
Dr. Gabriel Sara: 08:09
So I was a fellow in my third year, and I was called to see a woman from, I think, Puerto Rico, who was found to have a liver cancer by chance. She came for something else. They did some tests, they found that she had a tumor in the liver that was inoperable, incurable, but giving her zero symptoms. So she was feeling perfectly fine. So she was an old lady, and I gave a consultation as an oncology fellow, and I didn't tell her what she has because the family asked me not to tell her what she has. And I thought it was reasonable not to tell her what she has because she had no symptoms. So why bothering her with the truth? And about three months later she comes back to the hospital. Now she is very sick. She is yellow. She's jaundiced. Her tumor had grown markedly in her liver. And the family again told me not to tell her what she has. And I said, "No. This time she's sick, she's going to die. She needs to know what's going on. I cannot play games with her." And I went down and sat with her, held her hand, and I told her exactly what she had. I told her that she had a bad cancer that grew in three months, that she's going to die from this probably in weeks. And she probably felt my sincerity because all what she did when I finished, she hugged me, gave me a big smile and thanked me. She told me, "I know what I'm gonna do now. I'm gonna take the plane and go to Puerto Rico and die there." And she was kind of happy about her project to go home and die there. And she made her family feel good about it. And I felt that I set her free by telling her where her life is going. And now she felt not only, I think, that she knew what she had so she can make a decision to go home and die there, but I think she felt respected and dignified. And she felt in control of her life. That day I said to myself, "That's it. I should learn from this case. Never again."
Dr. Gabriel Sara: 10:18
So it was a big lesson for me. And after this I did not understand how people could lie.
Explain the temptation.
Dr. Gabriel Sara: 10:27
The temptation is huge. It's huge. Because it is very painful to tell somebody he's gonna die. Very painful to say this to people. You think it's easy for us to say that? It is painful. You don't want to hurt anybody's feelings. So you feel that if you don't say it, it will not be as painful. I had a patient who just passed away this morning. Okay. He was admitted to the hospital four days ago, not doing well, and I knew that he was not gonna make it probably out of the hospital. And I come and I sit down next to him, hold his hand, talk to him. And he tells me, "Doctor, I don't understand where we're going." I told him, "We know exactly where you're going. Your cancer is growing in your lung. You're not gonna survive this. You have probably a few days left." So it sounded horrible to say this to somebody. Even me, who I feel I am experienced in telling the truth and I worship the truth. Don't think it was easy. When he asked me this question with the whole family around me, sitting next to him and crying. You feel like you're a butcher. Like you put the knife in the chest of the guy. But no, it wasn't. I overcame that moment where I hesitated a little bit, but I said, "I can't play around with my words. He's asking me a question. He needs the answer." But I can tell you after I said that, he relaxed. Because now he knew where he was going! And he died this morning very peacefully. The last three days were very peaceful for him and his family. So it's never easy to tell the truth. Never. Never. But it's always rewarding to say the truth. Always.
There's another aspect which is being honest with yourself about your experience. And I know that that also has played a part in your work.
Dr. Gabriel Sara: 12:32
So I am against actually the idea that we oncologists build a wall to protect ourselves from being upset or sad. I don't believe—I think this is actually lying. This is for me lying to yourself. We should hug our patients. We should be happy with them. We should be sad with them. We should cry with them. I don't have any problem with that.
Dr. Gabriel Sara: 12:54
Because I think that it's a dance. You know, you're dancing with a patient very intimately. You are really—just imagine the responsibility you have when you are treating a life-and-death situation, and that patient trusts you. Trusts you more than his family, probably. So I think you need to show—not to show, to feel close to these people. I feel close to all my patients.
I'm reminded of a clip I saw of you singing with a patient while taking bone marrow out.
Dr. Gabriel Sara: 13:26
Yes. Well that's exactly what I'm talking when you have an intimacy with your patient. You know when I look back at this video myself—
What do you see in that video?
Dr. Gabriel Sara: 13:39
Well, I see harmony. Harmony, basically. And I see transforming an intense moment into beautiful moment. Instead of having a painful, scary torture. You know, actually it was fun. We laughed so much after that, the three of us.
I'm wondering if there are any other steps along the way that are significant to forming your ideas about honesty, about truth telling—
Dr. Gabriel Sara: 14:09
I think it's like going to the gym, being honest, being truthful. The more you do it, the better you become at it. And I feel—I am not like super, super old, but I am way older than you guys, and I've been around for a long time, and I am much more aware today about how delicious the truth is. It's delicious.
What does it taste like?
Dr. Gabriel Sara: 14:38
It tastes amazing. You always walk away feeling that you had a great meal. If you are honest. And you are able to be honest with empathy. To be honest by keeping the dignity of the person, to be honest and show them how much you care, and that's why you are so honest with them. And that feeling is
amazing. And patients appreciate it.
What do you tell the doctors and nurses working under you? What sort of advice do you give them in terms of both being good physicians but also being resilient?
Dr. Gabriel Sara: 15:19
It's a work in progress and it's not like one advice. I think it's much more—you can teach them by example more than by talking. I think if they see you operating based on your own principles, they can get what you're talking about.
So they learn by example.
Dr. Gabriel Sara: 15:37
Yeah. Learn by example and also state of mind. You know, you can't prepare your speech. I don't believe in preparing any words I say. I never prepare what I'm gonna say to people. Never. I put myself in a state of mind of listening. That's the most important thing. If I'm gonna talk to you about something that is very important for you or your problem, whatever, I wanna clear my head of my daily life to the point where it's empty. Once it's empty, I can sit with you and feel your feelings.
Sounds like a meditative state.
Dr. Gabriel Sara: 16:12
Yes. And if I am able to do that when I'm sitting with you, now I am not only going to listen to your words, I'm going to hear you're feelings, I'm going to feel your feelings, and I'm gonna talk to your feelings. And the right words will come out from my mouth because I'm in communication with your feelings. But that needs training. It doesn't happen overnight. That needs awareness. And that needs accepting to spend the time to listen to the other person. Today we're not taking the time for anything anymore. We're constantly rushing. So you need to empty your head and be completely available to listen to the other person. And then you know what to say. So with every patient I will say something different depending on the state of mind of that moment.
So it all sounds like if you were to give advice to someone, you say, how does someone learn how to tell the truth? If I were to try to boil down what you said, it's—spend time with people who tell the truth, and really listen to the person that you're talking to.
Dr. Gabriel Sara: 17:18
Read between the lines, listen to what they are really feeling and what they really need.
Dr. Gabriel Sara: 17:22
Exactly. And be a militant of the truth. If the truth is your way of operating, you build gradually strength, inner strength. Because you are validating your principles. And I think when you have principals that are well-grounded, even if you lose everything in life, you remain grounded.
I'm just wondering how this—how do you transfer this to life? When you take off your white coat and go out into the world. Are you a maniac about the truth with your kids?
Dr. Gabriel Sara: 18:00
Oh, more than ever.
With the waiter at the restaurant?
Dr. Gabriel Sara: 18:02
More than ever. More than ever. And I know that my wife or my friends tell me, "Why don't you shut up?" I say, "Listen, if I tell this guy that he didn't do a good job, and with respect, I'm helping him. He's getting feedback. And if I tell him he's doing a great job, I'm helping because I'm giving him feedback." Feedback is critical, but I have to say it with respect. There is a way to talk! I can tell you something really difficult to hear, but if I do it with respect and empathy, you will not feel insulted.
Later in our conversation, we talked about what it means to die a beautiful death. It's a little off-topic, but I loved it too much. I couldn't leave it out.
Dr. Gabriel Sara: 18:48
It doesn't have to be ugly. It doesn't have to be ugly. You don't have to laugh about death, no, I never do. But you can be light about it. And if you have no choice but to die, why does it have to be ugly? Why can't it be beautiful? When I see that it shocks people. I'd like to have beautiful death, why not? You're going to die regardless! So it might as well be a good experience.
What does a beautiful death look like?
Dr. Gabriel Sara: 19:19
I think it's not one way of looking at it, and I think it will change from one patient to the other, from one experience of death to the other. But at least one thing that I think should always prevail is having peace going into the process of dying. Accepting that you're going to die, appreciating what you went through. I find there are five magic words—maybe there are more, but at least those are pretty good—when you're dying is to tell people around you, "Forgive me. I forgive you. Thank you. I love you. Goodbye." If I can say this to my people around me, I think I'll have a beautiful death. But to be able to feel that you can say these things, you have to be going peacefully. You have to be accepting you're dying, and the people around you have to be accepting your death and supporting your death and giving you permission to die. You know the people who love you have to detach themselves from like, "I want to keep you for me." No, I want to give you the freedom to die. And I'm gonna be okay after you die. And that's what is the permission to die. That both patients' family has to give them and the doctors as well. And I think when you give permission to die to somebody, it's a gift. Because they don't feel that they're abandoning you. As long as you are hanging on, they feel that they are stabbing you in the back by dying. That they don't have the right to abandon you. Because after they die, you're gonna be really bad. If you make them understand that, "You know what—you can die. Go ahead. I'm okay. I'm accepting your death. I thank you for what you've done for me," et cetera, et cetera, then you make them feel free. You set them free. You need to set them free. And I tell these things to my patients, what I'm telling you right now, these are things I say to my patients' families and to my patients.
Dr. Sara, thank you so much for being on the podcast.
Dr. Gabriel Sara: 21:31
It's my pleasure. Thank you for coming.
That's all for this episode. If you liked the podcast, please rate and review us on Apple Podcasts and tell a friend about us. We really appreciate it. Road to Resilience is a production of the Icahn School of Medicine at Mount Sinai. Our team includes Katie Ullman, Nicci Hudson, and me, Jon Earle, our executive producers are Dorie Klissas and Lucia Lee. Nicci and Justin Gunn shoot video for us, and Cathy Clarke shoots photographs. From all of us here, thanks for listening. We'll see you in a couple of weeks.