Date Published: June 25, 2019
Overwhelmed by grief for patients who had died, Cardinale Smith, MD, PhD, then an oncology fellow, embarked on a self-care journey that led to unexpected places. Dr. Smith, Director of Quality for Cancer Services at the Mount Sinai Health System, shares the ritual she uses to process loss, offers tips on having hard conversations, and reflects on the end of life.
Oncologists and palliative care specialists commonly experience patient loss and are often affected by unprocessed grief. An approach to mitigate the emotions is self-care; having a self-care and self-awareness plan is crucial when caring for patients with life-limiting cancer.
You're listening to Road to Resilience. I'm Jon Earle.
Cardinale Smith, MD: 00:02
I had this patient who died, and happened to die in the same room that my dad died in in the hospital. And his story was very similar to my story. And so I sat down and I just started to write, and I started to write about my father's memory. And then that triggered me starting to write about this particular patient and I just started writing about what I remembered about him, the good, the bad, the ugly. And I realized when I got up and I finished, I felt so much lighter.
Today you're going to hear a conversation with Cardinale Smith, MD. She's an oncologist and a palliative medicine physician here at Mount Sinai. Now there are a couple of reasons why I wanted to have her on the podcast. The first is that she's got some really smart things to say about how to process loss. It's something she has to do more than most people because many of her patients are critically ill. And as I found out, it's not something she learned in medical school. She had to figure it out on her own and she came up with a ritual that helps her grieve and stay present for the next patient. That's a resilience hack to me. And I think we can all learn from it. Now the second reason is that Dr. Smith has to have really tough conversations all the time. I mean, she has to tell people your cancer has gotten worse and she has to help them in their families, navigate the most difficult period in their life with all the emotions that come with that. And so I really wanted to know how she does it. And I think her answer again, is something that everybody can learn from. So I hope you enjoy this conversation and you get something valuable out of it. Here we go.
So Dr. Smith, can you tell me just a little bit more about your work? Take us through your typical responsibilities, the sort of things you do on a day to day or week to week basis?
Cardinale Smith, MD: 01:47
Okay. So clinically I take care of primarily patients with lung cancer. I do that one day a week in our outpatient cancer center. I also attend on our inpatient palliative care service, so I see patients for consults or in our palliative care unit.
Research is really focused around improving the quality of care for patients with cancer with a special emphasis on minority populations. So disparities in the use of and access to palliative care and hospice services is where my research primarily focuses. Additionally, I do research on physician-patient communication and teach physicians how to communicate better or more empathetically with their patients.
And then from an administrative side, I really oversee the quality program for our cancer center, which is related around improving outcomes for patients with cancer.
So in terms of the clinical side, about how many patients do you see a week and what sorts of illnesses do they have?
Cardinale Smith, MD: 02:52
Yeah, so I see about 20 to 25 patients per week. They primarily have lung cancer, and unfortunately because lung cancer is typically diagnosed later, I would say about 75 percent of my patients are diagnosed with stage four lung cancer, which is incurable. And then the other 25 percent are diagnosed with more earlier stage disease in which the goal of care is cure.
The question I really want to ask you is, were you a really chill, like person, like a child? Like you knew you were going into this specialty, you knew you were going to encounter a lot of really hard stuff.
Cardinale Smith, MD: 03:33
So I do happen to be very chill at baseline. That is my general temperament. However, I don't think that that is why I chose this field as a specialty. I think what initially drew me to this field was science. So, you know, oncology was a field where treatments were changing drastically and that part of it fascinated me. And as I went through training and got to realize there's this big component of oncology that really is about that patient physician relationship. And this continuity in this, there's this connection where patients and their loved ones bring you in to this really hard time and really trust you and you become essentially a part of their family. And there's something that's truly appealing about that. Even if I'm not able to cure everyone, I'm able to really get a sense of what they value most and make sure that I can give them that type of care that I know they would want.
So switching gears a little bit to self-care, where does your self-care journey begin?
Cardinale Smith, MD: 04:45
So it's actually an embarrassing story. When I was in hematology-oncology and palliative medicine fellowship, it was my last year of fellowship and we started this book club. Not really sure why we did that. It's not as if you have tons of time to read for pleasure when you're in training. But the book we chose is called "Leukemia for Chickens.” So if you've never read it or you want to read it, stop listening because I'm going to give a spoiler. So the only time I had to read this book was when I was going on vacation. And in hindsight, that was probably poor planning on my part. But I was on the plane with my husband and we were flying to Puerto Rico and I was reading the book. As I got towards the end of the book, suddenly the person in the story is talking about how he essentially had leukemia, he had a bone marrow transplant, and then he developed a graft-versus-Host disease as a consequence of that transplant and was admitted for a second time and was having really horrific symptoms. And when I turn the page, it said epilogue and I thought I must've missed a page. But in fact the epilogue began with his wife saying, I am now writing this for him as he asked me to continue the story if he was ever unable to continue it because he died. And I became really emotional and started crying, ugly, crying as they say. And I really couldn't stop. And I remember the flight attendant came over to us to ask if I was okay. And even though my husband kept elbowing me to stop crying, I couldn't.
And it was, I realized in that moment that I was remembering all of those patients I had cared for in the previous three to four years that I had been a fellow that had died and that I had actually never grieved for. And in fact, it was even during my fellowship when my own father died of stage four cancer. And I thought about that also and I realized that I took care of all these people and got to know them and their loved ones and they died, and I never grieved for them. I never said goodbye to them in any meaningful way. And I knew that if I was just now at the beginning of my career that this was something I was going to have to address and really have to think about how I was going to acknowledge that and manage it.
So you had never been taught self-care techniques in medical school, for example?
Cardinale Smith, MD: 07:07
I certainly was never taught self-care techniques in medical school. Part of our palliative medicine training does certainly touch on self-care. At some of our meetings we would have, you know, the first couple of minutes where there would be some meditation. But I, you know, as a trainee when you have to like get to the next patient and get to the next patient, it's really hard to take a pause and to focus internally on yourself. And so I never really took advantage of those opportunities. And by the time I finished my palliative care year, which was just one year of four years and then went back to oncology, there certainly are no opportunities at that time to focus on self-care within oncology. And in fact, you know, the book club was an attempt to do that.
Yeah. So you have this moment, you're like, oh man, I need to take care of myself better. And what do you do?
Cardinale Smith, MD: 08:04
First thing I did was I asked my friends, you know, what do you do? I went to some mentors or advisors whom I trust to ask what they do. And I realized that from my friends or my mentors, advisors within oncology, no one really had a good answer.
Wow. How do you explain that? Is that like a macho thing or?
Cardinale Smith, MD: 08:27
You know, truthfully, I think part of that is there is this sense of failure when patients die. That, you know, perhaps as the clinician you didn't do everything you could do. And there is this internal guilt because ultimately we become clinicians, physicians specifically to help cure people, right? To help them live longer lives, and when we don't do that, we see that as failure. It's also something that we're taught, to make a priority, which is why what ultimately happens is that you end up getting a lot of burnout within health care. And in the field of oncology specifically, that's very high.
So you've talked to your oncology colleagues, they didn't have good answer for you. You talked to your friends, they started to have some answers. And you said a moment ago that you started experimenting with some of these things. What were some of the things that you experimented with?
Cardinale Smith, MD: 09:20
Yeah, I tried meditation in the many forms in which it comes in, including the apps. Thinking in my train ride in, I'll do the app and it'll be a couple of minutes and I'll get it done. Or even longer, you know, at home before I had children. It is really, for me personally, it's really hard for me to shut my brain down. And I recognize that I likely did not give it as much energy and effort as I could have. But if I had to put so much work into just shutting down my brain, I figured there was something else that I could do. So then I turn to, I started trying to exercise, you know, which is not something that I sustained particularly after I had children because there are really just only so many hours in the day. Then I turned to reading. Reading is certainly a pleasure of mine and I still do it, and I read trashy books that I probably won't talk about, but you know, along the lines of “50 Shades of Gray” because they helped me get outside of myself, you know, tried to read self-help books and medical dramas, because I feel like that's what I do all day. Then I turned to swimming. I really enjoyed swimming, I did that with one of my daughters. But none of those things were things that I really felt like were something that were sustainable long-term.
And you were still feeling like whatever this thing was inside of you wasn't being processed or?
Cardinale Smith, MD: 10:56
Is that accurate?
Cardinale Smith, MD: 10:57
I would say that's accurate. You know, I would find that when I was at home with my family, I would be preoccupied or if I was watching a TV show and there was a scene on this show that somehow triggered the memory of a patient, I would remember that patient, and then I would start to get tearful and that's, you know, not quite normal. Or if I was speaking to a loved one or a friend and they said something that reminded me of a conversation I had with someone or a specific circumstance, particularly with a patient or their family, then I would also get a little sad, and then I would start to get angry and I had no idea where those feelings were coming from.
So how did you end up finding a way to process it?
Cardinale Smith, MD: 11:44
Trial and error. When I was in college, I always knew I liked writing, but I never wrote for, not to say fun, but for my own pleasure. And one day I had this patient who died and he happened to die in the same room that my dad died in, in the hospital. And His story was very similar to my story and I realized that, you know, that really brought back memories of my own father's death. And so I sat down and I just started to write. I came home one day and I just started to write. And I started to write about my father's memory and the interactions that I had around his death, and then that triggered me starting to write about this particular patient. And I just started writing about what I remembered about him, the good, the bad, the ugly. And I essentially started to write like a goodbye. It was like a goodbye. I finished that with, you know, it was great to have the pleasure of taking care of you. I hope you're in a better place till next time. And that was it. And then I realized when I got up and I finished, I felt so much lighter. It felt nice to do it. And I didn't know if that was because it was related to my father or him, but when I had the next patient who died, I sat down and decided just to write about that person similarly. And I realized again, it felt lighter. It was very, it was closure for me. I felt like it was a really great way for me to honor that person's memory and yet also say goodbye. And so I started doing that for probably close to a year.
And I kept this journal and I would just, every time write in this journal, and then my daughter who started to learn how to read, picked it up one day and she's like, mom, what's this? What's this? And I thought, oh no. And I went back and I had never previously read the passages that I wrote before. And as I started reading them, it brought back all of the memories of those patients and I started to, I felt sad again at that loss. And so I don't know where it came from, but I just had the idea that I would start shredding these entries after I wrote them. So what has now become my practice through trial and error is, once I have a patient who dies and it doesn't have to be that same day, but certainly within that week, you know, once the house is quiet, I go to my desk, I like an electric candle, and I write about that person. Usually with a glass of wine, but maybe sometimes with water. And then when I'm done I blow out the candle or turn it off, and shred that piece of paper. And that shredding that piece of paper feels really final and like closure to me. And it very much internally feels like I've now closed the door on one chapter and I'm ready to move forward to the next.
So do you have a piece of writing that you can share with us today?
Cardinale Smith, MD: 14:55
Yes, I do.
I first met you about one and a half years ago. What I remember most about that encounter was how I was struck by your intelligence, both street smarts and book smarts and also how your anxiety and fear of the world was utterly paralyzing. The world had not been fair to you. And I often wondered what life could have been like for you had you had different experiences and did not have an incurable lung cancer at such a young age. Unfortunately, your cancer did not respond well to any treatment we gave you. Your anxiety was certainly a challenge. And I can remember more than one occasion when I felt apprehension when I got your email or MyChart message. Caring for you was hard with multiple exclamation points. It took twice as long and was incredibly draining. It's hard not to feel like somehow I let you down instead of the inadequacy of our current treatment options. Still I think my team and I did the best we could given the resources of the healthcare system and your own abilities. You enjoyed two trips during your treatment and I'm overjoyed that you had the opportunity to enjoy them. In the end, I believe you had a peaceful death. I was able to say goodbye to you, which is sadly something I'm not always able to do with my other patients. I know faith was important to you and I hope that provided you with solace and that you are now free. May your memory be a blessing.
Thank you. There's so much that I love about that. It's like it's personal, but it's also a very kind of real and level headed and it's, I guess this ties into something I am wondering about, it's like, how do you protect yourself without desensitizing yourself?
Cardinale Smith, MD: 16:48
Oh, that is a great question. I don't know that I do that 100 percent all of the time. I think that I have come to a place where I'm more insightful. And so when I realized that I'm being more curt or I'm feel like I'm being much more dismissive or short, then I realize, ah, I've probably hit a wall. And I'm reaching, you know, some form of burnout. And then that's when I will take a step back. And so actually that happened to me recently and I told my husband, I just need a little break. And so we randomly booked the trip for a couple of days to go somewhere with the girls. You know, I don't know that there is a way to protect 100 percent of that. It's hard in this environment. The best I can do for myself in this moment is trying to be aware of when that happens and also my team and I challenge each other to recognize that in one another. And I think that's critically important because none of what I do is alone. And I have, you know, an interdisciplinary team of nurses, social workers, chaplains who also hold me accountable and that's really helpful.
What do you hope that other physicians can learn from your experience and what you've learned?
Cardinale Smith, MD: 18:11
Yeah. Well, I hope, you know, other physicians will realize that self-care is not a bunch of hand-holding Kumbaya stories and in fact, that this whole topic of resilience and self-care, that there is an evidence and science basis for it into why it is so incredibly important. Also that it's not a one size fits all approach. So, you know, don't get thrown off if people tell you you have to go do Reiki or meditation, you just have to find what works for yourself, but you have to work on it.
Is there a spiritual component?
Cardinale Smith, MD: 18:56
Oh, that is a hard question for me as, you know, I grew up very Roman Catholic. Church every day. Oh yes. Church every day until I was 21. And I decided I didn't have to do that anymore. I stopped church everyday probably when I went to college. But, very much entrenched in that religion. So yes, spirituality, I don't know what form that is though. I think that's still something that I'm figuring out for myself.
What are your tips for kind of, I guess I would say delivering really hard news?
Cardinale Smith, MD: 19:40
So the motto that I live by is that communication skills can be learned and therefore they can be taught. So when delivering bad news, there is actually a communication skills scaffolding for that. It has several different acronyms, but the basic premise is, one to make sure you have all the right people in the room, who needs to hear the information. Two, is that you get a sense of what that patient or loved one knows about the underlying illness. And that's because if you start to tell them what you know and they're not there, then you've just unleashed Pandora's box. Next is to really invite the conversation and ask if it's okay to share what you know, because if they say anything other than yes, you're not going to be in the place where they're going to be able to hear the news. And then next is really to give that news, but to give that news in a way that there is a warning shot, you know, whether that is, unfortunately, I wish I had better news, to give it succinctly without a lot of medical. So, you know, I could say the cat scan shows that the cancer in the liver has grown by several centimeters and also in the lung. Or I can simply say the cancer has gotten worse in the liver and in the lungs.
And then the next part is to recognize that people are going to have emotion when they hear the bad news, right? So it is to respond to that emotion by not hearing questions as cognitive questions. So, what does this all mean? Either I could take that as a cognitive to say, well, this means that your cancer has gotten worse and then we have to talk about the next steps in treatment. Or you can take that as the emotional question it probably is and then respond with, I can only imagine how scary it must be to hear this news. And then finally summarizing and strategizing about next steps. So, you know, I know we talked about a lot today, if someone asks you sort of what's going on, what are you going to tell them? And then making sure that information is correct and saying, that's right and here's what we're going to do now.
What's something that happens in your work that you can't explain?
Cardinale Smith, MD: 22:00
That's a really interesting and hard question. I can think of two things they're kind of related. I would say one is, there is this phenomenon that I see with patients who are at the end of life where, I don't know if you want to call it a rally, but they have this moment of intense clarity. Either, you know, the day or several days before their death where they just all of the sudden get more energy, they're more interactive, they're having great conversations with their whomever family and loved ones, and everyone's like, oh, they're getting better, they're improving, and then they die quickly thereafter. And that's something that I cannot explain why that happens, but it is something that I see frequently.
What was the other thing?
Cardinale Smith, MD: 23:00
Oh. The other thing is, so patients with advanced cancer who are no longer getting cancer directed therapies, so no chemo, radiation, nothing for the cancer itself who choose to get supportive care only. So palliative care only, whether that's with hospice or not, often live longer than I anticipate them to do. And I'm thinking of one patient actually who was just disenrolled from hospice after being on it for nine months with stage four lung cancer that's not being treated. I think there are certainly are some reasons for that and we know that focusing on someone's symptoms and quality of life can lead to prolonged survival, but often not in those terms. So who knows what's happening with the actual biology of that cancer that's contributing to that.
Wow. What does death sound like?
Cardinale Smith, MD: 24:13
I think that depends on the circumstance. I think death can have no sound at all or death can sound, you know, like my toddler when she's having a tantrum. It can sound like screaming and wailing and lots of sadness.
What's something you've learned about death and dying from your patients?
Cardinale Smith, MD: 24:47
I've learned that death is promised to everyone, that it will happen to everyone eventually, and that it is an intricately personal experience. And that even though patients may not choose a death that I would choose for myself or for my loved ones, ultimately it is aligned with how they have lived their life. And that really my part in that journey and their ability to intrust me in helping them through it is to make sure that I have heard them and listened to them and provide them with the kind of care that they have asked for when it's the end of their life.
And what have they taught you about how to live a good life?
Cardinale Smith, MD: 25:38
Oh, they have taught me to not neglect the little things in life and that each moment is precious. And it can be so hard in the day to day to realize that this thing is not really a big thing in the grand scheme of things. And that sometimes you just have to learn to let things go. And I won't say that I am perfect at that, but I think that I am definitely better than others.
Thank you so much, Dr. Smith.
Cardinale Smith, MD: 26:10
It's been such a pleasure.
Cardinale Smith, MD: 26:14
It's been a pleasure. Thank you.
Cardinale Smith, MD is an Associate Professor of Medicine in the division of Hematology and Medical Oncology and the department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai. She's also the Director of Quality for Cancer at the Mount Sinai Health System. Thanks so much Dr. Smith for sharing your story with us. Road to Resilience is the production of the Icahn School of Medicine at Mount Sinai. It's produced by Katie Ullman, Nicci Hudson, and me, Jon Earle. Our executive producers are Dorie Klissas and Lucia Lee. We're available on Apple Podcasts, Spotify, or wherever you go to get your podcasts. If you like the show, please subscribe and rate us on Apple podcasts, and if you really liked the show, say hi. Our email address firstname.lastname@example.org. That's it for this episode. I'm Jon Earle. We'll see you next month with more stories from the Road to Resilience.