Benzi Kluger  0:06  

Welcome to The Cure for Bullshit, a podcast where we interview patients, doctors, researchers and skeptics about their practical advice for navigating the healthcare system and avoiding medical scans. These interviews will also be part of a forthcoming book that will serve as a master class for avoiding and dealing with medical bullshit. I'm your host Benzi Kluger neurologist, researcher and advocate for empowering citizens to play a greater role in directing their health and health care.

Janece Matsko  0:30  

And I'm your co host/producer Janece Matsko. Resident bullshit aficionado and devil's advocate here on The Cure for Bullshit.

Benzi Kluger  0:44  

This is episode one "Love and Bullshit: practicing compassionate medicine in times of COVID". In this episode, we interviewed Rob Horowitz, Chief of palliative care at the University of Rochester, about the challenges of supporting people with serious illness and even terminal illnesses who may have very different views about medicine and truth and their doctors. Along the way, we'll hear about his unplanned journey into palliative care, the importance of love and medicine, and his advice for curing bullshit with the palliative care approach. Okay, Rob, could you introduce yourself to our audience?

Rob Horowitz  1:17  

So yeah, I'm from Rochester, and I'm a I'm a father and, and a husband and a friend and a community member and a doctor. You know, I see myself as a healer whose work has been many things over the 30 years, I've been doctoring. My calling that I discovered somewhere along the way, what I'm best at what I think I'm most a value to the rest of the world is in palliative care is providing real you know, as you call it, Benzi person centered but I say patient and family centered care that is focused on living the best life possible in the midst of really serious illness. Why

Benzi Kluger  2:03  

don't we start, you know, since this is the cure for bullshit with with medical bullshit. And I don't know if any of you had any recent experiences with medical bullshit, I could think of several that probably would have crossed your path. But I don't know if there's any fresh shot bullshit on your mind that you'd want to talk about.

Rob Horowitz  2:20  

I came in here with such an open hearted and loving, loving nature, I wasn't prepared to talk about bullshit, even though I know that was the name of the podcast. Please, just primed me a little bit here. Give me a couple of cues. What are you thinking about Benzi?

Benzi Kluger  2:37  

You know, one thing that's, you know, come up a lot. And I think there was actually a grand rounds on this recently is about vaccines. 

Janece Matsko  2:44  

What's a Grand Rounds? 

Benzi Kluger  2:46  

Sorry, yeah, Grant Grand Rounds is a pompo us name for a lecture, makes it sound more grandiose. But it's basically a doctor giving a lecture. And there was a lecture on "the edge of empathy" that had to do... and this is, I think, very pertinent actually, to our discussion of bullshit. You know, 90% 95% of the people in our ICU and a lot of people that Rob is seeing are people who have a preventable illness, which is COVID, who have not gotten vaccines, and sometimes even on their deathbeds, or, you know, refusing and holding their guns, that it was a good decision to not get a vaccine. You know, this is not a place to pass judgment or blame, but I won't speak for up but I, you know, myself, I'm vaccinated, I do believe that the vaccines can save lives. I can respect some of the reasons why people don't, but it sometimes gets really tough when we're seeing people who are dying, who maybe didn't need to die if they came at information in a different way.

Rob Horowitz  3:46  

Right. Yeah. Big sigh there. Yeah. I you know, I can share this. Yes. So I'm, I'm, I'm vaccinated. And I think Benzi is, you know, Ja nece, you would know this yet, but um, five weeks ago, my family of five I have three sons in their 20s. And my wife and I were vacationing our long awaited vacation in the Adirondacks. First time since COVID, that we were all together and we all got COVID 

Janece Matsko  4:13  

Oh, no! 

Rob Horowitz  4:14  

We're all quite careful. Four of us medical professionals, or healthcare professionals in some way, had been in a vaccine only wedding. And prior to which there was there was a gathering that was going to be an indoor concert or an outdoor concert became an indoor concert. We're guessing that's the the focus, the locus of his infection, and we all got it. And none of us got terribly sick, but we had fevers and felt pretty yucky for five, six days and then got better. It has been painful witnessing the conflict that has arisen about this and the politicization of the vaccine or no vaccine, which I've not seen in my lifetime before, at least to this extent. When I drove home on Monday there was the weekly gathering of people carrying placards and waving flags and standing strong against vaccine mandates with Fauci dressed up as Hitler. You know, in my heart, I feel terribly mixed about it, because I see in that crowd, some people I know some health care professionals I know and care about and good people who are feeling affronted by the mandate and are actually so committed to their belief system, which is not mine, but that they're, they're gonna lose their jobs or livelihoods.

Janece Matsko  5:43  

And I know, we don't necessarily want to make this entire podcast about misinformation surrounding COVID, we obviously could very easily. But just pretty quickly, I did have a question about how your views of like medical misinformation or medical bullshit, if you will, how that has changed over the course of the COVID pandemic for you,

Rob Horowitz  6:09  

You know, over the course of medical training, and then apprenticeship and then doing the work I, I've really come to be maybe even more skeptical than I used to be. And more open to the reality that this path to wholeness, that healing of patient from from being a person with illness, you know, contracted around that identity to feeling whole again, like a person is about a lot more than medicine, or therapies, per se, and a lot more about relationship, connections, community, even, dare I say, love, you know, I think love is on the plate here in terms of capacity for healing. So I'm not quite sure that my, my bullshit meter, you know, has has been amplified all that much in the last while I think it's, I think it's ever on in some ways, while not trying to avoid it, I'm just aware that the the healing is about so many things. Outside of that,

Benzi Kluger  7:21  

you know, part of the heart of palliative care is trying to provide care that is consistent with this person and their belief system. And that belief system, you know, may not include vaccines, it may not include Western medicine even well before we would have patients in ICU who are Christian scientists or other things and may not want a blood transfusion. And I can remember as an intern, you know, just seeing the moral distress in some of my attendings who, you know, just did not want to let somebody died, that objectively was preventable, but maybe subjectively wasn't preventable. And that was acceptable to the person who was making that decision, right, and trying to honor their integrity. And I actually wouldn't even use the word bullshit there. Because I actually do want to really honor and respect people's personal beliefs. Sure. So what you're saying kind of gets at that. And then there's also the public bullshit, which is like horribly enriching. And when people take advantage of beliefs or blind spots, that that causes me a lot of moral distress, a lot mor e moral distress, actually, then dealing with the individual one on one who may make a decision. I don't agree with.

Rob Horowitz  8:32  

The dedication to not get political, which many of us say, and I say that sometimes I don't want this to get political Well, in ways that all is, you know, our interaction with one another in community is political by its nature, I think, in some ways, but not long ago, I was in the room of a patient who was dying in the discussion. The one of the family members brought up a question around vaccination, and said, "I thought proudly, he was vaccinated", and I thought, Ah, I'm safe. I'm safe here. And I said, "Oh, I'm so glad there are so many who aren't, you are now well protected". And the other person or their family member in the room at the bedside of the dying person said, "What? What? What do you mean by that?" That, I don't think she said bullshit, but something very close to that. And I asked what she meant, and she said, you know, "there are people trying to convince us to put that evil stuff in our bodies, and I won't have it." And all I did then was was heard her and said, "I honor your decision on this", and then talked about the patient in front of me and, you know, Benzi, like you're saying, I mean, I don't think there's a fruitful discussion to be had there are argument to be had, at least not at that moment in time. The challenge is how that information was ingested. or how it came to be that she had made this decision? Where was her source of information? That's where I, I take issue.

Janece Matsko  10:08  

What do you see as the cure for bullshit in your understanding and perception of what bullshit is,

Rob Horowitz  10:15  

I don't know if this is your cure, but it's at least it's a guard against bullshit, I suppose to some extent. Benzi the three E's is what comes to mind. So those three E's is for me to keep in mind when I'm teaching this are empower. I want to be empowered, I want to empower my patients, my families, to say, I do have the power here, this is my body, this is my life, I, you know, I own this body. And I have agency over it, I want you to empower me, and I want you to be explicit with me. So I don't want euphmizing. And I don't like hearing bad news. But I want to hear the truth. And if it's bad, I want to hear it. So Empower, explicit and empathetic. Compassionate really is the action verb, I suppose. But E's are easier to remember. So I hear medical students on this all the time saying, Oh, I was so blunt. By blunt, I think people mean explicit without empathy, or without compassion. Yeah, and that I think, is far from ideal. But being explicit, telling the truth with permission, and with kindness. And with heart, I don't think those are incompatible. Even though often it appears like it might be

Benzi Kluger  11:33  

I love it, I hadn't, hadn't framed the cure for bullshit in terms of the three E's. 

Janece Matsko  11:38  

I like it 

Benzi Kluger  11:39  

I mean, another area this comes up in palliative care is people have hopes for miracles. And that may be surprising, but it's actually a source of consternation for doctors are like, Why don't people you know, drop their miracles, drop this unrealistic hope and go with the program here. Like, you know, people have too many miracles that makes them a difficult patient,

Janece Matsko  12:01  

right? Can I Can I jump in there a little bit. So my, my primary experience with a medical system, in the past few years was, so my father had a very sudden, very extreme heart attack. And, you know, medical technology was able to keep him clinically alive. And in those first few hours, I was definitely, in my mind, at least one of those people that was like, wait a minute, I see it on TV all the time, that you, if you can get to a hospital, you're gonna be okay. So I had to go through this grieving process of like, my expectations when it comes to the medical field and what they are capable of. And I think there's a lot of media fluff that happens of like the power of medical professionals, and we put all of these expectations on you all, which isn't fair. And also, then there's, you know, that added level of like, well, I also have my faith, which tells me that remarkable things are possible. So like, Why can't those two things work together to have this miracle happen?

Rob Horowitz  13:12  

Sure. There's been at least one study that looked at Gosh, this is many years ago now must be 20 years ago, maybe more that looked at all the TV depictions of CPR, and their outcomes, and the vast majority of those had people walking, dancing, making love and the next next half hour next episode.

Janece Matsko  13:31  

Yeah, I actually did witness some CPR that was performed on my father. And now every time I see it on TV, I'm like, That is a joke.

Rob Horowitz  13:39  

Yeah. So so yeah. So the question of miracle, though, Janece, is it okay to ask you something? Of course, you know, so Dad, dad had this severe heart attack and was on life support, it sounds like, and you said you had your faith. I don't know if you met your faith in the medical community, your faith in other ways. Was was there in you as Benzi is asking about miracle? Was there some wandering or hoping or praying or yearning for things to happen?

Janece Matsko  14:11  

Not so much in me personally, you know, I I'm kind of secular in my faith. But yeah, absolutely. I think there's still some of that mentality culturally that spread and in other people that I could I could see how, how those would be compounding factors in this desire for miracles and this like, kind of otherworldly belief in the capabilities of doctors and the medical system. And then on top of that, also, like varied levels of spiritual faith.

Rob Horowitz  14:44  

Right. It's amazing how it plays out. I appreciate that and Benzi I appreciate your asking. Yeah. Because Because what comes up in our discussions around difficult medical decisions, you know, patient a person has had a catastrophic brain injury, let's say a traumatic  brain injury imagine or severe stroke and is no longer communicate is on life support. So Benzi and his colleagues in neurology are often asked, you know, to prognosticate, what what do we think, given the scan given the function? What do we think the capacity for recovery is? It's far from exact science, there are some signs that will lead us toward or away from some likelihood of some degree of recovery. It is normal and natural in that setting, then to you know, to wonder how much power the body the human's.. the body's capacity has for healing. And it does that all the time, it heals and all sorts of ways, how much we the medical team can help facilitate that, or at least remove obstacles from it happening, I suppose. And then, and to the extent there may be or are other energies that play processes at play, you know, how much they might figure those things that we can't measure, we can't see that there aren't material, maybe whatever that all is, outside of our power to understand. Things happen. Amazing things happen sometimes. I suppose in general, it's hard for rationalists scientists, often not all scientists to engage in a discussion around probabilities and medical interventions that are that are material and measurable, and incorporate into that a discussion around miracle they seem such separate realms, to many. I do think, though, it's possible to allow both in the room just like compassion and hard truth. And so to share what I believe is the truth given what I know that the best we can tell from this vantage with our strong but imperfect capacities, that the likelihood of your loved ones recovery is extremely low. At the same time, you're welcome. You're welcome to have a miracle. And I will welcome the miracle in the room if it happens. No one wants to take away hope. No one wants to vanquish the possibility of a miracle. I think though, we are obliged to share what we know as frankly and kindly as we can, and allow for the possibility that there are many things outside of what we know that may be at play here.  

Benzi Kluger  17:28  

 I think one of the gifts of palliative care is really helping us to focus on the relationship. More so than the medical facts, or at Rochester, we use the fancy term biomedical model, which just means that you know, we are treating a collection of cells in different processes and chemistry as opposed to a person. I kind of frame things more in terms of regret. And what can we do to try to minimize regret? And it's not about convincing somebody a miracle is or isn't possible. It's about When the smoke clears. are they're going to have regrets about what happened? And are they going to feel connected and supported? And that's kind of become my approach. And I don't know, Rob, if you've developed something similar, I have a different take on it. 

Rob Horowitz  18:11  

 Very much I, you know, I don't use the language of regret. But I think that's very much what, what, what I do and what I encourage colleagues to do, and those who are learning from me as to help the people before us do the best they can now and to consider in the calculus in the planning, how they'll look back on this. Yeah. And so part of what we're doing right now, is taking care of your loved one. And you now and your future you.

Unknown Speaker  18:39  

Yeah, I think I think so it's having, bringing this wider perspective to the table, you know, that we've been through, you know, not this individual situation, but similar situations. And so we can share that perspective, hopefully share some wisdom, try to bring them again, using, you know, using words like peace, love, meaning regret, you know, these very personal words, these very relationship centered words, at the end of the day, and that there's not an objectively right decision. It's really measured in these kind of fuzzier terms like, you know, five years later, as you say, Do they look back and feel like they did the right thing? Or they, you know, they stood by their dad, and you know, I'm glad we did x, or I'm glad we didn't do Y or whatever.

Unknown Speaker  19:23  

I want to talk about love, can we do that? 

Benzi Kluger  19:25  

yeah!

Janece Matsko  19:25  

Yes, absolutely. 

Rob Horowitz  19:26  

So fresh on my mind from a from a conversation not long ago. Last time, I was working on my inpatient unit. So we have a palliative care unit or a hospital, and I'm one of the physicians who serves that service, two weeks at a time and seeing a woman I had known from zoom visits over the course of six months, who had a very, very severe and progressing cancer. She was from 90 or so miles away, and so zoom actually virtual visits are the perfect way to help take care of people who are home and suffering, were able to look each other more or less than the eyes, you know, between camera and screen, and really have heartful conversation about what was going on treating her pain as best we could. And she came in hospital because her pain became unbearable, the cancer was progressing, and she was on our unit to try to get her as comfortable as possible with a treatment plan that would allow her to return home to die ultimately. And this was the first time we met in person, face to face. And we knew each other from multiple visits over over zoom, but it's our first time meeting. And I was accompanied by the resident, I came in the room and she cried. And I cried. And I sat at the edge of the bed. And we talked a bit and we talked about what was going on in as you're saying Benzi truthful and compassionate way. And then included dying and included her grief about leaving her children behind and her wondering what was going to come next. And and could we get her pain under control enough that she could be home? And what would would she be accompanied as she died? And it was a very moving conversation. And at one point she began weeping. And and she said, "You, You" pointed to me? She said, "How do you do this every day? How can you do this?" And what I said and this is where my resident was was was, I'm afraid I kind of freaked her out. We talked about it afterwards. I said, "Because I love you." And I and I said her name. And I said I hope that's okay to hear. And she said "it's so good to hear." And she didn't get better. But something happened in that moment that that was meaningful to her. And to me. I mean, there's so many power differentials there that I need to be super sensitive to. And at the same time I was taken with love, it's love. And we despite it being COVID I'm looking side to side in case somebody's watching, we hugged at the end of this visit and ended it and I asked my resident how that went in. She said it was okay. I've just never seen anyone say that to a patient before. But But I share that this this this notion of of loving our patients. And we do we don't love them all the same. We don't love them all. By which I really mean this very specific, you know, heart opening, welcoming of who they are and all of who they are, unconditionally. That doesn't mean without opinion. That's powerful. I was about to say the word medicine, I'm not sure that's medicine, but that's powerful healing.

Unknown Speaker  22:46  

You know, to me, I'm hearing at least that, you know that there was an impulse of you that just had to come out and, and almost always I mean, that impulse is right on. I mean it, you know, once you learn to trust that part of yourself, whether it call it healing or medicine, I mean, that's always you know, for me, it's always it's the target it you know, we don't we don't use the word love a lot in the world of medicine. And I think it's a shame when you were telling that story. One of my flashbacks with for my time at Colorado, we would have a beginning of the day, we would set an intention for the day. And, you know, our intention might be that I want to be present. But when we were doing this, at least early on, I felt a bit uncomfortable. You know, initially it was like our private group and our chaplain in social worker and people that I would consider my friends. And then we had residents and fellows who are joining us for this morning intention setting. And I don't know, I probably underestimate how much people already think I'm a weirdo. I was like, If they didn't already think I was a weirdo they're going to think so now. But But I would say nine times out of 10 for medical students and residents and fellows. It was a really positive experience. Yeah. I mean, it's kind of what brings people into medicine in the first place. Then it gets beaten out of them, yes, but to be able to show up with kindness and with love and compassion. And for us to be talking about it and to use those same words that people will often use in their medical student essays that then they don't use again for the rest of their careers. Right. can be very, I think healing for us as professionals.

Rob Horowitz  24:32  

Yeah, working with medical students, it is something to see that the data is clear that the empathy by the various measures diminishes over time during medical school. That's for lots of reasons. Part of it, though, you can see the medical students from day one and I meet with them day one in their first intro to clinical medicine interviewing class, and see how eager and earnest they are to be of service to touch people's lives. And I say to love they they rarely volunteer that but I believe that is true. And when I say that, I usually get some smiles and nods, even if that's language, they're not comfortable quite with, and how quickly then even that first interview when they're when they're putting on the white coat and introducing themselves as a medical student, Rob Horwitz here to... fumbling over their words, because they're trying to put on another persona. And it feels as if the only way and I remember this, the only way to put on this other way of being is to suppress or eradicate the one that I came into the room with in the first place. Because this calls for me to be serious to have gravitas to, you know, to be the expert. And with that, if if making room for that means giving up who we are, what a terrible sacrifice, and many of us do, and many of us have, and I certainly have, over the years sacrificed some of my core in order to do the work. Both because I thought I had to at points, and I think I just didn't know how to make room for all of me. So this notion of the healing of the healer, you know, making whole again, us, you know, if we're honoring our calling and doing this work from our heart, then then our healing is possible. And I think in that then healing up our patients and families making them whole again, persons is possible.

Janece Matsko  26:26  

Well, and I certainly don't know from experience, but I understand that becoming a physician, just a physician, not even specializing in in a particular field is a long and hard road. And you know, you often hear people say, like, why did you become a doctor? Oh, I want to help people, I want to save lives, right? There are many paths to those end goals in our society. And you know, such as, as other first responders, firefighters, that kind of thing. But also just in, in personal interaction, social work, and, and that kind of thing. What is it about medicine? More specifically, like, how is medicine that means to that goal?

Rob Horowitz  27:13  

Yeah, that's a that's a it's a good question. A hard one. So it's hard work. And but there are more than a million physicians in the United States right now active right now. So it's, it's not that rare a thing and it's special. It's work I'm very proud of, I'm glad to be doing it. I'm quite I have fidelity to it in some ways. I came to medicine. With skepticism, I had an incredibly nonlinear path into medicine, I really did non linearity. I think that's really important. And in a way, I thought, I think when I was in grade school, that I was destined to be a doctor, you know, I grew up in a middle class suburb of Rochester, a reformed Jewish household. There were no doctors in the family, but it just somehow felt like that's where I was headed. I can't honestly tell you why, except that I had a friend down the street who had a book about surgery. And I thought, well, that looks cool. And I knew my folks would be proud.  That's all I can tell you. And I remember in high school, then I applied to college, and I got into college and I was on the pre med track and two years into it, I just, I just didn't trust it. It just didn't feel right. I just it wasn't informed by life experience in any particular way. Other than I knew I like to make people comfortable. I like to, I like to listen to stories I like to I had a sensitivity to, I guess I would say suffering in some way. So So I stopped college two years in and I grew my hair almost as long as Benzies was as last I saw it and hitchhiked around the states and did this subversive thing and, and ultimately started doing some work, I had to support myself and found work in human services, taking care of kids and residential treatment for at the time, we call that emotional disturbance. But these were kids who were mostly marginalized by incredibly chaotic home lives and socio demographics. And and I loved doing that work. And I loved being with fellow humans whose lives I had not experienced in that way. But But in some way, one of my colleagues or I member said, you know, Rob, no, you haven't lived their life, but you know something about what it is to be in pain. You know that from some of your own life experience and losses, even if they're not these kids losses, and that that has always stuck with me and actually figured greatly in my decision eight years later, after doing other work with people struggling with substance use, that figured into after a friend of mine from grade school died, realizing that we only have so much time I, and that my caring for others was really important to me. And I looked at a number of options in medicine just felt, right.

Benzi Kluger  30:11  

So, fast forward a bit. You finished medical school and residency, and then you got a job not in palliative care, right? And then at some point is switched to palliative care. Yeah. What? What prompted that

Rob Horowitz  30:25  

I pursued a residency in medicine and pediatrics, which means I take care of complicated illness and children and adults, and to support my then growing family coming out of residency with three kids at 33 with a huge debt. I worked in ERs, rural emergency departments in my region, and I really liked that word quite a lot. I never really thought of myself as a so called adrenaline junkie, but I was good under pressure. I liked taking care of the sickest of the sick, I liked being the one who would attempt to resuscitate someone who was destined to die. And rarely did that. Prevent the dying that was going to happen. But I sure took care of a lot of people who arrived in pain and unsure, offered a lot of comfort. I liked that. And over time, I gravitated towards not those coming in who needed the resuscitation. But but the old guy who was coming in with another bout of emphysema attack, who just wasn't sure he wanted to keep coming into the frickin hospital Doc, I don't know, do I really want to be here again, I really was drawn to that, or to the patient was coming in who was clearly dying, dying. I was good at that. And something. Something in me said, Wow, this, this is really powerful work. So I found that I was I was good at that I was drawn to that I was good at comforting at humanizing this this really scary, last experience for some people. And so between that and taking care of another practice I did was running our adult cystic fibrosis program in Rochester for a number of years. And that is largely palliative care at that time. These are folks living with chronic progressive disease, life shortening disease and in the adult population, while lifespan has increased and the miracle of lung transplant has prolonged life dramatically for many, I was taking care of a lot of young adults who were dying. And ultimately, the final key was at one of their funerals. I was asked if I would give the eulogy, because the family just really appreciated me and they liked the way I talked and yeah. And that was some of my best work and to stand up there. Sharing a eulogy with a crowd of people crying as they cried and to think and my patient has died. And this is some of my best work. I somehow knew that what a weird experience. That is, right? Yeah. And in the audience was a friend of ours. You know, Dave Coronas, Benzi pediatric palliative care person and he he came up to me and said, "Rob, have you heard of palliative care?" And I said "I don't know if I want to do that work, Dave." And anyways, a year later or so I made the switch.

Janece Matsko  33:26  

We've talked about it several times. And I know that some of the listeners maybe have gathered what palliative or palliative power, 

Rob Horowitz  33:34  

yeah pal, we're your pal. 

Janece Matsko  33:36  

Oh, there you go. I like it. Palliative care what that is and what that entails in in terms of somebody's experience within the medical care system. 

Rob Horowitz  33:47  

Yeah, and Benzi I wanna I want to hear your your sort of take on my take. It's interesting, because there's a lot of debate about how to define this thing. There was not long ago, a very long article in one of the main journals of around palliative care. That was an attempt to reach a consensus definition of palliative care with experts across the world and they could not reach a consensus. There's so much division in terms of even defining what this crazy specialty is, but it has it clearly. The specialty came out of mounting evidence in the 70s but more of the 80s and 90s that incredible advances in technology and technological medicine. We're doing amazing things, changing life ending illnesses to chronic illnesses, HIV one, cancer, many others transplants incredible stuff. And people who were sicker and dying and mortality truly being a universal reality for folks. They were left not as well attended to as it should have been, and people were dying not well. And so out of that gap came a focus on the very large and growing group of of human beings in the world who have serious illness, illness that tends to shorten life and or really impair function, or life engagement in meaningful ways for the person with the disease and or their loved ones. This palliative care is really focused on helping enhance their well being throughout the course of that of their life. A lot of that focus in the beginning was strictly at end of life. Palliative care was called when people qualified for hospice, meaning it was likely they had less than six months to live, and most of the time that was in the last days or a week. But over time, palliative care as a specialty has grown to really take care of more and more people and communities of people with different kinds of serious illness, sometimes from the time of diagnosis, even with the potentiality that they're going to be living a normal lifespan or, or decades.

Janece Matsko  36:01  

Yeah, something about what you said made me think I was like, hmm, in a way, like all people who care for other people are caring for someone who is dying, because yeah, we all die. At some point, we're all being cared for up until the point that we die. So but I think that differentiator of people who are seriously ill in in need of a little bit more medical attention than just kind of maintenance, or, you know, are dealing with chronic pain and chronic issues, I think, interesting differentiator there,

Benzi Kluger  36:33  

That was kind of one of my moments that brought me into palliative care. And she was I was at a Buddhist monastery. And I was there because I was in a bit of an existential crisis about what I was doing in medicine. And a monk there is a close friend of mine, meets up and volunteered at hospice. And to me, that was kind of mind blowing. Because to me, as a doctor, hospice was an intimidating place to be. And he was going in there, you know, quote, unarmed, and, you know, what was he going to do, and that seemed to be very scary. And his response to me, which, which stuck with me is that, you know, all I'm doing is that there is somebody in front of me, who is facing death and suffering, and I'm somebody who is facing death and suffering. And if I can be present with that person, you know, that that's a great gift. And it's also, unfortunately, in our society, a rare gift. And it's a particularly rare gift, I think, in hospitals and with doctors, that we're not with the person, necessarily, that that we are focused on the illness, we're focused on the, you know, their lungs, or their heart, or their brain. But we lose sight of the person in front of us who is also dying and suffering, and it's such a lonely place to be in our society. And I think, you know, as Rob said, the rise of technology and science, and all of these things are tantalizing. And yet, people still die, and people still suffer. And, you know, I think particularly in this culture, there's almost a denial that that's happening. And I think she needs to kind of name that, you know, we have a lot of faith in the miracles of science and the miracle of doctors, the miracle hospitals, that we, you know, almost pretend that death is optional, but it's not. And it's a very lonely space to be in, when everyone around you is like, fight this, you can be that whatever, and you know, you're dying. And for me, that was, I think, for a lot of people that's been kind of opening into palliative care in one way or another, you know, maybe kind of twofold. Question, Rob as you've gotten into palliative care. You know, obviously, it seems like it's a good fit, and maybe there's more nonlinearities to come in your career. But, you know, assuming that you know, what to you are kind of the greatest gifts that come out of it. You know, because I think that's what a lot of people miss when they say, oh, you know, poor Benzi poor? They do this day after day.

Rob Horowitz  38:56  

Isn't that depressing? Right? 

Benzi Kluger  38:58  

Right, you know that there are some real gifts. And then I'd also like to ask, you know, what are the really the hardest parts of the job for you, because they may not be what people expect would be the hardest parts.

Rob Horowitz  39:08  

Others have said it better than I than I can. But I hear a lot of language around empathy burnout, that, you know... We can never feel another's experience. But we can, we can certainly resonate with others emotions, we can imagine ourselves in their place. That's an important thing. And if we believe we're experiencing their pain, and some people do believe that and think that's part of the necessity, actually, that I think is exhausting. If I have to feel pain in each room, and I've seen that I've seen people burnout from that from feeling pain in the room with people who are having pain, for example. And I mean real real pain, body pain, heart pain, and spirit pain. This notion of compassion, though, I think it was Jon Kabat Zinn, you know, said empathy. We only have so much room for that pain. We can only have so much pain, that compassion is bottomless, you know And I think that's true of compassion as being with another who's in pain as being being in the presence of his choosing to attend to them in their suffering. Its work, it is tiring, no doubt, it's also enlivening, you know, feeling love for others for humanity that is self generating in some way and fueling. So I may be tired at the end of the day, and I may need to sleep I'm not a very good sleeper. But, but that's filling. And I love that work. Because others who are drawn to this work sometimes don't know, like, I didn't have language for it, when I first was drawn to it. And now I do and it's imperfect, you know, the language is a model, and the model is only as good as, as it can be. But I'm finding words for it still. So Benzi, sharing this sharing this mission, this passion around tending to others, and expanding the reach of this message of humanizing others of, you know, recognizing their patient hood and helping them be whole in their person. And in the midst of of suffering. That's a beautiful, satisfying thing, and it builds community. So these are some of the things I love. What's hard about it, seeing when it's not done so well. It's something you and I have talked about, and in even your work in helping neurologists have a palliative care approach in their work, because the things that we do, Janece, when you were asking this round of care, stuff you would want any of your clinicians to do to help optimize your well being and take care of your pain and help clarify your care goals. I mean, you know, we all want that from everyone, of course. So it's not just a specialists place, how to how to help others be okay with this make room for it, have time for it, even though it's not necessarily time consuming if it's done well. That's where some of my struggle is, I think, and I guess, in a way, some of this is, you know, politics or public policy, helping share the message in a way that is, feels like advocacy, and not adversarial-ness. I guess if that's the right word.

One of the things I was going to ask you about that ties into that, which is tough for me. So you were a part of the training yesterday with Tom, is that right? So Janece, just so you know, and listeners know. So we were in the midst of a project, which is a very exciting project, I think, which is to make palliative care as an approach, part of neurology care and part of Parkinson's disease care. 

Janece Matsko  42:35  

Awesome. 

Benzi Kluger  42:36  

And there was a sticking point, which I told time would be a sticking point. And I don't know if he knew how deeply entrenched this was. But there were several neurologists who were very insistent that Parkinson's is good news. 

I'm sorry, what?

that getting a diagnosis of Parkinson's is good. That's a good news. They come into it with a relativity bias. So So kind of explaining why this happens is that for the average neurologist at and I will admit that I felt this way before and I've been guilty of this, but that if I diagnose five people with Parkinson's in a day, I left and I pat myself on the back, like I was a bearer of good news, because compared to Alzheimer's, compared to Lou Gehrig's compared to the brain cancer, Parkinson's is relatively good news. And you can start sentiment you can see, 

Janece Matsko  43:25  

I see, 

Benzi Kluger  43:25  

you know, and I think, you know, sometimes, you know, Tom used the example today, which I think was helpful, because it brought it outside of the field of neurology is that, you know, if I'm diagnosing somebody with diabetes, that might be the worst news that person has ever gotten in their life. Yes. And so we kind of had to personalize it. In order to make neurologists recognize that this may not be good news and time actually personalized it further today. And things went much better by saying, you know, if you were to wake up tomorrow morning with the tremor, and started to get stiff and your handwriting was changing, you know, you probably wouldn't be overjoyed about that, you know, you would know where it's going. You know, even though it is treatable, even though you can do exercise and medications and there's surgery, it's still far from good news.

Janece Matsko  44:11  

Yeah, context and perspective is so incredibly powerful, you know, like we only have our own experiences right and and the number of times that you're exposed to something like you said, you might spend all day talking to patients, one after the other about Alzheimer's and, you know, cancers that are terminal within the year and then having to deal with their families and this really terrible terrible news. Yeah, relatively, I could see how maybe getting put on a medication and having a little bit of a tremor and some other symptoms would be way preferable to those things. But yeah, context and perspective is just so insanely powerful when it comes to these discussions about like, what is something that you're willing to live with versus the lengths that you're willing to go to, to, quote unquote, solve a problem or, or find a cure. Or,

Rob Horowitz  45:10  

for me, the palliative care person to be in the midst of a bunch of neurologists who've done this, some of them 1000s of times, I had somebody in my small group, who had given the diagnosis to patients with Parkinson's 1000s of times over over decades. So for me to come in having never done that specifically, and and into intimate that they might be able to do that better felt out of place, and I know can create distance and resentment and, and that's where part of my struggle is and so having you in there, a neurologist, a bona fide a neurologist, you know, who can lead off that conversation and then say, Oh, and you know, and by the way, you know, Rob and Tom have some a model here that might be useful when we take responsibility for upping our game. Because I have alienated colleagues many times over the years, when I with good intention came to them about a about a patient who might have been served better the message being they're feeling talked down to or criticized or challenged. And that is a hard thing to hear. So this, that's what was coming up for me in the midst of this, I saw such sort of defensive posturing and and understood it enough to be very sensitive to it and supportive of it and to name it. I'm glad you've you've talked with him and things were better.

Benzi Kluger  46:40  

Yeah, things went.. things did go better today. But but it is, I don't know, it gets back to this kind of idea of healing the healer. And it gets back to something that actually I think it's really important for the show for the books and other things I'm working on is that everyone in this crazy Healthcare System or non-system is human, and is fallible. And you know, no matter how high the pedestal is, there's still a person on top of it, who shits and farts and feels insecure. And in fact, some of the most insecure people are on the highest pedestal. Yes. And that's part of why they do what they do. 

Rob Horowitz  47:15  

Yes.

Janece Matsko  47:17  

Yeah, you know, it's interesting, because sometimes we don't necessarily think of doctors in that way of having that like pecking order or whatnot. Or that maybe there's an assumption of more camaraderie within the field, then maybe there is but I think in any career track any field that people work in, there are those people who have years of experience that feel like that has earned them a certain level of respect, or it's a type of experience that might be more valuable than the education and coming out of a prestigious school or having done a specific type of research. How do the both of you kind of see those dynamics play out or like the importance of those kinds of dynamics and people understanding how that works within the medical field,

Benzi Kluger  48:06  

I mean there's, there's different communities. I sit in on on tumor board, and there have been moments where people are suggesting things, including surgery, because that's what the surgeon's preference is, and the person living with the brain tumor is not really part of that discussion, right? Yeah, actually, this came up dramatically. I was given a grand rounds, which we all know what Grand Rounds are now. For anesthesiologist at Colorado about palliative care, and a question came up from one of the anesthesiologist, you know, he's like, this is all well and good, but sometimes I have a surgeon who's breathing down my neck and wants to start the case. And and I don't feel comfortable questioning the decision to move forward with surgery. And then there was another anesthesiologist who said, you know, you may be a specialist and anesthesiologist but you're also a doctor. And so if you don't feel comfortable with this, you know, the hospital's money, and the surgeons ego be damned. You have to stop it, but it takes some courage. 

Janece Matsko  49:16  

Absolutely. 

Benzi Kluger  49:17  

It takes some real courage to speak up to certain doctors and nurses have a tough time with this and getting back to the idea of bullshit. I mean, that that is I think, some serious bullshit and some serious damage that this expertocracy can cause is that, you know, people literally lose their lives for the sake of a surgeon's ego sometimes.

Janece Matsko  49:38  

Yeah, I was gonna say from the perspective of someone and in the non medical field, like that's as big a bullshit thing that could possibly happen. It's just like, well, this is what I like to do. So let's use that method instead of whatever method truly is the best for the scenario that I find myself in.

Rob Horowitz  49:59  

So So in a way, then that's sort of the perfect entry point for palliative care. Not necessarily the specialist but but to have gosh, I hate to even co opted as the palliative care competency, but to have a conversation then surgeon says this, based upon this data, you know, talking with our, with our patient family, the medical people say this, this is what we think is going to happen with either of these interventions. Best case, worst case, likely cases is what we think this is the best we can conjure, the future will look like for you. Now, given that, given this information, what's important to you? What are you hoping for what matters to you? That's the piece of the conversation that's so often missing. So it's not about, Benzi and I sees the patient and says, you know, this is what you get for that. It's, this is what's going on. And this is what you can get for that. It might be obvious, it might be simple, you know, I'll give you a penicillin for a strep throat, we're not probably going to have a values discussion there in most cases, right. But for the more complicated stuff, the high stakes stuff, we better, we better. And that's not built into the process of making decisions about treating serious illness. It's just not built in all the time.

Janece Matsko  51:18  

Well, and it's not profitable to do it that way. You know, like, and I know, we shouldn't be thinking about health in that way. But when you talk about, okay, let's get this person's input and this person's input, and have you seen this specialist and get their input on this thing. All I hear in my brain, and I would imagine that some other listeners are too is just cha-ching, cha-ching, cha-ching, like, I'm going to have to pay for that. And I'm going to have to pay for that in order for me to live comfortably. And that is a crime.

Rob Horowitz  51:52  

It's absurd that we should have to consider costs. And yet there there is cost and in the United States. Cost, I don't say cost us everything but it but it matters in a different way than it does in some other much of the developed and not as developed world where there's much more highly evolved system of universal health care. So yeah, that's one reason to put on the brakes and talk about what really makes sense for you, given what's going on. If there is a financial cost to you that that ought to enter into the conversation. I hate to believe that that will influence a an important decision. And yet, yet it does.

Benzi Kluger  52:33  

And I think there's, you know, to Janece's point, there's kind of suspicions that happen both ways, you know that you're doing this, because you want to make money, you're not doing this because you're trying to save money, I would say the absolute toughest part of my job, you know, that I use the word bullshit the most when I deal with it is bureaucracy, and the finances of medicine and systems. And I just have recognized now that it's not all about, you know, the best evidence or the best science, it's about, you know, what happens in the real world. And in the real world, if doctors and if administrators and the hospitals believe this, or this is the way Medicare is set up, that's what's going to happen, no matter where the science is, or where the compassion is, or, you know, however you want to find truth, or whatever it happens to be... ego. I mean, there's all kinds of things that drive decisions other than evidence, 

Janece Matsko  53:25  

right

Rob Horowitz  53:25  

Yeah, yeah. You know, and doing the stump speech for palliative care. One of the lines that catches people's attention, is the fact that palliative care tends to save money. It tends to save the system money. I don't share that in my stump speech around palliative care, because I'm not I'm not, I should say, most of the time, I don't, if I'm trying to influence an administrator, because I think more palliative care is important, for reasons other than the cost, and it happens to have the collateral benefit of saving money, then I might say something about it. But I want to be careful about this message too. And the reason it saves money Janece by the way is when people choose what is right for them given serious circumstances, oftentimes, more often than not, they choose an approach to care that that happens to not cost as much money they happen to choose care that is about feeling as well as they can and that is not a high tech approach. More often than not particularly at high stakes, end of life, you know, potentially end of life decision making. It just happens to be that human nature is I you know, I want to feel well I want to be in my home, I don't want to be in the hospital in the ICU if I can choose 80 plus percent of people in some surveys, proclaim that, That, that does cost the system less money. That's not the reason I peddle it. That's not what I am looking for when I talk with a patient or family about their wishes. And hospitals have reason to be happy about that and happy with me. They're not as happy when I go into a room and somebody thinks It would be the right thing to do to stop this crazy, futile, aggressive treatment that is going nowhere, they say and the patient family have good long standing character illogical and cultural reasons they want to continue that. I come out of the room head held high, and I'm advocating for my patient and family and say, No, we will continue this because that is right.

Benzi Kluger  55:27  

You know, one of the things that's been a gift for me and going into palliative care, and I think you've named this too is the world's become a lot more mysterious of a place. And so I don't know, if you want to share any stories that you've had around end of life or other things with people where it's like, this is kind of hard to hard to explain with a scientific model.

Rob Horowitz  55:48  

Yeah, yeah. So yes, smarty pants, doctors like to see people who are sick, who aren't communicating in the sort of more familiar manner that we're accustomed to and call that delirium and try to treat that to make it better. There's good reason to do that. I mean, delirium is problematic, and it is expressive of many, many processes. It's also an amazing thing, amazing thing, how people when they're dying, more often than not, will sometimes if not continually have an a non ordinary state of consciousness, an altered state, and by which I mean, a state that is not the baseline that they had experienced prior to this dying time. And, you know, we see that in smarty pants, you know, health care professionals call that delirium and say, let's get some medicine in them and stop this, often that processing that that other experience, looks to be pretty darn okay for the person who's having it, even though it freaks people out. And the experience of people who have that and can talk about it, in the midst of it, or after it often will reveal that they were engaging in communication with, with other people, other times, ones that we can't see. And while I used to call that hallucination, and delirium and a haldol deficiency, meaning I need to give the medicine and fix that I've, I've become way more agnostic or open to any number of possibilities about what that is. All I know for them, though, is this is a real experience. Yeah. And if they're visiting with dad, who died years ago, or that loved, you know, their partner who died some time ago, they are visiting with that person. So that is a compelling thing to witness time and time again. And there's some similarities room after room after room of people who are approaching that place of dying. And regarding some space out there, looking up to the ceiling, reaching maybe, and I've seen this in my family members, as I sat at their bedside. It is remarkable. And I wonder who is at the end of their gaze, or who's touching that hand. And I'm not talking about so called Near Death Experience, I'm talking about the experience of approaching end of life. And the vividness of the experience of a kind of connecting, it's not always pleasant, it's sometimes unpleasant, it usually has to do with somehow grappling with with some piece of their past or their world or their uncertainty. It's meaningful for them. So So my job I think, in a way, is to witness that to support that to process it to the extent the patient or family wishes to, to encourage them to go in again, and see where that leads them because it's safe in there. Even though our desire sometimes just draw it out in to make it go away. You know, Benzi, as I'm saying that you're nodding. I mean, this is familiar to you, right? Yeah. Yeah.

No, it is. It's another thing I'll admit is and I don't know if this was a case for you, but I, I was not mature enough to do palliative care when I started medicine, yeah. mature enough in the sense of, you know, I think emotionally and spiritually. And, you know, I think it was only later, you know, after I, you know, became a doctor and a resident and did my fellowship and all of these other things that I don't know, I maybe had enough life experience that I had enough humility, to really listen to really appreciate these things that were happening. And, you know, if you're talking to me as a medical student, and everything, then I had the brain worked. I free will was an illusion. I knew how delusions worked and, you know, probably offer some bullshit explanation about what your experience patients were experiencing was, the result of neurochemical release and I....

Benzi Kluger  59:16  

and my description would have sounded like bullshit to you then Right? 

Rob Horowitz  59:59  

Oh, yeah. I would have, I would have been very turned off by this conversation. You know, sometimes I, you know, you just have to experience it. And so you know, you used the word love earlier, but I've, you know, worked with people who I loved and have seen them through to the other side. And I've talked to their families about what happened before they died, and sometimes what happened after they died, and, you know, some visitations that happened. You know, it maybe because of that love that these people who I love have have taught me a lot about the world and, you know, opened my eyes to things that I never learned about in medical school. 

This just so leads beautifully into the realm of psychedelics, I don't know if we want to even touch on that 

Janece Matsko  1:00:38  

go there go there. 

Rob Horowitz  1:00:40  

There is a so called psychedelic Renaissance now. You know, psychedelic research was stopped in its tracks because of criminalizing marginalizing policies in the 60s and 70s. And there has been a resurgence in interest in and research around psychedelics and related medicines. That has been remarkable and in the realm of palliative care, particularly regard to what you and I are just talking about. The experiences are different with the different drugs and different in different people with the same drug. Oftentimes, though, the studies of people with serious illness approaching end of life refractory depression, addiction shows a commonality of experience, that that is a deeply mystical experience. And the language is used variably, but a sort of a letting go of ego, dissolving of ego, a transcending of ego that allows the person to experience being, without the, the "me" watching. Without the rational mind, trying to make sense of things, just pure being. And more often than not, some of these studies 70 plus percent of people who experience this have a profound deep experience of unity with others, of a sense of ease, and a letting go of some of the fears that have been getting in their way. And this really matters as I'm talking about people that end of life, who are connecting with something somehow in a way that looks peaceful. There seems to be an opportunity in psychedelics, to allow people, not just who are dying, but who are mortal and will die sometime, but don't know when to have some of that peacemaking opportunity, if well guided way before they are confronting their own death, imminently. 

Benzi Kluger  1:02:38  

It touches on you know, the intersection of medicine and spirituality, whether you're religious or not religious, believe in God don't believe in God, that people have a spiritual dimension, that there's a part of people no matter what they believe in, that needs to connect, that needs to have choice that needs to have meaning. You know, that the word that's used in medical literature, is "death terror". Which I think we can all, you know, identify with, we I think we've all experienced it sometime. And I think we could, you know, imagine to some extent that if we have a diagnosis that we know is going to be our death sentence. And we're approaching that wall that end of you know, the rational mind that it can be terrifying. And some people you know, can draw on spiritual traditions, some people, you know, have other ways of doing it, but a lot a lot of people feel very, very trapped. And it does seem like you know, psychedelics can open an escape hatch can open in a new window, a new door of perception is Aldous Huxley would put it that allows them to see things differently and find peace in a situation that is, it's such an insult to the ego and to the rational mind and is literally incomprehensible. 

You're speaking from a place of knowing it sounds like. 

Janece Matsko  1:03:57  

Yeah, even without psychedelics, it's kind of weird. I've I've actually had two dreams that I remember very, very vividly where I have been confronted by my imminent death and made complete peace with that. Before I won't I woke up. 

Rob Horowitz  1:04:12  

Oh, wow. And, and and not presaged by, if I may, by ingestion of anything that was that just came up organically? And has it left you in a place with less angst? Or was that momentary?

Janece Matsko  1:04:29  

Um, I wouldn't say it was, you know, necessarily, like, Oh, I'm near death experience where like, I changed everything in my life, and I made different decisions. But I think knowing that I am capable of getting to that place of like, peace and acceptance that I'm like, okay, whatever were to happen, like, I'm already good.

Rob Horowitz  1:04:47  

You've practiced,  you've practiced the dying. 

Janece Matsko  1:04:50  

Yeah, basically. 

Rob Horowitz  1:04:51  

And I think there's something in that the experience of those who have been able to talk about who are approaching end of life and have been fearful of that. And there's some lovely interviews you can see on... god, you can watch Netflix, "fantastic fungi", which is a beautiful documentary actually, which includes some about this very thing. The Johns Hopkins, psilocybin guided therapies. There's there's one man who's fearful of dying, who had his experience and came out of that saying his fear is, I don't know if he said his fear is gone. But he, but he wasn't consumed by fear of dying interest, he was more at ease and he could continue living. And it really allowed him to continue living for some time in his family remarked on that, yeah, amazing.

Janece Matsko  1:05:35  

There's a very specific philosophy within stoicism that kind of shows the power of letting go of the fear of death. So if you don't fear death, there's not really anything anyone could do to you. Yeah, to force you to do something you didn't want to do. 

Rob Horowitz  1:05:53  

Yeah, isn't that wild? To die before you die is not to die when you die?

Benzi Kluger  1:05:58  

You know, one question that, you know, I think is relevant, particularly as we've talked about doctor's egos and things like that is if you or  a loved one are in a situation with a serious illness? How can you get a palliative care approach? What can you do to advocate for that? And maybe a related question? You know, how can you find doctors who see you as a whole person and may be willing to engage you in this spiritual side of things?

Rob Horowitz  1:06:25  

Oh, boy, you know, so much, I think is going to depend on who you are and where you are and who your people are? I'd say I'd say in general, though, are you feeling heard? Are you feeling seen? Is anyone in your health care? I say team, it's not always clear that you have a team, by the way, you could be admitted to the hospital without a primary care physician and wonder who the heck are my people? I mean, there's so many people running around. So it's not that everybody recognizes they have a well formed medical team. And yet is anyone is anyone giving you a sense in your in your gut in your heart, that you matter? Are you feeling cared about? And if not, that's a problem. I think more often, it is a no than a yes, if you're coming into a system like this particularly acutely ill even with skillful practitioners. This is not just about having good medical personnel you want and you want you want community who can speak for you advocate for you have conversations about things that matter. Identify a healthcare proxy, we all should have one, and talk about some of this really, really tough stuff so that you can be well represented if you can't speak for yourself. Most hospitals now have at least a rudimentary palliative care program, not that everyone with serious illness should need a palliative care specialist. There are plenty of primary care physicians and specialists in oncology and neurology and other specialties who are just really good at this stuff. They just do it. They know it, some of them have learned additional to do it well. So you don't all need a palliative care specialist. But if you're not feeling seen and heard, then to ask is palliative care at this hospital? It may or may not be.

Benzi Kluger  1:08:06  

last question, which maybe the last question a lot of people will ask in their life is what advice would you have for people who want to die with dignity want to die at home, don't want you to die in a hospital hooked up to machines. You know, we both know this, that a lot of people are afraid of that. 

Rob Horowitz  1:08:23  

Sure. So even if or maybe especially if it's difficult to talk about is to talk about it Benzi and Janece you and I would probably have fun at a so called cocktail party because we'd like talking about some of this deep stuff some people are don't want to hang out with me at such a party, because I'd like to talk about this stuff. But um, you know, if you do, then maybe you have people in your community but but identify people who can speak for you if you can't speak for yourself. Because if you're facing a severe illness, in which you can't speak for yourself, then you're going to be depending on others to make decisions for you, and you want them to honor your wishes. And if you know that when your dying time comes, you can do some planning around that. But if you have a catastrophic illness that you can't plan for, which for younger and healthier folks is a relative commonality in terms of their dying. It's important to name somebody who can who can speak for you. If you have any sort of serious illness, if you're anticipating the potentiality of of your dying and I don't mean suddenly out of the blue but, but because of progression of disease in the next six months, 12 months a year or two. It is worth talking with your medical team, your medical colleagues, your medical representatives and advocates to discuss potential futures and to help orchestrate the kind of living and ultimately when the time comes the kind of dying you want. We all have way more power over that than I think we know. There's a lot we can't predict but there is a lot we can plan around that you and it takes, it takes courage, it takes hutzpah to, you know, to really engage in such conversations.

Benzi Kluger  1:10:07  

I think that's a great, great place end that, you know, we have have more power than we know. Well this is a great start to the series. Rob it was very, very fun conversation covered a lot of ground, ended up in places I didn't expect to be, which is always that's always the gift of palliative care or friendship of interviews of any kind of art. So, thanks so much for sharing time with us and I will see you around the hospital and see you around the neighborhood.

Rob Horowitz  1:10:35  

That sounds good. Yeah, no, this was a lot of fun. Thank you for the honor of hanging out with you.

Janece Matsko  1:10:41  

Thank you for your time, Rob. Yeah, pleasure.

Rob Horowitz  1:10:43  

Okay. See you again. See you soon.

Benzi Kluger  1:10:46  

I'm your host Benzi. Kluger, the executive producer and editor is Janece Matsko of Empowerment Ventures. Our theme song is by Timothy OTT.

Janece Matsko  1:10:54  

If you enjoyed this podcast, please subscribe and share it with your friends. Then go to thecureforbullshit.com and sign up for the newsletter to learn more about Benzi's speaking appearances, blog posts and updates about the book. 

Benzi Kluger  1:11:06  

If you're thinking about suing me, please don't. This podcast is for general informational purposes only. I'm not your doctor. This is not medical advice. In fact, it might be bullshit. It's really up to you and your health care providers to figure that out. And if you don't believe you're getting the advice or care you deserve, ask more questions or get another opinion