Stephen Nutik and Jessica Nutik Zitter

00:02 My name is Jessica nutik zitter. I'm 48 years old. Today is October 2nd 2013, and I'm at Highland Hospital in Oakland, California. I am Stephen new text daughter.

00:16 I'm Steven nutak. I'm 74 years old and same date same location and you're my daughter.

00:29 Great. Well Dad. I'm so glad you came here because I've always wanted to talk to you. We've talked a little bit about these issues in the past. We're both doctors and you are a big role model for me and going into medicine. And so I've as I've gone through my medical career. I've always kind of opposed it against you and some Curious to hear about some of your thoughts on some of the issues that come up in my own personal practice. You are an MD Ph.D. Brain surgeon, you are an intense guy your previous marathon runner, whatever you do you do intensely you sort of chief of neurosurgery at a huge largest Neurosurgery Group in California for decades.

01:17 Recently retired. My first question for you is neurosurgeons are often thought of as being God like, you know, it's not brain surgery is a common refrain. How do you feel about the way Society sees neurosurgeons are brain surgeons and other types of Interventional doctors as Heroes.

01:41 You know what? I've always wanted to be important and I've always wanted to have an image like that. But I think that I and and most of the people that I work with have not felt any different than regular people and it's only rarely that people come up to you and say, oh my gosh, you're an ER surgeon and and we always respond by saying it's not rocket surgery.

02:15 So, you know why I don't have much more to say on that. Do you like your personality was well tailored for being a surgeon?

02:35 You know.

02:37 I don't know how to answer that. I think that I'm less intellectual than what we used to say is the internist profile. I am not I do think and I'm and I'm not stupid but I don't think that the the idea that that surgeons are somehow just mechanics is is after either but I just think that I'm a I'm a door and I'd like to work with my hands. So this was tailor-made for me.

03:13 Whenever I think of you and talk to you about YouTube to other doctors and Friends of my colleagues. I always talk about how conservative a surgeon I think you are and I always feel confident that if you that you would never advocate for doing surgery or doing any kind of procedure unless it was absolutely necessary. Do you see yourself that way?

03:39 You know, we've talked with touchdown this in many ways before but in fact, there's a big evolution in not and how you see what you're doing and how you see whom you're doing it for. I think we all start out with learning the tools of our trade and

04:08 I think that didn't many times we say, you know, we have this tool and we should use it. It's obviously there for a reason.

04:19 This whole idea of

04:25 Medicine being based on statistics and outcomes is really recent. We've always thought that what we did was logically the best thing there was no other alternative but a lot of this is not Based on data and is that is being collected now is as a part of how medicine is practiced so

04:53 We started out as you know, when I trained I didn't do very much surgery and one of my attendants in my final year said.

05:05 Oh, why don't you operate on this recurrent brain tumor you could take out a certain part of the brain and maybe that would help. Well, it was obvious that it wasn't going to help it was something being on I said, yes, maybe I'd be a better surgical technician after that, but I'd be a I wouldn't be as good a doctor and so even early we

05:32 We realize that we didn't always have the answers and that you really were trying to help people. I did I evolved into kind of specialty. Where is Service subgroup? As you know, I did a lot of surgery at the base of the skull then and vascular surgery with aneurysms and the only Alternatives were at the time there were no Alternatives other than taking these tumors out which often involve a lot of risk for operating on the aneurysms which again involved water risks. And now you would say, oh there's a 10% chance. This is going to happen. There is a 50% chance you might be better. There's you know, we didn't have those statistics, but we thought that overall the best chance.

06:32 Doing it.

06:34 As we evolve we got better at doing what we were doing, but then new technologies came along.

06:42 And it was very hard even though you had the feeling that the new technologies might be better than what we were doing was very hard to give up what you were doing. But had the same thing my father felt the same way in certain surgeries. He did that. He had developed technology technology the techniques for doing them and he had good results, but he thought no you don't maybe just x-ray treatment might be better. Well as new techniques of come along and we know the risks of ours, we sort of have had to see to these. I must add that many of the new technologies are not proven better either but on the other hand somebody else is taking the responsibility of the of the Fallout of these of the procedures, so,

07:42 You know it is and evolution but it's not completely based on fact and what's better. So yes, we always try to do what was best and

07:59 That's being conservative in surgery doesn't mean not operating and their many surgeons. Who were

08:09 Conservative in that way, we just weren't very good surgeons and they knew their limitation in my opinion you feel like as you've gone through your career you

08:24 Reluctantly, maybe gotten even though you started out pretty conservative and you weren't doing things just to do them. You've maybe become even more humble than that way to say. Well, you know what what I have to offer may not be the best thing for you to a patient.

08:42 Yes, they're often.

08:46 You know we've had this.

08:50 This specific issue which has everybody can understand is somebody gets a has a hemorrhage in their head.

09:01 And it's obvious.

09:03 That the treatment of that should be to take the blood clot out if it's causing pressure and and yet.

09:12 You have to be sure that the results are better than not taking it out and we don't always know the answer to that but people who have these clots or their families will have to say all you have to do something. That's the hard thing and that's where I've been conservative said. No, I don't think I have to do something here. I'm not going to give you I'm not going to give you your loved one back.

09:42 What day are you never going to get them back to where the family is hoping? They will go give me a little bit to the question of how you talk to patients. I've always thought of you and knowing you as a kind of a shy person.

10:01 And you sometimes seem more comfortable with the surgeon the technical aspects for surgery as opposed to actually talking to patients. And is that true?

10:12 You know it it turned out just something that I found that the one place where I was felt completely confident was in the operating room. I am shy but in business people are able the they talk to people and I really do think that I was pretty good at explaining things to people hello often times you get feedback this suggest you weren't

10:44 But do you know your sister wrote the road a little story a one-page story called doctor hijackal?

10:55 And the of all I want I don't have it to read you hear it sometimes I often sit. How did she know? I remember sitting with Mark my husband at a dinner with and you were with mom was there and she was telling us about how you won this award those kind of a big deal about, you know, being a patient a patient's feeling that you were very supportive doctorin really liking you and I remember you looked at me you said Jessie. I see your your mouth hanging open. He said I know my family thinks I can be difficult, but my patience love me.

11:35 I think some of my patients love me. They love their surgeons if they do. Well that's another issue that I think is so interesting. I remember you always had all sorts of stuff delivered to the house around the holidays jams and wine and smoked fish and all sorts of fabulous chocolates, and I remember coming in once a few years ago and

11:57 Mom and I are both Internal Medicine doctors and why is it that the surgeons get all the glory for doing stuff, you know where internal medicine it's about talking and treating with medications that this sort of idea of going into someone's brain or going in and doing a surgery somehow gets so rewarded. Why is that

12:19 I mean, I think I think people just feel that you do you've invaded them and you and you allowed them to return to what they were and I don't you know, I don't think it's because we're any better people just feel that way. It's not because we're any different. Well it is my next question is a donor surgery is a terrifying brain surgery is a terrifying Prospect for any patient new having somebody literally in your head strikes me as being as the essence of being vulnerable. So my question to you is when you go into a room with patient to talk to them.

12:59 Do you think about their emotional state and does it affect how you talk to them?

13:05 Yes, it does suck of course, but that is just a professional relationship that you've developed and you try to.

13:19 Get people's confidence and and and be friendly and and be just the person you are and to include their families and to talk to them. I think that I think we have to be like that some people are better at it than others and really to say that I am better. I don't I wouldn't want to say that truthfully. Have you ever had a patient who had an emotional reaction that you thought you couldn't handle or that was uncomfortable for you? And how did you handle it?

13:58 We're human beings when your mother was a medical student 2 years behind you in medical school and she did some time with me and then some of the neurologist in my department and I'm one person came he was very late for his appointment and he call the East he said he was 30 minutes away and could I wait and it was lunch time and I said, how can she come at 1:30?

14:39 And he said no, no. No, I have to come right now and

14:45 India finally arrived and he had something that was very straightforward. And I said what I could offer him and he gave all reasons why he didn't think that that maybe I could handle it hurt. My team could handle it then and it was and it it just really need me. I was so anxious and so and after after the session in which it came out that really

15:18 He was just there to get us to refer him to someone else that he had appointment with in the afternoon. And Mom said to me she said

15:28 You should Jen do his office right from the beginning. Didn't you pick it up and the answer is no I didn't often people say that, you know, when you're anxious there's something about that. You know, what my I didn't deny. I sort of reactant that got the cut ways other people see see that I think that's a different personalities.

15:50 What about in a situation where you're giving somebody bad news, then one of the hardest things for dr. To do obviously it to deliver bad news to a patient. And I remember when I was in medical school once I was rounding with you, I went you took me on rounds in your hospital and I remember watching you break some just terrible news to one of your patients and you were very matter-of-fact and clear and the patient sang too. But with very very shaken. I'm sure you don't remember that particular incident, but I have a couple questions about that type of thing.

16:24 What's hardest for you about breaking bad news to a patient or their family?

16:33 I think it's it's very hard. It's very hard for everyone and often the bad news is that they don't have that long to lived and we I was trained in a place where we were we were told to be honest.

16:55 Over the years I developed the technique of

17:03 When I saw something that look bad and this usually has to do with malignant brain tumors. I would I would take it. You don't think it says but I don't know how long we won't know until we have the biopsy and that we would talk about all the possibilities both the good ones and the bad ones.

17:24 And I said that that you know, I already given them the statistics.

17:30 And and I

17:35 What I would do is tell him after we had the report of the biopsy back what it was and very often the patients didn't ask any more questions. The family's always ask questions and I didn't have much more to have at that point and because you've gone to the scenarios prepared them. So I don't know in retrospect now is whether that's a cool way of doing it, but I don't have much way to make people feel good about that. I can answer questions about where we're going to go from here what we're going to do. I seldom have to talk about what I think the statistics are Alloy always add this to cystic sir statistics and then there are extremes and so I think

18:35 People always and I try to pick the long.

18:40 The the longer at times and survivals in the better survivals.

18:49 You know, the question comes at the difficult difficulty comes with these people when you're when they have a recurrence of the tumor.

19:01 And the question is whether they want to go through.

19:07 More invasive things more surgery for example more chemotherapy and they've already been through these treatments and so they have a pretty good idea of what they're like interesting the most people choose if they're in good condition to go to go with whatever it is that will give them even short periods of time.

19:34 But some people don't and I think that that's

19:39 Where you able to be supportive in really and telling them that there are things that are going to help you with you the way you feel and like what well like pain control.

19:54 And that's a very important one. Do you ever make a recommendation for hospice or send somebody to hospice? Of course, this is relatively recent as

20:14 I think that your interaction with the people like me is an important question and this whole is whole picture. I think that palliative care and the specialist who practices have been a godsend for for us what I want to ask you specifically about that because I will I'll do I became an intensivist. I also practiced an intensive type of medicine like you but not surgery I practice intensive care medicine over the many years of my practice I decided that I was concerned that there wasn't quite enough of a patient-centered approach that we would do stuff and we wouldn't necessarily think about whether or not the patient wanted it done or whether or not it was ultimately going to be a real big big picture benefit. And so I went and started doing palliative care as well. So I do both intensive care and palliative care and I want to ask you something when I decide

21:14 Palliative care I was a little afraid to tell you. I don't know if you know that because you know intensive types of doctors like you and Austin thinks that palliative care is too touchy-feely and and I wonder

21:30 If you are in original when you first thought about palliative care, and we're starting to hear about it when it was starting to be a subspecialty. What did you think about it?

21:41 You know.

21:43 There was palliative care even way back a lot of it developed in in.

21:53 The Old Country For Us Canada and there it has a lot to do with pain management and I think just as inside United States as actually surpassed what Canada does now in Canada looks like it's in the Backwoods. I never

22:19 I mean, I think that patients need care and I have known limitations of what I can do and it's one thing to try to talk to people but in fact in our Specialties and subspecialties, we have to have people that can take care of

22:43 Lee, you know we often start the treatment and it gets handed over to someone else so with are malignant tumors, we couldn't function without the radiation oncologists in the neuro-oncologist in their specific chemotherapies, so that no, I don't have I never had any yeah.

23:08 In any negative feelings about your taking taking up palliative care and I think that you and one person though. I have you do you you have a critical care aspect and the palliative care and so it must be you have to answer that question for yourself even more than I've had to because I can give it to someone else for you. There's no what was nowhere for for it to go but do you also

23:41 We had an issue for me because a lot of the time I feel like my colleagues in the Intensive Specialties. Look at me as almost a Doctor Kevorkian figure that somehow this concept of talking to patients about death and dying is is somehow causing the patient's more distress and I'm going to worsen their outcomes and shorten their lives when in fact all the data that we have shows quite the opposite. So I was just curious if in the beginning when you started hearing about the subspecialty if you thought it was, you know for the touchy-feely types or

24:15 And and how has that changed as you as you seen me get more involved in palliative care.

24:24 I wasn't fishing for a compliment. Thank you. Let me ask you how has your career?

24:35 And watching all see all the things you've seen over so many decades of practicing brain surgery. How is that influence the way that you look at death and dying for yourself?

24:48 You know who I am.

24:53 How many people the sociologists have suggested that people go into medicine because they're afraid of dying and I don't know that that's true for myself. I but I don't think about it. I tend to think that I'm going to be here forever except when there's certain things will stop me in my tracks but only for a short while

25:22 Interesting, you don't put yourself ever even if a patient come in and think allow that could be me or oh, wow. I could be my kid never have that kind of people.

25:37 A lot of your empathy comes from seeing your patients as people that you love.

25:47 But not as yourself, I think it's I think that. I don't I didn't do that.

25:53 Interesting. So are there certain types of patients that you might be more that you would treat differently than others for example in Breaking Bad News.

26:04 How you would talk to them differently than other types?

26:13 You know what? I don't I don't I don't.

26:19 Ideally, no.

26:22 In reality, there's some patients that you just empathize with more and so yes, I do tend to the most differently one of those.

26:36 Well

26:39 This is not a malignant disease and it wasn't even at nerve surgical condition in this case. But I remember one of my colleagues who was a good friend of mine saw this man with a bad back and he was overweight and he and this guy just told a matter of fact look you don't have anything for a surgeon to do for you. What you have to do is lose weight. You're just too fat and the man was insulted by how he was dealt with and and he wanted another opinion and I saw him and I saw my brother when I looked at him you just he look like my brother he acted like my brother and I sit and I

27:29 Treated him like my brother and I took him very seriously, and I said no, I didn't think that there was anything for us to do and and I thought that he could use physical therapy and you really should strengthen up has abdominal sand and I told him that he could lose weight and I would see if we couldn't help I do that and I I just treated a more gently. I told him the same thing, but just more gently and I think that

28:02 LOL, I would have treated anybody more gently than this this this colleague of mine who had a reputation but I just felt differently about this man. I'm sure I would have felt like about with someone else. Do you have any opposite types of relationships with patients? Are you really for some reason didn't click with him or didn't like them and treated them in the way that you may not have felt great about I think that you do get into personality things that you don't understand like that individual. I told you about who had another agenda. I didn't know what its agenda was if I had understood right from the beginning. I might not have got emotionally involved but I was very anxious and tense with this individual. I think this happens to all of us. We are human beings and I wish you could be that you were even better trained than you were but it's hard to separate your emotions.

29:02 Do you think that your feelings towards a patient or your association's about that patient might make you more or less likely to do a procedure on them?

29:14 No, I don't. I don't think I think that you you try to evaluate what their condition is in your sort of professional in that way. But how well you do with individual by the individual trust you to do a procedure or trust your recommendation against doing something I think depends on how you deal with it.

29:38 How have you dealt with real raw emotion with patients that you've tragic stories? Were you giving bad news and just is a 34 year old woman with three kids and just a horrible situation or she's going to die. What do you do in that room when people are crying and

30:02 Bereft

30:08 You know.

30:11 I've always found it very hard to say anything. You know, your emotions are affected by this and but I have I just had a hard time being able to deal.

30:30 To really make them feel better. And so what do you do?

30:36 You know, I always say my peace by off and we'll stand up and

30:42 Touch them, but you know how often you have to leave them with her family.

30:49 And then later on deal with their questions.

30:55 So

30:58 What would you do? Have you ever thought about what you would do if you got diagnosed with a malignant brain tumor God forbid.

31:07 I don't dance I say I tend to try to put those things out of my mind. Okay d u

31:16 Feel that you've been clear with those of it, you know, I'm a palliative care doctor and I always think about making sure that everybody has communicated as well as we can about those God forbid situations, which I hope we will never have to deal with

31:31 Do you feel confident that Mom and I and Audrey and the rest of our family could take care of you in a way that would be acceptable to you.

31:44 I think your mother knows exactly how I feel. I think you know pretty well.

31:50 Yeah, you don't want to talk about it more.

31:56 Hi Aiea.

31:59 I don't believe in.

32:01 Uses therapy and you play I want to be what I am but you know our history my father had a stroke and live for

32:13 For a number of years in a very debilitated Nishan and

32:22 I'm not sure.

32:25 That he was he was very depressed and all but I I just don't know what he would have wanted. Of course. He never told us what that what about

32:35 You and Grandpa was a very vibrant surgeon top of his game.

32:41 Well respected member of the society Community independent wealthy.

32:49 He had a stroke that left him wheelchair-bound and not really able to do much at all.

32:58 But not at the risk of sounding morbid because the last thing I want is forever to deal with that, but would that be an acceptable life for you?

33:09 As I saw it from the outside the answer is no but

33:15 I don't know. I don't I don't think so.

33:20 And just by the way, I was three years younger than my father when he retired because I said at least I'll get some time to do the things I wanted to.

33:32 So will you made a big decision about Grandpa? You were the one who I believe when he was lying in the hospital on a ventilator decided that we should take a ventilator out off without knowing what would happen. Is that correct? No, that's one of the problems of course that I've often seen in medicines at once. You start a treatment. It's hard to stop it. It's better not to treat and see what happens. I think that what happened with my father was that he was on vacation and I saw him and you look fine. I I left and then he stopped breathing after his stroke. You're saying yeah on my way home. He stopped breathing and and both my brother and mother couldn't get hold of me, too, and he was intubated and

34:32 Can you put on a breathing machine breathing machine then and then and then it was taken out, but I would have not put them put in put the tube in his case, but I don't think it would have made that much difference because he didn't really need it according to the in retrospect.

34:55 Had you not as a family. I mean when you say he looked okay when you saw him down in Florida after the stroke, he didn't really look okay.

35:04 He looked like he was paralyzed we was talking and he was awake. So so you're saying the stroke went on to progress further after that. You know, he did he did worse.

35:20 And do you think if as a family you would had conversations about?

35:28 This kind of stuff and planning about what do you do in a situation crisis situation when someone had a stroke you think it would have changed whether or not that too but ever gotten put in him in the first place.

35:44 You know, I think that although I was called and wasn't available and they felt exactly the way I did. And I think my father felt that way and I think the things just happened in treatment than you've seen that it just say you think that he got put on a breathing machine just automatically

36:09 Are you going to put on the I think he got the tube put in and on the machine because they thought he would do better and I you know, I I don't I wouldn't second-guess. I think they did what they thought was the right thing and I don't think that it. I'm not sure but not doing anything would have been the right thing. I think that's the problem. We always have his knowing what's right and what's wrong, but after that happened did you as a family say okay going forward, you know, Grandpa's not himself. He's not living in a way that he would want to live for prolonged. Of time. Let's not put him on life-prolonging treatments if something like this happens again, did you

36:57 You didn't do it, but did you have a do you have a conversation about it?

37:02 Well, we've had the conversation about the two then we sort of all agreed that maybe it wasn't a good idea and then but I think we were on the same wavelength the night. I think we would have group regrouped and I don't think we would have been like the families who had no knowledge of what was going and what was happening where they insisted everything be done because

37:29 I mean, I think it's a it's a situation that every family deals with in one way or another and it wasn't that we were at that we were at odds with each other course or with my father as an ICU doctor. I see situations like this all the time even with families who are really educated Savvy and to talk about these issues. You know, I wouldn't want to live this way or I wouldn't want to live that way and still the same thing happens when you get kind of caught up in the frenzy of the Intensive Care Unit where things just happen and you can get attached to machines that as you say are difficult to take off because it's a very emotional thing and so even the most Savvy of families can get caught up in that

38:18 In that Whirlwind serve conveyor belt and I think you know, what eat? What are we going to do to make sure that doesn't happen our family.

38:28 Have we done enough?

38:34 You know, I want to tell you that.

38:38 I am

38:42 I don't really think that we have to discuss that much more in fact because I think

38:48 Your mother knows how I feel in terms of me and she knows how we know each other and have what we want and we'll have to evaluate the situation. It's funny that not all people talk and I told you that just if I could repeat the one story that I I was fairly close to my father we used to work together. We built a house together. I was Labor. He did all the fine work never. Let me do any find anything that would have been any fun but we work together and we and when he had the stroke, I don't know if you remember but when I was leaving to to see him

39:35 Hey, you you said what are you going to say to him said I think I'm going to tell him I love him.

39:41 I went there we sat and we and then I came back and you said so did you tell him I said no he knows.

39:50 I think that there is I think that that a lot of people do know other people and I think that

40:01 I hope that were in that situation doesn't always take that much talk.

40:07 What was your father's full name Oscar Oscar neudeck? No middle name.

40:19 The dad in the one minute remaining

40:24 Any final thoughts on any of the stuff we've spoken about

40:30 You know.

40:33 I loved my career.

40:37 I love

40:39 The technical aspects of the work I did and I loved A lot of my patients and

40:48 I was really proud.

40:51 You went to medical school?

40:54 And I was really proud and your mom went to medical school. I thought that did somehow reflected on what I had done.

41:03 And I'm really proud of what you're doing and I hope I know you have all these questions and I know you're writing a lot and I know you're going to come up with the answers or at least you're going to put the free movement away. The people least we'll be able to think about them.

41:19 So that's why I think we're where I rest. Thanks Dad. This is really terrific. I really appreciate your talking to me about these tough subject. Thank you.