Vivian Garcia and Jasmine Garcha

00:00 Hi, my name is Jasmine. Garcha. I'm 28 years old today's date is February 11th, 2021 and I'm recording from Salinas California with my friend and colleague Vivian Garcia. Hi everyone. My name is Vivian Garcia. I am 31 years old. Today's date is February 11th, and I'm recording with Jasmine. Garcha.

00:27 I think I just wanted to start off by asking what made you interested in medicine. Yeah, so I really developed my interest in medicine when I started undergrad and I was working in hospitals kind of volunteering and I would see the different doctors and the nurses that interact with patients and I really wanted to be involved in the care of people who needed help and we're vulnerable particularly in populations that are vulnerable and sensors. Like they don't always have the resources that home to help care for themselves or you don't have the money or the insurance to be able to go to the doctor every day. And I feel like those that population of patients are the most and so I felt like I could really make a difference in the community in that sense.

01:22 For myself, I think it came from a more personal perspective. I started thinking about it and high school and I think it was because when I was in sixth grade, my mom's been diagnosed with my I'm support she got from her nurses and her doctor that she just got brakes are overall and after she you know, she was treated with her chemotherapy and I just remember being so grateful to

02:09 Career paths in introductory for my career and I realized I also wanted to make an impact on other people and other diseases. I realized I want to be nice to you about.

02:36 What you thought medicine was going to be versus now, we're in it going into med school undergrad. It was the connections with patients were and how I really like interacting with people in learning about their stories and just talking with them and we don't really get that experience anywhere out now, I do remember that, you know in my first like Internal Medicine rotations that I was talking to a little

03:36 Yeah, yeah me the most was the fact that you're not just doing medicine. You're kind of like their social worker and the psychiatrist and the friend and the person who just they go to for Life advice and and the medicine on top of that and I don't know I didn't feel like med school really prepared me for that as much as I would have hoped I think residency is really where I realized how much it actually matters especially in our population has a community people with such a high mean

04:34 And there's so many things that you have to coordinate their care and not just like prescribing the medicines. It's never that simple, right? It's always like oh, but they have this insurance and so I can only prescribe them this number of medicines and so I'm limited in the way that we can treat this and unfortunate part about medicine their socio-economic status and based on their insurance coverage and we can't necessarily treat everybody the same as much as we want to because of that disparity so true.

05:12 I think I feel I've had experiences with that two were people are trying to decide whether they can afford to ensure that other options are are worse.

05:31 What was your first experience with working with a patient who was with that was the death of my grandmother before I started medical school. It was right before and I just found out that I gotten in and you know, we as a family have never really had any conversations about end-of-life care before and so when she was in the hospital, it was always just like she's going to get better after you just going to get through and nobody really talked about like what she would have wanted. And so unfortunately that conversation have to be had while she was in the hospital getting sick and getting worse and I think with a challenging part of that with everybody had their own opinions about it and nobody can quite agree on what they wanted to do and eventually after you know talking to the doctors and realizing how sick she real

06:31 Why is there wasn't consensus finally to put her on comfort care and let her go as comfortably as possible, but that was like my first experience and I remember after it all happened. I ended up thinking like that was really chaotic and stressful for everybody and it had been laid out from the beginning like this is what she wants and felt like it would have been easier of everybody and not only that I always wonder like those weeks that she was in the hospital would she have really wanted that or would she have just said I don't want to suffer like this cuz I really do feel like she did suffer when she was in the hospital.

07:12 And then after that when I started medical school, I had my first patient experience with deck when I was on one of my surgical rotations, and I remember and I talked to you before about this and we're like, you know in those kind of circumstances I kind of really don't have an emotional response right ran in there. And so I remember it happened and the piece of passed away and we did the evaluation and that come out of the room and I'm like, okay. Well, I have all of these things to do. So I didn't really have a strong emotional response that I know some colleagues. Do you have after patient passes away, but now I am beginning to realize that even though I don't have that emotional response in person like at work it comes out in other ways, like for example, there was a time where I had like a really

08:11 Talk week with a lot of patients were really sick and just continuously calling family members and telling them that their family wasn't doing well and while I was at work done. I remember coming home and I just watched this really emotional movie and it would just like the tears blooded and I feel like it wasn't even the movie. It was just like the week what caused all of that sort of emotional response. Yeah. I think I didn't have too much experience or personal experience with what's that or or or dying or that I felt a big impact in my life before med school, like my my grandparents passed away or my grandfather passed away in college, but I wasn't super close to him and I

09:11 Doing college so I didn't go to the funeral or anything. But I remember hearing about the fights my family was there and it was just I think of someone passing away was in Mexico and that was going to be the inevitable outcome and I feel like I was afraid to go talk to her husband go talk to her family members because I

10:09 The part they needed in that time it mean a personal experience my mom medical school and for us it wasn't it wasn't a very big surprise. It was kind of radiation and despite like all the treatments to answer engineering.

11:09 Because

11:11 She's been fighting with us for so long as they realize the importance of our conversations about to go to hospice facility a nursing home. And at the end. You know, she when is the palliative care at home? We got my sister.

12:08 And she passed away even though me and my siblings were all the medications were giving her just like he really understood the importance of could she have kept doing chemo?

13:04 You know just being comfortable and I think a lot of people don't really understand and when they see the word hospice, they think that you're automatically giving them a death sentence. Where as I did care truly are I don't know a lot of people when I talk to them before have said they don't know if they didn't know that you can be at home that you can be with your family. They think that you're going to go into some Facility by yourself and you're just giving up on your family members that you don't do that to them that you're you're essentially killing them.

13:59 And then I I think the only way to really combat that is just have honest conversations with people about what it really is and what it involves and what they can do for their family while they're on palliative care hospice and but it's very very tough conversation. Even the Hispanic Community where people go to die. So I think it's just it's really hard here. Like you said people about hospice or palliative care because it's just they think it's just giving up

14:59 Feeling when you know, they're giving for the educated and interesting Lee never heard of palliative care before we underutilized at so many more people could be comfortable with their illnesses or discomfort in you more about the benefits.

15:54 The conversation

15:58 And I think that it empowers me now as I see people outside of the hospital in the clinic to bring it up more before it was like, oh no, I don't really think that this is an appropriate time or conversation to have with people that's like their personal and they'll come to me when they're over there like past year-and-a-half is that a lot of people even if they're they want to talk about something they won't initiate the conversation with you and it takes really asking them first for them to really start talking to you about really anything and that's including like what would you want if you were to ever go to the hospital and you couldn't make decisions for yourself and I think it also challenges people they think about it a lot of people even when you're young I feel like you should think about it because I mean how many times have we seen 20?

16:58 Who are on ventilators or in a situation where they can't speak for themselves and they need somebody to be able to make those decisions for them or at least be able to stay but this is what this person wanted. And so I think it empowers me to talk about it with people in clinic and in-person think about it for myself to is like what would I want? What would I tell my parents that I would want if that was the case, and you know who wants to?

17:52 Have like this decision of what they want for the rest of their lives. I know that I thought about it about what I want. I talked about it with my family, but I'm actually just so many young people.

18:39 And I think in terms of end-of-life care and planning for the future. It makes it harder because in the hospital and their family members can't even see them before it was a little bit easier to explain things to people because they would be sitting there at the bedside of making visually see that their family members were getting worse or getting better and it could really understand when they're not there and they're just hearing information over the phone and sometimes maybe having a couple minute video conversation and with their family that's in the hospital. It's hard to really wrap your head around it. And so it's hard to really see for yourself that oh, yeah, they really are getting worse or they are getting better.

19:37 So it makes that a bit challenging and I've seen that one talking to families there when we're trying to explain to them that they want to start number cycle. What's their heart rate today? Or what's the blood pressure today or what's their you know renovation settings today? There's something there and so I try as gently as possible. What kind of explained in those situations that really those numbers at the end of the day don't mean much compared to the overall picture and I think that it can be pretty shocking for people if they were to truly see a person in the ICU on a ventilator and having respiratory distress and how bad it really looks I think that would change people's perspective a lot.

20:38 Yeah, I completely agree. I know that you know, we were relatively sheltered. You know, I see you this past July and I remember my first my second week of ICU and they are all relatively young and I just remember how hard it must be for them not to be able to see them in person.

21:30 And like you said, he was trying to hold on to the numbers and and just trying to have that faith that number could go through.

21:49 Was really young and she was doing pretty well with multiple family meetings talking about, you know.

22:05 What the goals of care wherever what she would have wanted and it took finally just having like a video conference with the family just to show

22:16 The overall picture and talk to you.

22:53 I do think having the conversations opening the discussion as to how to be comfortable with people that

23:09 Peace of mind

23:18 Providing the best character to their loved ones and making sure that they are dead or maybe a lot of guilt associated with that at first I think that at the end of the day there's a lot of comfort in knowing that you did what this person is. So close to you and you have been such a big part of your like you did what they wanted instead of just guessing cuz that's the thing that I think about a lot in terms of my grandmother's like we really just assumed that she would have wanted to hang on for as long as possible. I can imagine or even think about how much pain she was in her how much she was told tired. She was her how much she just wanted to be done and not suffer anymore. Was there a time where we allowed?

24:18 Her to just suffer for like 3 or 4 weeks when she could have just passed with less pain. And so that's something that I think about all the time. That's something that I I think that everybody should think about when they think about their family being in this kind of situations.

24:37 Now that you say that I remember I had this past year and she just had this really bad infection. Just

24:55 You know once all her organs and and now she wasn't going to be able to overcome a country and her sister that lives here in Salinas, but we weren't having any visitors at that point conference call with the whole family and everyone and I never really thought about writing a will or last erupted so hard for me I think on one and the daughter's crying face.

25:55 Rock quarry in your emotional crying and saying that she wouldn't have wanted that then they were just going to make her as comfortable as possible.

26:38 The conversations are never easy. No, they're not.

26:55 I think the pandemic is just Amplified. By 10000 and specially in our community and particularly when there's people.

27:09 Who all live together and all may have affected each other and you know, there's someone in the hospital who's the primary income for these people and then they have to make decisions for somebody who

27:28 Is the only is there open Sunday?

27:32 Mental Health

27:38 See the hospital number.

27:42 Yeah, but I think that the one thing that providing end-of-life discussions for patients has taught me.

27:57 Mental health unit

28:05 It's that you know, when you're talking to your patients about these things there's a way to approach it.

28:14 In a way that is sensitive to people's ideas of death. A lot of people may be completely comfortable and say that's exactly what I want in a lot of people will get offended that you really think that we need to be having this conversation.

28:36 Death it's about talking about you know, when you are in a situation that you can't speak for yourself. I think that's the that's the most important part of that whole conversation that you or letting you die. It's about us being able to see your voice when you can't be that voice for yourself.

29:04 Maybe I think I've learned from patients who have been in the hospital and who have died from cold later for any other diseases that never happens to you. It's your it's your family that's going to be left behind who's going to pick up the pieces. And so not only are you heading to develop a trusting relationship with the patient. You're going to be developing a relationship with my family. So the more you're able to have these conversations in a gentle and approach that they will be able to understand where you're coming from the better that relationships going to be at the are going to trust you as the doctor more because of that.

29:58 I don't think that it means that you should give people false. Hope or that you should be optimistic all the time. I think you have to be honest with patients. But I think if you're honest in a way that allowed them to process information emotionally rather than stronger than people into making a certain decision that you think is right or forcing them to make a different decision. She quickly be I think those are all the strategies that we try to practice and residency to make ourselves better. It can be really easy as a doctor to think like why would this family want to keep this patient on these machines for so long this seems unreasonable.

30:43 And then you kind of think about it from the perspective of everybody else and you realize that like, it's just a very slow process that you have to get an emotionally prepared for.

31:01 I think you're right. I think that approach part 2 is still on for that and I have to say I don't think I have so many conversations outside of the hospital talking about advance directives and what your wishes are if you weren't able to make decisions for yourself is partly because people don't want to have a conversation with her during our visit and was acting like it was terrible.

32:00 I'm not going to die anytime soon. Maybe I would have been okay groceries topics and you know, I don't think anything's going to happen now, but in an emergency already built a trust

32:51 I think we would allow those conversations to have any more comfortably naturally in the hospital with family members and not sufficient themselves Ellie's right now.

33:09 Now I definitely feel like I would never a dress or breakfast topic with a patient that I had first met like this the very first visit. I have never talked to them before because they don't know me and they don't they're not going to feel comfortable telling me things just like telling me about other person and so you definitely have to with someone before it can feel like the right time to bring it up and I feel like it can be difficult to find that right time sometime cuz you feel like all the patient has so many problems. There's so much to get through but I really

33:52 Kind of prepping the patient for that and say Hey, I want to have a visit where we just talk about like what your goals are and kind of stuff. I'm up for that. We're going to be talking about. I think that's really patient or patience with the lot of comorbid health conditions that you know, like they were to go to the hospital.

34:26 But yeah, but it's a tricky way to navigate that situation will be for people who are uninsured. I think that's part of the reason why it's important because the people we are unable to reach a yam.

35:16 And it's hard and I feel like if history has any idea of what the future is going to be. Like I think that people need that pushed a lot of people realize that to have these conversations on their own without someone I think about it from what I've seen

35:38 But I hope that that changes and I hope that becomes more of a normal thing with how we ask in a systematic way about people's medical history and their social history Alcohol Tobacco. I hope in the future it becomes as palliative care and end-of-life Care becomes more and more important and it just becomes a standard part of all the questions that everybody knows of the doctor's going to ask you that you as a doctor know that you're supposed to ask your patience and I hope that with that we can kind of prevent any of those negative experiences not families have while in the hospital where they're just fighting at the end of someone's life.

36:24 And I hope so.

36:28 Are because of that people are able to take advantage of the services that support is not just supporting the sick person but supporting the whole family and I think that's my mom. You know, my sister like hey.

36:56 You have an important thing you want to do sometime this week. Let us know the time will come you can go relax and take time for yourself because it's such a such a burden on the person going to the store. So underutilized that people don't realize that it's not just

37:45 The heart topic

37:49 Well, I hope somebody who listens to this is empowered by it and has this conversation with her family?