Neurosurgeon Dr. Ramin Javahery on Humility in Medicine – Podcast Transcription

It was an honor to interview Dr. Ramin Javahery, here is our important discussion on “Humility in Medicine:”

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Dr. Denise: This is the Dr. Denise Show. I’m Dr. Denise McDermott, an Adult and Child Psychiatrist, specializing in an integrated approach to mental health. I believe in prescribing the least amount of medication, coupled with a comprehensive treatment plan. My goal is to empower you to thrive and I take a multidimensional approach to wellness, not illness. You are not your symptoms. Call upon your best and highest self to embrace your mental health. On this program you will meet many doctors, experts and pioneers who have helped pave the way to shift the paradigm of getting rid of the stigma of mental illness in our society. This show was created for those of you who would like new ways of thinking and understanding about mental health and helping your loved ones to thrive and cope in empowered ways.

Today I’m excited and honored to interview Dr. Ramin Javahery. He is a Board Certified Neurosurgeon. His education began at UCLA where he graduated Magna Cum Laude with a degree in English Literature. During his undergraduate years, he also engaged in research in the field of Molecular Biology. He went on to medical school at USC and became Editor-in-Chief of the USC Journal of Medicine. Beyond his academic pursuits, he was also interested in humanitarian activities and organized the USC-Rwanda Relief Fund to send money to the victims of the Rwandan genocide. At this time he is Chief of Adult and Pediatric Neurosurgery at Miller Children’s Hospital, where he practices both Adult and
Pediatric Neurosurgery, as well as Spine Surgery. His interest in patients extends beyond curing their diseases. He has passion about caring for patients and is a member of the ethics committee at Long Beach Memorial.

Dr. Javahery:: Good morning!

Dr. Denise: Good Morning Ramin, thank you so much for being on the show today.

Dr. Javahery:: Thank you for having me.

Dr. Denise: How much time do we have today? I want to respect your surgery schedule.

Dr. Javahery:: I have patients at 10am so we have plenty of time.

Dr. Denise: OK, fantastic! Ok, so everyone, I’m so excited and honored we have Dr. Ramin Javahery, Chief Neurosurgeon at Miller’s Hospital here for an interview and he and I met very fortunately on social media. We actually, it turns out, Ramin, it looks like we’re neighbors.

Dr. Javahery:: We are?

Dr. Denise: Yah. I live in Manhattan Beach too.

Dr. Javahery:: Then we are neighbors.

Dr. Denise: Did your kids get a good start to their school week?

Dr. Javahery:: My kids actually go to school at Chadwick so they don’t start for another two weeks.

Dr. Denise: Oh, ok. We’ve got one at Rolling Hills Prep, one that’s on their way to college and another one at Pacific. So we’ve kind of got a lot going on.

Dr. Javahery:: That does seem like a lot.

Dr. Denise: Yah, but a lot of good stuff too. So I really appreciate you being on the show. Can you give us a little bit of background on your path to being a Neurosurgeon and also some of your other humanitarian activities, just to give us an idea of who you are and what you do?

Dr. Javahery:: Sure, I, let me just start by saying that there are really two types of doctors I think, doctors who enter the field as scientists who want a practical application of that field and doctors who want to do things that are good for humanity and pick medicine as the path. And those doctors may not be scientifically minded; it’s more of a desire for connectivity and being a humanitarian in some ways. And I think for me it was more of that path. I was an English Lit major in college and I really couldn’t decide what I wanted to do, I had thought about going into ah, the law or going into business and it just never resonated with me, I wanted to find something that allowed me to be connected to people, to do things that made a difference in people’s lives. And my dad happened to be a surgeon and it kept calling to me and it was, despite my father’s best efforts that I went into medicine. He actually consistently tried to dissuade me from going into health care as a field.

Dr. Denise: You know I have to say something about that, my uncle, Raymond Vahl, Dr. Vahl is a Dermatologist in the Chicago area and I experienced the same thing. My uncle was like, I don’t know, medicine’s changing, you don’t get the sort of the essence of the art of medicine and he really, really kind of did the same thing, so I find that very interesting. And it sounds like on your path, which was similar to mine, you know, I love surgery, you know I got an A on surgery, I was into Ophthalmology stuff, I was one of those people, sounds like you, that had so many interests, but I followed my path of being more of an innate healer that I really wanted to make a difference in a care-giving profession and so I was really interested when I read your bio and saw that you were an English Literature major and you were editor at USC, so it sounds like you’ve always had a lot of interests and you kind of then, how did you things, how did you listen, not listen to your father? How did that happen?

Dr. Javahery:: So, it’s interesting. I think that my perspective about health care was really because of my dad, despite what he said, you know, the old adage, look at what people do, not what they say. And I lived in a home where my father was respected and loving in his community because of what he did, through his work. And that seemed unique to me. No other profession, I mean there are other professions, but no profession that was open to me at the time seemed to have that where, again, a trite cliché, where you can do good and do well at the same time was available to me. And, but it wasn’t just to do well that was the animating factor, it was that I didn’t think that I would be a successful enough businessman to have a Gates Foundation. I didn’t think that I would necessarily be able to do as much good on a daily basis if I was a lawyer even if I was in a philanthropic organization as I could as a physician. Literally on a daily basis I can affect people for the better. And, more importantly, than that is that the community that you build in health care with your patients and their families is much more robust, I think, than in almost in any other position. Just think about the fact that you walk into an office and you see a physician and without having anything told to you about their background, who they are, what they believe, you trust them. That innate faith in the person that’s in the office that you’re seeing is remarkable and it’s a um, it’s a privilege that physicians have and we should work extremely hard to preserve it, not, and I think that some of the problems that we see are because there’s a certain amount of abuse of the inherent faith that society places in physicians by certain physicians and I think that, we should fight that, but it also means that we are such a privileged group and it makes our jobs very satisfying.

Dr. Denise: Well, the, what you are talking about is very much the doctor patient
relationship,

Dr. Javahery:: Absolutely

Dr. Denise: and I know that in the line of work I do as an adult and child psychiatrist, I always enjoyed the whole picture of a person. I was not someone who could see myself in a clinic where I had five to ten minutes to say are you depressed are you sad are you this and so I took a leap of faith and I started my private practice when I was finishing up. It looks like you and I have the UCLA connection. I was finishing up my Child Psychiatry at UCLA and I was like, you know what, I am just going to go for it, I want to be able to practice medicine in the way that I want to, create the office environment and really I decided not to do a managed care route because I didn’t want to lose the art of medicine and I’m in a unique situation, I know with surgery there’s different challenges and I think we need to address that because I think you want to talk about the doctor- patient relationship and how doctors and patients can have the best relationship whether you’re in managed care or you’re in a kind of fee for service or a private practice. But what you’re talking about when I actually look at my schedule my patient schedule every day and I really connect I have some people that come to me for therapy some for med management some for a second opinion. I have people in my practice that I’ve had for 15 years. I might only see them twice a year cause they’re just thriving. But there is a real connection and the essence and the art of connecting. When you say humanitarian I look at things as we’re really connecting soul to soul. And so I think it’s such a privilege and such an honor and I think it’s such an important time for us as doctors to be role models. And I’d love to get your take on what it’s like being a surgeon and I know you wanted to talk about the doctor-patient relationship and the future of medicine. I’d love to hear your A quote from history:” It when you want to find a diagnosis go to the patient if you’re confused go back to the patient.” It’s really the patient that is the key, the patient is the place you have to go and the doctor- patient relationship is the key to it. And I think one of the things that is lost in the healthcare reform and the conversation about healthcare reform is that everything we talk about seems to be diminishing the doctor-patient relationship and part of the problem is that much of it is animated by this progression and it’s not the health care reform under President Obama wasn’t a change it was just a natural progression of what’s been happening which is that health care went from mostly small mom and pop small businesses and then academic institutions to more and more big business, large, I mean large multi-billion dollar corporations that own the facilities and own the physicians. I think that is, I can’t stop that. I don’t think anybody can. I think that we have to involve doctors in the process and at least make people understand that there is a cost when you eviscerate the bonds between patients and doctors, and the again another cliché; nobody cleans a rental car. When doctors don’t own their patients, when the patient belongs to the system and the doctors aren’t individually responsible, then there’s really nobody responsible, you need to own your patients they have to feel that at the end of the day you are going to be responsible for what happens to them because that feeling of responsibility, which is inherent in a doctor-patient relationship, will encourage you to be a better physician and encourage the patients to trust you. I think that that bond is being broken and I will say one thing about the whole health care reform system; it lacks humility. One of the things I love about being doctors and one of the things I hate, I hated about when I was first going into surgery, about a lot of the surgeons I met was humility. The lack of it and the surgeons I met and the prevalence of it among most good physicians. I think that, one of the real assets. I’m sorry, go ahead.
Dr. Denise: No, I just want to jump in because I’m so aligned with you. I actually, I did a tweet that said ego is the enemy.
Dr. Javahery:: Yes.
Dr. Denise: I really wish all of our children, because I’m a child psychiatrist, and I think about health and prevention and people being empowered with their health and kind of having self-awareness. And, can you imagine, I know in our schools here in Manhattan Beach they’re doing a lot of integrated kindness and care and character, but can you imagine a world where our children were being taught about what ego is, what humility is, learning how to say they’re sorry and also feeling almost honored and privileged? I was raised that if you have gifts, and you know everyone has their different spiritual beliefs or their higher power their God their source or maybe in just this lifetime they don’t believe and there’s the high morality. But I believe if you have a level of intelligence and compassion I think if you’re able to take care of yourself and your family and you have more left over and you have the ability to be a surgeon or a doctor or a humanitarian in any way, we want to be of service to others. And you know not everyone has the same capabilities. I have a lot of humility because I work with a lot of children with learning issues, ADD, autism spectrum and those people are working, you know, at a different more strenuous rate just to get through their day. So if someone has the intelligence to get through medical school on pretty much any different type of profession in medicine and someone’s coming to be helped you want to make sure, I do agree with you, there needs to be humility. And also I think it’s so important to meet our patients where they’re at. And I think I’m just so excited to have you on the show because I feel like you’re a kindred spirit. I bet you spend a lot of time really connecting, educating your patients, making them feel like they’re empowered. Would you, can you speak to this?
Dr. Javahery:: So I do think we have a similar perspective on this. I think the belief that I am flawed and that I am not, me meaning anybody, that I as a person am flawed and that I shouldn’t think too highly of myself because there’s always there’s always someone smarter, there’s always someone better educated, there’s always someone better looking, there’s always someone taller, thinner, more attractive, whatever it may be. We should all have a little bit more humility because, we are, we all have our flaws and I think that walking with that understanding makes us much more compassionate to everybody else around us. Again, the cliché, he who has no sins cast the first stone. We seem to be living in a world where people are so confident of the truth of what they believe, that they are almost blind themselves to the ability to connect with other human beings. I read a book, the name of which I don’t want to share because the name of it will kind of temper the perspective, but what the book said is that it was about Miller-Urey Gnostics which were the Christian version of modern day Islamic fundamentalists at the turn of the first millennium when they were, they believed that Christiandom was not Christian enough and then needed to be more adherent to the laws of Christianity so that there would be the second coming, and the quote is that, “the believer knows that he believes, the zealot believes that he knows,” and this blind faith in our own knowledge is completely antithetical to what being a good doctor is. Doctors are inherently insecure we question, we have M & M’s and we criticize each other and we’re confrontational with one another.
Dr. Denise: So that for everyone out there in M & M is morbidity and mortality correct?
Dr. Javahery:: Yes.

Dr. Denise: When you have conferences when something doesn’t go quite right and doctors want to learn like what could we have done better. So that’s what Dr. Javahery: was talking about.
Dr. Javahery:: Sorry about that. Yah…
Dr. Denise: That’s ok. No problem.
Dr. Javahery:: I got into the weeds.
Dr. Denise: No, but what I want to say though, we’re talking about compassion, we’re talking about love, we’re talking about humility. And so when I was in medical school, I have to admit, the first year of med school I actually went and saw a therapist and you know why?
Dr. Javahery:: Why?
Dr. Denise: I thought people weren’t kind enough. I actually went and talked to a therapist and I said I thought 80% of people, by the way I don’t want it say that I have this exact number right, I just like to do estimates, I thought 80 to 90% of the people were smart enough to be there, but only 40% felt kind and compassionate enough. I was a little bit disappointed I know as a young I went straight from undergrad right into med school so I had to do a couple of therapy sessions because I’m like, oh my God, these people are mean like how are they going to grow up in like four years and turn kinder. So I just wanted to share that just came back to me when you’re talking about, you know, maybe this kind of segues into young doctors. But I have this idea that doctors, you know, are supposed to be healers, they’re supposed to be helpful. And this does tie in with your ego discussion. I saw a lot of ego at my medical school.
Dr. Javahery:: I did too. I was. I was a little bit taken aback by the egos in the in the world of neurosurgery when I was first applying for residency. I was truly shocked because growing up my dad was a surgeon but he was a very humble man. And I always thought, physicians, and especially surgeons is more like just privates in an army where we just did the grunt work. We just worked and worked and did good things for people and that’s what we did. And I didn’t view, this is funny because I didn’t view doc. as surgeons as, the smartest. I always thought I was always impressed by the cognitive ability of internal medicine docs. But I viewed surgeons as just, we, we took it. We just were tough and we worked and we were kind of manual labors in the world of health care. And as such we should be humble and, in our deficiencies. And take pride in just the fact that we worked hard. And when I was applying I saw so much ego and it was, I agree, off-putting and going back to this issue of humility. I think on a global scale what we can do as physicians is first police ourselves and remind each other that humility in what we do is a necessity, it’s not a flaw. And then take that and apply it to the bigger issues of reforming the health care insurance market, access to care, because I think those things do need to be changed they need to be fixed, but they should be fixed maintaining a doctor-patient relationship and they need to be fixed with a certain amount of humility about what it is that on a macro scale we can never anticipate occurring on a micro level when you change macro policies. And, I think again, people who work in the trenches like I do have should have a voice and should participate in the health care reform because I think all too often people who have, who do public health and who do large scale analysis don’t really pay attention to the ground level affects on patients and their families and the relationship between the patients and doctors.
Dr. Denise: I agree with you and I think I’d love to meet with you outside of the show to discuss ways we can do that, but one thing that we’re also talking about, for any young physicians listening and also for patients, but for young new physicians, I think they have to have they have to make you have to make the decision, like you and I did, and it sounds like you are just naturally this is kind of innately who you are. But if you’re somewhere in-between the science and the healer you describe two types and you’re maybe a little bit of both, really standing in your own truth as an M.D. and making sure that you decide that your patient-doctor relationship is sacred and that, meaning you are, that is your patient, that is your doctor, and that no matter what managed care is telling you, that you need to sort of stand up if you don’t agree, that you need to shorten your appointments or you need to do this coding or whatever you need to do, stand true and also try to do whatever you need to do for good self-care. We all need to do this good fitness, good nutrition, because I think when doctors and anyone’s overworked you can get a bit jaded and sometimes you can just go along with the program. And so you need to really still stand in your truth and it looks like this is a good time to talk, and I know there’s a couple of other topics we want to get to, but you’re on the Ethics Committee.
Dr. Javahery:: Yes
Dr. Denise: So it sounds like what you’re talking about is something you’re so passionate about can you tell us a little bit about your work on the Ethics Committee?
Dr. Javahery:: Yeah. I joined the Ethics Committee because I was so disturbed by a lot of the ways that patients were being treated by physicians. One of my pet peeves and then one of the things that I always bring up with families and I’ve never heard anybody else talk about it, but I see them practice this in the wrong way is the difference between moral and medical futility of care. So we live in a world where doctors don’t think about what they do in a moral paradigm, but it is, and yet they approach patients and give them moral advice believing that it is purely medical advice; I’ll give you an example: a patient comes in with a bleed in their brain, a hemorrhage, the patient is 80 years old. The bleed is devastating, but if we do everything we can as a physician that patient will survive, they will survive with a pretty poor quality of life, but they will nevertheless survive. The physicians go in the room. And talk to the family and say well this is futile to do anything and therefore we would recommend withdrawal of care. Now, the family may believe that it is futile and that the quality of life that that person will have is not worth fighting for or they may disagree. And, but that is their choice. The physician in that situation is making a decision about moral futility not medical futility. You can help medically. You just don’t agree with the outcome morally. We should be more humble. We should present it, and I do often, I go listen, the strategic goal here is the moral perspective you bring. If this is a quality of life that you find acceptable, on a tactical level, I’ll fight the fight for you because medically I can make a difference, but I have to tell you, and I’ve said this to patients, I’m, from a moral perspective wouldn’t fight it. My moral code tells me that this is not a fight worth fighting. But I will fight for you if you feel that this is what you want for your family. And it is such an empowering conversation. I can’t tell you how many people will say wow I get it. No let’s not fight it, in a circumstance where they were, they were defensive prior to my conversation with them. And I think that one of the things that I do with the Ethics Committee is I constantly try to push back against the moral blindness of a lot of physicians when they try to impose their morality on the families of patients especially in a culture, in a multicultural environment like ours where, you know, you’ve got often white upper middle class physicians who are religious, but maybe more on the periphery of religiosity and we’re dealing often with, in my case, I mean they’re very heavily Hispanic population, very Catholic and very religious who don’t view, it doesn’t have to be Catholic, you can be in an Orthodox Jewish environment where they are very reticent to withdraw care or to diminish the care that their family receives, and that creates conflict. Well it’s not your job to change this person’s morality, if they believe this is a life worth living, even if I don’t, my job isn’t to teach them my morality my job is to care for them and as long as it’s not medically futile, I will do as my patients families request because that is my, it’s my oath.
Dr. Denise: So everyone I think what I love about what Dr. Javahery: is talking about is really meeting the family. There’s the medical outcome of yes I can keep this person alive. But then respecting the person having a conversation where you respect them soul to soul, person to person, human to human, and you look at what their beliefs are, but you do what a doctor needs to do is have compassion and also patient education. So you’re letting someone know. If we do this here’s the quality of life. And you’re really educating and telling someone here all the possibilities. But you’re not telling someone well they’re goner, or this. And so I’m wondering, can you give all the listeners out there that might be going into like a surgery situation maybe some tips on how If they could talk to their surgeon depending on their surgeon’s style like what tips you would give people? And how to have that conversation?
Dr. Javahery:: So one of the things I tell all my patients is that any doctor who’s afraid of a second opinion is a doctor you should be afraid to see.

Dr. Denise: I love that. Thank you. I do too. Go ahead. I’m like, go ahead see as many because you want them to feel good. So keep going. So first of all a second opinion is something that no one should be afraid of, we should encourage that.
Dr. Javahery:: Right. Because either I’m wrong and you get a second opinion and it opens my eyes to a bad, an error in my judgment or you get a second opinion and it corroborate what I had said and you are more faithful in what I have to say. you believe more strongly in what I have to say.
Dr. Denise: Or there is even a third option right, that there’s a little bit of both. I’ve had that people go and get like three or four different opinions for really complex surgeries in my practice and they come to see me for the psychological piece of what to do.
Dr. Javahery:: No absolutely. I think as all good health care there is a collaborative aspect to it. But what I was going to say in terms of your question about what families should do. I tell them this and the reason I say this is that families should, or patients and their families should not only seek a second opinion if they are looking for more medical information you should also feel connected to your physician because at the end of the day what I do as a surgeon is an extraordinarily intimate act. I enter people’s bodies. That’s not a small issue. Forget about the technical ability or whether I do a good job or not. Just think about it. Do you like this person enough to have them violate your, your being. If you don’t find some of that you do feel is you’re OK with letting them into your body. This is, it’s kind of like dating, find someone that you are in sync with. If it’s not me, fine, find somebody that you’re comfortable with because every surgeon will have complications. Everyone, if there’s a doctor who tells you a surgeon tells you that they’ve never had a complication they’re lying, everybody does and you want to feel that if there is a complication you have faith that this doctor did the best for you they could, and that the complication was unavoidable. So I think that connection with a physician is important that emotional link that you speak the same language, that you view life through the same prism of life experiences, morality, ethics, all of those things that matters. Now, some people it matters less, some people are just, you know, they go I don’t care as long as he’s a good doctor if doesn’t affect me, more power to you, then that’s as much of an issue. But, whatever your metrics are for trusting your physician, if you find a doctor that doesn’t fit it, don’t be afraid to find someone who does.

Dr. Denise: I completely agree and we’re talking about the therapeutic alliance, and when someone comes to us, I believe that we are all a part of our own healing, so whether someone is coming to me and they have depression or anxiety, or if they’re coming to you for a surgical procedure, yes but we’re facilitators of health and well being, we need to have that partnership and the hope and belief and the relationship, because the outcomes are so much better. In fact, I don’t know which journal I read, but a lot of surgeons, when people are sort of like, “I know I’m going to die, I know I’m going to die..” sometimes you’re like I don’t know if I want to work with that patient. I want to be very specific here, there are situations where the surgery is so complex where there’s a high chance of dangerous surgery, but my point is we need to engage our patients in the healing process and the hope. So when someone comes to me and says nothing can help my depression, and I’ve worked with them for four times, but they keep repeating that thought to themselves and they’re maybe not engaging in exercise, good nutrition, cognitive therapy, mindfulness, then I don’t have a partnership for them to engage in their health and well-being. So, I think it works both ways, I think we want our patients to find doctors that they trust and care, and I will say and I’m sure you can agree that there are different character styles in medicine. Just like there are in law, and everything, and there can be an exceptional surgeon, that maybe is a bit shy, and is an outstanding surgeon, but maybe doesn’t like to do a lot of the talking, but it still doesn’t mean they’re not compassionate, so you can pick up on their vibe that they’re very caring, but maybe they don’t talk as much to their patients because they’re ready for the next thing. Would you agree that there sometimes there’s that style, too?

Dr. Javahery:: Oh, yeah, I think that the, our judgments about people are tempered by our experiences, and sometimes people who are shy come off as aloof, totally agree. And especially for patients who are looking for someone to comfort them through the process, if you’re shy and don’t reach out to the patient, it can come off that way, I.. my perspectives are generalities, I don’t profess to say on every specific case they are applicable, there are going to be exceptions. Just like, you know, when I was dating, there were girls who thought that I was one thing, even though I would just happen to be shy about dating, and they were not interested, and the same thing applies to the doctor-patient relationship, you may think that someone is aloof just because they’re shy. But, can I just make a… I want to share a story about the doctor-patient relationship because I think it really animated it in my perspective. Since I was in residency, and there was a woman who had broken her back, she was paralyzed, we operated on her, stabilized her back, but obviously made no change in her paralysis, she was a former nurse and had some respiratory issues, she would have recovered if we were fully aggressive in her care, she decided to request that we remove her chest tubes, and she would go on hospice, and, meaning that she was going to die, and she was would have died because she still had respiratory issues, she had gotten pneumonia, and eventually passed away. But, she wanted to die because she didn’t want to live as a paraplegic. And I remember, nobody else broached the subject with her, her son, I did, I went in the room and I said, “Listen, life, you know, just because you can’t walk, doesn’t mean that you can’t be productive, my dad died of ALS and he was paralyzed, and it was… I felt very strongly that human beings exist between their ears, not below their necks, and that our physical abilities should not define our humanity…” And I told them this, and I told the son, “Listen, I’ll do what you ask, I’ll do what she asks, but I have to tell you it makes me sad, that I think you guys are doing, from my perspective, the wrong thing, but I will definitely help you, I mean I won’t stand in your way, I just have to tell you, I think that you’re not giving life a chance here.” So, she eventually did this and died. The son came back and said, “I so much appreciate that you were honest with us, that although you disagreed, you told us what you felt, and we did what we felt was right, but at least there was an honest conversation.” And I think that that was really significant in my life, because it told me that I can disagree with people, and they will still respect me if.. If I do so honestly and with respect, again, with humility.

Dr. Denise: Absolutely, so we’re talking about respecting another individual’s world view, soul view, and that you, you have the advantage as an M.D. of also seeing people feel that way, about, “Oh my Gosh, I might be paralyzed,” but then you see on the other side people thriving, and so do I, I see people go through unbelievable medical issues, surviving cancer, surviving things, and finding out that their inner world or their mindset, that they’ve actually enjoyed life to an even greater extent, but at the same time, we have to respect another individual’s viewpoint, so giving options and sort of being true to your feelings, but not saying you have to make this decision because I feel this way, really also, I believe everyone allows for the doctor-patient relationship to be vulnerable, and to be real and authentic and not from a distance. When you start talking about statistics, but also feelings, that allows our patients to kind of open up and share their feelings more so I think that was a great example and I really appreciate you giving that.

Dr. Javahery:: Yeah, I think…Thank you. I think that overall these issues, like you said, humility, respecting other people… makes us better physicians, and, you know, if you go back historically, physicians were respected way before we could actually help people, for centuries. We had very little in our armamentarium to help most patients, most of our patients died, and there was a few cases where we could help, there was some things, but the mortality for surgery was so high, diseases were often untreatable, but people still respected us, why?

Dr. Denise: Well, there was innate desire to be a healer. There was an innate desire to connect with another soul and help them thrive and have the best life.

Dr. Javahery:: I agree, and I think it was also a perspective that linked us to the clergy. You know, miracles don’t happen all the time, yet people believe in the value of clergy, why? Because they were guides, they helped you through a process. Whether or not you achieved the goal that you desire, a miracle or whatever, or health from the doctor, was secondary to you were a guide through the process. And too often, physicians, because we so much rely on our ability to heal, we forget about our ability to comfort and to guide people through the disease process. If I guide you through a disease process, no matter the outcome, if my job is to guide people through a disease process, no matter the outcome, I, and the patients, always win. Even if the disease takes that patient, if my job is only to cure, the patients lose, I lose. But if my job is to cure, and to guide, there’s always victory in that process…

Dr. Denise: Can I say something? What you’re saying is so fantastic, because we’re- the world’s using a lot of buzz words these days, and what you’re really talking about is the journey, not the end point, so we’re talking about not just the material result, does the person live or not from the OR, we’re talking about the process of, the engagement, and we did the best we could, but we also honored someone’s belief system, so we’re really respecting someone’s mindset, and their kind of the unspoken energy exchange between two people, so we’ve got the human, material realm science, but what we’re really talking about is also post material connection, the unseen energy exchange of, you know, we can use words like compassion, humility, and so I agree, I completely agree with you.

Dr. Javahery:: Oh, good.

Dr. Denise: And I think it’s fantastic, and I wanted to ask you because we have a little bit more time, I think that one of the topics you wanted to address, I know that you work with children, you work with teens, you work with adults and I saw on Twitter, I saw one of your cases about a six-year-old who, you know, you removed a tumor on their brain stem, and you’re dealing with post-op recovery, with healing, so can you give us a little bit of an idea of your treatment philosophy on pain management? And how you educate your patients and how they can be an active participant in their recovery?

Dr. Javahery:: Yeah, so this goes, my philosophy about pain goes back to, to my mentor in residency, Dr. Heros, he’s the, he was the Chairman at University of Miami where I did my residency. And he used to tell us stories about the old days of Neurosurgery, and one of the stories is, that, back 30 years ago, 40 years ago, there was a very vibrant field in Neurosurgery which no longer, which is no longer as vibrant. And this field, this part of Neurosurgery was basically surgery pain management, it was surgical management of pain. There was a surgery that they did, not very often, but when patients had incapacitating pain, it was called cingulotomy, bilateral cingulotomy. The cingulate gyrus is one of the gyri in the brain that is part of the circuit that controls our emotional response to pain, and it’s basically, what that means is it controls suffering. If people were, had incapacitating pain, the surgery would be to disrupt both cingulate gyruses and what would happen is that the pain would still be there, and he would describe, I’ve never actually seen a patient like this, I only know the stories that Dr. Heros said and he’s, his veracity is unassailable. He would say, these patients, you would do the cingulatomies, and they would wake up and he would go, “Are you in pain?” And they would say,”Yes.” And he would say, “Well, does it bother you?” And they would say, “No.” And it was this epiphany for me that pain and suffering are distinct and they shouldn’t be brought together. That pain is a body’s physical response to a noxious or dangerous stimuli, like a, sharp object, heat, fire, things like that. We all have that same nervous response, goes up the sensory nerves into our spinal chord into our thalami and then to our consciousness, that’s pain. Suffering is the emotional overlay on our pain, that emotional overlay is adjustable-

Dr. Denise: I agree.

Dr. Javahery:: You can, sorry…

Dr. Denise: No, I love it, it’s the mind body connection, so I want to hear your perspective as surgeon and then I see and hear that in my office.

Dr. Javahery:: So, my, my, what I tell patients is you can do it surgically, you can disconnect that surgically or you can do it emotionally. We all walk in life with a certain amount of emotional reserve, the more you exhaust your emotional reserve, the more you will suffer. The less you… The more emotional reserve you have in life, the less you will suffer for the same amount of pain. I have patients, two patients, same surgery, one patient is in agony, riving, the other patient, you walk in the room and they’re smiling, and you go, “How much pain do you have?” And they go, “Oh, I’ve got pain doctor but it’s OK.” It is the emotional response, and you can teach people to have a more measured response, and you can encourage them to build more emotional reserve to face those difficult physical ailments. And part of that I think is encouraging patients emotionally to have more connectivity with the people they love and the people around them. I think isolation is an extraordinary emotional suck, it basically, being isolated is an emotional vacuum cleaner, you become completely exhausted. Obviously, it’s a chicken and egg thing, do people who have chronic pain become isolated because they have chronic pain? Or do people who have more emotional issues develop chronic pain issues? I think that these are conversations you should have with your patients, because I think that once you have them, people are more aware of the intellectual tools they have to overcome their pain, and so…

Dr. Denise: Do you refer your patients or does your team at your office have someone that’s very savvy with cognitive, I know it sounds like you’re an educator and very compassionate surgeon, do you have a team approach that helps people rank their pain, and look at quality of life and holistic healing and how much sleep they’re getting, how much exercise, what’s your physical therapy, what is your wrap around service at your particular clinic with this discussion?

Dr. Javahery:: So, unfortunately, no, I don’t. Part of it is that, there’s a paucity of neuropsychologists, psychiatrists who are able to participate in these processes. If you’re in a, because I work in Long Beach, I mean I do get a lot of affluent patients, but the majority of my patients are not, I take care of Medical, patients. I, my practice is broad and therefore the patients I get often don’t have access to the psychological aspects of these things, so, I’m sorry go ahead-

Dr. Denise: No, I was just thinking that kind of something that’s not the extent of a neuropsychologist or a psychologist would be a really amazing nurse practitioner that floats between a couple different surgeons and then you haven’t sort of an empathy outcome rating scale or something where someone’s even checking in with them. Because there has been data to show that, you know there’s apps and things that have been created, and when people feel that someone’s connected and they care, that helps them feel engaged in what they need to do to heal, and then they have less pain because they are more hopeful, and they’re not lonely. So maybe with that patient population that you’re talking about, and this is by the way, something that’s more of a global solution, it’s not something that’s such an easy fix .I know change takes time, however, if you had a very engaging nurse practioner or it doesn’t have to be that, it could be a social worker that floats that kind of just checks on people. It would be really interesting to see the outcome, and maybe the faster recovery and less pain.

Dr. Javahery:: I would love to have somebody that could do that, and we’ve been, I’ve been trying to get funds from the hospital for a variety of things, like a research nurse, and all these other things, I got to tell you, it’s, in the world of, you know…

Dr. Denise: Corporate redtape, medical…

Dr. Javahery:: Yeah, big corporate no- even though it’s a non-profit, it’s still a corporation. It’s financially at the end of the day. And the majority of children’s hospitals are run off of Medical CCS dollars, there’s very little, unless you have a private foundation funding it, to pay for all of these things. And I think that in my world, at least in the pediatrics side, there is, a lot of the onus falls to the parents to kind of provide that support structure for their children. We do have neuroscientists for the oncology program, but, like, I have a hard time getting my traumatic head injury kids into a supportive environment, but I do think you’re right, we should get somebody.

Dr. Denise: Well, I just had another idea too, and again, talk about this more on a phone call or I’ll meet with you at some point, but you’re such an innate healer on top of being a surgeon, and I think our patients really connect. Like I know when I, I’m going to tell you this, I’ve had a lot since the, and I’m not trying to make this political, the current world milieu environment, in all my years, I’ve been in practice for 20 years, and I’ve had more people that have been suicidal this year than any other year in practice. And I’ve had 12 people under age 18 that have wanted to kill themselves, and I had to, right before I went on vacation, ‘cause I had to make sure I had the emotional reserve. Now, I have 14 people who are no longer suicidal, I think we need to, like when I call my patient back, like, I thought, “Oh, my goodness, that week,” and I just have this, I’m really in tune with my patients and when they hear my voice, immediately they’re like, “Oh my God, I had hope, that feels great.” I’m wondering, Dr. Javahery:, because you’re so compassionate and kind, maybe part of your follow up is just getting a beautiful voice recording that you tell people there’s this recording thing that you do, it doesn’t mean that it forgoes them going to see someone, but that you really care about them, and it’s not realistic for you to call every patient back yourself all the time, but maybe there could be something, because I think when they hear your voice, and your care, there’s a level of healing, it reinstates the connection and we know that there’s so much healing that goes on that’s not just the knife healing, or the here’s your meds healing, there’s the actual, “Wow my doctor really cares.” So I’m wondering if there’s not the funding to get the full on neuropsychologist or nurse practioner, there can be some other protocol put in place because, I would think, if your patients even heard your voice more frequently, that would help engage them in the process of healing. You know?

Dr. Javahery:: Well, it’s funny you say that because I actually.. You know, even though I’m busy, I do.. If my patients call, I try to get back to them. My office knows to let me know. And I have another theory, I don’t, most of your listeners may not know this, there is a physiologic term about the heart muscles, it’s called the Starling Curve, it’s basically it’s a theory about how best heart muscles contract, and then the preload and afterload. Preload means how much do you stretch the muscle, and afterload means how much does that muscle contract and there is an optimal preload, meaning an optimal amount of stretch for a muscle that allows it to give you the best contraction on the back end. If you don’t stretch the muscle enough, the preload is too low, the muscle doesn’t contract well. If the preload is too high, you stretch the muscle too far, the muscle can’t contract well. Just think about when you lift the barbell, the easiest point is at the midpoint of your arm you can, you have the best strength, that is your optimal preload, doctors are the same way, we have an optimal preload. There’s a certain number of patients that allows us to be the best version of ourselves…

Dr. Denise: I love that, keep going… I agree with you.

Dr. Javahery:: If we have to few patients, we’re not good we don’t have enough practice to be good at what we do. If we have too many patients, it dilutes our ability to do our job well and be committed to each patient individually. So that’s what’s happening with the corporatization of health care, your doctors are seeing too many patients in order to, which prevents them from doing a good job for each individual patient. I don’t do that. I have, we run a private practice, I don’t have, it’s not a mill, on office day I may see…

Dr. Denise: Can I say something? Way to go! Yay! I do the same thing, so keep going, cause I had to do a waitlist, not because I don’t want to help people but because I wanted the current patients in my practice, and I’ll be very honest, I told someone, “The acuity of what’s going on in my current practice doesn’t allow me to take someone on, but here’s a great referral,” and then I put people on waitlist, because I believe what you’re saying, we can’t, you want to stand up strong and have your A game as much as one can in everyday when we’re working with our patients.

Dr. Javahery:: Yeah, absolutely. I think that I, our practice, I’ll see like 12 or 13 patients in a day, maybe14, but I can’t see more than that because then I’ll be rushing them in and out of the office and that’s not fair. The…forget about fairness, it’s not good medicine. So, that allows me to be much more available for my patients, now, I have the advantage over you in that my, I have episodic relationships. I see patients, and there’s a blip in time where they’re really, really sick and I’ll take care of them and then everything settles down and I’ll see them once a year and those once a year visits are short, brief, they’re OK with it, they know I care.

So, they know to trust me because I’ve committed to them in the past. But, overall, I get what you’re saying and I feel it. I don’t overdue it because I don’t want to be, I don’t want to be an economy of scale kind of person, and I don’t want to ramp up the number of patients to make more money. I make money based on the quality of my work, not the volume of my work. And I don’t need to make 20% more money by providing 30% less quality of care. I’d rather do my best work and make less money.

Dr. Denise: Well, and I think that this is a conversation where often times you’re in the field helping your patients, we’re on the front lines helping our patients, and I think a lot more doctors, and then you get on these committees, and then there’s bureaucracy. ‘Cause I’ve been on committees where I’m like, “Why am I on this committee? They’re not getting much done. They just kind of want to say they’re on a committee.” But this type of thinking, this mindset, the kind of a patient, compassionate, humble , and ethical mindset is something that I think needs to be taught in medical school, and then it would be really incredible if doctors took back medicine a bit more, and that we didn’t allow it to be so corporate, that’s like a whole other podcast, but I think that it’s really fantastic to hear that you’ve done that, and hopefully I’ve had some people that have come to me for supervision or mentoring that are young new psychiatrists, I think it’s very important that in all fields of medicine that people stay true to the best quality care and really the best doctor-patient relationship.

Dr. Javahery:: Totally. My mentor Dr. Heros used to say, we were so busy, we would not get our notes done often and he goes, “I don’t care about the notes. As long as you provide good care, everything else is B.S.” and he would say, you basic-, “If you do good care for my patients, you’re basically bullet proof. Nothing will hurt you. No one will criticize you, and I’ll stand in their way. I don’t care if the hospital says you didn’t do your discharge summaries, you didn’t do your notes on this day, you do good work, you take care of the patients, everything else is secondary.” And I would say to most doctors who are coming out, if you’re afraid of the hospital or the insurance companies or lawyers or whatever, just concentrate on being a good doctor, it will make you bullet proof.

Dr. Denise: Have you thought about writing a book about this? For surgeons, for young surgeons, almost like a How-to, some quick tips, and then you know, kind of every surgeon needs to have this book before they go out there.

Dr. Javahery:: I haven’t thought about that, no.

Dr. Denise: You might want to do that because we are living in such a fast forward economy and this is why, I’m doing my private practice but I’m growing my following and I’m meeting fantastic people all around the world, and I think we are here to inspire one another and I really, truly think, I’m not saying you have to do this right away, but can you imagine if there was some book that you did with great bullet points that the medical school could have? It would really help. I really think that our young doctors need to hear that. They need to hear that you can practice medicine like you’re practicing surgery and I am practicing psychiatry. And then also we have to give back, like you are, you’re working with Medical, so I give back with some sliding scale and also by the social media stuff I’m doing by providing education. So, I don’t know, I think it would be cool, I mean, the title could be Bullet Proof. Bullet Proof Surgery or something. I think people would love that, I really think so. The way…the clarity with the way you speak, about humility and compassion and just giving exercises, and examples would be fantastic.

Dr. Javahery:: I’ll think about it. I enjoy the process of thinking through life, and thinking about the methodology of how to be the better version of myself. If people, if you think that people would want to hear more of it, I’d be interested, I just hadn’t really thought about it that much. My wife makes fun of all my theories by the way.

Dr. Denise: What kind of medicine does your wife practice?

Dr. Javahery:: My wife’s a dermatologist.

Dr. Denise: Oh, you know what’s great about you is I feel like you’re a Psychiatrist Neurosurgeon. You’re a mindset Neurosurgeon. You, and I guess I’d love to talk with you off-air just about your belief systems, but I feel very aligned and I think you really understand and I’m so happy with that incredible mentor Dr. Heros, he sounds fantastic.

Dr. Javahery:: He is.

Dr. Denise: Wow. You had a gold standard doctor, and I think that’s what we need patients to realize that there’s hope out there, that there’s doctors out there, that it’s not just here’s your prescription, or here’s your surgery or here’s this. In fact, my patients know that the last thing I want to do is prescribe a medicine, I’m not afraid to do it, of course, usually by the time people come to me, that is possibly what’s needed, but I talk with them about lifestyle, medicine, holistic thinking, I empower them, one doc- one patient really thought her last psychiatrist was like a God, there was such a pedestal and I was like, “Whoa. I’m like, I don’t know if any..” I said, “I just want you to know that the fact that you made the decision to feel well, and to get better, you’re your own biggest fan.” And so I think empowering people and I think that’s what our society needs to realize, that you are a big part of your own healing process and that there are doctors out there…that most people that go into medicine don’t go into it just for the money, would you agree with that these days?

Dr. Javahery:: Oh, I totally agree with it. I didn’t go into it for the money. I remember I had a job opportunity that was at the time worth, I was going to get paid significantly more than I’m making now and this was 25 years ago and I didn’t take it because I really feel that I do better at this. And I got to tell you that it’s made me such a better person to be a doctor, and I am so fortunate because, I was as a teenager kind of moody, and I had a depressive personality, and I was angry, I’d lived through the Iranian revolution and all this stuff. And my dad and my grandfather were in prison in Iran and were beaten and I was kind of like angry, and I found that I was, I’d become a better person because I’ve been in medicine and it’s given me perspective. I would describe it, there’s a Farsi expression that says, “Health is a crown worn by the healthy that only the sick can see.” And..

Dr. Denise: I’m smiling by the way about everything you’re sharing. I’m just smiling. I know that we’re on an audio show, but I am just so excited to hear what you’re saying.

Dr. Javahery:: And I, and I was blind to it. And, I, being a doctor opened my eyes to how stupid I was as an adolescent to be depressed about things that I couldn’t change and that were not that important. And now I, you go, “Well, don’t you get depressed about what you do?” I go, “No!” And, yes, the things I deal with are sad, but I have no right, no right to be sad. Because it’s an insult to people who have real problems if I walk around depressed. These, there are people who have it really bad in this world, and for me to be moping when I have so many blessings is an insult and I will not give myself that level of self indulgence. And I try to teach my children and my family the same lessons, and I would have never have learned this if I wasn’t a physician. So, no, it’s not about the money. It’s about the ability to be the better version of yourself.

Dr. Denise: Can I say that with what you, you’ve said, be the better version of yourself, I think that’s a fantastic way for us to wrap up our interview, because that is where we’re in alignment and that’s how we met. I think, if we’re raising our children at a very young age, you know, what’s my neurostyle? I came up with the word neurostyle, like how do I think? Am I shy? Happy? Am I this? And so having a level of mindfulness, of being in the present moment when our young children realize that they have to love themselves, and self love that’s not a selfish love, but a healthy self love, then you’re actually able to align with the best version of yourself. I think the biggest thing for us being able to be the best version of ourselves is coming from a place of love, humility and service, to ourselves and to our neighbors.

Dr. Javahery:: Yeah, no I totally agree and because I, my dad used to say a lot of things, the most important thing is to love other people. And I used to make fun of him when I was a teenager, and I was like, “What do you mean? What’s love?”

Dr. Denise: Oh, my, that would be an interesting conversation with our 16 year old right now..

Dr. Javahery:: Exactly, Are you just quoting the Beatles? What does this mean exactly? And I remember a few years later I realized what he meant. Because, what is the definition of love? Love is the ability of a human being to care for another human being as much as they care for themselves. That is love. In my view, that’s what love means. Now, there are people that you love more than yourself, like my wife, my kids, I love them more than I love myself. Everybody else I can love, maybe, I’m not perfect, so maybe close to as much as I love myself, but the goal is to care for others as much as you care for yourself. And if you do that, that’s love. And if you bring that feeling to your outward relationships, then you will, I think, be the better version of yourself. And, they will be better versions of themselves because your ethics and your morality will change other people.

Dr. Denise: I agree with you. We’re talking about the tsunami or ripple effect of love resonating back and forth between one another. So, I really appreciate our discussion on kindness, compassion, and the doctor-patient relationship. I’m very excited that you are one of my neighbors, and I want to make sure I connect with you after the show’s released, and, is there anything else you want to say? I just, I’ve been, it’s been so great to have you, and maybe I can have you on the show again.

Dr. Javahery:: Sure, if you’d like. No, I think I’ve spoken too much already, and you can’t shut me up sometimes.

Dr. Denise: Thank you so much and you have a great day seeing all your patients, and it’s been an honor to have you on the show today.

Dr. Javahery:: Well, thanks for having me and take care.

Dr. Denise: Thanks you.

Dr. Denise: Thank you joining us today on the Dr. Denise Show. If you are interested in more mental health tips, tools, and discussions, I’m also on the web, at DrDeniseMD.com and I’m also on Twitter @DrDeniseMD and on Facebook. Ok, thank you again everyone, have a nice week, bye-bye!