3:00 P.M. with Shawn Hatosy, Cynthia Adarkwa and Dr. Justin Baker

- Monica's a retired clerk, best of the best.

She was kind enough to come in on a holiday and help get us back in the shade. Played off by the digital revolution, not retired.

“And how's all this digital shit working out for you now?”

- Oh, it's okay, exactly. All right, then. I'm just handling the charts and the orders. - That's us right here. - How long have you been clerks?

- Just today, we're medical assistants. - Then get out of my space and go do something you know how to do. And no personal calls. Red phones are for emergencies only.

This is a hospital for God's sake. - Oh, you better. (upbeat music) - Welcome to the pit podcast. The official companions to the pit on HBO Max.

I'm Dr. Lokhotel and I am stoked to get into this episode. - And I'm Hunter Harris. It's three o'clock in the pit this week. It's episode nine. And we get to hear from Sean Hadese,

who plays Dr. Abbott, who also directed this episode. And here from Cynthia Adarqua, who wrote on this episode. - Like the big part of directing this show, there's so many components,

but the main one is the mapping of it, understanding where each scene is and how we can kind of flow it to the next and the most sort of grounded way that makes the most sense. Today's shift starts now.

- I lit one and it went off first.

I dropped it, but we're gonna take advantage of now. - Okay, I don't wanna see, you don't have to. - Just give me. - Okay, cut it, sorry, you're doing great. - Oh, that looks like a lot more than a firecracker.

- I'm more like a man, you're a cherry bomb. - I'd rather I think I had a fear. Made a reference to these types of injuries in one of our first episodes. - Yeah, I mean, that was really, really sad

and really disturbing, but I wanna say, I love how Dr. Santos immediately becomes so understanding. She says, you don't have to see it. It's really good that you dropped it. You say the rest of your hand.

I thought that moment was a very good character moment for Dr. Santos. - Dang, even though this is just a show, I feel for this kid,

'cause I've seen this exact scenario.

- Yes, this is, I don't mess with fireworks like that. - No, but I do wanna say that the Jude storyline gets into his sister, who is his primary caretaker, because their parents have been deported to Haiti, and I could not feel more for the sister

who seems like she's truly a difficult position. They have to eventually call in like family and child services to do an assessment maybe, because you did have alcohol on his breath, but this is like a young sister who's trying her best,

who's trying to take care of her brother, and I just really feel for the whole situation. It was very sad. - Parents aren't there. They're doing everything they can,

so then all of a sudden you can empathy for this kid, who, I don't know the scenario, and no, she was holding or potentially throwing or lining a firework, but he's just doing whatever he can to kind of fit with the group of people while.

She started going at the entire thing sucks, and it's happening all over America right now. - And I just like the immediate emotion in his voice, like I don't wanna look at my hand, I don't wanna see it. It's like, wow, he's so young and like this mistake,

like total accident has like, you know, changed his life forever.

“- Do you still need a rain check for a washing fireworks tonight?”

I thought you were coming over. - I made other plans. - Okay, cool. I'll try hitting you up tomorrow. We're just keeping it casual, right?

- For sure. - Hello, there's some big news in the pit. We have confirmation that there's a little love connection between Garcia and Santos. I mean, we kind of, they kind of tease it earlier in the season,

because how else would would a Cardinal like that he accidentally used Garcia's toothbrush, like how would you know how loud she is? But I was like, I'm kind of into their connection. Does that make sense?

I don't know, how do you feel? - I think the connection is awesome, and it's human, and they do such a good job of like teasing out that there's an imbalance maybe, and how invested Santos is versus Garcia, it's also kind of forbidden.

But I just wanna say, I made a joke to you, Hunter, about Whittaker and Santos hooking up. I wasn't being serious, and Reddit wasn't having it at all. Reddit was like, does this fool watch the pit? - Santos and Garcia are clearly having an affair.

What shows this guy watching? I was just joking people.

“I think we suspected that these two were having a moment,”

and that elevator scene, I was like, my gosh, we've gone into like the drama of a romantic comedy right now. - I'm like, oh my gosh, Santos girl, you were being left on red verbally. That was hard to watch.

I kind of like though that like they're both kind of tough nuts to crack, and they together have this like

- Look, I'm just gonna say like,

Santos resident in the ER Garcia surgery fellow also wild schedules that they're so human, they're still trying to like find a connection. And I may or may not be saying this from experience, but sometimes the inter-hospital romance,

it's like forbidden, but it's fun, but you don't know what to do with it, but it's like, when does casual fun cross into something more and like then your colleagues find out and like, you know, I'm just gonna stop there.

- Okay, yep, we're under a friend DA, so don't worry, but I do think that there is something that I like about how Santos and Garcia are like casually together, but they don't work directly together on every single case in every single hour of the day,

“which I think probably makes for like a little bit”

of distance that that can let this work. - Did you feel for Santos a little bit when Garcia was like, I made plans for keeping a casual, right? - Of course, of course. And it's nice to see Santos who's usually so confident

and you know, very cock-short, finally be a little bit like vulnerable, a little bit afraid of like how she's feeling, and wanting connection and like being rejected a little bit in that moment.

- Come on, Sweetie, come here, is it always like this?

- Yeah, pretty much. - Wow, there are a lot of smelly people. - Yeah, it's okay, but you're gonna help them all? - Yeah, but let's start with your first. Okay, so Mel's sister comes into the ED

and Mel brings her back immediately. She's about to care for her and Robbie stops her and says, okay, you're having a rough day with the deposition and it's probably not the best idea for you to care for your own sister.

It's gonna be hard for you to be objective.

“And who walks in beautiful scene choreography there?”

But Dr. Langdon, who is Mel's favorite resident, and she volunteers him to take over and Langdon immediately is so sweet and gentle and caring with Mel's sister. Literally, as Mel's leaving the room, he says,

"Would you like to turn off the light

"because that's, they had the interaction last season "where a patient will respond maybe a little bit better "in a lower light room?" As someone who hates overhead life, I love that moment. - Yeah, I think it's show like some emotional growth.

On Langdon's part, maybe there was a little bit of preferential treatment because he's got a special relationship with Mel, but also Mel's sister, like wonderful acting job. Like that is Mel King's younger sister.

They just nailed that part. - I really liked watching how patient Dr. Langdon was with Becca and it really goes back to like how close he and Mel are. I think they are like, really two peas in a pot. I love their friendship and seeing him work with Becca

was very sweet and also how Mel was so uncertain on the day and so distracted, but like, was immediately put at ease and that her sister was gonna be helped by her favorite person in the ED. - Yeah, she was put at ease and also she kind of forgot

about all of her stress and it turned into almost panic. When she heard that Becca was in the yard she sprinted like every hour for everyone. And this ER is just a beating, but yeah, Mel is definitely, there's a lot of things coming out of from every direction.

- What about her friends and family? - Yeah, they're around supporting her.

“- Yeah, I think they try too, but mostly she's just leaning on me.”

- She's really grateful for everything that you do, but it's important to have boundaries. - Yeah. - And you want to do me a favor? - Yeah, you want to house it for me while I'm gone.

- I like this moment where Dr. Abbey kind of looks forward pauses, like isn't that look like bro? You hitting that, like what's happening? - And what occur is like two sweet and innocent. He's like, well, she has no one else to help her

and I grew up on a farm and, you know, I feel very close to the situation because I was overseeing her husband's care. And while I empathize, it seems like about situation you're involved in.

But what do you think of Dr. Abbey offering Whittaker a spot like a bachelor pad? I love that he says no smoking, no parties, and it's like you ride your motorcycle without a helmet on. - I can't tell what percentage

is him truly looking after Whittaker? And being like, hey, I know you were struggling with money, like here's a way to help you out and take care of the situation, but also like trying to rain in whatever he thinks

might be happening. I don't actually know, but obviously like Amy is coming to Dr. Abbey's house. I'm just gonna tell everyone that now. Like Amy 100% is crashing at that house.

Like she's bringing the goats, I don't know what's happening, but they're a party will be thrown. - No, I, yeah, I think that's very astute. I think it's very like almost paternal of Rabbey to be worrying about Whittaker getting like too involved,

but I almost wonder if it's coming from place of experience

in his professional personal life

and also like within with his patients with even his coworkers.

“So I think it's sweet, but I'm also a little bit skeptical.”

It just makes me concerned. And then right after that we have like Dr. Alhash me coming in, like making a joke and I'm like totally. Like this is exactly what we need to kind of like deflate the moment just a little bit

'cause it does get pretty emotionally, I think, intense. - This is when Dr. Alhash me comes in and makes that comment about the CPR mannequin and being like, who dressed him up, we have done that so many times.

In medical school and residency in hospital, dressed at mannequins, have in all kinds of shenanigans. Manicins, shenanigans at rhymed. - And now we're gonna look at a fix this in 60 seconds with a rectal tube.

Now she needs major surgery. Sorry, not good enough. Neville baby, you fucked up. Don't trust anything or anybody else when the system's down.

- I have so much to say here. So just the quick background. Based on what Dr. Robby saw on the X-ray, it seems like this woman had a volvula so the intestine essentially turned on itself

that causes an obstruction. And if it happens on and off for a long period of time, people can have abdominal pain vomiting. If it's an acute thing, you can actually have a surgical emergency.

People can die as is hinted here and it was missed. You know, there's a code black and the systems are down and you're just backhawking everything and this X-ray wasn't around on time, et cetera. I really feel for Javadi.

- Yeah, every single health professional, I know of, I can think of at least one situation where something was missed and maybe it wasn't a human error but for whatever reason, something was delayed.

I mean, didn't come through.

“Whatever it may be and you will always remember that case”

and what's crazy is the one that I thought of was a volvulus case that I was involved with when I was a resident in the child almost died. It was a delayed presentation, came to the emergency department, really late.

It's a long story but I could feel it for Javadi. But the one thing that got to call out is she's still a medical student. Yeah, this is actually not on her, like she's taken ownership for it

and like Garcia is treating her like an equal in the situation

but this is on Whitaker and ultimately an attending.

This is not Javadi by herself as she would be taking blame for this. - So when they were trying to resuscitate her and fix her heart rhythm, watching Javadi's face like Shabana,

that was like truly, I think some of the best acting I've seen in this show, like she just seemed in such a state of despair and like froze and Robby's like, okay, like you need it, like we need it, like get this moving

and also like Javadi, Whitaker and Robby, like running around the ED, trying to like get this scan that X-ray. It's just like one of those things that I really emphasize on a day like this when you don't even know

like if it was just put your own patience on the board where the forms are, where the clipboard is, I was like, geez, everything. It's a real like humbling moment for Javadi who has really been like, you know,

kind of it girl, like really like the baby genius of the ED who's like has made this big mistake. - What reality is is that, you know, you can be the baby genius and know everything in the textbook,

but sometimes these tricky clinical scenarios happen or the technical support goes down

“and all of a sudden you have to rely on experience and instinct.”

And as you mentioned her visual acting, like I got hit with a visceral sledgehammer. I know exactly what it's like when you're like worried about a patient and you're like, oh my gosh, did we do this right?

Did we miss something? I mean, you find out the patient's okay or you find out that things are gonna be cool. You're like, oh my gosh, like, wait has been lifted. But sometimes it doesn't go that way.

That's, that is the harsh reality. And, you know, Garcia is now explaining to her, like this is a big deal. Like they could have initially used a little tube. It goes up the rectum, straighten out the intestine.

Now they potentially have to do major surgery, take out part of the intestine, big deal. Big learning moment, yeah.

- Yeah. - The young devotee that she will never forget.

- I don't like that Garcia said, called her Neppo baby because we know that she's smart. We know that she's really good at what she does but she is just like young. The center of all the scenarios we've talked through

in previous episodes, one that I am curious to hear about real world experiences and just to listen to people is the situation with Amaya. This woman who's got this history of PCOS, polycystical variant syndrome,

who winds up having a variant torsions, so one of her overseas turned threatening the blood supply. She's in a lot of pain. But the fact that McKay used her experience in her instinct to keep her there and say,

"Let's just keep her a little bit longer and also hear her out." But also it touches into some patients who have either been gaslit or symptoms haven't been taken seriously, they haven't gone. Care they needed, they'd had to advocate for themselves.

And if you look at the statistics, there's estimates that around 70% of women with PCOS

are black women.

We're not listening to these items or completely missed.

I mean as a black woman, that story really hit home for me. And you know, Amaya has that line where she says, like I would call it lazy doctrine that like I went undiagnosed for so long. And you can see a kind of like bump McKay

who is not a lazy doctor who really does try her best. But it's like that's Amaya's experience. And I mean, who are we to tell her otherwise? Like she has been suffering for so long. And I'm so happy that Whitaker got to see this lesson

“in like, well, what do you think all of her other doctors have done?”

And what can we do differently for someone who obviously has had, who is like, you know, suffered from medical racism? - Damn, Hunter Harris culture critic, what's that? (laughing)

I got nothing that, but it's such an important lesson for anyone watching, not only on the patient side

and you know, knowing to advocate for yourself,

but also for society, for physicians, for everyone to say like, sometimes what you're saying, there's more that meets you, I mean, we have to listen. A PCOS presents the hormonal imbalance people have irregular menstruation.

They have changes in their body hair. They have acne, they have emotional changes. Like these could be a larger part of an underlying issue. And I just want to add that, you know, in this country right now with systemic racism,

but also so many pockets of the country where there isn't access to primary care, there's no women's health and these hospitals are shutting down. Like I look at Amaya and I just wonder

and I worry and I stay up at night thinking about how many more women are being left ignored and untreated.

Hunter, I want to get a beer with Dr. Abbott.

I feel like there's stories, I feel like there's a vibe, I feel like there might be some like trauma, male bonding that can happen, I don't know. Totally. I feel like there's aside from male bonding,

there's like an interesting duality between badass, swat, medic and then someone might be holding back something, I don't know, I don't know, but you also are a fan of Sean Hadassia, we all are. - I am, I think Dr. Abbott is so funny

and so like very, very creepy, very pithy, I'm into it. - So it's only fitting that we talk to Sean who direct this episode and Cynthia Adarqua, a writer who works closely with him. Let's get into it.

(gentle piano music) - Cynthia Sean, thanks so much for being here. Hunter and I could talk about this show and all the emotional complexity with the cool medical jargon and terminology all day long,

so this is gonna be exciting. We learn that Dr. Abbott is kind of badass. We learn that he's a swat, medic and a bullet greys him while he was saving his colleague's life. I mean, like all star moments.

So Dr. Abbott, he's kind of an adrenaline junkie. He's got this bravado, but then that's balanced with his sincere compassion. I just want to ask you, what is, what's really driving Dr. Abbott?

What's his motivation? - Well, I don't think he sleeps very well. I think he hates to be alone. Part of it is that coming off of last season, we see them up on the roof together.

“And I think Abbott's idea of what his purpose”

is crystallizes in that moment. We're the bees that protect the hive. He finds comfort through the mass casualty of it 'cause he knows his purpose. And as we go into the end of the finale,

he sort of present this idea to Robbie that this stuff has a heavy toll on us. And I've been working on myself and maybe you should, too. So as we go into this season,

and we meet Abbott as a swat medic. You know, he kind of says my therapist says I need a hobby and I suck it golf. So I think he's mind, he's working on himself. But in reality, he's chasing the same kind of dangerous path

that Robbie is. Like he thinks he's doing this great work for himself but in the end, he's still dodging bullets. I mean, it's how different is that from Robbie going up on a motorcycle with that helmet?

Cynthia, I want to know about the writing for this episode. And can you talk to me, particularly, about Jude and his older systems sort of telling their story? Absolutely, yeah, that story is so important.

“I think, you know, there's a lot happening in America right now”

and we just wanted to kind of reflect that in this episode. All walks of life come into the ER. So obviously it's July 4th. We have this firework accident. But we wanted to add like a little twist to the story

with his back story, with his sister. With these immigration issues happening, you know, it really touches close to home for me because I'm a child of immigrants. So telling this story, I felt was super important.

Hey, children of immigrants rise up. I'm one as well. Cynthia, I read an interview last year with you in Valerie Chu, kind of about the process

with the actors. And that interview referenced Noah. I just have to ask you, what was it like working with Sean

“in writing this episode and creating that character?”

I mean, working with Sean is amazing, you know?

Like I brought the words and he brought kind of the emotion. And obviously he was directing the episode, working with the actors. And it's just, it's so exciting to see words come to life. Like there's, we can't do it without the actors, you know?

So I mean, particularly with the Jude, like he's a young actor and Sean was amazing working with him. - In my experience, there's usually not a writer on set. So this show is very different. You're, we work together from the beginning.

You were there with me when we were doing all of our prep, when we were doing our walkthroughs. So it's such a collaborative process. As we're sort of like the big part of directing this show, there's so many components.

But the main one is the mapping of it, understanding where each scene is and how we can kind of flow it to the next and the most sort of grounded way that makes the most sense. And we would go through, do the walkthroughs

and, you know, I might say, hey look, we're in north over here, like let's throw it to central. It's just so we can connect this piece and make it, you know, a continuous take. And just having the writer and being able to collaborate

in a way like that was just, it was awesome. And I hope I hope I get to do it again. - I hope so too, you know? And just like Hop on what Sean said, I feel like prep on this show is so important

because we're one big stage, our hospital settings. So yeah, we would go on these walkthroughs and we have pass-offs with our characters. And if it wasn't working, I'd work with Sean and like adjust that in the script.

So super collaborative and super hands-on. - Sean, did you know that this role of a swat medic existed before taking on this part? - I had no idea. Did you know?

- Sean, that was all Scott, our share runner. He brought that to the table, it was super exciting. - You guys had already been up in the writer's room and I just, you know, I wasn't sure what was going on with Abbott and he presented this idea to me

and I thought, oh, that sounds exciting.

“- Yeah, I think people are gonna take that.”

- You know, we've heard about these positions before and just to see that come to light, as you just raises awareness on more topics. So on that note, I was curious, if you both could share something

that you learned about the ER, the medical world that surprised you, as an actor, director, as a writer, was there's something that you're like, oh my gosh, that's so cool. - I mean, I'm surprised every day.

I really am, I'm always thinking about the health care workers

and medical professionals when doing this work. I just have so much respect for an admiration for what they do and how they have to deal with things. Minute to minute, the world is so immersive and I, you know, it becomes this experience

of emotion and pain and watching things happen. And some of these people just have no, they just go through it. And I don't know, that to me is the most, like, when I first read the role of Abbott,

I thought about this experience where I was at a basketball game and one of the referees fell down, collapsed on the court and he was going through some kind of cardiac event. And everybody was freaking out. The children were moved away and, you know,

we were calling 911 and somebody was trying to, nobody knew what to do and then the paramedics came in and it was like they were just calmly walking over and they just saved the guy. Like, and it was nothing and they weren't,

I don't know, that surprised me the most that the training just kicks in and it's nothing.

And I always thought that that was Abbott

when I, when I think about the work and I'm always thinking about these guys when I'm doing it. - We talked a little bit about how Abbott and Robbie are like foils of each other,

but Cynthia, can you tell us a little bit more about how you think about these characters as mirrors, as foils and what they have in common about what sets them apart? - Yeah, I love the dynamic between Robbie and Abbott.

“I think what, it's exciting because they're equals.”

So there's only really one person that can step to Robbie and it's Abbott. We had a scene in 209 this episode that literally gave me chills watching Noah and Sean do

about their mental health and like, Robbie's trip

“and Robbie can kind of get away with, you know,”

joking about it with the other staff, but Abbott sees him. - It's gonna be a lot of time to self-proflet. Should we get him out? - Abbott has experienced what he's experienced

as far as these mental health struggles go.

So this is kind of the first time

that we're like poking the bear, you know? And it's really kind of the first time that we're seeing that this trip that Robbie's been talking about isn't like the golden rainbow strip

that we thought it would be, you know? It may be a little bit more dangerous than we expected and we get that because of the dynamic between Robbie and Abbott. - Yeah, it's like his goodbye tour

really starts in episode nine. He's not sure he's gonna see Abbott again. So that's where it kind of like you sort of see the shift and then once he gets in there with Whittaker and he says, "We'd you take over my house

and he's like, you know, "and if I don't come back, "you'll have a swing in bachelor pad "and Whittaker's like, it's the first kind of like just hint of it "and I know we played with it a couple of ways on the day

"and is that, you know, is that a joke? "Is that your tough exterior wall coming down a little bit "or so, and it's the beginning of that sort of story "and what we're gonna see from Robbie "and his decision to drive off into the sunset?"

- Cynthia Sean, I've heard a lot of references to the production of the show and theater and a stage and long takes and kind of the difference between what happens on that show versus another TV show. Can you speak a little bit more to that?

I think it's fascinating. - Well, I've noticed that a lot of the cast has a pretty strong theater background or training

“and I think that's by design and I think that was a decision”

because it is even as a director. It is very rare to shoot a television show in order.

So that's one thing that's amazing, but yes,

the amount of some of the scenes can be five pages and we sometimes will put two scenes together. So you know, you could be doing eight pages of work which is like a play and our resets are not lighting resets. We reset props, we reset blood, bandages and things like that.

But it moves so fast, it is a lot like a play and it requires a certain kind of focus and training. For me as Abbott, I find that on other characters, when you're just relying on emotional dialogue or things of that nature, I can kind of know it

and then just come in and sort of find it. But with this, you really have to understand exactly what you're saying, or at least be able to fake it, like you know what you're saying. With theater, you're doing a big rehearsal process.

You have all the time to spend to get it right. And when we do that on this show. - Yeah, I feel like obviously our stage is one set.

“So I think that speaks to the theater aspect”

and the fluid motion of the camera, which was designed by our DP JoJo. She's amazing, our camera ops are amazing. They're constantly following the action. And our actors, as far as the theater background goes,

they're able to do these procedures and their lines and show these emotions interacting with each other at the same time. It takes big chops, you know? Like it's not easy work.

And as a writer sitting back and watching it, I commend all of them, I think, our cast is phenomenal. And they really do help bring this hospital to life. - It's funny, because no matter what no matter how well I think I understand it

or know the dialogue, there's always a take

and I might be my close up or whatever where I will. It's not that I freeze, but you get lost in it. And you know what I mean? And all of a sudden, you're doing a recestitative astronomy, you know what I mean? And like all of that, that just doesn't come off the tongue.

And it's not something I understand. And so you get lost in there and then all of a sudden the words aren't right. And I, you know, we freeze sometimes and it's always embarrassing. (both laughing) - Gosh, this uses like even more respects for what you both do.

And even more reason why this shows incredible.

But appreciate you both. Thank you for sharing all the inside. The pros of wisdom with us. - Yes, thank you, guys. - Thank you.

(gentle piano music) - So I was really interested in what Sean had to say about that last conversation between Dr. Robbie and Dr. Whitaker

“about like, "Hey, if you want to like use my house,”

"you can house it for me, if I don't come back, "you get like a swinging bachelor pad." After talking to Sean about that, I had a total reframe of like that conversation as being a lot, moodier and almost like,

"I mean, sad and depressing than I had originally thought." 'Cause I, and my, had I like, okay, Dr. Robbie, he's like funny, joky. But after talking to Sean about that like shooting that scene, it felt a lot more like, okay.

Maybe Dr. Robbie is like in a darker place than even we imagine at the beginning of this season. - And I think Dr. Abbott is one person who can just go straight to it and call him out and be like, "I'm here, let's open up about it."

Chargers day and I kind of does. It's sometimes feels like a big sister or caretaker relationship that Abbott's like, "Brow, open up." A you have experience in writing TV. It's almost fascinating to me to see how

and hear how actors work directly with writers and they bring forward a concept. And it lands. - And totally, I mean, I was very interested to see what Cynthia had to say about writing about Jude and his sister

because their story to me was like, one of the most heartbreaking, only because you're talking to people who are very good, who are just totally out of options with their parents being in Haiti.

And I just feel like what you said about that. - I so far, every person we've talked to, who has been instrumental in writing or directing or even acting in this show has brought something about their own personal life,

their own cultural social experience to the show. It's like the authenticity of the charts. - Yeah, I agree. - Simon asked you about the story, and also about this soul-flash-back,

just about what's right and then what's right. - Yeah, Paul, no, I don't know, like this story is so my safe space. - Mm, do you think that's all right? - Yeah, exactly.

Like this story is so deep story app that I just understand. Egalobstudium, job or unzug. - A stint? - Cras?

- I feel like I don't understand. - Story on a ledic? - Safe. - With this story, yeah. - I wanna go outside a pen,

and what's talk about some bio-ethics because throughout the show, we've seen multiple scenarios in both seasons, where there is an ethical choice, and there's different people involved in helping,

kind of the family, the patient, colleagues, a riveter decision, and I wanna bring in one of the foremost experts in this area, none other than Dr. Justin Baker, who's a pediatric oncologist,

as well as a pediatric palliative medicine doctor.

So basically, the boss, when it comes to everything

we're talking about regarding bio-ethics, Justin, I'm also partial because you are at Stanford, children's health as the head of the pediatric palliative care program, and the head of the quality of life for all AKA the Kuala program.

I'm kind of sad, you're not in a Kuala costume right now, but I think it's so much for joining us all the way from Switzerland. - It is so great to be here. And even though it's very late here in Zurich,

no other place I'd rather be right now. - Oh, I love that. - Justin, could you kind of give us an overview of what exactly bio-ethics is when it comes to medicine and how these situations show up for you as a doctor?

“- Yeah, I think one of the most important things”

to recognize is that when we're talking about bio-ethics, we're talking about the actualization, the coming to the bedside and having to make real life decisions with families who are faced with impossible questions, with physicians and clinicians who are faced with things

that many of us would never imagine except

when they watched the bit. These are things that we face every single day. Questions about life or death, questions about right and wrong. When really there are no rights and there are no wrongs,

we're trying to think of what's the most right thing to do, what's the best thing to do in the middle of all bad choices. And so if you can picture this, it's something where you would think as simple as a yes or no answer would do, but that's never the case in medicine.

We're always thinking about shades of gray. We're always trying to think about the patient and the family, what are their needs? What are the needs of the healthcare providers? What's the right thing to do from each person's perspective?

And what we have to do is we have to bring all of that together to the bedside and frequently in the middle

“of some pretty quick decisions, that's what bioethics is.”

It's making real life decisions for real life patients and families in the middle of very murky and difficult situations. And I just want to clarify,

it's not always just a situation about life or death.

There's other, it's not all about terminal illness, I should say.

Bioethics is much broader.

“It might just be about trying to think about”

what's the right thing to do in this particular situation when you're thinking about a particular medicine to give it or to not, to think about how do we involve a child in decision-making. It might be in thinking about, oh my goodness,

look at this family member is involved in this family member disagrees with the other one, or it might be in a situation where there are clinicians who disagree. All sorts of situations need bioethics engaged and involved

and we're so thankful there are such high-level experts out there to help us as we're thinking through all of these different decisions and all these different situations. - I don't even know what hurts more.

- The cancer?

How are you? I'm never going to see my son's cry.

It feels like a cool joke. - So on the pit, we see a case of a patient named Roxy who Dr. Robbie recommends that she gets pain medication which could help her pain but also maybe hasten her death because she is in palliative care.

- Where are we at the morphing? - 10 milligrams an hour. - Okay, you can both another two and go to 12. - I will let Princess know. - 12 an hour is a lie.

- Yeah, on top of the MS cotton she could stop breathing.

“- Are you familiar with the doctor of double effect?”

- Not in a really. - It is an ethical principle and palliative care. We treat pain and if you're doing so, there's a negative side effect, we accept it. - Even if the negative side effect is death.

- In some cases, that could be the best outcome. - Can you sort of tell us about the doctor of double effect and how that works? - This actually comes up fairly often. It's a great fear of people that opioids,

that morphine or other opioids such as fentanyl or hydromorphone or methadone, that these medicines might hasten death. What we know is that when these medicines are used appropriately, that's not really what happens.

What happens is that patients are able to relax. They actually usually live even longer. But what I will tell you is the principle of double effect, the doctrine of double effect is something that's very important to understand.

And that is because intent matters.

“Every time we think about giving a medicine,”

we have to be thinking about why are we giving that medicine. In this particular situation with Roxy, we're giving the medicine to address suffering, to address pain, which is a very straightforward reason. If we were to give that medicine and Roxy

were to have her breathing slow or she were even to stop breathing in her life or to end early, as long as the intent was to make sure that we are giving that medicine to address suffering, to address pain, it would be appropriate.

That's the doctrine of double effect, intent matters.

And the reality is, again, when we use opioids,

this is not usually the case. We're not really generally struggling with, if we give the right medicine to treat pain, that somebody might die by it. However, because of opia phobia, the fear of using opioids,

we have to talk about the doctrine of double effect all the time. We're even if we were to give that medicine. If we gave it for the right reason, but something like dying came about because of it, if we used it for the proper intention,

if we used it for pain and symptom management, that would still be appropriate. - As opia phobia, okay, I learned something new today. That's very interesting. - Yes, opia phobia, the fear of opioids,

actually hundreds, fascinating. We here in the United States have driven opia phobia all over the world, and that is because of our huge opioid epidemic, a massive problem caused over the past many decades, which is now causing a fear of opioid use all around the world.

So I do a lot of work in Africa, and even in Africa now, because of opia phobia, many patients are unable to get opioids, even though they deserve, they should be getting those medicines. It's almost impossible because the system

is responding to issues that we have here in the United States.

- Oh, wow. - I never thought of that.

- That's fascinating. There's another case I want to ask you about Justin, and it's a young woman who has become her brother's primary care take, or when their parents move back to Haiti, and he is like drinking with friends

and a fireworks pose in this hand. But how do we think about what's right for that family when maybe it seems like on paper, she shouldn't be as caretaker even though she is like the closest person in his life?

- Hunter, this is why bioethics and these conversations matter so much. It is never so obvious when we think about these situations as to what's the right thing to do. We need to do the very best.

We need to engage whichever family member is there. We need to do our very best to get a hold of family members,

And this is extremely complicated.

We need to be taking into account, what do we know about this young man?

“We need to be thinking about what is the impact on his family?”

We need to think be thinking about all the different aspects, what are the likelihood of his condition improving? What is the likelihood of deterioration? What is the impact on all aspects of his life? When we think about caring for patients from Haiti

or as I mentioned earlier from Sub-Saharan Africa, it's also common that the decision-making locust, meaning the way that we make decisions in the United States is very autonomy-driven, very person-centered.

That is very different than many other cultures around the world. Many other cultures, it's really a communal decision. It's a familial decision. And that is so difficult for us as clinicians. We so frequently take our United States autonomy-based mindset

and try to apply it to almost every situation. And unfortunately, sometimes that actually causes additional suffering, additional complications for patients and families. This is so enlightening, as we look at kind of the difference

in palliative pair and medications in an American standard, an American kind of stereotype versus other cultures.

I never thought of things in this light before.

How do you include children in the decision-making and pediatric palliative care?

“Yeah, Hunter, I think this is one of the most complicated questions.”

How do you involve children? So the answer needs to be that we're always engaging the child, the question is how. And that how is really dependent on each family dynamic. And the reality is, usually when we talk to children,

we're going to bring them into this conversation in the way that works best for them. That might be through play therapy. That might be through the parents having the conversation. It might be through a child-life specialist

or a psychologist having the conversation. What I do know, and actually here in Europe, when I was doing some of my teaching over these last few days, I was doing this work with Ulrika Kreigsberg. And we know from study that she has done

that if families involve their child

and let them know that they are actually approaching their end of life, none of the families regret talking to their child about the fact that that is happening. Sometimes, if families hide this from their child, they regret it.

And that's a super important concept. I try to make many of my decisions out of the context of how will we have the fewest regrets possible. And when I think about this, I think of myself being in the regret prevention business.

And one of the best ways to prevent a regret is to engage the child, to involve the child in whatever way they want to be involved in the decision-making in the entire care plan. - The regret less.

What did you call it again? What type of business? - At least regret. - What do you say though? - Yes.

We try to be in the regret prevention business. Or sometimes I call it, I wanna be the superhero of regret prevention. And here being from the Bay Area, sometimes I like to think of myself being in the rock band

that is called regret prevention. Anything to help us think about preventing regret is what I try to do when I teach. - You know, I think-- - I think--

- It really speaks the fact that there is a much more nuanced conversation than just Dr. Robby saying, "Hey, Dr. of double effect." Just so this is why everyone needs to go

and watch Justin Bakers tent talk, by the way, in which there is a Kuala costume involved. - There's a couple of Kuala costumes that is very true. So the Kuala comes from QOLA, and you're like, that doesn't look like Kuala.

Well, it means quality of life for all. And we have a Kuala as a mascot. And the all in all is all capital letters, A, L, L, all capitals. And it's for everybody.

Every patient, every family, every clinician, because the way that we're able to do this work for a very long time is also by taking care of each other. This is super hard work. I'm so impressed by how the pit really beautifully represents that.

I'm sure people watching are like, how can these people do this for any period of time? And that's why quality of life for all is also about people like Dr. Robby. How do we make sure that we can take care of him

so that he is able to do this work for much longer, even after his sabbatical? How can he come back, refresh, revitalize, and ready to really make a difference in everyone's life? - I'm not sure if that's a loss cause or not with Dr. Robby,

but I'm in for the intention with him. I hope he puts on a helmet also during the sabbatical. - Yeah, he's got to wear a helmet. That is very clear.

“I have a pediatrician, you must wear a helmet”

if you're going to ride a motorcycle, even better don't ride one. Sorry. (laughs) - That's the pediatric motorcycle club, like please don't exist.

- Awesome, well Justin, thank you so much.

- I just wanted to say thank you so much.

I'm so excited. I can't wait to see how things turn out. I'm so happy to help. - Hunter Wilde, that is why Justin is just in because he speaks with so much expertise

and compassion and relatability.

“For my perspective, I think what a lot of people”

don't understand about palliative care and bioethics. It's not just about life or death. There's so much more that goes into it in training the individual on the specific situation. What surprised you or what stuck out for you

from this conversation? - Oh my goodness, I mean, I think the pit, he's in one really changed how I thought about palliative care and end of life, questions with two adult children who were dealing with their dad and Robbie was telling them,

why would you innovate, like a painful tube down the span throat? And thinking about how to involve everyone in the decision making was like, from Justin was a really big reframe for me.

- I'm glad he brought that up because people might see TV shows the pit and think that it's a smaller discussion but oftentimes as Justin mentioned, you have spiritual services and you have a nursing team,

you have pharmacists, there's nutritionists involved, there's players art therapy, there's so much there. Even though I've heard him mention it about a thousand times,

I still always get kind of choked by taking a step back

and really reflective when he brings the idea of involving children in the decision and why that's important.

“- No, I mean, I think the idea of minimizing regret”

and involving children in the decision and letting them know what's happening is, I mean, gonna say with me for a really long time. - All right, on minimizing regret, complex medical decision making, cultural competency,

all wrapped up in one that was a heavy, powerful, necessary interview. - Hello, I want to play a game, a fantasy game for just a second. Let's say you are dealing with this disaster

at a water park, you know, what is going on? Exactly, you don't know how to ignore injured or what the situation is, but you get to make a super team of one attending, one resident, and one med student, who would you choose?

- When you first said, let's play a fantasy game,

I was like, Hunter, are you talking my anthropocon again? Okay, this is more, this is more in line, okay. Wow, this is tough, okay. For attending, in this type of disaster situation with limited resources, I'm going Dr. Robbie.

Go and Dr. Robbie. - Okay. - And as far as a resident, I'm thinking, I'm thinking Whittaker, I'm gonna go Whittaker with Dr. Robbie,

because if you could remove social scenarios, I would go Lainton, but I don't know yet that Robbie and Lainton are working well together. So I'm going Whittaker, I'm going Dr. Robbie, and for med student, I'm going Joy.

- I like, I like the pairing of Robbie and Whittaker, I think they get along really well

“and have a good working relationship, I think that's fine.”

- I'm gonna ask you the same question though, who's your all-star trio, to handle this? - Yours is a good list, however, it's not the right list. I would say for resident, Dr. Mohan, for attending Dr. Abbott and medical student,

Jibadi, we're going to queen out together. - So Dr. Abbott is in your list of queens, I like it. - Of course, he's one of the girls. He can key key with us. - Can I key key with people?

- I think you do every day. - That's it for today's episode of The Pit Podcast. We'll be here every Thursday right after a new episode drops, and hopefully we'll see you in the comments with any observations, insights, questions, whatever.

- And if you work in an ER, not just doctors and nurses, but hey, environmental services security, case manager, social workers, my unit clerks, we really want to hear from you. Watch us on HBO Max or listen wherever you get your podcasts.

(upbeat music) - The Pit Podcast is a production of HBO Max in collaboration with PRX. The executive producer PRX is Jostlen Gonzalez. Our managing producer is Courtney Florentine.

Our editor is Lucy Perkins. Our production managers are Abouda Choa and Tony Carlson. Our video producer and editor is Anthony Q. Artis with Assistant Editor Damon Darrell Henson. This shows engineering by Tommy Bazarian,

special thanks to Joe Carlito. - The executive producer of HBO Podcast is Michael Glugstatt. The senior producer is Allison Cohen Cerrococh and the associate producer is Aaron Kelly.

Technical Director is Insang Huang. I'm Alok Patel. - And I'm Hunter Harris. We'll see you next week in the Pit.