#135 - BJ Miller, M.D.: How understanding death leads to a better life

KEYPOINTS

• 01

  BJ Miller's accident reshaped his life and work

  Shortly after Thanksgiving in 1990, Miller, then a Princeton sophomore nearly 6'5", climbed on top of a parked commuter train, the 'Dinky', with friends on the way to a Wawa store. Electricity arced to his metal watch, entered his left arm and grounded through his body. He survived, but lost both legs below the knee and his left arm below the elbow, after a touch-and-go stay in the burn unit at Saint Barnabas in Livingston, New Jersey. He now thinks of it as perhaps not a change for the worse.

• 02

  Trying to be tough delayed his grief

  Miller absorbed the American idea that you get straight back on the horse. When his mother, disabled by polio for most of her life, came in crying, his first response was an almost cheery 'now we have so much more in common.' Later, a burst of tears felt like a dam breaking, and he noticed he felt no physical pain while crying. He wonders about a link between crying and pain relief.

• 03

  Accepting his new body was liberating

  Miller says the work wasn't asking 'why me' but cultivating a mindset that cuts down on regret and second-guessing, rather than living with 'if only I had four limbs'. Visible suffering, he says, gives him something that able-bodied clinicians may lack in connecting with patients.

• 04

  A broad education can make a better doctor

  While bored in a hospital bed, he switched from East Asian studies to art history. He argues that most pre-med content is relearned in medical school, while studying perspective in art translates into seeing patients differently. His advice is to love the nuts and bolts, not to do chemistry merely as a means to an end.

• 05

  His sister's suicide nearly drove him out of medicine

  On 1 December 2000, almost exactly 10 years after his injuries, his sister Lisa took her own life. She was posthumously diagnosed with manic depression, which he had studied in medical school without seeing it in her. He started making a list of reasons to quit medicine, then found palliative care at a programme where he happened to train, watching a mentor discuss code status with a patient on his first day.

• 06

  Palliative care is not the same as hospice

  Palliative care is for anyone with serious illness who cares about quality of life. You don't have to be dying soon. Because people conflate it with end-of-life care, many suffer for years without support they could have had. Miller argues that the definition of palliative care, focusing on the person rather than the disease, should be the mission of all of healthcare.

• 07

  Healthcare's problem is its design, not its people

  Healthcare is full of people who care and are trained 'at the hilt', yet care falls short because the system is organised around diseases, not people. Medical training reinforces this: 100% of patients die and 100% suffer, yet no rotation is built around that. Miller says medicine is a victim of its own success over the last 150 years, which has fed a death-phobic culture.

• 08

  Separate fear of being dead from fear of dying

  Fear of the process of dying is the more tractable one: its physiology is understood and medications help. Fear of being gone is existential. Miller sees a two-phase effect: people notice how fear has gripped them, and then, once failure is guaranteed anyway, it stops being worth fearing. Death becomes a reason to try and a way to forgive yourself for 'failing'.

• 09

  The deepest regrets are about not living as yourself

  Beyond the stock regret of working too much, dying patients say things like 'I wish I'd dared to love more,' 'I wish I hadn't been so afraid' and 'I wish I hadn't been so hard on myself.' The common thread is wishing they had come to terms with death earlier, because it would have changed their decisions. Since most people now die of chronic illness, they often have months or years to reflect.

• 10

  Physician-assisted dying is spreading state by state

  Miller believes about nine jurisdictions allow some form of it, starting with Oregon in 1997 and California in 2016. He prefers language other than 'suicide'. He worries that making it too easy can cut short a meaningful final stretch, as Randy Sloan's story showed.