05 - Language as Medicine, with Dr. Sandeep Kapoor
“We try to teach every young doctor that you can’t really care for a patient unless you care about him or her as a whole person. What better way to show and grow this basic empathy than by learning how to have meaningful, sometimes difficult, and absolutely necessary conversations about substance use?”
Dr. Sandeep Kapoor is a physician, a teacher, and healthcare innovator. As the Associate Vice President of Addiction Services for Northwell Health, he is on the frontlines of the fight against opioid addiction — at a time where substance use and abuse is on the rise.
Dr. Kapoor has taken a different approach to this fight than many others — he’s starting with words. He trains clinicians on the power of language, how the terms we use around addiction can reinforce the shame and silence that keep people from seeking care, or can open up new conversations that de-stigmatize substance use. Dr. Kapoor and his team have helped clinicians broach the subject of substance use with over 1.5 million patients to date. This approach has proven so successful, Dr. Kapoor was recently awarded a major grant from the National Institute of Health to study gun violence prevention and establish and implement a first-of-its-kind protocol to universally screen among those at risk of firearm injury.
We were also pretty excited to venture outside with Dr. Kapoor, because, in the stir craziness of Coronavirus, he and his family got a modest motorboat as a way of escaping the claustrophobia of quarantine. We got to spend the day on the water traveling from Hempstead Harbor out into the Long Island sound, talking about how to approach public health issues from alcoholism to gun violence with more science, less fear, and a healthy dose of shared humanity.
Transcript
Sandeep:
Okay. So about 45, 46 days into boat ownership, I'm going to go over some safety things with you guys.
Emily:
Right.
Sandeep:
Under this seat, which comes up, there's more life jackets. There's two right here as well. These will be easily accessible, those are under the chair. Under that chair or this seat cushion is an anchor, in case we need to stop or anchor up. There's no brakes on boats so the anchor is your brake. It's a small boat so we'll be very careful. If you do fall into the water, stay where you are, I'll bring the boat back to you. If you feel more comfortable you can wear the life jacket the whole time or you could just put it on if we need it. Radio Channel 16 is the Coast Guard. Other than that, I guess I'll be your captain for today.
Emily:
Let's head outside. Dr. Sandeep Kapoor is a physician, a teacher, and a healthcare innovator. As the associate vice president of addiction services for Northwell Health, he is on the front lines of the fight against opioid addiction at a time where substance use and abuse is on the rise.
Jay:
Dr. Kapoor has taken a different approach to this fight than many others. He's starting with words. He trains clinicians on the power of language. How the terms we use around addiction can reinforce the shame and silence that keep people from seeking care or can open up new conversations that destigmatize substance abuse.
Emily:
Though we work for the same organization, I first met Dr. Kapoor in Austin, Texas, where I saw him speak at the South by Southwest Festival. His passion for this work and clear-eyed critique of the role shame and stigma play in fueling the opioid crisis earned him a standing ovation from the crowd. We reached out to Dr. Kapoor because he is working on a new frontier of medicine. One that requires an awareness of the cultures and communities in which our patients live.
Jay:
We are also pretty excited to venture outside with Dr. Kapoor, because in the stir craziness of coronavirus, he and his family had got a modest motorboat as a way of escaping the claustrophobia of quarantine.
Sandeep:
Should we go on the boat? All right. Should I tell you the name of the boat?
Emily:
Please.
Sandeep:
It's called On The Lam.
Emily:
On The Lam.
Sandeep:
Anyone know what that reference... what that means?
Jay:
Well, I was curious about it. Is it like a witness protection program?
Sandeep:
Yeah. Kind of, right. If you watch The Sopranos, when they were like, "Paulie's on the land," that means he's escaping. He's hiding out. The reason why I got this, I was just telling Emily is, work has been burning me out of it so this has been my escape for the last 45, 46 days-
Emily:
There you go.
Sandeep:
... and so we named it On The Lam.
Emily:
Nice. I like it.
Sandeep:
All right. I'm going to start the engine. I hope it's not going to be too loud on your ear, but it will be loud for a second.
Emily:
We went to this very cool little town called Sea Cliff, and there is a harbor right there. This is on the Northern Shore of Long Island, past the border of Queens and kind of along that Northern edge. And there's all these beautiful little harbor towns that have these lovely bays that are fishing villages right there. And because it sort of runs up the length of Long Island, you can literally look out back across the water and you can see the Manhattan skyline, you can see Harlem, you can see Jersey, you can see Connecticut. It's this really interesting view of the city that people don't often get, because oftentimes if you're moving through the city you're on highways. But the water is literally... it's right there. It's easy to forget how close the waterfront is to pretty much every single point, in Manhattan, in the Bronx, in Harlem, in Queens, et cetera.
Jay:
Mm-hmm.
Emily:
Not just the Island of Manhattan but Governors Island, City Island, Roosevelt Island, they're all clustered so close together and these bridges are really the arteries in-between them. The other reminder was, we sort of drove out on Long Island, we got on this boat and suddenly we were on the water. It was sort of minutes before we were some place that looked completely transformed, right?
Jay:
Right.
Emily:
It was not like we had to travel for hours to get to a place that was almost unrecognizable to us as New York City.
Jay:
And it was peaceful, and there were seabirds, and beach.
Emily:
I don't know if there's very many places where you can go that short of a distance and find something you've never seen before. Right?
Jay:
Yeah. I've been looking at the New York skyline my whole life but never from that direct angle and also never from a small boat that's moving around. I've been a terrestrial viewer of the city. So that was also interesting and felt just being in a very different space.
Emily:
Being out on the boat, not only are we seeing the city we know so well from literally a new angle, but I was also struck by the ability to take in the multiplicity of the city in one view. You could be on this boat and see these gorgeous, gorgeous mansions. You could also see housing projects, you could see family homes, you could see industrial areas, and you could see skyscrapers. You could see everything in-between. It was fascinating to be out on the water and in, just a rotation of your head left to right, be able to take in all of these versions of New York, all of these versions of this city in a glance, and the water really afforded you that kind of view.
Sandeep:
I have never seen water this flat in my life. This was meant to be. We're pretty much almost in Long Island sound and there isn't a wave to be seen, which is nuts. I'm just shocked. You see the lighthouse in front of us? The white one? That's called Execution Rocks. And there's a myth there, or a story or legend, that they used to tie people up to the rocks and wait for high tide to come in. Actually on Google Maps it's called Execution Rocks. And that's what I wanted to show you. There's the New York skyline right there.
Emily:
It's so easy to forget how close everything is.
Sandeep:
I mean, it's nuts.
Emily:
And then it's really just archipelago. It's like this collection of islands that we never treat as islands.
Sandeep:
How about here? This good?
Emily:
It's perfect.
Sandeep:
Let's just chill. The sun's coming out a little bit too.
Emily:
Beautiful. Yeah, you can see the skyline here and both bridges.
Sandeep:
Ain't that cool?
Jay:
We're in a totally different zone, space.
Sandeep:
Completely different. And you guys were just on the highway like 20 minutes ago.
Jay:
Yeah.
Emily:
So nice and quiet out here too.
Sandeep:
Yeah. Right?
Emily:
What's special about being on the water for you and this place you brought us to?
Sandeep:
I think we are feeling it right now. This calmness. Even though there's people living there on their Wi-Fi doing work, it feels like you're in a different world right now. You can see the horizon, which is pretty cool. You can't really see that from home or working in a basement. It's just like freedom of it. That's kind of why I got the boat. It was to free myself a little bit of the tensions of real life.
The biggest, I think, stressor was being at home but not being present. I have two little kids and we're all in the same location. Back in the day I would go to work and I would be away from the house so there were boundaries. I'm away from home, I'm away from home. Now, being around, everybody forced to do as much as they can remotely, I felt like I was cheating them of their childhood a bit because when it first started, I set up shop in my dining room. And all I was doing was hushing them every five minutes saying, "Hey. Listen, you got to keep quiet." And I realized very quickly it's so unfair to them, being nine and six years old, that they have to walk on eggshells in their own house, especially because they also have this big trauma of not being in school.
So I found the furthest corner of my basement, set up shop, and I thought that would do it, but then I realized that even when they came to talk to me or if I was upstairs, my mind was always downstairs even though physically I was there. So I think all that added up. Everything combined together and trying to figure out how do I navigate work and family and this new normal that we're living in. So I had to figure something out.
I'm not going to lie, I came to a breaking point, which was like, I had to decide to do something different. All of our vacations were canceled, all of this family time that we would have had if I was going to work and then coming home and that was home time, all that was... It was all gone without a moment's notice. So I was at a decision point and the decision was, we're going to do something, and hence where we are right now on a boat.
And look, all of us we turn to something in times of crisis or just to cope. Even if it's not like crisis level, we all turn to something. It may be food, it maybe alcohol, drugs, tobacco, boating, other hobbies. And just [inaudible 00:10:19] data, alcohol sales is up like 45% to 65% in this country. To me, it's even more important that we talk about substance use now because what else are we left with? We're socially distancing. We're isolating ourselves. We're feeling alone, both at work, as well as at home. There's all these different crises happening at the same time.
If we don't talk about substance use especially in a humanistic way, we're going to lose people. People are going to unfortunately fall into substance use disorder. We are already seeing an increase in drug related overdoses throughout this country especially in our region. We need to have open conversations, and say, there's other pathways towards coping, there's other pathways towards handling situations that come up in life.
Emily:
What does that mean to have a humanistic conversation about substances versus some other way we might be approaching that?
Sandeep:
Great question. Let's reflect back to our dinner tables for a moment growing up. How many times did we really talk about drug or alcohol use in a non-judgemental way? Then, we all come to work as healthcare professionals, as contractors, as a bus driver, whatever our profession is, and instantly we are supposed to care about people? I remember having conversations when I was younger and it was always about "that drunk uncle" or it was "that kid down the street." It was never really about a conversation that was on the table, it was hidden under the table about what was going on in that immediate family.
I would say, when you come and work, particularly as a healthcare professional, you put on an ID, it doesn't instantly make you like the superhero. You have to understand we bring whatever we were raised with to the table when we're working. So if we're bringing these hidden conversations that no one's ever talked about and now we're saying we're going to help someone that's dealing with a substance use issue, how are we equipped to do so? The way we do it is in that same judgmental way. We shame people because they do cocaine, or because they're using heroin, as opposed to understanding the suffrage that they may be dealing with, which is driving why they're using the cocaine or the heroin.
And same with alcohol. We bring this level of impatience to the equation, like not my problem, but we don't do the same when someone's struggling with their diabetes, or someone is struggling with heart disease. We've been trained to look at somebody and be like, "Hey. It's not your fault. It's genetic, hypertension. There's medications for you. There's all these different options," but when it comes to substance use we never really been educated other than those conversations around our dinner table.
Medical education has unfortunately not prepared us to talk or to be compassionate towards people dealing with substance use issues. I guess what I'm trying to say, what being humanistic is, really not forgetting that's an individual. They have their own life. We need to meet them where they're at before we step back and be like, "Oh, no. You're a drug addict, or you're an alcoholic," because those are the words that we use left and right in society and around our dinner tables.
Jay:
This instinct that we have as a social species say, you're either belong to this tribe, this group of people, and we protect each other or you're the other. And when you're the other, there's no space for... it's hard to conjure compassion. Those are addicts. That's not me. That's not us. There was a quote that I found that I wanted to sort of form a question up.
Gabor Maté wrote a book, In the Realm of Hungry Ghosts, and there's this quote, "This is the domain of addiction, where we constantly seek something outside ourselves to curb an insatiable yearning for relief or fulfillment. The aching emptiness is perpetual because the substances, objects, or pursuits we hope will soothe it are not what we really need. We haunt our lives without being fully present. In our materialist society with our attachment to ego gratification, few of us escape the lure of addictive behaviors. Only our blindness and self-flattery stand in the way of seeing that the severely addicted people are people who have suffered more than the rest of us but who share a profound commonality with the majority of "respectable" citizens." So I ask, Sandeep, is there a soul sickness in this culture driving addictive behavior across the board, phones, food, porn, et cetera?
Sandeep:
I mean, there's a couple of words in that quote... And I never heard that quote before, but it's really interesting because even when I speak I use a couple of those words. And I think the one that has struck me the most from that quote is commonalities. If we already check out on people because they're dealing with alcohol and drug issues, how are we ever really going to understand why they're dealing with it or what brought them to that state of mind or that state that they're currently in? Because there's always more to the story. Do we take the time to find out that story?
Jay:
So you're saying almost that addiction, it can almost be a symptom and there's some underlying conditions that can be systemically addressed.
Sandeep:
Yeah. Agreed. I think that any kind of addiction, be it the phone, be it the computer, or substances, or food, those may be the manifestation of a different issue. But in its right state it also could be its own issue. Not everyone has this deep rooted trauma that they may be coping for, some folks may just have a substance use disorder. As opposed to many others, and probably the majority of us, have had some sort of trauma that's affected us that we're trying to find our way through to live a happy life.
Emily:
When you think about the words that struck you here, and then you were also mentioning some of the words that we use, like addicts and things like that, I've heard you talk often about how powerful those words can be one way or the other to sort of work against us or work for us. Tell me about the words that you wish we could just get rid of. That you wish we would just stop using.
Sandeep:
I'll give you an example. My mom had breast cancer. She's doing great now, but she had breast cancer, and that's a big deal. I never heard anyone ever call her carcinogenic. No one ever called her by the disease that she had or the disease she was dealing with. There's similar ways of how we're trying in this industry not to call patients diabetics. They are a lot more than the diabetes that they may be dealing with. So it's Mrs. Smith with diabetes as opposed to, that's a diabetic.
Now, you look at the word addict, if I was someone dealing with addiction and I'm calling myself an addict, that's my privilege. But if I'm a healthcare professional and I'm going to call that patient or that individual or that person's family member an addict, I need to check myself. Why am I calling them by the disease process like carcinogenic? Why am I calling them that when literally that's Mrs. Smith dealing with a substance use disorder?
Same with alcoholic. You hear people say, "I'm an alcoholic." That is their privilege. It's another thing for someone else to call them an alcoholic. There's shame, there's stigma. So I do think that words matter, and the words that we choose can make or break someone's trajectory. If we were to come to somebody that was in dire need of help, and we're using framing that is harmful, then how are we ever going to build a partnership with that person?
Emily:
Do you see that happening just in clinical settings where that word is written, you know, addict, somewhere in a chart, and it's changing the way someone's approaching patients?
Sandeep:
Oh, yeah. I mean, look, we know very well there's no shortage of biases. You read a name that may be foreign. You read a disease process that may be unknown or known to be infectious. Even COVID is a great example. The words that we use can, again, really change the trajectory of someone's care, not the care that we give them but even downstream. There are diagnosis codes like alcohol intoxication.
What does that do downstream? When everybody else sees that, do they already check off, like this person is not worth it to me? Are they saying that? Are they thinking of their uncle, or their aunt, or their mother that no one ever talked about because it was bad, very bad? Is that going to affect how they're going to treat Mr. Smith now? I believe it does, by far. And that's why I think even the simplest changes. You don't need to be trained in treating addiction, you don't need to be a doctor or a nurse. Even if we just change our vocabulary, that is, to me, very innovative in the sense that it could change the whole landscape of how people are treated.
Emily:
You've been putting some of these programs into place, both with your team and also at the medical school. Could you tell us about each of those programs a little bit?
Sandeep:
Sure. I've had the privilege of, over the last seven years, trying to motivate 72,000 fellow colleagues and the largest health system in New York state to reframe the conversation. Not to look at substance use as abuse and addiction but looking at it as substance use. Look at it from the most broad perspective. Understanding that alcohol and drugs and tobacco can affect your health. And that's how simple of a message it is. Look at it as a healthcare issue as opposed to keep looking at it like our dinner tables, which is a moral failing. And in turn getting the same scientific evidence-based minds that treat every other disease to now focus over here and be like, "Oh, wait. Healthcare issue? I'm a healthcare provider. I could do something about that."
It's shaped into universal screening. So we're giving every patient an opportunity to talk to us about how alcohol and drugs affect their life. It's turned into interventions, onsite talking to someone using motivational interviewing to understand what consequences they're dealing with and if they're willing to make a change, how do we partner with them. It's come down to creating networks of treatment and care so that patients aren't left trying to figure out who's going to help them. We're going to connect them to care. We're going to follow up with them and make sure that they're doing well. It's about educating people, especially now more than ever about opioid overdoses and how to prevent every single one of those by using a rescue medication called naloxone, and actually giving it out free of charge into the individual's hands so they have it on call whenever they need it.
It's also in the form of education. If you look at our School of Medicine at Hofstra/Northwell, six years ago, we had a two-hour footprint around alcohol use in a four-year curriculum. Fast-forward to today, we have close to a 30-hour curriculum that our team put together, which includes experiential kind of events, where they go out to addiction treatment and see how people are being treated and what kind of science is being utilized. There's role-playing with standardized patients on communication skills. Understanding words of partnership, words of affirmation, so that you could have a conversation with someone as opposed to shutting it down. Continuing education for our physicians, our nurses, our ACPs. As well as we've flipped some of this education out to the community. 90% of what we talk about, you don't need a medical degree to understand. So we use the same exact slides and the same exact conversation with what we would call a layman in this industry, folks that aren't healthcare professionals, and they get it.
Jay:
Can you just stack that investment in professional development against the scale of the epidemic? I mean, just what does it look like at a national scale?
Sandeep:
To me, we're light years behind because we've lost way too many people in this country to substance use related deaths that potentially could have been prevented. The same way we're seeing more diagnosis of diabetes or heart disease early on in life, that's because we screen. We've been screening for these disease processes for years. We've been intervening for these disease processes from pediatrics to geriatrics.
We have made it a point to stop the progression of these big diseases otherwise we would be in an epidemic of heart disease. We would have people dying of heart attacks left and right if we never started taking their blood pressure, putting EKG machines in every mall and every single public setting there is. We need naloxone in every single mall and every single public setting as well. We've lost people in parking lots of hospitals to overdoses, in bathrooms in libraries. I mean, you name it. This is all somewhat preventable, we need to accelerate our process.
Jay:
Developing standardized tools. Just the same playbook that you bring to other pathologies.
Sandeep:
Yeah. That's the beauty of it. And I love how you're getting it, and I'm assuming that you're not a doctor or you're not a nurse. That's just my assumption.
Jay:
I play one on TV.
Sandeep:
There we go. I'll tell you right now, the way you just got that is exactly the aha moment we want 72,000 fellow employees as well as the rest of this industry to get. It is not different. There's a journey here when it comes to substance use and substance use disorder. If we interact in a compassionate way early enough, we can prevent the trajectory of that journey. We could realign somebody back towards wellbeing or recovery. But we just need to come up to this understanding that, if I take someone's blood pressure, it's because I'm screening them for heart disease. If I ask somebody questions about how alcohol and drugs are affecting their life, it's screening them to understand where they're at on the spectrum of substance use disorder.
Jay:
Right. And understand the co-morbidities in the relationships.
Sandeep:
Absolutely. Don't stop there. Understand, there may be some behavioral health issues, there may be other traumas. I mean, all of us have had trauma on our lives, we deal with it differently. We need to be compassionate with how people deal with it.
Jay:
And just for the sake of people, I don't think people understand the statistical breadth of the problem.
Sandeep:
40 million people over the age of 12 in this country have a substance use disorder. Theoretically, that's one in seven people in this country. And when you compare that to three other big disease processes, like heart disease, diabetes, and cancer, those are hovering around 30 million. We're talking about 40 million people dealing with the disease. And now let's go back to those med school days. Four hours of education for 40 million people versus my nine-year-old can talk to you about heart disease and diabetes at this point. Because they talk about nutrition, they talk about blood pressure. They understand that their grandma may be dealing with something because it's mainstream. This has been falling.
Jay:
It's the elephant in the room.
Sandeep:
It's the elephant in the room supported by an inadequate framework of education. When it comes to substance use disorder, as a country, privilege has played a really big part in it. I speak a lot about the current state of the opioid epidemic. The opioid epidemic has been around for many, many, many years before it's become mainstream in my generation. It's been in low socio-economic status environments, communities of color for years, and years, and years, and as a federal government, as a state government, even as society, we've done very little about it. Now there's millions and millions of dollars being pumped in for research and for treatment and for navigation. But where was that before when we were losing fellow mankind to a disease process that was always a disease process. It always should have been approached with compassion and that stigma. If we can talk about hemorrhoids, if we can talk about sexually transmitted infections, if we can talk about gynecological issues, why can't we just talk about alcohol and drugs without it becoming controversial, stigmatizing, judgmental?
But we have to understand that there's two parts to the equation. We need to bring a welcoming approach so that our patients and our communities will feel comfortable with us. 99% of this is all about communication and comfort. If we could build an environment that's trusting and comfortable, people will talk to us about it. But if we're not willing to do that, then we're going to continue to suffer from this epidemic and these pandemics left and right, and lose many people to a disease that we really don't need to lose them to. We could prevent that progression. So I think it's really just to get people to understand this from a lens of compassion, a lens of justice, a lens of empathy, that we could do so many powerful things with even the smallest acts.
Emily:
So compassion, and empathy, and justice are good medicine.
Sandeep:
I would want someone who's treating me, or my mom, or my dad, with those three elements by far.
Jay:
What's compelling too is how you seem to be marrying that, and it's not just about heart, it's not just about empathy, but let's also bring evidence-based practices, clinically validated instrumentation. It's where those things meet, I think, it sounds like there the power is.
Sandeep:
Yeah. And then look, take that, Jay. Take that and bring it to a group of healthcare professionals that already understand everything you just said. All we need to do is to superimpose that onto this disease process. You don't need to be this board certified addiction psychiatry or addiction medicine certified person. That care or treatment can start with your front desk team member that answers the phone and doesn't treat that person like crap. I mean, that could be the whole... It could be from your medical office assistants, or your primary nurse that's helping you in an emergency department not being rude to you because you say you drink or do drugs or you came in because you just overdosed.
That in itself is probably the most important touchpoint. Not the downstream specialty care. That's all very important and we need to get people there, but how are we going to get someone there if we can't even welcome them? It's like inviting someone to our house and having a bouncer at the door, and if they're dealing with substance use issue, you got to bounce. Everybody else. "Oh, heart disease, come on in. Diabetes, come on. You got the VIP table. Oh, no, sorry. You go sit in the corner."
Jay:
Because you're a failed human being.
Sandeep:
You have a scarlet letter on you that's superimposed by us because of those conversations around our dinner table. Literally. It's not because we learned in medical school that people who use alcohol or drugs are bad, we just didn't learn anything. Other than maybe hanging out at the bar after with our friends and seeing things. That's where we got our evidence. Our evidence was like, "Oh, no. I know how my uncle drinks. He's a bad dude." That's not science. That's not evidence. That's our social primers that we bring to the table. We need to encourage people to put those aside.
Jay:
And that messaging that it's something that you've done to yourself, that you have made bad choices, or you're a weak human being, whatever that messaging is, it's so in and of itself debilitating and perpetuating of the disease.
Sandeep:
Yes. And if you speak to folks that are in recovery, or folks that are dealing with substance use issues, or folks that are dealing with eating disorders, or folks that are dealing with smoking issues, whatever it is, there's enough shame to go around already. There's already enough lack of self-confidence. There's already enough of that there. How is it our right as healthcare professionals to add to that?
Jay:
It'd be like pouring salt on the wound.
Sandeep:
I mean, why would we want to make it worse as opposed to capitalizing on all the science that we know and try to make it better?
Emily:
You even took that science and built an app to help people, right?
Sandeep:
We did. Yeah, we built an app to help educate other healthcare professionals, to show them that it's so simple. That using evidence-based screening tools, the same way like a blood pressure is, or the same way you ask somebody about domestic violence. There's tons of different screening tools that are out there that are evidence-based. All we're trying to do is teach people to use the same skill set for substance use.
And better yet, we created an app that they could use with a patient face-to-face and walk through the whole process. Understanding about what their goals in life are, or what their goals are in terms of their alcohol use. Could it be cutting down? Could it be saving money? Could it be having a better relationship with their family? It's like a menu of behavioral options they choose from. And then after this thoughtful conversation between patient, a healthcare professional, and this app, it comes out with a summary. A summary of what the patient wants to do.
As opposed to us saying, "You need to stop drinking," the patient has come up with their own motivation and their own understanding, on paper, of why they would contemplate making a change. And that change doesn't need to be, stop drinking. The change could be, "Hey, I'll drink one less beer a day." Whatever it is, it's probably better than current state. Even the smallest acts of change or the smallest acts could be exponential in that trajectory of that person's life.
Jay:
It's intrinsic.
Sandeep:
It's got to be intrinsic. You'll push somebody, they'll do what you want, but it doesn't mean they wanted to do it or they did it for the right reason. How do you spark that internal generator of somebody? And the way you usually we do that is by talking to someone. What's important to somebody? And if it's important to them, is it important enough to them to think about, "Maybe I should go to the gym so I could play with my kids."
You may have someone dealing with, let's say obesity, that starts suffering because he can't keep up with his kids when they're playing soccer, and it's hurting them. Maybe that's the reason why that person's going to go to the gym. Not because their wife is saying, "Go to the gym," or their doctor is saying, "Hey. You need to lose weight." That's not what's going to drive people. It may drive them, but we need to as human beings figure out how to facilitate, not drive. We don't want to push people, we need to be by their side, and say, "I'm right by your side. No matter what you decide, I'm still going to be by your side."
Jay:
That's a compassionate piece.
Emily:
And then you'd no longer have the divide between you, right?
Sandeep:
Right.
Emily:
So if your goal is just to perhaps drink less or maybe not smoke on workdays or whatever, that doesn't mean you somehow failed the doctor's goal.
Sandeep:
Well, that's the thing. We are very keen on driving our agendas as human beings. We want our kids to clean their room. We want them to be back by curfew. We want them to read X amount of time. These are all directions. We're being very directive with our kids. And what usually happens? It ends up in an argument, a tantrum, a fight. We're frustrated, they're frustrated. If you could figure out a way, which I'm still trying to figure out, but if you could figure out a way where your kids like reading, they're going to read. If they find the adventure in the book that they're reading...
I wasn't one of these kids. I did not like reading. And all I was being told and yelled at was to read. It did not make it any easier for me. So I think if we look at just the way we were treated as children and what worked with us and what didn't, why can't we put that and superimpose that into our approach with other human beings? No one wants to be scolded, or yelled at, or shamed, or given ultimatums. We shut down. We completely shut down.
And one analogy is, and I ask a room full of people and it's my favorite question to ask is, "How many people drink coffee?" And everybody raises their hand. And it's usually like a morning so everyone's needs their coffee at that point. And then I say, "Okay. Great. What if I were to tell you tomorrow, never drink coffee again? How many of you guys would be successful?" And like all the hands go down. I'm like, "Look, if you can understand that, then you should understand what people dealing with alcohol, drugs, tobacco, food, whatever issue they're dealing with, you need to understand by you telling them to stop, their hand is going to go down just like your hand just went down."
I'm not a coffee drinker but I know, if my colleagues don't have coffee, forget it. It's over, dude. It's like war. And all these people they're admitting. They put their hands down. They're like, "No way. That's impossible." So if we can understand that, then how are we still telling people what to do? And if they don't want to do it, you got to meet them where they're at. It's okay.
Emily:
That sounds like a really radically different approach to a doctor-patient relationship that I think a lot of clinical encounter sort of set up in terms of a paradigm. I mean, what's been the response from your colleagues in trying to ask them to sort of shift and work in this different kind of way?
Sandeep:
Here's the beauty of it. It's not just one person saying this, there is a paradigm shift happening in terms of communications, and how important communications is part of being a healthcare professional. And it's not just docs. And nurses, social workers, you name it, all of us can benefit from training, and education, and practice, and hopefully, mastery in communication. If we can understand the basics of how to empathize with somebody, how to convey to them with our words that we understand them, as opposed to the fail safe of what this industry was like, which is, I'm going to tell you what's good for you, people would come to physicians, and nurses, and doctors, and whoever else and ask, "What should I do?" But again, that's that pushing mechanism. We could-
Jay:
Literally a prescription.
Emily:
Yeah, literal.
Sandeep:
It's literally prescription. Wow. Jay, man. What are you? A wordsmith? What's going on here? We got Webster on this boat over here. This is amazing. Dude, absolutely. Yeah, it's prescribing as opposed to co-constructing.
Jay:
Inspiring.
Sandeep:
Oh, man. Jay, dude.
Emily:
That's why I bring this guy around.
Jay:
I get paid by the word.
Sandeep:
Yes. Wow. Prescribing versus inspiring.
Jay:
I'm not going to write you a prescription, I'm going to write you an inspiration.
Sandeep:
Wow. Better yet, let's both write it together.
Emily:
Let's create an inspiration. Let's co-create it an inspiration.
Jay:
Let's write it together.
Sandeep:
Let's create it.
Jay:
Let's co-create an inspiration and then hold each other accountable in a supportive way.
Sandeep:
Yes.
Emily:
You were recently given a grant to start to look at taking some of these same techniques around asking questions and taking a clinical approach to substance abuse into the realm of gun violence and treating gun violence like a health issue. Talk to me about that.
Sandeep:
That was an interesting thing. So we recently received a $1.4 million grant from the National Institute of Health, so the feds, to research if a universal screening process, intervening process, as well as referral to resources, the exact same model that we built for substance use, if we could apply that to help in the pandemic of gun violence. So theoretically, looking at yet another societal issue and reframing it as a healthcare issue. And in doing so, can we build championship amongst this industry to say, "Wait a second. Healthcare professional, healthcare issue, I can do something about this."
The majority of deaths with guns is not what we think. It's not the mass shootings. Those are horrible. It's incidental, accidental. Folks who own guns, it's fine to own a gun. It's our right in this country to own a gun. The question is, are we educated on safe storage, on safe utilization? Do we understand the risk our children or their play dates that come over are at if there are firearms in the household? These are the kinds of conversations we want to have in the healthcare setting, the same way we used to talk about car seats and continue to talk about car seats.
Car seats weren't a thing until it became a healthcare issue. Until people started seeing children dying in car accidents, all of a sudden physicians, nurses, NPs, midwives, you name it, started talking about the importance of car seats. To now, at our children's hospital, or any hospital that delivers babies, they'll come downstairs into the parking lot and help you put in a car seat properly in your car so that beautiful life that you brought into this world is safe. So we're trying to take that and now superimpose SBIRT into firearm injury and mortality prevention.
Emily:
SBIRT. Can you define it for us?
Sandeep:
Sorry. Screening, Brief Intervention, and Referral to Treatment. Let's look at cardiovascular disease. It is taking someone's blood pressure, screening, it's talking about diet or nutrition or medication, that would be your brief intervention, and if you need to get that patient to, let's say a cardiologist or start treatment, that's your referral piece. ESBIRT's been around for almost any other chronic condition. We now know it really for substance use in our health system. It's Screening, Brief Intervention, and Referral to Treatment.
If we apply that now to gun violence prevention, and we ask a couple of thoughtful questions of access to firearms, we could understand if that patient's at risk of potential firearm injury. And at that point, we can have a discussion with them about what's available. Gun safety locks. It's a $15 device. You just put it over the trigger and lock it. It keeps everybody that doesn't have that key safe. Safe storage using a gun safe, as opposed to keeping it in your bedroom side table. I mean, simple things like this. Or in the height of COVID, we've seen in this country gun sales on the rise. So now we may have a whole new society that has a new gun ownership that really don't understand what that weapon can do and how to keep it safe. We're not saying destroy the weapon, we're not saying get rid of it, it's all about prevention of preventable injuries.
Emily:
We're not saying get rid of your car, we're saying buckle your seatbelt and get your kids in the car safe.
Sandeep:
Make it safer.
Emily:
Make it safer.
Sandeep:
Absolutely. I couldn't care if you own a gun or not, and nor should we. What we should care about is if you do own a gun or have access to a gun, that there are certain safety measures in place. I know what measures should be in place for a boat. And how did I learn that? When I got a boat, I did safety courses. There is some sensibility behind standing up a program like this now because we know that our communities are flooded with guns now, because the sales have skyrocketed during COVID.
Emily:
One of the other things we like to ask everyone we interview is to take us far field. Take us to something that you're passionate about, that's a hobby, that's an interest. It could be just a recent obsession or Wikipedia death spiral that you've been on that is not necessarily directly in the line of your work and tell us a little bit about it.
Sandeep:
A hobby. I think, one thing, and going back to that quote from before about commonalities, there's no shortage of diversity in this world, which unfortunately we harp on the differences and we have those conversations about others. The one thing that I think is this ultimate commonality that no matter who you are there's some way to find with individuals, different tribes, different cultures, it's music. I'll tell you one of the reasons why I feel this.
I can't hear out of my left ear. And I have a couple of friends that I know that can't hear at all, but music still plays a role in their life. The vibrations, the joy that they can see and feel, to me, that speaks volumes, no pun intended, but it speaks volumes in the sense that music is this commonality that just binds us. No matter what we look like, what color we are, whatever it is, where we're from, music is this central touchpoint.
So for me, one of my hobbies is I collect musical instruments, and I tend to try to learn how to play them, regardless if I have any comfort level around this. So I have a room about a mile and a half away from here at my house, which is my music room, and I have close to like 120 different instruments from around this world, from my travels, from travels from friends and family. Folk instruments that cost like cents to the dollar in different countries and here would be like 30, 40 bucks.
To me, that room is also a place of respite, because when I go in there, I could just pick up some random thing, it'd be a percussion instrument or a string instrument, and just lose myself. As a father, I'm also in my infancy of trying to understand how to be the best father I could be or parent I could be, giving my children access to that, has also been pretty magical to see if they're interested or not in something and just allowing them to appreciate that one commonality that we have.
Another point about this. Despite the content of protests around this world, there's always music in them. There's always either someone with a djembe, there's always somebody with like a cowbell. There's always some music either with a physical instrument or chanting. And that, to me, again, no matter what the content of the protest is or the protestors are against each other, people got to step back and just understand that there's a commonality there. They are strumming to a beat, like a similar beat, even though it may be different viewpoints. That's that one commonality that brings people together.
Jay:
It so hearkens back to the way you spoke about your work of, not bad uttering and sitting with someone, being with people, and realizing that someone who might be going through a substance abuse episode or condition, maybe it's just a different tune but there's this... You both have beating hearts, you're are both human beings, you both can connect. It seems so resonant with that. And I love that. 120 instruments. So out of 120, what's your current favorite or your weirdest?
Sandeep:
I should have brought it with me. There's two, I would say, and they both happen to be from India. One is called a dhol. D-H-O-L is how you spell it. I don't know if you guys ever seen an Indian wedding or been to an Indian wedding, but it's usually like this big drum that strapped around someone's neck. It's fairly large and you play it with two sticks. Obviously there's a bass side, there's a treble side. But the sound of it, obviously being... my heritage is from Northern India, it just does something to my core when I hear that beat.
So I, in medical school went and volunteered in India for a month. And beyond the mission to help people, my mission was to come home with a dhol. I wanted that drum. And the cool thing is my kids, again, at nine and six, they kind of know how to play it, which is sick, because it's not easy to play the Punjabi beat per se. But the only reason they know is because they have it there and they had access to it, and I'm loving every second of it.
The second one also is a folk instrument from India. But there's a lot of similarities. A lot of instruments are very similar around the world. So this one's called the tumbi. T-U-M-B-I. I'll send you some pictures if you want. It's also called the Iktara. Ik in Punjabi means one, and tara or tar means string. So it's a one-string instrument. It's like a banjo if you will. On the bottom it has like a drum head, and it has a bridge like a violin would, and then it has one string that goes up to a peg that you tighten. If you ever heard that one song everyone knows from Panjabi MC like the... That's that instrument that plays that song.
Jay:
Just so you know, you're listening to Dr. Kapoor play the tumbi, and the rest of the music you'll hear in this episode is him playing an instrument from his collection.
Sandeep:
So when I was in India in... Where was it? It was on Jail Road in Tilak Nagar. It's a small, small shop. I just randomly walked into it looking to get a dhol. And I asked the guy, "What is that?" And he's like, "Oh. It's a tumbi." He pulls it off, and he tightens it, like tuning it, and takes one finger and literally starts playing that beat from that song, which... If you're a New Yorker you know that song. It's played everywhere. It's like part of our Hot 97 culture. It's there. And me, some New Yorker kid who grew up in America whose parents are Indian, I was just like, "Oh my God. I need that." And I'm like, "I want it." I'm like, "I'll take it." And he's like, "Okay." It's my favorite instrument by far and I love the sound of it.
I actually have one in my office at Northwell sitting behind my desk on the wall, the one I got from India. And on my wall in my music room, I have about 30 of them. Because they're all different. They're all folk instruments. So they're all different designs. Some are made from wood, some from metal. Different graphics on it, different pinstripe, and different carvings. So I bought a bunch. Okay. Should we head back in?
Emily:
Yeah.
Jay:
Sure.
Sandeep:
I'll put this in here. Yeah. All right. You guys decide where you want to sit, where you're comfortable.
Emily:
Actually... Yeah.
Sandeep:
Where do you want?
Emily:
I'm trying to say if I want to sit in the back-
Sandeep:
Yeah. Sit in the back, you'll enjoy it. It's actually a cool feeling back there. All right.
