In this episode Dr. Audrey Nath speaks with Dr. BJ Miller, a palliative care physician at Mettle Health in Mill Valley, CA. Dr. Miller shares how an accident that resulted in the loss of three of his limbs challenged him to look at life and death in a new and positive perspective. Dr. Miller also talks about participating in the series Limitless with Chris Hemsworth, a series that explores overcoming the challenges of aging, featured in an article in Brain & Life.

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Episode Transcript

Dr. Correa:
From the American Academy of Neurology, I'm Dr. Daniel Correa.

Dr. Nath:
And I'm Dr. Audrey Nath.

Dr. Correa:
This is The Brain & Life podcast.

Dr. Nath:
Welcome back to the Brain & Life podcast by the American Academy of Neurology.
Daniel, you're not going to believe who I got to talk to. He's a total rockstar.

Dr. Correa:
Oh, okay. You've piqued my interest.

Dr. Nath:
I got to talk to the famous palliative care physician, BJ Miller. He's written tons of books and articles, and he's been the face of rethinking how our healthcare system deals with aging and dying, which traditionally our healthcare system has not been the greatest at. He's talked about new models of care. And, we got to talk about his role in the new Chris Hemsworth project on Disney+ called Limitless, where Chris faces his fears in life head on.

Dr. Correa:
There's a bunch of Chrises in Hollywood. There's like a full deck of cards, whether it's Pratt, Pine, Evans, Hemsworth. Which Chris and action hero is this?

Dr. Nath:
Chris Hemsworth is the Chris that plays Thor and is on the cover of Brain and Life Magazine this month. So exciting.

Dr. Correa:
So now, we're delving into the Marvel Cinematic Universe and brain health.

Dr. Nath:
Yes!

Dr. Correa:
Perfect. I'm looking forward to exploring the superpowers of the brain.

Dr. Nath:
Absolutely. Everyone's just going to have to watch this on Disney+ because it's a great series. But basically, how BJ Miller created like a fake retirement home for Chris to experience what it's like to be aging and in the last days of his life.

Dr. Correa:
Okay. I'm adding it to my list for shows now, and I'm really looking forward to this discussion.

Dr. Nath:
Today, we are joined by BJ Miller, palliative care physician, who has taught all of us so much by sharing his own story of loss and hope with the public. In brief, he wasn't initially all that interested in medicine, based on what he has said before, that experienced a life-altering accident at the age of 19 that resulted in losing two of his legs and an arm while fighting for his life. In the long grueling days and weeks of rehabilitation, he had a chance to do a lot of thinking about life, and then he went into medicine and became drawn to palliative care to help people with the suffering that is part of life. It would take me far too long to go through everything that BJ Miller has accomplished in his career. He was co-author of a Beginner's Guide to the End: Practical Advice for Living Life and Facing Death. He's spoken about his experience to many, many media outlets, and is founder of Mettle Health, which helps with practical, emotional and existential issues with patients, which he's coined as praxistential care.
He's here because BJ was a part of this awesome Disney+ series, Limitless, with Chris Hemsworth. I highly recommend the series. It's directed by Darren Aronofsky, with really cool imagery to show physiological processes like chronic stress and how memory works. In this series, Chris explores facing his fears head on. In the last chapter, with the help of BJ Miller, he explores confronting aging and death and the incredible peace and clarity that he gained from this experience.
Welcome to the podcast, BJ Miller.

Dr. BJ Miller:
Thank you, Audrey. It's really nice to be here. That was a lovely intro. Thank you.

Dr. Nath:
You know, watching you and Chris Hemsworth talking about life, it's like drinking a warm hot chocolate. It is just so comforting to watch you guys process these things. I guess I'll just let everyone know a little bit, if anyone hasn't seen this episode yet, but essentially you created this experience for Chris where he could live as an elderly person near death in a really creative way. You created... No, I guess I shouldn't give too much away, but you created this older folks' home where he could stay, and had him wear a suit that made it hard to walk around to try to mimic the aging process. How did you come up with all this stuff?

Dr. BJ Miller:
I wish it were all up to me. The truth is, it was a big, creative, collaborative project. I mean, there were three or four production crews involved, and Tom Barbor-Might, who was the director of that actual episode, a really lovely person, really sensitive. So together, we talked out a lot of the issues that we wanted to make sure to bring into the fold and talked about how to honestly simulate some of this stuff so that Chris is having an honest experience because otherwise, it's just sort of an intellectual exercise or pontificating about what aging must be like. Especially, when you're a 38-year-old hunk like Chris. How... That would've been a little...

Dr. Nath:
Yes. I am not that functional of a person at all.

Dr. BJ Miller:
No. No.

Dr. Nath:
It's true.

Dr. BJ Miller:
I mean, how were we going to get anyone to believe that Chris was really having an experience, not just an intellectual exercise? So, the credit for building Sunset Pines, and that's a shared credit, and Tom, Darren, other producers, a lot of folks involved in making that happen, the suit that you described comes out of MIT, the sort of way to simulate the feeling of being in an older body. So, it was a coming together of a lot of brains besides my own. That's for sure.

Dr. Nath:
When coming up with all this, what was your hope or your big goal for the viewers to take away from watching Chris Hemsworth navigate this retirement home? What did you want people to take away from this?

Dr. BJ Miller:
There's just so much here. The subject matter is sort of life, and life's kind of huge and has a lot of things going on in it. One answer to the question is, I think the uber message, the overriding point, is to connect things which are normally or often held out as opposing or in contradiction. For example, I think most of us talk about strength as an opposition to vulnerability, that vulnerability is aligned with weakness; strength is strength. And our rhetoric, the way we use this language, suggests that if you're vulnerable, you're not strong. I think a lot of us who've actually lived life in these bodies, one way or another you come around to thinking, "Well, geez Louise, no, no." Having to be vulnerable is the source of strength, is what teaches us our strength, is what shows us our strength.
So, it's this relationship between our fragility and our durability. So, connecting this loop that modern life has and our languaging and our habits have alienated from each other. We're trying to reacquaint these non-opposites that look or smell like opposites. And maybe the biggest of them all is life and death, that we think of death as this countervailing force that robs life. It's the thing that ends life. Death is somehow held out as the opposite of life. I think we all intuitively know and maybe have to relearn that, oh, actually no, that's a little too pat. No. Death is entirely part of life and life needs death and death needs life. You don't get one without the other.
So, in answer to your question, Audrey, I think those are sort of the big messages that we really wanted to get across, was to reconnect these circles. The effect might be that we don't have to be at odds with ourselves because our bodies quote-unquote fail. If we turn our attention to our nature, our reality and find some way to work with that thing, then we're really cooking with gas, then we're really alive. That's a lesson that is not always obvious and needs, I think, to be pointed out, especially in, perhaps, modern Western life.

Dr. Nath:
When you talk about that, that there's loss as a part of life and you can't have one without the other, I just keep thinking about what you have said in another interview where you described the accident that you had when you were 19 years old, and how you went from being this tall person with four limbs to having the body that you have, and that you kind of thought of it as the loss of your other body and that it was, in a sense, a death of the person that you were. Is that something that you find informs your present view?

Dr. BJ Miller:
Yeah, absolutely. I think of death now as much more mysterious and nuanced and not just this sort of black curtain that comes down, and bonk; that's it. Because one of the rewards, whether by force, like in my case, or by choice, if you start looking at the bigger truths, all sorts of beautiful things get revealed. Death and life, you and I know from our medical training, our bodies, we're shedding cells all the time. Our cells die. Red blood cells live, whatever, what is it, 90 days or something? We're all this sort of swirling heap of living and dying all the time.

Dr. Nath:
Absolutely.

Dr. BJ Miller:
So, you start looking at these things and they're not these stark, harsh, concrete things that our constructs in our language pretend they are. And that's exciting to me. I love that. I have learned that through watching my own death. If you expand this definition to death to be something more piecemeal and mysterious and not necessarily this end, well, you can start seeing it all over the place, in some ways as a metaphor, some ways as a partial death. But one way or another, these are ways you can invite this subject into your daily life because it's already there. You can start seeing it. So in this way, death may not be so terrifying anymore if you realize you're doing it all the time. You already have some familiarity with it.
It very much helped me after my injuries when I lost three limbs, came close to death in the big way. Well, I got to see what kept going. I got to see what could be reborn from those ashes, and it took me a while. But you may have your own experience with this where you're comparing and contrasting yourself with your old self or your old body or other people. What a cruelty we do to ourselves in this way. I get it. We're social creatures. We need to kind of place ourselves in relation to each other and we need gauges to help us understand where we are. But those are just tools; those are tricks.
So, it was very helpful for me to stop pretending I was the guy before my injuries. It was much more constructive for me to let that be a death, let that guy go, give myself the grief and sorrow that goes with that, as well as the appreciation for what I still have and what I could make new now, what I could create going forward. So acknowledging the loss, acknowledging the death, in a way, allowed more life and allowed more creation, allowed me to go new places. We are the ones that get hung up trying to name it or own it or contain it or something. But this stuff's flowing all the time.

Dr. Nath:
I suppose you don't feel like you're living on borrowed time now?

Dr. BJ Miller:
I don't use that language per se, and I said it in that film at the end. I talk about life being a gift. That's true enough. I do think another day is amazing. We get another day. Wow. There's no guarantee of that. I do like that construct, but it's still a construct. I think in a more scientificy way, another day is just incredibly improbable. How outrageously unlikely is it that you and I have ended up on the same planet at the same time or the same little Zoom room? What are the odds of that? And the odds of this tomorrow, this is going to happen, we're going to have some other version? That's the way I like to think. Just sort of in awe that we get more time. You can call that a gift; you can call that just incredibly improbable or whatever it is. But I just think it's amazing. I just think it's an amazing fact, and it allows me to really appreciate what I have while I have it.

Dr. Nath:
As a palliative care physician, do you work with people who are experiencing grief and loss and confusion with genetic testing results specifically? I'm just curious if that's something that comes up with your work.

Dr. BJ Miller:
It has come up. Not frequently, but it has come up. Especially in my new, you mentioned Mettle Health, our new practice that we started a couple years ago, and we can talk about it in any detail you'd like. But very much on purpose, we pulled the practice outside of healthcare, outside of the medical model, to free us up to go different places, to make it easier for people to reach us, including family members and caregivers. By pulling it, by recontextualizing palliative care outside of this medical model, it has meant that a lot of people come to us with all sorts of sort of existential crises, little deaths of other kinds, deaths of identities, a job change or relationship change. Within that purview, sometimes it's a genetic counseling moment. So, the answer to your question is yes. It's not a big one, but it's something I love in our new practice is that we see folks who are suffering from all sorts of different angles, not simply a presence of a disease or whatever else.

Dr. Nath:
When you say not a traditional medical model, so I guess you're not in a clinic in a five-story building somewhere with an elevator and the front desk. What do you mean by not the traditional medical model?

Dr. BJ Miller:
We are telehealth business. We are online. More importantly, to me anyway, is that we dropped, like I am a physician, but at Mettle Health, if you were our client, and I would call you a client, not patient. If you are our client, Audrey, I would not become your doctor per se. I'm not prescribing you medications. I'm not diagnosing anything. I may coach you how to use your doctors more prudently, how to use healthcare, to keep it in its place and not get too caught up in it. Because I think you and I both know healthcare, for all its wonder and amazement can also become a source of heartache and absolutely suffering itself, for us as providers, as well as us as patients. So we're trying to free ourselves of some of the...

Dr. Nath:
[inaudible 00:14:08].

Dr. BJ Miller:
... structural challenges that happen in healthcare. We are a social model of care. We are not a medical model of care. We are using our clinical expertise from the periphery to guide people through healthcare. But we're trying to open up space to depathologize these things. Nothing has to be wrong. There's nothing pathological about you for coming to see us. We're trying to free ourselves of all those structural impediments to good care, all the structural things that limit it to a 15-minute encounter or force me to diagnose you before I treat you, or it doesn't allow for your family members to come see me because we can't bill, et cetera. So, that's what I mean by getting out of the medical model.
If we get to grow, I think a lot of our counselors will end up being folks who are late in their career or even retirees who have all this accumulated wisdom.

Dr. Nath:
Gosh, that's true.

Dr. BJ Miller:
Yeah, sure, from seeing a zillion patients, but really from living their own lives. By dropping the white coat sort of vertical hierarchy, we can get, like, "Oh, you're a human being? Oh, I'm a human being. Let's feel our way together as two human beings who live and suffer and love and all that stuff." It's a way of drawing on our personal experiences as well as our professional credentials.

Dr. Nath:
So about that, the counselors, I'm guessing, are physicians who are now working in kind of a different way. What specialties are these physicians in? Are they all palliative care or not?

Dr. BJ Miller:
They're all palliative care. We think palliative care is bigger than healthcare. There's nothing purely medical about suffering or death. These issues, there are self-realization. These are issues way bigger than any medical model or any one model. We still wholly feel part and parcel of the palliative care world, but we're trying to make the case that this is a philosophy more than a clinical discipline. We want to see how far we can take this philosophy. So at this point, all of our counselors are palliative care clinicians. Maybe we'll expand that, but at this point, we still feel very much part of the palliative care family in this way.

Dr. Nath:
What did you learn from your patients as they were passing on?

Dr. BJ Miller:
Oh, yeah. Well, so much, really. One is you get these sort of vicarious deathbed moments yourself if you're paying attention. I, like maybe all other human beings, I'm really good at appreciating something once I've lost it. I appreciate what it was like to have two hands now that I only have one. Sure. Okay. Watching folks who are at the end of their life, some at peace with it, some are not, and learning about their own regrets as they face this big truth or watching how they navigate, watching how they find themselves even while they're falling apart, watching them realize all the things that they spent so much time worrying about, like we said earlier, comparing themselves to others, et cetera. So, letting fear get in the way of their love.
I get these vicarious deathbed moments from where I essentially, it's a little cheat. It helps me appreciate all that I have before I lose it, which I think is one way of really understanding, perhaps, a life's quest. There are many variations on that theme, but in a snapshot, that's the big one that I kept taking away from that work.
So I think we, in the healing professions, perhaps, and maybe in modern life, we need to put love into things, but we also need to learn how to take that stuff in, how to be cared for ourselves, how to be vulnerable, which is another back to Limitless and Chris Hemsworth. God bless him for helping us connect these dots.

Dr. Nath:
Yeah. And put that back together. You talk about medical training. It's so interesting. In the Limitless, you guys were talking about how, wow, you're not guaranteed another day and that discussion. I think back to during medical training when I just remember my mantra was, "I can do anything for a month." It didn't really feel like living. It was like, okay, just put one foot in front of the others. I think it's very much kind of what you're speaking to, that you can really turn off that sense of mindfulness and gratitude and just like, "I'm going to soldier through this and I don't even know who I am anymore." So, I think that's an interesting thing.

Dr. BJ Miller:
Oh, amen. It is, Audrey. Once you kind of get hipped to this idea that, whoa, this stuff's precious; it can go up in any second; I could die tonight, nevermind tomorrow. Whoa. Then all of a sudden that math starts. If I could hold my breath for a couple weeks here, I could just get through it, just get through it. But before you know it, you could just apply that to your whole life and you're just getting through it. Then you get to the end, you're like, "Wait. What did I do? I just put life on hold to get through it."

Dr. Nath:
I'm amazed. Your love for life, your perspective. How can people find you online or on social media?

Dr. BJ Miller:
I have a Twitter account that I rarely look at, but it's there. That's @BJMillerMD. But the bigger place, please come find us at Mettle Health. Mettle is M-E-T-T-L-E. Mettle, like one's inner strength. That's what we're going for here. So Mettle Health. We have an Instagram. That's where we're most active, and it's @Mettle_Health. And just visit our website, mettlehealth.com, and reach out. I should mention, Audrey, maybe 60% of our clients are family members, caregivers. Many are patients. A minority, but a healthy minority are actually clinicians who reach out to us who are burning out or who want to talk through a consult on a patient kind of thing.

Dr. Nath:
Oh, yes.

Dr. BJ Miller:
Yeah.

Dr. Nath:
Well, thank you so, so much for joining us and sharing your story and Chris Hemsworth.

Dr. BJ Miller:
It's such a pleasure, Audrey. I such enjoyed talking to you. Thank you for this conversation. These conversations used to be very rare, and they're less and less rare. And that's really good news, I think, for all of us. We can stop pretending that we don't die. We can stop pretending that we aren't vulnerable, and maybe you can be a little bit more okay with ourselves as we are.
I just want to say, I've done a few interviews around Limitless, and I keep forgetting to say how much I love Chris Hemsworth. I just want to say what a beautiful spirit he has, and it was such a joy to work with him, and this whole thing would never have worked if he had acted his way through it. To have a superhero dare to be seen as a real person, I'm sure that came as some risk to him and his career on some level. But I'm so grateful to him for doing this and for the creators for making this, and again, connecting this loop between life and death and strength and vulnerability. I just love what they came up with, and I'm very proud of Chris, and I'm just very grateful to him for doing this. What a beautiful human being in all that that means.

Dr. Correa:
Thank you again for joining us on The Brain & Life podcast. Follow and subscribe to this podcast so that you don't miss our weekly episodes. You can also sign up to receive the Brain & Life Magazine for free at brainandlife.org.

Dr. Nath:
Also, for each episode, you can find out how to connect with us and our guests along with great resources in our show notes. You can also reach out by email at blpodcast@brainandlife.org, and you can call in anytime and record a question at 612-928-6206.

Dr. Correa:
You can also follow the Brain & Life Magazine, Audrey and me on any of your preferred social media channels.

Dr. Nath:
A special thanks to the Brain & Life team, including...

Dr. Correa:
Andrea Weiss, Executive Editor for Education and News Publications.

Dr. Nath:
Nicole Lussier, Public Engagement Program Manager.

Dr. Correa:
Rachel Coleman, our Public Engagement Coordinator.

Dr. Nath:
Twin Cities Sound, our audio editing partner. We are your hosts.

Dr. Correa:
Daniel Correa. I'm joining you from New York City and online @NeuroDrCorrea.

Dr. Nath:
And Audrey Nath, beaming in from Texas and on Twitter @AudreyNathMDPhD.

Dr. Correa:
Thank you to our community members that trust us with their health and everyone with neurologic conditions. We hope together we can take steps to better brain health and each thrive with our own abilities every day.

Dr. Nath:
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Dr. Nath:
Thank you!

Dr. Correa:
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