Special Bonus: Physician BJ Miller’s Recovery from Phantom Limb Pain

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.
Audrey, we're doing a little bit of a special re-release today because we had some excellent content from your interview from the BJ Miller episode. We wanted to honor the time you have spent with us as a host for the Brain & Life podcast, and we're grateful for all the important conversations you've had with our community in promoting awareness about neurologic conditions and brain health.

Dr. Nath:
Thank you. So we had a whole discussion about his life as a patient since he had experienced an accident when he was a teenager, back when he was in Princeton, where he had climbed on top of a parked train and his left arm hit an electric wire, which caused a really massive, massive electrocution injury. He ended up losing both of his legs and his left arm. So we ended up having a whole chat about his life as an amputee, and specifically with neurological issues related to losing his limbs such as phantom limb pain.

Dr. Correa:
I was exposed to the whole idea of phantom limb pain, even before I really got into neurology, while I was working as a med student at Walter Reed and later on training there.

Dr. Nath:
Oh yeah, you're military. That's right. Yeah. You've seen this a few times.

Dr. Correa:
Yeah. I mean, it's crazy because even if you get an amputation, people forget and realize every part of your body has a representation in your brain.

Dr. Nath:
That's right.

Dr. Correa:
And all those nerves going down your arms and legs or other parts of your body have connections and send signals back to the brain.

Dr. Nath:
Absolutely. So the limb can be gone and physically not there, but the brain might not know that yet, and that can result in sensations or pain, or BJ Miller describes itching in the limb that isn't there, which is fascinating from a scientific point of view, but also can be a really huge issue for patients with missing limbs.

Dr. Correa:
Make sure to stay tuned after the bonus content for a replay of the full episode with BJ Miller that aired back in January. So now to BJ Miller in his own words talking about this.

Dr. Nath:
I have a total mechanical neurologist question for you. I'm just curious for our viewers, I can see BJ talking right now, and when you speak and you're gesturing with your hands and you have your right hand gesturing, and I see your left arm raise as well. I am totally curious, do you, in your mind's eye, have your left hand, which is not there also moving?

Dr. BJ Miller:
Not so much any more.

Dr. Nath:
Are you gesturing with that left hand that isn't there?

Dr. BJ Miller:
Well, I am, but it no longer really feels like a hand. It's been 32 years. Actually, my anniversary was two days ago, 32 years. So as happens, you probably know this from neurology, you know this idea of phantom pain and phantom sensations and feeling a limb that's no longer there. I still have some of that to some degree, but what happens is that hand telescopes in, it tends to come back towards the stump. And it's not this thing so far out anymore. So when I wave my arm around, it no longer registers. If I close my eyes, I'm waving a hand out there it just feels like my arm now. Yeah. The phantom sensation has evolved.

Dr. Nath:
Did that take a while to kind of come to be?

Dr. BJ Miller:
Yeah. Yeah.

Dr. Nath:
Initially would you have seen a left hand there in your mind's eye?

Dr. BJ Miller:
Yeah. Yeah. Essentially, yes. And I would've definitely... I used to have phantom pain much more, and I get it sometimes, these little zingers, but I used to have a much more phantom pain in the feet, and then the hand was a phantom... It was so annoying, it was an itch that I couldn't scratch. And it was like my hand, the feeling if I close my eyes, the feeling was like I had a hand, but it was like bound, it was wrapped up. I couldn't really expand the fingers and it felt like a bound hand that often itched.

Dr. Nath:
What sort of therapy did you do for that? Was it some sort of, and for our listeners, there's mirror box therapy where there's basically a mirror and you can use your good hand in the mirror to make it look like there's two hands, and then make that look like you're actually relaxing the other hand. Did any of that stuff help you?

Dr. BJ Miller:
Yeah, so I was a few years into my own physiological evolution on this stuff when someone, a student made me a mirror box. It was so lovely, I still have it. And so I was not in the hot throws of phantom pain at that point, but I played around with it and it was effective, but answer your question, in my case, it was really just time and patience and meds to some degree. But I can't even remember the effect on the phantom pain, it may have just dulled my reaction to it, but the biggest answer to your question was simply time. And I also think I had really good PT guys. I was really careful to try to use my left arm however I could to stay somewhat bilateral, and make sure to do bilateral activities. And I think that kind of orientation, that activity helped my nervous system reorient in a more functional way.

Dr. Nath:
Yeah. This is something `that may come up with our patients and that's why I'm talking about this next. So you have your right hand. I'm guessing you were right-handed to begin with and-

Dr. BJ Miller:
Thank the gods. Yes.

Dr. Nath:
So basically, it seems like it could be easy for you to get by with your right arm and not do much with your left at all. And I bring this up because this is something that comes up with patients. Do you have any advice about that? If someone has a dominant hand still intact and a non-dominant arm, which has been amputated, what do you do to use that left arm?

Dr. BJ Miller:
Yeah. Find ways to use it, either symbolically like I'm doing here, waving it around, just moving it.

Dr. Nath:
Gesture wildly. Okay.

Dr. BJ Miller:
Yeah. Gesture wildly. So that just movement, I think actually purposeful function probably recruits more of your nervous system in a healthy way. In my case, fortunately, they originally thought they were going to have to take the arm at the shoulder.

Dr. Nath:
Oh goodness.

Dr. BJ Miller:
I'm very lucky to have a longer stump. I have my elbow and maybe six inches below the elbow so I can really use that stump. And because it's such a nice short lever arm, it's actually pretty strong. So anything with a handle, I can carry something by just looping the handle around the stump.

Dr. Nath:
Oh, cool.

Dr. BJ Miller:
I'm definitely careful to do that.

Dr. Nath:
So you have to make a conscious effort to use it, right?

Dr. BJ Miller:
Yes.

Dr. Nath:
Okay. Okay.

Dr. BJ Miller:
Absolutely. In the early days, that meant wearing the prosthetic arm, and I did that. I never really liked it. I didn't use it much, but I forced myself to the encouragement of my physiatrist and the PT guys and all the OT guys, and I stopped wearing it after a few years. But those early days, I wore it even if I wasn't using it much, just to kind of get used to the idea of having a prosthetic arm and to attempt to use it. And I still use a prosthetic arm now to ride a bicycle and my motorcycle.

Dr. Nath:
Oh wow. You ride motorcycle.

Dr. BJ Miller:
Yeah. Love it, love it, love it.

Dr. Nath:
Is there a neurological condition you want to hear more about on the podcast? We want to hear from you. You can call in any time and record a question at (612) 928-6206.

Dr. Correa:
Welcome back to the Brain & Life podcast. To accompany the BJ Miller's story about his experience with phantom limb pain, there was one person that immediately came to our minds as the expert to talk to today. I'm truly honored to talk to one of my inspirations for entering medicine, award-winning author, neuroscientist, distinguished professor, Dr. Vilayanur Subramanian Ramachandran, or as many know him as V.S. Ramachandran. He's well known for his research and books on cognition, psychiatry, and behavioral neurology, including developing a treatment for phantom limb pain.
If you haven't already, I encourage our listeners to check out his books: Phantoms in the Brain, A Brief Tour of Human Consciousness, and The Telltale Brain just to name a few of them. Thank you, doctor, so much for joining us here today.

Dr. V.S. Ramachandran:
Thank you for inviting me. I'm pleased to be here.

Dr. Correa:
In one of our past episodes interviewing BJ Miller, he described an experience that he had with phantom limb pain and sometimes an injury may not be in the brain, but actually in our body and the disrupted connections lead to discomfort or other issues. You've explored this and the concept of phantom limb pain in your book, Phantoms in the Brain and in your work, and developed even theories and later therapies. So can you describe for us what is phantom limb pain?

Dr. V.S. Ramachandran:
Well, simple description is losing an arm from amputation so for example you have a car accident, the patient continues to vividly feel the presence of the missing arm. Sometimes the arm moves, sometimes we go and grab a phone and phone rings, pat his brother on the shoulder, pet dog. All of these are very real experiences for the patient. Now, he's not delusional, unlike a delusion where the illusion, which means he knows it's not real. There's no real hand there to pet the dog. But the illusion nonetheless is very compelling. We call that a phantom limb. And the long history of initially did not accept it by the medical establishment, considered weird.
In fact, a man who first described it, Silas Weir Mitchell, famous Philadelphia physician, was concerned about this, that people won't believe this even though he had hundreds of examples returning from war, having lost their arm, continuing to feel the presence of the missing arm. And then he called it phantom limb, coined the phrase, but he published it in a relatively obscure journal called Lippincott Journal under as pseudonym for fear of being ridiculed by his colleagues. Eventually people figured out it was him Silas. And you know about the mirror treatment. You want me to describe that?

Dr. Correa:
Yeah, so I'd like to go to that. So the patient that you worked with and how his therapy opened the door to relief for many others with phantom limb pain.

Dr. V.S. Ramachandran:
One guy who came, who had a phantom pain typical and fingers were clenching into the palm, phantom fingers into phantom palm, phantom nails because he could feel the nails on the palm. Imagine your fingernails poking into the palm. You don't literally feel it, you imagine it. But if the arm is removed, then the pain becomes almost literal 'cause ordinarily signals coming from your hand, in a normal person, you have a hand signaling, "No, you're not being hurt. Don't worry." The emitter doesn't take over completely, thank God. So imagination can partially substitute with reality. They help you remember going on, but you can't completely replace it. So when you have this hand going into a spasm, clenching spasm, the phantom hand going into the spasm, you have memories of real fingers going to real palm are revoked.
But in the case of phantom pain, there's no negating signal coming from the arm saying, "Don't worry, it's not real pain. Don't have to shout ah, it's just endure it, it'll go away." But in the case of phantom, there's no signal coming back to inhibit that imaginary pain. If anything it gets amplified. But how do you treat this pain? Phantom, the pain, how can he make him open his hand or move his hand again when many of these patients their hand is immobilized, they can't move. The phantom is immobilized already a paradox there. What do you mean phantom immobilize? Phoneone rings ordinarily you grab it and pick it up, but this patient says, "I can't do that. In fact, I can't move my hand at all. It's fixed like in a block of ice, fixed like a block of cement and I can't move it. I can't budge it." "Try hard." "I can... ah," and starts sweating. You can't move the phantom, it's extremely painful.
Now you say, okay, where does this happen? I looked at all the case sheets. The few patients I had were able to move their hand, right? Were able to move their phantom, have much less pain than the patient's arm was fixed. But maybe when the initial say this, when the arm was just paralyzed because of a brachial evulsion namely the nerves going from the arm, pardon from the spinal cord to the arm. Those nerves which allow me to do this, those nerves have been yanked off the spinal cord 'cause of motorcycle injury, the arm almost paralyzed, lying in a sling, a real arm, real sling, completely paralyzed, excruciatingly painful. What does he do? Nothing basically, but in a misguided the doctor cut the roots, and that didn't help much either. So then we said, "What's going on here? Maybe the patient had memory link between the very attempt to move the arm, the signals coming back saying, 'No, you can't move.'"
So when you initially had the brachial evulsion nerves yanked off the spinal cord arm was still there, but it was paralyzed. Every time the brain attempted to move, then say, "No, it can't move, move, no move, no move, no." This gets entrenched in the brain. Then what you do is you say, "What if I convey the visual illusion, the patient, the arm is obeying his command, moving again. How do you do that? He doesn't have an arm. How do you convey the illusion to a patient that does not have a functioning arm, he has a phantom, that his phantom is moving and not immobilized?" Well I do this in virtual reality. So I told one of my colleagues at Caltech, "When is this being developed?" They said, "Well, we can do that quite easily, but it's a little bit crummy. Certainly welcome to use it. You want to purchase one cost you half a million dollars."
Forget that. Then I hit on the idea of using a mirror. You just buy a mirror, and you put it on a table. Let's assume my left hand is paralyzed, I'm the patient, the amputated left arm is now a phantom. Right arm is in the right side of the mirror. You look inside, you see a reflection of the right arm in the mirror, superimposed optically on the felt location of the phantom. So it looks like the phantom is being resurrected and is moving in response of my command, move bilaterally, conduct an orchestra, stir a cup of tea, do something symmetrical. Then your command goes to the phantom, which has now been resurrected visually, and then you move both. It looks like the phantom is obeying your command for the first time in 10 years. This guy had lost his arm 10 years ago in a motorcycle accident. He had phantom arm for 10 years and in a misguided attempt to get rid of the pain.
So patient initially had motorcycle accident, nerves yanked off the spinal cord, so arm completely immobilized, painful. So a misguided attempt to get rid of the pain surgeon removed the arm. Then of course what happened was he had a phantom arm with phantom pain. So he didn't remove the pain at all. Very frustrated by this and he came to see me. We put a mirror in the middle and I said, "Put the normal hand on the right side, phantom on the left side of the mirror, move the normal hand, send commands to both hands." The left hand appears like it's resurrected and is moving in response in precisely with the command as wound a normal person. When he did that, to my amazement, and to his amazement "Oh my God, you're not going to believe this." I said "What?" "It's moving for the first time in 10 years. Moving again." "Close your eyes, try it again." "Oops. No it's not moving." "Open your eyes." "Oh my god, it's moving."
So this is really repeatable. Patient has learned an association between attempt to move, very attempt to move the hand and moving the hand. Now what you've done is you've been able to false visual feedback and this seems to animate the phantom and relieve the pain. So when I do a proper clinical trial, take this with you now for about a month or two weeks, and try doing the same experiment on yourself. If any change in pain call me immediately. But one week I phone him, "What's going on?" "Well, well I doctor, I know what you want. You want me to move your hand and it moves and I move my normal hand and it moves and it helps a little bit, but not much. I mean it doesn't go away." "Well c'est la vie keep trying." He told me after just one week and he said, "Dr. Ramachandran, you don't believe this." I said, "What?" "It's gone?" I said, "What's gone?" "The phantom, it's gone completely. I had it for 10 years. It's now gone completely." Then I said, "My God, being able to move his phantom limb, pain is relieved."

Dr. Correa:
Thank you so much Dr. Ramachandran for all of your writing and for everything that you've done to help all of us understand more about science, or maybe even just ask more questions.

Dr. V.S. Ramachandran:
Thank you.

Dr. Correa:
That was such a great discussion and interviews and I'm really glad we got to release that content to our community.

Dr. Nath:
Oh, thank you.

Dr. Correa:
But thank you so much, Audrey. You've been working with us for over 50 something episodes.

Dr. Nath:
It's been an absolute joy and thank you Daniel for helping create this into a bigger conversation with our community and with our patients and other physicians about not just the ins and outs of anatomy, but how neurology affects people's lives.

Dr. Correa:
And I'm looking forward to hearing your voice continue to work in advocacy for many communities, not just our patients in neurology.

Dr. Nath:
Thank you very much.

Dr. Correa:
Thank you, Audrey, for your time working with the Brain & Life podcast, and we really look forward to your continued pursuits. Now stay tuned for the re-release of our full episode with Dr. BJ Miller.

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. It's 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. And 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, it's the Chris that plays Thor and is on the cover of Brain & Life magazine this month. So exciting.

Dr. Correa:
So now we're delving into the Marvel Cinematic Universe and brain health. 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, then 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, and 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, is coauthor 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 prexistential care. He's here because BJ was a part of this awesome Disney Plus series, Limitless with Chris Hemsworth. I highly recommend this series. It's directed by Darren Aronofsky, with really cool imagery to show physiological processes like chronic stress and how memory works. And in this series, Chris explores facing his fears head on. And 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's a lovely intro. Thank you.

Dr. Nath:
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. And 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. So 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 they 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. And 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 38 year old hunk like Chris. How-

Dr. Nath:
Yes, I'm not that functional of person at all.

Dr. BJ Miller:
No. Look 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, Tom, Darren, so all other producers, a lot of folks involved in making that happen. The suit that you described comes out 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 so much here. I mean the subject matter is sort of life, and life's kind of huge and has a lot of things going on in it. So 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 if you're vulnerable, you're not strong. And I think a lot of us who have actually lived life in these bodies, one way or another, you come around and 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.
And 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, and answer your question, Audrey, I think those are sort of the big messages that we're really wanting to get across was to reconnect these circles. And so the effect might be that we don't have to be at odds with ourselves because our bodies "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. And 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 there's losses 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's 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 and 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 cell lives, whatever, what is 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'd start looking at these things and they're not this stark, harsh, concrete things that our constructs, our language pretend they are. And that's exciting to me, I love that. And 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. And 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. And 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 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 at the same point 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. So you can call that a gift, 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. And by recontextualizing palliative care outside of this medical model, it has meant that a lot of people come to us with all sorts of existential crises, little deaths of other kinds, deaths of identities, job change or relationship change. And 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, I would call you a client, not patient. If you were 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 suffering itself for us as providers, as well as us as patients. So we're trying to free ourselves as some of the 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 de-pathologies these things. And nothing has to be wrong, there's nothing pathological about you for coming to see us. So we're trying to free ourselves of all those structural impediments to good care, all the structural things that limit it to 15 minute encounter or force me to diagnose you before I treat you, or doesn't allow for your family members to come see me 'cause 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, and 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." So 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 or self realization, these are issues way bigger than any medical model or any one model. We still as 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. So 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. And I like maybe all other human beings, I mean, 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. Shit. Okay. And watching folks who were 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.
So I get these vicarious deathbed moments 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. So 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 how 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:
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. And 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 other. 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. And once you kind of get hip to this idea that, "Whoa, this stuff's precious, 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:
So I have a Twitter account that I rarely look at, but it's there. That's at BJ Miller MD. But the bigger place, please come find us at Mettle Health and 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 at 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 and 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 had such enjoy 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.
And 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. And 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. And to have a superhero dare to be seen as a real person. I'm sure that came as some risk to him in 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, and 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 and all of 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 any time 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 Lucier, 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:
Follow and subscribe wherever you get podcasts.

Dr. Correa:
We really appreciate it. If you could give us five stars and leave a review, this helps others-

Dr. Nath:
Thank you.

Dr. Correa:
... find the Brain & Life podcast. Thanks again. See you next week.

Special Bonus: Physician BJ Miller’s Recovery from Phantom Limb Pain

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