BJ Miller on Processing Our Regrets

0:02When you are pioneering anything or introducing new ideas to the culture, you get criticized. You do? Yeah. Did you hear about that? I didn't find the one. I found someone I respected and we made it the one. In a sort of longing kind of view of love, people understand each other as if by magic. Nothing in itself is addictive on the one hand. On the other hand, everything could be addictive if there's an emptiness in that person that needs to be filled. I now know that nobody changes until they change their energy. And when you change your energy, you change your life. I'm Gwyneth Paltrow. This is the Goop Podcast, bringing together thought leaders, culture changers, creatives, founders, and CEOs, scientists, doctors, healers, and seekers, here to start conversations, because simply asking questions and listening has the power to change the way we see the world.

0:58Here we go. This week, we're sharing a gem from the Goop Podcast archives,

1:07Today I'm sharing one of my favorite conversations from our wellness summit in Goop Health. It's with BJ Miller, the author of A Beginner's Guide to the End. BJ joined me on stage with his dog, Maisie. BJ is a doctor who specializes in hospice and palliative care. He has his own incredible personal story, which I'll let him tell you about. And he has so many wise insights about what it means to live a good life and die a good death. I love getting to talk to him about regret and ego and connection. I'm way more interested in the things that you can't control. That lights me up. That kind of puts us humans and that gets us creative, but it also kind of puts us in our place, keeps us in proportion to the world.

1:54Let's get to my conversation with BJ. Hi, good morning. Good morning. It's so great to have you here. Thanks for having us. This is Maisie, by the way. Good old Maisie. Hey. Hey, baby girl. Okay. So I know this is territory that's a bit well-worn, but I think part of the fascinating aspect of your concentration as a doctor really comes from where it seems from the outside. It stemmed from the accident you had while you were at Princeton. which puts you on a different trajectory. Is that right? Totally. So will you tell us a little bit about what happened? Yeah. It's coming up on the 30-year anniversary.

2:37It was November 27th. It's just after Thanksgiving holidays. We had just come back to school and we were just out having like a basic time. It wasn't a crazy wild night, but we were, a couple of my friends and I, we were walking to get a sandwich at the Wawa Market, which is sort of like a 7-Eleven-y kind of late night deli place. And there's a commuter train that sits right on campus. It was just parked. It was just sitting there. And we just climbed it like you'd climb a tree. But the wires run overhead. The train wasn't moving. But the wires were electrified. And I had a metal watch on. And so when I stood up, I got close enough to the power line and an arc to the watch.

3:16And that was it. So lost both legs below the elbow and one arm below the... I'm sorry, both legs. Yes, much far below the elbow. Legs below the knee and this arm below the elbow. Where are you going, girl? Maybe I was sensing, she was sensing I was vulnerable. Down you go, baby. And at the time, did you know that you wanted to go into medicine? No, no, medicine, down you go, sweetie. She wants on this couch. Come here. Come on. You want to come up here? Yeah, there she goes. There she goes. Oh, Gwyneth, I really like you a lot. Come here, mates. Come here. Down you go, baby.

4:03Sorry. So anyway, yes. So all that experience being a patient is what turned me on to medicine. I had not had any interest in medical, in medicine at all before that. I wasn't pre-med or all that stuff. I went back and did the pre-meds after college. And was there a particular moment or person or realization you had when you were getting well that triggered this career path? Yeah. I mean, there wasn't a thing or a moment. So I went back to college, and there's something about while I was in the hospital, there was something that was lighting up. I was heading for East Asian studies. but there was something about the experience of being a patient, losing limbs, trying to kind of refashion myself in some way that art lit up as the thing for me to study.

4:55It seemed more relevant, weird, not weirdly, just some more relevant that this was a creative act that I was going to put myself back together and that felt like a creative thing to do. So studying art kind of got me into it, like allowed me to play with this rather than sort of run away from it or be embarrassed by it. There was a funny moment actually in one of my first lectures, just sitting there, we were looking at old Greek statues and you just notice, you know, like a lot of old statues, they're missing parts, you know, they're just from the years, like an arms lopped off or whatever else.

5:28And here we are looking at these beautiful objects and admiring them and reading so many things into them. And no one was sitting there talking about, wouldn't that sculpture be great if it had both of its legs or whatever else. And it felt strangely really relevant to me. And then there was this time, and well, I'd go on too long about that. But the bottom line is there was this feeling like I was learning something that felt very important for me and that also felt very universal. And I couldn't help but think if I had a doctor who looked something like me, how different my experience could have been.

6:01In other words, someone who just shared their experience of being in the bed. And it felt like so much to leverage and so much to work through rather than overcome. Right. And I was curious when I was reading about you, if at that point you had to in some way dismantle your ego in order to re-envision yourself as, you know, different than how you imagined you would be in your life. And if that was the first step in this work around separating ego. Yeah. It was a huge piece of it. There was so much of the, you're right on. It was like a dismantling. Like my sense of self was dismantled. My body was dismantled.

6:50It would sort of take you down to the studs. And I certainly, you know, would never have chosen that. But like so many things that you can't choose, there's a lot of power in it. If it's bigger than you, it's a force bigger than you, and it makes you, you have to reorient to it. If I had had a choice, this would have been a very different experience, and I would have not learned nearly so much. But the fact that it was just a brutal fact helped me get over it and helped me work with it and helped me kind of see life as raw material again, and that I can rebuild and I can have a different sense of myself in the world in a way, I don't know if this is the wrong word, but a better sense of myself in the world.

7:33Less afraid because I had fallen and realized that falling wasn't so bad. And less afraid because I knew that there wasn't unlimited time in this world. And less afraid because I had come to, this is huge, I'd come to realize how much we need each other. Becoming dependent as a young man, fully dependent for everything from nurses and friends for a while, super humbling, but it really makes it very, very clear that autonomy and independence aren't real. Like there's no such thing as living in a vacuum. We really need each other. And that was a very beautiful, hard-earned lesson. So did you, it's interesting that you learned these lessons so young and you were able to take them with you into medical school.

8:21How do you think that shaped the way that you viewed medicine in comparison to some of your classmates? Yeah, I feel like such a, I feel bad for some of my classmates, especially the young docs who look super young and they're meant to sit and be with people through these very hard times and impart wisdom, but they look 12. I feel like, honestly, it's no joke. I don't mean to be Pollyannish. I really feel like this was an advantage. I mean, I think the smart thing was choosing a profession where this was relevant and even an advantage. So it wasn't something I could regret. And yeah, because a patient will take one look at my body and know, okay, you've been through something.

9:02You've been in the hospital bed. There's not so much distance between doctor up here and patient down here. It puts us side by side much, much more quickly. And so how did you choose to go into palliative care? Nice word with the word. I'm really trying guys. I can't say it three times in a row. It's a terrible word. I just really, we make it pretty challenging. But well, I was, I went into medicine thinking that I could use these experiences from sort of disability rights movement and advocacy, seeing disability as a civil right, that I wasn't less of a person because I had less body parts, fewer body parts, really I knew that in my bones and that was thanks to my mom and others in the sort of movement of disability rights so I knew this was something to work with not overcome and apologize for so in medicine I thought I'd go into rehab medicine work with other folks who had just become disabled or gone through some trauma but I fell out of love with that for a couple reasons and then sort of stumbled on on palliative care as an elective and it lit up you know like immediately, like that day, it was like, this is exactly what I was interested in.

10:09And I think it was because, you know, a lot of medicine's about preventing suffering or fixing you. I'm just much more interested in things that can't be fixed. I'm way more interested in the things that you can't control. That lights me up. That kind of puts us humans in, that gets us creative, but it also kind of puts us in our place, keeps us in proportion to the world. So anyway, here's this field that is all about dealing with things that you can't change, that you just have to work with, whether it's chronic illness or mortality. And that was thrilling. I love that it wasn't pure, hard medical science, because I'm not a pure, hard medical scientist.

10:47I love that the subject matter is totally universal, like everyone in the world suffers, everyone in the world dies, and for that to be the subject I get to work on, you know, that just makes you endlessly relevant. So all of those things I loved about it. And then lastly, I suppose it was the fact that it was underdeveloped. You know, the world needs more palliative care. And so it was fun to join something of a movement that way. Yeah. And it seems that culturally we don't have a way of dealing with death except to fear it and resist it. so first of all just on a more pragmatic level what is your approach when you are having that first conversation with somebody who knows that death is more concrete because I think for all of us now if we're healthy God willing it's something that's abstracted like we all know we're going to die but I don't think we really think about it that much yeah and I imagine that when somebody understands that this is imminent or much more finite.

11:56There's a big shift. So how do you begin the process? Because I know you're not one and done with people, right? You go through the journey with them. You point out something really important for everyone to understand. This is not like a transaction. It's not like the rest of medicine where you can kind of go and get a procedure and be something done with it. It is totally, it's a relationship and it has to happen over time. And sometimes you meet patients who are at the very end with hours or days to go, and that's sort of one approach. But usually I'll meet folks who are upstream a fair bit, and they may feel relatively well, but they've recently been introduced to the thing that one day will kill them.

12:37They may be years, but to your point, this abstraction that we all, okay, yeah, we die, becomes realer. And there's a process of it getting realer and realer and realer all the way to the end. And so you have to kind of stick with people over time. And I guess the major answer to your question, Gwyneth, is you don't talk, you don't go right to it. I mean, most of the first visit, unless someone's really an extremist and in agony or something like that, then I'm pulling out the prescription pad and working with medications and really talking folks through a traumatic moment. But otherwise, you're really just trying to get to know each other.

13:14So the first visit, we may just talk about their family or sports or anything that they love in life. Because if you can get into the what I love about life, then you can get to what I'm afraid to lose. And that's where all the action is. So that's how it starts. Okay. And is there, in the course of these conversations, do you act as a therapist in the way that you start to identify where those misgivings, misunderstandings, unspoken traumas are that you know inevitably if they're working with you and have the good fortune to have that sort of context of care that will start to emerge as they get closer to death?

14:01Yeah. It's amazing what, yes. I mean, it's amazing what happens. Maybe all of us know this. When you feel safe, you know you start revealing yourself and so really so much the job is making a safe little zone part of that's a physical thing but a lot of it is a sort of an attitude like i'm not going to judge you whatever got you here i'm just going to see you i'm not going to say good or bad whatever it is it just is and maybe you know that feeling of someone who's looking not strategically not to find a way to affect you, but just seeing you for anything you are. Like once you're in that zone, then guards go down, trust builds, and then one way or another people start revealing themselves.

14:47So it may be explicit where they'll say, gosh, this pain reminds me of a time when I was a kid and this and that happened and I've never gotten over it. I mean, sometimes it's that explicit, but very often you'll just pick up, just by being a sort of attentive human being, you'll pick up body language. You might broach a subject and watch their eyes start off. Or you might try to broach the subject of, you know, preparing for the end or how their kids are going to do with life without them. Or when subjects get harder and you can watch how they bounce off the subject, they may have it in them for a minute to talk about it, but then need to change a subject.

15:23And so as long as you have time, you're sitting there reading in real time, seeing how much can be taken now and how much needs to wait. And that's so much of the job is that sort of judgment and intuition of how much can someone take? Because in medicine, it's not uncommon that a lot of us would not even know that our diagnosis is terminal. A lot of people are walking around with terminal diagnoses that don't know that somehow. And you may say, oh, those darn doctors don't tell the truth. And sometimes that is true. Sometimes we smear it or we blur the edges and make it a little vaguer than it needs to be.

16:00We're afraid to take away hope or afraid to dash someone's feelings. It's not such a simple matter as just, did I, the doctor, convey the truth? First of all, we're not very good at prognosticating. We don't always know what the truth is. But the bigger question is, if the truth is meant to serve you, patient and family, it needs to be received in a way. And sometimes we can bludgeon each other with truth in the name of breaking through denial. The truth is denial is a very powerful and important force and needs to be used thoughtfully and needs to be dismantled thoughtfully. So all that is to say, it's not the simplest thing as just delivering the news.

16:44You have to meet it out in a certain way that it can be received. My job is not to tell you something. My job is to help you receive something. Do you believe that these diagnoses, especially if they're coming earlier in our lives than we would want, can serve an important spiritual purpose? Totally. Oh yeah. How many times have you seen like with specific patients that come in hardened to these ideas and then are able to soften? Most of the time, you know, if you have enough time with someone, because mother nature is going to take care that will, you will be broken down. You know, you are going to, your ego and your body, it's going to be, it's not a matter of if, it's when.

17:33So if you can hang in there with the patient if you have enough time you don't need to engineer that coming apart it will happen and you're and you you just get to be there for when it does and your job really is to inculcate trust in advance of that moment but one way or another whether you choose to lean into your vulnerabilities or you're just overwhelmed by forces of nature larger than yourself we you'll get there.

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19:08Is letting go of ego, is there a correlation between letting go of ego and fear of death? I think so. I mean, I'll just speak from what I've seen in my own experience. Yeah, there's proof of immortality all over the place. You just have to see beyond yourself. This thing is that we want to live forever, which most of us actually don't. Actually, I'd take a question. If you could hit a button and live forever, would you push the button? I love this question. I think most of us, we absorb this idea that death is all bad. And it is hard. I do not want to be Pollyannish. let's be clear, it is very difficult stuff.

19:56And at some point, it's even a relief. And when you watch folks over time, letting go of their ego, or maybe not even letting go of their ego, sort of blowing up and seeing themselves in everything. And you see that proof of yourself in everything. And so this body's going to go, but my effect on the world, the energy that I've consumed for a while will go back in the world. I don't see that as a spiritual belief. That's just a fact. You can empirically watch this play out. So to your point, Gwyneth, absolutely. Once you either let go of your ego or have such an expansive sense of your relationship between self and other, one way, if you get beyond the confines of this body, there's a lot of relief waiting for you.

20:45It's not so sad that this body is going to go. Life will go on. The real misnomer when we talk about the end of life. It's just the end of this life. And so how, one thing that I really wanted to understand from your point of view is regret and how people cope with regret when they're dying. You just said, you know, we're all contributing something to this world. And for those of us or ourselves or maybe our parents or people we know who feel that they have contributed to trauma or negativity. How do you help people address that? And can we make those energetic repairs? Yeah, that's a really great question.

21:34I mean, that's where so much of it comes down to. I see a lot of the sorrow at the end of life is this confrontation with regret. I mean the first thing that I think get across is regret like all this stuff is first of all let's like de-shame it it's just normal as a sentient conscious human being you have to make choices and when you go this way you can't go that way and sometimes it would have been better to go that way and you know there's just regret is just part of the deal so part of the work really is sort of taking the stigma off it just like so much this taking the stigma off of being sick, taking the stigma off a disability, whatever.

22:10And then you can settle into it a little different. So that's point the first. Regret is normal. You don't have to feel bad for feeling bad. You don't have to feel bad for having regrets. And this is one of the great impulses for, I'm so grateful for this conversation with you, is to get us thinking about death earlier in life. So it's not a surprise at the end to learn that we die, in part because, so we can prepare ourselves, yeah. But so much of it is because so we can gain these beautiful lessons in life that time is precious, that mistakes will happen, that ultimately you really can't fail.

22:46You're going to die either way. And it's to get that sort of sense of perspective earlier in life so that you can appreciate what you have while you have it. And appreciating what you have while you have it is probably the thing that will inoculate you against more regrets, against piling it on. So one thing is to sort of, it's almost like harm reduction, reduce regret. But the regrets that are real, when you finally sit and dare to look at them, very often it's not so hard. It may be a, I need to call you up and say, you know, Gwyneth, I'm so sorry about the dog on the couch. I feel horrible about it or whatever it is.

23:21Like just a simple, sorry, a simple, it goes so far. Just acknowledging what happened, you know? So yeah, things are repairable. Sometimes it's a simple I love you. Sometimes it's a simple thank you. You know, one of the things I love about this subject too is it gets us back to the fundamentals and the fundamentals really hold. I think for so many of us, we, if we're holding shame around something or holding a regret, we don't necessarily, it's not that comfortable to, you know, when we're healthy and we're busy and we're doing our thing to kind of pick up the phone. Yeah. But would you encourage that?

24:00Like, I, you know, it's like if we sit here, it's such a gift to think about, gosh, this is an opportunity to sort of take an inventory of your life and think about the things that you're still holding on to. Like, I've had probably six or seven things come up for me myself while I'm sitting here. And then when I think about going to repair them, I feel like heaps of shame coming on, even thinking about having to confront it. What are some of the ways we can identify what those things are and what are some tools that we can use? Well, you just named one. I mean, shame, guilt, that's sort of when you catch yourself defending, that's a little sign.

24:45Say, hey, there must be something here. So you can dog ear it for later and hope to get to it. Or you can deal with it now. There are only so many hours in the day. But I think the first point would be note when you're getting defensive. And that should be a sign that you're covering up something. And that deserves some attention. And maybe there's not enough time to get to all these regrets. Maybe there's not enough time to even acknowledge them in yourself. And that points us to sort of the next layer in all this, which is another muscle for us all to get better at, which you guys, I mean, I know is front and center for you.

25:21I mean, it's just compassion, just being kind, not just to others, but to yourself. Because again, you are going to fail. You are going to regret. That's normal. So yeah, learn a lesson where you can, but at the very end of the day, probably my favorite human capacity is forgiveness. You know, if you can just say, hey, I did what I could. I'm sorry I couldn't get to the rest. It's also an acknowledgement that I'm just one person. It puts me in proportion. There's only so much I can do. There's only so many hours. And at the end of the day, after all that trying, there's still going to be all sorts of things and we need to forgive in ourselves.

26:04And that's, for me, in any way, one of the sort of final layers to this is get really good at forgiveness. Especially to yourself. Including and especially to yourself. Yeah. Yes. Is that something, a trait that you see exhibited in people who are dying a more peaceful death? Yeah. Self-forgiveness? Yes. Yes. Less clinging, less clutching by the fingernails, less sense of unfinished business, more reconciliation, more humor, you know? Yeah, absolutely. This is sort of what you'll see if your goal is a peaceful death. But let's be clear, not everyone has that goal. Some people want to go down swinging.

26:44Some people want to be in the ICU with all the chemo hanging and whatever it may be. So I just want to be clear. That's okay, too. Each their own on this stuff. It's hard for me to judge how you're dying. But with that little caveat, yes. But you can observe that one seems more whole. Yes. Yes. But that's it. That's exactly it. It's like feeling whole. It's sort of like it's self-referential. It's consonant. If my identity is BJ the fighter, then for me to feel whole, I got to be fighting something. For me to be whole, ICU may be the right place for me. If I see myself as someone who enjoys peace and whatever, pick your word, let's just stick with peace.

27:26Well, then ICU probably wouldn't be the place for me to choose. And then, you know, maybe home is the way for me to be. and sort of, so anyway, I guess I didn't want to call out, there's no such thing as a good death in any objective terms as far as I can tell. Good death may simply be just being yourself, playing yourself all the way out, whatever it is you are. And you don't necessarily, enlightenment and other things may or may not come. But if you play yourself out, all your last little cells, however you are, whoever you are, to me, that's about as good as it gets. And that doesn't have to look any one way.