A Heart Doctor on What Really Happens During a Heart Attack and How to Talk About Death

Vance Crowe [00:00:00] This is is The Man's Crow podcast. What is up guys? Welcome back to the podcast. Today's guest is a man named Dr. Alan s Sofer. Dr. Ser is a cardiologist here in the city of St. Louis, and he's been in the field for more than 30 years now. What you'll find out very quickly is that Dr. Ser is really soft spoken and introspective. The thoughts that he has about his career and what it's been like to work in the medical field for more than 30 years are really quite profound. And I'm glad that he was willing to come and sit down and talk with me because Alan's actually a really quiet guy. This interview, I got to ask really deeply probing questions, and when I go back and look at the interview, I wonder, man, did I make him uncomfortable by asking him that? But I saw this as a rare opportunity to be able to ask someone questions that most of us never get close enough to anyone to be able to ask, including if you're a heart doctor, the very thing that symbolizes life, and you're sitting across from patients that are now learning that they may not have much time left to live. How do you respond to that? How do you react? How do you behave to help them come to terms with the future? That doesn't seem like it's going to go on much longer. This was a really interesting interview, and at times I kind of felt like I wish I had better interviewing skills to be able to draw more out of Alan.

Vance Crowe [00:01:33] But what you'll hear in this interview are some really deep thoughts about what is it like to go from being a person training to be a doctor, to actually becoming one. What is the medical field learned about what actually causes heart attacks and what are the things that cause people to die from cardiovascular disease? There's a lot of stuff that I learned during this interview and I find it to be really interesting to go back and listen to. So I hope you enjoy it as much as I did. I was greatly honored that Dr. Ser came by, and I think it'll be time well used for you. So enjoy. I'm sitting here with Alan Ser, who is a cardiologist. Your family is deeply into philanthropy here in St. Louis, and you and I have become friends over the last, I think year and a half, two years. That's right. And so welcome. Thank you for stopping by. Thank you. Well, thanks for being here. So I spent quite a bit of time thinking about this conversation well in advance of inviting you to be on the podcast. And then when I was making the, the ask the invitation about what we would talk about, and I've actually stressed about this quite a bit because from our interactions, I know you were very introspective, pretty quiet if not shy kind of person. And so I was thinking, what are the questions you could ask? And it dawned on me, I don't think I've ever actually spoken with a cardiologist before. I, I, I know what I've seen on TV and I know that a cardiologist works with the heart, but I don't have any idea what that means.

Vance Crowe [00:03:08] So I guess maybe the very first place to start is what is something about the heart that you think people should know this, but they don't?

Allen Soffer MD [00:03:20] Well, that's an interesting question as far as what people should know about the heart is that most of us die of heart disease. So that's probably to, to begin with, not, not what we want to hear, but probably the most important thing, at least in western society, is people die of cardiovascular disease and stroke. So by definition, one of us is gonna die of that on, on average.

Vance Crowe [00:03:45] By definition you mean the 50 of percent between us. Oh, really?

Allen Soffer MD [00:03:47] Yeah, over a little over 50% die of cardiovascular disease. So we hear a lot about lung cancer and breast cancer and, and, and infectious disease, but over half of us die of, of heart disease or stroke women, men, just how it is.

Vance Crowe [00:04:02] And when you say heart disease, is that encompassing? I I'm you're not saying when you're sitting down with the patient, you're not like, oh, you have heart disease. You're much more specific. Right. And you're saying heart disease encompasses a whole variety.

Allen Soffer MD [00:04:14] That is correct. When we talk about people dying of heart disease, we generally talk about people who have blockage related issues, heart attack related issues, things that lead to heart damage and, and make the heart more vulnerable to, to illness and, and, and, and eventually to death. That being said, heart, the, the, the field of cardiology has been very progressive over the last 20 to 30 years. And mortality rates are, are decreasing because of medications, because of technology, because of lifestyle changes. Outlook for patients with cardiovascular disease is much better than it used to be. That doesn't mean we still don't die of it eventually, but people are living to be older, much older with heart disease from, from diagnosis till till death from heart disease or something else. And, and people's quality of life because of technology and lifestyle changes has, has really improved as well.

Vance Crowe [00:05:16] And when you, so,

Allen Soffer MD [00:05:17] So it's an optimistic outlook. Absolutely.

Vance Crowe [00:05:19] When you started in cardiology, was it killing 50% of everybody or is this a, a problem that came up and now is regressing?

Allen Soffer MD [00:05:28] Well, it would in western society it's been doing that. So if so, so it has been doing that. When I started out in cardiology, which is about 30 years ago now, is when I, when I first started in practice following training.

Vance Crowe [00:05:41] So, you know, I, I have, I know people that are into the medical field and they have some level of caring that's just intrinsic in them. And I care for my family and for my close friends, but I have virtually no interest in having the intimate level of knowledge about another person and what makes them tick and or doesn't or what they're sick or, or if they're in pain. So when I hear that somebody not only went through medical school, but then spent the next 30 years of their career doing this, I, I have to wonder, did you know the requirement of how much you were going to have to care for other people or at least understand their pain before you went into this? And did that influence your decision as to become a cardiologist?

Allen Soffer MD [00:06:30] No, I didn't. No, I don't think I did. I, I don't think I did. In fact, I was, you know, I was, I was pretty much brought up by you're, you're probably gonna be a physician when you grow up. Which it was, it was almost an, it wasn't almost, it was an expectation from my father who, who, you know, is my role model and who I respect more than anybody, but, but that's really it. It was an expectation. And so I naively followed it along and he, he clearly saw something in me that I didn't see in me. But, but, but it's difficult to, to predict what, what that is going to entail and as it is with anything that you devote your life to, not, not just this profession, but any profession. It's, it's hard to know exactly what it's going to be until you're, until you're faced with it. And it is, it, it can be all encompassing. No, no question about it. And, and it's interesting because I've, two, two of my four children are, are going into medicine. One is in a,

Vance Crowe [00:07:33] I didn't realize that.

Allen Soffer MD [00:07:34] Yeah. One, one finished medical school a year ago. So she's in her first year of residency in pediatrics and another just started medical school, another daughter, this is her first year of medical school. And so I'm, I'm looking at it at from a different perspective, from their perspective now and, and, and looking back on what I knew or or didn't know then, and, and it's, it's fascinating.

Vance Crowe [00:07:55] As somebody that now has wisdom of hindsight, is there anything you can tell your daughters that will prepare them for the adventure that they're going to go on? Because they don't know, right? They're in, they're in their books or maybe they've had a few experiences with patients, but is there anything you can say ahead of time to let them know what's about to happen?

Allen Soffer MD [00:08:15] Well, I, I, I look back at, at my training and, and, and things that I listened to or didn't listen to from, from mentors. I remember when I was chief resident listening to Steve Rack at Washington University, who, who was head of our head of the training program that I was part of a, a wise man, love, lovely, compassionate man, but brusque at times. So I I, he was talking to the incoming interns. So these are, these are people who just graduated from medical school and now they're starting their internship in this case, in, in internal medicine prior to going on and, and being, becoming internist or primary care physicians or specializing in, in, in branches of internal medicine. And so that was the beginning of a three year program. And then specially training after that, after these people have already graduated from a four year medical school and after they've gone to a four year college and, and, and are just coming in with

Vance Crowe [00:09:13] An unimaginable amount of education,

Allen Soffer MD [00:09:15] Right? But, but also completely naive about what's in front of them and scared and anxious about what they're, what, you know, this is the first time they're gonna be in charge of, of patients and, and, and you know, more, much more than a medical student and first time they're facing the responsibility of, of, of dealing with a patient, patient's needs and, and, and physical needs and, and sometimes making life and death decisions and such. And so what he said to them was, was, you, you guys are the cream of the crop. You know, you have always, you know, from grade school on, you have made straight a's you've, you've always been considered the, the most brilliant of your class. Everybody knew you know who you were. And, and in order to get here, you've done great in high school. You've gotten to a, to gotten into a college where you have excelled. You've gotten to the top of the top in grades. You've gotten to the top of the top in, in, in the testing that has been required, that MCAT testing and and such to get into medical school. You've graduated from medical school at the top of your class and how you are in a, in a entry in a residency program where, where, where you will are expected to excel and all of a sudden we're gonna stop grading you, you know, we're done with that.

Vance Crowe [00:10:47] Oh, we're going to stop grading you.

Allen Soffer MD [00:10:49] That's right. Everybody's, you've been graded your whole life and you've been always at the top and everyone's always said, oh, you're great, you're great. And you go, yeah, yeah, that's how it is. And, but, but that stops now. Nobody really cares about that anymore. What do you, what do you care about? You care about taking, you're gonna be care. You care about being right, about taking care of people, making the right decisions for them. Grades don't matter anymore. They don't, they don't even exist. And whereas up until now, you've been, you've, you've been told you, you, you've been def defined as having excelled

Vance Crowe [00:11:29] All the time. Yeah. There's a top, there's, there's a, there's a leaderboard, there's a, there's a thing that you can measure

Allen Soffer MD [00:11:33] And you have positive reinforcement on that all the time that stops right now. And you have to start getting your satisfaction not from other people telling you how you're doing. 'cause that's gonna stop now. You have to get it from doing the right thing and by making, by, by understanding your patients, by doing what you're supposed to do as far as perceiving what they're telling you by doing the proper examinations and, and ordering the right tests and analyzing them. But the biggest thing is that you have to be, you have to understand that you're not being graded anymore. You're gonna be, you're gonna have to have, have your satisfaction come from, from doing the right thing. And, and that's all there is right now. And, and some people can't handle that. Some people need that constant reinforcement of saying, oh, you did great. You're the best and such, that stops now. And you have to do the, you have to get that satisfaction now from, from not just being correct, but by knowing that you've done whatever you can to help that person. What

Vance Crowe [00:12:45] Do you suppose happens to a person? I mean, you, you were in that place of excelling, and if they, if if they were not prepared for that statement and walked past it, you know, then you get into the real world and you're not being graded in the same way. What, what happens psychologically

Allen Soffer MD [00:13:00] To personally? Well, I, well, I, I think it's a change and, and some people can handle it well, and, and, and some people can't. It's, you know, it, I guess it has to do with security and maturity and, and, and, and a lot of things. But I, I think the important part is that you, you have to learn what's important. And, and yes, it was important to excel in order to get to this place, but now that you're at this place, what's important is the outcome and the process that get into that outcome as far as taking care of people.

Vance Crowe [00:13:35] You know, you're describing the concept of transcendence, right? If you reach a level, and then if you wanna go to some other level, now the rules that got you to this first plateau, they don't, they don't apply or they don't apply in the same way. And it, I've been actually thinking a lot about this, this concept of, of transcendence lately. And, and that in order to grow the things that you defined being successful by always have to change, right? U unless you're, you're striving for, you know, one ultimate goal. But, but I think in order to reach one ultimate goal, you have to have a series of, of small goals. As a doctor, you're getting better at caring for patients, right? You start this process of transcendence from excelling at the top of your medical school, and now you've gotta care for people. What are the ways that they can mark, I'm progressing forward, I'm becoming a better doctor, because the challenge of I'm becoming a better doctor means you have to look at the times when you were not that good of a doctor or you, or you fell down or you failed in some way. That seems like a very difficult thing to stare down.

Allen Soffer MD [00:14:46] Well, I, I think there's introspection in any, in any growth, and I think it's a, it's as simple as that is you have, you know, you can, you have to reflect on your mistakes, you have to reflect on your successes. And there's, I think that's, that's part of, part of growth, whether it's personal growth or professional growth.

Vance Crowe [00:15:07] Do you, when you're 30 years into a medical career, are you still looking back and being like, man, I'm a lot better than I was last year. I mean, or how, how do you, how do you do that when you're, you know, clearly have wisdom and experience, and how do you keep measuring it now?

Allen Soffer MD [00:15:24] Well, I I I, I think you, part of the process is, is you're always measuring it within yourself. You know, part of the medical profession has to do with peer review, whether that's with yourself or formally reading medical journals and, and, and growing professionally in that way. And, and you look back on things that you used to do that used to be the state of the art. And you know what, no longer, they're no longer the state of the art. And in retrospect, we were, we weren't doing things properly then. And so clearly we're doing things now every day that is considered proper in the medical profession, but five years from now it won't be. And so you have to take that into account and be humbled by that.

Vance Crowe [00:16:04] What, what, what is something that when you look back over the last 30 years that you thought you knew about the way the heart works or the way that you should treat hearts, that is very, very different. Now, nobody would fault you for what it was, but now we think very differently about it. Well,

Allen Soffer MD [00:16:19] We, we didn't really know the etiology of heart attack and heart damage and life threatening rhythm problems,

Vance Crowe [00:16:25] Etiology

Allen Soffer MD [00:16:26] The cause causes, we didn't really know the causes of heart attacks per se. You know, we thought that people would get a, everybody has three major arteries within their, within their heart. And those arteries supply blood to the heart muscle. And one of those arteries is typically more important than the other two. But, but each of the three are important. And, and any of the three can can get blockage formation, plaque formation, which if, if become significant enough, can impede blood flow and then cause a heart attack. And we used to think when I was just starting medical school, that that blockages would come from risk factors from heart disease, from people who smoke or have diabetes or high blood pressure, or don't exercise and the like, have a family history of heart disease, a lot of other things. And we used to think that people would get a blockage and okay, they have a, they've developed a 40% blockage over the years because of their lifestyle and such, or, and living in western society and such. And then they get a 50 and a 60, and then it progresses to an 80 and then a 90, and then a 95 and then a 99, and then eventually it blocks up completely and we have a heart attack. That's what we used to think. Whereas that's

Vance Crowe [00:17:37] What I think right now. Exactly.

Allen Soffer MD [00:17:38] Well, and, and it makes perfect sense. But, but we, we don't do things based on perfect sense. We do things based on, on what we have found really happens scientifically.

Vance Crowe [00:17:47] Okay, now I'm dying to know, so what is it? And

Allen Soffer MD [00:17:49] So there should, there's evidence-based medicine, it and physicians researching physicians, Eugene Brunwald and some other just greats of cardiology realize that when, that the really, the cause of a heart attack that is the cause of blockage of a heart artery leading to lack of oxygenation of, of the heart is really caused by typically occurs on 40, 50, 60% blockages where that blockage for reasons that are still unclear, a little bit of, you know, a medium sized blockage will crack in that crack inside that artery will release substances that attract other substances to the blockage. And it attracts cholesterol deposits, it attracts little blood clot forming agents. And then all of a sudden that 40 or 50% blockage that is just cracked and release substances will form a blood clot. And so you go from 40 to 50 to a hundred percent just like that,

Vance Crowe [00:18:52] That would be a pretty big game changer.

Allen Soffer MD [00:18:53] And that's what a heart attack is.

Vance Crowe [00:18:55] Wow.

Allen Soffer MD [00:18:56] And that's, and that's, and, and that's what happens. And so treatments were developed aimed at first of all, getting rid of that blood clot that forms so that if somebody comes in at hour zero with a heart attack, then it was, it was figured out that that time means heart muscle. So if you can get that, if you can get rid of that blood clot and reestablished blood flow within a matter of minutes, or actually within an hour, hour and a half or so, then you're gonna have less heart damage than, than if you aren't, are able to open up that artery. And so treatments were devised, aimed at initially dripping blood clot dissolving medication directly into that artery right above the blood clot. So people would put a catheter, a thin tube in the leg artery, which leads up to the aorta, which leads, which is leads up to where these three heart arteries come out and drip blood clot dissolving medication, just drip, drip, drip. And all of a sudden the blood clot would go blo and disappear. It would, it would have dissolved and flow is reestablished.

Vance Crowe [00:20:10] Okay. Sounds like problem solved then.

Allen Soffer MD [00:20:12] Well, problem, acute problem improved upon. Okay.

Vance Crowe [00:20:17] Which is important.

Allen Soffer MD [00:20:19] And, and, and that led to improved, improved survival of patients and improved quality of life because of decreased heart damage. So that, that was fascinating. So that was, you know, just what didn't exist when I was first training. But as I was training that that type of treatment began to be developed. And then the next part of the treatment was to learn that catheters, after you get that blood clot open, you could put a thin wire across that in now incomplete blockage and put a balloon across that wire below a deflated balloon, and then open up the balloon and push that blockage away from the middle of the artery to the sides of the artery and reestablish better flow. And then from there we learned to add stenting, little, little metallic cylindrical stents that would come in through the catheter as well, lay across the artery and then be expanded. And by that, trying to keep with the goal of keeping that artery open at that point. So all those were new things that really changed the, the face of cardiology as well. We also used to think that kind of a, a, a similar but related tangent, we used to think that when people die, suddenly they died of heart attacks, which would make sense. And in, and indeed, you know, we used to think that okay, they had a heart attack and from decreased blood flow and, and they died from that people who die suddenly out in, out in, you know, on the street are in bed and and such.

Allen Soffer MD [00:21:58] But we've now realized that most of those people, and it this happens about 500,000 times a year in the United States, 400, 500,000 times a year where people will die suddenly of heart disease, often unrecognized, and often as the initial presentation of heart disease. You know, everybody unfortunately knows of people who died in their forties or fifties suddenly. And, you know, they just didn't wake up. And, and, and the vast majority of people, those people who die, suddenly die from unex, from unexpected heart disease. But they don't die from a heart attack. They die from, from the, the result of having a certain amount of blockage within arteries, which then makes the heart electrical system unstable. And people will have a life-threatening heart rhythm problem and die suddenly from that. So, so they actually haven't had heart damage or heart death or heart attack per se, but they've died because from a, from a life-threatening electoral accident, if you will,

Vance Crowe [00:23:00] Oh my God, I've never even heard of this

Allen Soffer MD [00:23:02] Because of that. Well, that's called sudden death. And sudden cardiac death is usually from a life-threatening rhythm problem in, in the setting of underlying severe, often unrealized blockage

Vance Crowe [00:23:17] That, so as I'm thinking about this, what I'm imagining is it's one thing to be like, okay, my, I I'm gonna go in and do people do checkups where they say, can you check out how much blockage I have in my heart?

Allen Soffer MD [00:23:30] They do. They do. And we're probably not doing it enough. And, you know, cardiologists spend all day talking to people with heart problems and pro and and it's improving now, but now our now preventive imaging is, is available and such. And so we probably don't spend as much time as we should in people coming to us who don't have heart disease, who, who should be looked at to see whether they could be developing heart disease again, while knowing 50% of us are gonna die of cardiovascular disease. And many of people of those people don't know that they have heart disease brewing.

Vance Crowe [00:24:09] So the question that seems obvious to me about one of the things I wanted to talk with you about, but I I think it's actually a relatively personal question, is as a doctor and that's looking at people's heart, knowing that, hey, this is the 50% killer, I'm, I'm going to be working with people that, that largely, a lot of them are going to die somewhat soon. They've come in with a problem. You are one of the very few people in the world that knows something deeply about another person that they don't know yet. You are, you know, you get test results, you read them, you can interpret them on a very deep level, and you have to walk into a room and communicate their odds of survival or almost like a report card on how did you do over your factors you could control and over factors you couldn't control like genetics. Sure.

Allen Soffer MD [00:25:04] And

Vance Crowe [00:25:05] Now I'm about to tell you, you know, where we're going from here, what, what, what your diagnosis is. What, help me understand that experience from the doctor's side.

Allen Soffer MD [00:25:18] Well, well, well, fortunately there's lots we can do. And so, so I think it's different than, than if we had had this information available to us 30 years ago, but not have the, the resources to do something about it. You know, again, it's, I think it's a very optimistic outlook for, for most of our patients. 'cause we can make them, we have the technology to make them feel better with medications. We have the, the educational information to help them decrease their risk of heart disease progression by, by teaching them what they should be doing and what they can be doing for themselves. And, and we have the technology to, to prolong their life by, by life saving and life prolonging procedures. So, so it's, it's not just like walking into a room and saying, you know, okay, you've got, you've got 10 days to live. You know, it's not like that.

Vance Crowe [00:26:13] Okay. That's exactly what I was, that's what I imagined. That's what I thought that it was.

Allen Soffer MD [00:26:17] Well, it certainly doesn't mean that there aren't people that, that have end stage heart disease that, that you have not much to offer them from a life extending point of view. But even for those people, you have something to offer them as far as philosophically helping them deal with, with what they have in front of them. I think that's certainly part of a physician's job is, is, you know, probably sequentially to help them ex help them understand what they have to, to the best of our knowledge to help them, to help them understand what they can do about it and, and such and how they can improve their, their out, their potential outcome. How, how they can, how they can improve their survival and improve their quality of life and such. And, and when you get to the point where that's no longer possible than helping them deal with, with what is ahead, with their, with their impending death and such, not that that's always predictable. Sometimes it's very predictable and very precise, but, but often it isn't. We're much better at dealing as doctors at predicting as a group how, how people will do than than how an individual will do if you have, you know, we know how a thousand people are gonna do, who have poor, who have a heart that's who have hearts that are working a third of that, of a normal individual.

Allen Soffer MD [00:27:49] But we don't, don't know how that one individual within that thousand is going to do. And yeah,

Vance Crowe [00:27:54] Therein lies the problem of statistics. I can tell you, you know?

Allen Soffer MD [00:27:57] Absolutely.

Vance Crowe [00:27:57] And, and everyone that's sitting there is hoping I'm the one in a thousand that this is no big deal.

Allen Soffer MD [00:28:03] Sure.

Vance Crowe [00:28:04] But you just never know. And it is, that's right. Sticking your hand in a, in a bag of marbles. So you mentioned using some philosophy about life and death and helping your patient through that when they're in end stage heart disease, which means you must have thought quite a bit about something that most people spend a lot of time trying to avoid thinking about, which is death. And I, I'm, I'm curious as to somebody that faces this, that has patients, many, many patients certainly that have survived longer than they thought, but then also patients that have passed away. What are your thoughts on, on, on death? I mean, you're around it quite a bit. You must have an interesting, well,

Allen Soffer MD [00:28:48] Well certainly from a patient perspective, I think my thoughts of death are irrelevant. And I think that's, and I'll be glad to talk to you about this, but I, I think it's much more important to help somebody else deal with their concerns already.

Vance Crowe [00:29:03] Well, so I'm, I'm interested in hearing about both of these. The first one being interesting because you, now, what do you mean when you say I have to work through their thoughts on death?

Allen Soffer MD [00:29:14] Well, my job isn't to communicate my feelings, it's to help them deal with their feelings as far as, as far as that goes. And, and, and it may be that, that they don't want to deal with, with any of this, which is fine, but I'm here for them or, or I hope to be there for them. If, if that's something that they want to pursue on a more, on a more individual basis or philosophical basis.

Vance Crowe [00:29:42] Do you feel like you have a fairly solid sense of how someone is going to react to the, the, the information that that death is not necessarily imminent, but, but strongly there now that they, that it, that what they could have pushed off into the future saying, oh, that's something you deal with when you're old now, is something that's become present. Are you a fairly good predictor at how people are gonna react to this?

Allen Soffer MD [00:30:10] You know, I'm, I'm, that's a tough question. I'm, I'm, I think it, again, it's an individual thing. So I, I guess the answer is, it, it varies again, from person to person. And sometimes you, you are, and sometimes you're not. But, but that's okay because your, your job isn't to to be right in that sense of the word. Your, your job is to be available to them.

Vance Crowe [00:30:33] Oh, there you go. That's right.

Allen Soffer MD [00:30:35] In a way that, that hopefully is helpful to them or, or to not be available if that's how they wanna deal with this.

Vance Crowe [00:30:42] Yeah. Your prediction model is not all together that important other than to prepare you for no matter what you have to react. So it doesn't really matter.

Allen Soffer MD [00:30:49] That's correct. I agree. Okay.

Vance Crowe [00:30:51] Absolutely. And so, you know what, this is probably the most personal question you could ask anyone, let alone to be recorded while asking it. What are some of your thoughts on, on, on death? How, how, what can people learn from a person that is studying the very organ that we think of as the core of life? The heart. What do you think is important for people to recognize or think about with regards to their impending death that's going to come someday?

Allen Soffer MD [00:31:21] Well, I, I, I think I'd probably turn it on you. And I think that the, that thinking about life is much more important.

Vance Crowe [00:31:27] Okay.

Allen Soffer MD [00:31:29] Because the rest is, is the rest. And who knows where we go from here, you know, I personally think we probably just stop. But, but that's irrelevant. Again, I think it's much more important how we live than how we prepare to die.

Vance Crowe [00:31:45] Very interesting. And you know, right now I don't actually have a fear of death, but when I, that, that may be in large part because I don't really let myself get to a position to think about it. I had a friend I was talking to the other day, and we were talking about the practice of meditation and, you know, we've both been experimenting with this. He's had a lot more experience. And he said, well, in the practice that you're using right now, have they, have they gone through any meditations on death? And I was instantly like, I don't know. And if they did, why, why, why would I, that would be the last thing. Like, I'm trying to go in the other direction.

Allen Soffer MD [00:32:25] And,

Vance Crowe [00:32:25] But he was keenly interested in this and he said he wanted somebody to help him think about these things. And, and really at its core, he was saying, 'cause I want it to help inform how I live my life. And Okay,

Allen Soffer MD [00:32:38] That's fair.

Vance Crowe [00:32:39] It, it sounds somewhat like that. Like, I, I don't, you know, if I grasp an image of death, it seems so foreign to me as to be something that happens to other people as opposed to something that could happen to me.

Allen Soffer MD [00:32:50] Sure, sure. And that, and that's fair. And I, I think most people are like that. I, I, I often ask my elderly patients the upper eighties, mid nineties, you know, did you ever think you were going to, you were gonna be, you were gonna live to be 88, did you ever think you were gonna live to be 94? And I have almost never had an answer of, yes, I was prepared for this. Oh, it's fascinating. None, none of us really envision ourselves to grow old or to be old, but we certainly can't envision ourselves dying either. It's just a That

Vance Crowe [00:33:31] Is very interesting. It's crazy. Do, do you now looking at how, how old are you?

Allen Soffer MD [00:33:36] 61.

Vance Crowe [00:33:37] So did did you have a model of, of the person you would be at 61 when you were 31?

Allen Soffer MD [00:33:44] You know, I, I probably did.

Vance Crowe [00:33:46] Interesting. So say more about that.

Allen Soffer MD [00:33:48] I probably did, you know, I was, you know, I knew I was on the medical track, which means in this case I knew that as per what I wanted to do professionally. And, and I've, and I've pretty much followed that, you know, once I decided that I wanted to specialize in medicine and then cardiology and such and have a practice and see patients all, all day. I mean, that's really what I wanted to do. And that's, that's what I've done from a more personal life. I, you know, have the, the honor of meeting the love of my life in, in high school. And, and

Vance Crowe [00:34:21] I didn't realize you guys have been together since high school.

Allen Soffer MD [00:34:23] Oh yeah. She was 15. Mary Beth was, and, and I was just about turning 17 when we met. So I was two grades above her in high school. And, you know, we've had an amazing life together with four great children. And, and there you go.

Vance Crowe [00:34:41] So it, it's the process of even thinking about me being, so I'm 37

Allen Soffer MD [00:34:47] And

Vance Crowe [00:34:47] At 21 to think about 37, that would be like an ancient person. I think it does become easier once you get into a seam of life and you start saying, I now know at least what my skillset is and the, and the route that I want to go. So it becomes easier to, to picture.

Allen Soffer MD [00:35:07] Well it does, but then all of a sudden you wake up and you're 61 or 81 and that's gonna happen tomorrow. That's just, that's just how it works. And that's how people describe it. And, and just like, you know, you remember what you used to think 37 was? Yeah.

Vance Crowe [00:35:22] Are you

Allen Soffer MD [00:35:23] Kidding how old that was when you were eight and you were looking at your uncles or your, or your, or your parents or something, how old that was and just how it goes. Click, click, click.

Vance Crowe [00:35:35] Do you mark time in some way? Do you write in a journal or keep, you know, copious notes or do not save all your calendars?

Allen Soffer MD [00:35:43] I, I do not.

Vance Crowe [00:35:45] So I wonder because, you know, so you and I have spent quite a bit of time together in just weird hours, and I know at all times the phone can ring in your pocket and you, you can be talking about someone that clearly that they don't call you for fun. Right. They're calling you because something,

Allen Soffer MD [00:36:03] Something's

Vance Crowe [00:36:04] Going on. They

Allen Soffer MD [00:36:04] A concern.

Vance Crowe [00:36:05] And that's always led me to wonder, because that has to be, I don't know if it's adrenaline for you at this point, but there's gotta be some signal that goes off in your brain, Hey, this is an important moment. If, if, if that would be a thing that would mark time in, in, in your life, right? Because I can look back, the, the moments that I remember the most clearly in my life are the ones when it was something important is happening, you've gotta pay attention. And it seems like when that phone goes off, something as important is happening and you've gotta pay attention. Does that mark time for you? Can you does that?

Allen Soffer MD [00:36:38] I've never really looked at it that way. So I'm, I'm not I'm not quite following you.

Vance Crowe [00:36:43] So I, I guess we'll go in a different direction.

Allen Soffer MD [00:36:49] Okay.

Vance Crowe [00:36:51] So, so the, the reason I was asking is about the, the, if you, if you write in a journal is because I have come to the experience that I don't actually, I, I write down every day I try and write it, I treat it like, like I'm making my bed and I don't have to write anything profound. I just have to sit down with a pen in my hand and write one sentence down.

Allen Soffer MD [00:37:15] And

Vance Crowe [00:37:16] From there, whatever happens, happens. But I have trouble going back and looking at it. I, you know, I don't really want to know what I was thinking. And that's gotten me thinking about, well then why do you do it? Right? What what's the point of that? And one of the things that I have noticed, if I have, you know, peaked back at the stuff, it is that, that sentence is usually whatever is the peak moment going on in my life, that is the first thing on my mind when I wake up, or the first thing that I can force myself to that, that my monkey brain throws up and says, write this one sentence down. And I realize that a lot of that has to do with, there's some explosion going on in my life that I have to deal with. And your life is filled with these tiny explosions, which are, are this is the most important thing going on. Someone somewhere in the world has a question that it is very important that Alan ser pick up the phone and answer that question. And I wondered what that did to your perspective on Well,

Allen Soffer MD [00:38:20] Well, I, I think I, you I do think about that or I have thought about that and, and certainly, you know, some of these are in the, in retrospect or could, could be trivial encounters, but they may not necessarily be trivial encounters at the time, which means that, that you, you, you as a physician, you, you hopefully will learn that, that when you're talking to the patient, then, whether it's in the office or on the phone, that that has to be the only thing that's going on in the world. Right? Right. Then absolutely, you have to have, you know, your, that's the only thing that's important. And, and then it should be like that with, with many relationships, but certainly on a professional level that it, you, you focus has to be there, period.

Vance Crowe [00:39:12] Oh, that's interesting. It really, you know, the best relationships you have are the ones that you're either willing or able to dedicate your, your full attention to them. Because if they're talking to you, that is the most important thing going on them.

Allen Soffer MD [00:39:23] Yeah. And, and, and it, the only thing, it's gotta be the only thing going on right then. Absolutely. Does

Vance Crowe [00:39:27] That inform why? So, you know, the listeners won't know this and you've been, you know, really open and, and and talkative, but you and I have been at entire breakfast where there's five people there and you don't say a word, you know, until the very end, you're pleasant, you know, you smile and say hi, but you're very, very quiet and you're quiet in meetings and you're quiet when you're out to dinner in the groups that we've been in, would you, I find it to be so interesting how quiet you are. Clearly I'm on the opposite scale of this. Is this genetic for you? Is this something that you temper in yourself? That, that you say, I'm, I wanna reserve.

Allen Soffer MD [00:40:03] I don't, I I don't temper it. I don't, I think it's natural for me. I just have always been a better listener than a, than a talker. No, no question about that. Which is interesting. 'cause I think that's the most important skill as a physician is to be a listener. No, no question about that. And, and, and you're learning medical school, how, how 90% of everything you do is listening. You know, it, it, you know, it, it's the testing that you do, the, the high technology that we have, the procedures and such, those are in general confirmatory. And yes, you'll find some surprises, but, but you can learn most things as a physician just by listening to somebody and paying attention to their, to the, the signals that they're giving you that they may or may not be meaning to. And just hearing what they say. And I guess that, I guess that has informed, informed how I deal with people as well. But I've, but I've never, I've never enjoyed talking for talking's sake, just, and which is why this is such an atypical thing that I'm doing today.

Vance Crowe [00:41:09] Well, I mean, I am, I am over overjoyed with how well this conversation is going. And there's an interesting function that happens when I, and I think there's, there's two ways to get to this function of, of, I'm gonna talk about intimacy, right? Like when someone feels comfortable enough to o open up. And I think there's a couple of different ways to get many, probably many different ways. And you and I maybe have different ways of, of going about it. In my case, I often make observations and ask people a question that they haven't really thought of before. And if you stick around for the answer, then, then they'll tell you very interesting things. And yours, you're intensely interested. Your, your, but you don't, you don't necessarily have least as, as far as my experience, that many questions. But you stay and you listen. But there becomes a challenge, I think with a doctor as an, as an interviewer or a communicator. I can get it as intimate and as close with a person as they wanna let me, and,

Allen Soffer MD [00:42:12] But

Vance Crowe [00:42:12] We're gonna hit a point where there's no danger of being too intimate. Right? Or I mean, I guess maybe in some obscure situation, but in your case, you have to help someone to open up so that they feel comfortable enough to tell you things that are deeply important to what their case is, to what's going on with them. And yet you can't get that attached to them, or, or I would imagine if you get attached to people, you, you can't do that dozens of times in a day then, you know, hundreds of times in a week. How do you deal with that balance between having people open up to you, becoming intimate, but not becoming too connected to them?

Allen Soffer MD [00:42:50] Well, I think that's part of being a human being. I mean, you're obviously, you, you forge a connection, but you can't let it, you, you, you, you, you can't let it destroy you every, every 20 minutes either. 'cause that doesn't do anybody any good.

Vance Crowe [00:43:09] And you know, one of the, the words that you and I talked about in our emails back and forth setting, setting this up was a word that comes, there's, there's two books that you have ever recommended for me to read. And one of them came as a function of you visiting Cambodia and treating the, the refugees that were coming outta that crisis. The name of that book. What, what was that was

Allen Soffer MD [00:43:33] It was William Shaw Cross, the Quality of Mercy.

Vance Crowe [00:43:35] The Quality of Mercy. Right.

Allen Soffer MD [00:43:37] And

Vance Crowe [00:43:37] Then just when you came over today, you, you brought a book called Just Mercy and, and kind of what would you say is an overview of the, what prompted you to bring this, this

Allen Soffer MD [00:43:46] Particular Just Mercy?

Vance Crowe [00:43:47] Yeah,

Allen Soffer MD [00:43:48] Just Mercy is a, is a book by Brian Stevenson, who is a, is an attorney who has really dedicated his life to, to helping marginalized, you know, the most marginalized citizens we have, which are, those are incarcerated and, and with death sentences, some wrongly convicted and such. But he is really dedicated his life to, to helping that, those individuals.

Vance Crowe [00:44:22] So, you know, when we bounced back and forth these ideas about, and I said, I want to talk with you about the, the word mercy. And I mentioned to a friend of mine that we were gonna have this conversation and I said, I'm talking to a doctor and we're gonna talk about something that I think is central to being a doctor, which is mercy. And he looked at me like I was crazy and I didn't really understand why. And he goes, you know, have you ever really thought about what that word mercy means? And, you know, it had always been a word that I had grown up with in the Catholic church and oh sure, knew we should have mercy, but I never really understood that there is some component until he brought this up with me. And I'm, I'm interested to hear your thoughts on it, that mercy requires that you have compassion for someone, but they don't deserve it. So that's not really the position that, that you as a doctor are in is as to judging.

Allen Soffer MD [00:45:14] Sure. And, and, and Brian Stevenson goes into this, in, in his book, I mean, there's certainly, mercy is compassion and mercy is forgiveness, but part of mercy, I think a central part of mercy as, as it's defined is, is having to do with mercy has to be given by someone in a position of power and authority who has, who can absolve somebody, you know, who, who can forgive them and such, so, so there's a, there's a relationship there that, that that is an unholy one there, you know, there of, of having of, of a someone in a, in a position of authority and power giving the mercy. And, and that's, that's a relationship that's that's on tour, that's

Vance Crowe [00:46:10] Yeah. An asymmetry that seems really uncomfortable.

Allen Soffer MD [00:46:14] A absolutely. And and and Stevenson says in his book, he says he, he, the the book is called Just Mercy, not Mercy. And he talks about the difference between mercy and just mercy just meaning as injustice.

Vance Crowe [00:46:30] Oh, okay.

Allen Soffer MD [00:46:30] And, and he says that yes, mercy is, is is mo is is given and, and compassion and forgiveness and, but the just mercy has hopefulness involved. It's gotta have hope involved. But, but also it's, it's, it's, it's most productive if it's given to people who are undeserved and unask. And, and that's a, a point that he makes. I'm not sure I agree with that, but he thinks it's important that, that that mercy in that, in that setting is, is the highest form of mercy

Vance Crowe [00:47:12] To some, some form of redemption in that case of a person thinking that they, they are beneath the level of redemption, so they wouldn't even dare ask for it

Allen Soffer MD [00:47:21] Or they wouldn't even ask for it or, or feel deserving of it.

Vance Crowe [00:47:24] Interesting. So where I think this intersects with some of the things that you've seen in life is if you encounter a patient that you can tell that they were not thinking ahead on, you know, taking care of themselves and their body and their, and their heart health and then they have a problem, it has to be very difficult to not, well, I don't know, for, for, for an outside observer, I would imagine that it would be very difficult not to be in a position of, of deeply judging, if not altogether coming some

Allen Soffer MD [00:48:01] Oh, no, no, no. I don't think that's, I don't think that's difficult at all. I think it's important. You, you just can't be judgmental 'cause that just doesn't serve them well.

Vance Crowe [00:48:08] But that's not a, that's not normal for, I, I don't, I I think, I think it is an intrinsic thing for humans to be judgmental. And as you grow older, you begin to have other ways of looking at the world. But, you know, look at your reaction there, you're like, oh, no, no, but well,

Allen Soffer MD [00:48:24] It's 'cause it's, it's easy. It's just not productive. It just would not be, and it's usually not productive to be judgemental, but certainly in a professional encounter, it, it just wouldn't help to be judgemental. You know, I, I certainly have patients who have had heart attacks and undergone bypass surgery and continue to smoke and it's my, not my job to be judgemental about it, but it is my job to inform in every single visit, talk, talk about that to, to the point of ad nauseum sometimes. And, but, but to, to judge 'em on that just again, would not help them and wouldn't help me either. So

Vance Crowe [00:48:58] That would be a deeply valuable, I mean, therein lies one of the great abilities of a human being to, to transcend and have better relationships and more empathy and probably more peace would be to not judge. Are you able to, to take those lessons or that ability and apply it into, into other areas of your life?

Allen Soffer MD [00:49:22] Oh, I think I, I try to be just like, I think everybody does. I think people are, are better human beings if they, if they do that doesn't mean I do it all the time, but I certainly try,

Vance Crowe [00:49:32] I find myself being the most judgmental when, and it takes me a second, I have to stop and think about it. You know, when I find myself being really judgemental, I end up saying, wait a second, what is it about that person that I am afraid that I am sure you're

Allen Soffer MD [00:49:50] Projecting it in a

Vance Crowe [00:49:51] That's right. And, and when you have that realization that the more I feel judgmental, the more it is something I'm running away from. Sure. So I should be cognizant of it that, that, that is where judgment becomes helpful. But that goes back to that level of introspection that you have. Sure. That I, you know, probably went 30 some odd years without, So in almost a complete non-sequitur. And for people that are outside of St. Louis, the, what I'm about to ask about probably won't at first seem that relevant to them, but people in St. Louis, this is gonna be something they know a lot about. Your family is very involved with the World Food Day, and I'm very interested in hearing, first just a small description of what is World Food Day, but then second of all, where did you and your high school sweetheart and your children, how did you guys become so intimately involved with, with this program?

Allen Soffer MD [00:50:51] Well, world Food Day is a United Nations initiative. I started, I believe in the late forties commemorating just World Food Day, commemorating humanities quest to, to decrease hunger and such around the world. And so my son Donald was involved in, in a, in, in a World Food day commemorate commemorative packaging event, food packaging event with the Danforth Plant Science Center. And they did that for, for, for I believe two years. And,

Vance Crowe [00:51:31] And to describe the packaging day, you're saying there's all these volunteers, they come in and they have rice, some soy protein, and then some flavoring, and they combine it into packages

Allen Soffer MD [00:51:43] Packaged, dehydrated meals. That's right.

Vance Crowe [00:51:45] And it

Allen Soffer MD [00:51:45] Is a community event. And, and ba basically he was involved in this and, and do some administrative changes and such. The Danforth Plant Science Center decided not to do it anymore. And and our son, who was probably 13 years old at the time, came to us and actually probably 15 ish or so at the time, came to, to Mary Beth and me and, and asked if we could do it as a family, could we take it over? And this was about two months before the event was supposed to take place. So we said Sure. And Buroughs High School was, or bur John Burroughs School, the, the school where our, where our secondary school, where our kids attended was, was kind enough to offer us their facility to, to do this event and was kind enough to offer the, the, the maintenance people and the plant plant services to help us. And, and, and basically we, we did it that year and we've done it for seven years since then. So it's an annual event, it takes place on one day. And we have about 2000 volunteers from, from across the St. Louis community, all kinds of different people. We have, we have underserved schools that come and package, we have law firms that come and package, we have corporate sponsors that help, help take, help relieve the, the cost burden for, for this event. And, and, and basically at, in one hour shifts people at tables of eight to 10 people stand up and, and package food ingredients into, into a package that the dehydrated food package that can be, that boiled water can be added to and, and can serve four to six people.

Allen Soffer MD [00:53:38] And so, so basically what we have is we've got eight one hour sessions during the day and then a three hour session at night, which is where high school students come. And just for a continuous three hours, we've got 22, 23 high schools

Vance Crowe [00:53:52] And there's music playing festive that come and music is

Allen Soffer MD [00:53:55] Blaring. It's loud, it's just, it's really crazy. And they, they are just focused on packaging food for the hungry and it's a remarkable thing to see. And so half, approximately half the food goes to a school-based feeding program in Tanzania, Africa. A particular program where that feeds about a thousand feeds, about a thousand children and such daily. And

Vance Crowe [00:54:22] I didn't realize, so it goes to a specific place. Yeah. There's, it's not just, Hey, we're shipping it off to people in Yeah.

Allen Soffer MD [00:54:27] Half of the food goes there to a specific F place.

Vance Crowe [00:54:30] Oh, that's really interesting. A specific feeding program. I didn't, I did not know that.

Allen Soffer MD [00:54:32] Right. And our food basically supports that program. And so for many people, this is their only meal of that day. You know, they come to school, they eat, they haven't eaten before and they don't eat after they go home. So this is their meal of the day.

Vance Crowe [00:54:45] Wow.

Allen Soffer MD [00:54:45] I supported by that. And, and, and we've, we've grown to enough, we we're packaging about 450,000 meals per year now. And that's enough to support this one feeding program in Tan the school-based feeding program in Tanzania. Which is, which is a, a, a wonderful thing. And then the other half the meals that we, we packaged during the, during the day and evening are, are go to the St. Louis area to, to families in need through the St. Louis food, food bank. They helped distribute.

Vance Crowe [00:55:15] So your son was, we'll say 15, that meant he maybe had at most three years at school and then he was done. Why have you, why has your family stayed so deeply involved in it? I mean, I, I got a, an email from Mary Beth the other day about it.

Allen Soffer MD [00:55:28] Well, you know, she's, you know, our family's committed and, and that being said, she does, she does the legwork. I mean, she is, it is a, it is a big production that, and she puts a lot of time and energy into it from just, just logistically getting it so that it's a smooth process for 2000 people to sit down and, and package meals together, to, to getting the sponsors to, to help underwrite the cost of the, of the, of the packaging to, to getting the underserved schools transported to the event and to getting the high school students signed up. And it's, it's all, it's all encompassing, but it's, it's, it's, it's great to see people that, that wanna give both of their, of their time to, to a worthy cause, which is hunger relief. And, and it's just very satisfying to, to see it come together for the last seven years.

Vance Crowe [00:56:20] The, the key interesting thing about that event, to me, outside of the good that it's doing and the number of, of people that are fed, every time I've ever gone, I've been at a table where I knew most of the people there, but I didn't know somebody else. Okay.

Allen Soffer MD [00:56:38] And

Vance Crowe [00:56:38] So you have this experience of you're becoming a cog in a factory, right? You're, you're like, I'm the rice guy that measures out to make sure it's the exact amount of rice. And I'm the person that puts in soy and everybody's got their task. And by doing this, you all have, I know what I'm supposed to be doing. So sitting across from another person, they know exactly what they're supposed to be doing. I think it lowers people's inhibitions and they become much more open to talking about who are they, why are they there, what's going on? Invariably I have met people that are very very interesting that you wouldn't find otherwise. And I, there's no way to, there's no reason necessarily to sell that into, Hey, why you should come do this program. Sure,

Allen Soffer MD [00:57:24] Sure.

Vance Crowe [00:57:25] But it is one of those things that I've watched, even the most shy people that I know open up and talk with the person across from them and meet somebody. And I, I can't even imagine how many friendships have probably been born out of that project. Sure. Which I think is an interesting,

Allen Soffer MD [00:57:42] It, it's, it's a community builder. No, no doubt about it. And in, and in fact it, it's kind of getting outta hand, but, but corporations are coming and, and coming more and more each year and, and because they see it as, as such a great team building experience just in the corporate world per se, but obviously on a community basis that that's the same type of thing. You have like-minded people who are trying to do some good and, and, and when people are doing that together, they, they open up. I, I think that's a interesting observation.

Vance Crowe [00:58:13] So speaking of community, you have done something over your lifetime that I think, well, I don't know what the statistics would be, but I can say that among most educated, you know, middle, middle, upper, middle income people, they, they don't do very often, which is, you were born in St. Louis, you met your wife and you went away to school, I think that's right. And then came back, you did some traveling, but you built the entirety of your life here in St. Louis. Tell me about what that was as, as you look back on it to say, you know, there's, there's trade offs. You're not living in a cosmopolitan life in New York or out in sunny Arizona, but there's something that comes from spending your entire life seeing people that you grew up with now 62 years later. What, what, what was the value? Why did you make that decision and what, what do you think was the consequence of it?

Allen Soffer MD [00:59:14] Oh, I think the decision was easy. It was, it was because of family certainly wanting to be near my, near my, near my family. And, and as, as Mary Beth and I started a family by, you know, her family as well. So it, it was purely because of family that that's easy, you know, and I, St. Louis, I think is a wonderful place to, to, to raise a family. And we were committed to that. And, and so it's as easy as that. It's certainly not because we love the winters here or, or, and, and such, but you know, it's purely that I think family is one of the most important things there is. And, and we think St. Louis is a, is a great place to, to, to foster that love.

Vance Crowe [00:59:59] This isn't true in your case, but I'm fond of telling people that the arch is like a magnet. And the way that it works is young women leave St. Louis to go to college or to have professional jobs, and then eventually they get married and they come back home and they, and they get pulled back into St. Louis, which is how they get the genetic diversity that's here.

Allen Soffer MD [01:00:18] That's funny. That's interesting.

Vance Crowe [01:00:21] Alan, this has been an excellent conversation. I am so glad that you've been willing to sit down and chat with me and kind of go through my fumblings. I am grateful for our friendship, which started over maybe two years ago and has, has included excellent conversations just like this one. So thank you so much and I hope you'll come back after I've had a little more practice and I have better questions for

Allen Soffer MD [01:00:43] You. My pleasure. Thanks for, thanks for having me here.

Vance Crowe [01:00:45] Thanks everybody for listening to the podcast. I hope you enjoyed it. It was with Dr. Allen Ser, really interesting guy. And if you did enjoy this podcast, I hope you'll go to wherever you subscribe to podcasts and consider leaving us a five star review and maybe even make some comments on it. Those kind of comments help the algorithms decide, hey, what shows are people listening to and really enjoying? And we wanna get that spread out to more people. And we really wanna do it before next week, because next week's guest is going to be the world renowned bee expert Jerry Hayes. Now, if you've never heard of Jerry Hayes before, you can find him on the cover of Wired magazine. He is an extraordinary guy. He has all sorts of crazy stories like the first time he ever had to go to an autopsy as a result of Africanized Bees. And we even talk about things like colony collapse disorder, neonicotinoids, and what people can do if they wanna help out the bee populations. Jerry's a really great guy, it's a fascinating interview and I hope you'll join us next week. Thanks.