9:00 A.M. with Sepideh Moafi and Shawn Hatosy

Tomorrow I am leaving to go on sabbatical. He's leaving us for three months on a motorcycle. Motorcycle? You're joking. Why would you do this? Why? Why? Why? Because, uh... You middle-aged man, don't be stupid. Don't hold back. Tell me how you really feel. Forgive me for being blunt, Dr. Rabinovich, but how old are you, huh? 50... Ish. Ish. 50-ish year old man on a motorcycle. Very sad. Welcome to The Pit Podcast, the official companion to The Pit on HBO Max. I'm Alok Patel, physician, journalist, basically a loudmouth for public health. And I'm Hunter Harris, a culture critic and screenwriter. Every week on this show, we go inside The Pit and look at the characters, the patients, the storylines that keep the Pittsburgh Trauma Medical Center running. And then we'll step outside the emergency department to talk about real-world issues that find their way on this show. Today, we're talking about episode three, season two. And we're also going to be joined by Sean Haddesey and Sepeda Mouafi, who play Dr. Abbott and Dr. Al-Hashimi. She's like, this is everything that's wrong with this place. I wrote a manuscript. This is what I think you need to change. I know, I mean, she enters this dynamic environment with an established sort of staff, the ensemble, an established sort of culture, and she comes in and sort of wants to shake things up. Let's go. Today's shift starts right now. Another week, another episode. I don't know if I was, like, emotionally ready for all the life lessons in this episode. We talk about implicit bias and forgiveness and tragedy, just a lot of life lessons jam-packed in this one. This was a big one. This was a heavy one. I want to start off with Dr. McKay, who has had quite the episode. So she has two patients who are sort of hitting on her, an older man and a guy that's kind of her age. So she's juggling that, but also one of her patients who was, I should say, presenting with a little bit of erratic behavior. Good term. Good term. Thank you. I'm learning. A little bit of erratic behavior, and she was trusting her gut and thinking, something is going on here that I don't know what it is. And she sends him up for a CT, and he comes back with a four-centimeter mass on his brain, which that really hit for me. My dad had a brain tumor when I was in high school, and so that was, like, really getting me in all the feels. We also had a family, a big family, a loud family for sure, who was playing a bit of, like, a pill roulette. I still can't figure out what's happening Like, for some reason, they think it's acceptable to, like, pull their medications and just say, yeah, that one guy who's not a pharmacist or a medical professional at all can decide who takes what when. It's so strange. Yeah, not working out, I would say. And then we also are checking in with the college student who was tased by an overzealous, a bit, like, high in his own supply, campus security guard. And he seems to think... to think it looked a bit of a know-it-all i'll say but we have that clip should we watch it yeah we should because i think this is this one is like a lesson i think an implicit bias and jump into a conclusion before you know the whole story let's watch this one can i get some help over here yeah what's going on man crazy kid in there screaming all right have a seat yeah it's him still going nuts probably meth animal what's your name sir tony cinchillo campus security yeah i was at work when this happens, so I'm gonna do everything documented. I think it really pushes people, the viewer, to look to see what's happening with Jackson Davis, the security guard, into figuring out if they have an implicit bias, if they jump to a conclusion about, like, what's actually going on. Mm-hmm. Again, like, the writers and creators of this show are brilliant, because everything has some type of hidden meaning. They're always, these are all, like, fortune cookies mixed with clinical cases. And so, like, I think this was a powerful moment. You know what it reminds me of? the sickle cell patient from last season. I think if a non-white person comes in, like, yelling, raising their voice, the mind immediately for some of these people goes to, like, they're being disruptive or something's going on here. It's like drug-seeking behavior. That's where this security guard's mind definitely went. Because why is he so adamant that, like, this kid has done something wrong? What can happen in a library at a college that would make someone get tased? Like, that just seems so over the top to me. Yeah, and I think it's seeing both of the emotions play out. Yeah. Matters. But I have to go back to something you mentioned about the four-centimeter brain mass and McKay doing that. Like, the storyline is so powerful. The way McKay goes from how he presented to not trusting her gut, to then him going and getting the imaging, to finding out it's the mass. Like, you see a lot unfold in such a short amount of time. And I like that McKay is really with him in that uncertainty. Like, that she is giving him a lot of time and a lot of space to process what is, I'm sure, extremely shocking. And she's honest. She uses these powerful words called, I don't know, it could be, maybe. Basically, this honesty, like, we're going through this process of discovery together. I've got your back. And then when he mentions, like, is it a brain tumor? And she's honest about, like, we don't know yet. We have to do a biopsy. I really love that you said that. That I don't know feels very important here. That's an important term that doctors have to say sometime. So we also, in this episode, meet Nancy and Mark Gee, a couple who accidentally hit a bicyclist, Motorcycle driver? Motorcyclist, yeah. Yes. And I don't know if you noticed, there's that one scene where they're like assessing the motorcyclist and someone says, oh, isn't, didn't he take like the course that you took, Dr. Robbie? And Robbie's like, well, I always wear my helmet. Which we know is a lie. Yeah, it's an interesting little moment to leave uncertainty to the audience. Yes. Eight millimeters, not reactive. AKA bloom, sphix, and dilated. Oh, gosh. Scull with tons of gray matter extravasation. At least it was quick. No helmet? Nope. Because he took the PennDOT motorcycle safety course. Isn't that what you took, Robbie? All compressions? Yes, but I still wear a helmet. Is he a donor? Also, nope. That is too bad. I like that we... It takes us back to, like, okay, Robbie as an unreliable narrator, which is, like, a really interesting place to leave the audience in. But we kind of later see that, um, Mark and Nancy Yee feel similarly about each other. They're in... They're very concerned for one another. But also, they were, like, having a fight, and that's kind of when this crash happened, which is a very sweet, somber, solemn moment. Um, we also have a moment of little flirtation between Dr. Rabi and Dr. Al-Hashmi, where I... it's not just like they're kind of, like, tensions are down, but it's a little bit of, like, flirtation, a little bit of friendship at the very least. How about we each take a lap and meet here when Mr. Yu's back from CT? Splitting up so soon? You're free to see other people, Dr. Rabinovich. I'm looking for cooperation, not commitment. A little cat and mouse. Yeah. Uh, yeah, cat and mouse, sure. Then we check back in with Kylie, the little girl, who Santos is really trying to figure out what's going on with her. But we see a fight between Kylie's dad and Kylie's dad's girlfriend that turns very tense very fast. And it's the kind of thing that keeps you thinking, like, okay, well, if he's getting this heated in this moment, who knows what's happening at home. Stop, stop, stop! Kylie's playlist is only 9,000. What does that mean? It's... it's not what we thought. It's probably ITP. What the hell is ITP? Something we can treat. Yeah. He's like, he's dialed up. Yeah. And I almost get it. Like, he kind of walks in as a concerned father, and it immediately turns into... accusations. Yeah. What is happening? What do you mean? the part that I struggle with is how they approached him initially to be like, here's a social worker. It seemed very fast. As opposed to being like, here's what we've done. Here's her chin laceration that they didn't really even talk about. And then saying like, hey, this is standard procedure. And the social worker mentions that quickly. So they get standard questions and they just kind of like pull them aside. And then Sanchez is like, she's got some bruising and you play rough with her. Like, what's up? As opposed to like, hey, like, you know, we just... We're covering all of our bases. This is what we're looking at. Because I will tell you from experience, like, it is... It is a lot of emotions to talk to a parent about suspected, keyword, suspected child abuse. Yeah. I think something important here is that, like, what I'm keeping in mind with every one of these cases is that we're watching someone on maybe, like, the most difficult, the most stressful day of their life so far. And so, of course, tensions are gonna be, like, running much higher than normal. So does that make his behavior acceptable or understandable? Not necessarily. But I can give a lot of grace and empathy for like, yeah, there's a reason why he's coming a little hot. Because his daughter is in the hospital, and he truly doesn't even know why yet. I think it's just the empathy. Like, you got it from the hospital staff standpoint. It's like, we understand you're going through a moment. But then there's also the point to being like, do you know yourself well enough to know you have to check yourself? Like, step outside for a second. Let's go in a different room. Because when he screams at the security guard, That's the part when I'm like, oh, you've crossed over. The episode ends on a pretty big cliffhanger, code black, which I didn't know what that meant. But it's that another hospital is going through something, and all of their traffic has to be diverted to the pit. Is that correct? The pit cannot catch a break. No, not today. Like, another cliffhanger, another potential disaster, suspense, I feel for them. But one scene that I want to, like, linger on a little bit, because it was very touching to me, is that a patient comes in, an older woman, and she has a severe burn on her leg. She puts honey on it, which is honestly what I would do. That feels very smart to me. But it turns out that she heard fireworks and it reminded her of being at the temple on October 27, 2018 at the Tree of Life shooting. And she has severe PTSD from that. And it is like one of the more touching moments of this entire series, I would say, that Robbie's able to see her and understand her in that moment. I was on my way inside October 27, 2018, to the synagogue when the shooting started. There was nothing I could do. I went in after the police arrived. I felt I had to. I'm better now. But... You're here to see the 4th of July, when kids have their fireworks and firecrackers, I... There is no clock on how long it takes. This is such a powerful moment in terms of empathy, connection, recognizing grief. Even the way the scene almost started when she mentioned the samovar and Dr. Robbie walks in And he's like, oh, yeah, Samovar, tea kettle. And she hears his last name and there an immediate connection And you know you take this moment the viewers everyone takes a moment to realize that she speaking about the Tree of Life synagogue shooting one of the deadliest anti attacks in US history Eleven Jewish individuals were killed that day in Pittsburgh. So this is a really important moment. And we don't know if Dr. Robbie was working that day. We don't know what his connection is. Is it just the fact that he's Jewish? Is it the fact that he's in the community? We don't know, but there is, as you mentioned, There is this connection that doesn't require any words. But it's like a masterclass in bedside behavior and just listening. It drives home the pit as a Pittsburgh show that other things happen outside of this world that we haven't necessarily seen on camera during this season, last season. I really need your opinion on Santos this episode, because she's trusting her gut and thinking, there's something going on with this little girl and something that the dad and the dad's girlfriend is not telling me. And I wonder how much she should follow that instinct or how good it is to follow that instinct, but how much it's maybe like a little bit of a heightened awareness that may be to the patient's detriment, right? What do you think about that, about seeing a case of abuse where there is none, but you have to ask anyway? And you may have a predisposition, or you may be going in there kind of already suspecting something. And like, that's that concept of implicit bias coming again. Like, we talked about it with Jackson Davis, and I think in this situation, Santos, again, like, rightfully brings up the possibility of child abuse, and almost seems like she's locking in on it. And even when the social worker's like, hey, like, I don't know, I don't suspect child abuse, and she's kind of like, well, wait till the dad shows up. If he doesn't show up, like, I think we have our... Like, she's kind of already kind of leaning in that direction. And then when Dana runs out in the middle of that whole confrontation, and she's like, the platelets are 9,000, and it just puts water on all the flames, because now they have a diagnosis. I think that raises another important issue is, you know, a patient comes in and you might suspect one diagnosis, and you can't close off to everything else. So what she has, what Kylie ends up having, ITP, immune thrombocytopenia, your platelets drop, you can get bruising, you can get bleeding, and it is easily treatable, becomes this really important learning lesson, I think, for the residents. And then Santos even says, she says, oh, like, I got a zebra diagnosis. I don't remember the exact phrasing, but she mentions, like nothing like a zebra to start the day. And a zebra is a joke term for a diagnosis you weren't suspecting or a rare diagnosis. When I bet you now, like Santos the resident, the next time she sees this, ITP will not be a zebra. She will say like, hey, let me not immediately assume this child abuse. Let me think about all these other things. And vice versa, if she sees ITP, she might say, well, hey, let me make sure this isn't child abuse. This is a big learning moment, I think. It is. It is. A big speed check. And I think it's good that it's happening to Santos, because last season she was right about Langdon. She's been right about patients in the past. And even as Dr. Robbie and the social worker are kind of throwing up flags, being like, hey, maybe slow down. We're going down, jumping to a conclusion. She's still, I mean, her heart is in the right place. She wants to care for her patient. And I'm not even faulting her. Listen, I'm faulting her as if I'm the attending. No, I'm just saying I get where she's coming from. Because, you know, you're right. She was right about it previously. but then she correctly mentions that Kylie has old and new bruises, which tells us that there's some type of ongoing process. So if we were to see a baby or a toddler, for example, and we get x-rays on them and they have old and new fractures, you're like, oh my gosh, has someone been continuously harming this child? Or is it a congenital condition that's causing brittle bones? So it's like, it's just keeping the radar open for different possibilities. I have to wonder, too, about the dad's girlfriend, because what is she thinking? She's like, get me out of here. Like, she doesn't know what's going on. And also, the boyfriend, like the dad, coming in so hot and turning the blame on her immediately. I'm like, that's not a person you want to be with. That's not a man who handles conflict very well. They had problems before they came to the ER. Yes. We got the chance to talk to two of the attendings, Sean Hadassi and Sepeda Mawafi. We've seen Dr. Al Hashimi a couple times this season so far. We haven't seen Dr. Abbott yet, but I'm waiting. I'm a lady in waiting for him. I'm totally with you. And I was excited we got to talk to them because Dr. Abbott, incredibly important role at the end of season one, and kind of established his difference in style to Dr. Rabi. We've been talking a lot about Dr. Al Hashimi. And so I think getting to talk to the two of them about what went into their character, awesome. Viewers, watchers, people, Let's go inside the pit and check out this interview. Tepid, I want to start with you. Okay. So, start of season two, Dr. Al Hashimi, like, comes in. Brilliant firecracker, guns blazing, all of it. Fascinating character. Almost set up initially as like an adversary to Dr. Robbie. Yeah. Who the audience is already kind of rooting for. Yes. But change can be a good thing. So what do you feel Dr. Al Hashimi is really bringing to the ER? I love this question. Yeah, it's a great question. She's like, this is everything that's wrong. I'm so wrong with this place. I wrote a manuscript. This is what I think you need to change. No, I mean, she enters this dynamic environment with an established sort of staff, the ensemble, an established sort of culture, and she comes in and sort of wants to shake things up. And at first, it might be kind of unclear as to why. First of all, she was brought in by Gloria to shake things up. Gloria, the chief medical officer. But it really is to sort of implement her sort of vision of elevating patient-centered care. That's sort of her overall vision for, like, in medicine, her approach altogether. She enters the space, and maybe they might look at her as a disruptor. Dr. Ravi certainly does. But ultimately, she introduces a new rhythm, a new cadence to the pit, and sometimes it's in dissonance with Dr. Ravi, and sometimes they They harmonize beautifully, but I think their goals are the same when we put all of our differences aside. Because Dr. Al-Hashimi, she sort of represents the modernization of medicine, this more progressive approach. And Dr. Rabi embodies the sort of more traditional doctor that we know. And the reason why she wants to bring in AI and technology is to sort of relieve the burden that so many physicians have, like offset some responsibility and admin and charting and all of that so that they can spend more time at the patient bedside and take more time to nurture their own lives, their families, their mental health. So I think she's really well-intended. And I would just say, look, anytime there's a woman in position of power, we kind of go hard on her. So maybe let's question our own biases of why is it that when a man has such a strong POV, We kind of accept it, but when a woman comes in to do the job she was brought in to do, why do we question that? Someone drop a mic right now. That's a very good point. I'm gonna take down this mic and drop it. You know? You're right. Yeah. I love that. Can you tell us a little bit more about how you feel like Dr. Al-Hashimi maybe navigates the resistance to some of the tech that she wants to implement? Look, I think you know this. Any woman on this planet knows this. Whenever you enter any space, especially as a successful woman, a professional, you always have eyes on you. There's a magnifying glass. And whether it's true in that space or not, we've grown up with a certain level of expectations that's been imposed on us by society and that are self-imposed. So she knows she has to be 10 times better than any of her male counterparts. She knows that she needs to hold, you know, anchor herself and be strong despite the winds and resistance she's met with. And I think she goes, they go kind of head to head at times, but ultimately, this is the reason why Dr. Rabinovich respects her. Because she has a vision, and her priorities are in the right places. She does not introduce this new sort of rhythm and cadence for novelty's sake. It's always to find ways to improve the system from within. They don't necessarily see eye to eye all the time, but at the end of the day, like I said, they have a similar sort of goal and end game in mind. Just in terms of like, you know, from the research process and just having a lot of friends who are physicians who work around the world as doctors, everybody has a different approach. Everybody has a different style. And so I think our differences ultimately make us better. And that's something that we see in the pit. Sometimes it brings up some resistance and it's challenging to sort of confront our differences. But I think ultimately our characters at least have respect for one another, even though we might have different views. But yeah, we do share. Abbott is always seemingly like, whatever, man, as long as it gets done, you save that person. I don't care. Don't worry about that. I know Robbie and Abbott are mirrors of each other. Can you tell us a little bit more about Dr. Robbie and Dr. Abbott being mirrors of each other and kind of how they. Well, I think it's just the characters are so well drawn because you meet Abbott in the first episode of season one. He's up on the roof. He's had a really rough night. And we get to learn a lot about, you know, without having to say too much exposition, that he's, you know, he's very deeply affected by losing this veteran, so much so that he writes the letter. And he's just struggling with, after this very traumatic shift, why he's here, why he keeps coming back. He says it. I don't even know why I keep coming back here. And Ravi kind of talks him off the ledge. And so as the series unfolds, you and this mass casualty comes in, you, Abbott comes back, and his experience as a combat medic, it really, it really shines in this moment, his calm in the face of chaos. This is no frills combat zone medicine. No ultrasound, no x-rays, no CT, no labs. Assessed based on mental status and pulse strength. Every critical patient gets an IO, intubation, a unit of blood and chest tube if needed. Um, and for him, it provides clarity to that question that's poised in that first episode. And then by the time we get to the last episode, the roles have reversed. Robbie's up on the ledge. And I think it's beautiful that Abbott is able to articulate what his purpose is. There's such comfort in knowing, you know, we're the bees that protect the hive, that not a lot of people can do this. We are the ones, you know? And what it sort of presents is the big question for Robbie going into season two, which is now we got to deal with the fallout of what this work does to us. Dr. Abbott finds comfort in the darkness. That's what his therapist tells him. So he presents this to Robbie, and will Robbie take the advice of the guy that he looks to as somebody that's an equal? And we get to find out. Last question, Sepheda. Can you tell us, as an attending, you have to have a palpable command of medicine. What sort of prep did you do to embody that? I mean, I didn't have much time, but I tried to sort of take in and absorb as much content as I possibly could. I read several books about AI in medicine, about, you know, doctors' sort of experience in residency, experience in their practice and their approaches. I spoke to some friends and colleagues in the States and overseas I work with an organization called the IRC the International Rescue Committee as an ambassador So there are a lot of field doctors humanitarian doctors who work in various crisis zones So I just basically collected as much information as I could. We had our medical boot camp, and I let go of it, because I wasn't hired to be a doctor. I was hired to be an actor. And you just kind of have to relinquish some of the control and stress and anxiety around it and trust that these people clearly know what they're doing, the producers, our technical advisors. I mean, I lean on... I still... I'm constantly texting and calling them and asking them about every moment of every episode, not just for the medical procedures, but also for their sort of... What would that cost you emotionally? What does this mean to you physically, emotionally, psychologically? Because everybody has a different approach and a different sort of perception of these events that we sort of see throughout the show. I just try to, like, hunt and gather as much as I can, and then when it comes down to it, let go, and hopefully something's there. We present well, we fake it really well, but inside we're crippled with fear and anxiety. But that's also the characters, too, and that's what I really... I mean, we really try to embrace that, is that this level of uncertainty, it's not foreign to Dr. El Hashimi or Dr. Abbott. It's just that their relationship to the uncertainty and their relationship to the fear is slightly different. Awesome. Thank you, guys. There's humanity in that. I love it. Yeah. Thank you. In this interview, I really loved Sean saying that he is a mirror. Dr. Abbott is a mirror to Dr. Robbie. Because they do kind of have similar conflicts, maybe, but they approach them in very different ways. That was a real highlight for me. Yeah, and they almost like check each other. Yeah. Like, during some of the resuscitation scenes at the end of season one, like, you saw Dr. Abbott being like, hey, like, Dr. Ravi, like, what are you doing? We need resources, et cetera. Like, they really, really know each other. I have some questions for you. Hit me. I wanna just kind of talk about a few procedures that I want some more information on. First of all, Dr. Alok Patel, how many beads have you pulled out of noses in a hospital setting? I don't know if I've counted. The amount of beads I've pulled out in the hospital setting, but in residency, I pulled out a ton in the ER. I've gotten some out in various settings. I've gotten some beads out non-clinically, like friends' houses and stuff like that. Because it, as anyone could probably guess, it happens a lot. I've taken a bead out of my own daughter's nose before. Don't tell anyone. But actually tell everyone. But something that's really interesting in that scene is Langdon comes in and is asking questions about the beads. The dad then says, I tried to blow in his mouth, but I got snot on my face. What that dad was likely referring to is this technique called the mother's kiss. That's what we call it, where you essentially blow into your child's mouth forcefully while plugging the other nostril that doesn't have something in it. And it causes pressure, and oftentimes, the object will either lower down or it'll come right out. Oh, wow. Mother's kiss. The amount of times that I have texted somebody that, who has texted me and been like, oh, my God, my kid got a pee up their nose, or a Lego, or whatever. And I'll be like, try the mother's kiss, and it'll either gradually push it down, or sometimes it just completely dislodges it. So that dad tried the right thing. That was awesome. And then that device, the balloon dilator or cat's extractor, is essentially just exactly what we saw. You insert the device past where the object is and flick that balloon and you pull it right out. But oftentimes you can use forms of forceps. They look like massive tweezers to get it out too. But kids put things up their nose. It's important to teach them not to do that. Yeah, that's bad. It's not ideal. Tell me about the other thing we see. this like sternum rub? What is that? Sternum rub. All right, can we do a demo right now? I want you to take your knuckles and put them on your sternum and push really hard and rub up and down. Doesn't feel great. No. I know, exactly. So the sternum rub is such an irritating motion that if somebody is out or we don't know what their mental status is in the hospital, and you throw them a sternum rub, if they don't respond to that, you're like, yo, unresponsive to sternum rub. We've had situations in which people, I don't know if they were really high, or if they had altered mental status, or if they were, you know, slipping in and out of consciousness. I had one patient fake a seizure. If somebody's having a real seizure, guess what? They will not respond, not necessarily respond to a sternal rub. This person immediately the seizure stopped. And she got up and yelled, like, what the hell are you doing? So you just irritate someone awake. Yeah. I want to go back to Michael Williams. His story in this episode and how personalities may or may not change, and there might be an underlying diagnosis. The whole setup with Mark Williams and McKay is a great example of like, you don't know where a patient case is gonna go. You're like, where is this gonna take me? This is the pit. I know there's gonna be meaning. And then his ex-wife comes in because she is his emergency contact, and she's like, why am I here? And then everyone learns together that he has this potential reason for his recent personality changes, this brain mass. And you almost see in that moment, her guard disappears, where she's like, oh my gosh. He gets in this moment of emotion. He's emotional and he almost has this moment of being humble. And all of a sudden he's no longer the tough guy. And so, you know, there's, it's a really important kind of lesson in human behavior and of life. So I wanted to ask you, like, if you were to put yourself in the shoes of Mark Williams' ex-wife and someone who deeply hurt you, that you had been like, I don't want to talk to you anymore because of their personality, their behaviors. If you found out that what they were doing or how they were acting was related to an illness, would there be room for forgiveness? I honestly don't know. I mean, this was the moment in the scene where I thought, like, I truly don't know what I would do. Because the scene hits on so many different levels where you see this, like, moment of grief and realization that, like, the man that she married became the man that she divorced for something that was out of both of their control. And she really doesn't know. Now it just looks like she's rethinking the divorce and the breakup and how much of her life now would have been different had this brain mass not happened. He hadn't had that. And there's that sweet moment, too, where they're in the examination room together, and he's like, oh, I heard you got remarried. And it's just so much the intimacy of people who used to be lovers, but also the distance with which, like, they're both not who they were when they got married. And I feel like her finishing that, you know, encounter and saying, like, keep me as his emergency contact was the perfect way to end that scene. And it provides just enough closure where she wants to be close to him, but, like, they can never get back where they were before. And it makes me think about the larger conversation about what happens at the end of life, and can physiologic changes affect your personality? just this entire kind of world of things. And so fortunately, we have someone that we can step outside the pit and talk to. Dr. Shoshana Ungerleider, who is a physician and also the founder of the nonprofit, Endwell, which really, really helps to kind of boost the conversation about end-of-life care, palliative care. But she also is a producer and produced a film about Robin Williams and kind of really dove into the conversation about neurological conditions. in Robin Williams' case, Lewy body dementia, and how that might affect your final days, your personality, your decisions, all of it. Heavy conversation. Let's go outside the pit and talk to Dr. Ungerleider. Let's do it. Dr. Shoshana Ungerleider, it's such an honor to have you here. I'm sure people have come across your work, whether or not they know it, but you are such a prominent voice in the space of what happens when we age, and the many things that come along with that with that in terms of our personal relationships, the outside world, medical care, all of it. I want to start by asking you a question that I'm sure some people who watch The Pit may inevitably be asking about their own relationships. You know, as we age, our personalities might change. Our dynamics with our loved ones might change. And that could also be a function of an underlying medical condition or the process of the brain just getting older. How do people tease out if relationships and personalities are changing because of that's human nature versus this is something that we need to go get medical treatment for? Yeah, that's a really good question. And thank you so much for having me, by the way. It's really an honor to be with you. One of the most helpful things to ask is, is this new in terms of the newer behavior? And is it moving fast, right? So when behavior or personality changes come on quickly over weeks, maybe over months, rather than gradually over many years, I think that's often a clue that something medical could be going on. I think especially if the person doesn't have a history of mental illness or if these changes are happening later in life, typically after age 50 or older, right? That should raise some questions. I think another red flag is when behavior feels really out of character, like poor judgment or loss of empathy, for example, or if someone's being incredibly impulsive, going out and spending tons of money, if that's not, you know, typical character for them. Sometimes emotional flatness that just doesn't kind of match who this person maybe used to be. And sometimes we'll hear families say, you know, I don't know who this person is anymore. That's not a diagnosis, certainly, but it is important information. And then finally, you know, there are these physical clues, right? Sometimes that get overlooked. Somebody has new or different headaches, for example, a seizure, problems with memory or focus that are new. Maybe it's trouble finding words or inability to have a normal gait, meaning problems with balance. Again, these subtle personality shifts, right? They can come with cognitive changes. And so these are all things to kind of look out for. It might be a warning sign if you're getting treatment and it's not working. It's a sign that maybe you're treating the wrong problem. That's so interesting. In this episode, we see and spend time with a man named Michael Williams who has some type of brain mass. And we meet his ex-wife who says that, like, toward the end of their marriage, she started behaving very differently, was like a lot angrier, a lot more frustrated. And how often do you think it could happen that like someone's behavior changes? And how common is it for like a serious illness to manifest in this way? Like that could even lead to a divorce. Well, I will first tell you, I am certainly not a couples therapist or an expert on relationships, but what I can say and what I've seen in the context of neurological illness, whether it be dementia or brain tumor, one of the hardest things is that personality change often shows up before you have a diagnosis. So someone like maybe this person you're talking about may become more irritable or, again, impulsive or even withdrawn, aggressive even, almost unrecognizable to the people who love them. It happens in the context of brain tumors somewhere like 50 to 60% of the time people do have these changes. So it is quite possible. That's not to say that, you know, people as humans don't change over time and relationships are very complex, as we all know. So not everything has a medical diagnosis. But again, this idea that if something changes are coming on quickly, if there's a real shift in who this person is from a character perspective it worthwhile to kind of take a look and make sure there nothing else going on I have a follow question and I don know if this is like an academic show me the data question or more just like we friends in a bar spitballing right now But if you see relationships falling apart, like if someone is like, oh my gosh, this individual I'm married to, or my child or my sister has had difficult behavior, strains relationship. Now they're not speaking. Then there was a diagnosis. There was neurodegenerative disease. there was a brain tumor, something that explained it. Do you think that changes the rebuilding, regaining trust? Do you think that just depends on the individual? Do you find that with some situations, it's so damaged that there's no rebuilding no matter what the reason is? My instinct would tell me that if you found out it was a brain tumor, I'd be like, oh yeah, like that's why you were yelling and screaming and possibly abusive or something. But I don't know, it's a really interesting thought puzzle. Yeah, no, it really is. And I, you know, I have to say, this is obviously not, you know, my wheelhouse necessarily, but I think it certainly makes the repairing of the relationship different, right? I mean, I think we tend to moralize behavior before we medicalize it, right? And by the time maybe a diagnosis comes up, a lot of damage has already been done. And relationships certainly do get strained and trust gets broken because nobody realized, right, the brain itself was sick. So that creates certainly, you know, complications going forward about how to think about it. It doesn't mean that the damage wasn't done, though. I think that's a really important thing to point out. Regardless of why it happened, damage is damage to a relationship. And it can be really hard to repair. That phrase, we moralize it, not medicalize it. that is like spot on. I'm even thinking about mental health issues, substance abuse, when the damage is done and then somebody comes back and says, hey, I went through therapy. You know, we see this play out in the pit. We see this play out in the pit. And, you know, people are like, hey, I need time to get over it, but I'm glad that you went on your journey. Yeah, it's like you're playing catch up emotionally almost. You know, things were not good at the end. He was a really different person. And he had a huge temper. Not like when we first got married. I'm so sorry. Could that mass have been there for a while and only recently got worse? Yes. Could it be responsible for how much he changed? You know, his moods and tempers? He was... he was getting into fights with strangers. It's possible. Oh. What do you make of that dynamic and how, maybe how frequent that kind of interaction could happen where you're kind of re-litigating how someone behaved based on new information? I think from a medical perspective, I think it's unlikely that, you know, as we often see with brain tumors, if they're, you know, big enough to make, you know, personality changes, I think the time course was years, many, many years. So I think it was unlikely to be there. But, you know, who knows? It's possible. One thing that what she said kind of, I was feeling a bit, and it's a piece that we maybe don't talk about enough, and that's safety. Sometimes, you know, partners can feel on edge or afraid because behavior can become unpredictable. I think you can love someone and still feel unsafe around them, and that doesn't make you a bad person, right? That's very human. I think illness doesn't automatically make everything okay. So that was like a little bit of energy I was maybe getting from her. And then, you know, I also think, and it happens all the time, and maybe people would ask, like, why is the X still the emergency contact? And that's actually incredibly common, and it's, you know, sometimes we just don't update date those things, but we really should. And at the same time, you know, even if a marriage doesn't survive, that person may still be the one who knows you the best. And if you have a relationship there, somebody who understands your values, that they may be the one showing up in a crisis. So something, you know, just to be thinking about as we all, you know, are planning ahead. Mic drop moment. Emotional mic drop moment. I want to talk a little bit about your work with Robin's Wish. Are we able to draw some parallels between these sorts of neurological conditions and how they can change people's behavior, both in real life and in art, like the storyline in this episode? I do think, you know, is somewhat important to be specific, right? Because it sounds like the person in this particular case had a brain tumor, has a brain tumor, and Robin Williams had Lewy body dementia. But, you know, that documentary is certainly looked at how... how a neurological disease profoundly can impact behavior. With him, it was impulse control, emotional regulation. That often happens years before it's diagnosed. We know how long it takes for people to get an accurate diagnosis. Unfortunately, it was something like that. And so I think from the outside, people thought that he was simply depressed or struggling psychologically, right? when it was his brain undergoing a devastating disease process. I think that mirrors what we see, I think, in this show and in real life all the time. Relationships strain, people get blamed, sometimes marriages fall apart, I think, long before anyone realized the brain itself is sick. And once the diagnosis comes, if it does, families are left often reinterpreting years of pain through a really different lens. I don't think it erases the hurt, of course, but I think it can help people kind of explain and maybe even make meaning out of the struggle they went through. Mm-hmm. Robin's Wish is an incredible film, and I think everyone has some type of memory or touch point with Robin Williams and his work. And so, you know, those last days of his life, as you mentioned, were such a shock for people, and people were speculating, and there's a lot of things flying on the internet. And then you touch on the science and the way the brain responds to illness, to neurodegenerative disease, to mental health issues, all of it. What is something you wish the general public understood more or something that was talked about more as it relates to the way the brain changes and how personalities or relationships may suffer or change? Ooh. Yeah. Man. I think there's so many different things to say about that. my goodness, I would say that we know our loved ones best. So if somebody's behavior is seemingly off to you, trust yourself, trust your judgment, encourage them to go get things checked out. And then on a completely unrelated note, and because of my work with Endwell and thinking about end of life and caregiving, I think it's really important, like we saw with Robin's Wish and what we know caregivers often going through in the context of a particular kind of grief that doesn't get talked about enough, and that's anticipatory grief. If you sort of are seeing someone you love slip away, now, certainly without a diagnosis, you sort of don't know what you're grieving necessarily, but that's a real form of grief. You're mourning the version of someone that you loved. It's their personality, maybe their emotional availability to show up for you, the relationship maybe that you thought you had. And that can feel incredibly lonely because I think socially, there's no permission to grieve someone who's technically alive, right? And I think also, right, caregivers very, very often absorb the hardest parts behind closed doors, right? We don't see it. The outside world, they only see a patient or the person as sick and the caregiver as, you know, being strong for them. And I think so often when caregivers feel burned out, they feel resentful or even like overwhelmed. There's a lot of shame that comes with that. And so I think, you know, that struggle is a really human response to prolonged stress and loss, you know, happening in real time. And I think one of the most important things we can do is name this as grief, not failure and not lack of love, but really grief. Stay curious. Shoshana, Dr. Angleiter, thank you so much for taking the time, for sending us on this thought-provoking emotional rollercoaster as we evaluate aging and change and personalities and grievance and moralizing before medicalizing. That one's going to sit with me. That one's going to sit with me. Thank you. Thank you for being here. Thank you so much. Thanks for having me. After hearing that conversation, I feel like I'm rethinking how personalities and behaviors affect relationships and the amount of patience and empathy we might have. Like, my mind is all over the place. Where's your mind right now? Yeah. No, I feel the same. And I also, I was very moved by this idea of the grief of a caregiver and how you can almost like preemptively grieve someone who's still here, but it's not who you remember them to be. I like naming that because I think it helps sort of normalize it and help us through it. And I know we weren't specifically talking about Langdon and Dr. Robbie, but it came up to me because there is this moment of grieving that Dr. Robbie goes through at the end of season one. And Langdon comes back now and he's like, hey, I went through it. You know, there was a diagnosis. I owned it. I went through rehab. I'm doing the steps. And Dr. Robbie almost seems like he's like, well, I'm grieving the relationship I had. I need my own time. No, that's what I think. It's like emotional catch-up. Langdon is at one place for this relationship, and Robbie is still several places behind trying to figure out how he feels in the moment. I like that this show kind of addresses that from multiple different storylines, from different angles. It's made me think a lot. And it's fascinating how Dr. Robbie and Langdon are still working through it, whereas in this specific case with the brain tumor, they almost patched things up right away, and the empathy was there immediately. Well, I think it's different stakes. Like when you're thinking about a marriage and a divorce and how quickly someone's personality has changed, it feels more urgent maybe in that moment because I think Dr. Robbie is still like, let's keep laying it out and triage and I don't have to deal with out of sight, out of mind. That's it for today's episode of the Pit Podcast. We won't be gone long. Don't worry. We'll be back on Thursday right after the new episode drops. Watch us on HBO Max or listen wherever you get your podcasts. And don't forget to comment with a question, a hypothesis, a diagnosis even, let us know. The Pit Podcast is a production of HBO Max in collaboration with PRX. The executive producer of PRX is Jocelyn Gonzalez. Our managing producer is Courtney Florentine. Our editor is Lucy Perkins. Our production managers are Edwin Ochoa and Tony Carlson. Our video producer and editor is Anthony Q. Artis with assistant editor Damon Durell Hinson. This show is engineered by Tommy Bazarian. Special thanks to Joe Carlino. The executive producer of HBO Podcasts is Michael Gluckstadt. The senior producer is Alison Cohen-Sorokach. And the associate producer is Aaron Kelly. Technical director is In Sung Huang. I'm Alok Patel. And I'm Hunter Harris. We'll see you next week in The Pit.