Country Music Star Tim McGraw on Caregiving and Palliative Care

Shoshana Ungerleider, MD: Good morning.

I know many people are intrigued by what, from the outside, may seem like an unlikely pairing for End Well: a country music legend and a palliative care physician turned entrepreneur.

Welcome, Tim and Jim.

Tim McGraw: Thank you.

Jim Meadows: Thank you.

Shoshana: Jim, I’ll start with you. Five years ago, you were seeing patients in your clinic. Narus did not exist. Today, your team is serving patients nationwide.

How did it begin?

Jim: It was a combination of luck, timing, shared frustration, and strategy. Ultimately, though, it has taken a great deal of hard work from a passionate group of people. I’m proud to represent our team today.

Five years ago, I was minding my own business, working in a large oncology practice. We had a small but excellent palliative care team seeing a couple hundred people each month.

Every day was wash, rinse, repeat. We were doing meaningful work, but only for a small group of people. I would go home with a bittersweet feeling because, for every person we saw, there were 50 we could not reach.

It wasn’t sustainable, and it did not feel as though anything was going to change.

Then a colleague asked me to consult on a man named Tom Cato. I did not know it at the time, but that experience would change my career.

Shoshana: How so?

Jim: Tom was an extraordinary man and became a mentor figure for me. He was a highly successful healthcare executive. If anyone understood the healthcare system, it was Tom.

He was also very Type A. As a clinician, caring for Type A patients can be helpful because they are great historians and take detailed notes. They also want to control everything.

Tom understood that he could not control having a serious illness. But when he suddenly needed to rely on the healthcare system, he became deeply frustrated by his inability to influence even the practical logistics of his care.

Tom died from ocular melanoma in 2014. In addition to the grief his family experienced, the entire process profoundly affected them.

His son Todd left a successful career and said, “I’m going to build a collaborative team that can help people facing this.” He did not yet know exactly what that would look like, but that was the beginning of Narus.

I was fortunate that they asked me to join.

Shoshana: Many entrepreneurs in this field have similar stories. Serious illness and the end of life touch everyone.

Tim, you serve on the board of Narus. How did you become involved?

Tim: Todd had been a friend of mine for a long time. Our children attended school together. I have three daughters, he has two, and they were all around the same age.

I coached his daughters and mine in basketball and softball when they were in grade school. Our families became close.

I also knew his father, Tom. As Jim said, he was a wonderful man, someone you immediately fell in love with.

Todd called me one day and explained that his father had cancer. I understood the impact it was having on him.

When he later told me that he wanted to start this company, I said, “I’m there. Absolutely.”

Shoshana: You have also known people throughout your life who experienced serious illness or lost someone they loved. Was there something different about Tom’s experience?

Tim: We all know that life is not a linear process. We see wonderful people develop serious illnesses that no one deserves.

What stood out to me, both in my own life and in watching Todd’s family, was the difficulty of the process surrounding the illness.

It was hard to understand what the doctors were communicating and to bring all the information together. Families had to explain the same things repeatedly to different physicians. They had to revisit and relive painful details, manage medications, and constantly rehash what was happening.

Many people here understand that experience. But when you first enter it with your own family, it feels like stepping into a Nashville recording studio and being asked to read a music chart without knowing the language.

It takes a great deal of work simply to understand what is happening.

Shoshana: You’re absolutely right. My husband and I were recently discussing how difficult the system is to navigate and how medicine often has a language of its own.

Even as a physician, I can tell you that navigating it from the inside is incredibly hard. It is frustrating for everyone involved.

Jim: I think every participant is frustrated because the system has gradually evolved into what it is.

Physicians are frustrated. Payers are frustrated. But the patients and families are the most vulnerable people in the process, and they bear the greatest burden.

That should not be the case.

Shoshana: Tim, you mentioned that Tom’s illness occurred around a decade after your father was diagnosed with glioblastoma.

Tim: Yes.

I did not know my father very well growing up. I discovered that my father was Tug McGraw, the professional baseball player, when I found my birth certificate while looking through my mother’s closet.

I grew up in a small town in Louisiana, in a rural community with very little money. Discovering who my father was is a long story of its own.

We came to know each other when I was an adult. We were beginning to learn more about one another and reconcile parts of the past when he was diagnosed.

We had a lot of support during his illness. Many people were around us and willing to help.

Even with those resources, the experience was difficult to navigate.

When Todd said that he wanted to build a company specifically to address those challenges, I thought, “We should have had this when we were going through it.”

Shoshana: The more people understand what palliative care is, and how it can support patients and families early in the course of an illness, the better.

Having an advocate like you can make a real difference.

Tim: I’m grateful to have a platform that can help. I feel fortunate that I’m able to use it that way.

Shoshana: What exactly does Narus do?

Jim: Anyone who knows palliative care physicians knows that brevity is not our strongest quality. We bill by time.

In a nutshell, we identify people who need our help now, or who are likely to need it soon. We reach out, explain the service, and enroll them with their consent.

Our goal is to build an alliance with the patient so that they see us as an unbiased, trusted advocate throughout their healthcare experience.

They can bring us anything connected to that journey, and it becomes our responsibility to work on their behalf.

We do not want patients and families spending valuable time chasing logistical details. We are connected to the system, so we can do that work for them.

Tom was frustrated by the process, and his family was frustrated as well. We understand the importance of engaging families and caregivers.

With the patient’s permission, we contact the relevant stakeholders and communicate with family members wherever they may be. We help everyone stay informed in real time.

As a physician, I understand both the value and the potential frustration of having a third party involved in the relationship between a doctor and patient.

That is why we work collaboratively with all treating physicians. We connect the information on the back end and try to give doctors more useful information than they had before.

Shoshana: I love that. Collaboration and teamwork are essential.

Tim: When someone believes they have limited time remaining with their family, the last thing the patient or family wants to manage is a long list of tasks.

Serious illness is already frightening and anxiety-producing. Communicating with relatives, keeping everyone informed, and trying to make decisions can create enormous stress and even conflict within families.

Having someone who has your back, supports you, and helps keep everyone on the same page is what Narus is about.

My wife, Faith, and I experienced this ourselves when she lost her father earlier this year.

He lived out of state, and our family was spread across different places. We enrolled with Narus just like any other family.

They assembled a team for us and created a system for communicating through calls and text messages.

For many people, communicating from a distance can feel safer and more comfortable. You can keep your notes in front of you and take time to formulate your questions.

When you are face-to-face with a doctor, anxiety can cause you to forget what you wanted to ask. The doctor has limited time, and so do you.

Being able to communicate in different ways, on your own time, can help people open up and feel more comfortable.

Shoshana: I love that you are both a board member and someone who has used the service.

Tim: It was incredibly helpful. It relieved a layer of anxiety and allowed us to spend meaningful time with Faith’s father during the final month of his life.

Shoshana: You recorded what may be the greatest song about living with limited time, “Live Like You Were Dying.”

You mentioned your father’s death. Would you share how that experience influenced the song, how caregiving affected you as an artist, and what it is like to perform the song now?

Tim: As an artist, you are always looking for a way to connect with your audience. That connection is what makes the experience work for you and for them. It is where the cathartic power of music comes through.

“Live Like You Were Dying” is a special song. It moves me every time I sing it.

I do not feel as though it belongs to me. I feel like I happened to be the vessel through which it came.

You can see how deeply it touches people. Audience members arrive while going through serious illnesses or other struggles. When we perform that song, you see people put their arms around one another.

You see families huddled together, crying and singing along.

It gets me choked up even talking about it.

The song was written by Tim Nichols and Craig Wiseman. I found it when my father was ill, but I never played it for him.

I did not record it until after he died. I had the demo while he was alive, but I did not want to press that emotional button. I did not know how it would affect him.

About three weeks after he died, my band and I rented a studio in upstate New York. It was an old farmhouse on thousands of acres at the top of a mountain. There were three feet of snow outside and large fireplaces burning inside.

The vocal booth was made of glass, with the band surrounding me.

My uncle Hank, my father’s brother, had joined us from the Bay Area. He was sitting on a couch nearby.

We had been recording most of the evening. At around two in the morning, I looked at Uncle Hank and the band and said, “I think this is the right time to record ‘Live Like You Were Dying.’”

We began recording, and I could see my uncle sitting on the couch, crying the entire time.

The version you hear on the radio is the one we recorded that night, with me watching my uncle and thinking about his brother.

It was a very special moment for all of us.

Shoshana: Jim, where is Narus today? Has the company developed the way you expected?

Jim: Thanks for making me follow that.

It has not developed exactly as we expected, but that is okay.

We always knew what we wanted to do, whom we wanted to serve, and the kinds of people we hoped to help. That has never changed.

We also knew we wanted a large footprint because many people in need do not have a palliative care physician nearby.

We built tools to help us reach them, but we never expected employers to become as involved as they have.

Originally, we thought we would primarily partner with insurance payers. That seemed logical. Payers cover millions of lives and are always looking for ways to reduce costs and improve outcomes.

We had many positive meetings. Every meeting ended with some version of, “This is great. We’ll follow up.”

But payers move slowly. When you are a startup attempting to work with an organization that has a three-year implementation plan, it can strangle you.

Then a self-insured Nashville company approached us. It was a sizable employer spending approximately $50 million per year on healthcare.

The company was frustrated because its leaders did not understand what they were purchasing or the quality of care their employees were receiving.

They wanted help.

We had a solution that we believed could improve quality and support, strengthen the company’s culture, and hopefully reduce costs.

We began collaborating, and they agreed to try it.

They became our first client in July 2017.

At that point, we did not know whether people would welcome the service. We were flying in the dark.

It worked extremely well.

Over the following two and a half years, we formed several important relationships, including a strategic partnership with Lucent Health.

Today, we have approximately 170 clients and provide some form of support to 150,000 people.

It has been remarkable.

Shoshana: That is incredible. Congratulations.

Tim, you are passionate about helping people care for themselves physically and mentally. Part of that awareness came from the strain you and Faith experienced as caregivers.

What did you learn?

Tim: Over the last ten years, and especially during the last three or four, I have focused on understanding what helps me care for myself physically and mentally.

The two are deeply connected, especially when stress is involved.

Taking care of yourself is important. So is forgiving yourself.

We all have things we need to look at in the mirror and forgive ourselves for. Forgiveness is an incredibly empowering tool.

When you learn to forgive yourself, you create more room to forgive other people and to accept forgiveness from them.

That is part of well-being. It allows you to be more present for other people.

It matters for you, your family, and your friends. It is especially important for caregivers.

I often use the oxygen-mask analogy because I am a pilot and it resonates with me.

On an airplane, you are told that if the cabin loses pressure, you should place your own oxygen mask on first before helping the person beside you.

That is because you need to remain conscious and capable if you are going to care for your children or anyone else who depends on you.

The same principle applies throughout life.

Care for yourself physically and mentally, especially when you are caring for others. It allows you to be more present for the people who need you.

Shoshana: We were discussing burnout among clinical staff. We know it is an enormous issue in this country, and it is something your team is working to address.

What are you doing?

Jim: Burnout is a major concern, especially in palliative care. It is difficult work.

I experienced burnout myself. I did not always care for myself in the ways I should have, and perhaps I still do not.

We did not want Narus to contribute to burnout or overextend our team.

We have implemented several ways to support our staff. One involves examining each team member’s workload within our system.

We look beyond the number of patients assigned to someone. Five patients may be relatively straightforward, while another group of five may be emotionally and medically exhausting.

We examine the medical complexity of each case, as well as the psychosocial issues involved.

Each team member can also give a subjective assessment of how demanding a case feels.

We combine all of that information to help ensure that everyone is working within their capacity.

Over time, we continue learning what makes one case more complex or demanding than another. It functions as a kind of barometer for our team.

Shoshana: I love that you are learning in real time and collecting data about social determinants of health, caregiver availability, and the realities of people’s everyday lives.

Much of the country music I love is about those real-life experiences.

Tim, is that part of what drew you to Narus?

Tim: Absolutely.

I run a company. I have employees, a band, staff, and management teams. Many people depend on me, and I depend on them.

We are a family.

As an employer, I want to support the people who work for me and their families.

We should all strive to do more of that. We need to be present for ourselves, for the people who work with us, and for the people we love.

Narus is a powerful tool for employers who want to offer that support.

Shoshana: The service goes beyond traditional healthcare. You approach care and data differently.

How far are companies willing to go to support their employees?

Jim: It has been refreshing.

Many companies were already thinking outside the box when they considered our service, especially self-insured employers.

Business owners want their organizations to succeed, but they also want to care for their people.

Employers are highly motivated, and they want us to become involved quickly and meaningfully.

Our team enjoys learning about the different companies we serve because each one has its own culture and personality.

Some clients now hire us to support their employees’ aging parents, even when those parents are not covered by the company’s health plan.

Employers recognize the strain on people in the sandwich generation who are raising young children while caring for parents who may live a thousand miles away.

They are asking us to support those parents because doing so improves employee engagement and productivity.

It is an incredible benefit for employees, and we are excited about where this work is going.

Shoshana: I am thrilled by what Narus is doing and grateful to have both of you here.

We look forward to following the company’s continued growth and seeing how your work improves the lives of people and families facing serious illness.

Thank you both so much.

Tim: Thank you.

Jim: Thank you, and thank you for all the good work you do.