Making Sense - Sam Harris - September 21, 2017


#98 — Into the Dark Land


Episode Stats

Length

29 minutes

Words per Minute

148.7755

Word Count

4,459

Sentence Count

198

Misogynist Sentences

2


Summary

Siddhartha Mukherjee is a cancer physician and researcher. He is an assistant professor of medicine at Columbia University and a staff cancer physician at Columbia NYU Presbyterian Hospital. He graduated from Stanford and Oxford where he received a PhD studying cancer-causing viruses and from Harvard Medical School where his lab focuses on discovering new cancer drugs using various biological methods. He s published everywhere you would expect, but he s also a regular writer for The New Yorker, and he has won the Pulitzer Prize for his book, The Emperor of All Maladies: A Biography of Cancer. And our conversation ranges widely from his experience as an oncologist, how to think about a cancer diagnosis, the biology of cancer, how the mapping of the human genome has changed our understanding of cancer and the possibilities of treatment, how cancer spreads, and the difference between remission and cure. There s a lot here, and it was great to steal another hour of Siddhartha s time. Sam Harris This is a really important conversation, and before you decide that you don t feel like listening to a conversation about cancer, please reflect on the fact that you or someone close to you will almost certainly get it. This is made possible entirely through the support of our subscribers. So, I'm really looking forward to having this conversation because we only had about 10 minutes last time around to touch on this all too important topic. I can imagine that being an ER doc is not at all the same thing as being a dermatologist, is it? In order to access full episodes of the Making Sense Podcast, you ll need to subscribe to your favorite podcatcher, you'll need to SUBSCRIBE at Samharris.org, which will help you become a supporter of the podcast, by becoming a member of The Making Sense podcast? You'll get access to everything that we're doing here? And a chance to hear more like that, I'll be hearing more of it, I won't need to become a member, I get it, too, I know that I'm making sense, I can get more of that, right? - Sam Harris, too says it, right he s got it, he says so, I hear you, too he s not just that, he s made it, so I'll hear it, I'll say it, He s made that right, right He s not only that, so he s that too, right I say it.


Transcript

00:00:00.000 Welcome to the Making Sense Podcast.
00:00:08.820 This is Sam Harris.
00:00:10.880 Just a note to say that if you're hearing this, you are not currently on our subscriber
00:00:14.680 feed and will only be hearing the first part of this conversation.
00:00:18.420 In order to access full episodes of the Making Sense Podcast, you'll need to subscribe at
00:00:22.720 samharris.org.
00:00:24.060 There you'll find our private RSS feed to add to your favorite podcatcher, along with
00:00:28.360 other subscriber-only content.
00:00:30.260 We don't run ads on the podcast, and therefore it's made possible entirely through the support
00:00:34.640 of our subscribers.
00:00:35.880 So if you enjoy what we're doing here, please consider becoming one.
00:00:46.480 Today's podcast, I think, is a really important conversation.
00:00:51.260 It is a conversation about cancer.
00:00:53.080 And before you decide that you don't feel like listening to a conversation about cancer,
00:00:58.760 please reflect on the fact that you or someone close to you will almost certainly get it.
00:01:05.700 This is just a virtual guarantee.
00:01:08.980 My father died of cancer.
00:01:11.180 I've had friends die of cancer.
00:01:13.500 Someone in my own family has cancer now.
00:01:15.780 This is just all around you, whoever you are.
00:01:20.700 And today's guest is one of the great authorities on the topic.
00:01:24.700 You've heard him before on the podcast, but today I'll be speaking with Siddhartha Mukherjee
00:01:29.460 about the topic with which he is most closely associated.
00:01:34.380 Siddhartha is a cancer physician and researcher.
00:01:37.660 He is an assistant professor of medicine at Columbia University and a staff cancer physician
00:01:42.700 at Columbia NYU Presbyterian Hospital.
00:01:46.200 He's a former Rhodes Scholar.
00:01:48.200 He graduated from Stanford and Oxford, where he received a PhD studying cancer-causing viruses
00:01:55.160 and from Harvard Medical School.
00:01:58.520 And his laboratory focuses on discovering new cancer drugs using various biological methods.
00:02:04.640 He's published everywhere you would expect, but he's also a regular writer for The New Yorker.
00:02:09.960 And he has won the Pulitzer Prize for his book,
00:02:15.180 The Emperor of All Maladies, A Biography of Cancer.
00:02:18.660 And our conversation ranges widely from his experience as an oncologist,
00:02:24.900 asking many questions from both a patient and doctor-centered point of view,
00:02:30.240 how to think about a cancer diagnosis, the biology of cancer,
00:02:35.460 how the mapping of the human genome has changed our understanding of cancer
00:02:40.400 and the possibilities of treatment,
00:02:42.440 how cancer spreads.
00:02:45.080 We talk about whether we're always getting cancer and simply fighting it.
00:02:49.540 We talk about the difference between remission and cure.
00:02:54.360 We talk about how much of cancer is due to environmental causes.
00:02:57.940 There's a lot here, and it was great to steal another hour of Siddhartha's time.
00:03:02.300 So, without further delay, I bring you Siddhartha Mukherjee.
00:03:13.660 I am here with Siddhartha Mukherjee.
00:03:15.880 Siddhartha, thanks for coming back on the podcast.
00:03:18.360 My pleasure. Thank you.
00:03:19.680 So, the last time around, we spoke about your more recent book,
00:03:23.900 The Gene, which was fascinating and also led us a little further afield
00:03:29.960 than at least you realized we would go.
00:03:32.580 I had just come fresh off my controversial podcast with Charles Murray
00:03:36.060 and then led us into a discussion about the genetics of intelligence
00:03:41.440 or suspicions of such
00:03:43.560 and exhausted both of our interests, if not our patience, on that topic.
00:03:48.760 I won't do that again this time around
00:03:50.820 because we're talking today about your book
00:03:55.060 for which you are certainly best known
00:03:57.740 and for which you won the Pulitzer Prize,
00:04:01.200 The Emperor of All Maladies, A Biography of Cancer.
00:04:04.640 And you are an oncologist
00:04:07.720 and spend a considerable amount of your time
00:04:10.480 working with patients and also doing research
00:04:12.700 into the biology of cancer.
00:04:14.620 So, I'm really looking forward to having this conversation
00:04:17.720 because we only had about 10 minutes last time around
00:04:21.200 to touch on this all-too-important topic.
00:04:24.180 First, before we get into the biology of cancer and treatment,
00:04:29.720 what's your story here
00:04:31.780 in terms of how you got into becoming an oncologist?
00:04:35.560 People tend not to think
00:04:37.000 about how the different medical specialties
00:04:40.660 dictate a very different experience
00:04:43.400 from the side of the doctor.
00:04:45.940 I can imagine that being an ER doc
00:04:48.100 is not at all the same as being a dermatologist.
00:04:52.080 I mean, you don't get calls in the middle of the night
00:04:53.860 when you're a dermatologist.
00:04:55.040 You're not constantly seeing people die.
00:04:57.800 I would imagine you're dealing as much with human vanity
00:05:01.100 as with actual health concerns.
00:05:03.900 First, what is the experience of being an oncologist?
00:05:08.180 Because it seems like it would be emotionally very challenging.
00:05:10.940 And how did you decide to take this on yourself?
00:05:14.580 So, I came into cancer medicine a little bit in reverse.
00:05:20.220 In the 90s, I was at Oxford.
00:05:24.040 I was training as an immunologist.
00:05:25.800 My graduate work is in immunology.
00:05:27.800 I was interested in vaccines.
00:05:29.160 You know, this is a time when
00:05:30.500 the immunology revolution was taking off.
00:05:33.720 And it was researchers,
00:05:39.520 the biology community had just figured out
00:05:41.320 sort of some of the most important things
00:05:43.180 about how the immune system works,
00:05:45.300 how it might allow for enabled vaccination and so forth.
00:05:49.560 So, I went to Oxford and I studied viruses.
00:05:52.760 I was an immunologist and a virologist by training.
00:05:56.560 The one particular virus that I got interested in
00:05:58.500 is actually a major human pathogen
00:06:01.660 called Epstein-Barr virus, EBV.
00:06:06.020 And part of the reason that we still deal with it
00:06:11.120 is that it's one of those strange viruses
00:06:12.740 that lives in the human body
00:06:15.200 but doesn't seem to cause overt disease.
00:06:18.780 I'll come back to the word overt in a second.
00:06:20.580 But virtually all of us have Epstein-Barr virus.
00:06:24.960 This is a virus that's evolved with us,
00:06:26.960 with human species for tens of thousands,
00:06:31.500 hundreds of thousands of years.
00:06:34.620 And, you know, there may be 70 to 80% of people
00:06:37.480 are infected in some parts with EBV.
00:06:39.860 And it seems our immune system
00:06:41.780 doesn't seem to reject it.
00:06:43.600 We never clear it during our lifetime.
00:06:46.020 So, the question I was interested in is
00:06:47.340 why is it that we don't clear Epstein-Barr virus
00:06:50.240 whereas, you know, if you have influenza,
00:06:52.600 if you have the flu,
00:06:53.800 you get the flu,
00:06:54.760 your body clears the flu,
00:06:56.000 and you don't have flu virus left in your body.
00:06:58.080 What's the difference between these two things?
00:07:00.020 Why is it the flu gets cleared
00:07:01.440 while EBV remains persistent?
00:07:04.600 And I tried to solve it.
00:07:06.140 I partly, you know,
00:07:06.980 I helped partly solve that mystery.
00:07:09.980 But then it became obvious to me
00:07:12.320 if you read the epidemiology of EBV,
00:07:15.220 it turns out that, in fact,
00:07:16.620 this word, it doesn't cause overt disease,
00:07:19.240 but, in fact,
00:07:20.800 there's a long history of it being linked
00:07:24.220 to various cancers,
00:07:25.700 including lymphomas and other cancers.
00:07:28.160 In fact, it is,
00:07:30.360 the links between EBV and cancer are quite deep.
00:07:34.480 And so,
00:07:35.600 I began to,
00:07:36.300 became more interested in cancer,
00:07:38.240 began to think more and more about cancer.
00:07:39.640 Cancer genetics,
00:07:40.920 why is it that,
00:07:41.920 what genes in EBV allow it
00:07:43.560 to do the things that it does?
00:07:44.860 Why is it able to stay persistent
00:07:47.240 in the human host?
00:07:48.900 And I became interested in cancer.
00:07:51.300 And as I became more and more interested in cancer,
00:07:54.060 became more and more interested
00:07:55.000 in going to, you know,
00:07:56.220 thinking about cancer medically,
00:07:57.820 and then became an oncologist.
00:07:59.260 So,
00:07:59.880 I sort of did my,
00:08:01.200 I came into cancer
00:08:02.580 through the world of science and immunology.
00:08:05.480 And it's,
00:08:06.260 it's only interesting
00:08:08.120 because immunology,
00:08:09.380 as you might know,
00:08:10.140 has suddenly come alive
00:08:11.160 in the world of cancer again.
00:08:13.220 The question you asked is,
00:08:14.160 you know,
00:08:14.360 what is it,
00:08:14.800 what is it like to being,
00:08:16.120 what is it like being an oncologist?
00:08:17.700 Well,
00:08:17.860 it's,
00:08:18.240 it's,
00:08:19.440 it's very unlike,
00:08:21.880 the examples you gave,
00:08:23.000 it's very unlike being in the emergency room.
00:08:27.100 Because you,
00:08:28.280 you need to,
00:08:31.000 things change extremely quickly.
00:08:33.140 The things that I knew
00:08:35.720 were absolute certainties
00:08:38.200 in 10 years ago,
00:08:40.460 five years ago.
00:08:41.800 So,
00:08:42.080 I think one of the things
00:08:43.160 about being an oncologist
00:08:44.480 is that you,
00:08:46.440 the amount of information
00:08:48.080 and the,
00:08:48.420 and the,
00:08:48.780 the rapidity with it,
00:08:50.320 with which it changes
00:08:51.680 is striking.
00:08:53.620 Things that I knew
00:08:54.440 as absolute certainties
00:08:56.100 10 years ago
00:08:56.800 are up in question now.
00:09:00.040 You know,
00:09:00.740 10 years ago,
00:09:01.540 if someone told me
00:09:02.360 that we would be
00:09:03.000 manipulating the human immune system
00:09:05.000 to reject cancers,
00:09:07.180 I would say,
00:09:07.700 ah,
00:09:07.900 chances of that being true
00:09:09.240 are pretty minor.
00:09:11.200 10 years later,
00:09:12.420 you know,
00:09:13.380 that's the new direction of cancer.
00:09:15.440 So,
00:09:16.140 that's one of the surprising things.
00:09:17.500 You don't get up
00:09:18.100 in the middle of the night
00:09:19.260 like a surgeon might,
00:09:22.340 or as often as a surgeon might,
00:09:24.180 but you stay up
00:09:26.220 in,
00:09:26.880 in the middle of the night
00:09:27.700 because you're finding out new things
00:09:29.280 that wouldn't be the case
00:09:30.800 10 years ago.
00:09:32.460 Do you work with children
00:09:33.760 as well
00:09:34.300 or only adults?
00:09:35.800 I,
00:09:36.320 I do all my work
00:09:37.240 with adults,
00:09:37.860 although,
00:09:38.480 you know,
00:09:39.600 within the word of cancer,
00:09:41.400 leukemia is one area
00:09:43.240 that I particularly
00:09:43.880 am interested in.
00:09:45.780 It's a funny,
00:09:46.640 it's a funny story,
00:09:48.160 Sam,
00:09:48.900 the,
00:09:49.120 the leukemia
00:09:50.560 for the,
00:09:50.920 for the longest time,
00:09:52.640 blood cancers
00:09:53.360 led the charge
00:09:55.140 in the science
00:09:55.860 and treatment of cancer.
00:09:56.880 and what we can,
00:09:58.460 we can explore why,
00:09:59.480 there's sort of deep reasons why.
00:10:01.540 And then,
00:10:02.480 now,
00:10:03.320 the world of cancer
00:10:04.160 is moving beyond leukemias
00:10:05.800 and looking for,
00:10:07.120 you know,
00:10:07.320 how to,
00:10:07.700 how to take those lessons
00:10:08.780 and learn them
00:10:10.320 in,
00:10:10.940 in solid cancers
00:10:12.820 like breast cancer
00:10:14.420 and lung cancer.
00:10:15.680 So,
00:10:16.400 so I see both,
00:10:18.140 I see all,
00:10:19.020 I see,
00:10:19.800 but mainly,
00:10:20.460 I'm still interested
00:10:21.340 in blood cancers.
00:10:23.040 The history here,
00:10:24.220 again,
00:10:24.520 I'm now focusing
00:10:25.380 not so much on the disease,
00:10:26.820 but on the,
00:10:27.340 the doctor,
00:10:28.900 patient experience.
00:10:30.400 There really was this
00:10:31.400 amazing stigma
00:10:32.840 associated with cancer.
00:10:34.740 I recall
00:10:35.340 a story about
00:10:36.780 my own grandmother
00:10:37.660 who I never met
00:10:38.380 who died before I was born
00:10:39.580 where she had
00:10:42.080 metastatic melanoma
00:10:43.560 and was in the hospital
00:10:46.020 really to die,
00:10:48.140 but I believe
00:10:49.180 it's true to say
00:10:49.900 that she was never told
00:10:51.460 her prognosis at all.
00:10:53.160 In fact,
00:10:53.520 she was lied to
00:10:54.440 about what it was.
00:10:56.080 I think she was told
00:10:56.760 she had arthritis
00:10:57.660 and would recover.
00:10:59.700 I mean,
00:10:59.840 it's just something
00:11:00.320 so unthinkable
00:11:02.120 at this moment.
00:11:03.840 It used to be,
00:11:04.520 I don't know how widespread
00:11:05.400 this practice was,
00:11:06.540 but I've heard from,
00:11:07.380 from many other sources
00:11:08.260 that it,
00:11:08.660 that it was routine
00:11:09.460 for doctors
00:11:10.700 to lie to patients
00:11:12.200 about their prospects,
00:11:13.640 especially women patients,
00:11:15.580 and this is sometimes
00:11:16.580 in collaboration
00:11:17.220 with their husbands.
00:11:18.800 And there was,
00:11:19.560 there was one point
00:11:20.340 in your book
00:11:20.820 where you painted a picture,
00:11:22.180 a very flattering picture
00:11:24.780 of one of the people
00:11:26.240 you studied under,
00:11:27.260 I believe it was Thomas Lynch,
00:11:28.600 a lung cancer specialist,
00:11:30.380 and you described him
00:11:31.480 as a kind of virtuoso
00:11:33.520 of telling people bad news.
00:11:36.740 But there was a kind of,
00:11:38.460 correct me if I'm wrong,
00:11:39.280 but there seemed to be
00:11:39.820 a kind of necessity
00:11:41.000 of shading the truth
00:11:42.660 even there.
00:11:44.020 How do you think about this?
00:11:46.060 What was the practice then,
00:11:47.340 and what is the practice now
00:11:49.080 in terms of delivering bad news
00:11:52.100 in a context of real uncertainty?
00:11:55.340 Because it seems to me
00:11:56.240 that oncologists must,
00:11:58.460 in many cases,
00:11:59.200 take refuge in uncertainty.
00:12:01.300 Because even in the most
00:12:02.260 dire circumstances,
00:12:03.840 there are still these stories
00:12:04.980 of the, you know,
00:12:05.560 the outliers,
00:12:06.480 the less than 5% cases
00:12:08.860 where someone makes a recovery
00:12:11.040 even from some fairly dire
00:12:13.660 stage 4 diagnosis.
00:12:16.620 It's a complicated issue,
00:12:17.940 as you point out,
00:12:18.860 and it's an important question.
00:12:20.880 And I think the capacity
00:12:24.500 to take refuge in uncertainty
00:12:26.140 is an important
00:12:27.400 philosophical question, actually.
00:12:29.020 I mean, you know,
00:12:29.420 to what extent are human beings
00:12:31.620 allowed to take refuge
00:12:32.900 under uncertainty?
00:12:36.000 And to what extent
00:12:37.160 does that become
00:12:38.040 a kind of opium?
00:12:39.360 So, I think oncologists
00:12:44.480 have very individual styles
00:12:45.960 around this.
00:12:47.980 But there's,
00:12:49.600 the one thing I think
00:12:50.540 you learn
00:12:51.280 in cancer
00:12:54.280 is that hope
00:12:56.420 is negotiable.
00:12:57.360 negotiable.
00:13:00.240 And that you
00:13:01.640 navigate your way
00:13:03.520 through
00:13:04.240 an individual's
00:13:05.980 journey,
00:13:09.360 your patient's journey
00:13:10.440 through their cancer.
00:13:12.300 I think the most
00:13:13.280 important thing
00:13:14.180 that I try
00:13:16.220 to convey to patients,
00:13:17.560 and I think the field
00:13:18.400 has tried
00:13:19.180 somewhat now,
00:13:20.520 is to convey
00:13:21.940 that uncertainty
00:13:22.620 without
00:13:23.060 sort of
00:13:24.280 washing it up
00:13:25.920 and cleansing it
00:13:27.080 and sterilizing it.
00:13:29.600 And that's a tough
00:13:30.760 question.
00:13:31.780 That's a tough thing
00:13:32.480 to convey
00:13:33.180 because on one hand,
00:13:34.580 there is the
00:13:35.480 hard
00:13:36.680 statistics.
00:13:39.120 But on the other hand,
00:13:40.360 there are
00:13:41.240 the individual truths,
00:13:42.700 whether you lie
00:13:43.280 within the
00:13:44.460 distribution
00:13:45.260 of patients
00:13:46.560 who are likely
00:13:47.080 to die in five months
00:13:48.100 or whether you
00:13:48.640 will be the one.
00:13:49.600 Your patient
00:13:50.120 will happen
00:13:51.060 to be the one
00:13:51.760 who will survive
00:13:53.340 at that time.
00:13:54.360 I think
00:13:56.560 that the most
00:13:57.300 honest way
00:13:58.220 of dealing
00:13:58.640 with it
00:13:59.200 is
00:13:59.740 to imagine
00:14:03.700 this as a process.
00:14:05.260 That on day one,
00:14:06.480 when I meet someone,
00:14:07.760 I can give them
00:14:08.360 the bare statistics,
00:14:10.060 and then
00:14:10.320 I try
00:14:12.040 to also
00:14:13.460 describe
00:14:14.200 what the
00:14:15.420 outliers
00:14:15.860 look like.
00:14:17.000 Who is an
00:14:17.780 outlier?
00:14:18.820 Why I think
00:14:19.700 they were
00:14:20.040 outliers.
00:14:20.760 Is it because
00:14:21.300 of the location
00:14:22.020 of the cancer
00:14:22.580 they had,
00:14:23.500 the genetics
00:14:24.040 of the cancer,
00:14:24.840 the genes
00:14:25.320 that the cancer,
00:14:26.020 the mutations?
00:14:27.140 Is it because
00:14:27.980 they happened
00:14:28.820 to have a
00:14:29.280 particularly
00:14:29.840 successful
00:14:30.540 surgical resection?
00:14:32.120 Is it that
00:14:32.560 they were
00:14:32.820 the best
00:14:33.380 responders
00:14:33.900 to that
00:14:34.300 particular
00:14:34.720 chemotherapy?
00:14:35.520 So I try
00:14:35.840 to describe
00:14:36.440 that.
00:14:37.460 And I tell
00:14:38.100 people honestly
00:14:39.040 that I don't
00:14:39.640 know where
00:14:40.060 they will sit,
00:14:40.900 but the curve,
00:14:43.620 the mean,
00:14:45.080 the medians
00:14:45.620 look like this.
00:14:47.120 And then
00:14:47.480 in time,
00:14:48.400 the next time
00:14:48.900 I meet them,
00:14:49.500 I know
00:14:50.120 a little
00:14:50.340 bit more.
00:14:52.320 And so
00:14:52.580 I'll modify
00:14:53.460 my understanding.
00:14:55.780 If you wanted
00:14:56.360 to have a
00:14:56.760 formal name
00:14:57.260 for it,
00:14:57.580 this is
00:14:57.900 Bayesian
00:14:58.300 statistics.
00:14:59.380 It's a wise
00:15:00.060 way of thinking
00:15:00.580 about the
00:15:00.940 world.
00:15:01.500 When you
00:15:02.140 take your
00:15:02.660 priors and
00:15:03.440 you modify
00:15:03.980 your priors
00:15:04.760 to make
00:15:06.120 conclusions
00:15:06.600 about how
00:15:07.840 these people,
00:15:08.520 how individuals
00:15:09.160 will behave
00:15:09.820 given the
00:15:11.460 circumstances.
00:15:12.860 I think,
00:15:13.840 and I've
00:15:14.240 written about
00:15:14.760 it,
00:15:15.440 I think
00:15:15.680 Bayes'
00:15:16.140 insight into
00:15:16.920 the world,
00:15:17.460 Thomas Bayes'
00:15:18.040 insight into
00:15:18.540 the world
00:15:18.780 is very
00:15:19.240 profound.
00:15:20.620 And medicine
00:15:20.920 is still
00:15:21.480 trying to
00:15:21.960 deal with
00:15:22.340 it.
00:15:22.500 We're
00:15:22.600 coming to
00:15:23.080 terms
00:15:23.400 with
00:15:23.640 that
00:15:23.760 idea.
00:15:25.660 Again,
00:15:25.820 in terms
00:15:26.220 of your
00:15:26.780 emotional
00:15:27.460 experience
00:15:28.080 as a
00:15:28.520 physician,
00:15:29.600 I remember
00:15:29.960 at one
00:15:30.200 point in
00:15:30.480 the book,
00:15:30.840 I think
00:15:31.280 you were
00:15:31.520 describing
00:15:32.040 what it
00:15:32.360 was like
00:15:32.640 to be
00:15:33.200 a resident
00:15:34.060 at that
00:15:34.400 point.
00:15:34.820 I don't
00:15:35.060 know how
00:15:35.360 it's
00:15:35.660 since
00:15:36.000 changed,
00:15:37.000 but you
00:15:37.640 were
00:15:37.780 talking
00:15:38.080 about
00:15:38.380 a
00:15:38.540 kind
00:15:38.860 of
00:15:39.180 professionalization
00:15:41.140 of your
00:15:42.280 emotional
00:15:43.560 range
00:15:44.240 in the
00:15:44.660 presence
00:15:45.120 of
00:15:45.740 these
00:15:47.020 distraught
00:15:47.680 families
00:15:48.240 or patients
00:15:49.580 for whom
00:15:50.500 you have
00:15:50.940 to deliver
00:15:51.760 very scary
00:15:53.420 news.
00:15:54.300 And you
00:15:54.580 were talking
00:15:54.900 about that
00:15:55.320 as a
00:15:55.840 kind of
00:15:56.760 necessity,
00:15:57.380 but also
00:15:57.740 as a
00:15:58.160 perhaps a
00:15:58.960 psychological
00:16:00.080 or ethical
00:16:01.140 error.
00:16:02.440 you obviously
00:16:03.800 weren't
00:16:04.040 comfortable
00:16:04.500 with this
00:16:05.240 change
00:16:06.080 that was
00:16:06.340 coming over
00:16:06.800 you,
00:16:07.220 how this
00:16:07.820 was becoming
00:16:08.280 you had
00:16:08.820 a routine
00:16:09.980 way of
00:16:11.380 distancing
00:16:12.400 yourself
00:16:13.060 from
00:16:13.560 the pain
00:16:15.240 or just
00:16:16.260 kind of
00:16:16.700 dampening
00:16:17.240 down
00:16:17.580 your
00:16:18.040 empathy
00:16:19.400 so as
00:16:19.880 not to
00:16:20.200 be
00:16:20.480 bowled
00:16:21.000 over
00:16:21.320 every
00:16:21.600 time
00:16:21.940 you had
00:16:22.380 to
00:16:22.560 talk
00:16:23.020 to
00:16:23.180 a
00:16:23.880 very
00:16:24.160 sick
00:16:24.440 patient.
00:16:25.240 How
00:16:25.580 has
00:16:25.820 that
00:16:26.180 evolved
00:16:27.220 for you
00:16:27.820 and is
00:16:28.740 there an
00:16:30.380 optimal
00:16:30.860 way of
00:16:32.100 being
00:16:32.520 in that
00:16:33.560 role?
00:16:34.620 I don't
00:16:34.780 know if
00:16:35.020 there's an
00:16:35.380 optimal
00:16:35.820 way of
00:16:36.180 being in
00:16:36.420 that role
00:16:36.700 but I
00:16:37.080 think that
00:16:37.400 the conflict
00:16:38.220 that you're
00:16:38.640 talking about
00:16:39.260 is very
00:16:39.580 important
00:16:40.000 because
00:16:40.420 the
00:16:41.160 professionalization
00:16:42.460 of empathy
00:16:43.240 is a
00:16:45.380 rather dire
00:16:45.940 thing as
00:16:46.760 you can
00:16:47.020 imagine.
00:16:48.960 It creates
00:16:49.900 all sorts
00:16:52.740 of internal
00:16:54.020 conflicts.
00:16:54.780 I mean
00:16:54.920 there are
00:16:56.280 now classes
00:16:57.200 which hope
00:17:01.180 to
00:17:01.540 professionalize
00:17:02.820 medical
00:17:03.180 empathy.
00:17:04.580 There are
00:17:04.900 good things
00:17:05.420 about that.
00:17:06.540 There is a
00:17:06.960 kind of
00:17:07.400 importance
00:17:08.860 to
00:17:10.180 sensitivity
00:17:11.220 training
00:17:11.820 if you
00:17:12.060 want to
00:17:12.260 call it
00:17:12.600 an Orwellian
00:17:13.820 word
00:17:14.300 sensitivity
00:17:15.160 training
00:17:15.800 in medicine
00:17:17.660 but that
00:17:18.780 said
00:17:19.160 I think
00:17:19.940 there's also
00:17:20.720 a regret
00:17:21.260 that people
00:17:21.880 have
00:17:22.360 that the
00:17:23.200 spontaneity
00:17:23.880 that you
00:17:24.240 had
00:17:24.700 when you
00:17:25.620 were a
00:17:25.900 resident
00:17:26.120 when I
00:17:26.460 was a
00:17:26.700 resident
00:17:26.900 when I
00:17:27.100 was an
00:17:27.280 intern
00:17:27.620 to be
00:17:28.340 able to
00:17:28.600 tell people
00:17:29.280 honest
00:17:31.140 news about
00:17:32.360 themselves
00:17:32.820 is somehow
00:17:33.700 being filtered.
00:17:34.540 You feel
00:17:34.880 as if there's
00:17:35.220 a filter
00:17:35.700 that's come
00:17:36.240 into your
00:17:36.620 life.
00:17:37.920 I think
00:17:38.460 I personally
00:17:39.340 try to
00:17:39.740 resist the
00:17:40.260 filter.
00:17:41.540 I try to
00:17:42.140 maintain the
00:17:42.660 honesty.
00:17:42.980 I told you
00:17:43.340 my method.
00:17:43.940 My method
00:17:44.340 is to
00:17:44.720 think in
00:17:45.240 if you
00:17:45.780 want to
00:17:46.020 call it
00:17:46.360 formally
00:17:46.840 a kind
00:17:48.000 of
00:17:48.140 Bayesian
00:17:48.480 way
00:17:48.920 about
00:17:50.280 medicine.
00:17:51.160 I think
00:17:51.880 that helps.
00:17:52.940 It allows
00:17:53.740 you to
00:17:54.140 maintain a
00:17:54.880 personal
00:17:55.600 honesty
00:17:56.200 in the
00:17:56.640 face
00:17:57.020 of
00:17:57.400 when
00:17:58.320 someone
00:17:58.600 says
00:17:58.940 to
00:17:59.120 me
00:17:59.340 am I
00:18:00.140 going to
00:18:00.340 die
00:18:00.600 in five
00:18:00.980 months?
00:18:01.300 You don't
00:18:02.100 resort to
00:18:02.960 the kind
00:18:03.520 of nonsense
00:18:05.360 speak of
00:18:07.060 professionalized
00:18:10.080 empathy
00:18:10.440 training in
00:18:11.920 which you
00:18:12.360 hold their
00:18:13.000 hand and
00:18:13.460 pretend to
00:18:14.320 be
00:18:14.920 aggrieved.
00:18:17.280 You try
00:18:18.340 to assess
00:18:19.480 yourself what
00:18:21.100 your own
00:18:21.440 feelings about
00:18:22.120 their
00:18:22.600 impending
00:18:23.560 death is.
00:18:24.140 You try to
00:18:24.580 understand.
00:18:25.360 You try to
00:18:25.720 help.
00:18:27.540 I think
00:18:28.200 it's a real
00:18:29.240 struggle.
00:18:31.120 And I
00:18:32.640 know like
00:18:33.600 many
00:18:34.100 disciplines,
00:18:35.640 the
00:18:35.840 exaggeration
00:18:38.340 can
00:18:39.320 ultimately
00:18:40.200 the
00:18:41.340 exaggeration
00:18:42.080 of
00:18:42.440 false
00:18:43.260 empathy
00:18:43.640 is
00:18:44.180 detected
00:18:44.620 by
00:18:44.860 patients
00:18:45.240 very
00:18:45.440 quickly
00:18:45.800 and
00:18:46.480 they
00:18:46.620 shut
00:18:46.800 themselves
00:18:47.060 off.
00:18:47.460 The
00:18:47.560 last
00:18:47.780 thing
00:18:47.900 they
00:18:48.020 want
00:18:48.160 to
00:18:48.260 hear
00:18:48.440 is
00:18:48.580 false
00:18:48.820 empathy.
00:18:50.740 So
00:18:50.840 I
00:18:51.640 think
00:18:52.020 you're
00:18:52.860 pointing
00:18:53.120 to
00:18:53.320 an
00:18:53.720 important
00:18:54.040 struggle
00:18:54.520 that's
00:18:55.280 very
00:18:55.500 much
00:18:55.760 inside
00:18:56.180 the
00:18:56.360 discipline.
00:18:57.480 And they
00:18:57.600 also
00:18:57.740 probably
00:18:58.300 don't
00:18:58.740 want
00:18:59.080 a
00:18:59.640 physician
00:19:00.260 who
00:19:00.820 bursts
00:19:01.620 into
00:19:01.840 tears
00:19:02.180 and
00:19:02.380 begins
00:19:02.720 sobbing
00:19:03.320 on
00:19:03.560 their
00:19:03.760 shoulder
00:19:04.120 when
00:19:04.520 he
00:19:04.680 delivers
00:19:05.040 the
00:19:05.240 news.
00:19:05.620 So
00:19:05.640 you
00:19:06.280 can't
00:19:06.580 be
00:19:06.760 clear
00:19:08.300 eyed
00:19:08.620 when
00:19:08.760 your
00:19:08.880 own
00:19:09.040 eyes
00:19:09.260 are
00:19:09.400 clouded
00:19:09.720 with
00:19:09.880 tears.
00:19:11.180 So
00:19:11.460 I've
00:19:11.820 written
00:19:12.000 a little
00:19:12.320 bit
00:19:12.460 about
00:19:12.640 this.
00:19:12.900 I
00:19:12.980 wrote
00:19:13.280 an
00:19:14.480 essay
00:19:15.000 for
00:19:15.540 the
00:19:15.760 New
00:19:15.960 Yorker
00:19:16.300 on
00:19:16.740 numbness
00:19:18.380 which
00:19:20.380 is about
00:19:20.860 this
00:19:21.120 idea
00:19:21.580 and
00:19:22.340 about
00:19:22.580 trying
00:19:22.860 to
00:19:23.080 connect
00:19:23.640 life
00:19:25.320 as a
00:19:25.620 doctor
00:19:25.980 and
00:19:26.780 how
00:19:26.980 it
00:19:27.140 benumbs
00:19:27.580 you.
00:19:28.680 The
00:19:28.880 fastest
00:19:29.780 response
00:19:30.520 to
00:19:31.660 living
00:19:33.080 as a
00:19:33.860 doctor
00:19:34.180 is
00:19:34.680 to
00:19:35.000 shut
00:19:36.100 it
00:19:36.240 down,
00:19:36.500 become
00:19:37.380 numb
00:19:37.700 to
00:19:38.840 all
00:19:39.340 the
00:19:39.500 enormity
00:19:40.460 of
00:19:40.720 the
00:19:41.260 suffering.
00:19:42.340 And
00:19:42.360 I
00:19:42.520 was
00:19:42.760 there
00:19:43.900 is
00:19:44.260 something
00:19:44.620 in
00:19:44.940 one
00:19:45.620 of
00:19:45.840 the
00:19:45.920 connections
00:19:46.220 I
00:19:46.460 sought
00:19:46.760 in
00:19:46.960 that
00:19:47.140 piece
00:19:48.420 was
00:19:49.740 to
00:19:50.320 Chekhov
00:19:50.780 who
00:19:51.080 was a
00:19:51.900 doctor
00:19:52.120 and a
00:19:52.440 writer
00:19:52.760 and about
00:19:53.880 his
00:19:54.300 capacity
00:19:55.760 to remain
00:19:56.360 clear-eyed
00:19:57.420 about
00:19:58.100 the
00:20:00.060 world
00:20:00.480 without
00:20:01.520 shutting
00:20:02.000 off
00:20:02.380 without
00:20:03.880 becoming
00:20:04.360 numb
00:20:04.580 to
00:20:04.760 it.
00:20:05.320 It's
00:20:05.560 a
00:20:05.660 pretty
00:20:05.780 tough
00:20:06.000 act
00:20:06.400 but
00:20:06.820 I
00:20:07.200 think
00:20:07.460 we
00:20:08.180 try.
00:20:09.220 Yeah,
00:20:09.320 well,
00:20:09.500 it's
00:20:09.740 just
00:20:09.880 amazing
00:20:10.280 to
00:20:10.560 witness.
00:20:11.100 I
00:20:11.280 also
00:20:11.820 watched
00:20:12.620 the
00:20:12.960 documentary
00:20:13.640 based
00:20:14.260 on your
00:20:14.580 book
00:20:14.880 that
00:20:15.280 Ken
00:20:15.580 Burns
00:20:15.840 produced
00:20:16.340 and
00:20:17.340 again,
00:20:18.360 given this
00:20:18.940 is so
00:20:19.380 far
00:20:19.860 outside
00:20:20.280 the range
00:20:20.800 of my
00:20:21.500 professional
00:20:22.440 experience,
00:20:23.320 I just
00:20:24.160 was
00:20:24.640 amazed
00:20:25.700 at
00:20:26.120 what
00:20:26.700 oncologists
00:20:27.700 have to
00:20:28.740 go through
00:20:29.420 as their
00:20:30.460 patients
00:20:30.920 go through
00:20:31.540 the scariest
00:20:32.500 moments
00:20:32.900 in their
00:20:33.160 lives,
00:20:33.760 especially
00:20:34.200 when you're
00:20:34.700 talking to
00:20:35.260 the parents
00:20:36.000 of children
00:20:36.560 who have
00:20:37.280 received a
00:20:37.880 diagnosis of
00:20:38.700 leukemia or
00:20:39.500 some other
00:20:39.800 cancer.
00:20:40.740 It was just
00:20:41.180 so lacerating
00:20:43.340 for me as
00:20:44.300 a viewer.
00:20:45.000 It was very
00:20:46.160 difficult for me
00:20:46.580 to watch
00:20:47.000 until I
00:20:47.340 just kind
00:20:47.660 of surrendered
00:20:48.160 to it.
00:20:49.500 But basically,
00:20:50.620 for me,
00:20:51.380 it's just
00:20:51.940 the continuous
00:20:53.320 effort to
00:20:54.640 stifle tears
00:20:56.400 seeing people
00:20:57.520 go through
00:20:58.100 that experience.
00:20:58.560 But just
00:20:59.220 to remind
00:21:00.120 you and
00:21:00.780 your readers
00:21:01.220 or your
00:21:01.860 listeners
00:21:02.200 that,
00:21:03.380 of course,
00:21:04.280 the point
00:21:05.000 that you're
00:21:05.240 making is
00:21:05.680 incredibly
00:21:06.100 important,
00:21:06.600 which is
00:21:06.800 that you
00:21:07.840 cannot,
00:21:09.820 no one
00:21:10.140 wants a
00:21:10.500 sobbing
00:21:10.780 doctor.
00:21:12.360 And you
00:21:13.720 want someone,
00:21:15.560 you know,
00:21:15.840 there is a
00:21:16.460 fundamental,
00:21:17.940 and I
00:21:18.320 suspect that
00:21:19.560 I will
00:21:20.380 raise some
00:21:21.660 hackles as
00:21:22.080 I say this,
00:21:22.600 there's a
00:21:22.860 fundamentally,
00:21:24.460 the fundamental
00:21:25.240 relationship
00:21:25.920 between a
00:21:26.500 patient and
00:21:26.920 a doctor,
00:21:27.460 even today,
00:21:28.560 the power
00:21:29.700 lies in
00:21:30.280 one direction.
00:21:30.980 The doctor
00:21:31.380 knows the
00:21:32.160 patients are
00:21:33.680 there to
00:21:34.160 try to
00:21:34.660 seek help.
00:21:36.800 That is
00:21:37.480 not to say
00:21:38.060 that that's
00:21:38.440 a good
00:21:38.700 thing.
00:21:39.000 It is just
00:21:39.360 to remind
00:21:39.860 ourselves
00:21:40.480 that there
00:21:41.100 is a,
00:21:42.220 that the,
00:21:43.420 that empathy
00:21:44.240 can be
00:21:45.240 helpful,
00:21:46.140 and of course
00:21:46.580 is a
00:21:46.840 prerequisite
00:21:47.440 for medicine,
00:21:49.100 but false
00:21:49.820 empathy and
00:21:50.900 trying to,
00:21:52.120 trying to,
00:21:52.600 trying to,
00:21:53.440 trying to
00:21:54.380 emulate
00:21:54.940 the actual
00:21:56.900 experience of
00:21:57.700 the patient
00:21:58.180 as a doctor
00:21:58.800 is going to
00:21:59.160 be necessarily
00:21:59.820 flawed.
00:22:00.920 You are not
00:22:01.940 the person
00:22:02.420 with cancer.
00:22:03.640 It is the
00:22:04.720 person sitting
00:22:05.240 in front of
00:22:05.820 you that
00:22:07.440 has the
00:22:07.840 real,
00:22:08.180 that has
00:22:08.680 the real
00:22:08.960 problem.
00:22:10.780 So,
00:22:11.620 actually,
00:22:11.940 there's a
00:22:12.380 good distinction.
00:22:13.120 I don't know
00:22:13.360 if you know
00:22:13.680 the psychologist
00:22:14.320 Paul Bloom
00:22:15.040 at Yale.
00:22:16.140 He's done a
00:22:16.720 lot of work
00:22:17.060 on empathy,
00:22:17.480 and he's,
00:22:18.380 he wrote a
00:22:18.700 very controversial
00:22:19.220 book entitled
00:22:20.120 Against Empathy,
00:22:21.600 where he
00:22:22.240 differentiated
00:22:23.160 what he
00:22:24.040 calls
00:22:24.400 cognitive
00:22:24.980 empathy,
00:22:25.600 just
00:22:25.780 understanding
00:22:26.740 what another
00:22:27.520 person's
00:22:27.920 experience is,
00:22:29.180 and the
00:22:30.380 more emotional
00:22:31.440 contagion
00:22:32.200 style of
00:22:32.900 empathy,
00:22:33.160 where you
00:22:33.580 just find
00:22:34.020 yourself
00:22:34.320 crying when
00:22:34.960 you see
00:22:35.260 someone is
00:22:36.140 sad.
00:22:37.160 I think
00:22:37.440 in this
00:22:37.720 case,
00:22:37.980 he would
00:22:38.160 say that
00:22:38.460 what we
00:22:38.860 want are
00:22:39.620 physicians
00:22:40.620 who have
00:22:42.580 a lot
00:22:43.660 of cognitive
00:22:44.340 empathy.
00:22:44.960 They know
00:22:45.440 what you
00:22:46.080 are very
00:22:47.000 likely to be
00:22:47.520 going through,
00:22:48.160 and they
00:22:48.420 care to
00:22:49.180 alleviate your
00:22:49.800 suffering,
00:22:50.800 but
00:22:51.120 they're
00:22:51.680 not being
00:22:52.780 held hostage
00:22:54.300 by their
00:22:54.840 own emotional
00:22:55.720 reaction to
00:22:57.180 suffering
00:22:58.100 vicariously
00:22:58.780 through you,
00:22:59.580 or thinking
00:23:00.060 about how
00:23:00.960 would I
00:23:01.280 feel if
00:23:01.700 it were
00:23:02.220 my kids
00:23:02.740 I was
00:23:02.960 talking
00:23:03.220 about,
00:23:04.040 and all
00:23:04.340 of that.
00:23:05.620 Absolutely,
00:23:06.240 and it
00:23:07.100 comes down
00:23:07.600 to,
00:23:08.420 again,
00:23:08.860 very,
00:23:09.100 very important
00:23:10.020 basic things,
00:23:10.900 is that,
00:23:11.540 I mean,
00:23:11.780 in the
00:23:12.180 laboratory,
00:23:13.240 when we
00:23:13.580 study cancer
00:23:14.340 genetics,
00:23:14.840 or study
00:23:15.200 cancer cell
00:23:15.840 behavior,
00:23:16.940 you're
00:23:17.220 abstracting
00:23:18.180 away so
00:23:18.960 much from
00:23:19.860 the experience
00:23:20.640 of the
00:23:21.100 illness,
00:23:22.300 but it's
00:23:23.260 important to
00:23:23.660 remember the
00:23:24.260 experience of
00:23:24.900 the illness
00:23:26.420 lived through
00:23:27.120 the lives of
00:23:27.800 your patients
00:23:28.360 as well.
00:23:28.800 It's what
00:23:29.120 motivates a
00:23:31.080 laboratory life,
00:23:32.000 at least for
00:23:32.480 me.
00:23:33.360 So I think
00:23:34.660 it's very
00:23:34.960 important,
00:23:35.460 and the
00:23:35.960 distinction,
00:23:36.380 I've certainly
00:23:36.780 read this
00:23:37.840 distinction
00:23:38.220 between the
00:23:39.940 cognition of
00:23:41.200 empathy,
00:23:42.020 the cogitation
00:23:43.140 of empathy,
00:23:44.300 and the
00:23:44.680 enactment
00:23:45.260 of it,
00:23:45.640 and I
00:23:48.460 would agree
00:23:49.360 that I
00:23:49.700 think that's
00:23:50.080 an important
00:23:50.740 distinction,
00:23:51.400 and I
00:23:51.540 think it's
00:23:52.140 a struggle,
00:23:52.660 it's not
00:23:52.980 simple,
00:23:54.020 I don't
00:23:54.400 think,
00:23:55.000 I would be
00:23:55.980 lying if I
00:23:56.460 said to
00:23:56.700 you that
00:23:56.980 one doesn't
00:23:57.480 bleed into
00:23:57.880 the other
00:23:58.160 quite quickly,
00:23:59.300 and this
00:23:59.600 I think
00:23:59.820 goes back
00:24:00.400 to the
00:24:00.700 idea across
00:24:01.640 the board
00:24:02.360 that in
00:24:05.260 a behavioral
00:24:06.100 sense,
00:24:07.360 you can
00:24:08.580 teach being
00:24:10.980 a doctor,
00:24:12.300 but of
00:24:13.520 course that's
00:24:13.960 just merely
00:24:14.420 in a behavioral
00:24:15.020 sense,
00:24:15.440 what does
00:24:15.680 it mean to
00:24:16.060 behave,
00:24:16.300 what words
00:24:16.740 do you
00:24:16.980 say,
00:24:18.340 but patients
00:24:19.900 very quickly
00:24:21.000 pick up the
00:24:21.700 idea that
00:24:22.060 you're saying
00:24:22.480 them without
00:24:22.840 believing them,
00:24:24.020 so believing
00:24:24.500 it,
00:24:25.080 believing inside,
00:24:26.120 what it means
00:24:26.760 to have,
00:24:27.480 if you want
00:24:27.840 to call it
00:24:28.200 cognitive
00:24:28.640 empathy,
00:24:29.920 is a
00:24:31.120 psychological
00:24:31.560 realm which
00:24:32.100 is actually
00:24:32.360 quite deep
00:24:33.260 and understudied,
00:24:34.040 actually,
00:24:34.380 we don't fully
00:24:35.160 understand it.
00:24:36.440 Is there
00:24:36.620 anything that
00:24:37.120 you know
00:24:38.540 from the
00:24:39.000 side of
00:24:39.480 being an
00:24:39.940 oncologist
00:24:40.600 that you
00:24:42.440 think cancer
00:24:43.780 patients,
00:24:44.420 or their
00:24:45.040 family members
00:24:46.200 should know
00:24:47.400 but often
00:24:48.300 don't in
00:24:49.040 terms of
00:24:49.980 the experience
00:24:50.780 of receiving
00:24:52.340 a diagnosis
00:24:53.020 and going
00:24:54.140 through treatment
00:24:54.740 and talking
00:24:55.340 to their
00:24:55.640 doctors,
00:24:56.120 is there
00:24:56.540 any question
00:24:57.200 you would
00:24:58.100 ask your
00:24:58.820 doctor or
00:25:00.120 anything you
00:25:00.580 would do
00:25:01.040 differently
00:25:01.540 given how
00:25:02.620 much you
00:25:02.960 know about
00:25:03.500 what it's
00:25:04.420 like to be
00:25:04.840 an oncologist
00:25:05.520 and what
00:25:06.700 the full
00:25:07.420 course of
00:25:08.260 treatment
00:25:08.920 often is,
00:25:10.360 and just
00:25:10.680 what does
00:25:11.560 your experience
00:25:12.320 give you
00:25:12.940 as a
00:25:13.720 prospective
00:25:14.220 cancer
00:25:14.720 patient
00:25:15.240 that most
00:25:16.020 people don't
00:25:16.460 have?
00:25:17.720 Well,
00:25:17.900 one of the
00:25:18.260 things,
00:25:18.660 I'm thinking
00:25:19.400 of an
00:25:21.040 important
00:25:21.420 essay which
00:25:22.240 I often
00:25:22.620 encourage
00:25:23.160 patients to
00:25:24.640 read by
00:25:25.200 Stephen Gould.
00:25:26.520 Well,
00:25:26.800 the median
00:25:27.200 is not
00:25:27.560 the message
00:25:28.200 in which
00:25:29.380 the back
00:25:30.520 story is
00:25:31.040 that Stephen
00:25:31.500 J. Gould
00:25:32.280 was diagnosed
00:25:33.840 with a
00:25:34.520 very unusual
00:25:35.220 cancer,
00:25:36.200 abdominal
00:25:37.200 mesothelioma.
00:25:39.880 And if
00:25:40.160 you read
00:25:40.380 the statistics,
00:25:41.840 Gould's
00:25:42.300 prognosis was
00:25:43.660 extremely grim.
00:25:44.780 It was very,
00:25:45.520 very sobering.
00:25:47.280 And the
00:25:48.140 question that
00:25:49.640 Gould asked
00:25:50.400 himself in
00:25:51.000 this essay,
00:25:51.600 and I
00:25:51.800 encourage people
00:25:52.300 to read it,
00:25:53.220 is if you
00:25:54.360 take the
00:25:55.980 curve of
00:25:57.000 survivorship,
00:25:58.880 so if you
00:25:59.360 just plot,
00:26:00.060 you can
00:26:00.740 plot the
00:26:01.660 number of
00:26:02.320 patients who
00:26:02.980 are alive,
00:26:03.700 5 months,
00:26:04.280 7 months,
00:26:04.740 12 months,
00:26:05.880 20 months
00:26:06.420 after the
00:26:06.760 diagnosis,
00:26:08.460 it might
00:26:09.180 look like
00:26:10.700 a Gaussian
00:26:11.100 curve.
00:26:11.580 It might
00:26:11.760 look like
00:26:13.060 any kind
00:26:13.480 of curve.
00:26:14.340 The question
00:26:14.820 you want
00:26:15.040 to ask
00:26:15.280 yourself is
00:26:15.720 where are
00:26:16.260 you located
00:26:17.200 in that
00:26:17.940 curve?
00:26:18.560 Are you
00:26:18.740 on the
00:26:20.140 side of
00:26:20.660 the kind
00:26:21.400 of person
00:26:21.740 who is
00:26:22.000 going to
00:26:23.020 rapidly
00:26:23.560 succumb
00:26:24.300 to this
00:26:24.660 cancer?
00:26:25.640 Are you
00:26:25.880 likely to
00:26:26.420 survive
00:26:26.940 the
00:26:27.660 batterings
00:26:29.460 of surgery,
00:26:30.240 radiation,
00:26:30.740 and chemotherapy?
00:26:32.100 If you
00:26:32.540 do,
00:26:33.320 what are
00:26:33.600 the chances
00:26:34.080 that you
00:26:34.580 will
00:26:34.760 survive
00:26:35.140 this
00:26:35.420 with a
00:26:35.780 meaningful
00:26:36.080 life,
00:26:36.540 et cetera,
00:26:36.820 et cetera?
00:26:37.420 So he
00:26:37.700 tried to
00:26:38.220 place
00:26:38.600 himself,
00:26:39.680 and once
00:26:40.160 he had
00:26:40.460 placed
00:26:40.840 himself
00:26:41.280 in that
00:26:41.980 curve,
00:26:43.040 he was
00:26:43.540 able to
00:26:43.960 make
00:26:44.140 decisions
00:26:44.660 about
00:26:45.060 treatment
00:26:45.820 more
00:26:46.620 accurately.
00:26:48.660 So if
00:26:49.420 I were to
00:26:50.320 become a
00:26:50.660 patient,
00:26:50.900 and I
00:26:51.120 will,
00:26:51.620 statistically
00:26:52.160 speaking,
00:26:52.880 you and
00:26:53.140 I will
00:26:53.480 both
00:26:53.940 likely have
00:26:55.200 cancer,
00:26:56.480 one in
00:26:57.080 two men,
00:26:57.560 one in
00:26:57.780 three women,
00:26:58.240 one in
00:26:58.960 three women,
00:26:59.380 pardon me,
00:27:00.320 and again,
00:27:02.020 statistically
00:27:02.360 speaking,
00:27:03.300 there's a
00:27:05.220 good chance
00:27:06.280 that we
00:27:06.480 will die
00:27:06.920 of cancer.
00:27:07.940 So if I
00:27:08.440 were a
00:27:08.740 patient,
00:27:09.060 I would
00:27:09.260 try to
00:27:09.660 ask,
00:27:10.200 when I
00:27:10.620 was sitting
00:27:11.120 on the
00:27:11.380 other side
00:27:12.100 of the
00:27:13.060 desk,
00:27:13.400 as it
00:27:13.660 were,
00:27:13.860 I would
00:27:14.020 try to
00:27:14.280 locate myself
00:27:15.620 as Stephen
00:27:16.020 J.
00:27:16.260 Gould did,
00:27:16.940 and say,
00:27:17.500 what's the
00:27:18.500 likelihood that
00:27:19.440 I will be
00:27:20.380 one of the
00:27:20.780 few people
00:27:21.220 who will
00:27:22.120 succeed
00:27:22.580 with some
00:27:23.580 kind of
00:27:23.860 novel
00:27:24.140 therapy
00:27:24.740 versus
00:27:26.200 the
00:27:26.460 chances
00:27:26.740 that I
00:27:27.100 won't?
00:27:28.380 And once
00:27:28.760 I know
00:27:29.140 that I
00:27:29.460 might be
00:27:29.760 able to
00:27:29.960 make
00:27:30.120 decisions
00:27:30.660 thoughtfully,
00:27:33.340 the questions
00:27:34.320 that I like
00:27:34.760 to ask
00:27:35.160 myself is,
00:27:36.000 what are
00:27:36.180 the strong
00:27:37.340 endpoints
00:27:38.060 that I
00:27:38.600 should
00:27:38.760 stop
00:27:39.060 treatment?
00:27:39.960 I'd ask
00:27:40.340 my doctor
00:27:40.760 that.
00:27:41.380 What are
00:27:41.680 you looking
00:27:42.160 for when
00:27:43.340 you would
00:27:43.560 say to
00:27:43.900 me,
00:27:45.080 you know,
00:27:45.840 I think
00:27:46.220 we're getting
00:27:47.120 to the
00:27:47.360 point of
00:27:47.620 time where
00:27:47.980 we'd
00:27:48.260 better
00:27:48.420 seriously
00:27:49.840 consider
00:27:50.480 hospice,
00:27:52.560 seriously
00:27:53.560 consider
00:27:54.160 the
00:27:54.840 withdrawal?
00:27:55.240 What are
00:27:55.660 those
00:27:55.900 endpoints?
00:27:57.520 And in
00:27:58.320 the opposite
00:27:58.760 sense,
00:27:59.320 what are
00:27:59.600 the things
00:28:00.600 that you're
00:28:01.780 looking for
00:28:02.440 that would
00:28:02.720 tell you,
00:28:03.720 this is the
00:28:04.140 kind of
00:28:04.460 patient that
00:28:05.140 I would
00:28:05.380 rather treat
00:28:06.060 more
00:28:06.380 aggressively,
00:28:07.640 treat more
00:28:08.220 proactively
00:28:09.120 than with
00:28:10.940 chemotherapy?
00:28:12.220 This is not
00:28:12.660 to say that
00:28:13.340 hospice and
00:28:14.620 palliative care
00:28:15.500 are not
00:28:15.880 proactive
00:28:16.280 treatments.
00:28:17.160 Please don't
00:28:17.500 make that,
00:28:18.680 let's not
00:28:19.360 make that
00:28:19.680 mistake.
00:28:20.240 But this
00:28:21.660 is just to
00:28:22.060 remind us
00:28:22.760 that that's
00:28:24.360 the direction
00:28:25.480 that those
00:28:26.500 are the kinds
00:28:27.480 of guidance
00:28:27.920 that I'd
00:28:28.260 like to
00:28:28.580 know.
00:28:29.180 And it
00:28:29.580 could be
00:28:29.940 hard science,
00:28:30.880 it could
00:28:31.080 be genetics,
00:28:31.940 it could
00:28:32.240 be the
00:28:34.120 microenvironment,
00:28:35.120 it could
00:28:35.380 be the
00:28:36.100 nature of
00:28:36.600 the tumor.
00:28:37.220 I'm
00:28:37.540 looking for
00:28:38.440 a hitchhiker's
00:28:42.680 guide to
00:28:43.180 Bayesian
00:28:43.520 cancer.
00:28:44.360 Right,
00:28:45.040 right.
00:28:45.920 The fact
00:28:46.440 that so
00:28:47.000 many people
00:28:47.460 are dying
00:28:48.220 of cancer
00:28:48.780 and will
00:28:49.440 continue to
00:28:50.060 die from
00:28:51.100 cancer is
00:28:51.940 in some
00:28:52.940 perverse way
00:28:54.000 good news
00:28:55.060 because it
00:28:56.500 shows that
00:28:57.360 many of the
00:28:58.120 diseases that
00:28:58.820 killed us
00:28:59.280 before we
00:28:59.760 even had a
00:29:00.220 chance to
00:29:00.620 get cancer
00:29:01.140 have been
00:29:02.000 cured or at
00:29:02.720 least beaten
00:29:03.220 back into
00:29:03.880 submission.
00:29:04.800 Let's talk
00:29:05.420 about the
00:29:06.340 disease itself
00:29:07.060 and I'm
00:29:07.820 sure there'll
00:29:08.100 be other
00:29:08.440 questions that
00:29:09.520 could come up
00:29:09.920 here relevant
00:29:10.460 to the
00:29:11.160 patient experience
00:29:12.080 because as
00:29:12.900 you say,
00:29:13.760 virtually everyone
00:29:14.720 will either
00:29:15.480 get cancer
00:29:16.420 or have
00:29:16.980 someone close
00:29:17.540 to them
00:29:17.860 get it.
00:29:18.960 So,
00:29:19.760 the simple
00:29:20.360 as possible
00:29:20.940 question for
00:29:22.180 which no doubt
00:29:22.860 there is no
00:29:24.140 perfectly simple
00:29:24.920 answer,
00:29:25.460 but what is
00:29:26.800 cancer?
00:29:28.000 Cancer is a
00:29:29.100 family of
00:29:30.020 diseases that
00:29:30.820 shares the
00:29:31.740 phone numbers
00:29:32.460 and itself.
00:29:33.520 If you'd like
00:29:34.240 to continue
00:29:34.660 listening to
00:29:35.120 this conversation,
00:29:36.340 you'll need to
00:29:36.800 subscribe at
00:29:37.500 samharris.org.
00:29:39.080 Once you do,
00:29:39.700 you'll get access
00:29:40.220 to all full-length
00:29:41.100 episodes of the
00:29:41.760 Making Sense
00:29:42.160 podcast,
00:29:43.180 along with other
00:29:43.720 subscriber-only
00:29:44.500 content,
00:29:45.480 including bonus
00:29:46.180 episodes and
00:29:47.280 AMAs and the
00:29:48.420 conversations I've
00:29:49.140 been having on
00:29:49.600 the Waking Up
00:29:50.100 app.
00:29:51.020 The Making Sense
00:29:51.540 podcast is ad-free
00:29:52.800 and relies entirely
00:29:54.200 on listener support.
00:29:55.600 And you can
00:29:56.080 subscribe now
00:29:56.860 at samharris.org.