The Peter Attia Drive - #37 - Zubin Damania, M.D.： Revolutionizing healthcare one hilariously inspiring video at a time

00:00:00.000 Hey everyone, welcome to the Peter Atiyah Drive. I'm your host, Peter Atiyah.

00:00:10.140 The Drive is a result of my hunger for optimizing performance, health, longevity, critical thinking,

00:00:15.600 along with a few other obsessions along the way. I've spent the last several years working with

00:00:19.840 some of the most successful, top-performing individuals in the world, and this podcast

00:00:23.620 is my attempt to synthesize what I've learned along the way to help you live a higher quality,

00:00:28.360 more fulfilling life. If you enjoy this podcast, you can find more information on today's episode

00:00:33.000 and other topics at peteratiyahmd.com.

00:00:41.440 Hey everybody, welcome to this week's episode of The Drive. I'd like to take a couple of minutes

00:00:45.980 to talk about why we don't run ads on this podcast and why instead we've chosen to rely entirely on

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00:01:46.240 know, the tried and true way to do this is to sell ads. But after a lot of contemplation, that model just

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00:03:32.800 And as I said, we're not taking ad dollars from anyone, but instead what I'd like to do is work

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00:04:02.960 to listen to this. If you learn from and find value in the content I produce, please consider

00:04:08.480 supporting us directly by signing up for a monthly subscription. My guest this week is Zubin Demania,

00:04:15.100 AKA ZDogMD. Zubin and I have been friends for about 20 years and we talk about that actually at the

00:04:21.540 outset. So how we met and things like that. We kind of lost touch for a few years, but then reconnected

00:04:25.880 at TEDMED in 2013 when we both spoke. This is a kind of interesting episode in the sense that

00:04:31.700 I wanted to interview him, but he wanted to interview me. So when, when, when it got to

00:04:36.580 his studio in Vegas, which is where we did this and his crew is there, we filmed it and actually

00:04:42.580 ran it as a sort of a Facebook live. And in the end, it really, I think comes across as a pretty

00:04:47.780 equal balance of about a 50, 50 of just two dudes sitting there talking about this stuff. And it was

00:04:52.540 really a mutual interview. Zubin, or as we call him ZDog, is kind of one of the most talented people

00:04:59.340 I've ever met. I mean, not only is he talented as an amazing doc, but he's just musically gifted.

00:05:04.380 He is comedically gifted and he has put those things to an amazing use in what he does. So he

00:05:11.080 has all the usual accolades. He trained at Berkeley, UCSF, Stanford, internal medicine. And of course,

00:05:16.600 that's where we met. And he went on to found something called turntable health in Las Vegas,

00:05:19.880 which was part of this broader ambition of the urban revitalization in Las Vegas that was

00:05:25.060 spearheaded by Tony Hsieh, who is the CEO of Zappos. And that's the guy who recruited Zubin there.

00:05:29.920 This all started because, you know, Zubin was working as a hospitalist at Stanford in internal

00:05:34.860 medicine, but he had this whole side gig of doing comedy and music. And it was that which Tony saw

00:05:40.880 that made him think, Hey man, you got to do something a little bigger than just being an internist

00:05:45.340 at Stanford. His videos are amazing. And we're going to link to a lot of them in particular,

00:05:51.460 ain't the way to die. Lose yourself in seven years are my three favorites, but I've seen every one of

00:05:57.100 them multiple times. And I've been following this for a long time. Many of these videos have gone

00:06:01.000 viral. And I think in aggregate, he's got about half a billion views on Facebook and YouTube. And

00:06:06.460 these are educating patients, educating providers, and kind of mercilessly creating a satire of our

00:06:12.040 entire dysfunctional healthcare system. We do talk quite a bit about healthcare and Zubin's given this

00:06:16.940 much more thought than I have, but it was just so interesting to get into this stuff. And we get into

00:06:20.840 some really deep philosophy stuff. Basically, he just stumps me all day long with philosophical

00:06:26.020 questions about consciousness and the mind and other things like that. I would say overall,

00:06:30.980 this is probably one of the most enjoyable discussions I've ever had with somebody in

00:06:35.160 this sort of format. I've talked a lot about how the discussion I had with Jocko a few years ago was

00:06:39.060 one of my favorite. I would put this up there as well. And probably the top three discussions just in

00:06:43.940 terms of overall enjoyment. So the show notes will link to a bunch of really cool stuff,

00:06:49.100 but you can also go to his site, ZDogg, and that's just two G's on the dog, md.com.

00:06:54.700 So I'm really excited to introduce all of you to Zubin Damania.

00:07:00.480 We are live. What is up, Z-Pack? It's your boy, ZDoggMD. I am live and direct out of Studio Z.

00:07:05.940 You are not going to believe it, but we're doing something absolutely different. What's this big

00:07:10.320 phallic symbol in my face? It's called a microphone. Okay, learn about it. And I have it because I have a

00:07:15.620 good friend that goes way back to my Stanford days. He is a physician. He's an engineer. He's done

00:07:21.940 crazy stuff, worked with the world's top performing individuals to try to teach us not just how to live

00:07:28.180 longer, but how to have a longer healthy life, a health span. He is one of my favorite people because

00:07:33.960 he's uber smart, hangs out with all kinds of hoity-toity people like Tim Ferriss and Sam Harris and all

00:07:40.000 these smarty pants, intellectual dark web people. But more important than that, he's a bald, off-white

00:07:45.220 doctor. Welcome, Dr. Peter Atiyah. Thank you so much for having me on this co-hosted event today.

00:07:50.840 That's right. So what we're doing different now is we're co-hosting this. You're in Vegas to give a

00:07:54.500 talk. You have your own podcast called The Drive, which is a stunning deep dive into the nerdiest shit

00:08:01.440 I've ever seen in my life. I love it. Like you're talking about... I heard Dr. Seyfried's one about how

00:08:08.560 cancer may be a metabolic illness and how the mitochondria are abnormal. And you're like in his

00:08:12.140 face going, well, just because they're morphologically abnormal doesn't mean that the function have you

00:08:15.880 actually fractioned. What's your ideal trial? And I'm just going, nerd, nerd, nerd, nerdgasm.

00:08:20.160 But also, you are even more than that. You're talking about how to maximize human potential

00:08:26.520 in a way that's uniquely human. And that's what I love about you ever since our Stanford days.

00:08:32.240 Well, speaking of those, let's retell that story. So I'll do this from the lens of how I would

00:08:36.040 introduce you to my listeners. But I think your listeners will also be intrigued by this. So

00:08:40.120 I was one year behind you in medical school. Now you went to UCSF. I went to Stanford. Is that

00:08:45.220 correct? That's right. It was a gang war type of deal. That's right. This was back when the merger

00:08:48.580 was trying to happen unsuccessfully. That's right. So there was pure animosity between the two best

00:08:53.500 programs on the West Coast. That's right. You guys thought you were all that because you were rich

00:08:56.700 and we were ghetto as fudge. But in the end of the day, you come to Stanford to do your residency in

00:09:02.520 internal medicine. So you are now an intern in the internal medicine program. I am a fourth year

00:09:08.240 medical student. Yeah. And I had already decided I was going into surgery. So I had done the heavy

00:09:14.760 lifting to begin that application process. So I'm doing internal medicine, but there's no pressure

00:09:20.360 because Stanford is pass fail. And it's like, how can you fail the rotation? It's not like I wasn't

00:09:26.020 going to show up, but I didn't have to be the smartest kid in the room. I didn't have to impress the

00:09:31.740 hell out of the residents. I was like, hey, I'm going to be a surgeon. I might as well learn whatever

00:09:35.560 things in medicine apply to taking care of surgical patients. So we show up on day one

00:09:41.100 and you're the intern. I don't remember who the second year was. I don't either. Yeah. The third year,

00:09:47.740 I'm blanking on his name, but you called him Darth Vader because his fantasy, he said, was to walk.

00:09:53.940 We can't name him now. No, we can't. Even if you remember. But he's described that his fantasy was to

00:09:58.600 walk down the hall of the hospital with a cape because he was so smart and everyone would think

00:10:04.860 he was Darth Vader. I know exactly who he was. You know who I'm talking about? Yes. Oh my gosh.

00:10:07.840 I remember his name now. Malignant narcissist. Yeah. We're not going to say his name. We won't say

00:10:11.280 it. Yeah. Yeah. Welcome to Stanford. So I was kind of like, this guy seems like a douchebag,

00:10:17.140 meaning the chief resident. I thought you were pointing at me because that also is true. Yeah.

00:10:20.360 And the second year was a non-personality, was my recollection. They were sort of there,

00:10:26.780 but not there. And you were the intern and it was out of control. I could not imagine how much one

00:10:34.180 could enjoy a rotation of internal medicine. I don't even remember where we were. Were we the VA?

00:10:39.920 We were at the mothership. We were at Stanford. You know, it's weird. I'm getting like this weird

00:10:43.300 emotional reaction because I remember you so well. And the thing is, look, look, look, dude,

00:10:47.640 I've taken care of a lot of people. I've been through a lot of teams. There are very few people

00:10:50.780 I remember. And I remember fucking Peter Atiyah coming up, medical student, fourth year,

00:10:56.580 cocky as hell because you were going into surgery. Did you already match? No, I hadn't matched.

00:11:01.320 But in your mind- I knew I wanted to go into general surgery. You knew. And so on a medicine team,

00:11:05.700 we've already written you off as someone who doesn't matter to us because you're not going down.

00:11:08.920 There's no point putting any energy into teaching me anything. And then you sat down and did the entire

00:11:14.860 monologue from Austin Powers, Dr. Evil and the therapist, like, oh, my life is- I don't even

00:11:21.140 remember it. And you were bald at the time or shaved head and had the finger here and did the

00:11:25.340 whole thing. And I'm an intern, right? The only way I can cope with this shit is through comedy,

00:11:29.140 through humor. Humor was my coping mechanism from the beginning. And this guy does this thing and

00:11:33.240 you're a medical student. First of all, you have the balls to come up and do that thing,

00:11:35.900 which in a hierarchical system like that, already I'm like, this guy's my hero because I'm

00:11:40.060 oppositional defiant. And then you nailed it perfectly. And I'm like, who is this guy?

00:11:45.700 So there's an interesting backstory to that. So my very, very first rotation was pediatrics

00:11:50.640 because when I went to medical school, I thought I was going to be a pediatric oncologist.

00:11:54.020 Wow.

00:11:54.600 So I figured I better figure this out quick. And so I'm going to do pediatrics first.

00:11:59.600 And this was the moment when I knew I couldn't be a pediatric oncologist was when I realized I

00:12:04.980 couldn't be a pediatrician. And I'm not saying that to upset the pediatricians because maybe it was

00:12:09.100 just, I couldn't be a Stanford pediatrician. But on about the fourth day of the rotation,

00:12:14.480 there was like this really chubby, cute little baby in the nursery. I forget what was wrong with,

00:12:21.760 dehydrated or something like that. And we were taking care of it. And I just decided at that

00:12:27.620 moment, it made sense to walk down the hall and pretend I was fat bastard and talk about wanting

00:12:32.440 to eat the baby. So I came out of the room and I was like, baby, get in my belly.

00:12:37.840 And the whole rest of the night, all I did was talk about the other, other white meat.

00:12:43.540 Oh my God.

00:12:44.500 And I mean, literally not one of them, not one of them even smiled. They were mortified by my

00:12:51.680 existence.

00:12:52.800 Humorless bastards. Forget about fat bastards. You know, it's so funny. See, this is why you and I

00:12:57.280 get along. You're an introvert. I'm an extrovert. You're incredibly science-minded,

00:13:02.040 diligent, industrious. I'm the opposite. I'm lazy. I procrastinate.

00:13:05.320 And I use smoke and mirrors to get any success I can and grasp onto it desperately. But the truth

00:13:10.840 is we have a very similar disturbed sense of humor. One time in hematology. So here I am,

00:13:15.720 like I'm a second year resident and the attending is a guy named Steve Goutre, really renowned guy.

00:13:21.140 And we're on, everybody's stressed. It's young people who are dying, like all over the place.

00:13:26.200 And I had already built, you know what happens in medicine? You start building this brick wall

00:13:29.940 around yourself so that you don't feel what's going on. Because the minute you feel it,

00:13:32.740 you're in the stairwell crying back and forth and it's just morally distressing.

00:13:36.540 So to cope with that, I built a wall, but then I'd started using humor. So

00:13:39.700 Coutre, we had these really hard sick service. And there was this creepy puppet that one of the

00:13:46.400 patients had donated to F Ground, which was our onk floor. And it was this weird hobo, like

00:13:52.040 home, had a little stick and these little things. You put your hand in its butt and you make it do

00:13:55.960 stuff. And that's not, that came out wrong. It's a puppet.

00:13:59.280 What did she mean though? You know what I'm saying? They have a very large anus.

00:14:02.200 Extremely loose sphincter tone. Yeah. Yeah. And so. And no curvature in the colon. It's,

00:14:07.380 it's more of a mono, like the GI tract basically goes, the esophageal anal canal is one.

00:14:11.980 It's a straightened and shortened tract. You know what? That always bothered me.

00:14:15.140 That being said, rounds are happening and Coutre goes, so Demania, did you see, you know,

00:14:20.200 Mr. Pickles in three? And I go, I didn't, I'm sorry. And he, and you could see him just like,

00:14:25.340 you know, this guy fucking sucks. And I go, but mini Z did. And I pull out the hobo clown and he's

00:14:34.960 like, this guy is okay. He's feverell overnight. He's probably got some tumor lysis syndrome. And,

00:14:41.260 and Coutre looks at me for a second and I'm thinking I'm done. I'm, I'm, I'm fired. And he

00:14:46.800 breaks into laughter with tears rolling down his face. And the whole team is laughing. And I'm like,

00:14:52.720 you know what? I found my path. It is to, it is to try to bring some levity to situations that

00:14:57.960 are disastrous. And that gave me hope because it could easily have gone the other way. I've been

00:15:02.220 told things like, Hey, you speak and then think you should just reverse that or better yet, just

00:15:07.020 think. And attending told me that at UCSF. So when you and I took USMLE two, so the final exam to

00:15:12.520 graduate from medical school, we were about the last classes to do that before they switched to like

00:15:19.960 live patient actor interactions. Is that right? Yeah. Or we were very close to it.

00:15:25.140 We were close to that. Because they used- Because I had just a scantron.

00:15:27.040 That's right. Yeah. As did I. Yeah. But then they brought in, they said, you know,

00:15:30.540 Stanford's going to be one of the test sites for, you know, doing this whole thing. Because

00:15:34.880 USMLE two is moving towards half the test being written and half the test being clinical with actor

00:15:40.600 patients. You know, we were basically just being asked to do this so they could figure out the,

00:15:45.420 you know, the kinks in the system. So for whatever reason, it was just too long a day. And I just

00:15:50.200 wasn't really in the mood to deal with these actors and actresses who were annoying as hell to me.

00:15:55.120 You know, you'd go in there and you sort of knew what was going on. You'd ask all the right questions

00:15:58.600 and then they'd give you this scathing feedback. Like they didn't even know what they were talking

00:16:02.440 about and it just bugged me, right? But you can picture this, right? I don't know if you guys can

00:16:05.820 hear me breathing angrily, but this is, I had the exact same experience. Keep going.

00:16:09.120 So we had to do nine of these in a full day. Each encounter took 30 minutes, 20 minutes to do the

00:16:17.020 thing, 10 minutes to get the feedback. I do a really honest to good job for the first eight.

00:16:24.260 I really, I'm trying as hard as I can. I'm doing the best I can. I'm taking my beatings.

00:16:29.640 We're going into the last one and I just lose it. I can't do it. And so I pull the chart out of the

00:16:37.000 medical thing and it says, you're, you're seeing Mrs. Smith and Mrs. Smith is here to talk about her

00:16:42.100 daughter, Susie, who is wetting the bed at night. That's all the information you have. So you got

00:16:46.220 to go in and now play the pediatrician or whatever. So I walk in and I say, hello, Mrs. Smith. And she,

00:16:54.320 she looks at me kind of funny and she says, um, hi. And I said, my name is Dr. Evil. I went to

00:17:01.280 evil medical school. And she's okay. Um, well, um, Susie is some, and she starts talking about

00:17:10.740 Susie and I said, I don't really want to hear about the details of Susie's life. Let me tell

00:17:15.360 you about the details of my life. And then I do the entire monologue from Austin Powers.

00:17:22.020 They are quite inconsequential.

00:17:23.560 Ending with a Zoroastrian named Vilma ritualistically shaved my testicles.

00:17:30.060 And as a Zoroastrian.

00:17:31.680 Yeah. You can appreciate this.

00:17:32.960 It hits close to home.

00:17:33.740 And I keep going. And then all of a sudden the door like basically breaks down because

00:17:38.200 they're videotaping this whole thing, which you knew, I knew that this was happening.

00:17:41.280 And they get so pissed. They run and they go, this is over. This is absolutely done. What,

00:17:46.300 it is totally inappropriate what you just said. And I said, I said testicles. I said,

00:17:51.400 shorn testicles. That's a medical term. That's completely legitimate.

00:17:55.340 Did you tell them, have you ever experienced shorn testicles? It's quite exhilarating.

00:17:58.980 I suggest you try it.

00:18:00.000 I suggest you try it.

00:18:01.600 So I got the boot. It was a huge deal. They basically dragged me out of there.

00:18:06.160 That is the most amazing thing I've ever heard in my life. I'm so proud of you,

00:18:10.680 Peter Atiyah, as your superior officer in school, because I thought that those patient actor things

00:18:17.200 were the stupidest bullshit in the world. Okay. This is what they do. This is what they tell you.

00:18:20.480 You know what? You need to have empathy. You need to be able to read people. You need to be

00:18:23.440 able to see through lies and get to the heart of what's going on. So what do they do? They put you

00:18:27.700 in a room with a professional liar. And when you see through it, when you see it for what it is,

00:18:33.140 which is zeros and ones, you go, this person's faking it. I can't, how can I show empathy to

00:18:36.900 someone who's pretending? You want me to pretend? I can become a liar too. And so I did the same thing.

00:18:42.660 I went in the room, hands in my pockets like this. The woman had fake bruises on her face. She was

00:18:47.740 supposed to pretend to be abused. And my first reaction was, how dare you pretend? How dare

00:18:51.920 you mock people who've actually been abused? You're doing a shitty job of it. You're not a

00:18:56.360 great actress. And I'm being judged on how I pretend? Right. Like, this is horrible. Give me

00:19:01.540 a real patient. So did you pass? Well, it didn't matter because it was, right, it was just, we were

00:19:07.400 being used as a trial site. Oh, I see. So the next day I get a page. It was back when we used to carry

00:19:11.860 those alphanumeric, not even the alphanumeric pages, just the straight numeric pager. Right.

00:19:15.300 And it's the dean's office. And I'm like, you've got to be freaking kidding me. It's

00:19:18.980 like a month before graduation. I'm like, so I call and it's like, hi, this is Peter

00:19:24.680 Attia returning a page. And they said, oh, Dean so-and-so wants to speak with you. Wait

00:19:28.380 a moment on the line. And I'm like, God damn it. So I just get all defensive. So he gets

00:19:34.740 on the phone and he goes, hi, Peter. And I'm like, Dr. So-and-so, look, before you say

00:19:38.680 it, I just want to say one thing. This was totally ridiculous. And I go off on like a four

00:19:42.600 minute rant about how idiotic the whole process was. And he goes, well, look, I just want to say

00:19:47.500 I watched it last night and I thought it was hilarious. And I really think you should question

00:19:52.940 whether or not you should be at least incorporating some of that into your career. So I just wanted

00:19:57.600 to call you to say, good job. And I was like, that is fantastic. That's like the highlight

00:20:02.140 of my medical school.

00:20:02.860 There is hope in the universe, Peter Attia. I had a similar experience at UCSF when I did a

00:20:07.380 graduation speech that actually launched my whole career as ZDoggMD because I later put

00:20:11.220 it on YouTube. It's in my 1999 UCSF graduation speech. It's there. It's all captioned and

00:20:15.480 everything. And it was, I just went through it as I saw it. And it was all just like, this

00:20:19.400 is bullshit. This is bullshit. This is bullshit. This is why. This is bullshit. It's about actually

00:20:22.620 connecting with our patients, isn't it? And the majority of the faculty behind me were

00:20:26.480 just like stone-faced for 90% of it and then finally start to crack. And you see Michael

00:20:30.320 Bishop, who's like a Nobel Prize winner, finally he's like. And afterwards they were

00:20:35.260 like, that was very well done. But there was one guy who was like, that kid shouldn't be

00:20:39.300 allowed to graduate. And actually was lobbying to have my graduation revoked for giving that

00:20:44.560 speech. I mean, so this is the thing. It's a hierarchy. And I can tell you don't like

00:20:49.400 hierarchies so much.

00:20:50.720 I probably have more respect for it than you actually.

00:20:53.220 Being a surgeon.

00:20:54.560 Yeah. I don't, I don't know. I feel like I'm not as, I don't bristle as much at it as

00:21:00.480 probably some people. I mean, I would say for a surgical resident, I respected it much less

00:21:05.080 than the other residents. And I definitely got into trouble on a few occasions as a result

00:21:09.980 of it.

00:21:10.560 Yeah. Yeah.

00:21:11.180 Yeah. I've met people who completely have absolutely disregard for any hierarchy and

00:21:15.240 many of them go on to just do the most amazing things. So I always felt like I wish I had

00:21:19.220 less respect for it.

00:21:20.240 Well, you know, it's a complex thing because I think certain personality types don't like

00:21:23.880 to be in the middle or bottom of hierarchies. They either want to be on the top or they want

00:21:27.720 to be off the hierarchy. It's hard for them to feel like other people are controlling

00:21:32.100 them or they're beholden to others in the higher hierarchy. And they either have a tendency

00:21:36.740 to dominate those underneath or to treat them as equals inappropriately, in which case the

00:21:41.560 lower down in the hierarchy don't have the competence and what they need is actually to

00:21:45.740 be trained and lifted and supported. And instead it's like, why aren't you, why aren't you at

00:21:49.780 the level that I'm asking you to be? And so it's, it's interesting. It becomes tough in

00:21:53.240 the higher echelons of performance and stuff.

00:21:55.080 I think the problem I had in residency was I really loved hierarchy when I could respect the

00:22:00.200 person I was reporting to. So, you know, luckily I did my residency at a hospital where most

00:22:05.480 of the residents were just exceptional. So it, for the most part, was really easy to respect

00:22:10.020 the hierarchy. But the problem was when I encountered somebody and I didn't think that they were good

00:22:15.440 enough or smart enough or knew enough, I wouldn't hesitate to just steamroll them. And that gets

00:22:21.500 you into a lot of trouble.

00:22:22.980 I saw that in you when you were a medical student. I remember it. It was one of your characteristics

00:22:27.100 that I actually respected a lot. Because again, if you, like you said, and you kind of described

00:22:31.980 our team pretty well. And the person at the top was fairly narcissistic. The one in the middle was

00:22:36.200 kind of a non-entity. Then there was me who was the class clown. And then there was you. And it speaks

00:22:42.280 to our medical training in general that it really is about kissing the ring of the authority figure.

00:22:49.300 So one day you will be the ring that's kissed. That's the majority of our training. The first two

00:22:53.100 years we're fed a bunch of information, 50% of which is wrong, but they don't tell us which 50%.

00:22:57.940 And then the 50% of the residual will be outdated by the time you finish.

00:23:01.640 Exactly. So it's 100% bullshit. And yet we're expected to kind of suck it all in and regurgitate

00:23:07.100 it with respect for this hierarchy. And we don't ask questions. We don't step out of that. And you're

00:23:12.020 right. You have to respect your authority figures, which is important when you trust and respect them.

00:23:16.120 But when you're questioning things like, why are we doing this? Why are we giving Lasix to this

00:23:20.140 person? Or what's going on with this renal failure? Actually, what about the root cause of that?

00:23:23.960 You start asking this question. No, no, no, no, no. That's when I was told, hey, you speak,

00:23:27.460 then think. You should reverse that. They don't want to hear that from a medical student. And you

00:23:31.860 know, we had the short white coats and everything. You guys had the long white coats. It wasn't as

00:23:34.840 hierarchical.

00:23:35.080 It was very unusual. Yeah. I didn't realize how, quote unquote, special that was until I saw that there

00:23:41.320 were many programs where even the interns were still in short white coats. And I didn't realize

00:23:46.140 what a big deal that was. How much obsessing went into the white coat thing. I feel like an idiot

00:23:52.620 even just voicing this right now, because I've never thought about this for like 20 years.

00:23:57.120 But what a big deal that white coat is. And I feel bad. Maybe I should be more respectful of the

00:24:01.160 white coat. You know, when I came from UCSF, nobody wore a long white coat except for fellows and

00:24:06.620 attendings. So even the residents wore short white coats. I think Hopkins was that way. They're just

00:24:11.040 starting to change it. When I came to Stanford, I saw you wearing a long white coat.

00:24:16.140 And my conditioned unconscious wanted to smack you. I haven't earned it. You haven't earned it. I

00:24:22.240 haven't earned the long white coat I'm wearing as an R1 as an intern. It's such an interesting

00:24:27.220 process. It's almost militaristic. It's a very military hierarchy. And the question is, is that

00:24:32.020 good? Do we need that? I think some degree of organization hierarchy is important when people's

00:24:35.700 lives are on the line. Same within the military, right? You're friends with Jocko Willink and these

00:24:39.820 guys. I mean, what would he say about this? I don't know. I'd hate to speak for anybody,

00:24:43.400 especially Jocko. But the challenge comes when you have to make a decision that is probably

00:24:51.200 not the best decision for the patient, but it's the one that's coming down from the person just

00:24:56.940 above you. And I always found the stickiest situations were, and I had an example and I

00:25:02.040 want to be very careful. I don't reveal too much because this was such a vivid example in my residency.

00:25:06.620 But there was a time in my residency when I was an intern and it was a small surgical service.

00:25:12.300 So it was me and a chief resident only. So you didn't have all like the 17 layers. So it was,

00:25:17.040 you know, you basically had attending fellow chief resident intern. So there was only like four people

00:25:22.360 in the chain of command. And there was a situation that was in my mind, clearly a case of someone that

00:25:29.280 needed to go to the operating room. I don't think you even needed to be a physician to know that this

00:25:34.060 person needed to go to the operating room. I think if you walked into McDonald's and just polled a

00:25:38.780 hundred people there, 97 would say, yep, that's a surgical case.

00:25:43.060 Yeah. And the third would be like, I want extra.

00:25:45.060 Right. The other three, they might miss some finer detail. So I called the chief resident and this was

00:25:51.240 a weekend that I was on call. And I said to him, hey, I got this case and, you know, blah, blah,

00:25:57.500 blah, blah, blah. It needs to go to the OR. And he was like, just deal with it yourself.

00:26:01.280 And I said, look, I know you're upset at me. I've already called you twice today. This was 8 PM.

00:26:07.520 And I had already called him twice on the Sunday and he had had to come in both times because of

00:26:11.880 the injuries were so severe that I was calling him about that they had to be taken to the OR.

00:26:16.340 So he'd already been to the OR twice that day. It's a Sunday. He's pissed. It's his day off.

00:26:20.780 So now I'm calling him at 8 PM to say, this is a surgical case. He's saying, you fix it yourself.

00:26:27.580 I'm saying, look, I technically could address this in the ER, but that's not the best thing

00:26:34.340 to do. And he was like, stop being such a fucking pussy.

00:26:39.260 So this-

00:26:40.340 This was your attending?

00:26:41.080 No, no. This was the chief resident.

00:26:42.140 Chief resident at Hopkins.

00:26:42.540 This was the chief resident. Yes.

00:26:44.060 Yeah.

00:26:44.740 So again, I don't want to get into the details of it because it could kind of give away the

00:26:48.960 identity of any of the people involved. In the end, I did deal with it in the ER. And

00:26:54.380 I dealt with it the best I could. Admitted the patient. The next day, everyone's rounding

00:27:01.260 and they see the patient and they're like, God damn, how did this not go to the OR?

00:27:06.780 So what I realized in that moment, and I was very early in my internship. I mean, days into

00:27:12.880 my internship actually. What I realized was the mistake I made was I didn't call the attending

00:27:18.560 directly.

00:27:19.380 Go right above.

00:27:20.480 Yeah. Again, it was so obvious that this chief resident was wrong. It's so obvious he

00:27:25.700 was being a lazy sack of shit. So I should have just called the attending. Now at the

00:27:31.380 time, that wouldn't even occur to me. I mean, that's like, you can't break the chain of

00:27:35.180 command. But I look back at that and I view that as probably, certainly one of probably

00:27:39.460 my five biggest failures in residency was the weakness, the inability to break that chain

00:27:46.280 of command and deal with the consequences of it. Because there would have been consequences

00:27:48.940 of that, even though it was the right thing to do. And even though that patient would

00:27:51.860 have gotten much better care, I would have paid an enormous price for that through the

00:27:55.360 duration of my residency, at least in that era. And I don't know, I feel like in some

00:27:59.300 ways I was just a coward, you know, or deer in headlights. I just didn't know what to do.

00:28:03.240 So I thought, okay, I'll do the best I can.

00:28:04.920 You know what? I want to dig into that because this story is at the center of what we're now

00:28:09.940 calling burnout. And I don't think it's burnout. I think it's moral injury. And Talbot and Dean

00:28:15.540 and others have written about this in STAT and other places. You were in a position where

00:28:20.640 all the system was arrayed to make it very difficult for you to do the right thing for

00:28:24.980 the patient. You knew it was the right thing. You knew the patient needed to have this done.

00:28:28.900 And you knew that it would cause serious consequences to you to have it done. And you

00:28:34.920 erred on the side of, okay, well, maybe the system is this way for a reason and it'll be

00:28:38.740 okay in the morning and it may not have been. And then you had to live with the shame and

00:28:43.440 the guilt of not having done something that was self-destructive, that was not in your

00:28:47.940 best interest to help this other person. And to this day, I can tell sitting across the

00:28:52.080 table from you that this bothers you deeply. You're saying it's one of the five things...

00:28:54.900 This bothered me so much that for at least 12, 15 years after, I would contemplate asking

00:29:05.720 one of my friends who was still at Hopkins. You know, by this point now, a few of my friends

00:29:09.440 who had finished were still attendings at Hopkins. I had contemplated asking them to dig through the

00:29:14.480 medical records to find out what happened to that patient. Because I couldn't remember the

00:29:17.840 patient's name, but I remembered the date. So I was going to say, hey, go back to this date and look

00:29:22.500 at everyone that came in the ER on that day. And I will be able to figure out which this person is.

00:29:27.580 I want to know what this person is doing today. And I kid you not, this is actually a really funny

00:29:34.580 story. I mean, funny in this one twist. I know you're a huge fan of Dr. Oz, right?

00:29:39.560 Massive. Love him. So glad you were on his show, by the way.

00:29:42.020 Right. So I was on that show and a little embarrassed, truthfully, because I felt silly

00:29:46.860 and I didn't think it made sense for me to be on. But nevertheless, I was on. And I didn't know when

00:29:51.660 it actually aired. But when it aired, I heard from the patient's mother, who was also there.

00:30:01.040 And to make a very long story short, it reconnected me with the patient who was doing

00:30:04.440 exceptionally well. And it was, you know, in a way, maybe it's wrong that I could alleviate some

00:30:10.860 of the guilt by knowing that the patient turned out okay. But it was unbelievable because even this

00:30:16.220 patient said they'd never watched this show before, this Dr. Oz show. They just happened to be in the

00:30:21.600 waiting room, I don't know, getting their car fixed or something. And they saw it on TV and they're

00:30:25.600 like, hey, I know that dude. That patient recognized you across the years.

00:30:30.840 Yeah. This would have been 15 year Delta. And then connected with me through my blog or something

00:30:35.860 like that. Really, we have to let that sink in. That at the heart of all of this, and you're,

00:30:40.440 you know, listen, you're an amazing scientist. Your podcast is unbelievable. Like I listened to it,

00:30:45.380 I'm enthralled by it because I'm also a huge nerd. But the fact is that was a human connection that you

00:30:51.180 made that also was a victim of a system that was so broken that it caused you moral distress that

00:30:59.140 lasted for years and was only partially ameliorated by reconnecting with that human at the center of

00:31:05.720 that. Now, let's take that, that you suffered, and scale it by a thousand times every single day

00:31:12.660 when we have to take care of patients. We know full well what needs to be done. We know where the

00:31:16.960 fuck-ups are and where things have gone wrong and where our system has failed. And we have

00:31:20.180 powerless. Not only powerless, if we do the right thing, we will lose money. We will lose time with

00:31:25.660 our family. We'll be charting all night. And it still may not work for the patient.

00:31:29.780 Now, for my listeners who aren't as familiar with this stuff, help me understand what that means. So

00:31:35.680 you trained in internal medicine. When you finished at Stanford, what was the first job you took as an

00:31:41.200 attending? So I'll be honest with you. About year two of my residency, I wanted to do GI because I was

00:31:46.800 always intellectually interested in it. Your dad is a gastroenterologist, isn't he?

00:31:49.380 He's actually a primary care doc who also trained in pulmonary. But I just, for some reason,

00:31:54.220 I always loved GI physiology, loved hepatology. I loved the way that digestion works and the mind-body-gut

00:32:00.440 connection I thought was fascinating. Like I loved irritable bowel syndrome because I thought how

00:32:05.300 interesting that the mind can influence what we sense in our gut when we get butterflies and that

00:32:09.880 kind of thing. So second year though, I did the rotation. Had a terrible mentor. It was just scoping

00:32:15.400 routinely doing colonoscopies and EGDs and it was horrible. The idea that that could scale for a

00:32:22.500 career was mind-numbing to me.

00:32:24.380 Because when I hear someone saying, I want to go into GI, I assume they mean they want to be a,

00:32:28.640 you know, they want to do scopes because that's the most lucrative part of GI, right? But you were

00:32:31.840 more interested in like the medical part of GI.

00:32:34.180 I like the medical part of it. And even hepatology was a little too much, but I wanted to scope that

00:32:38.520 was cool. That was video games in people's buttocks. Awesome. Great. But I like talking

00:32:43.340 to patients. I like the relationship and I like the physiology of it. Talking to people about their

00:32:47.940 issues because abdominal pain, chronic abdominal pain, constipation, nausea, vomiting, a lot of times

00:32:52.720 these are deeply connected to the mindset. And so that's what I loved. But then when I saw the

00:32:58.680 scoping part of it, I was like, I hate this. I hate it. And this is most of how I make a living.

00:33:02.680 It was repetitive, mindless to me. It didn't sit with me. Plus, I was starting to get disillusioned

00:33:08.960 in general with medicine because most of what we did seemed like bullshit. Most of what we did

00:33:12.560 either harmed people or just wasn't thought out. You know, it's half-baked. And the thing is that

00:33:18.120 caused a kind of moral distress. So I was like, forget it. I was burned out. I was tired. So by third

00:33:22.480 year, I remember my program director had to pull me in and he's like, you're a bad influence on the

00:33:28.860 interns. It's one thing to be burned out and tired. It's another thing to model that for the younger.

00:33:34.420 And it changed me totally. Then I became this great teacher and got focused on that as a way

00:33:38.900 to have self-worth. And what were you doing to be at a bad influence? Sarcasm or like had the humor

00:33:43.200 gone too far? Like what was it? The humor got very dark. It became more of a wall than a coping

00:33:47.980 mechanism. So it was more like, how can I mentally victimize everyone around me by throwing blame to build

00:33:54.560 a wall around myself? The fact that I feel morally bereft doing this job. So, you know,

00:33:59.800 calling patients gomers, you know, this slang that we use.

00:34:02.140 Where does it stand for again?

00:34:03.280 It stands for get out of my ER. And it comes from the book House of God.

00:34:06.460 Yes, yes, yes.

00:34:06.840 And so I would use every...

00:34:08.140 I haven't heard that in like the longest time.

00:34:09.980 Because it's a horrible thing residents say.

00:34:11.540 Yeah, yeah. But we heard it all the time. I just had forgotten what happened.

00:34:13.460 Not only do you hear it all the time, I had conjugated every form of that verse. So I was like,

00:34:17.020 that guy's gomed out. He's in status gomaticus. You know, this guy's preparing to gom.

00:34:22.680 He's like proto-gom. He's got serious gomopathy. Like every version of gomer I could use. And it

00:34:29.780 came from this black hole in my center where it was like, I'm a bad person, right? I'm a worthless,

00:34:36.860 poor... And that's burnout. But it's really moral injury. So because of that, I decided I was to

00:34:42.060 take a... I told our program director, Kelly Skeff. He knows this story. I've told publicly. I said,

00:34:46.220 Kelly, I can't. No, I'm not going to match. I'm not going to do a fellowship. And I'm not going to

00:34:50.620 practice medicine. I'm going to go into tech because I'm in the Silicon Valley. I'm going to

00:34:54.500 work for a couple of startups and see what happens. And I did that for a year. And in that year,

00:34:58.340 I learned a lot about myself. I learned that without that stimulation of that deep relationship,

00:35:04.060 like money as a stimulus was never going to cut it for me, which I wanted it to, Peter. I wanted

00:35:08.760 to be rich. It couldn't happen. I was doing well. I was moving up in these companies. And then I just

00:35:13.180 felt empty. So my buddy, John, offered, said, hey, there's this hospitalist gig at Stanford.

00:35:18.340 You should take it. It's all your colleagues from residency. We're doing this cool stuff. It's

00:35:22.580 great. And I said, I'll try it for a couple of months. I was there for nine years. And that was

00:35:27.120 the first real medical job. I was moonlighting and I loved it, but this was it. And being able to spend

00:35:32.260 time with patients when they're acutely sick in the worst day of their life, in the hospital,

00:35:36.480 sitting with them, spending time. It was before the EHR, the electronic health record,

00:35:40.160 kind of destroyed our ability to make eye contact. And it was beautiful, man. I kept a diary

00:35:44.500 because I was weird in those days. I was like 30. And I was like, I'm blessed. Who gets to do this?

00:35:50.780 I found my perfect niche. And it lasted probably four years before things started to change.

00:35:55.360 So then what changed four years into that nine-year stint?

00:35:58.440 I think what changed is what's been changing in medicine across the board, which is the creep of

00:36:02.680 medicine as business, medicine as assembly line, medicine as process to be improved,

00:36:07.240 not medicine as deep human relationship. That's a sacred calling.

00:36:09.760 So what ended up happening is the EHR goes live, productivity. We start to lose house

00:36:14.920 resident support. So we're more, they're expecting us to just see a bunch of patients to generate

00:36:18.840 revenue. And it's not so much about teaching. It's not so much about mentorship. It's not so much

00:36:22.240 about a team. What I love about the hospital, you go through, you go, hey, Bob, how are you doing?

00:36:25.400 Social workers there. Case managers there. We know everybody. RTs. And they're all, we're all

00:36:29.380 supporting each other. It's not hierarchical. It's like holarchical. Everybody brings their thing.

00:36:34.060 That started to disappear with the pressure of click, click, click. Then I was going home and

00:36:37.580 charting at home. And then I had my daughter, my first daughter in 2007. And that was a tipping

00:36:41.600 point where I was like, I'm treating my daughter like, you know, my burnout is expressing in how

00:36:48.800 I'm treating my daughter. And I can't spend time with her. I can't read her stories at night. I'm

00:36:53.380 thinking about clicking these boxes in Epic and I haven't finished this note. And did I remember to

00:36:56.980 check the potassium on that guy? And I, you know, I'm the type of guy who can't just sign it out. I have

00:37:00.580 to like, I own it too much. So it just got horrible. And I started being nasty and like my

00:37:07.120 relationships were suffering and, you know. What did your wife think at the time?

00:37:10.680 So she was a radiologist, academic radiologist at Stanford. So she found a path that was really

00:37:15.980 perfect for her. Introvert, very science minded, loved the team dynamic of it. She looked at me and

00:37:22.580 was like, you're in a bad. Did you guys meet at UCSF?

00:37:25.400 We met at Stanford as interns the year that I met you. She did all of medicine and then came

00:37:30.200 to an epiphany. Don't like medicine. Parents were really into medicine. Both were medical people.

00:37:36.620 She's like, they didn't see radiology as a real doctor. You know, Chinese parents. It's a lot

00:37:41.080 of pressure. So she's like, you know what? I'm not going to specialize in pulmonary critical care.

00:37:44.740 I'm going to go back and do chest radiology. And Zubin, you're going to support me, by the way,

00:37:48.740 for four years, if more residency and fellowship. And I was like, all right. And so when that table

00:37:53.520 turned and I was miserable and depressed, she was the first to say, you know, because we had gotten

00:37:59.540 this, I mean, that's another story. We started making videos, putting them online. And Tony

00:38:03.920 Shea, the CEO of Zappos, reached out. But before that, she was like, what can we do for you? Do

00:38:07.700 you want to just stop working? I'll go up to full-time. She was 80% and you can just stop

00:38:11.600 working. We won't have a ton of money, but we'll, in the Bay Area, you're poor no matter what you do.

00:38:16.520 And I was like, I don't know. I don't know. I don't know.

00:38:18.820 And this is how long after 07?

00:38:20.400 This would have been 08.

00:38:23.000 Okay. So your daughter's a year old.

00:38:24.420 She's one. And then by 09, what had happened was we went to visit. So Tony Shea went to Harvard

00:38:30.940 with my wife. And Tony Shea built Zappos and then sold it to Amazon for like a billion dollars

00:38:36.500 and just wrote a book called Delivering Happiness, became this national sort of thought leader in

00:38:41.460 the space. We went to visit him for Thanksgiving. He's having a bunch of friends over. So he does

00:38:45.400 this thing that Tony does. You know Tony as well. We all kind of roll in the same circles.

00:38:48.800 And he kind of looks at me and he's like, so are you happy doing what you're doing as

00:38:53.620 a doctor? It sounds really amazing. And I looked at him and I'm like, absolutely not. Absolutely

00:38:59.400 not. And to see you living this life where you're doing what you love and you're financially

00:39:03.800 successful and you're affecting people's lives and people come up to him in restaurants

00:39:06.700 going, you changed my life with your book and this and that. I'm like, it was a mix of

00:39:11.140 jealousy, like deep jealousy. Like how can someone be so connected and me feel so isolated

00:39:16.500 and self-hatred? Yeah. Cause it wasn't the money. You certainly saw money everywhere in

00:39:21.760 the Silicon Valley. I remember one of the things in Tony's book that I liked so much. They paid

00:39:26.640 you to quit after a period of time, right? Was it three months in? Three months in and they

00:39:30.020 give you 2,500 bucks to just go away. Just walk away. Yeah. I love that. And if you walked

00:39:34.040 away, then you weren't really a good fit. They were happy to pay the money. That's a Zappos

00:39:37.640 culture in Tony. Oh my God. It's amazing. Brilliant. Imagine if we did that in healthcare. Give

00:39:41.580 somebody, it'd have to be like a hundred thousand dollars. Okay. Quit now. And if you're still

00:39:45.200 with it, it means that you're doing this because there's nothing else in the world you'd rather

00:39:48.580 do. And that's what I tell medical students, you know, like, whoa, should I go and do it?

00:39:51.380 I don't know. Like, is there, if there's anything else you'd rather do, do it first. If there

00:39:55.960 isn't, then this is your path. Cause it is hard, but it is a sacred calling and you'll feel

00:40:00.840 it and you'll feel it. So you had that discussion over Thanksgiving with Tony and then what?

00:40:04.500 I've never been so depressed in my life because I went back to Stanford. It's winter. You know,

00:40:10.480 winter is in medicine wards. Every single old person with pneumonia tries to die in the

00:40:14.740 hospital. It's gloomy. The residents are stressed. They're midway through. I'm supervising an

00:40:20.580 intern who was a young lady who I remember was such a wonderful human being, but she was

00:40:25.180 stressed and I was stressed and we're looking at each other. Like, how do we help each other

00:40:28.200 get through this? Cause it was just she and I, cause they peeled back our support from a

00:40:32.200 big team to just one intern, one attending. So I'm a uber mentor. I'm resident attending

00:40:38.500 second year, sub I, everybody in one. I would literally cry in the shower so that the wife

00:40:44.420 wouldn't know that I was crying. And, you know, and it's funny cause I talked about some of this

00:40:47.120 in the Ted talk where we met again. So super burned out. But Tony had, and this is why I think it's so

00:40:53.400 important to have mentors that matter. Tony told me, so if you had one thing you could do, that was in

00:40:58.260 that visit, what would you do? And I'm like, dude, like I, I did this speech for graduation.

00:41:04.080 I felt so connected to the audience. I felt like I was revealing truth through humor that could help

00:41:09.800 motivate people to change stuff. I would do that for a living. I would put these videos on YouTube,

00:41:14.720 which was a new thing. And, but I can't cause I'll lose my job and it's dumb and no one will watch.

00:41:19.840 And he's like, you're wrong. Like, look at this guy, Vaynerchuk. He's like a wine salesman.

00:41:24.720 He made a whole living out of this. Look at, look at this guy who co-founded Dig. What's his name?

00:41:29.600 Kevin Rose.

00:41:30.080 Kevin Rose. Kevin does this show and I watched the show and I'm like, that's funny and awesome.

00:41:35.220 So part of my depression was, why can't I just get through this inertia to do this thing?

00:41:39.720 And when I finally did, when I put my first video on YouTube on my birthday, basically in 2000 and-

00:41:45.060 Which one was the first one?

00:41:46.100 The first one was Colon Wars. And it was a parody of me talking about GI

00:41:50.320 through the lens of Luke Skywalker going down the trench. So he's doing a colonoscopy and he's like,

00:41:55.280 stay on target. I can't hold it. Stay on target. You can't do any more good back there,

00:41:59.000 Wedge. Pull up, pull up. About this whole thing. And it got a bunch of views and people were like,

00:42:04.960 that's nerdy as fuck. I like that. And that's when the depression started to lift. And then just on

00:42:10.220 the side as this character, ZDoggMD, which I created to try to make sure Stanford wouldn't fire me.

00:42:15.440 And the thing is they never even knew because they weren't on YouTube. And so it's more and more

00:42:19.640 videos and more. And then we did one called Manhood in the Mirror, which was our first big music parody.

00:42:24.400 This is the first one I saw.

00:42:25.460 Right. And it's good because I'm grabbing my crotch repeatedly, which is important for you

00:42:29.800 to see, Peter. It's very important. And it was Michael Jackson's Man in the Mirror,

00:42:33.600 but it was about testicular self-examination. I'm checking out my nads in the mirror.

00:42:39.500 I feel my junk for lumps and stuff. And it gets a bunch of views and people are playing it in these

00:42:46.720 like student health clinics on repeat. And they're saying, oh, kids are catching early testicular

00:42:50.860 tumors. And I'm like, shit, am I responsible for overdiagnosis now? Are people having their testicles

00:42:54.140 removed that don't need to? And all this self-blame again, but it woke me up.

00:42:57.920 So you were still at Stanford when you made that video?

00:42:59.820 Full-time.

00:43:00.280 Okay. I didn't realize. I thought you had already left by then.

00:43:02.180 No. So two years at Stanford while making these videos full-time until Tony saw the videos and

00:43:06.420 was like, okay, here's a proposition. Unplug from that matrix. Come to downtown Vegas. We're doing

00:43:12.220 startups here and I'm investing in some things. Do something that's going to transform medicine

00:43:17.160 that's about you and about the community. And that's when we imagined that conversation with my

00:43:22.300 wife. Hey, you told me to follow my dreams, honey. So my dream is we quit this beautiful Bay Area

00:43:27.120 lifestyle and we moved to downtown Las Vegas, which is currently a demilitarized zone for this pipe

00:43:33.840 dream of starting a clinic.

00:43:35.120 And it's a little warmer than Palo Alto in the summer.

00:43:37.880 Vaguely. Yeah, vaguely. And very different.

00:43:40.620 And did she bristle or was she all in from the first moment?

00:43:43.320 You know, it was crazy. I was the one who bristled. I was like, that's dumb. I can't do that. And she was

00:43:48.480 like, listen, this is your chance. You gave me a chance for four years to pursue what I cared

00:43:52.560 about. Now's my chance to pay you back. We'll go. We'll give it a shot. And if it doesn't work,

00:43:57.500 no problem. We'll come back and who cares. And if it does work, then great. So she was the one who

00:44:03.040 pushed me. I mean, without being married to the right person, I think the biggest decision you can

00:44:07.600 make in your life is who you partner with. I mean, I agree completely. And my decision to leave

00:44:11.720 medicine, that was a hard decision to make. You know, when you're two years left in your 200 year

00:44:18.120 residency and I was like, yeah, I don't want to do this anymore. But actually my wife helped me see

00:44:22.920 that because she said, you are so miserable. Why are you so miserable? And I gave her 12 reasons.

00:44:30.120 You know, she sat on it for a few days and then she said, I know you enough. We hadn't been married

00:44:35.680 that long, maybe a year. And she said, but I know you enough to know that there's only two ways you're

00:44:40.800 going to get better. You either have to fix those 12 things on that list or you have to leave.

00:44:46.160 And I thought about that for a few days, probably for a few months actually,

00:44:51.780 because this would have been the August of that year. So when did you guys get married?

00:44:56.040 We got married in 04. So this is now summer of 05. So I'm really thinking this isn't for me,

00:45:04.960 you know, reasons X, Y, and Z. Like it would be, I mean, I loved the operating part. It was just,

00:45:09.080 there were too many things about the system I couldn't stand. So then I came to that really

00:45:13.020 hard decision, but I thought her framework was the right framework, which was, it would be great

00:45:17.960 to stay if I could fix all of these things, but I can't. So I probably need to go. And so that was

00:45:23.740 the decision to go. Now I didn't know what go meant. I didn't know if it meant go into another

00:45:27.540 specialty, leave medicine altogether, go into the lab full-time. And because I had just come back

00:45:33.500 from NIH where I had spent two years in the lab. So all of these options were spinning through my mind,

00:45:38.780 which was, look, maybe I'll just get a PhD and just full-time do research or go and do this or

00:45:43.800 go and do this. I mean, it's funny. I found it recently. I found the document that I made. This

00:45:48.960 is how nerdy I was. I put a table together in Word and I had all of the things that I was considering

00:45:55.540 doing with my life and the pros and the cons and the optionality triggers. And if you do this,

00:46:01.880 it'll cut you out of this. But if you do this, you might be able to then pivot and do this.

00:46:06.080 It was this whole thing. Wow. Engineer mindset. That's amazing. See,

00:46:09.740 we're so different that way. Because I was like, let me throw some feces and see where it sticks.

00:46:13.840 Oh, it sticks there? All right. I'm going to leave medicine. So for you, it was thought out,

00:46:17.540 but it was prompted by your wife. In a way, did you feel like you needed permission from your wife?

00:46:21.620 I think so. Because people often say to me when they find out I left before finishing at Hopkins,

00:46:26.880 they said, you must have really hated Hopkins. And the answer is not at all. I freaking loved that

00:46:31.920 place. In many ways, it's hard to say one of the best chapters of my life,

00:46:35.820 because I feel like I've been really lucky. I think the only really shitty chapter of my life

00:46:39.160 was college. But medical school was an incredible chapter. Residency was an incredible chapter.

00:46:44.400 You know, work post-residency was, all of these things have been very enjoyable.

00:46:47.880 So no, the reality of it is like, I had amazing friends there who I am still incredibly close to,

00:46:53.620 wonderful mentors. Obviously, like all hospitals, there are, I think, 20% of the surgeons at Hopkins

00:46:59.460 you wouldn't let operate on your cat because they're absolute, I mean, assassins.

00:47:04.740 It's true everywhere.

00:47:05.560 Yeah, yeah, it's true everywhere. But you also were surrounded by some of the most skilled,

00:47:09.420 gifted, remarkable surgeons. And the residents above me, meaning the people that I was trying

00:47:14.400 to emulate, these chief residents and senior residents and the fellows, I mean, oh my God.

00:47:18.800 I mean, some of them were just gods to me. And I still keep in touch with most of them,

00:47:23.420 right? Many of these people who were like, you know, my heroes are still my heroes in a way.

00:47:27.420 I actually just ran into one in the Vons, like very recently. She was my fellow on pediatric

00:47:34.400 surgery when I was an intern. And she's now, you know, an attending in pediatric surgery in San

00:47:39.580 Diego and we jumped into each other. So, and she was, yeah, Vons of all places.

00:47:43.360 Did you have your card? Because that's important. You don't get a discount.

00:47:45.880 I just can never remember it. So I mooch off my wife's phone number every time.

00:47:49.760 That's what I do.

00:47:50.260 Yeah. In a way, I think I needed permission. I think my parents thought it was crazy.

00:47:54.860 You're Egyptian.

00:47:55.760 Yeah.

00:47:55.940 So do you have the classic immigrant parents or were they first generation, second generation?

00:47:59.600 Yes. No, no, no. Super classic. My mom actually is completely supportive. So whatever I do,

00:48:03.280 my mom is, I literally could be a garbage man and she would be delighted. But my father was very

00:48:08.900 upset when I finished engineering, turned down my scholarships to do the PhDs in engineering,

00:48:14.360 and then had to go back and do a postbac year to go to medical school. He was super upset about that.

00:48:19.500 Right. Because you did that postbac where you got all the prereqs for medical school. What changed

00:48:23.340 your mind from engineering? It's a tough story to tell. It was hard for me to get into that.

00:48:27.200 Yeah. Okay.

00:48:27.560 Yeah. Super emotional.

00:48:28.720 In a future.

00:48:29.940 Maybe.

00:48:30.380 Yeah. When we're both more woke.

00:48:32.280 Yeah.

00:48:32.620 Because it's tough. There are things I won't talk about. And it's because it's so personal and

00:48:37.200 it's a thing that I'm still working through. We're constantly in this evolving thing. And again,

00:48:42.560 our identity as type A kind of crazy driven people, and you work with like some of the

00:48:47.520 top performers around the world and you do this crazy shit. Like guys, for my fans who don't know

00:48:51.940 Peter, this guy does shit that will blow your mind.

00:48:55.800 Actually, I don't do any shit. I don't do anything.

00:48:58.740 But how many miles?

00:49:00.060 I have in the past, but I don't do anything now.

00:49:01.940 What's the longest swim you've ever done?

00:49:03.700 Probably 25 miles.

00:49:04.680 Oh, just 25 miles.

00:49:05.500 Yeah. But I mean, if you dropped me five miles from shore today, I would pretty much die.

00:49:11.280 Yeah. But you know, because you're evolving to something different every minute, which we were

00:49:16.120 talking even before this started just a little bit about our mutual admiration for Sam Harris and

00:49:20.720 his idea of the self and how it's an evolving, transient, almost illusory thing. But so is our

00:49:26.880 identity. The story we tell about ourselves.

00:49:29.000 Yes, absolutely.

00:49:29.880 So the story of I'm an engineer, no. I'm a doctor, no. I'm a consultant. What's your story now?

00:49:35.900 I mean, people who've listened to my podcast sort of know this and I've gotten a little bit of

00:49:39.920 grief for it. If ever given the choice, meaning if I'm at a party or if I'm somewhere where I'm

00:49:46.040 asked what I do, I only have two answers. The first is I'm a shepherd. And the second is I'm a race

00:49:52.020 car driver. And the reason is usually the former, nobody really asks you any more questions.

00:49:57.460 Right.

00:49:57.860 Like I'm a shepherd. What do you mean?

00:49:59.500 Is this a religious thing?

00:50:00.540 Yeah. And I was like, no, no, no. I mean, it's just like, you know, I tend to sheep and they're

00:50:03.300 like, are there a lot of sheep in San Diego? Yeah, no, no. I mean, it depends. You have to go

00:50:06.340 inland, but yeah. And then that's just my way of like, I don't want to talk about it. And then

00:50:09.900 with the race car thing, at first they think it's sexy, but then I explained that I'm on the Formula

00:50:13.760 2000, like the Formula Renault circuit. And I can just throw two or three sentences out and they

00:50:19.400 already, the eyes glaze over and nobody will. Like if you're not doing NASCAR or Formula One,

00:50:23.120 it's not like they have a follow-up question. So it usually just gets me out of having to talk.

00:50:27.900 That's amazing. All I would be doing in that conversation. And we haven't caught up in a long time.

00:50:32.060 Last time I talked to you, you were talking about installing a race car simulator in your house.

00:50:37.120 In fact, I remember, it was at that long ago. Yeah. I was actually driving back from the track.

00:50:40.480 That's right. Yeah, yeah, yeah. That's right. And you were so, I'd never heard the amount of

00:50:44.360 passion in your voice. You were like, this thing is amazing. It's got all these buttons. And like,

00:50:48.380 my wife is a little pissed, but the thing is, it's like amazing. And you got to, you got to try this

00:50:52.080 next time. And I'm like, who is this guy? So now you're actually driving on these circuits.

00:50:57.000 Yeah. But more importantly, it's just, to me, it's like, I'm only interested in how well I drive versus

00:51:01.840 myself. Like, I'm not, you know, this is not like something that's going to occupy much space in my

00:51:06.280 life beyond just my own obsession with it, like all the other things I obsess over. But the point is,

00:51:12.240 I don't have a narrative. I struggle with all of that stuff. You know, even when my kids are asking

00:51:16.760 me now what I do, like, because my daughter's 10, my son is four and a half. I have a younger son who

00:51:22.560 obviously doesn't ask me anything. But yeah, I think they know I'm a doctor. I think they know that

00:51:26.920 that's my job. But they don't have a clue what that means. And I just say, yeah, it means, you know,

00:51:32.480 you take care of people. And my daughter then asks, what kind of doctor are you? And that's where I'm

00:51:37.960 like, yeah, I don't, I mean, you know, I just, I usually change the subject. Yeah. I'm with you on

00:51:46.460 that. You know, for you, I always see you as this kind of oscillating electron probability cloud wave

00:51:53.060 that what you settle on at any minute can be on how you're observing yourself or what you're

00:51:58.620 obsessed about at that moment. And it's always changing. So when people ask you, tell me your

00:52:02.880 story, tell me your narrative, it's almost like when they ask me that, I get a little insulted. I'm

00:52:07.880 like, you can't reduce the cloud that simply. It's more complex than that. But I think that's true

00:52:13.920 for everybody. And that's why I think, maybe that's why I find that type of question difficult to

00:52:19.240 answer and frustrating. And I think it's why, like even today I did it, the Uber driver who brought

00:52:26.400 me, I came from a hotel over here and not really nice guy. I always love taking Uber in cities that

00:52:31.320 I don't know. Cause really the only two cities I spend, you know, a lot of time in is San Diego

00:52:35.080 and New York and San Francisco. So if I'm in a city like Vegas, I'd love to like, Hey man,

00:52:39.920 where are you from? Did you grow up here? You know, no, he'd been here 14 years, blah, blah, blah,

00:52:44.200 blah, blah, blah, blah. So I'm asking him like 30 questions. So I now know his life story.

00:52:48.320 And then he turns to me and he's like, well, what about you? Where are you from? And I'm like,

00:52:52.200 God damn it. How do I get out of this? So I'm like, you know, I'm from San Diego. What are you

00:52:57.140 doing in town? Business or work? Now the reality is I'm kind of here to give this talk, but I was

00:53:00.920 like, Oh, I'm just here to see a buddy. Yeah. Oh, you staying for the weekend? Nope. Going home

00:53:04.760 tomorrow. And it was like, you know, and I wasn't rude about it, but I think he could tell what this

00:53:09.000 guy's a boring dude. Like there's nothing else to ask. So I was like, I got to dodge the whole bullet.

00:53:13.600 Same thing. Cause how do you, you have to tell almost like it's a huge complicated unfolding.

00:53:19.560 And he didn't want that. I mean, like there is no circumstance. Like the other place where I will

00:53:23.460 be equally dodgy is at like the parties of the parents at the school where you're with all the

00:53:28.960 other doctors and all that stuff. And this is my favorite thing to do is like, I will spend an

00:53:33.400 entire evening talking to a group of doctors and like learn everything about what they do and

00:53:38.840 manage to not reveal one thing. They will think the entire night, this guy, you know, I'll be

00:53:45.220 dressed like this and they're all dressed nice and you know, they will think I'm a shepherd or a race

00:53:52.260 car driver. That is magical. I actually want to hear about what they do. And truthfully, I think

00:53:57.060 it's just selfish. I mean, if I'm going to be brutally honest, you know what it is? I don't learn

00:54:00.940 shit when I'm talking right now. I'm not learning anything when the other person's talking, I get to

00:54:05.660 learn. And I'm kind of selfish when it comes to desiring knowledge. So I think the real reason I

00:54:11.760 enjoy being in that setting and hearing what does that doctor do and what does she do and what does

00:54:15.980 he do is I'm soaking it up and I don't have to waste any of my time hearing myself say the same

00:54:21.540 stupid thing. And you and I both read this book, which I have, I just happen to have here, The Mind

00:54:25.520 Illuminated. I was trying to understand myself better, understand meditation better, stop screwing

00:54:30.740 around trying to meditate for five years and just being like, I can't seem to get it.

00:54:33.980 I actually think I read that on Sam's recommendation two or three years ago.

00:54:37.340 Oh, really? Yeah. I discovered it just randomly on Amazon, read it and was transformed in my

00:54:42.380 practice because it was, do you remember The Greatest American Hero? It was a show in the 80s

00:54:47.600 with a guy, this guy Ralph, he's like an insurance broker or something. And these aliens come down,

00:54:53.260 find him, give him this suit that's a Superman type suit and it gives him superpowers. And they give

00:54:59.120 him the- I actually do remember this. Do you remember this? Believe it or not, I'm walking

00:55:03.400 on air. And they give him the instruction manual to the suit and they go, here's how you use this

00:55:08.180 shit. And he's like, cool. And he reads it and these bad guys are coming. So he learns how to

00:55:12.060 shrink himself down. He shrinks himself down with the suit and then he gets himself grown again,

00:55:17.920 forgets the fucking manual and it's microscopic now and it's gone. So he has to figure out how to use

00:55:24.280 this powerful suit all by himself for the rest of the season. And that's where it's fun. Well,

00:55:29.280 that's what it felt like with me for meditation, trying to understand myself and what is my narrative

00:55:33.360 and who am I and what's going on. You're blindly scraping around, trying a little of Harris's

00:55:37.800 meditation and doing a little headspace and doing a- Then I got this book and I'm like, it's the

00:55:41.440 goddamn manual for nerds and for type A's who want to process. And part of what this thing talks

00:55:47.160 about is this sub-mind system. This idea that our mind is really like a boardroom where you're

00:55:53.980 projecting stuff on a screen and that's our conscious awareness. And what's doing the projecting

00:55:57.860 are these sub-minds. There's a auditory sub-mind projecting sound, a visual sub-mind projecting

00:56:03.280 vision. And then there's a narrating sub-mind that ties these things together, integrates them and

00:56:09.960 projects them as this sort of integrated picture. And that's what tells our story at any given

00:56:14.520 second. I am a race car driver and a shepherd, or I am a former burned out doc who's now trying

00:56:20.380 to transform medicine, which is the lie I'm currently telling myself. And it's created like

00:56:25.200 a beads on a string in these moments, these slices. The liberating thing about that is that at any

00:56:31.220 moment your next slice could be something completely different. It's influenced by the momentum of the

00:56:36.200 previous slices, but it is in itself an unknown and anything is possible. So what got you curious

00:56:42.680 to start exploring this?

00:56:45.180 You know what it was? It was moving to Las Vegas from the Bay Area.

00:56:49.040 Which was what year?

00:56:50.040 This would have been 2012.

00:56:51.400 12.

00:56:51.640 Now I'm a type A materialistic, high strung, I need a house and a car and keep up with the Joneses and

00:56:59.040 my career and so on. That's how I'm conditioned. And I come here where people like Tony Shea are like,

00:57:04.940 are you happy? Like, are you connected? There's this thing called community and relationship. And I'm like,

00:57:10.140 these people are hippies. They don't know where they go to Burning Man. They have no fucking idea

00:57:14.100 what they're talking about. And then I had an experience. Now, look, I've done psychedelics

00:57:19.140 in college, you know, LSD, psilocybin, MDMA, those kinds of things. They are transformative drugs.

00:57:24.740 But when I was dabbling in them in those days, I didn't have an intent to change myself.

00:57:30.360 Something crazy happened. I was up in Tony's place and he has a friend who we'll call the sorceress

00:57:35.900 because that's what she called herself. She's a former fashion designer. And she's like, hey,

00:57:40.220 we're all hanging out. You want to smoke some weed? And I was like, well, I haven't done this in

00:57:43.800 months and months and months because I'm an upstanding doctor and a father and my kids

00:57:47.940 are taken care of right now. Everybody's in bed. Sure. I ended up smoking a heroic dose,

00:57:53.180 like a Terrence McKenna level heroic dose of weed. Because again, low tolerance, et cetera, high.

00:57:57.820 And it turns out she is very adept as a guide and had known me for a few weeks now.

00:58:05.800 And broke, she sat down with me and goes, so this is what I see in you. I see a person who's this,

00:58:10.020 this, and this, and this, and this, and this. And now you're here and you do these videos,

00:58:13.360 but really you're trying to deny that that's an important part of who you are because your

00:58:16.720 identity is a doctor. And she goes this whole thing, basically breaks me down, destroys my ego.

00:58:22.460 Everything I thought I was dissolved. And then she started making-

00:58:25.700 And this was with marijuana? This is just with weed.

00:58:28.780 It's so interesting. I've never liked marijuana. I actually can't stand it. I can't stand the way

00:58:34.200 it makes me feel. So it's hard for me to imagine that that could happen because I don't view it as

00:58:38.900 sort of one of those ego dissolving drugs. I guess for me, I just would always get paranoid,

00:58:44.000 especially if it was sativa. I mean, that would just make me beyond paranoid.

00:58:47.260 So this was the most potent sativa you could imagine. And in my paranoia, which I also get,

00:58:53.200 and I also don't love weed, in my paranoia came this paradoxical disillusion of ego as a protective

00:59:00.780 mechanism. So-

00:59:01.700 So interesting. So you might have gone to a place I'd never been to.

00:59:04.720 That's what it was. And I'd never been there. And with this guide who, you know,

00:59:08.440 she's a Bikram yoga instructor. She, you know, something very spiritual about her, but in a

00:59:13.120 strange way, I would have thought as woo-woo and forget it, crazy, you know, says some very

00:59:16.840 unscientific things, you know. But as a guide for this, triggered me to look at myself and go,

00:59:22.780 what a worthless piece of shit I am. Like what a lying fraud and imposter that I am.

00:59:28.500 And she starts noticing these things. And what happened is a protective mechanism to live with

00:59:34.080 this thing I thought was myself was to dissolve that thing and realize that wasn't really me at

00:59:40.080 all. Like the me is the awareness in which all this arises in moment to moment. And I can be

00:59:44.760 something totally different the next day. And I should have gratitude for all these amazing

00:59:48.300 connections and things that I have. And the, I tell you, and I thought, I told her at the time

00:59:52.060 when I was super high, I said, I'm going to forget all this in the morning, but this is

00:59:55.680 transforming. I was crying and all this shit. And the next morning I woke up and I remembered

01:00:00.780 everything. The transformation was still there. And over the course of weeks, I had this glow.

01:00:05.680 My wife was like, what happened? And I told her, I'm like, I've been changed. And she actually

01:00:09.880 went and talked to this lady and was like, yeah, she's got something. And we're both

01:00:13.000 hardcore scientists, skeptics, right? And that change, it decayed over time. And so the ego

01:00:19.080 reasserts itself, but I've never been the same. And that combined with living in the desert of Vegas,

01:00:23.940 which is a blank slate and being told basically reinvent yourself or go out of business was a

01:00:29.840 personal awakening for me. And since then that got me interested then. And I listened, it sounds cheesy,

01:00:34.880 but I listened to Eckhart Tolle's power of now, just listening to the audio book and listen to his

01:00:38.620 voice, you know, there's nothing but now and consciousness is this. And I'm like, okay,

01:00:42.920 this is bullshit. And then about, you know, 20 minutes into it, I'm like, yeah, no, yeah,

01:00:46.860 this is amazing. Like he's got some truth here in all the woo, there's truth. And then I started

01:00:52.240 down this path. I mean, I have found this to be some of the most insightful, difficult material to

01:00:57.120 digest. You know, you and I were joking about this before. A lot of things come easily to me

01:01:02.020 in terms of understanding. I feel very blessed and privileged that, you know, whatever subject I

01:01:08.200 needed to learn in school, like if I decided I wanted to learn something, I could learn it kind of

01:01:11.860 thing. When it comes to understanding consciousness, when it comes to understanding the nature of my

01:01:16.280 mind, I feel like a complete moron. And you could argue, well, everybody struggles with that, but

01:01:23.880 it's like, no, no, I feel like I'm three orders of magnitude below the average person in this regard.

01:01:29.660 It's very difficult. And for me, like the biggest breakthroughs have been catching the narrative,

01:01:36.040 catching the self-talk. That's like, that's a huge breakthrough for me. I didn't realize how much

01:01:41.140 I talked to myself. That was a huge breakthrough. And also recognizing the transient nature of

01:01:50.040 emotions. Also just an incredible insight, very powerful insight for someone who's so prone to

01:01:57.420 volatile emotions as I am. You know, that's funny. So I just took a personality test. I scored off the

01:02:01.920 charts in volatility and in withdrawal, which is another aspect of neuroticism. And I think,

01:02:07.400 and again, I don't want to, I can't put myself in your mind, but kind of knowing you the way I do,

01:02:10.820 I, the people who are very good at learning and are very good thinkers have these sub minds that

01:02:16.120 are very loud. They're always pitching you ideas. It's like being in an elevator with the most

01:02:20.320 obnoxious fucking startup guy in Silicon Valley. Okay. This is the thing. It's going to be called Dickly

01:02:24.840 and it's about taking dick pics and really democratizing them, like including vaginas and

01:02:29.960 also balls, because I think balls are important. They're often missed. And so anyways, that's my

01:02:33.780 elevator pitch. Can I have $20 million? And then you get $20 million. It's like constantly along with

01:02:38.660 the self narrative. So when you say, I feel like a moron, I understand exactly what you're saying,

01:02:43.120 because being able to see clearly through the turbulence on the top of the water to the dick at

01:02:48.340 the bottom, because that's really what it's a big dick with extra hairy balls. That's very hard. So

01:02:53.260 meditation is one way. Psychedelics are a way to jumpstart it. I know you and Tim talked about

01:02:58.060 this on the show and I don't want to rehash all that, but I want to say that I think you guys are

01:03:02.100 on the exact, all these paths converge. And it seems like pretty smart people are all saying the

01:03:06.540 same thing, which is we need to restart psychedelic research. We need, meditation is a crucial tool.

01:03:11.800 I've kind of followed Tim's journey remotely. I've never met him, but he kind of takes the classic

01:03:17.080 path that a striver type A takes in meditation, which is I'm first, I'm going to use this to help me

01:03:22.080 perform better. Then I'm going to use it to quiet the demons. And I'm going to, and ultimately what

01:03:26.500 it is, you use it to actually understand and appreciate your mind and transform it so that

01:03:32.340 your day to day, actually, all these defilements, these little voices and the emotional reactivity

01:03:38.060 are uprooted permanently. And in this book, he talks about it and having that, those inside

01:03:42.720 experiences. It sounds very esoteric.

01:03:44.040 I found that book very difficult to read, which is not to say it's not well written. I just,

01:03:48.140 I think it again speaks to the problem. I mean, look, I had to read Waking Up by Sam Harris,

01:03:51.780 like four times.

01:03:52.640 I did too.

01:03:53.020 And I think I'm at the point where I understand the first third and the last third. I still don't

01:03:57.600 understand the middle third of the book, Sam. It's just too hard for me. Like I just, I don't

01:04:02.720 have the CPU. I don't have the neurons. There's something that I can't fully understand.

01:04:07.180 This is a huge problem. You know, we talk about the ineffability, the inability to describe these

01:04:12.080 kinds of experiences, and it's a huge problem. I found that the mind illuminated was the closest

01:04:16.180 I got as a rationalist to understanding it. And even then it's like shooting electrons off

01:04:22.640 something and trying to reconstruct the image that this guy already ineffably feels that,

01:04:28.240 you know, he knows it. And it's taken me a lot of repetition. I think the point is we can't give

01:04:32.960 up. I still don't entirely understand.

01:04:34.500 Yeah. You brought up swimming earlier. So I learned to swim as an adult. So I was about 31.

01:04:38.660 Wow. And I decided relatively early in my flailing that like, I really want to do this

01:04:44.300 thing. I want to, you know, swim these long marathons. And like the amount that I had to

01:04:51.200 put into doing that, the amount of hours I had to swim to catch up from being, you know,

01:04:56.660 what I called an adult onset swimmer to being able to do this thing was a lot. And I used to

01:05:02.560 sometimes get frustrated like at swim practice because, you know, like I couldn't swim as fast

01:05:07.120 as like half the people there. And, you know, you had to sort of remind yourself, like they've

01:05:11.620 been doing this since they were four. You know, these people have been on swim teams in high school,

01:05:16.460 in, you know, college, blah, blah, blah, blah. You know, there's a song by the Smiths where

01:05:21.140 there's this line where Morrissey says, you just haven't earned it yet, baby. And I just love that

01:05:24.920 line. It's like, that is my mantra. Like every time I find myself getting sort of frustrated that

01:05:29.180 I'm not good enough at something, I just say, you just haven't earned it yet, baby. You know,

01:05:32.120 you just have, like these people have swum 20 times the number of hours you have.

01:05:37.120 And similarly, when I find myself getting a little frustrated at, you know, my ability to

01:05:41.180 understand consciousness, and I always think about Sam because he's just such an amazing teacher,

01:05:45.980 I think, well, dude, you just haven't earned it yet, baby. Like Sam's been on this journey his

01:05:50.260 whole life. You know, and Sam is probably in a similar boat to us in terms of he's a hyper

01:05:55.400 rationalist. You know, we use this metaphor that John Haidt uses, the psychologist Elfin and Ryder.

01:06:00.500 So Elfin is our limbic system, emotions unconscious, and then our writer is the cortex on top that's

01:06:05.220 conscious. And the thinker and the planner, our writers are hypertrophied. They're super

01:06:09.980 big, but they're still fucking completely beholden to this totally dumb ass elephant

01:06:14.880 that's like, pissed off. Look up something online that backs me up. It's like, well,

01:06:19.340 according to my data, this. And so Sam had to get through that by long retreats. And what I find

01:06:26.040 is I'm in a position in my life now where by straight necessity to alleviate personal suffering,

01:06:31.460 and that happened in 2012, where I just had this break where suddenly I see things differently.

01:06:36.160 Sometimes it takes that, a letting go, a relaxing. So something I hear in what you're describing

01:06:41.320 concerns me in the sense that, and again, this is from my own experience, that it's the striving to

01:06:46.900 striving to treat this like a pursuit like swimming or anything that requires like racing that will

01:06:53.780 hinder ultimately. You'll reach a wall where you can't release until you relax into it and let it

01:06:59.060 go and surrender to it. And it sounds woo-woo, but I think there's something there. So this morning,

01:07:04.240 I do an hour a day now using this. And I know Tim was talking about like 10, 20 minutes a day,

01:07:08.780 and that's great to start. But what I find is there's a therapeutic threshold. And I think it's

01:07:13.940 around an hour, and it's hard to pitch that to people. But once you get into that mold, first,

01:07:18.700 you have to set that intention when you sit down, like this is what I'm doing in this sitting.

01:07:22.260 And the intention creates a momentum of those mind moments that then drives you into the meditation.

01:07:26.800 So you're not lost. When you get lost in thought, you remember the intention and you come back.

01:07:30.700 But at about an hour, you're in a state where the noise actually quiets. And when noise appears,

01:07:37.940 you recognize it and you ignore. And you're floating on the breath, and the body feels like

01:07:43.140 this pulsing wave of energy. And you realize, oh, this is all just experience happening in the present

01:07:48.180 moment. And it's not even, I can't describe it. It's an insight that you have. And then it vanishes

01:07:53.060 about 20 minutes after you're done, where you lose it, you're back in the world. But I'll tell you,

01:07:58.580 if you keep repeating that, I suspect if we can maintain that even for five minutes a day,

01:08:02.980 it's such a relief in humans.

01:08:04.420 I think the benefit's even greater than five minutes a day. I mean, I think, so going back

01:08:08.420 to the example you used about the psychedelics, there's a book that Sam recommended called

01:08:13.800 Altered States or Altered Traits?

01:08:15.640 Altered Traits, yeah.

01:08:16.420 Yeah, yeah, yeah. The point it makes, now it's a book about meditation. And it talks,

01:08:21.180 I think it does a great job explaining that like exercise, the purpose of the hour you spent in the

01:08:28.560 gym this morning was not because there's something particularly insightful about moving a

01:08:33.940 dumbbell from here to here, here to here, here to here, isolating this muscle and putting this

01:08:38.860 thing on your back and moving it in this direction. And in other words, those are simply tools that

01:08:43.920 we're using. There's a state that we create in that hour of exercise. But the goal is to give you

01:08:49.440 traits that last for the other 23 hours. I would suspect you're getting a hell of a lot more than

01:08:54.260 20 minutes or five minutes of benefit thereafter. My guess is that kind of a meditative practice

01:09:00.240 is infused into the other 23 hours of the day in how you react. I mean, because I don't even

01:09:05.760 practice that long and I feel the difference. Like I feel infinitely less aggressive. I feel

01:09:13.060 infinitely more empathic. I'm a little jealous actually. And I really feel like I need to up

01:09:18.580 my game. And no, I'm not saying that in a competitive way, but like realizing there was,

01:09:22.060 because I just had this discussion with Kevin Rose the other day and he said the same thing,

01:09:25.440 which is, you know, he has just totally upped his game and he's going like 45 minutes a day.

01:09:31.160 And he also mentioned that there's a real threshold you're getting over in terms of the

01:09:36.200 practice and the settling of the mind. And this is the thing. It is a threshold effect

01:09:40.820 because something does happen. People who've talked to me, they haven't talked to me in a long

01:09:43.460 time are like, what happened to you? You're so much nicer. There's something edge that's been taken

01:09:48.680 off. Again, you don't notice. And one thing that he says in The Mind Illuminator is that

01:09:51.860 if you practice meditation without somehow applying it in your daily life, it's like a

01:09:57.520 bucket with no bottom. The stuff goes through. It's like a sieve. Whereas if you're starting to

01:10:02.080 collect some of that mindfulness and mindfulness is just simply a lack of reactivity, being able to

01:10:07.160 go, oh, that's happening. Okay. Instead of making a choice. Tim said it best on your podcast. He said

01:10:12.200 you become response able. So you're able to actually make a response instead of an autonomic

01:10:16.460 knee jerk to your elephant. All right. We just have to acknowledge, we took a pee break. We probably

01:10:20.520 forgot what we were talking about beforehand. And the last thing we were talking about was I was

01:10:24.020 revisiting your dick pic joke that was making me laugh so long. That's right. And I realized I

01:10:27.900 didn't add taint into the mix because the taint is often neglected. You know, we had a joke actually

01:10:32.780 when we were admitting patients. When I was in attending at Stanford, the team would come to me

01:10:37.080 and go, yeah, surgeons are trying to admit this gallbladder to us even though we don't do

01:10:40.400 operations. They're saying it's non-surgical and this and that. I go, you know, this reminds me of

01:10:43.800 when I worked on the taint transplant service. And they're like, what do you mean? You've never worked

01:10:48.120 on taint transplant where you're taking donor taints and you're flying in and you're, you know,

01:10:51.760 a homeless guy dies on the street and you take, you excise the taint, you put it on ice and you

01:10:55.200 fly it off. And I would ask them, I say, listen, is this person in the hospital for anything other

01:11:00.580 than their taint? If the answer is yes, it doesn't belong on our service. If this is for a taint issue

01:11:05.900 and a taint issue only, I mean, I'm talking about taint the balls, taint the ass, the space between

01:11:10.400 those two, then it's ours. It's a simple algorithm. And by the way, the graft versus host disease

01:11:15.680 on a taint transplant. It can be devastating. It's devastating because both your balls

01:11:19.820 and your anus are affected. And when they both go down, what do you have? You know, really?

01:11:27.140 Can I pitch something to you? Because we were talking about meditation. Then I want to talk

01:11:30.020 about what you do as a doctor and you can ask me anything like it, but I want to pitch you this

01:11:34.280 theory of consciousness and reality. And I want you to tell me as a smart person what you think.

01:11:39.600 All right. Dr. Donald Hoffman is a professor of cognitive science and computer science at University

01:11:45.360 of California, Irvine. He was on our show. He has posited this theory and it starts with this basic

01:11:51.200 idea, which is, do we see the world as it is? Or are we seeing some fabrication that isn't even close

01:11:59.480 to reality? And he actually was able to look at this evolutionarily. He studies visual perception and

01:12:04.880 how people actually perceive stuff. And what he determined through lots of different studies and

01:12:09.960 also different approaches and different fields was that organisms that see reality as it actually

01:12:17.360 is go extinct. So if you see the matrix as zeros and ones, you go extinct. And the reason is it

01:12:23.920 takes a lot of energy to actually see reality in all its complexity. And so the second proposition is,

01:12:29.880 well, then maybe we just see part of reality, but it's still real. It's just not all of reality. And

01:12:33.660 that's what most visual scientists propose. What he proposes is based on his cognitive models and his

01:12:39.080 computer models and his simulations is that organisms that see any aspect of reality as it is go extinct

01:12:44.820 in just a few generations. Whereas organisms that see reality as a fitness icon designed to help them

01:12:53.160 reproduce thrive. So in other words, there is no bottle of water here as such. There's no water,

01:13:01.680 there's no atoms, there's no paper, there's none of that. This is a graphical user interface that I,

01:13:07.040 as a human, have evolved to see to help me survive. I see something wet that I know that if I drink it,

01:13:12.340 I will not die. So we have this shorthand hack in how we see the world. And over and over and over,

01:13:19.420 he gives examples of insects who will go extinct having sex with a beer bottle because it's perfectly

01:13:24.880 hacked their interface to look like a female insect. And these male insects in Australia,

01:13:29.580 these beetles will have sex with this bottle to the exclusion of beautiful females nearby because it is

01:13:34.320 so perfect. This has been hacked in advertising with humans to make things look hyper appealing.

01:13:40.600 Any McDonald's ad where they're opening the burger and you see the juicy cheese and all that. By the

01:13:45.400 way, the vegans hate us, don't they? All that, that's designed to hack our interface. And his theory is

01:13:49.840 the interface theory of perception that every species sees reality through a series of evolved hacks

01:13:56.560 that allow us to reproduce. And so here's the punchline of that. What is reality? Is there a

01:14:02.820 reality? And what he argues is, yes, there is. There is an objective reality. It's not,

01:14:07.840 we're all not just making this up. Our visual cortex isn't just constructing it. It's not something

01:14:12.700 where, and he's looked at, you know, the number of neurons in the visual cortex is way more than it

01:14:16.480 takes to reconstruct an image, but just enough to construct an image. So we are constructing the world

01:14:24.300 second to second in our minds every day. But the question is based on what? And if you look,

01:14:29.820 he then digs into quantum mechanics. And I read his manuscript of the book that he hasn't released

01:14:32.960 yet. In quantum mechanics, they've pretty clearly established that there is no such thing as local

01:14:39.300 realism. In other words, something doesn't exist until it's interacting with a conscious observer.

01:14:43.380 It's a probability wave. So the moon maybe doesn't exist until conscious entities interface with it.

01:14:48.420 But what is it that we're interfacing with? And this is what, when he described this in a TED talk,

01:14:52.980 and then I read his stuff and I had him on the show, I was convinced it felt intuitively

01:14:56.120 correct to me. I want to see how you feel. You may say it's bullshit. The world is actually

01:15:01.120 nothing but consciousness subdivided into things he calls conscious agents, which are little

01:15:06.740 subdivisions of consciousness that sum up and break down kind of the way you can have a one bit

01:15:13.300 conscious agent. And all a conscious agent is, is it's able to, it's a simple mathematical function.

01:15:18.800 And he has the formulas to kind of show this, how they interact with each other and how they sum

01:15:22.500 them. The smallest one bit conscious agent is a plank length thing, the smallest thing you can

01:15:29.260 imagine that can have three things. It can perceive, it can decide, and it can act. And the currency of

01:15:36.480 reality is experience. It's conscious experience from the tiniest levels all the way down, all the way to

01:15:42.080 the largest structures that we have. And so when we try to explain the consciousness, the hard problem

01:15:50.200 of consciousness, how does the brain, how does this three pounds of wet goo create the experience of

01:15:54.600 me seeing Peter in his cool racing hat with his kind of sexy stubble, which I wish I had? Yeah, it's an

01:16:01.260 icon, but I like it. I'm going to call it my con because I want it. How does it create that experience,

01:16:06.960 the smell of, of baking, you know, bread? And the answer is we've been going about it wrong. We have

01:16:12.540 to invoke a miracle in our current understanding. How do we go from atoms, neurons to experience?

01:16:18.180 Well, at some point there's a jump that no one has been able to explain. You can wave hands.

01:16:22.600 What he's saying is how about you start with the miracle, which is everything is awareness and

01:16:27.560 consciousness. And matter and neurons are icons that we use in a species-specific way to understand

01:16:33.640 this vast network of social, the social network of consciousness interacting with itself.

01:16:39.220 So when I see Peter, I see a sexy dude, but what is really there on your inside is this vast

01:16:46.660 realm of experience and perception and awareness and thought and emotion that I don't see. What I

01:16:52.720 see is my species-specific hack that allows me to get through the world, allows me to reproduce,

01:16:57.780 allows me to stay alive, and allows me to survive in a way because we don't have enough processing

01:17:01.780 power to see what I really think is there, which is this incredibly complex series of nested consciousness

01:17:09.300 all interacting. And when you talk about books like this, where they talk about sub-minds and meditation,

01:17:15.100 what you're doing is you're taking your highest instantiation, which is the kind of aggregate of

01:17:20.340 all these sub-minds, and you're looking and listening at those inner-nested consciousnesses interacting with

01:17:27.960 each other. And you're also connecting to maybe the deeper connection between all of us as a higher

01:17:32.720 consciousness. It sounds like Wu, but in his formulas, he actually shows how these things work

01:17:38.480 mathematically. And actually, the formula reduces to the Heisenberg sort of formula for electron

01:17:43.000 probability cloud. So it's really quite fascinating.

01:17:45.240 Can it be tested experimentally?

01:17:47.220 Right. So this is what he's working on now. You can computer model this stuff. And the problem is,

01:17:51.960 it's as valid as any other model because it's hard to test. So the question is, how do you test that

01:17:57.120 we're all awareness interacting with awareness?

01:17:58.920 Yeah. There's a famous... Actually, I don't remember which physicist it was. I don't think

01:18:01.760 it was Fermi, but a very famous physicist once said, all models are wrong, some are useful.

01:18:06.780 That's right. And he himself says, this is probably only partially correct. Because the idea is then,

01:18:12.060 well, why would evolution even happen if conscious agents just exist and they're outside of time and

01:18:17.480 space? It's really just an important piece of this. So we're wondering about time and space and are

01:18:22.800 they real? Are they an actual thing? No, they are a species-specific data compression algorithm

01:18:28.460 that allow us to make sense of this social network and allow us to survive. So space and time are

01:18:36.200 different for you and me. Well, we're similar because we have the same species, presumably,

01:18:41.660 although you're probably more evolved than me. But like a dog or a cat or a fruit fly

01:18:46.240 are all awareness interacting with other awareness. But the way they see the world in space and time is

01:18:51.040 a totally different construct. And so all of it is constructed, which transforms in my mind.

01:18:57.160 Let's say it's true. And we'll talk about how we can test it because I think we should brainstorm

01:19:00.000 ways to test it. But I think it transforms how you think about mental illness. So what is mental

01:19:05.060 illness? But in our reductionist, materialist viewpoint, which we're very good as doctors

01:19:10.360 at thinking because we've been conditioned to think that. And I think there's a lot of truth.

01:19:14.320 The way we do medicine now is we are really good at moving the icons around on the desktop.

01:19:18.600 We know that a serotonin icon, when put into a human icon's bloodstream, does something to

01:19:25.360 a subjective description of experience from that human subject in terms of depression.

01:19:30.100 But what is really happening? We're like monkeys moving these icons around, but what's the

01:19:35.100 transistors and the electrons that actually make it up? If the serotonin molecule is really

01:19:39.020 a conscious agent that's the sum of little conscious agents, and it's interacting with our conscious

01:19:43.220 agent, that re-shifts how we think about how these medicines work, how the mind-body connection

01:19:48.940 actually makes it up.

01:19:49.040 What if that's not correct? What if the serotonin agent doesn't have the ability to perceive?

01:19:54.220 So if serotonin is actually electrons, if electrons are materially real?

01:19:57.840 Yeah. What if serotonin is simply nothing more than atoms with all of its constituent elements,

01:20:03.740 right? Electrons, protons, neutrons.

01:20:05.400 So if that's true, then it negates the entire model because it says something is materially real.

01:20:11.920 This model says there is nothing real beyond awareness itself, and it creates reality on

01:20:17.340 icons that allow it to evolve. And this is difficult stuff to grasp as scientists, which both of us

01:20:25.280 are. You're much more than me, because it goes against everything we train, which is big bang

01:20:31.640 happened, somehow matter organized into complex structures through which consciousness emerged.

01:20:36.440 We're saying consciousness was and subdivided into these smaller agents that combine into bigger

01:20:43.840 agents and evolve over time into complex agents like ourselves that interact with other agents

01:20:48.020 and social networks that probably form higher levels of consciousness. So you could actually

01:20:52.100 posit what is God, but all these conscious agents at its highest instantiation in a way that it knows

01:20:58.380 more than almost anything, because it's the sum of all these agents. Now, how do you test it?

01:21:02.180 So if serotonin is a molecule, then yes, our reductionist approach is right, and we should

01:21:06.340 continue to hammer at it. If it's wrong, we should still hammer at the reductionist approach because

01:21:11.680 we're moving icons. So as Hoffman says, he says, just because the desktop trash icon on my computer

01:21:18.320 desktop isn't literally a trash icon, and I'm not dragging real documents into it, that doesn't mean

01:21:23.120 I drag my life's work into it and hit delete. Just because I don't take it literally doesn't mean I

01:21:27.540 don't take it seriously. So yeah, we take our icons seriously. We should know all about them,

01:21:31.880 but we're going to hit a wall, and I think we're getting there in our understanding, because until

01:21:36.720 we understand what is the fundamental nature of reality, we're not going to be able to manipulate

01:21:40.900 it in a way that reduces suffering, which I think is what we're trying to do, right? When you talk

01:21:44.800 about health span, you're talking about the longest possible life with the most enjoyment or happiness

01:21:51.120 or fulfillment or whatever their individual's goal is, and to me, that's like a lack of suffering.

01:21:54.800 No one wants to live to suffer unless you're a BDSM bondage person, and even that's not suffering

01:22:00.340 because it's actually pleasure for them. So suffering is a mental construct. Pain is eternal.

01:22:05.400 Suffering is optional because it's how we frame it. What do you think?

01:22:08.380 I don't know. It's hard for me to actually internalize that because, I mean, letting go

01:22:13.880 of subatomic structures as sort of not being real, that would just require a lot more understanding

01:22:20.660 on my part.

01:22:21.420 Let me say this. Subatomic structures are absolutely real as icons.

01:22:24.800 So in other words, they mean something. They're an image of something.

01:22:28.680 Yeah. I think trying to imagine that they have their own state of consciousness is hard

01:22:33.020 for me to understand.

01:22:34.020 It's not even that. So okay, let me dig into that a little bit because this is something

01:22:37.600 that I have to think about a lot. That's a dualist belief. So in other words, the subatomic

01:22:43.060 structure, electron, is an electron with some awareness. That's a belief called dualism. It means

01:22:49.620 that there is matter and there's consciousness and they're related. What Hoffman's saying,

01:22:55.340 what I think I intuit from this is, and I could absolutely be wrong, and people get violently

01:23:01.920 disagreeable to this idea. There's no electron at all. Electron is a conscious agent that we see as

01:23:09.080 electron through our species-specific interface. It's how we've evolved to see the world. We see it

01:23:14.800 as, and we don't ever see electrons. We use equipment to intuit them.

01:23:19.220 But then how would we explain physical experiments that have independently validated the same construct?

01:23:26.300 Meaning?

01:23:26.660 So for example, when Newton came along, he was the first to define a set of physical laws.

01:23:33.160 And they held pretty well until the early part of the 20th century when at one layer below the

01:23:41.180 Newtonian understanding, there was a new layer of physical laws that had to be described.

01:23:46.240 Many of these laws have been independently validated. And I would think that if it was all a hack,

01:23:52.940 meaning if we were all creating our own construct, our own icons, it strikes me as improbable that we

01:24:00.200 would be converging on the same descriptions, the same experimental identifications.

01:24:06.140 This is a great way to think about it. And here's how I would think about that.

01:24:10.960 We have our hack, but it's based on reality. And reality is these conscious agents exchanging

01:24:16.280 experience with each other. We see it as the laws of physics. We see it as an electron binding to

01:24:22.280 this and this chemical reaction happening. And of course it will be validated because it's actually

01:24:27.100 happening in the sense that these agents are behaving relationally to each other in predictable,

01:24:32.440 precise ways that we can measure and science can quantify.

01:24:35.520 But wait, but why would the electrons, the protons behave in a predictable way when you and I can't

01:24:41.220 behave in a predictable way?

01:24:42.320 Ah, because we don't behave predictably, Peter, because we are complex instantiations of multiple

01:24:49.020 conscious agents that emerge a very high level of consciousness. So part of the reason you have

01:24:54.700 these voices that are telling you you're an asshole and I have them is that we have, that are

01:24:59.660 unconscious to us, agents that are making decisions in the background that are feeding it up to our

01:25:04.100 higher instantiation. It's very unpredictable. It's a complex system. The simplest systems, in other

01:25:09.800 words, one bit, two bit, 12 bit, 100 bit conscious agents behave predictably because they have three

01:25:14.520 actions, perceived to side act. It might be that the one bit conscious agent can only have two

01:25:18.860 perceptions, two actions. And so it sums up scientifically, mathematically, as absolute

01:25:25.160 predictability.

01:25:26.320 But wait a second. If you collapse that to one and one, you could have a reductionist world.

01:25:31.000 If you had no choice, if all of the subparticles had no choice, it would become a semantic game.

01:25:37.580 Well, if none of the particles had a choice-

01:25:39.640 Meaning you always knew how they were going to behave.

01:25:42.580 Right, right, right. Well, then you have, it's the same as being materialist. It's saying they

01:25:45.940 have no consciousness.

01:25:47.400 That's right.

01:25:47.920 So the definition of this is they have choice. And here's something that's even more interesting.

01:25:52.120 Yeah, which again, I just can't. So probabilistically, that just strikes me as

01:25:55.980 impossible.

01:25:57.740 Yeah.

01:25:58.340 Right? Because you couldn't have the order that we have in the universe if there was any choice

01:26:04.700 to be made at that level. Again, I'm saying this as a guy who's bullshitting because he's hearing

01:26:09.480 about this for the first time, but that's my initial reaction is I don't understand how you

01:26:13.800 could preserve any order in the universe if there was any choice to be made in that regard.

01:26:18.020 Yeah. So what's interesting is when you look at actual quantum mechanics, there is uncertainty

01:26:22.240 at the quantum level.

01:26:24.120 There is uncertainty.

01:26:25.180 But there is a predictable uncertainty.

01:26:26.780 Yeah, but exactly. It's defined by a probability function.

01:26:29.300 Right.

01:26:29.460 But it collapses to something that's known once it's observed.

01:26:32.820 Correct. So what is observation but two conscious agents interacting and exchanging experience

01:26:38.340 that then allows this particular conscious agent to settle into a particular choice?

01:26:43.040 So to me, it's not exclusive of that having choice at the smallest level. Now, again, this

01:26:47.180 is the simplest of choices.

01:26:48.820 Yeah, exactly.

01:26:49.240 And one thing you said was interesting to me because I struggle with this, which was

01:26:52.280 if we all see things differently as a hack, how can there be reality? How can there be

01:26:56.180 objective, predictable, scientifically valid reality? Well, look at it this way. So he

01:27:00.560 gives the example, which I think is very powerful, of synesthetes. So people who have synesthesia,

01:27:04.360 which is they experience the world very differently. They smell colors or they hear sights and you

01:27:11.140 see colors when you hear sounds. And he gives examples of a guy who anytime he tastes mint in

01:27:17.360 his hand, he feels a basket of ivy. And it turns out that guy is a synesthete. So his interface is a

01:27:24.180 mutation. Something has changed in the way-

01:27:26.560 How do you know that without functional MRI? Or is that the way that one can validate that?

01:27:29.900 So he's actually done some of that on these guys. It's interesting. And it's parts of the

01:27:33.040 brain that light up with touch light up when he's actually thinking about mint or something.

01:27:37.360 So you've basically just, you've disaligned, if for lack of a better word, the relationship

01:27:41.980 between the external and internal sensory. You know, the cortex has basically been remapped.

01:27:47.680 There's some remapping. Now, I would argue that the cortex is an icon we use to actually

01:27:51.740 consciousness interacting with itself. But imagine that person now is a mutation of some

01:27:57.580 kind that interfaces with the world differently. Because he can feel mint, it turns out he's

01:28:03.120 a glorious chef. So he has a career as a professional chef because he's able to take flavors and tactically

01:28:09.480 feel them. And to him, it's real.

01:28:11.500 Wow. That's interesting.

01:28:12.560 It's like a basket. He's putting his hand in a basket of ivy. When he tastes something else,

01:28:16.580 I forgot what it was.

01:28:16.900 He would make a horrible surgeon.

01:28:18.220 I mean, could you imagine having to taste all of those body parts to be able to, because,

01:28:22.940 you know, you rely on your feelings.

01:28:24.580 It's like a chilled monkey brains, Dr. Jones.

01:28:27.780 It's true. So a surgeon would go extinct having that skill, but a chef would evolve. Now imagine

01:28:32.640 evolution starts to put pressures on us where only the best chefs get laid and have sex and reproduce.

01:28:39.380 Now that-

01:28:39.640 That becomes the default. But see, to me, that is totally explainable

01:28:42.420 through Darwinian biology.

01:28:44.860 Right.

01:28:45.100 That is completely understandable.

01:28:47.420 So Darwin is essential for this theory as well. You have to, in fact, the core universal principles

01:28:53.520 of Darwinism have nothing to do with DNA and molecules. They have to do with, is something

01:28:57.940 heritable? Is there evolutionary pressure on it? And those sort of things. And that works just as

01:29:03.620 well with conscious agents as it does with material stuff. So conscious agents can evolve over time to

01:29:09.020 have perceptions that actually allow them to succeed in this social network where they're competing.

01:29:12.880 But I mean, and again, forgive me for just not having a goddamn clue what you're talking about.

01:29:16.900 Why is it that if that bottle is an icon, you can't make it lift up off the table by thinking

01:29:21.400 about it?

01:29:21.960 Because in the social network of conscious agents that happen to be this way, that is not a

01:29:26.940 perceptual decision or an action.

01:29:29.120 Why can't you override it?

01:29:30.820 Well, there are rules between how these things actually interact. In other words, it's not a free

01:29:35.300 for all. It's not magical thinking. It's not like, well, just because everything's awareness,

01:29:38.240 I create, like Deepak Chopra. He'll say something like, everything is consciousness, and so you can

01:29:43.700 secrete, which is my way of using secret as a verb, you can secrete success and happiness and all that.

01:29:50.660 Well, that's not true. That's magical thinking. What we're saying is no. Have you seen The Big Lebowski?

01:29:57.080 Dude.

01:29:57.700 Dude. The dude abides.

01:29:59.140 Stop.

01:29:59.760 There are rules, dude. Okay? This isn't fucking Nam. All right? There are rules. And the rules are,

01:30:05.280 these things behave just like... You know, one of the worst parts about trying to be health

01:30:08.400 conscious is that you can't drink white Russians as liberally as The Big Lebowski.

01:30:12.800 Who says so? You say so.

01:30:14.520 I mean, the Kahlua is just... If you want a proper... I mean, now you could drink a Caucasian.

01:30:20.200 Yes.

01:30:20.520 Right?

01:30:20.880 Yes. Just half and half.

01:30:22.520 Yeah. Which is a little cleaner. But if you want to do it right, you got to have the Kahlua in it.

01:30:26.740 And between the vodka, the Kahlua, and the cream...

01:30:28.980 Sugar.

01:30:29.620 It's...

01:30:29.980 Alcohol.

01:30:30.300 But I've never craved a drink. I enjoy alcohol. But I've never craved it until the first time

01:30:40.060 I saw The Big Lebowski, which was, God, 25 years ago.

01:30:43.000 I'm in the same boat.

01:30:43.680 And I was like, I want to have one of those drinks. And I need to grow a mustache because

01:30:47.500 I need to be able to lick that off the...

01:30:50.400 So good.

01:30:52.300 I love it so much. We should have white Russians. And that gets me this thing.

01:30:56.580 Guys, could you... Is there any way you could fire for white Russians right now?

01:30:59.260 Two white Russians. Throw a black Russian in, too, just for the heck of it. We want to be

01:31:03.360 equitable.

01:31:03.580 And one Caucasian.

01:31:04.500 And one Caucasian. We initially reconnected over your work on nutrition and diet. And we

01:31:10.160 had a patient in common and so on and so forth. And you did a bunch of testing on me that really

01:31:15.920 transformed how I think and know about myself. For example, I dabbled in ketosis. Yeah, I also

01:31:20.320 dabbled in pacifism. Not in nom. I dabbled in ketosis as well for probably eight months. You

01:31:27.700 were in it for three years with one day exception, I understand. And I learned a lot because I

01:31:32.260 learned that I make these very small, dense lipid particles that didn't seem healthy. And we ended

01:31:37.680 up going to Mediterranean and I did a lot better. But the idea that a white Russian would just...

01:31:41.520 I couldn't do it. It was devastating to me. So it wasn't sustainable. How are you thinking

01:31:45.900 about nutrition now? Because you have this patient panel, you're a functional medicine

01:31:49.220 doc, which I want to talk about as well.

01:31:50.380 See, again, I sort of squirm. Yeah. I don't know what to say. I don't even know what functional

01:31:55.280 medicine is. I mean, I know what the definition is, but I don't know what I do. I don't know

01:31:59.060 anything. I mean, I know what I know, but I don't know how to put a label on it and I don't know what

01:32:03.220 I'm... All I'm interested in, I can define my objective, I can define the strategy, and I can

01:32:08.860 define the tactics. But other than that, I can't actually take an existing description and apply it to

01:32:15.200 it. But the objective, which is the easiest part to state, is I want to figure out a way... And I'll

01:32:20.420 just use myself as an example, but I obviously would apply this to every patient. I want to figure

01:32:24.940 out a way to live longer than I am otherwise on a trajectory to live, which means I have to delay

01:32:30.340 the onset of the things that will kill me. And I want to improve the quality of my life, which I

01:32:37.140 define rather simply as having three legs. One leg being cognition. The second leg being

01:32:44.860 everything that has to do with the exoskeleton of my body. So the maintenance of muscle mass,

01:32:50.480 the ability to move, i.e. maintain mobility, stability, which I actually think is much more

01:32:55.720 important than mobility, but gets no attention, I can explain in a moment. Freedom from pain,

01:33:00.980 sexual function, all of the things that people our age take for granted, but you stop taking for

01:33:06.340 granted when you are in your 80s, in your 90s. Before we got started, we were looking at pictures of

01:33:11.580 our kids, playing instruments and stuff like that. I mean... Because we're gunners, man.

01:33:15.480 Like, how goes your kid, a drummer? Oh, it's pretty awesome, man. Well, mine's a virtuoso violinist.

01:33:20.280 How about you? Well, you know. But if you think about the way you were able to interact with your

01:33:25.060 kids in your 40s, and now imagine, would you be able to reproduce that in your 80s? And so a lot of

01:33:31.200 stuff you took for granted, right? Like, could you lay down on the floor, play blocks or dolls or

01:33:35.640 whatever, and stand up easily? Or is that like a debilitating activity? If your grandkid or great

01:33:41.100 grandkid came running towards you, could you dip down into a goblet squat position and pick up a

01:33:45.240 little 30-pound terror? So that sort of all is encompassed in this physical part. And then the

01:33:49.960 third piece, which I don't have a great name for it or anything, but it's... And it's by far the

01:33:54.400 hardest to impact as a physician, because I think the first two are a little bit more within the tools

01:33:59.880 that we can apply. The third piece is this ability to be happy, as nebulous as that is,

01:34:06.000 and to have what I describe as borrowing from a friend of mine, Paul Conte, who's always explains

01:34:10.180 what you know, Paul. I know Paul, yeah. Of course, yeah. It's just to have the highest degree of

01:34:12.960 distress tolerance possible. And of course, mindfulness and meditation becomes the single

01:34:18.140 most important tool to impact that. But there are other parts to that as well, social support,

01:34:22.180 sense of purpose, all these other things. And as you alluded to earlier, most people,

01:34:27.340 if you took those things away from them, they wouldn't want to live one more minute.

01:34:32.260 And there are exceptions to that rule. I mean, you look at Stephen Hawking, he had one of those

01:34:36.100 three completely taken away, yet for all indications, lived a completely fulfilling life,

01:34:41.240 and I'm sure wanted every additional day of life he could have had. But for many people,

01:34:45.580 they want all of those things, especially if they, at some point in time, have had all of those things.

01:34:50.060 So I guess the only way I'd describe myself, and this is why I generally like to be referred to as a

01:34:54.700 Shepard or a FR-2000 race car driver, is I'm a doc who's obsessed with that problem.

01:35:00.620 And I have to say, having experienced what you do from both a clinician and a patient side,

01:35:06.540 seeing you with a patient and with me, you have a gift for this. This is something that

01:35:11.420 very few people I've seen in medicine do, which is you look at the patient as a unique individual,

01:35:15.880 you educate them in a way that sometimes is hard to understand, actually. The same way when I'm

01:35:19.860 talking about consciousness, we're all struggling with it. Sometimes some of the concepts that you

01:35:23.520 talk about are so intuitive to us, but our patients look at us like we're crazy. But even then, this

01:35:28.860 idea that you can optimize a particular regimen to the goals of that unique patient is the foundation

01:35:34.680 of what we call Health 3.0, which we tried in our clinic, Turntable Health, and it is the same idea.

01:35:40.780 And if we had clinicians like you surrounded with a team, do you do it all yourself or do you have a team?

01:35:44.700 Oh, no, no. I have a monstrosity of a team, actually.

01:35:47.680 Tell me about your team.

01:35:48.300 Yeah, so I have two, soon to be three people who are basically interacting with the patients on all

01:35:54.160 of the logistics of what we do. We have a dietician, soon to be another, probably we need two health

01:36:01.560 coach dieticians. What we're realizing is that the hard part is not, I mean, it is hard to figure out

01:36:08.100 what is the optimal way for a person to eat, but there is a finite number of iterations you can make

01:36:12.980 until you start to converge on it. So that's what we call the efficacy problem. By far, the harder

01:36:17.860 problem is the effectiveness problem. I'm a walking experiment of somebody who knows exactly what he

01:36:23.040 functions best on. Problem is I just don't want to do it, right? So I'm one of those guys who actually

01:36:28.320 did incredibly well on a ketogenic diet. I mean, everything couldn't have gone any better. Now,

01:36:32.780 whether I should have been on it indefinitely or cycled it or whatever, we don't know the answer to

01:36:36.360 that question. The point is I just didn't want to be on a ketogenic diet. I mean, I missed too many

01:36:40.360 things. So now I take a totally different approach. I have a different framework around nutrition

01:36:44.320 entirely that, you know, starts at one end with the SAD, the standard American diet, and at the other

01:36:49.700 end ends with complete caloric restriction. So water only, which obviously you can't do indefinitely.

01:36:54.840 You should cycle that. And then in between there are three other steps. And it's one thing to figure

01:37:01.220 out how to optimize a person based on how they cycle between those layers. But, you know, like I said,

01:37:07.000 the harder part is figuring out how to make that the default as opposed to something you have to

01:37:11.880 work into. You know, I'm influenced a lot by Dick Thaler's work in Nudge, which is the easier you

01:37:17.840 can make something for someone, the easier it's going to be to do. And just figure out a way to

01:37:21.700 make them opt out of good behaviors rather than opt in to good behaviors.

01:37:26.960 Nudge is very similar to Switch, which is by the Heath Brothers, based on an elephant rider motif from

01:37:32.440 John Hyde as well. And it's the same thing. You create a path for the elephant rider to walk that is

01:37:36.480 default good. You motivate the elephant by making them feel something, like they want to change or they

01:37:40.740 want to do this. And then you gently direct the rider, the rationalist on how to make that change.

01:37:45.920 And, you know, when I talk publicly too, I talk about this as a model of how we can do health 3.0

01:37:50.220 to influence change in our patient. I remember what you were asking us to do was very hard. You have

01:37:55.140 to be motivated to want to do it. We happen to be. But let me ask a question, like, are fat people fat

01:38:00.240 because they just don't have the willpower that it's their fault that they're fat? Or is it that we just

01:38:06.220 haven't cracked the hack for how to motivate people, make the system by default better,

01:38:10.220 and find their optimal plan for them?

01:38:13.640 I mean, it's such a complicated question. There's something called the Dunning-Kruger effect. I don't

01:38:17.780 know if you're familiar with it.

01:38:18.580 Oh, anti-vaxxers love this because they know a little.

01:38:21.900 They're on that first spike, yeah. Can we come back to vax?

01:38:25.440 Absolutely. Oh, can we?

01:38:26.580 Yeah. I actually lost a patient over this once.

01:38:31.280 Lost, not died. Lost, left.

01:38:32.780 Lost, left.

01:38:33.560 Yeah.

01:38:33.840 A patient of mine had some questions about not wanting to get his kids vaccinated and came to me

01:38:42.040 assuming that I would agree with him that he should not have his kids vaccinated. And I said,

01:38:48.140 nope, you absolutely should get your kids vaccinated. And I said, look, here's the one

01:38:52.700 deviation I made from the protocol. We waited six months to do the first panel.

01:38:56.480 Instead of doing them on the first day. But yeah, that was no rhyme or reason. That was

01:39:00.360 just my intuition said, give the little bastards a break for six months. But yeah, I can't imagine

01:39:05.260 any reason why you wouldn't want to vaccinate your children. And he went loco. He was like,

01:39:11.160 I expected more from you. I can't believe blah, blah, blah. I mean, he was pissed. That was it.

01:39:16.840 Like he left. I mean, he stopped. He didn't want to ever see me again.

01:39:19.820 So as someone who dabbles in the anti-vax space a little bit, to the point where people are banging

01:39:23.680 on this door shouting obscenities at me during a live show with Paul Offit, I will say this,

01:39:28.860 what you triggered was that person's elephant. So their unconscious was triggered in a way

01:39:33.380 where their entire conception of the world, their ideas of liberty versus justice versus care versus

01:39:39.420 harm, this moral palette that John Haidt talks about, which we can talk about more later. But

01:39:42.660 this idea that vaccines are a violation of the sanctity of the body. So you're putting toxins in the

01:39:49.080 body. And the idea that he probably went to you thinking you were a little bit off the grid that

01:39:52.740 you're looking at the unique person. Therefore, you're not going to swallow the dogma, right?

01:39:56.960 But the truth is what he didn't realize is no, you swallow what works. And the things that have

01:40:00.880 been shown to work are in fact vaccines and not a whole lot of other stuff until you really look at

01:40:05.940 it. And you look at supplements, you look at a lot of things, Peter, like stuff that would give

01:40:09.300 standard American doctors or also SAD, so you have the standard American diet and the standard American

01:40:13.820 doctor or SAD, the hives, because you have taken yourself self-experimented with tons of supplements

01:40:20.200 and you've drawn blood a million times and you've done, you are the quantified person because you

01:40:23.660 care about finding out truth for patients and also for yourself. But this idea that you triggered that

01:40:28.420 person in a way that they made a moral judgment about you that was so far off their moral compass

01:40:34.360 that they couldn't tolerate stomach the idea of seeing you. Until we recognize how people work,

01:40:39.280 we'll never be able to connect with anti-vaxxers that way because we can't imagine why

01:40:43.620 people would think that way. And it's just one thing to understand them. It's another thing to

01:40:47.680 condone delusional and dangerous thinking in public forums, like running into a theater and yelling

01:40:52.300 fire. And that's what the hardcore professional anti-vaxxers do. And our platform has a zero

01:40:56.220 quarter for that. Now I just ban them. I ridicule them. I shame them. I drop F-bombs on them.

01:41:00.300 I will never stop until these professional anti-vaxxers are stopped. However, the mother on the fence,

01:41:05.820 the person who's like been conditioned by this stuff on the internet, that's where it's obligate on us to

01:41:11.160 be patient. But I think that's what happened with your patient.

01:41:13.300 Well, what's interesting is I'm not particularly equipped to delve into that. So I remember this

01:41:19.060 discussion because my next step was, and it's been so long ago. God, I don't even remember this.

01:41:25.860 But I think, I mean, I don't remember all the details, but I remember saying to him, look,

01:41:28.520 there was this one paper that got, made this an issue, but you know it was retracted, right? Like,

01:41:33.860 you know that it wasn't retracted because the calculations were wrong. It was retracted because it

01:41:38.380 was fraud. Straight fraud. And do you realize that all of this sort of propaganda you're buying into

01:41:44.160 emanated from something fraudulent, which was I think a bit more of an intellectual approach. I don't

01:41:51.300 think I had the resourcefulness or the insight at the time to take an emotional approach. Emotional

01:41:55.600 might be the wrong word, but less of a, let me just beat you down with more facts and explain to

01:42:00.680 you why this is right. So my guess is he was pissed not only in the fact that I was obviously a not

01:42:09.860 outside the box thinker, but maybe on some level he was just pissed that, you know, I probably talked

01:42:15.000 to him like an idiot. I was dismissive of him, right? You really put your finger on something that

01:42:20.420 we do in medicine a lot, and I'm guilty of it. And that is speaking all to writer, trying to give

01:42:24.880 them data when we haven't motivated elephant or understood elephant, unconscious motivation.

01:42:30.100 And this guy, what I've started doing is sitting down and going, yeah, so why do vaccines bother

01:42:35.560 you? Let's just take Wakefield and his study out of the equation. What is it about them that really

01:42:40.240 bothers you? Well, they're forced on me. I don't like this idea of toxins in my body, or I don't

01:42:44.820 trust the government. I don't trust big pharma. And I'm like, you know what? I don't either.

01:42:49.680 I wouldn't let government run healthcare. I don't want fully socialized medicine. I think that's crazy,

01:42:54.780 but I do think that the government does a lot of things that are good, and things are much more

01:42:58.820 complex. But let's talk about ways that maybe we can come to an understanding, because we both want

01:43:02.700 what's right for the kid. It's very hard, though, because we get our own emotional. I get so angry,

01:43:07.900 man. I've gotten triggered the point where I go on these expletive-laced rants on my show. And you

01:43:12.600 know what? Here's the thing, Peter. You know this as well as I. It will get a shit ton of views when I

01:43:16.980 lose my shit, and I'm like, fuck these anti-vaxxers and everything about them. And it will go crazy,

01:43:22.480 because doctors will be like, that's what I've been wanting to say forever, because my elephant

01:43:26.400 is conditioned a certain way, which is care versus harm. I want these children to live and not die

01:43:31.720 of preventable disease. When you see a case of measles, you see whooping cough in the hospital,

01:43:35.260 it will devastate you. And we're showing each other pictures of our kids. Like, imagine one of our kids

01:43:38.980 getting measles, and you didn't vaccinate them. How am I going to feel about you as a person,

01:43:42.940 as a doctor? So that kind of thing, it's easy, and it's seductive. I like to think of the emperor

01:43:48.340 in his robes going, yes, unleash your anger, and you will replace your father by my side.

01:43:55.780 And just beams of like dark force energy coming out. But the truth is that that is not going to

01:44:00.960 influence those people. And I've had to struggle with this, because my platform reached a lot of

01:44:05.200 people. And I get a lot of criticism on both sides of how you're being too much of a dick,

01:44:08.800 or you're not being enough of a dick. And it's like, the truth is nuanced, and people hate nuance.

01:44:13.460 And, you know, they hate it. And that's the thing about you. I remember, you used to get really

01:44:18.540 pissed when people would be like, so what are you eating now? What's your diet? And you're like,

01:44:22.460 it changes. My diet isn't your diet. And then you would say the diet. And then in the comments,

01:44:28.760 there'd be people like, I thought you were about ketones, man. You're a fraud. How dare you eat a

01:44:34.840 molecule of carbohydrate? And they're super triggered, because for them, this nutrition is a religion.

01:44:40.240 And I've experienced that. We did a show about that documentary, What the Health?

01:44:44.260 Have you heard about this thing?

01:44:45.300 Yeah, I've heard about it. I haven't seen it.

01:44:46.260 Yeah, so there's a bunch of docs there spouting vegan propaganda, cherry-picking studies,

01:44:51.200 and saying, this is the only diet. And that's the thing. I have no problem with a vegan diet.

01:44:54.960 The thing is, it's not the only thing.

01:44:57.400 Well, that's the funny thing. It's funny you bring that up, because that's the point I try to make, is

01:45:02.000 any diet that you do that's different from the SAD, if you compare it to the SAD, is amazing.

01:45:08.040 Like, you can't do worse than the SAD.

01:45:10.980 The standard American diet.

01:45:11.720 You can't, except eating more of it. So the only, if you're over here on the left side of my

01:45:15.800 framework, you're eating a standard American diet, which is this incredibly, perfectly engineered

01:45:21.480 ratio of just the right amount of refined carbohydrates, the right amount of sugars,

01:45:26.620 the right amount of fats. It's like you couldn't come up with a better way to kill someone than that

01:45:33.060 diet. And I'm not really into the conspiracy theory that that's deliberate. I mean,

01:45:36.800 I think the harm is absolutely not an intended consequence. It's the palatability. It's the

01:45:42.000 shelf life. It's the cost. It's the, all of these other things is the intended thing. It's basically

01:45:47.120 driven by profitability. I mean, let's just call a spade a spade. As an unfortunate consequence,

01:45:52.060 the drug kills the user. And that tends to be the case with good drugs. You know, eventually cigarettes

01:45:58.400 are going to kill you. If you drink too much, it's going to kill you. If you eat too much SAD,

01:46:01.740 it's going to kill you. So you're starting out here in SAD land. And then most people only realize

01:46:08.600 one box on the framework, which is called dietary restriction, which is when you restrict certain

01:46:15.200 elements of what you can eat.

01:46:17.200 Less SAD.

01:46:17.980 Well, it's, yeah, but it's, it's take something out of SAD or reduce some element within SAD.

01:46:23.400 So you don't restrict when you eat. You don't restrict how much you eat. You just restrict

01:46:27.300 certain elements of it. So it's an ad libitum diet that contains something or that is absent

01:46:32.180 something in the SAD.

01:46:33.240 Got it.

01:46:33.600 So a keto diet is a great example of dietary restriction, as is a paleo diet, as is a

01:46:38.660 Mediterranean diet, as is a vegan diet, as is a vegetarian diet. These are all, they're all,

01:46:44.780 so you think of all of the diets that people are out there talking about, they're basically

01:46:49.000 talking about one little cluster of the state space in nutrition, which is dietary restriction.

01:46:55.700 No one's talked about time-restricted feeding, hypocaloric feeding, caloric restriction.

01:47:01.600 So all of these guys are trying to nuke each other saying, my diet's the best. No, my diet's

01:47:06.200 the best. My diet's the best. But what they're forgetting is they're all comparing it to SAD.

01:47:11.280 Right.

01:47:11.560 And guess what? You're all right. All of your diets are better than SAD. I mean, that's like saying

01:47:16.520 like, my pancakes taste better than that dog shit over there. Yeah. I bet your pancakes will taste

01:47:20.700 better than that dog shit too.

01:47:21.780 How dare you? My pancakes taste vastly worse than dog shit. By the way, that's a bum

01:47:25.680 sticker. My diet's better than SAD. Like that's, I just, yes, it is. So they're all at this

01:47:31.160 reference point that's dumb. All of them contain probably-

01:47:33.620 And it's relevant. It's just like, there's too much focus on this whole thing. And, you

01:47:38.540 know, so when people say to me, like, do you think a paleo diet's better than a vegan diet

01:47:42.060 or vice versa? I'm like, it's kind of like an irrelevant question to me, truthfully. Like

01:47:45.980 if the alternative, if you're asking me, my choice is, you know, I'm going vegan or I'm

01:47:50.140 going back to my standard American diet. I'm like, you better stay vegan.

01:47:52.920 Yeah. Right? Yeah. Please don't ever deviate from this one thing if it's keeping you away

01:47:57.940 from being on the standard American diet. Yeah. Well, you know, and for me going from ketosis

01:48:02.860 into a kind of Mediterranean with intermittent fasting to now a feeding window of like once

01:48:07.480 a day, that I finally found a sweet spot where it's not only good for me. In other words, I feel

01:48:12.420 better. My labs are good, but I can do it. And I enjoy that meal so much. And it allows me to be

01:48:18.560 with my family during the meal we eat together. And I cheat on the weekend because I'm with my

01:48:22.300 family. So it worked for me personally. So this idea that I think obesity is something that's

01:48:27.520 going to take a multi-pronged approach and fat shaming. I did a video where it was a short rant

01:48:32.720 and it was called, it's your fault your kid is obese. And my take was this, and I love your

01:48:37.720 opinion on this. So I said, listen, yeah, there are social determinants of health. Yeah. Food deserts

01:48:42.240 exist. Yeah. It's hard to afford good food. But if your kid absent a medical cause is obese,

01:48:49.280 it is fucking your fault. It is entirely your fault as a parent because you control what goes

01:48:53.540 in that child's mouth. I'm talking about young kids and they don't make decisions. They'll say

01:48:57.400 they'll throw a fit and stuff. And yeah, you can negotiate with them. But if you're giving them a

01:49:01.600 soda or a big thing of orange juice, something that you got to understand, you're just giving them a

01:49:05.220 load of sugar. They're drinking their calories and then they're obese. That is on you. You need to

01:49:10.560 educate yourself. You need to understand these simple things. And a ton of people were like,

01:49:14.580 yeah, it's finally some doctor says what we're thinking. But then a lot of people push back and

01:49:18.420 they're like, sometimes this is fully systemic. And you're asking somebody who has poor education

01:49:23.960 to do this stuff. And I wonder where you stand on that. Am I wrong? Am I crazy?

01:49:27.440 I mean, truthfully, I don't spend much time thinking about this problem at all anymore. It has been

01:49:32.060 probably three years since this was something that was in my crosshairs. And as is often my want,

01:49:37.740 when I'm laser focused on something, it is generally to the exclusion of almost everything

01:49:43.440 else. So while I think that what you're describing from an end point is imminently relevant, I don't

01:49:50.520 have the data to speak to it. My intuition is that it is probably not as extreme as you were stating it.

01:49:57.620 I think I have over the years become more and more empathic might be the wrong word, but maybe it is

01:50:06.280 the right word. Probably just a little, you know, I look at my family, for example, right? So my father

01:50:12.300 knows everything I've ever thought, taught, described. My father will not for the life of him take one bit

01:50:21.700 of advice from me medically or dietarily. Is it because he's not intelligent enough to? No. Is it because

01:50:27.840 he can't afford to eat the way I suggest he would eat? No. There's some other reason there, and I don't know

01:50:34.340 what it is, but I also don't know that it's his fault. You know, I just, I don't know how to think of it in those

01:50:39.900 terms. It's certainly vexing to me, and it's probably one of the sort of few triggers that still, I have to be

01:50:48.960 very conscious of not getting upset in that setting, but I just don't know. So in the example

01:50:55.060 you gave, you know, you take those parents that are giving their kids whatever. I mean, do kids still

01:51:00.280 drink regular soda? Is that still, or has that been generally curbed out of the system? No, they still

01:51:04.480 drink regular soda, and not only that. It's on the decline, isn't it? There are kids in this town that

01:51:09.260 put, the parents put Dr. Pepper, fully sugared, in a bottle and give it to the kid thinking it'll keep

01:51:14.040 them quiet or it's healthy in some way. So, I mean, I guess to me, it's just hard for me to say

01:51:18.760 that that parent is at fault because they're not playing with the same template that you or I are

01:51:24.040 playing with. So again, if I were obsessed with this problem, I would solely be interested in

01:51:29.480 changing the environment. So what is it that's making you put diet pepper in that bottle? Is it

01:51:33.780 because it's cheaper? Is it because it's there? Is it because I had better shelf life? Is it because

01:51:37.900 it tastes better and it shuts the kid up? Like, I want to understand why it's the diet pepper, and I

01:51:42.100 want to figure out how it is you can put something that's not diet pepper in there that would still

01:51:45.560 check what I consider sort of these four boxes of the default food environment.

01:51:49.840 But that's a nanny state, Peter. People don't want you taxing sugar or preventing it from being...

01:51:54.180 And again, I don't know that taxing is the right way to do it. I mean, one of the things that I had

01:51:58.160 thought a lot about was an experiment that never got off the ground. So when I was still involved in

01:52:04.340 this world, I used to have these sort of thought experiments, and occasionally some of them become

01:52:09.040 interesting ideas for actual experiments. I think this would have been one, but it would have been

01:52:13.380 prohibitively expensive and I think logistically quite challenging. But it was to basically take

01:52:19.180 two areas that were in reasonable proximity and similar to each other that were both

01:52:23.460 quote unquote food deserts and do an experiment. So in the control group, you would give them an

01:52:30.840 amount of money that was going to allow them to sort of buy whatever they want, but you wouldn't

01:52:34.400 change the food environment or anything like that. So you just poured more fuel on whatever fire was

01:52:39.200 there. And in the treatment group, and you, by the way, have to do this as a crossover. So it's not

01:52:43.380 a random assignment. You have to cross them over. In the treatment group, you would do a whole bunch

01:52:48.300 of other stuff, which is you teach them how to cook, you give them the money, and oh, by the way,

01:52:53.600 then you go into... This is the really hard part of the experiment. You go into the stores where they

01:53:00.060 will buy all of their food and you price switch everything, position switch everything, and see if you can

01:53:07.140 create a new default. So the Cocoa Puffs are no longer $2.99. They're like $12.99. But the eggs

01:53:14.400 and the avocado and maybe the steel cut oats, those are now super cheap. And by the way, they're the

01:53:19.840 ones that are sitting in the front of the store with the buy two for one right now. But the Cocoa

01:53:24.840 Puffs, you can still buy them. They're just four times more. And you got to freaking find them. And

01:53:28.700 you got to ask Sally where they are. And Sally probably won't even remember where they are. And they

01:53:32.660 might not even be in stock. So it's like you totally change the food environment. And the

01:53:37.220 fantasy I had was you ran these one year in parallel and then you crossed them over.

01:53:41.140 And see, this is why it's so fucking hard to study nutrition, because that's what you would have to do.

01:53:45.220 Yeah. And I had done the math on how much this was going to cost. I mean, there was a day when I

01:53:48.860 used to think about this stuff so often that I sort of had what a budget for this would be.

01:53:54.220 And it was, in the grand scheme of things, not outrageous. I mean, it would be

01:53:58.820 sort of one-twentieth of the cost of developing a new drug, but still, you know, in the tens of

01:54:04.640 millions of dollars. So we'll never do it because prevention, proactivity, looking at root causes,

01:54:09.920 not something we do in American medicine. And, you know, when you were talking about giving people

01:54:13.160 the tools, education, et cetera, teaching them to cook, that's what we did at Turntable. So we had

01:54:16.800 a teaching kitchen in our facility. We had health coaches that would teach, you know,

01:54:20.680 Winnie the Pooh how to cook in a food desert on a budget without honey. And it worked. So these

01:54:25.700 patients transformed their lives and they would say, well, I really liked the health coach and I

01:54:31.520 felt accountable to them and they felt like they cared about me and I didn't want to let either one

01:54:36.060 of us down. And so this motivation component, the education component, and then going to the

01:54:40.760 supermarket, what the coaches would do is look at their shopping list and go, yeah, you're fucking

01:54:43.800 this up. So here's a simple thing, you know, shop in the periphery of the supermarket, et cetera,

01:54:48.120 all these little hacks. So it got to the heart of this issue of, first of all, patients need to

01:54:53.260 feel like we actually care and they're being held accountable to some degree because we function in

01:54:57.500 that way. If we're just left to our own device, like you and your dad, like your dad's like,

01:55:01.300 I'm not going to listen to my son about this shit. And that's how my dad is the same thing. I can give

01:55:04.820 him advice, he'll be like, whatever. There's an emotional component to it, but humans are humans

01:55:08.440 and we're driven by these unconscious urges and processes. And until we are able to understand them,

01:55:12.860 we can't hack them. And since it's all consciousness anyways, none of it matters. Let me ask you a

01:55:16.720 question though, relating to this free will. Do you think it's a real thing? Do you think humans

01:55:20.500 actually make these choices? Oh boy. I mean, I would say this, if you asked me this question

01:55:25.940 two years ago, I would have said, absolutely, 100% on the free will train all day long.

01:55:32.000 So people have free will, yeah.

01:55:33.260 Woo, woo, woo, woo, free will all day. I am now in a gray area where I'm starting to begin to

01:55:43.300 understand the counter argument. What I love about the counter argument is it's another great

01:55:49.880 empathogen. Do you know how much easier it is to go through life when you stop being a pompous piece

01:55:57.780 of shit who thinks you're so good because of your own free will?

01:56:01.980 You just nailed what I was going to say, which is empathogen, which is an amazing word,

01:56:07.700 something that generates empathy. When I came to the conclusion that free will was largely an illusion,

01:56:12.540 but I have some nuance to that, but it was Sam Harris' book, Free Will. And this idea that these

01:56:17.920 thoughts and impulses bubble up from dark spaces that we cannot nail down. I made a decision. I

01:56:23.980 made the decision. First of all, the state of eye is a bit of an illusion, but let's say there is an

01:56:27.920 eye, a little guy behind our head pulling levers. How did he come to that choice? Well, it bubbled up

01:56:32.320 from unconscious processes that we don't understand, states and causes and conditions. And so as a result,

01:56:37.440 when somebody does something dumb, in a way they could never have acted otherwise. The same person,

01:56:42.780 molecule for molecule could not have acted otherwise. And that's a tremendous empathogen because it means

01:56:46.300 instead of judging them and getting angry, you can say, let's see if we can perturb this neuronal storm

01:56:52.320 to spin in a slightly more productive way for what their goals are.

01:56:56.440 And to clarify, I think one thing that someone listening to this might get confused by

01:56:59.800 is that's not to say that there aren't consequences for the choices that are made. So if your absence of

01:57:06.120 free will enabled you to decide you wanted to take a drink, have a couple of white Russians and drive

01:57:11.240 home, and in the process you hit somebody, okay, maybe you didn't choose to do that or choose to

01:57:17.420 make all of the decisions, the bad decisions that led you there, but there will be consequences for

01:57:21.940 those actions. Yes, absolutely. And this is what people who say, you know, you don't think there's

01:57:26.740 free will, then the whole criminal justice is involved. Exactly. They're sort of confusing and

01:57:30.660 confounding two issues. They are because you murder someone. You made a choice to do it. You made a

01:57:34.540 choice. Well, it wasn't free will. That's my argument, Your Honor. Sure. You're going to jail forever.

01:57:38.600 Why? Because we need to make sure that others who also don't have free will have their sub-minds

01:57:43.500 conditioned that if you commit murder, you go to jail forever or you die, depending on what state

01:57:48.220 you're in and whatever your beliefs are in the death penalty. And so as a result, that deterrent

01:57:52.340 reconditions the unconscious that then allows different decisions to be made. So my feeling on

01:57:57.060 free will is that it's actually much more nuanced. These sub-minds actually have their own free will and

01:58:02.680 they feed it up and it's conditioned by our downward input. So what comes out is a consensus decision.

01:58:07.780 And so in a way, yes, we are kind of in charge who we decide to be around. If I hang out with

01:58:12.840 Peter Attia, I'm going to be better for it. If I hang out with Charles Manson, I'm probably going

01:58:16.940 to come up with some shitty, stupid ideas. If I fall into a Facebook hole where all I'm looking at is

01:58:20.680 alt-left or alt-right or alt-center, I'm going to miss. I'm going to be conditioned in a way that may

01:58:25.060 be malproductive. So those things matter. There are consequences. We should hold them. So when I do

01:58:29.240 the show about blaming, I say, it's your fault that your kid is obese. My secret reason for doing that

01:58:35.620 is not that I actually think they're to blame. It's that somebody will watch that and go,

01:58:40.560 I never, wait, what? I've been giving Dr. Pepper and the thing. Like, it's my fault? What do you

01:58:45.240 mean? And they, and they just, something clicks and they go, wait, so that I'm not supposed to do

01:58:49.420 that. Okay. I'm going to, I'm going to do something different. So it's a way of influencing

01:58:52.520 now. It may not work. So blame may not work. There's some data that it doesn't. And in looking

01:58:56.780 at hospital errors, just culture is one of these like blame-free kind of scenarios. There's some data

01:59:01.320 that people will hide and they won't come out and admit errors if they fear retribution. Whereas

01:59:05.920 in an environment where we're trying to make the system better, it could change. So again,

01:59:09.060 it's like gaming this bigger system. Totally unrelated. In medicine, did you guys do M&M?

01:59:13.960 All the time. Okay. I was the presenting party in M&M at least once. And that's morbidity and

01:59:19.880 mortality. Yeah, yeah, yeah. So, so it's really funny. I remember the first, this is totally off topic,

01:59:24.280 but just what you said about the coming out. One of the things I miss the most about being in an

01:59:29.600 academic medical center is M&M. So the morbidity and mortality conference. So might as well just

01:59:35.020 explain, and I assume it's the same in surgery as it is in medicine. What we would do is every

01:59:39.480 Tuesday morning at 6 a.m., there was no exception to this rule. Like there was nothing that would get

01:59:43.800 in the way of this conference. All of the surgeons, the residents, the fellows, the attendings,

01:59:48.400 everybody would meet in a room and all of the complications. So the morbidities, pardon me,

01:59:53.800 the mortality, the morbidities, and then all of the deaths, the mortalities would be presented.

01:59:57.780 And it was a very unemotional conference. So I would stand up there and I would say,

02:00:04.140 Mr. Smith was a 47-year-old man who came to the emergency room on such and such a day presenting

02:00:09.620 of left lower quadrant pain. We suspected diverticulosis, blah, blah, blah, blah, blah, blah,

02:00:13.280 took him to the OR, did this, da, da, da, da, da, da, da. And then, oh, and by the way,

02:00:17.200 he had a pulmonary embolism and died six days later. Okay. And so you just unemotionally present

02:00:23.720 the facts. And then comes the process. Okay. Let's start with the basics. Was he on sub-Q

02:00:31.440 heparin? Was he up walking? Did he have a hypercoagulable state? Did you do this? Did

02:00:35.480 you do this? Did you do this? And I've never been afraid of speaking in public with maybe one

02:00:40.020 exception. That was a very difficult conference to present at. But by the time you were presenting,

02:00:46.280 i.e. by the time you were senior enough to be the one to stand up there and present,

02:00:49.020 you had seen the beauty of it and the benefit of it, which is it hurts. There's no denying it. It's,

02:00:54.600 it, I mean, it's, it's a rectal exam without any lubrication, but there's benefit. You see this.

02:01:01.140 And so I remember when I left medicine, the first place I went to was to work at this consulting firm,

02:01:05.560 McKinsey and company, which I loved, you know, another exceptional fun chapter of my life.

02:01:10.140 But I remember like naively asking at one point, I'm like, why don't these companies do M&M? And

02:01:15.780 everyone's like, what do you mean? They eat M&Ms all the time. And I'm like, oh no, no, sorry. I

02:01:19.620 mean morbidity and mortality. Like why is it that there isn't a post hoc analysis of everything

02:01:24.160 that goes wrong in a totally unemotional way that just, and, and, and the reason M&M works

02:01:30.520 is it's completely closed. There is no legal recourse. So there's no hiding. Nobody who's not

02:01:37.800 a part of surgery is allowed in that room. Yeah.

02:01:40.040 And that's sort of what enables it to be that way, which I, look, if you're the, you know,

02:01:44.340 if you're running a publicly traded company, you don't have that luxury.

02:01:47.160 And I had the same experience with M&M. It was this horrible, painfully going up there on this

02:01:51.780 patient died because of a mistake that was made here. And then having to go through that and

02:01:57.000 everybody looking at you and being like, so what you did this, did you think about this? I did,

02:02:01.700 but I decided this. Do you feel like that was a correct decision? Well, obviously not,

02:02:05.680 but coming out just like, okay, first of all, I'm glad that that, that I was able to talk about

02:02:11.440 this. Cause you don't think I've been beating myself up about this. Like I'm just a second

02:02:14.760 year resident. Like this is devastating to me. Like I went into this to help people. My biggest

02:02:19.160 fear is hurting people. And I hurt someone and you come out so much stronger for it, even though

02:02:24.300 you've been put through this ringer. And we, you're right. We don't do that. Another, it's a blame

02:02:27.780 culture. Like you get fired if you screw up in, in a lot of businesses in the hospital. Nurses often get

02:02:34.300 fired if they make mistakes. And the truth is it ought to be a no blame culture. What was going on

02:02:37.240 in that Pyxis dispensing system that allowed that medicine to be dispensed, even though you

02:02:41.240 erroneously typed it in wrong. And it was a paralyzing agent instead of a sedative. And the

02:02:45.980 person died under torture in the CT scanner and you didn't check on them because there was no

02:02:49.780 protocol saying they had to be monitored. Well, we need to fix that. Was there malicious intent?

02:02:54.200 Was there recklessness? Was there substance abuse on the part of the, of the nurse or the doctor?

02:02:57.900 No. All right, well now we need to talk about how can we prevent this from happening? And what is

02:03:01.420 accountability? What does it mean? In the setting of maybe free will not being entirely a real thing,

02:03:06.360 but at the same time having, us having to behave like it is or else people won't,

02:03:09.940 it won't condition people to do the right thing. I love how we turn free will into Eminem. I never

02:03:14.340 get to talk about Eminem. This is why, this is why you and me need to do a show that no one will

02:03:18.520 listen to. It's just you and me about stuff we care about, you know, having been through it all.

02:03:23.200 What do you care about, Peter? Like what are you interested in these days? What's driving you these

02:03:27.880 days? And how can my experience, because what I've done is, is so different as well. And I can't

02:03:33.000 categorize it. When people ask me, I want them just to stop talking. Cause I'm like, I don't want

02:03:36.440 to tell you this. Yeah. You have a harder story. I don't know that it's harder. It's just, it's just,

02:03:40.840 it's more complicated narrative. What do I say? I'm a professional clown. Cause that's what my dad

02:03:44.940 says. So you've become a professional clown, huh? At least you're putting some non on the table

02:03:49.520 because otherwise it's just, you're just wasting. You went to all the medical school and now what are you

02:03:55.040 doing? You're just, you know, jacking off on this camera. He doesn't even know what that means. He

02:03:59.420 just hears me say it and he's like, oh, you're jacking off. I'm like, don't say that in mixed

02:04:04.180 company. It's not something, you know? So, so, you know, you're spending your time, but you're,

02:04:09.040 you're between San Diego and New York. You're doing all this cool stuff. You're talking with like

02:04:12.380 really smart people on your podcast. What's driving you right now?

02:04:17.220 Personally or professionally? Cause there's a bit of a divide.

02:04:20.020 I want to go personally actually. Okay. Let's go professional first.

02:04:24.380 I would say professionally, I am really, really obsessed with the question of what is the

02:04:29.640 appropriate dose of caloric restriction and the frequency and of the molecules that mimic that.

02:04:38.940 So when you start to think about metformin, rapamycin especially, and complete caloric

02:04:45.140 restriction. So I've really lost interest in much of the junior stuff that gets close to there.

02:04:49.740 So I sort of view that as filler when you're not fasting.

02:04:52.660 Okay. Let me interrupt for a second for my medical audience. A lot of them are going to

02:04:55.860 have no fucking clue what you just said. So rapamycin, metformin, caloric restriction,

02:05:01.020 operating on the principle that a lot of studies in animals, mammals show that some form of caloric

02:05:06.420 restriction increases longevity through a series of mechanisms. And there are molecules and receptors

02:05:12.360 that might mimic or be at least partially responsible for the action of this caloric restriction

02:05:17.360 in terms of promoting longevity. Rapamycin is one, metformin might be another.

02:05:20.860 Yes.

02:05:21.540 Sorry. I just wanted to make sure I understood because I am dumb about this stuff.

02:05:24.760 Yeah. No. Thank you for clarifying that. So molecules like metformin, which have a net effect

02:05:30.480 of activating an enzyme called AMP kinase, which is a nutrient sensing enzyme. It mimics something

02:05:36.100 that you see when you're being deprived of calories. Conversely, rapamycin inhibits something called the

02:05:42.360 mechanistic target of rapamycin. They got very creative on the naming.

02:05:45.220 MTOR. MTOR would be a great superhero.

02:05:48.280 Sounds like a He-Man bad guy.

02:05:49.780 Yeah. Absolutely.

02:05:50.380 Skeletor, MTOR.

02:05:50.820 Should have been an X-Man.

02:05:51.680 It should have been. Yeah.

02:05:52.980 So rapamycin inhibits that MTOR, which is sort of the central nutrient sensor for amino acids. So

02:06:00.260 again, when you inhibit MTOR, you are mimicking deprivation of amino acids. And then of course,

02:06:06.140 there's just the old fashioned way to do it, which is just don't have anything but water. And that's,

02:06:09.980 that seems to work really well, provided you do it in short enough periods of time. I mean,

02:06:13.460 if you do it indefinitely, you arrive at a state called malnutrition and you die.

02:06:17.600 But the problem is we don't have a clue what the optimal dose is. So if you treat caloric restriction

02:06:25.480 like a drug, meaning don't eat for this long a period of time, and then repeat that at this

02:06:31.860 frequency, we don't know the answer to that question. Furthermore, we don't know, like, do you

02:06:37.500 need to go all the way? Could you just eat 500 calories a day for a certain period of time and

02:06:43.680 repeat that at a certain frequency? So you pretty quickly realize that it becomes an infinite

02:06:49.280 problem. You have the number of calories you consume, somewhere from zero to something not

02:06:54.280 too big, the composition of those calories, if it's anything but zero, the duration at which

02:06:59.820 you're exposed to that, and the frequency with which you repeat it. And then by the way,

02:07:04.000 if you want to add a fourth variable, since we're talking quantum physics, add that whole three

02:07:08.880 layer three space onto the what you consume when you're not doing that. The problem becomes ridiculous

02:07:15.920 and it's unsolvable. That's an unsolvable problem. So what do you do when you're an engineer and you

02:07:19.860 have an unsolvable problem? You take a guess at states that would be discrete enough that they're

02:07:28.040 not too close to each other, that they should overlap that much, and you would test them. So you would

02:07:33.720 ask the question, well, if caloric restriction and or rapamycin and or metformin extend life,

02:07:40.140 what would be some of the readout states of that? So my obsession professionally is understanding those

02:07:47.340 readout states and basically collaborating with and facilitating the funding of research to answer

02:07:54.800 those questions. So there will be assays that need to be created to measure the readout states of that,

02:08:01.520 including things like autophagy. So autophagy, as the name suggests, autophagy, self-eating.

02:08:07.860 That is generally regarded as probably the most important, though not the only mechanistic change

02:08:14.720 that occurs under caloric restriction and administration of rapamycin.

02:08:19.000 Undertaking this line of research, as you said, is very complex. And what you're ultimately trying

02:08:22.460 to figure out is, really, what is the best mix of variables?

02:08:26.520 Yeah, because I have a fasting routine that I literally pulled out of my ass. And I have patients

02:08:31.280 that are doing slightly different ones or the same ones. And I have patients that aren't fasting at

02:08:35.220 all because it's still a bit scary. And in the end, I just sort of want to be able to give a dose

02:08:40.760 response. I want to be able to say to a patient, look, if you want to go all in, this would be as

02:08:46.180 reasonable or as aggressive a protocol as you might want to take. But look, you could get 50% of the

02:08:51.720 benefit of that doing this, and you could get 20% of the benefit doing this. And if you stack this

02:08:56.380 with this, you can do X, Y, and Z. So I have spent years experimenting on myself with this stuff,

02:09:03.720 but the measurement tools that I have are too blunt to actually make any reasonable inference.

02:09:09.740 So you need a better study.

02:09:10.860 I need much better tools to measure what we care about.

02:09:14.000 So that's your passion now. And you also treat patients, trying to help them. Are you using these

02:09:19.540 medications on patients? Metformin, yes. Rapamycin, no.

02:09:23.120 Right. Because rapamycin is a transplant rejection drug.

02:09:26.260 Yes. Now, rapamycin gets a bit of a bad rap. It's a much safer drug than people realize. Like,

02:09:31.440 I would be less afraid of a patient taking rapamycin than ciprofloxacin.

02:09:35.420 Oh, yeah, exactly. At the right dose.

02:09:37.720 Yeah, yeah, exactly. And at the right frequency. I mean, I wouldn't want a patient taking rapamycin at

02:09:42.800 the frequency that we gave it to a kidney transplant patient. But we certainly know enough now based on

02:09:48.340 all of the literature out there, including literature in humans, dogs, et cetera, that

02:09:53.380 rapamycin given at certain doses, at certain frequencies, actually enhances the immune system

02:09:59.180 and improves many metrics of physiology. So if you talk about giving rapamycin at that dose versus

02:10:05.880 giving, you know, cipro for a bad UTI, I'll take rapa all day long. I mean, given how small

02:10:11.460 my interaction is with patients, because I have so few of them, the fact that I've already known

02:10:16.460 to patients who in the course of their life have had tendon injuries during the course of

02:10:21.240 fluoroquinolones, I've become sort of paranoid about these antibiotics, which might be an

02:10:25.460 overreaction, by the way.

02:10:26.600 I'm not sure it is, man, because we used to give them out like candy. You know, it was a

02:10:30.100 moxie cipro era when I was training and everybody with pneumonia got that because it covered all

02:10:35.180 kinds of shit. And then, you know, it's interesting that we didn't see a lot of tendon stuff. It might

02:10:38.980 be, it was seen as an outpatient.

02:10:40.100 I was just about to say, the research I've looked into this is you have about a six-month

02:10:43.960 window of susceptibility to tendon injury following fluoroquinolone.

02:10:49.460 What we saw more often was a higher incidence of C. diff, C. difficile, a bowel infection. In fact,

02:10:54.680 I had a patient-

02:10:55.460 Have you done any songs on C. diff?

02:10:56.840 Yes. It's called Dawn of the Diff. And I took a lot of rapamycin so I could bust a rap about,

02:11:02.540 yeah, it was really dumb. It was one of our early songs, but it was all about how people will come

02:11:06.780 asking with intent for a cold antibiotics and go away with a debilitating bowel infection that could

02:11:12.340 be fatal. And I had a patient who died of it, coated in the CT scanner, and had a huge pericolonic

02:11:18.700 abscess from C. diff. And I remember telling his son, who was a marathon runner, that his dad had died.

02:11:25.780 I was in the ICU. And it was one of the most, I'll never forget it because the whole thing was

02:11:31.260 iatrogenic. I mean, it was caused by-

02:11:33.120 One error after another.

02:11:34.180 One error after another. And this is one thing I want to say because I think your listeners in

02:11:38.300 particular, they're not all doctors and medical people. They may be scientists or people who care

02:11:42.160 about this stuff. You don't understand how fucked up and terrible the hospital is as a place to be

02:11:50.440 safe and taken care of. It is a disastrous zone of chaos, of infection, of errors, of poor system

02:12:00.160 design, of lack of coordination, and of expense that doesn't need to be done. And until we feel

02:12:06.980 that emotionally in our elephant, we're going to continue to perpetuate a broken system.

02:12:13.260 We have to wake up and realize, maybe we need AI to help coordinate our care. Maybe we need better

02:12:18.620 technology. Maybe we need better processes. But none of it's happening because our incentives

02:12:22.380 are still fee for service, which is we get paid to do things to people. And in a hospital,

02:12:26.500 you can do a shit ton to people. The hospital gets paid. Nobody's incentivized to make it safer,

02:12:31.300 even though we all have a story of someone who we love or we took care of who died because of a

02:12:34.860 medical error or got injured because of a medical error. So to me, this has become a recent passion.

02:12:39.220 So when I hear you talking about rapamycin, I get excited because maybe we can keep people out of

02:12:43.220 the hospital through the selectivism.

02:12:45.280 Yeah. I think the thing about rapamycin that's so exciting is it doesn't just increase lifespan. I mean,

02:12:50.680 if that's all it did, it wouldn't be that interesting because the US healthcare system is pretty

02:12:54.280 good at increasing lifespan in the presence of deteriorating healthspan.

02:12:58.200 We can torture you in the ICU for years.

02:12:59.820 We can keep you alive for an extra year if your aorta ruptures, if we're really willing to go all

02:13:03.900 in.

02:13:04.100 ECMO.

02:13:04.640 Yeah, exactly. Yeah.

02:13:05.840 Yeah.

02:13:06.120 But it's the increase in healthspan that comes with it. Or stated more accurately,

02:13:09.740 it's the reduction in the rate of healthspan decline.

02:13:12.480 That's interesting because it's always going to decline. You're never going to be able to do at

02:13:14.720 90 what you did at 30.

02:13:16.340 That's right. That's right. My intention is to sort of understand what the 20 requirements are to be

02:13:23.440 a kick-ass 100-year-old. So consider like a new Olympic sport is the centenarian decathlon.

02:13:29.800 So you figure out what all those metrics are and then engineer your way back to what you need to

02:13:33.660 be able to do at 40, 50, 60, 70, 80 to hit that target. So that's the second professional problem

02:13:39.840 I'm obsessed with. So the first one is this whole thing around developing finer tools to probe

02:13:46.200 the molecular places where we're going to see readout states on caloric restriction,

02:13:51.640 rapamycin, metformin, other agents that are CR mimetics, meaning drugs that mimic caloric

02:13:56.700 restriction. And then the second completely independent obsession is codifying what does

02:14:02.960 the perfect training routine look like that makes me at 100 the thing I have in my mind.

02:14:10.540 In other words, that's why I don't actually care if I can swim 25 miles today. I don't care if I can

02:14:15.000 ride my bike 200 miles. I don't care if I can deadlift 500 pounds anymore. Like none of those

02:14:19.080 things matter to me anymore. Not that they weren't interesting and valuable and beneficial at one

02:14:23.740 point in my life, but I don't think they matter enough to this centenarian decathlon.

02:14:30.000 That makes a lot of sense. And it kind of brings it back to what your goals are and how you're

02:14:34.060 changing over time. And we all are. That's the thing. People expect something static of human

02:14:37.900 beings. They expect us to be the same person we were here and here and here and here and here.

02:14:41.660 And I think for me, that's very uncomfortable because I think we evolve over time and our interests

02:14:45.980 evolve. And I think medicine as an entity is a complex evolving organism. We treat it like some

02:14:52.360 easy system or something we can game or something that's not. Do you have any thoughts on what you

02:14:56.400 would do if you had a magic wand? How would you reform healthcare from a payment model? Have you

02:15:00.980 ever thought about that stuff? I have actually, but not in a very long time. I think my answers are

02:15:08.480 conceptually quite simple, but practically almost impossible. So I'll start with a story. And I've

02:15:15.060 actually given a talk on this once. Before we were shooting the breeze here, I was explaining how

02:15:19.220 much I hate giving talks. But one of the talks I gave was actually on this particular issue.

02:15:23.960 It's the only time I've ever spoken about it. It was like a hundred years ago. But I started with

02:15:27.780 this example. So I had a friend who's an expat. So he's an American, but living in Saudi Arabia.

02:15:32.580 But he would always spend like June, July, August, September back in DC because obviously it's pretty

02:15:38.220 hot in Riyadh that time of the year. And I remember him saying that, I don't even know how this came

02:15:43.740 up. It was just like in the conversation that he left the air conditioning on for those four months.

02:15:48.380 And he would just said it like in a matter of passing. I was like, whoa, dude, what do you mean

02:15:51.940 you leave the air conditioning on for four months? He's like, well, like if you didn't leave the air

02:15:57.920 conditioning on when you come back in October, like it's going to be 120 degrees in your apartment.

02:16:03.580 And I was like, yeah, but you'll turn the AC on. And in like three hours, it'll be 75 degrees.

02:16:09.220 He's like, yeah, but that would take like three hours of being like balls hot.

02:16:14.040 And I was like, dude, I'm struggling to understand the logic here. He goes, oh,

02:16:19.440 you don't understand. Like we don't pay for our energy in Saudi Arabia. I forget what the number

02:16:23.760 was. It costs like $2 a month to keep my air conditioning on the whole summer. So for me,

02:16:28.120 spending eight bucks or 19 bucks, whatever it was to keep my air conditioning on all summer is

02:16:32.380 totally worthwhile. And so we can listen to that in the United States and we can laugh our asses

02:16:36.700 off at how ridiculous that is. And oh, those stupid governments subsidizing their people.

02:16:41.760 And that's the root of all evil in the Middle East and blah, blah, blah, blah, blah. And it's

02:16:45.320 like, hey dude, get off your high horse and take a look at the US healthcare system. It's a long

02:16:50.420 story, but I basically got a bunch of data to plot out what the P&L looked like of the US healthcare

02:16:55.700 system, which turned out to be much harder than I expected. This took all of my McKinsey ninja skills

02:17:00.900 to get these data. And if you plotted basically where the dollars come in and who makes the

02:17:08.740 decisions on where the dollars get spent, guess what? We're in Saudi Arabia, brother.

02:17:14.420 The people who are driving the cost are not bearing the cost. And so it's not that dissimilar from you

02:17:21.620 going to the Lexus dealer and knowing that you only have to pay 9% of the cost of whatever car you get.

02:17:29.520 Do you really think that the parking lot that I'm looking at now would look as it does if people

02:17:35.800 were only on the hook for 9% of the car that they got? No. So fundamentally, if you want to fix the

02:17:44.360 cost issue, you must be able to couple decision-making to spend. You can't have those uncoupled

02:17:51.180 and they're currently uncoupled. But the other thing that is worth mentioning, and I'll get off my

02:17:56.280 soapbox on healthcare, is there are two other legs of healthcare that often get confused with the

02:18:02.440 third. So you have cost, you have access, and you have quality. And you don't get to move one without

02:18:10.760 the others coming along. So you can't fix one independently. So the other thing that sort of

02:18:16.320 frustrates me when people talk about healthcare, which is why I never talk about it, I view it like

02:18:21.940 religion and politics. I've decided I don't give a shit at all. I don't care what anybody thinks. I

02:18:27.920 don't want anybody to know what I think, although you've asked, so now you're stuck hearing what I

02:18:30.940 think. But what bothers me is that when people talk about this, they talk about those three things like

02:18:36.540 they're independent variables. Whereas the moment you decide, well, Canada's got the best healthcare

02:18:42.260 system in the world because of X, Y, and Z, it's like, no, no, no, that's actually not correct.

02:18:47.120 You have to understand what Canada has optimized for. Canada has optimized for cost. They've optimized

02:18:54.100 for quality to some extent, and they've optimized for access, but not in the immediate sense. So the

02:19:00.840 difference is in Canada, it's cheaper and you have X, Y, and Z. But like if you want to go and, you know,

02:19:07.320 like things that you and I would take for granted, like if you tore your ACL or suspected you tore your

02:19:12.100 ACL, you would have an MRI within 24 hours here. That's not going to happen in Canada unless you

02:19:17.360 have the money to cross the border and get it done in the United States. You could easily wait six

02:19:20.860 months for an MRI there. Access to physicians. I mean, the stories are horrible. And I know this

02:19:25.460 because my whole family's still there. So it's not just like I'm sort of making this stuff up. I mean,

02:19:29.640 I'm seeing what they're going through. And yet there are still things that are amazing in Canada.

02:19:33.580 Like when my father had an enormous operation there, I was totally impressed with his care. I mean,

02:19:39.200 it was as good as care he would have received at a great U.S. hospital. And it didn't cost a penny.

02:19:45.800 And that blows my mind because you don't need these sort of nonsense internal accounting system

02:19:50.460 that we have in U.S. hospitals where like the cup that you collect your urine in is 78 bucks.

02:19:55.940 And, you know, like that bag of IV saline over there is a hundred bucks and all this kind of

02:20:00.000 nonsense. So the short answer is if I could wave a magic wand on this system, as much as I hate to say

02:20:07.900 it, on some level you have to have at least a blanket called a single payer system. I do believe

02:20:14.040 that if you truly try to individually privatize this thing, you cannot get that silly decouple out.

02:20:20.400 The second thing, and this is also very unpopular to say, is I do think we as patients need more skin

02:20:24.960 in the game. Now, of course, under the current pricing regime, that would be impossible, right?

02:20:32.100 You couldn't allow patients to be exposed to more than the 9% that we're already exposed to. And it's

02:20:37.540 probably higher by now, by the way. Those are old data. You would probably know what the current

02:20:41.040 exposure is. But because the prices are so inflated and so nonsensical, and as you probably know, I mean,

02:20:46.760 you obviously know this, but maybe the listeners don't. I mean, medical cost is the leading cause of

02:20:51.400 personal bankruptcy. So the answer isn't patients need to spend more. They just need to own a greater

02:20:56.380 share of the cost, which really means the total cost can't be a bullshit scam, which is sort of

02:21:01.880 what it is right now. So as interesting and important as all of that stuff is, I never think

02:21:06.700 about it. I love it. Yeah. Here's my solution to this very complex problem, and I don't think about

02:21:12.760 it at all. You know what's funny? Everything you just said, I've been batting around this quite a bit

02:21:17.360 because it's part of what I try to do. I have a solution that I'm going to pitch to you real quick.

02:21:21.500 I think it fulfills most of what you're saying because our plans, again, converge. Like many

02:21:26.360 things. It's strange when people think about these things independently and they converge.

02:21:29.620 We've never talked about this. So my plan for fixing healthcare is this. First of all, you need

02:21:36.040 to put patient skin in the game, and the way you do that is you give them a personal health account

02:21:39.680 up to about $2,500. If you're very poor, that can be subsidized by the government. What do you use

02:21:44.640 that for? You use that for primary care services or out-of-pocket expenses. So it's use it or lose it.

02:21:51.600 Well, it's use it or maybe it grows, maybe you keep it. But it has to be used within

02:21:56.060 healthcare. So there's no incentive to not spend it.

02:21:58.320 Exactly. You want to use it in healthcare. And the thing is, you want to use it for primary care.

02:22:02.740 And the way you do primary care right is the way we did Turntable Health, which is a flat

02:22:06.200 membership fee for an unlimited all-you-can-treat access to a relationship-driven,

02:22:11.200 preventative-minded, team-based healthcare. That's technology-enabled, but not enslaved.

02:22:15.260 That's evidence-informed, but not evidence-enslaved. You can look at the unique patient. You're not

02:22:19.020 subject to metrics beyond the patient having outcomes that matter to them. Because otherwise,

02:22:24.960 they will take their money and they'll take their personal health account and they'll go

02:22:29.000 somewhere else. So it's people competing with each other based on what they're providing to

02:22:32.500 the patient. So you would be on that plan. They would use the money to pay you, et cetera.

02:22:36.680 Once they reach that $2,500, then it gets into deductible space. So at this point, if you're

02:22:42.940 a rich person, that deductible may be $7,500 or whatever it is for your family, which it is now.

02:22:47.340 It's like that now. If you're poor, it might be subsidized by either your employer or by the

02:22:51.740 government to some degree, but your skin is still somewhat in the game. And so you're paying for

02:22:56.560 that. Now, once you reach the deductible, that's where the catastrophic Medicare kicks in. That is

02:23:03.560 Medicare for all, but not in the single payer sense. It doesn't pay for everything. It's not like

02:23:07.300 carte blanche fee for service. You get whatever you want. It's a catastrophic wraparound. If you go to

02:23:14.100 the hospital, it will cover it after you paid your deductible, after you used your personal health

02:23:17.240 account. And it's given out and administered in the same way that Medicare Advantage is. In other

02:23:23.000 words, different entities compete to be the most efficient with that money. So in other words, if a

02:23:29.480 hospital system can actually keep you out of the hospital, it doesn't spend all the money. It gets

02:23:33.780 to keep the shared savings, something like that. So you have businesses competing. You have the

02:23:37.680 government covering everybody. Nobody falls through the cracks. Hospitals compete. Doctors compete. But

02:23:42.500 everybody gets to practice the way they want. You get to choose your doctor and their skin in the

02:23:46.840 game. And it doesn't bankrupt the country because you need maybe another 6% tax. And it's equitable,

02:23:52.060 but not completely unfair. And I think that's how you do it. But at the center of it is prevention,

02:23:57.020 primary care is the engine that drives it. And that also ameliorates burnout. And then you focus

02:24:01.700 on technology that actually enables that, quality science that actually enables that. And if you

02:24:05.880 discover that there's a particular dosing of rapamycin and you have a clinic that does that,

02:24:09.260 you're going to win the competition game. And your science will disseminate and then other people

02:24:12.640 steal it and it'll elevate the game. So that's my theory.

02:24:15.100 I mean, it's very interesting. Obviously, I think a lot of that makes sense. The one thing that is

02:24:19.600 very challenging in these systems, which are – because there's a portion of what you're

02:24:23.640 describing as almost capitated.

02:24:25.400 Yeah, that's right.

02:24:25.940 The challenge of these systems is – and this is why as much as I would love to say this should

02:24:32.240 all be done privately without the government, I think the one advantage the government has going

02:24:37.180 for it, if it knows how to play its cards right, which unfortunately it doesn't always,

02:24:41.040 is it owns the patient life forever and therefore it is truly incentivized to participate in a

02:24:47.560 capitated way. The challenge of privatizing this is the median tenure of a patient with a payer,

02:24:57.460 be it an insurance company or their employer, is in the neighborhood of what, four or five years?

02:25:03.820 Maybe less than that.

02:25:05.040 Yeah, maybe less than that. So if you have prediabetes right now, the cost to normalize – in

02:25:14.760 fact, if you are a newly diagnosed type 2 diabetic today or you have NAFLD today and I know I only

02:25:20.940 own your life for three or four more years, I have zero incentive to spend one penny because the

02:25:27.860 macrovascular and microvascular diseases that are going to destroy your life in 20 years,

02:25:33.880 I'm going to be so long gone, I won't even know you – I won't even remember your name.

02:25:36.960 And actually, this is a central piece of this, which is in this country we medicalize our social

02:25:43.160 problems. So diabetes, to a large extent, you know, in these very high utilizers is a social

02:25:48.620 problem. It's poverty, it's lack of job security, it's inability to exercise because of danger in the

02:25:53.440 community, these kind of things. It's adverse childhood experiences. So as a result, if you

02:25:57.780 start shunting money from healthcare into those social services like every other industrialist

02:26:01.940 country does, you can actually squeeze down the overall cost. So that may ameliorate some of this.

02:26:07.440 But that has to be – but that would have to be done centralized. There is no way any entity but

02:26:10.920 the government is going to do that, is there?

02:26:12.360 I agree. I agree with you. I think that's the role for government. And people will disagree.

02:26:16.520 Hardcore libertarians will disagree. I don't care. They can –

02:26:18.580 Well, here's the funny thing. I consider myself – again, libertarian is such a broad term that it

02:26:22.900 doesn't mean much because like you have such extremes on that. But I actually found Michael

02:26:27.880 Lewis's book, The Fifth Risk, to be quite interesting.

02:26:31.200 I'll check it out.

02:26:31.740 I knew about half of it quite well. I actually knew a lot about what the DOE does and what the USDA does.

02:26:38.180 But I didn't have much of a sense of what the Department of Commerce does. And his book is a

02:26:42.760 very depressing book. So I don't want to get into the politics of the book. But absent all of the

02:26:48.200 politics, if nothing else, whatever your political views are, is simply an exercise in civics to

02:26:54.440 understand what your government does. Because we have a lot of examples of what they do poorly.

02:26:59.540 I mean, and I'm as guilty of that as anybody. I could rattle off a hundred things that they are

02:27:03.620 mindlessly incompetent at. I think Lewis does a great job explaining things that they are competent

02:27:08.920 at. And in fact, so competent at that we don't realize how many close calls we have.

02:27:13.180 And he does that through going through what ag does, energy does, commerce does. It's a very

02:27:19.500 quick read. I think I read it in a day and a half. It was a hard time putting it down. It was so good.

02:27:24.560 A day and a half of busy work, by the way.

02:27:26.280 Yeah, yeah.

02:27:26.600 I mean, but this is why the center probably holds the truth for in most cases. That's where I am too.

02:27:31.440 I think government has a role. Listen, people will say, oh, get government out of healthcare. We

02:27:34.680 can't have them in healthcare. They're already 50% of healthcare. Medicare, Medicaid, all this.

02:27:38.860 Chip, they are a huge bear.

02:27:40.600 It might even be more than that. It's at least 50. So think of VA. Think about that. So now you're

02:27:45.240 like, okay, well, how can we optimize them? And don't let them break stuff that they have no

02:27:48.720 business in, but then have them do what they really do well. And I think that some of that

02:27:51.440 social support is something we do well. We don't have the political in this country, I think,

02:27:54.300 to come together on that. But if we did, we'd stop putting the moral distress on us as caregivers

02:27:58.760 because we feel terrible. It's a hamster wheel. When I go around at the county I did this week,

02:28:03.380 every single patient there doesn't need to be there. They're all preventable. It's all social

02:28:07.080 determinants. It's substance abuse. It's adverse childhood experiences, people who were abused

02:28:11.960 sexually and otherwise. And that manifests as adult chronic disease. We know this. So this is

02:28:16.000 a thing. I want to say one thing because I think my followers and yours will want to know how...

02:28:19.860 You're not scalable as a doctor. You do amazing things. But how are people going to find doctors

02:28:23.900 like you that think so differently and are treating people in a way that is trying to maximize these

02:28:29.680 outcomes that you talk about?

02:28:30.720 I mean, I think there are already sort of organizations that organize around this

02:28:34.740 through functional medicine and things like that. I'm not being facetious. I probably get 250 emails

02:28:39.420 a day. Now, obviously, a number of those are directly work-related, patients, colleagues,

02:28:44.600 whatever. But a very high number of those, which unfortunately I just can't respond to for the

02:28:49.320 most part, are through the blog or through the podcast or something saying, hey, Peter, I live in

02:28:54.980 St. Louis and I've been listening to your podcast or reading this and I'm interested in the way

02:29:00.560 you're thinking about metabolism or this or that or the other thing. My doctor kind of rejects

02:29:06.000 everything you're talking about as I have 12 minutes to see him and like it's basically refilling

02:29:11.520 my blood pressure medication and that's it. Is there a doc in St. Louis that you know that you

02:29:15.500 like? And so the answer to these questions is inevitably and invariably always, I don't. I just,

02:29:19.640 you know, I don't know. Once in a blue moon, I get asked that question and the person is asking it

02:29:25.600 from a place that I know and I'm like, great. I used to always tell people about you in Vegas until

02:29:30.040 they couldn't come and see you. So what we're actually doing is creating a doctor database

02:29:35.600 on our site. And we're making it a pain in the ass for the doctors to fill out because I want

02:29:40.920 them to do some work, right? So it's like you got to come to the site, you got to answer a lot of

02:29:44.980 questions and really get into the weeds on like how much time do you spend each month learning about

02:29:49.420 this subject or that subject or this subject? What is your process of re-education? What is your

02:29:54.860 philosophy on medicine? Because I think in about 2,500 words or less, and maybe we allocated a

02:30:00.740 thousand words or whatever, I don't remember what it was, but we gave quite a bit of room for people

02:30:04.120 to basically explain how they think about medicine. Because even though I can't do it in 30 seconds,

02:30:10.660 if given three minutes, I could probably provide a reasonable overview. And then the goal is to

02:30:16.180 basically figure out a way to get that to be a critical mass such that it now becomes just a sort of

02:30:20.380 directory for patients. So someone can say, if my zip code is this, boom, pull up all doctors within

02:30:26.720 20 miles, and then they'll be able to go and then read about those people. And obviously,

02:30:32.740 it's impossible for me to vet these physicians. So this in no way, shape, or form means like-

02:30:37.680 Endorsement.

02:30:38.100 I'm putting an endorsement on this person. Chris Kresser has done a bit of that through his work

02:30:42.140 through he can at least vouch for so-and-so has taken this course. But my hope is that given the

02:30:48.280 hurdle of how much work goes into that, it's not just someone mindlessly saying, I'm a doc, I want

02:30:53.600 another portal of referral. If it streamlines the process for patients by 50%, it's still valuable. I

02:31:00.020 think it could be more valuable than that.

02:31:01.500 How can my fans help with this? These are all healthcare people, activist patients.

02:31:05.200 They should just go and sign up. So if you go to peteratiamd.com, I don't look at my website enough

02:31:10.560 to know, but I'm sure that somewhere on there, it is physician network or something like that.

02:31:16.240 Right. It's not a porn site, so you have no business on it, pretty much. That's my criteria usually.

02:31:23.200 We've touched on this briefly, but I don't think we've done it justice, which is your music videos

02:31:29.000 are at once both incredibly funny and actually at times incredibly touching. Some of them are very

02:31:40.500 moving and they're always entertaining. So rather than me try to like describe, you know, six of

02:31:47.360 your favorite videos, we're just going to link to all of them in our show notes so that people can

02:31:51.480 see them. But every time I've asked you about it, either your modesty just downplays your process or

02:31:58.960 you really are a savant. But like, I don't know how you actually do that. So can you just pick one

02:32:06.300 and explain how you go from, there's a very popular song out there to, I have an idea that I would like

02:32:13.140 to parody to, I write the lyrics to, I make this video. You talk about that as though, like the same

02:32:20.340 way I talk about making scrambled eggs. Yeah. It requires a little bit of work. You know, you don't

02:32:24.740 want to get the shell in the bowl, blah, blah, blah, blah, blah. So you want to inside the doctor studio

02:32:29.340 with ZDogMD. You want to get into how I do this. And it's interesting because- Yes, exactly. Exactly.

02:32:34.100 So much of it is, it's like a creative process. Like for example, when I see what you do and the

02:32:38.280 way you dissect a paper or the way you think about science, it's inexplicable to me because my mind

02:32:42.580 works very differently. The way that I think about something, let's use an example of, there's a song

02:32:47.620 I did called Ain't The Way To Die. Yes. Which is one of the, I would say three of yours that I

02:32:52.940 actually find very touching because as funny as it is, if you've been there and seen it,

02:32:59.020 it's a tearjerker. And I'm sure we'll link to it so people can see it. The idea was everything we do

02:33:05.300 is try to be mission driven. So the why of what we're doing, and sometimes that's unconscious.

02:33:10.020 We don't consciously go, oh, why are we doing this video? It's more like, what's the message

02:33:13.440 we're trying to get? Now, when I was working full-time at Stanford, one of the most painful

02:33:17.060 things I saw was that people suffered and were tortured at the end of life because nobody had the

02:33:21.180 balls to have a conversation and say, what is it you want when this happens? And be very specific,

02:33:25.960 like talk to your loved ones. The loved ones will say, he never talked about it. He said he didn't

02:33:28.620 want to be a vegetable. Or the loved one's three states away and needs to come before any decisions

02:33:33.800 are made, but they won't come for weeks because they think it's not urgent. But this person is on

02:33:38.320 a ventilator, paralyzed, partially sedated, probably suffering, and didn't know that this was even a

02:33:44.520 possibility. So it starts from that emotional place of, what do we want to do with this thing? Then you

02:33:49.400 start to think of, I want to do a song about this. What would be a fit for this? And this is kind of

02:33:55.040 a bit of science. You're trying to fit this sort of peg in the right hole and figuring out what's

02:34:00.840 the right emotional valence, what's the right lyrical structure. And you're maybe going through

02:34:06.180 Spotify, flicking through, and then you see, and I saw Eminem. I'm like, I like Eminem. I mean,

02:34:11.500 he's one of those guys that you can listen to. You don't love it, but it's so clever. You just go,

02:34:15.160 that's clever. I admire that. But then he did that piece with Rihanna about domestic abuse.

02:34:21.300 You know, just gonna stand there and watch me burn. And you're like, that hits you right in

02:34:27.920 the elephant, right in the emotional unconscious. Okay, we can motivate the elephant, and then later

02:34:32.780 we'll think about the writer, how we direct them. So that made me feel something. It's about domestic

02:34:36.600 abuse. Isn't domestic abuse the same as the institutional abuse that happens to our patients

02:34:42.720 when we don't have this conversation. And then I really felt it. I was like, yeah, listen to the

02:34:46.440 lyrics. It writes itself. Then I sit down and I go through the lyrics and I create a spreadsheet.

02:34:52.040 So this is a kind of a Peter Atiyah approach. Yeah. I did not expect this. Yeah. This is where

02:34:56.740 my scientist inside me comes up and I go, okay, these two actually, so they'll sometimes help me

02:35:01.940 with lyrics. They didn't help with this one, but my friend Harry did. He's a pediatrician.

02:35:04.620 Well, they didn't get me a white Russian either, and I'm still a little vexed.

02:35:06.540 Because they're pieces of shit. Fade to black. Oh, he faded me to black. Actually,

02:35:11.100 he faded Peter to black because Peter wants his white Russian. Instead, he got blacked out,

02:35:15.120 which is another consequence of white Russians. The document, the nice thing about it, like a

02:35:19.600 Google spreadsheet is you have all the original lyrics here. And so this is the problem with,

02:35:23.920 I get, you know, you get to all these emails. I get that many emails and they're all like,

02:35:28.620 you should do a parody of OPP, but make it about ECG. You done with ECG? Yeah, you know me. I'm like,

02:35:35.000 that's dumb. It has no point. And they often get the meter wrong. So they're saying,

02:35:39.500 here are my lyrics. And the meter is totally off. Well, we were talking earlier, we were looking

02:35:43.140 at awesome vids of your daughters playing the violin. Are you musically trained?

02:35:47.720 So this is the funny thing. When I was in high school, we were talking about identity and self

02:35:52.300 hatred. I wanted to fit in. I was a short little kid with a funny last name who was kind of chubby.

02:35:57.480 So I always struggle with way to unhealthy relationship with food to this day, but I've

02:36:00.980 somehow managed to do okay. The way I got by was I would try to find these crutches to help me fit

02:36:06.340 in socially in the Central Valley of California, which is all white or all Hispanic. And here I

02:36:11.680 am, this like Zoroastrian, Persian, weird person. I had an Afro at that time, which-

02:36:17.040 I've seen photos.

02:36:17.760 You've seen photos.

02:36:18.360 It's impressive.

02:36:18.860 I used to pray, and I'm not even religious. I used to pray for my hair to fall out because I hated my

02:36:22.820 hair so much. And when it did, I was like, why God, why? I was kidding. So awkward kid. So I picked

02:36:27.880 up guitar as a way to try to impress ladies because I was like, you know what? Everybody, you know,

02:36:31.660 they're more than words, which I eventually did a parody of, by the way, called More Than Warts

02:36:36.120 about HPV. But the weird thing is I fell in love with the instrument because I always loved music

02:36:40.520 and Weird Al was always like a weird, because I was a nerd. I loved Weird Al. And so I was just

02:36:44.900 in love with this concept of parody. So I picked up a guitar, learned guitar. Then I went to UC Berkeley

02:36:50.180 and had this delusion that I was going to be a rock star. So I felt like-

02:36:54.380 Because Berkeley is, I mean, generally going to the best school in the state. It's an obvious

02:36:59.080 linear pathway to being a rock star. It's a one-to-one correlation. You're a scientist.

02:37:03.320 Why are you asking these questions? Yeah. For me, it was like, no brainer. I'll go to Berkeley just

02:37:08.000 to please my parents because they want me to go to a real school. And it's not Stanford,

02:37:12.180 so I don't have to spend all the tuition because my dad was like, you know what? Berkeley is just as

02:37:15.740 good and cheaper. I'm like, it's actually not, dad. Here's the secret. It's really cushy. Okay. It's

02:37:20.080 really cushy. So all that being said, I minored in music and I majored in molecular biology because I was

02:37:25.940 like pre-med with the hedge that I'll be a rock star. And increasingly it became clear that I

02:37:31.660 didn't have this thing called talent. I didn't have enough drive and talent and ambition in that line

02:37:35.600 of intelligence music to be famous. There were so many kids that were so much better than me and I

02:37:40.020 knew it. And the thing is, rather than beat myself up about it, I'm like, cool, I'll be a doctor who

02:37:43.380 plays guitar on the side. And that's what ended up happening. And so I actually majored in, I did

02:37:47.660 ethnomusicology. So it was like studying like the music of Indonesia and all these different musical

02:37:51.540 forms. And it turned out that was the perfect conditioning of my sub-minds, these little conscious

02:37:55.440 agents, to later in my depths of burnout, all this music came back out and the Weird Al component

02:38:00.880 came through. So here I am as a professional Weird Al now. I'm going, okay, here's my spreadsheet.

02:38:05.760 On the left, I have the original lyrics to Eminem and their structure. On the right, I have a blank

02:38:10.480 space. I come up with the title and then I reach out to my friend Devin Moore, who's our audio

02:38:15.440 engineer, who's just a genius. He's like a professional musician. And we met in Vegas and he's like,

02:38:20.320 this is how we do things. And I want to do your stuff because you suck at producing the songs

02:38:24.980 because I was doing it on GarageBand. So he creates the backing track and he did that in

02:38:28.440 that case. He sends me the track, then I have the feel of it. Then I'll sit there with the original,

02:38:32.620 I'll listen to it, and I'll just start coming up with lyrics. In my mind, I may have some notes.

02:38:36.480 I need it to hit this point and this point and this point. And then I'll brainstorm. And usually

02:38:40.020 this happens, my creative process is I get on a treadmill or a Stairmaster or I run, and that

02:38:46.020 silences the monkey mind on top so that the unconscious, which has been processing the stuff in the

02:38:50.480 background, starts to bubble up these ideas. So these little clever phrases or little things

02:38:54.540 that I remember from the ICU or a case that I remember bubbles up and then I start to put it

02:38:58.980 into the structure. So from open creativity to codified structure with parameters. So the nice

02:39:07.100 thing is there's a parameter. There's a structure in the song already that I can't violate. So that bit

02:39:12.440 of constraint allows me actually to excel at what I do. I need that constraint. If it's just open,

02:39:17.900 I will fuck it up because it's too much possibility and I'll mentally masturbate for hours and it won't

02:39:22.380 come out. So having that constraint is helpful. Then I put it in thing. Then I show it to friends.

02:39:27.240 Then I go back. And then this is the thing. The rewriting process of lyrics is even more important

02:39:33.120 than the initial writing. So it's going back and that one word is just emotionally wrong or it feels

02:39:38.260 musically wrong. And you tweak it and tweak it and tweak it and get a thesaurus out. You go to rhyme

02:39:42.820 zone and you find better rhymes and then you hone it. And when it's done, then I go into that studio,

02:39:49.000 which is right there, which I won't say the name of it because it uses the R word, but it has TARDIS

02:39:53.620 in it. It looks like a TARDIS from Doctor Who, but it's not okay. It's a developmentally delayed

02:39:59.020 TARDIS. And I record it and then Devin mixes it and then we put it out.

02:40:02.460 Okay. So put some time on that for me. From the moment you picked the Eminem song,

02:40:06.860 what was the length of time from the idea? I want to do a song on this topic to choosing the song.

02:40:12.460 Approximately.

02:40:12.820 A couple of days.

02:40:13.580 Okay.

02:40:13.920 I want to do this topic.

02:40:15.100 Often it is.

02:40:15.980 Okay. And then from the moment you pick the song to strip the lyrics out, make the spreadsheet,

02:40:22.380 do the runs, write the song is how long?

02:40:25.560 In this case, it was about one or two weeks. In the shortest case, it's a day. I do it right then.

02:40:32.420 And I have friends and they help me in the team here, Tom and Logan. If it,

02:40:36.500 in the longest, it's been a month where I'm just pounding my head on the shit and there's no

02:40:40.360 timeframe.

02:40:40.700 And do you ever in that process say, I picked the wrong song, I got to go back?

02:40:43.860 Yes. Our history is littered with half completed projects where there's actually a track and it's

02:40:49.620 just dumped. For example, we were going to do Amy Winehouse rehab about skilled nursing homes.

02:40:55.900 Oh, interesting.

02:40:56.620 Doc tried to make me go to rehab. I won't go, go, go. Yes, I fell bad, but I got 12 cats at home,

02:41:04.280 home, home, home, the little old lady who won't go to sniff. That was dumb. And the more we tried

02:41:09.620 to make it work, the less happy we were. Now then we may come back to it, but yeah,

02:41:12.640 so sometimes we just fail. But ain't the way to die, it just kind of started pounding.

02:41:15.980 Oh yeah, that's a...

02:41:17.220 And the more we realized, we got the sense of, you know, that sense of moral elevation you get

02:41:20.720 in your chest where you feel something hit and it raises you in this way where you feel it expand.

02:41:25.420 It sounds very woo-woo, but it's a real human sensation. John Haidt and others have talked

02:41:28.660 about the sense of moral elevation. Like, I've done something here. I've tapped into some

02:41:32.140 ethos that will help people. And recording a song like that is done in one day?

02:41:36.800 It depends. So that one we did over a couple of days. I went to Devin's studio, actually,

02:41:41.200 and we just kept banging it out. And he would coach me. He'd sit there in the engineer space

02:41:45.220 and be like, you know what? I'm not feeling anything with that. Try it maybe this way,

02:41:49.040 and then we'll do like 30 takes. Oh my God.

02:41:51.620 And then he'll be like, that's it. I got goosebumps. That's it. That's it right there.

02:41:54.800 How does one do that? Like, if you said to me, can you repeat something six times? Like,

02:42:02.600 I wouldn't. This is the thing that's always amazed me about acting. I don't think I've

02:42:06.800 appreciated it as much about singing. But, you know, if you've ever been on a set to actually

02:42:11.620 watch a movie being made, and there's like A-list actors there, which I've had the privilege of doing

02:42:15.580 once or twice. I'm amazed that, first of all, an entire day of shooting produces 60 to 90 seconds

02:42:21.720 worth of a movie. That's how many times things are being done over and over and over again.

02:42:25.660 And it's to watch the actors and actresses show up with the same level of emotion, the same emphasis,

02:42:34.280 correcting maybe whatever the director says to correct. I'm like, well, that's another great

02:42:39.360 reason why I could never have done that for a living. And these are professionals that are

02:42:43.060 really good at that. Now, see, I'm an untrained amateur. I like call myself a pro-am.

02:42:47.620 Uh, cause, you know, it's one of those things where I get paid a little bit here and there

02:42:52.840 with ads and stuff, but really I'm just, you know, it's for the love of the game.

02:42:56.120 But the truth is it's a craft for me and the finished product matters so deeply to me that

02:43:01.100 I cannot put out a stinky piece of shit. I've done it and I've regretted it. And sometimes I put

02:43:05.600 up something I think is good in retrospect. I think it's crap. Sometimes I think that's something

02:43:08.180 that's crap and it turns out being great, but ain't the way to die was one of those things. I can't

02:43:11.620 fuck this up. So you do 20, 30 takes and you'll see as they're all sitting there in logic,

02:43:15.420 that's the program we use. And you just take, take, take, take, take, take, take.

02:43:18.540 And what we'll do then is we'll comp sometimes. We'll say, let's take the best of this first verse,

02:43:22.940 best of that. And some people think that's cheating, but that's how most people do it now.

02:43:26.740 I didn't realize that would be thought of as cheating.

02:43:28.580 So some of the purists in the old school musicians say, well, no, you just got to go

02:43:32.440 and sing it live and that's how you do it. But that's not how anybody does it now because

02:43:35.460 you are trying to produce the best piece of art you can. And what's fascinating actually,

02:43:39.880 Peter, is again, I'm not a trained musician. I don't sing, I don't rap. It's something that I

02:43:43.620 had to figure out. I used to be really bad and Devin would tell me, you really suck.

02:43:48.740 Like it takes 30 takes just to get it to sound good. Have you thought about taking voice lessons?

02:43:52.020 And I'm like, don't insult me, dude. What's a, you can't train a voice. That's bullshit. You have

02:43:56.680 to, it's stupid. And then I went and got voice lessons, just a few lessons. And then these CDs

02:44:00.880 that I kept doing. And this is the thing, man, the voice, like anything, is a performance instrument.

02:44:04.940 It's a muscle and the vocal cords get stronger. Your control gets better. Your breath control gets

02:44:09.480 better. So the way you breathe for, for singing is so different than the way you would normally

02:44:13.460 talk or anything. And that helps when you do speaking because you don't get hoarse,

02:44:17.680 you warm up, right? You project better. So I'm a tiny little person who can project his damn voice.

02:44:22.880 Yeah. But you also, as a Zoroastrian, you, you come from the lineage of the greatest singer of all time.

02:44:27.960 We are the champions. Exactly. Freddie Mercury. Oh, God.

02:44:33.580 Oh, and Zubin Mehta, who I was named after as conductor. It's a musical lineage, our people.

02:44:38.960 My people call it maize. Peter Atiyah. Do you remember that commercial? It was an old

02:44:42.420 Mazzola commercial in the 80s. It was, they had a Native American guy in the headdress.

02:44:45.980 Oh, yes.

02:44:46.360 Yeah. And he's sitting in a boat and he's eating corn and he's like, my people call it maize.

02:44:51.020 And it was like, Mazzola, corn goodness. Anyway, so I trained my voice. And so now I have to do

02:44:57.900 less takes and I'm able to go live. So even though we do this art where we're cutting it up in the

02:45:02.600 studio, when I have to perform Ain't the Way to Die live, which I do 50 times a year when I do my

02:45:07.100 live shows.

02:45:07.660 Oh, really?

02:45:08.360 Yeah. So I do that one. I do seven years. There's about 20 songs.

02:45:11.160 Oh, so you're hitting on all the killers. Like seven years is, I think, the most touching of

02:45:14.940 them all.

02:45:15.220 Seven years is my favorite. And Tom was the genius behind how to, Tom and Logan back there,

02:45:20.280 genius of how to cinematographize that and the emotion of it. We're sitting in the edit.

02:45:23.840 Speaking of that, so the edit, there's-

02:45:25.380 Those were your kids.

02:45:26.840 Those are my kids.

02:45:27.480 That's your wife.

02:45:28.200 It's my clinic.

02:45:28.780 It's my family. It's my wife. It's my dad. So it was a personal thing.

02:45:32.120 And we're sitting in the edit on the apex where you're pushing in on my daughter and

02:45:35.480 it's like, soon I'll be 60 years old. And it's all emotional piece. And we didn't feel

02:45:40.400 it. We didn't feel it. We didn't feel it. And then we're like, how about this? Trim

02:45:43.420 that. One microsecond here, all of us are crying.

02:45:46.940 Wow.

02:45:47.200 And we're like, okay, that's it. Hit send. That's the thing. That's the process. And it's

02:45:51.660 the same with the musical piece. So then once you do it, you may craft this thing here,

02:45:56.160 but when you go and do it live, it takes on a whole new persona because you have this input

02:46:00.560 and you're doing it in one take. And that's where I think the real artistry starts to

02:46:04.420 try to have, I'm calling it artistries. I'm a fucking professional clown, but it feels

02:46:07.900 like that on stage because you're seeing the synchronization of the audience with the

02:46:10.680 message. People are crying. You're feeling this energy. And afterwards they'll tell

02:46:14.700 you, this is how you made me feel during that. And I'm a 20 year veteran. I'm a 30 year

02:46:18.900 nurse or I'm a 40 year RT or whatever it is. And that's what really gets you. So all

02:46:24.060 of that is for this. That's the process. Then we'll put it out. Then we'll brainstorm

02:46:26.500 the video. Then we'll go beg our hospital to let us shoot. Extras are all real medical

02:46:31.680 people. Nobody's paid. We'll go and do it. We'll rent the equipment. We'll get the crew

02:46:35.320 and we'll do it.

02:46:36.120 And how long does it take you to shoot, say, those two videos there?

02:46:38.780 It's like a day.

02:46:40.020 Wow.

02:46:40.740 Because we don't have a choice because we're operating in a real hospital with real

02:46:43.820 patients running around. So we have to go to a wing where maybe they're not on overflow

02:46:46.840 right now. So we can do it and they're kind enough to let us do it. And then maybe they'll

02:46:50.040 kick us out because the hip-hop police are-

02:46:50.820 You have extended the invitation to me so many times to be in a video. I got to take you up on

02:46:55.460 one of these. I'll be the guy that just walks by and no one will even see me.

02:46:58.360 We're doing a parody of the Barenaked Ladies one week. I don't know if I sent it to you.

02:47:02.280 You remember that song? It's been one week.

02:47:04.100 No, no, no. Hang on a second. You don't realize this. I went to high school with the Barenaked

02:47:06.740 Ladies.

02:47:07.200 Fuck you.

02:47:07.840 Yeah. Their dad was our guidance counselor. The Cregan brothers, right? Andrew and Jim,

02:47:11.820 their dad was our guidance counselor.

02:47:13.140 Oh my God.

02:47:13.940 Yeah.

02:47:14.340 So I saw them in 1991 in Berkeley in a small little club before they were famous. And I was like,

02:47:17.980 these guys are gods.

02:47:19.280 You know, this is me in grade nine, baby. Yeah. Oh my God.

02:47:22.760 And notice it's grade nine, not ninth grade.

02:47:24.500 No, because it's Canada. It's grade nine. So I always loved the Barenaked Ladies. One week

02:47:29.340 wasn't my favorite song, but I wanted to do a tribute for foreign medical graduates from India

02:47:34.300 and South Asia, like my parents, both of them were doctors. And I'm like, one Sikh, we'll make it about

02:47:40.100 doctors. And so this was one where it just, right, Tom? We were just like, here are the lyrics.

02:47:46.660 It took a second. And it was like, there's this one Sikh in the doctor's lounge, a Punjabi guy whose

02:47:51.840 name no one can pronounce. Four Janes in emergency saying, get that corn dog away from Dr. Mukherjee.

02:47:57.220 And when the rap comes up, it was like, you know, tikka masala, the Desi chicken. You have a drumstick

02:48:02.840 and your heart stops ticking. Watching Bollywood with no lights on. Check out Amir Khan. He does

02:48:07.320 a slow-mo run in this one like Bobby Jindal. I'm trying to act white. Okay, that just ain't right

02:48:11.200 because I always drive Camry. So we're shooting that in Texas next month. So you should come and

02:48:18.460 be in Victoria, Texas, this tiny town on the coast about an hour from Austin. I know you have homies

02:48:25.160 in Austin. We're flying into Austin. We're renting all the equipment. We're going to this cardiology

02:48:29.500 clinic that this Indian doctor couple runs. They heard the song. They're like, we want to be in it,

02:48:33.360 okay? What the fuck? And so we're going to shoot it there. So you should come and be an extra on that.

02:48:37.480 All right. Well, when we're off, Mike, I'll ask you for the details so that we don't

02:48:41.180 let all the fans in the world know where we're going to be.

02:48:43.740 That's a great idea.

02:48:44.900 Yeah, we don't want the anti-vaxxers to show up.

02:48:47.740 Oh, to these poor people's clinic? Oh, that would be terrible. So that's more or less the process.

02:48:53.220 Well, I got to say, I mean, if nothing comes of this discussion other than a set of people who

02:49:00.480 are not familiar with you, i.e. a subset of people who listen to me who don't yet know who you are,

02:49:05.320 figure out who you are, that's worth everything. In fact, I almost feel bad that we took up all

02:49:11.040 this time because what I could have just done is said, today's podcast is going to be really short.

02:49:15.880 It's just going to be me telling you, go check out all of Zubin's stuff. Because that's effectively

02:49:20.460 the most important piece of this to me.

02:49:22.860 Well, that's effectively what I'm going to tell my followers, which is Peter Atiyah is doing

02:49:26.320 brilliant work in the space that nobody else is doing. And the people that are collaborating with

02:49:30.120 him are amazing. And you need to check him out. And also, he's my homie from way back.

02:49:34.040 And we don't give an F about a damn thing. That's one thing that separates us from some

02:49:38.360 other so-called doctors. All right? Am I right?

02:49:41.980 Brother, it has been a lot of fun. This has been long overdue.

02:49:44.860 By about two decades, I think.

02:49:47.720 So it's been a real pleasure, Peter. Thanks so much.

02:49:49.860 Thanks for hosting me. And guys, despite the fact that you didn't bring me a white Russian,

02:49:53.700 I still love you over there.

02:49:54.700 You can find all of this information and more at peteratiyahmd.com forward slash podcast.

02:50:02.240 There you'll find the show notes, readings, and links related to this episode. You can also find

02:50:07.320 my blog at peteratiyahmd.com. Maybe the simplest thing to do is to sign up for my subjectively

02:50:12.580 non-lame once a week email where I'll update you on what I've been up to, the most interesting papers

02:50:17.440 I've read, and all things related to longevity, science, performance, sleep, etc. On social,

02:50:23.360 you can find me on Twitter, Instagram, and Facebook, all with the ID peteratiyahmd. But

02:50:28.340 usually Twitter is the best way to reach me to share your questions and comments.

02:50:31.900 Now for the obligatory disclaimer. This podcast is for general informational purposes only and does

02:50:36.420 not constitute the practice of medicine, nursing, or other professional healthcare services,

02:50:41.280 including the giving of medical advice. And note, no doctor-patient relationship is formed.

02:50:46.060 The use of this information and the materials linked to the podcast is at the user's own risk.

02:50:51.780 The content of this podcast is not intended to be a substitute for professional medical advice,

02:50:56.280 diagnoses, or treatment. Users should not disregard or delay in obtaining medical advice for any medical

02:51:01.700 condition they have and should seek the assistance of their healthcare professionals for any such

02:51:06.260 conditions. Lastly, and perhaps most importantly, I take conflicts of interest very seriously. For all of

02:51:12.280 my disclosures, the companies I invest in and or advise, please visit peteratiyahmd.com forward slash about.

The Peter Attia Drive - January 21, 2019

#37 - Zubin Damania, M.D.： Revolutionizing healthcare one hilariously inspiring video at a time

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