The Peter Attia Drive - January 21, 2019


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


Episode Stats


Length

2 hours and 51 minutes

Words per minute

214.94275

Word count

36,827

Sentence count

2,813

Harmful content

Misogyny

15

sentences flagged

Hate speech

44

sentences flagged


Summary

Summaries generated with gmurro/bart-large-finetuned-filtered-spotify-podcast-summ .

In this episode of The Drive, I talk about why we don t run ads on this podcast, and why instead we rely entirely on listener support to sustain it. This week's guest is Dr. Zadie Demania.

Transcript

Transcript generated with Whisper (turbo).
Misogyny classifications generated with MilaNLProc/bert-base-uncased-ear-misogyny .
Hate speech classifications generated with facebook/roberta-hate-speech-dynabench-r4-target .
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
00:00:51.660 listener support. If you're listening to this, you probably already know, but the two things I care
00:00:56.460 most about professionally are how to live longer and how to live better. I have a complete fascination
00:01:02.780 and obsession with this topic. I practice it professionally, and I've seen firsthand how
00:01:07.480 access to information is basically all people need to make better decisions and improve the quality of
00:01:12.560 their lives. Curating and sharing this knowledge is not easy, and even before starting the podcast,
00:01:18.200 that became clear to me. The sheer volume of material published in this space is overwhelming.
00:01:22.820 I'm fortunate to have a great team that helps me continue learning and sharing this information
00:01:27.880 with you. To take one example, our show notes are in a league of their own. In fact, we now have a
00:01:33.840 full-time person that is dedicated to producing those, and the feedback has mirrored this. So all of this
00:01:39.720 raises a natural question. How will we continue to fund the work necessary to support this? As you probably
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
00:01:52.440 doesn't feel right to me for a few reasons. Now, the first and most important of these is trust. I'm not sure
00:01:58.380 how you could trust me if I'm telling you about something when you know I'm being paid by the company that
00:02:03.740 makes it to tell you about it. Another reason selling ads doesn't feel right to me is because I just know
00:02:10.200 myself, I have a really hard time advocating for something that I'm not absolutely nuts for. So if
00:02:15.660 I don't feel that way about something, I don't know how I can talk about it enthusiastically. So instead
00:02:20.840 of selling ads, I've chosen to do what a handful of others have proved can work over time, and that is
00:02:26.860 to create a subscriber support model for my audience. This keeps my relationship with you both simple
00:02:33.080 and honest. If you value what I'm doing, you can become a member and support us at whatever level
00:02:39.460 works for you. In exchange, you'll get the benefits above and beyond what's available for free.
00:02:44.680 It's that simple. It's my goal to ensure that no matter what level you choose to support us at,
00:02:50.040 you will get back more than you give. So for example, members will receive full access to the
00:02:57.520 exclusive show notes, including other things that we plan to build upon, such as the downloadable
00:03:04.240 transcripts for each episode. These are useful beyond just the podcast, especially given the technical
00:03:09.180 nature of many of our shows. Members also get exclusive access to listen to and participate
00:03:15.940 in the regular ask me anything episodes. That means asking questions directly into the AMA portal
00:03:22.660 and also getting to hear these podcasts when they come out. Lastly, and this is something I'm really
00:03:28.000 excited about. I want my supporters to get the best deals possible on the products that I love.
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
00:03:37.360 with companies who make the products that I already love and would already talk about for free and have
00:03:43.220 them pass savings on to you. Again, the podcast will remain free to all, but my hope is that many of
00:03:51.000 you will find enough value in one, the podcast itself, and two, the additional content exclusive
00:03:57.900 for members to support us at a level that makes sense for you. I want to thank you for taking a moment
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. 0.95
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. 1.00
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 1.00
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. 0.99
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 1.00
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 1.00
00:15:50.200 wasn't really in the mood to deal with these actors and actresses who were annoying as hell to me. 0.99
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. 0.95
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. 0.98
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 1.00
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 0.54
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. 1.00
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, 0.87
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 0.95
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? 1.00
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 1.00
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 0.99
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 0.91
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 1.00
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. 0.97
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 0.94
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, 0.99
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. 1.00
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 1.00
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 0.67
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 0.75
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 0.90
01:11:19.820 and your anus are affected. And when they both go down, what do you have? You know, really? 0.67
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 0.98
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. 0.62
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, 0.83
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. 1.00
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. 1.00
01:30:56.580 Guys, could you... Is there any way you could fire for white Russians right now? 0.99
01:30:59.260 Two white Russians. Throw a black Russian in, too, just for the heck of it. We want to be 0.98
01:31:03.360 equitable.
01:31:03.580 And one Caucasian. 0.85
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... 0.99
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 0.91
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 0.77
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 1.00
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 1.00
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 0.75
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 0.99
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 1.00
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 1.00
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 0.97
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 0.55
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, 0.93
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 1.00
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- 1.00
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 0.85
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 1.00
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. 0.99
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. 1.00
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 0.73
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. 0.99
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 1.00
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,
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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.
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