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Welcome, welcome, welcome to chair. I'm Dr. Shepherd, this is my department. Oh, yeah, they sound like a record going backwards.

[00:00:07]

Yeah, my mom Omdurman well, experts on experts, that's what we got ahead of us today.

[00:00:16]

A really interesting expert on a topic we generally avoid death.

[00:00:21]

Now, Atul Gawande was recommended to us by Julia Louis-Dreyfus. She said she had read a book called Being Mortal Illness, Medicine and What Matters in the End.

[00:00:32]

And she said that was her favorite book on the topic.

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So we got to talk to a tool. And a tool is an American surgeon, writer and public health researcher. He practices general and endocrine surgery at Brigham and Women's Hospital in Boston, Massachusetts.

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He graduated from Stanford, Oxford, Harvard, Rhodes Scholar, MacArthur Fellow, you name it, he's done it. He's got four books, complications, better the checklist, manifesto and Being Mortal. We loved Tool. We did. And we learned a lot from it.

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Yeah, he gives you a great framework for conversations that we all will have at some point have to have. So please enjoy a two go one day.

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Again, the production values.

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So off the charts in these things, I don't know what the budget is, but they look spectacular.

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[00:02:55]

Monacan. I really, really believe in therapy and talking to someone to get you a grasp on what you're going through.

[00:03:02]

It's nice to have a third party weigh in on your issues. Yeah, because sometimes when you're in the center of a man, it's really hard to see what patterns you're forming and almost impossible.

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It's almost impossible.

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He's in our chat. We're intimidated to talk to you, this doesn't happen very often. You just had too much stuff to learn about, to be honest.

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So shame on you.

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Can I ask you really quick, because I don't want to get it wrong. Is it is it a toll or a toll?

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It's a tool like a hammer.

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You can imagine the jokes as a tool. You know, you're someone that has come up on our show several times. Many of our guests are big fans of yours. Enough so that we had to seek you out and beg you to do the show. So we we're very grateful.

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I don't know if it got to you, but, you know, Julia Louis-Dreyfus, who I worshipped, she's like a devotee of a tool.

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So there's a hilarious story behind that because she'd turn up on the show and I heard the podcast and then several of my friends like you got to reach out to her. She said she wanted to meet you.

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I'm like, come on.

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And then one friend, like, I know her agent, I'm going to ping them. Yeah. We talked today.

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Oh, dazing. We had a little Zoome date. Oh, wonderful. And it was amazing. It was amazing.

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We talked about our parents and we talked about a lot of what each other are going through at a similar age with kids who are now in their twenties and out of the house. And so it was great and it was thanks to you. And and she was just totally lovely, as you know. Yes.

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Now your children are grown. But have you guys been quarantining together? That seems to be something that's happening.

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No, I have my eldest at twenty five now is living in Berlin with his girlfriend, which is a thing now for us to also understand.

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And then my middle child is in North Carolina where she's working and my youngest is in Boston and has no interest in quarantining care.

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And now you're an Ohio native. You're a Buckeye. We could say you're from the Midwest. Where are you from?

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Well, I'm from twenty five miles northwest of Detroit, so right where the suburbs turn to corn. OK, yeah. So a big dose of hillbillies and then a big dose of folks who drove in to Detroit to work a melting pot.

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Ohio and Michigan rivals, but very similar culture. I'm from a small town, Athens, Ohio, which is Southeastern College town, but also the poorest county in Ohio. Oh, it is. Yeah. And so it's Appalachian foothills and everything from hunger to poverty as part of the picture there, while also having some of my friends come from all of the kind of fancy colleges you can imagine.

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Did you read hillbilly allergy. I did. You did.

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OK, I had a real argument with hillbilly allergy. Oh my goodness.

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So I had a huge one. And Monica is very disappointed in it. And I would love to hear what yours is. Yeah, I actually I wrote about it as well, which is that the hillbilly allergy look, Chillicothe, Ohio is rival high school to one of mine. It is the area we grew up. And no question, JD Vance, who wrote this memoir of growing up in extremely poor circumstances, unlike me, parents of two doctors with the only Mercedes in town, you know, not the same story.

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Right. But but what I what I never had you never hear about his friends. You never hear about who he dated and what that was like and that richness of the relationships beyond his family. But but for him and and how that changed him and affected him. And, you know, so when I went back, part of the premise of his or the conclusion of hillbilly elegy is it's a cultural failure. These are people who are stuck in their ways and are deteriorating the breakdown of the family.

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And they just got to pull themselves out of it. And, you know, the military and and family values was what pulled him out. And this is what we need. And without ever getting into the ways in which in my county, you start with thirty percent either uninsured or with inadequate health coverage. The larger picture that bothered me was that mix of I had friends who were unemployed for two and a half years and went through a lot and finally got a job at the waterworks working the midnight shift after all of that time and the ways in which you can get broken by the system and never have your shot.

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And I grew up getting to see I was going to get my shot. And yes, I had an amazing family upbringing as well that kept me on a good course. But it was also I was set up for success. And and, yeah, I see from the beginning that some of my best friends were not OK.

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So what's so interesting is I don't think I was pinpointing what my issue was. To your point, I have a couple of friends that. There's no pull yourself up by your bootstraps, that's an insane proposition. Mom was dealing with a stepdad who is regularly tearing the house down in such a fashion that there's no way you could have prioritized school work or learned anything.

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No one had their own bed to sleep in. This notion of. Yeah, just kind of overcome that, I guess. Didn't ring true. True to to me.

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And what I saw at the core of this in my high school, about half went to college and half didn't. And if you don't go to college, there is no middle class opportunity that's out there. And in the United States, 70 percent of people don't go to college and we don't have a solution for them. We don't have we have a future. We're offering to them then to say, well, why can't people get their act together?

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And yeah, because the military and because of his family, he became one of the first you know, he got to go to Yale and he got to get all these opportunities and move on and. Absolutely. But that's not the pathway that can save everybody beyond single digit percentage.

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People who sure get a trade job and then build their own company and become the one HVAC family who's rich as hell, even though they were from the dirt roads.

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Yeah, it's just not a high percentage endeavor.

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And then on the personal level, my upbringing was it was a lot around the fact that as an immigrant family, not feeling like you could fit in and having great friends, but at the same time, like, yeah, I spent my teenage life wishing for a date and not getting one.

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Right, right, right. Or I have to imagine living in some fear of physical violence because you're other and it's a town that's not afraid of a fistfight, right?

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Oh, I mean, everybody had a fear of physical violence in that town. Right. Right, right.

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And fights constantly out on the smoking patio. We were in the days where you had a smoking patio outside the cafeteria. Did you have a smoking patio at your high school growing up? Yes.

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So it was basically so I think I'm about to be young and well, I'm ten years younger than you, but my best friend, he got sent to an alternative high school where they just were like, you know what, half the reason they're leaving is because they need to go smoke. So we're just going to let them smoke in school.

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So we were in the transition phase where, like, the more progressive angle is like, well, let's just let them smoke and hopefully they'll stick around. So that was happening.

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And I think sometimes in the classroom they were guns and there were knives and they were a lot of fights. And and back then people drank a lot compared to I mean, kids today are so much better. Oh, my God, they're such better people than we were. Yeah.

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I mean, they're not having sex as much, which concerns me. But, you know, maybe that's part of being better and not looking for, say, ah, you're exactly right.

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Most people don't they don't really realize that. Right. And that actually their interpersonal connections and the weakness of some of those is a thing to fear in some ways. I'm with you on that.

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Now, one of my favorite things to do is to know very little about a person and then make a very sweeping psychological generalization, generalization.

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So so what I want that what I'm really tempted, which seems like low hanging fruit, is if I look at your career, you're an iconoclast.

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I have to imagine you're a little bit high on the disagree ability of psychological profile, which, again, yes, we're high on and we value it. So just know that this is a compliment ultimately. Yeah.

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This is where my wife would burst out laughing. My problem is that I want everybody to like me.

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Her argument is I'm not tough enough and not a jerk enough. I'm pretty low on the disagree ability index barrier I generally work on.

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OK, but could you be both a juicy, co-dependent and highly disagreeable and that really just that's the war that happens.

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It could be. I went into surgery as much because I loved how tough people were in surgery. The situation of surgery is in circumstances where people need to go to surgery. Often you don't have all the data. The studies aren't great. You don't have all the information even in that moment in front of you. And your skills are imperfect. You have complications and things can go very wrong. And yet going in there and being confident and taking your chances and living with the consequences is part of it and then being prepared and owning responsibility.

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It is a very heavy high on the responsibility culture kind of place and on owning failure and going to that next step. And I got in the operating room and you'd have these people who could dare to open up people's bodies and and know they were imperfect and know that things could go wrong, have the confidence and they could be jerks sometimes. Right. Sometimes in ways that I've actually ended up fighting against in my career in surgery, which is I don't think we need to destroy the people in the room and rip them apart.

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It actually makes for. Terrible results in surgery, so I can be an iconoclast in the sense that I want to push back and fix what's not working, but I wish I were tough enough to let people who disagree with me or angry with me not get to me. So as a result, I'm trying to win everybody in the room. And that's not always feasible at the time.

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Well, minimally, it's antithetical to a surgeon. So we've interviewed a handful of surgeons and I got to say we feel very confident in stereotyping after those interviews.

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And again, it's something I've kind of defended, which is I want a high level of arrogance. I actually want someone to be overly confident and self-assured, because what I don't want is doubt when things go haywire as they do. Right. You want someone with a real steady belief in their abilities, for better or worse, I'd argue now you're already you're breaking that mold and then I can already tell you're more empathetic and less narcissistic than what we like to see in our surgeons.

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But how dare you?

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Where I come up with this iconoclast label I want to give you is you you did not just inherit your system, right?

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You did not just get out of medical school. And I don't know what it's a product of. It could have been that you went a little later, right. You had some gap time where you got involved in the rest of the world and that that could be what it is. Or I was going to push this narrative that may be growing up in Ohio is, I have to imagine, one of very few brown people. I think that's good.

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Fertile ground for. Wow, should I accept the system I'm inheriting and do I want to perpetuate it or do I have questions for the overall system?

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We can try to unpack that because I don't have a good article is for you to leave here with with a mental diagnosis for two man professionals.

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I get very disturbed by things that don't feel right and that are especially confusing to me. For example, in surgery, I became a person who really pushed back on the culture of arrogance and intimidating people. There is a difference between arrogance and self-confidence.

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Oh, please tell me so I can stay on the right side of it.

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You do have to make choices and you got to forge ahead. But the ones who don't have humility that things can go wrong. Are the ones who then can't own it when things go wrong and learn from them, right. And so it's not the confidence that you are perfect, which is a dangerous confidence. It's the confidence that you can handle it and that you're aiming for perfection. But, you know, you'll never completely achieve it. Right. The best surgeons I know are ones that are able to have good judgment, make quick decisions in the face of uncertainty and are generally right and own it when they're wrong.

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Some of the best politicians, I feel like, are those kinds of people that, yes, they are able to recognize. Things are uncertain. You have to make a choice and then you've got to own it and live with it. Well, what's the saying?

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Right. They say, like, you make the best choice with the best information available and sometimes that's insufficient.

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You don't want someone dithering. Obama the night that he sent the special forces out to kill Osama bin Laden and his entire presidency is on the line. He happened to be at the White House Correspondents Dinner that night, yes, giving jokes, being as funny as any of the comedians roasting Donald Trump. But at that very night, regretable.

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Probably, right. Which, of course, pissed him off. But being able to make the call, it wasn't arrogance. It was confidence. It was like, I've done the best I can and then I'm going to own and live with the consequences. And I'm going to hope everybody comes with me when I then say, well, this is my choice I made. And here's here's how we deal with this consequence and where we are. Right. I have to walk out in surgery.

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Look, I've got it down to like ninety seven percent of the time it's going to go as I hope the three percent I'm going to have made worse off.

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By the way, that seems like one of the highest percentages in surgery, right? I mean, in general, there's a sliding scale right. Back operations. I don't know. They're like 50 percent effective or.

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Yes, that's right. You can have their operations like colon surgery where. Twenty five percent will have some kind of a complication that you have to deal with. And then there's you know, some of them are errors, some of them are not.

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But I have to be able to walk in when there is something that goes wrong and not say like, well, nothing went wrong. Look, this is what happened. This is our situation. Now, here's what we can do and this is how we can manage the situation. Nothing is ever going to always go work perfectly. Yeah. And so and so you have to be able to bring people along for the ride. And that's what I felt like.

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I got out of surgery, which was I was not that guy. My favorite New Yorker cartoon, which I felt like defined me, was the gravestone that said he kept his options open.

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And that was me. That is Kathleen, my wife. When we go out to pick a place to eat, she can't stand the process because it's like I can't there's so many options.

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And surgery pushed me to be more decisive and to push back where things don't seem right.

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You would have thrived in communist Russia, where they really limited your options. There was no option but to goes like you want a dairy product.

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Here it is now in your book, The Checklist Manifesto, you start coopting or looking at other areas where organizations have been successful in creating systems that mitigate accidents and disaster.

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And I guess there's an openness there to even do that. Again, I think it's a. arrogant to say, oh, some other disciplines have faced similar challenges and with varying success, and I'm open to learning about that. What was the catalyst for you to explore that?

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The core of this started with recognizing when I wrote my first book, Complications, that was about needing to navigate the learning curve, like how do I have the right to learn to operate on people doing all these things for the first time? How do I even ask permission from you? And half the time we're not really like you're in a teaching hospital, you know, ignore this person who's standing by the table here.

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They're just here to help out. Yeah.

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And then you get comfortable like you climb the learning curve and you start getting better and better. Then you realize we still suck.

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Ninety seven percent of time. It goes well, three percent of the time it doesn't. And most of the time when it goes wrong, it's because of something we already knew how to do. It's not because we were ignorant about how to fix the problem. The majority of the time it's a failure and the approach to failure. I've been obsessed with failure my entire career and part of what I love about surgery is how how high the stakes are and the way we approach it as well.

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We're going to teach you you're going to go through school forever. You're going to do four years in medical school and then eight years of surgical training, which is what I did. And then you're going to be perfect. And the reality of that and I'm on the research, I have done a bunch of research on this. I mean, we have over one hundred and fifty thousand people per year who die or permanently disabled because of complications from surgery. I mean, it's five times the number of people die in car accidents in the US, just in the US.

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Oh, my. Hundred and fifty thousand. Yeah.

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I mean, we do we do over fifteen million operations a year, right. Oh my gosh. So what does that one percent.

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Yeah. It's about, it's about one percent. OK, have a major complication from inpatient hospital surgery. Right. Big big major operations. And found that about more than half the time was avoidable with information we know. And those are all the people who went through all of that training and got that training. So then so then our usual reaction is, OK, well then let's issue guidelines and rules. Here are the rules you have to follow.

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You have to do it better in the following ways. You know, it's just the natural knee jerk human thing. Once we discover that we doctors aren't washing their hands enough and they're. Or we're getting all these infections in hospitals or people aren't wearing their masks or whatever you name it, like we need some rules. And so then you get malpractice litigation and you get insurance requirements and all those things and they kind of work, but they don't make you great.

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Can I can I ask something about that? Does it in some ways in the in the ethical brain? Does it offload responsibility? So there is such you know, people know we're a very litigious country and so much of our medical experience is driven by trying to head off potential litigation.

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So does it does that offload your own personal responsibility in some way as a physician where you're like, well, clearly this think tank that's trying to prevent losses will come up with the plan. And I should really just focus on this.

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Does that make any sense, like, oh, there's this huge organism that's supposed to prevent me from making liable mistakes so they'll probably think of it?

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I don't I don't think so in the sense that I think day to day you feel responsible for the person in front of you. But there is this lingering thing in the back of your head like, well, I certainly know moments when I'm aware that, boy, I could get sued for this. And and the worst of medicine is when we then decide to change the way we practice because of it.

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Right. Defensive medicine definitely can occur where you're getting the CT scan, even though you think it needs to be done because you're worried you'll get sued when you start playing that game. It does no good. I think the larger picture, though, is that the malpractice litigation, the whole idea that you can whether it's punish people or reward people to do the right thing, ignores the fact that when things go badly wrong, it's usually because you've been set up for failure.

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It's because the system never worked right in the first place.

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And so the whole idea behind an entire book on a checklist is the idea that places that work the best are the ones that get beyond fighting over whether there's malpractice lawsuits or not, and start saying, what can we learn from all the things that went wrong and then make into a system makes it easy to do the right thing. Right.

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We make it really hard to get the right thing done because we're never fixing the system around us.

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In your novel, in that you're saying, let's look at the system. Right. This is such a kind of individually celebrated, individually punished pursuit, like all the glory, as you say, goes to the surgeon and or all of the fallout. But let's look at that. They are a part of a system and that the system needs an intentional design and turning it into a tractable thing.

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Right. The minute someone says, man, we should do something about the system, it feels like I just gave up. Totally. Totally. Yeah, right. And so here what it was was saying, look, the oldest system that people have is a checklist for both makes up for the fact that I can't remember everything. Right. You get an airplane to go through the checklist. But then also it's a team construct. We're all communicating together about what we're going to do and how we're going to deal with it.

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So the book is the story of deciding to bring that into my own operating room and then making it into a kind of global standard. And the checklist that we designed was simply to say, when we come in the operating room, we're all going to make sure everybody in the room knows each other, make sure everybody understands what are the goals, what are we actually here to do today? What are the worries that anybody has about this person? What are the medical issues of the patient?

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It's like a one minute huddle, like set and then go. And then there are about six or seven things that are easily forgotten, like, are we giving an antibiotic or not? And are you getting it in on time or is blood available? Are you operating on the right side of the patient?

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That seems to be the one I've noticed most in previous surgeries is like you get asked nine times, like your right hand, right? Yep.

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Yep, that's right. But the powerful one actually turns out to be just people talking the checklist saying, including the medical student who's in the room, what's your name? What's your role here? Yeah. And then everybody owning what are we attempting to accomplish? And we rolled that out, rolled it out in eight cities to minute checklists and cut the death rate by forty seven percent. Wow.

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Monica forty seven percent. Oh my God. That's huge. Right.

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I'm just talking for two minutes and getting people on the same page and saying, look, this operation can go wrong in a million ways. How do we get prepared by saying what could go wrong? What's anything people here can think of that could go wrong? And how are we prepared for even the unexpected by knowing who we are, what's available and being set, and then at the end of the case, going back around and saying, OK, anything that should be the plan for the next twenty four hours for this person.

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And it sounds so kindergarten, but we were not doing that. It was just assuming everybody knew what they were doing and it and it dramatically cut the death rate. And so at this point now this is. This is tenth anniversary, actually, of the safe surgery checklist, it's now global standard was implemented. Seventy five percent of the operating rooms are implemented.

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And I've got a non-profit organization we've stood up called Lightbox for getting it implemented in the low income world because ironically, it's still got a long way to go in the low income parts of the world.

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Well, I wish that were ironic. It seems pretty predictable, I would imagine. And I'm sure you drill down into all this, but I would imagine there's kind of unforseen benefits of this one just being what you've also done in that moment has created a culture in this this room whereby I've invited you to talk. I didn't invite you in a you know, you can speak when I ask you a question. I've empowered you to bring up what you're seeing, which in essence, is what the co-pilot in a cockpit does.

[00:28:11]

Right. I was hoping you got this idea from that Malcolm Gladwell chapter about Cranbury, because we listen to this, one of the best podcasts of all time called Dr. Death. Did you hear that of the spinal cord surgeon now?

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Oh, you must listen to it.

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To your point about learning on a series. It's a series.

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It's absolutely the most horrific thing you could ever hear. And it sounds wonderful and underprepared. Surgeon was basically released from residency, having only done make one hundred and thirty surgeries.

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And they expect that number to be three thousand and then, you know, lies his way through all these different situations and just injures untold people. And again, largely into this, there are many of the surgical nurses that were saying, I could see he was doing it wrong, I could see what should have been done and did not feel empowered to raise a flag.

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So that is the critical lifesaving thing that we hijacked, basically smuggled into operating rooms, because one of the best ways we could tell that people were using the checklist, we discovered because we'd have observers and operating rooms alike in many ways to try to figure out whether it's working or not. And the places where it was working, we found the best way. Was that if only one voice was talking at the beginning of an operation, then they weren't implementing the checklist, but if it turned out that people were speaking fairly equally, you heard the surgeon, you heard the anesthesiologist, you heard the nurse, then the culture was one where they really were a team and they were working together.

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The culture of surgery traditionally has been one where that the biggest value was autonomy, the autonomy of the surgeon. What the surgeon says is what goes you you call it the operating theatre, even in many places. Right. It was the place where the surgeon came to perform. And the culture that this was trying to create was saying it's a place where there is humility to recognize anything could go wrong, where there is discipline in a belief that doing certain things the same way every time had real value.

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And there's teamwork where the voice of anybody in the room, it doesn't matter who they are, doesn't matter how much more experience or less experience they have, everybody's voice can matter. That's what saves lives. Yeah.

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And I love that Malcolm Gladwell chapter. Oh, Malcolm was the one who convinced me to write for The New Yorker. Oh no shit.

[00:30:39]

In nineteen ninety eight. You've known him for that long. I've known him well before that, before he started The Washington Post and before I ever wrote anything. He and another friend named Jacob Weisberg who started Slate convinced me to start writing. And then Malcolm sent me a note saying, Hey, my editor has been following your writing on Slate magazine and if you send him a letter, I'll bet he might like your ideas. So I sent them. It was totally like Connexions, right?

[00:31:04]

Oh, wow. He has always been incredibly generous about he's one of a small group of people where I will share my rough draft of each book and let them rip it apart.

[00:31:16]

Incredibly, incredibly valuable, I bet.

[00:31:18]

Yeah, we're just we're in love. We're we're a little too in love with me. Our objectivity.

[00:31:24]

I've heard your podcast with him. Oh yeah, yeah, yeah. I, I have.

[00:31:27]

About objectivity out the window. Whatever he says, I'm like, yeah, that's my new religion.

[00:31:35]

Stay tuned for more armchair expert, if you dare.

[00:31:40]

We are supported by sleep number as more places reopen and we safely enjoy summer quality, sleep is more important than ever. Not only is it a natural immunity booster, it also helps with energy and recovery. My back was sore, so what I had done is drop my sleep number down to 75. Oh, you did? Yes, but things got all better. OK, and now I've got my sleep number currently. Now is back to 85. And how are you feeling?

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Really good.

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[00:34:14]

Now, another topic that we have talked a ton about on here with a bunch of different great physicians and policy makers, is this insanely difficult conversation that happens towards the end of life. And I'm pretty critical of it. I've now done it twice. I did it with my father and my stepfather. And I learned a bunch on the go around with my father that I applied to my stepfather and it was really great. I think one of the big issues is recognizing right out of the gates, oh, this is their cancer.

[00:34:46]

This is not my cancer. The big decisions I would make, but they're not mine to make, even though it feels like I should have a big seat at the table, especially when I was the person with my father making all the decisions. But but I really did learn we had one fight over him eating a hamburger that I so regrettable. Right. Like the guy should have eaten twenty six hot fudge sundaes.

[00:35:07]

We were at that point, but I was just locked into this. No, this is almost shaming him. Probably this is why you're in this situation. Here you go again.

[00:35:16]

And I just really regretted that, like, you know, that we were down to hours and I spent one or two of the hours berating him about a hamburger. And and then I was in a weird position where I work with the Prostate Cancer Foundation. And so I had access to the clinical trials that could have potentially been medical things for my stepfather. And I got them in and he said, ultimately, I don't want to do this. And I said, go.

[00:35:38]

I had no pushback. And I try to pass that on to people who are going through this. And I know you experienced that yourself.

[00:35:45]

You said, you know, there's the conversation as people face and you had it with the stepfather and the father. What was your goal that what were you hoping to get out of the conversation? What was the purpose in your mind?

[00:35:56]

Well, I can tell you and this this has been unpopular, but it's very it's just dead honest, which is from the second he called me, I thought, OK, I've been asked to come in and co-pilot this thing. I have the singular goal of getting him across the finish line with his little of the gnarly parts as possible. So I probably was already waited to comfort over success. And part of it was my own life and having a job and having to fly back to Detroit.

[00:36:25]

I selfishly was motivated by I want to get this done peacefully and I'm not looking for a stretched out two year version where he's miserable.

[00:36:36]

So I already, you know, for numerous reasons that's where I was at, which makes a ton of sense. Right. Here's what I think the goal is. The goal is what is your father, my patient, my mother's, what are their priorities?

[00:36:54]

And I can't believe I had to write a whole book to figure this out because I wasn't I was never asking patients that question. Right. I mean, I interviewed over two hundred patients and scores of clinicians about how do you have this conversation? What I realized was the ones who are really successful, I just had a different goal. They realized people have priorities in the life besides just living longer. Yeah, those priorities are different from person to person and also different for you as you change and go through what you're going to go through.

[00:37:26]

And your only way to learn people's priorities is to ask them, yeah, what are your priorities besides just living longer? I don't think there's a contradiction. As it turns out, there's not between your goals for your length of life and your goals for your quality of life, because getting clear about the priorities you want to serve around your quality of life ironically helps people live at least as long, if not longer, as well as better. And when you don't ask people what their priorities are, no surprise the result is suffering.

[00:38:00]

Right.

[00:38:01]

You know, like I interviewed a woman with severe Alzheimer's disease who reached the stage where, you know, she could have difficulty swallowing and she had a medically ordered liquid only diet and she'd be caught by the nurses stealing cookies from her neighbors and hoarding.

[00:38:23]

And they go by and so they they take them away. And she got written up. I can contact the family like, you know, this is dangerous.

[00:38:34]

And you just want to say, let her eat the damn cookies. Right? Right.

[00:38:36]

She is telling you what her priorities are. And this one source of joy. And you can talk to the family who the proxy and say, like, you know. I think I think she's telling us what her priorities are. What do you know about her? What do you understand about her? Have you had this conversation? Would she want this taken away for the small risk and the real risk that she could choke on the cookie? Uh huh.

[00:39:01]

So in the same way is you're having a conversation with your dad. Maybe it was that was willing to not be comfortable. He was willing maybe to say, you know what, I want to get every shot I can add more time even at the cost of pain. Or he might say, you know what, I'm now in pain. My priorities have just changed. Yeah, yeah, yeah. And some of the questions that you end up asking that I found really powerful are what are your fears for the future?

[00:39:30]

What are your hopes if your health worsens, but then also like what's the minimum quality of life you'd find acceptable? It's become my favorite thing to just talk about, like for you guys. What would the minimum quality of life be acceptable for me? As long as my brain is working and I can talk with you, I can communicate with you and share memories and and have those stories. I could be quadriplegic. I could be paralyzed. But but if my brain is not working, let me go.

[00:39:57]

Yeah. My wife, her view is. I'm God's creature, if I I'm experiencing joy, I don't care if my brain works, oh, if I'm experiencing joy, keep me going. And if I'm not experiencing joy, if I cannot experience Joy, let me go.

[00:40:13]

That's a. Pretty sizable burden to put on you to evaluate someone's happiness, especially if they've lost kind of cognitive ability to check in with you. I mean, you're putting a lot of weight on a smile. Let's hope that's not gas.

[00:40:27]

Yeah, but I do feel like I actually feel like it took a lot of burden away. But I'm curious for you. So what's the minimum quality?

[00:40:33]

Well, let me let Monica go first, because I'm.

[00:40:35]

Oh, yeah, it's hard because I definitely my grandfather's so old right now and he barely remembers my mom or, you know, he'll sometimes remember her, sometimes not. He's just sitting and he was a professor of biology and he was always talking about it was that he's the smartest person I've ever known. Well second. Yeah, well, first.

[00:40:56]

And to see him, they're unable to contribute to a conversation.

[00:41:04]

I talked to one professor who said, if I can eat chocolate ice cream and watch football on television, that would be good enough for me. And his family was blown away. They're like, we don't even know you watched football yet.

[00:41:15]

You cared about it. Yeah, like like how can that be possible? We got to order a television package with football jerseys. But you're loving it. We don't have it.

[00:41:24]

But so that might be true for him. But how about for you?

[00:41:27]

Well, that's what's going to say is this is where it gets really, really tricky because you're projecting so much our own.

[00:41:32]

But that's what I'm saying when I see it. I think I don't want that. I don't want to be sitting in a room with my family and not be able to contribute or not be sitting.

[00:41:44]

And I love cookies and cookies the whole time. But would I be able to taste them? Yeah, yeah, yeah. You can do.

[00:41:50]

OK, well so so eating food, that might be really important to you. My dad came towards the end, radiation took away his taste and that really took away one of his joys. Yeah.

[00:42:02]

Can I tell you that to me, as I was evaluating, I took him out to this restaurant with great, great effort to get him in a wheelchair, the whole nine and get a pass out of the hospital. Got him his favorite goldbrick sun. And he just stared at it smiling. And I was like, OK, well, I know my dad was a real, you know, a canary in the coal mine moment where I'm like, we've transitioned into another phase.

[00:42:25]

What do you think? I'm with you a tool I want to be able to talk if I can talk with my kids and look at them, I feel like I would be good. But but I will say now, having. And you've gone through this many more times. People's own priorities evolve throughout the process. So my stepfather, who was an electrical engineer, very, very bright, did not want to get to a point where he mentally wasn't as sharp and that was a big moment for him.

[00:42:54]

He wouldn't want to be around for that. And also had a plan they lived in Oregon to do euthanised, assisted, which would have been great, full intention to do it. And then all of a sudden, as we got to this point where he would have had to gone to the place to prove competency, we passed that window when we were left. Then when he did say, I'm ready with a new problem on our hands. So I was like, well, best laid plans.

[00:43:17]

I know he didn't want to end up in this situation.

[00:43:19]

I didn't think we'd be in this situation. But here we are.

[00:43:22]

Yeah, so they evolve. Right. And as the co-pilot, you're like, OK, this wasn't the game plan, but I got to stay flexible.

[00:43:31]

But what you think right now is this. This is this is Joy. This is your purpose and what makes life worth living. Mm hmm.

[00:43:40]

And I'll just say that there's this cultural expectation that you are weak or cowardly if you don't want to fight cancer. And that came to really piss me off. It's antithetical to something in AA that has been the greatest gift I've been given in AA, which is like acceptance is the answer to all my problems. And in general, I find that to be largely true. Once you've figured out what what options you can exploit and when when they're done or the ones you want to exploit, I feel like there shouldn't be shame.

[00:44:09]

And in surrendering.

[00:44:11]

Well, there's a lot of discussion in the college world and most of my surgical practices in cancer surgery that we just want to get rid of this whole fight metaphor thing. I hate it whether it's fighting or surrender. It is a journey with this cancer. We have a lot we can do. But ultimately, if we're doing our job right, it's around. What are your goals? What are you willing to give up for the sake of more time?

[00:44:38]

Yeah, and what are you not willing to give up? The other way you can describe it is, OK, let's fight. What are we fighting for?

[00:44:46]

Are we fighting for your ability to be at home every day and go for a walk and see your friends? Or are we fighting to make the disease shrink on this scan?

[00:44:56]

Have you had to give your patients permission like you're not a coward, you're not weak if you don't want to spend the last three months of your life. With intervenors, harsh chemicals for your body, what what I used to do was get in arguments like that with people and I've never felt very successful, like you don't have to do this. And then they'd get the natural reaction to that as well. You know, what are you trying to kill me?

[00:45:25]

Like, what are you telling me something instead? It's sort of like, well, you let me know before was you really did not want to be in a situation where you couldn't live at home anymore.

[00:45:37]

And if we do this, you're not going to be live at home anymore. So has that changed you?

[00:45:42]

And then it's not about are you being tough? Are you not being tough? It's what you just what matters to you. And it isn't about who you are.

[00:45:50]

It's what kind of image you have of yourself. It's just about what do you want. This is tough.

[00:45:55]

Can I be critical of one component of it that I know you can't do? Wasn't that perfectly reasonable? Come on. No one systemic issue that I again, having gone through it twice, that seems like it puts people in in a very challenging situation, is declaring hospice. So if you haven't gone through this at home, first of all, we'll all go through this.

[00:46:16]

This is another frustration of mine is like the notion that you can avoid having this conversation, know this is the singular conversation you are guaranteed to have in your life.

[00:46:26]

You know, if you're lucky in your life, you don't get hit by a train or something.

[00:46:29]

Yeah, but but the declaration of hospice, as I understand it, and maybe I have it wrong, but basically the doctors are always waiting for you to declare hospice and that that's now will move you to your house.

[00:46:41]

We're going to we're going to now have the new goal of making everything comfortable as possible.

[00:46:47]

And we are no longer fighting. Now, what's tricky about that is there's so you're basically signing off your right for any medical treatment. Right, in this can get tricky because there are things like this happened to my stepdad, which is we had declared hospice. My my mom here is from the bedroom on, you're going to want to see this. She comes into the bedroom.

[00:47:10]

His testicles, which had become the size of cantaloupe, had split and one of the veins had severed. And it's literally spraying blood on the ceiling of the room. But we're in hospice.

[00:47:22]

So what do you do? Like, do you let them bleed out of this? You know, as it turned out, they made an exception and they they so that part of it back up. But there was one of these tricky situations where it's like you kind of want to reserve the right to get your husband's ball sack, which is spurting blood under the ceiling addressed. But you're not asking to go through chemo again. And there seems to be a little appetite for some hybrid of the situation.

[00:47:48]

What are your thoughts on that?

[00:47:50]

You've put your finger on something. I've actually been very critical of the idea that it's either or, you know, how this is not a fight for your quality of life versus quantity of life and you've got to pick. So, for example, the state of Massachusetts, all of the insurers now allow you to go into hospice without giving up your doctors and without giving up your medical care. And you can do it at 12 months before the end of life.

[00:48:14]

The goal is that you have options for people because it leads to people not going into hospice in the first place. And invariably what happens when you do go into hospice is then you end up saying, you know what, I'm so glad to be able to be kept comfortable at home. I can see I'm not getting any benefit from the chemotherapy, but I'm just getting sicker because of everything. And I'm feeling better and low and behold a lot of the time.

[00:48:38]

When you are not taking that chemotherapy in the last couple of months of life, you're you're actually living longer and doing better so that in the in private insurance right now, a lot of different companies have made the shift. We haven't persuaded Medicare yet, which is, of course, the most important insurer to make the shift. But it doesn't save money. It doesn't improve the outcome.

[00:49:04]

I got to imagine there's some counterintuitive outcomes which are like, for our example, we would have probably declared it sooner. He would he was happier at home. He wanted less services.

[00:49:16]

It actually saves money because people then having gotten the option that get good care for their pain and their needs at home, which weren't being addressed at the hospital, end up appropriately deciding to stop chemo and on average, living depending on whether it's lung cancer, pancreatic cancer, whatever, anywhere from six to 12 weeks longer on average with lower costs. So it's win win all the way around. But it comes from being able to say we're going to have a conversation about your goals.

[00:49:49]

Yeah. What's important here?

[00:49:51]

My other issue with it, and this sounds anything but emotional or compassionate, which is I have another issue just subjectively, with spending maybe 60 percent of someone's lifetime medical expenses in the last three months, it just doesn't seem like a super sustainable approach when we're already having other issues. And this person said, well, we tried to address that with Obamacare and then the right labeled it as death panels.

[00:50:20]

And all the death panel was was us way before you're in the situation saying, hey, let's commit some time to thinking about this inevitable scenario you'll find yourself in and let's make some decisions with your current self that's not going through the biggest crisis of your life.

[00:50:38]

You're absolutely right. There's two things I've sort of come away want to say about that. No. One is. It's true. We spend a disproportionate amount of our medical spending on the last three months of life. And it would be perfect if you knew when the last three months of life were, because then we could you know, we could change that. I've done some work showing that about nine percent of the population will have surgery on their very last few days of life.

[00:51:03]

And wow, you know that undergoing surgery, you don't have time to recover from it.

[00:51:10]

You're getting all the pain, all of the invasion and none of the benefit. But but we don't know when that moment is.

[00:51:16]

And so that's why that other part, which is that conversation ahead of time about what you're willing to go through and what you're not willing to go for the through for the sake of more time. The main value it seems to show is that having that conversation earlier means that you're making subsequent decisions sooner because you started to think about it. Right. And you've started to ask, where is my line in the sand? And you've gotten to experiment with that a fair amount.

[00:51:42]

We did a study at the Dana Farber Cancer Institute where we randomized training half of the clinicians in having these conversations. They would have these conversations on average at five months before the end of life rather than five weeks, because it's just a conversation you have with anybody. The trigger was would you be surprised if this person died in? Next year. And if you would not be surprised, that group absolutely had to have this conversation. And about half of them died and half of them didn't die.

[00:52:12]

But, you know, clearly this is the conversation you'd have if you wouldn't be surprised. And then that group had the conversation five months earlier and they ended up with having half the level of depression, half the level of anxiety, same survival rate. Wow. Another study along the way has shown that people typically, because they've done this thinking, will on their own stop their chemotherapy. And again, no reduction in survival in lung cancer was a twenty five percent increase in survival.

[00:52:41]

So the last thing I'll say is we're past the death panel, and that is the best news we've got, which is this is bipartisan support for this. Now, Republicans are not labeling this death panels. I feel like we have another leap to make. We finally made it. So having these conversations are like mom and apple pie. It's all great, right?

[00:53:02]

It actually needs to be a scandal that we don't have these conversations and you come to the end of your life. Right. It is such a worse experience. Three quarters of people who are seriously ill never have this conversation with either family or their clinicians. And everybody is uncomfortable. But I think when you understand, it's not about like, are you going to give it up at the end? Like, you need to surrender at the end. Now, this is about like, what are we here for?

[00:53:27]

What are we fighting for? What do you need me to do for you? Yeah. And what do you need me to not do for you? Where is your line in the sand?

[00:53:34]

Is it challenging knowing that you must deal with the full spectrum? Right. So we watch your Frontline episode that was about your book. And what I was immediately just confronted with is like it's not unlike the job I think we asked police to do, which is not to say I'm not very critical of the police and the systemic issues, but also, OK, where these people have to deal with every problem we've kicked down the road virtually. Right. They're dealing with real time.

[00:54:05]

And I would just say to expect you all to to learn everything you need to learn in medical school and in your surgical residency and to be at the forefront of all of that and then be some master communicator that can navigate how to help people, how to not trigger people, how to not talk down to people that could be its own specialty.

[00:54:31]

The interactions that you have with your patients on the hardest topic under the sun, you know, it's it's a lot to ask you all to to do that. I think actually that's totally misplaced.

[00:54:43]

It is part of the job that I should understand. What am I doing this operation? And it doesn't have to be the end of life.

[00:54:50]

My mother underwent a knee replacement and I never asked her, like, what are you hoping to get out of the knee replacement? She was an avid tennis player. I was thinking maybe she wants to play tennis again. She was at the point where she needed a wheelchair in the airport. She only did enough rehab that the pain went away and then would still take the frickin wheelchair at the airport, just like I like getting the right area.

[00:55:12]

And the orthopedic surgeon would want her to get let's get more physical therapy. But she wasn't really with the program. And the reason was her goal was I just want to get rid of the pain.

[00:55:21]

Right. Whereas another person, they want to run a marathon and I should be able to be good at finding out, you know, lawyers are good at this. Right. What is your goal? And then how how do I help you achieve that goal?

[00:55:34]

And we get to bring this huge armamentarium and 20 percent of the American economy to you and let's deploy that in ways that actually serve some meaningful function rather than, you know, with back surgery, where you have the majority of people undergoing it who still have just as much pain and just as limited ability to walk and no reduction in disability rates, like what are we accomplishing here when when we're doing that? So I think this is not too much to ask.

[00:56:05]

It's a basic skill.

[00:56:06]

And if you can't learn to have these basic conversations, I think it goes all the way back to how we pick people for medical school, that the skills are not just about the the technical stuff. The big skill is helping people achieve their goals and why we think organic chemistry in your freshman year in college is the right. Why is that our weed out mechanism?

[00:56:31]

Yeah, it seems like a very we just we just picked the wrong people.

[00:56:35]

Yes. That's our screen for whether you should be an empathetic, young, successful human being and navigating complex problems with people.

[00:56:45]

Oh, I couldn't agree more. Now, I think the patient largely gets off of all the blame. So I'm infected with a self-help program that doesn't tolerate a lot of horseshit. So when I imagine myself being you, I think it would be so hard because I only have had the experience where someone comes in, we go, look, there's these 12 steps. If you work them, this percentage gets it. Well, I don't like those two steps.

[00:57:14]

It's like, cool, go do ten and see how it works out. I know how it works out. I can't co-sign on your delusion. Now you can go do whatever the fuck you want, but I'm telling you, of the ten thousand people I've seen, try. Get sober, here's what I know works. It would be so hard for me to go along with what is ultimately sometimes people's delusions. How do you handle that?

[00:57:35]

I guess you have a different priority.

[00:57:38]

Well, I think it also depends on the field that you go into, because some people, you know, I think in primary care, you're navigating this all the time with people as they confront or don't confront what they're dealing with. For me, I have people coming in and they've got a problem, right? They have a new cancer or they have a tumor or they have something going on. And then, you know, the choices. Do you want to deal with it or not?

[00:58:01]

What's the goal that you want to have? And it's actually relatively straightforward. I will have, for example, people who will come in and they've got a inoperable cancer, but it's a cancer. And then they will say, Mom, you know what? I think I'm going to do a herbal therapy. I know this Chinese herbalist. And we're going we're going to do that. And what I say to them, it doesn't bother me at all.

[00:58:25]

My big thing is I'm just worried about them. Right. And so I'll just say you have to make your own choices. But I'm really worried about you. So can I ask you to come back in three months and let's see if this gets bigger or not? And just will you come back and when you browbeat them, yeah, they're not coming back and they're not going back to anybody. And I have seen people who died because of that and just offering a hand pull them along.

[00:58:52]

And that's what you're doing with them, right? You didn't tell them? Well, you can either do the 12 steps or you're gone. No.

[00:58:56]

Yeah. You're free to do however you want. Yeah. Yeah. You can say, look, do the ten steps, we'll be with you. And I'm worried about you. Yeah.

[00:59:04]

Also with sobriety, there's a clear check mark, like, did you drink or did you not drink. You know, it's different, like you said with your mom, where the goal is just no pain. But for somebody else or even like for you looking at your mom, you might be like you're not doing enough or I want you to be able to play tennis or whatever. So I do think also so much of this is about the people around the person at the end of life or in the middle of making those decisions, because I even what I did earlier, it's like you're just projecting what you want for them or what you would want for yourself.

[00:59:40]

And I think there's guilt. Like, I don't think my grandfather could ever tell any of his children, you got to let me go now, like, he just couldn't do it. But that's really on the children who are letting. Yeah, yeah. And never were never asking in the first place. Yeah.

[00:59:57]

Well could probably they don't want to know the answer. OK, two more things. Can I ask one. Yes. Yes, yes. Yes. Are you chewing tobacco. Yeah. Yeah, yeah. God that is so Midwestern.

[01:00:07]

I knew when I bought it and you were going to say something to and I was like, you know what I have I have an excuse. I'm quitting September 1st on my sobriety date. But please tell me.

[01:00:15]

Yeah. All right. All right. You should. You should. But but it does remind me of being home, you know, like I tried Happy Days in fifth grade and like, oh, I was throwing up and kill me.

[01:00:28]

I'm also reading the The Emperor of All Maladies, which is a great companion piece dipping. I got to say, I'll be packing wine and listening to and going to the leg of this. I'm creating lots of cell division.

[01:00:39]

I'm like, oh my God, that cell division.

[01:00:45]

Stay tuned for more armchair expert, if you dare.

[01:00:50]

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[01:03:21]

Back to the responsibility of the patient, and again, you're just you're very generous and kind and I admire it. I think it says a lot about your integrity. We know I don't know what the number is, monarchal fact check it. But the number is somewhere in the 70 to 80 percent range that physical therapy results in success, like physical therapy works.

[01:03:40]

It works in overwhelming majority of people who try it. And then surgery just doesn't.

[01:03:46]

In many of the surgeries, you'd get to deal with the physical therapy issue. And by the way, I've gotten surgeries. I've gotten several of them.

[01:03:53]

You know, we're fucking lazy to the patient's lazy, but we're so pissed at the system. And yet we won't do physical therapy. We won't watch our diet.

[01:04:02]

I'm dipping, you know. Is there any frustration on Yarl's End?

[01:04:07]

Well, I mean, it's not just patient. If we're giving him like I don't eat right. I don't exercise like we're human beings. And part of that is navigating risk and learning how you deal with that.

[01:04:18]

But on some of those things as well, I think we make it brutally hard to do the right thing. You can yell at people about not doing their physical therapy, but then you have a five thousand dollar deductible and you have no idea what the cost is. And they're not going to tell you. You don't know who to go to. In order to find out, you've got to make another appointment with your doctor so they can tell you where to go.

[01:04:44]

You have to take time off work that you don't have.

[01:04:47]

Right. This, again, is that sort of that hierarchy I talked about, like, we can teach you the right thing to do. And then when you don't do the right thing, then we can yell at you about it and punish you. And like, we should take your insurance away because why are we paying for Dax's head and neck cancer surgery after he's been doing all the dip?

[01:05:06]

There we go for personal now and then.

[01:05:11]

Look, you understand the risk and people still do plenty of stuff to take risks. And we should make it easy when you're ready to do the right thing. For example, that physical therapy, we know that if you have a severe, terrible back pain most people get routed to visiting a surgeon is the first step.

[01:05:30]

But there are clinics where the first thing that happens is they will get you a physical therapy appointment within 48 hours. Right. And within six weeks. And you never see the surgeon unless there is a neurological issue or the pain gets worse or isn't improving after six weeks and in 90 percent by six weeks, it has gotten better. But but it needed to make it so. Yeah, I could call up. Hey, here's what's going on. You've got an appointment.

[01:05:58]

Yeah. Here's your way in. And then if that doesn't work that you know, you will be routed right. To the surgeon who can help you figure out what you're going to do next.

[01:06:08]

Yeah, that's genius. Ideally, you go into that appointment and they go, great. So now I'm walking you over to this room and you're going to learn these four stretches and we're going to keep on the other thing. But like, yeah, if it's right there, if you make it that easy, your odds of success have to go up completely. We've made it incredibly easy to go get a surgeon's appointment, a scan and a sixty thousand dollar operation.

[01:06:32]

You made it incredibly difficult to get in the door to the right physical therapist within twenty four hours that could address that issue. That's true.

[01:06:41]

There's also an unavoidable incentive structure within the system that you find yourself in. So my father largely offloaded all the decisions to me. Now we did go through chemo. I really am grateful that I had a friend who's an E.R. doctor here in L.A. and I called her and she just said right out of the gate, she's like, look, small cell carcinoma. That's a wrap. There's no you're not going to find some miracle thing. You're not going to call the president and get to go see some doctor like this is on a three to six month timeline.

[01:07:10]

And that's that. I'm like, thank you for telling me that. That's what I needed to know. And so we did came out. That was mostly to appease him. I don't think I would chose that for him. But at the at the final stages, man, we get an oncologist comes on and says that the brain tumor is of such a size that he wants to do radiation. And I say to my dad, here's what's on the table.

[01:07:33]

I don't think you should do this. And he said, I want to do it. And I wasn't willing to fight him. And he had radiation. It was happened in the last week of his life. It had a very profound effect on his cognitive ability. So all we did is knock down his cognitive abilities.

[01:07:49]

And I said to the oncologist, I said, is it worst day of brain cancer than this small cell? Is there a hierarchy that I should be trying to avoid? And he he kind of and I didn't buy it.

[01:07:59]

He was like, well, brain cancer is a particularly brutal way to go.

[01:08:03]

And then at the end of the day, I was just like, I don't feel great that this person's incentivized to sell. Radiation, I don't know why we've linked their incentives to this product, I'm not super comfortable with that.

[01:08:15]

Yeah, I mean, clinicians are really uncomfortable discussing prognosis. And part of it is the idea that you're supposed to give a crystal ball like, well, you got six months the way your friend talked about it. You know, basically what you really want to do is give them best case. Worst case. And my dad, who had a tumor in his brain stem and spinal cord, and it had progressed to the same point that you're talking about.

[01:08:40]

You know, when the discussion came for radiation therapy, didn't work. And then getting to chemotherapy, which was just getting the first start of the therapy with steroids, was making him miserable. There was never a discussion I had to force. And I was like, what's the best case with the chemotherapy and what's the worst case with the chemotherapy and what's the most likely that you think you know? And it's actually a framework that a colleague at the University of Wisconsin created called Best Case.

[01:09:05]

Worst Case. Right. Give me the best case. Worst case with the treatment and then give me the best case. Worst case without the treatment. And when they finally did that, they said, well, the chemotherapy, the range of survival is like the shortest I've seen in three months. The longest I've seen is three years if you do nothing. And my dad was he thought because it's such a slow growing tumor, he thought he thought he had a lot longer than that.

[01:09:26]

So that was incredibly valuable, just knowing that. But then second, I said, OK, so now what is it? If you get the treatment, oh, it's still three months to three years, but, you know, the tumor will shrink and you might you might feel better.

[01:09:38]

Oh, well, maybe it'll shift a little bit towards the the three years rather than the three months. There are all these complications from it and maybe towards the end you feel better.

[01:09:50]

And my dad looked at that and said, no, that doesn't seem like a good deal to me. Right. But but no one was framing it. Carolyn is naturally laying this out in a way that you can make that choice like that. And that makes it much simpler.

[01:10:04]

Yeah. Do you think part of that is the doctor has some hope that, like they themselves will be the doctor, that that is the one to get the person to 10 years? Or is there some arrogance in that, too?

[01:10:19]

I've always chalk that up to just being myopic, like they have a singular goal of beating this cell. Exactly. I think that's you got it that you are fighting the disease. And if I see it shrinking, I feel I've got some victory here. And I presume they're going to be feeling and doing better. But I don't necessarily have the big picture. I don't know what's going on at home. I get 15 minutes in the office where I get to see them.

[01:10:42]

All right. Looks good connecting with me, but, you know, I'm not really getting the whole picture.

[01:10:47]

And so it becomes myopic. Whereas if I'm able to say, oh, well, you told me chocolate ice cream, football on television, are you still getting the chocolate ice cream and watch football on television? You still enjoy them. Is that still what matters to you now? We have a real conversation.

[01:11:01]

There's a couple of cheats I think I'm a critical of of humans. I think we have a real hang up about evaluating the quality of a life by its duration. And I've looked at many lives that ended shorter than I would want that have been to me, ones I'd pick over, ones that when one hundred and ten years. And, you know, it's a relevant question. Why do you think someone like Julia Louis-Dreyfus loves you so much? What do you think she got out of being mortal that people seem to get that you think is such an emotional that she would feel that emotionally connected to you?

[01:11:37]

That's awesome that you would say it that way. What she said was simply that on one level, it gave her a playbook for this very unknown thing and it gave her a sense of control. And she needed to figure out a sense of control, as she said on the podcast and said to me, she did ask the kinds of questions we were talking about, didn't completely necessarily get the answers she expected or the ones that she thought were necessarily wise choices.

[01:12:08]

But she got to understand where he's coming from and then feel like she knew where she stood and could make choices about where she's going to push, where she wasn't going to push and it just gave her a playbook. Yeah. And I think there's comfort in that. I agree. Well, I have children, you have children, even if you're presenting them with two shitty options, just the notion that they're going to get to pick the less shitty option is hugely empowering.

[01:12:33]

Yeah. And and they're not going for the fake option. Right. It's the situation we're in with coronavirus. We have enormous numbers of people in denial about how and just not wanting to have a conversation about how shitty this all is. Yeah. And then here are the tough choices. And let's not just keep pretending it's going to disappear, right? Maybe it magically will. But let's have let's have a conversation about what seems to be right in front of us right now and then actually do something.

[01:13:06]

But but that's, you know, just like people who can be seriously ill, you are dealing with people who are in denial and don't necessarily want to talk about it. And things have to get worse before they get better. But you open the door and then there become when to talk about. I see the country moving that way. Right. You suddenly have eighty five percent of the country now willing to wear masks. We have 10 percent or 15 percent who are going to be absolutely crazy and put the rest of us at risk.

[01:13:32]

And we might have to be saying, too bad you can endanger me at work or in my case, we don't have any rights in this country that allow you to endanger other people as part of your rights.

[01:13:43]

We just don't there's some illusion that that somehow exists. But there's not one I can think of in the Bill of Rights that's like you can hurt other people.

[01:13:52]

And and that's in the same way dealing with a family member who's going through illness.

[01:13:58]

They may not be completely rational. They may be in denial. They may be unwilling to deal with what's in front of you and there isn't control. Ultimately, the book gives you some sense of the playbook, but it's a playbook maybe for dealing with the fact that you're not really in control. Yeah, well, I think your work is amazing.

[01:14:17]

I'm excited for whatever you write, Max, because you're clearly drawn to some some kind of bigger picture looking at the system you're in, but trying to look at it in its totality, which again, is hard to do. You've got to make time for that type of analysis.

[01:14:31]

It's an admirable quality you have. Well, I don't think it's admirable or I happened to I get up very uncomfortable as soon as I'm seeing things from only one perspective and seeing it from inside the bubble and then getting outside and trying to see what it looks like.

[01:14:46]

Well, we hope you'll come back and talk to us, because what an asset you are, someone I would love to continue to talk to.

[01:14:52]

So just really quick, you don't think it's super productive to be calling it the human virus? Of all the things that seem like a waste of time, these people are trying new things out of someone for a virus.

[01:15:03]

Seems like the least productive. Certainly not not solving the question of whether we're going to get rid of this thing.

[01:15:10]

Yeah, thousand percent. Well, a tool. Pleasure to talk to you. And I hope we get to talk to you again. And I hope you and miss drivers somehow have some lasting friendship. I'm envious she didn't answer my email after the interview.

[01:15:26]

DAX Armonica. This is awesome. Thank you. Yes. Thank you, sir. Good luck in the rest year. Your Zoom's OK.

[01:15:32]

All right, bye. And now my favorite part of the show, the fact check with my soul mate Monica padman Brown to Fu.

[01:15:42]

Are there any of my accents that you like that like you would maybe request any impersonations or anything that you enjoy?

[01:15:50]

That I do. I like when you do own.

[01:15:52]

OK, listen, OK, I don't know how many times I can say I like all of them.

[01:15:57]

Just not when you're next to me.

[01:15:59]

No, just not when you can't stop it. I'll take any of them in a while. Not any, not the racist ones, but the impressions I'll take in a small dose any time you want to give them. But the problem is you just can't stop and it's uncomfortable.

[01:16:15]

Well, there's two issues afoot. One is I have impulse control issues.

[01:16:20]

Clearly, part two is I'm not an impressionist, so it takes me about twenty sentences before I remember how to do it.

[01:16:28]

OK, and then I finally find it. It's a minute and a half later, but now I want to do it because I finally found it.

[01:16:34]

I understand that, like if I was just great at them and could do them, when you click your fingers, they would probably go better. All right.

[01:16:42]

I mean, I think you're underestimating yourself. I think you sound pretty much the exact same. Ten minutes and then you do when you start one bong.

[01:16:50]

It's such a great kitchen. Yeah. See, you did it. But that's the one line. That's how I set myself up for own. Yeah.

[01:16:56]

I have that one line and then I launch into I don't know why you girls like Multi-stop still problems.

[01:17:05]

That same crow is back. He's in the tree today. Oh my God guys we have like a harbinger of good fortune. There is an enormous crow that now lives on the roof of the new house that we've yet to move into.

[01:17:16]

But now I see it residing in the oak tree and now we're obsessed with him because crows can do eight step. Problems, they're the smartest problems. Yeah, and that math problems were like, oh, they can do set pieces. It's like they got to open a box, they get a key, they take the key over to here, then they screw it in. Wow. This is just fucking.

[01:17:32]

Unfortunately, that was from our last episode because you said two factions in a row going hot and fast.

[01:17:38]

All things are getting muddy. Oh, there's too gross.

[01:17:41]

There's a family of crows living at the house.

[01:17:44]

The Crows can do a lot of problems and I think we're going to ask it to do a few problems.

[01:17:49]

Well, this was the funniest moment I saw out the window a couple of days ago. I said, oh, God, Monica, look at that size of that crow.

[01:17:55]

And then she was like, oh, you know, they look scary. And then I go, Those are my favorite birds. She goes, Really? I go, Yeah, they're so smart. They can do an eight set problem. And she goes, solve the problem. So you're yelling at the bird, solve a problem for us.

[01:18:07]

Maybe you can. Ah, my email, that's awesome, and the other fact, oops, and all you got to do is paying with like one kernel of corn, that's what they get if they like.

[01:18:16]

Well, I don't know what it is, but it's something really insignificant. You would not do the eight steps to get the reward. So I'm saying this would cost us virtually nothing if we had to do chores that we needed done. And it did eight of them.

[01:18:27]

And then we gave it a kernel of corn. Hmm. Let's have him. Is that slave with sound engineering?

[01:18:34]

Um, no. I can fly away at any time. Yeah, it has agency. It's just not it's not a living wage. It's not. I think it is a living wage in Cairo. One kernel of corn because that's how they live by eating corn.

[01:18:48]

I think they're eating a mammal up there. Oh really. Yeah. Yeah. Lean over. There's two of them and they're like, Teran, something apart. This is awesome and creepy. So far. I'm loving the fact that there's now two crow's nesting at the house. At what point do you think it gets super terrifying, like what amount you don't see on that big branch of the oak tree right there?

[01:19:06]

Oh, me. They're moving around right now.

[01:19:10]

I'm too full to go from lunch. You went from two hungry and borderline grumpy tonight to four.

[01:19:16]

Also borderline grumpy men. OK, I'll be scared when there's four crows.

[01:19:24]

I think you're right. Threes, good fours like wait are there twenty coming and it's like there's something dead.

[01:19:31]

What would you assess? Like how many crows would it take to kill me. To kill you.

[01:19:35]

I found ah no, no. I'm able bodied and I have all my, my faculties about me and they come for me and certainly stab or I could beat the shit out of four crows. Yeah.

[01:19:48]

So what is the number do you think that I'd get overwhelmed if this one didn't raise red flags from PETA?

[01:19:53]

I would love to do a pay per view event where we find out and we put like a unleash one hundred crows in me in an atrium.

[01:20:01]

I guess we've had a lot of fact checks lately that have involved animals doing unconventional things, i.e. the snake.

[01:20:09]

Oh, sure, sure, sure, sure.

[01:20:11]

So the Crows, I think I think you can withstand them big though.

[01:20:16]

They are big. They're big, they're bigger than a Yorkie, OK? And they've they've got talons. They've got a real strong beak and they're clever.

[01:20:25]

OK, then I'm going to say thirty odd fucking kick thirty crows, you know.

[01:20:29]

Yeah, yeah, yeah. Not if some I would have to be like they'd have to black out the sun because there were so many of them that I couldn't see and it was dark and, and then one of them would have to get lucky and hit my carotid artery or my femoral artery first.

[01:20:44]

They just pluck out your eyes and then you can do whatever they want to you. Great point. You're right. If they went for the eyes. Yeah. Is that what happened in Edgar Allan Poe, the raven.

[01:20:55]

Knock, knock, knockin at my chamber door. Do you remember that pass. I don't actually remember.

[01:20:59]

If the eyes got blocked and the beating heart gave it away was under the boards. I feel like they plucked his eyes out.

[01:21:07]

Now I have to look up the. No, you don't continue on with your thing. This doesn't need answering right now. Where are you going to go to Wikipedia.

[01:21:17]

Once upon a midnight dreary while I pondered weak and weary. Let's see how long it is.

[01:21:22]

He wants to long get to the bottom and just see if he's got his eyes plucked out. Holy fuck. That's remember, nevermore. Nevermore. It does kill him, I think.

[01:21:31]

Well, his beating heart gives away his location, I think, as I recall. What's the last paragraph? Spoiler alert.

[01:21:38]

If you've never read The Raven by Edgar Allan Poe, plug your ears. What is going on over there, are you having a seizure?

[01:21:52]

What about was that is last week, you scratch your tongue, this week you are in a seizure. That is a type of seizure.

[01:21:59]

I think those are pretty much all I have. Grand Petite LaCour.

[01:22:03]

What are those yummy cookies? Petite Delacour.

[01:22:06]

They're like really fancy cookies in the grocery store in their little girl with a nice piece of chocolate over and a little stamp like a Dutch boy, petite I liqueurs or something. I use them.

[01:22:18]

OK, take thy beak from out my heart and take the form from off my door. Quoth the raven nevermore and the raven never flitting still is sitting still sitting on the pallid bust of Pallas just above my chamber door and his eyes have all the seaming of the demons that is dreaming and the lamplight or him streaming throws his shadows on the floor and my soul from out. That shadow that lies floating on the floor shall be lifted.

[01:22:48]

Never, never more so we don't really know. I think the heart let me glance at that.

[01:22:54]

I want to see what voice I would enact for this. And the raven never flitting, still sitting still is sitting on the pallid bust of Pallas just above my chamber door, and his eyes have all the seaming of demons. That is dreaming. I don't know.

[01:23:10]

That was good. I was good. That was good. That felt like I was transported.

[01:23:16]

We need Cordery in here to read. We do. Well, OK, a tool.

[01:23:21]

Oh man. Did I like a tool. I loved his message. And just we don't talk about these things Mianzhu, but also just that people don't like to talk about end of life, of course. And unfortunately, it's important even calling it end of life.

[01:23:39]

That feels like a euphemism. Right. Like an attempt to get us to talk about it, to call it end of life instead of death.

[01:23:44]

Yeah, yeah. OK, so he said Athens is the poorest county in Ohio. Thirty two percent. Well, this was in 2014, but thirty two percent of Athens County residents were living in poverty below the poverty line.

[01:23:59]

Yeah. OK, he says 70 percent of people don't go to college. I think that's what he said. Maybe I misunderstood and he said, do go. No, he said don't. Yeah, OK. So the percentage of students enrolling in college in the fall immediately following high school completion was sixty nine point eight percent in twenty sixteen. So it's actually the opposite.

[01:24:23]

OK, but I have to imagine the amount of people who finish college versus enroll in one community class is just half the problem, which would put that at 30 percent, probably between 70.

[01:24:38]

Don't get a college degree. OK, that's true.

[01:24:40]

Don't get a college degree, though, is I think that's what he don't go. But going to a class in college doesn't get you anything career wise or.

[01:24:49]

You're right, but we don't know that. OK, so I'm sorry, I do have to check this.

[01:24:53]

OK, great. I'll watch the Crows percentage. Remember the movie The Crow. I never saw it. How should I phrase it?

[01:25:01]

What percentage of Americans have college degrees?

[01:25:04]

Percentage of US citizens have college degrees. Yeah, I keep showing me this dumb map of states percentage of population. What percentage of American students graduate from college? OK, the census in and 23 percent so fast this you're too full.

[01:25:23]

No, I'm not looking for fulness this time. Why did this happen?

[01:25:27]

But look at thirty four percent of us born Americans have a four year college degree. That rate is similar to the thirty three percent of those born in other countries.

[01:25:37]

Thirty four percent of US born Americans have a four year degree. The rate is similar to the thirty three percent of those born in other countries. OK, but look.

[01:25:48]

So you didn't get this chart? I don't know. And that is not a helpful chart. I don't know why you're not forcing me to read your try to get you an answer.

[01:25:57]

Oh, I am trying to compare what happened here versus what happened there.

[01:26:03]

Well, my search was what percentage of Americans graduate from college. That was my search. And read your search. You just what percentage of Americans with college degrees. So we had different searches.

[01:26:12]

I asked you what should I type? You told me to type. Well, yes. And then look, I do see you're thirty four percent. I just hadn't gotten there yet. So looking at my chart, you were very flummoxed with that chart.

[01:26:29]

So I guess what you might say was, thank you. And I will say to that you're well not thank you.

[01:26:34]

I would have I was starting to read U.S. Census. I was about to read you the 2010 census in its entirety. You.

[01:26:39]

No, I quit. Why are you quitting? Because you're Doval.

[01:26:45]

Oh, boy. Oh, boy. I think I'll make a pooty and get it over it, ok. Oh shit.

[01:26:53]

I text. Oh my gosh. I texted it back to Alison. She hasn't responded.

[01:27:02]

Look, we got to do another search. OK, ok.

[01:27:05]

I'm the guy. All right. I'm on point today. You said that seven. You go to Wikipedia. Hold on.

[01:27:10]

Let me open it up. You said that 70 to 80 percent of physical therapy works is effective. Yes. Yes. Let's see if that's true. How effective is physical therapy?

[01:27:22]

I don't think you're going to get what you want on that. OK, how about this? Oh, I got a great search. I got a great search. Listen to this.

[01:27:30]

What percentage of the time is physical therapy effective? Questionmark now, iRace, all this other crap I wrote.

[01:27:40]

I see you're no good. I'm doing really good. I'm doing all really good. OK, almost there. OK. What percentage of any physical.

[01:27:53]

Oh wow. This is physical. Let's get physical therapy.

[01:28:01]

Wanna get physical say nine truths about physical therapy.

[01:28:07]

Patients often misunderstood by and you know, I know like a hundred physical therapist, it's embarrassing that none of them have responded.

[01:28:16]

What is the success rate of physical therapy?

[01:28:20]

That specifically just for spine I found OK, two percent.

[01:28:25]

I bet it is going to have to be by body part or orthopedic versus.

[01:28:30]

Yeah. So there's no way to know. And that's probably why it didn't respond.

[01:28:33]

An intriguing physical therapy, statistics and facts. We're not going to find this out. We're not going to. It's OK.

[01:28:40]

But talk to any doctor. They'll tell you it's highly, highly effective, much more effective than most surgeries.

[01:28:45]

It's very highly effective. I know many, if any, armatures needle wreck. I know one in California. I know two in North Carolina. I know one in Atlanta. I'm sorry. I know two in Atlanta. Oh, my God. I'm so I have you covered.

[01:29:02]

OK, great. So just reach out to Monica and get connected with a great pity.

[01:29:07]

Don't send me any more emails. That's from the last fact check.

[01:29:10]

OK, all right. Well that's all. And I'm all ok. Great. That's not all. There's one thing I wanted to say because it's been cut out of an episode and I. Oh right. I wanted to just address this quickly.

[01:29:21]

So some people were upset that I had quoted Louis Farrakhan when we were interviewing Leslie Odom Jr. And the point I was making was that I had seen some footage of him making some points in the 90s. And when I had seen it in the nineties, it seemed very radical. And my point was, now that I'm hearing it, I really I recognize that he was completely right on the topic at the time he was discussing, which was redlining, steering black folks away, generational wealth, all these things.

[01:29:49]

Several people then wrote that I shouldn't be promoting an anti-Semite. So, yes, I am not saying we should build a Louis Farrakhan monument. I think he was anti-Semitic. I think he was a very flawed person. The only thing I was saying was that his take on why black people are systematically oppressed is very, very relevant. Still some 30 years later. And he. I was speaking many truths on that topic, and that's where I'll leave it.

[01:30:18]

I'm not condoning any other points he made other than that, I guess I'll add we did remove it, which I didn't agree with.

[01:30:24]

But I trust you more than I trust me.

[01:30:26]

We removed it because without hearing this part of it, it could be mistaken. And we don't want to be misunderstood. And because we weren't explicit about there's other parts that we don't agree with that are pretty extreme. We just decided to cut it out.

[01:30:40]

But if you had heard it, this is also if you're now hearing this and you love Louis Farrakhan and you want to explain to me why he wasn't anti-Semitic, I'm done with this topic.

[01:30:50]

I'm going to ask.

[01:30:51]

So this is this is where this is up against if there's another rebuttal. I love you. We love you.

[01:30:56]

We love you so much. Peace.