Dr. Pria Anand | The Mind Electric | Talks at Google

Welcome everyone to this Talks at Google event. I am Lucy Boyd Schachter and I am a qualitative researcher on the inception team at DeepMind. Before we get started, I just wanted to remind everyone that we will be taking questions toward the end, so if you hear anything exciting in the room, feel free to just hold it until you take questions. Or if you're watching on the live stream, feel free to add it to the dory as we go that we can ask them at the end. With that, I am so very excited to introduce today's guest, Dr. Priya Anand. Priya Anand is a neurologist at the Boston Medical center and an Assistant professor at Boston University School of Medicine. She is a graduate of Yale University and Stanford Medical School and she trained in neurology, neuroinfectious diseases, and neuroimmunology at the Johns Hopkins Hospital and Massachusetts General Hospital. Dr. Anand is here today to talk to us about her recent book, the Mind Electric A Neurologist on the Strangeness and Wonder of Our Brains, in which she demonstrates the compelling paradox at the heart of neurology that even the most peculiar symptoms can show us something universal about ourselves as humans. In the book, Dr. Anand reveals through case study, history, fable and memoir, all that the medical establishment has overlooked. The complexity and wonder of brains and health and in extremists and the vast gray area between sanity and insanity, doctor and patient and illness and wellness. And so with that, it is my pleasure to welcome you to Talks at Google.

Thank you so much for having me. Thank you so much for reading the book so thoughtfully. And thank you to Google for making the space for ideas and intersections. I'm so excited for our conversation. Me too.

Would you like to start us off with a short reading? Perfect.

Yes. So I'm going to borrow Google's copy of this book for my reading.

So I will read a little bit from early in the book, talking about my medical training. As a resident. I studied the neurologic art of localization, the search through those crumpled folds of the brain, the endless branching of axons and dendrites for where exactly something has gone awry. I learned by examining patient after patient, tapping carefully against a tendon to elicit the jerk of a reflex, gently probing skin with the point of a safety pin to understand where numbness ended and sensation began, methodically testing the structures of the brain, spinal cord, nerves, muscles, each linked to the next by an ephemeral connection with innumerable ways that each might fail. A young woman arrives at the hospital unable to close one of her eyes or drink from a straw, and I learned that she has a facial palsy, an inflammation of her facial nerve that has frozen half of her smile. By her bed is a heap of crumpled candy bar wrappers, and she explains that sweets have begun to taste strange to her in some ineffable way. I delicately interrogate the sense of taste on each half of her tongue with a drop of saline solution and then a packet of artificial sweetener from her lunch tray. I am testing the fragile branch of her inflamed facial nerve that would ordinarily translate the sharpness of salt or the chemical sweetness of the sugar substitute into a signal her brain can interpret. It, too, has been severed. The sweet particles taste like sand on half her tongue, she reports, and I file this description away for the next time I examine a patient with a facial palsy. I learned the difference between strokes of the left hemisphere of the brain, which rob their victims of their words, and strokes of the right hemisphere, which deprive their victims of something more subtle but no less important, the prosody of their voices, their ability to convey emotion or urgency, those moments of emphasis that determine meaning. Even more, I learned to anticipate the ways this loss will shape someone's life, how our inability to parse these subtleties will open a strange chasm between her and her partner that neither can fully understand nor articulate. At times, this quest to find narrative embodies feels inexorable, like a tic I cannot suppress. Stopped at a red light, I cannot help but watch through the windshield for the cadence of someone's gate crossing the street in front of me in the shuffling steps and stoop posture of a man with Parkinson's disease, tottering as if blown over by a strong wind. I see the vivid nightmares that likely haunt his sleep and the theatrically high steps of a woman with a foot drop, lifting her knee nearly to her waist as she walks to keep from tripping over her own toes. I see the hours she spent in labor to deliver the infant strapped across her chest, her legs lifted and bent as she bore down, the nerves connecting her spinal cord to her foot, stretching and compressing until finally they fatigued and failed. When I began medical training, I worried that I paid too much attention to the details of these stories and not enough to the technical details of cell biology or biochemistry, that my longing for narrative would make me a worse doctor. I've since come to understand these details are crucial to the practice of medicine. I've learned to piece together diagnoses not Only from the involuntary tells of the body, but also from the ways people choose to tell their story and informed by what they value, what they love, what their illness has taken from them.

Thank you so much. Related to that passage, a recurring theme in your book is sort of your craving for subjectivity in places of objectivity. And you describe this feeling of really wanting to understand the lived human experience that lives behind the charts and numbers. I'm curious if you could talk to us about when that feeling first crystallized for you and what was happening that made you realize the limits of the objective lens that you were being trained to use.

You know, it's interesting, I think, when. When I was a medical student especially I. The language of medicine, because it is.

A totally other language with a lot.

Of jargon that, that, that has to be kind of parsed in a very different way. When I was a medical student especially, the language of medicine felt very foreign to me. And I understood things better from the language that my patients or their communities would use to describe what they were experiencing. And I think there's this idea that sort of part of the transformation of medical school and residency is that you come out on the other side seeing things from the opposite lens. But I think there's a. You know, one of my favorite examples of this is the example of sleep paralysis, which I'm sure some, at least a handful of people in this audience will have experience at some point in their life. It's something like 1 in 10 people will have at least one episode at some point in their life. And sleep paralysis, if you've ever experienced it, is this really peculiar experience where you are just kind of like caught.

Between being asleep and being awake.

Your body is frozen, you see imagery from your dreams, but your brain is fully awake. It's this totally bizarre, otherworldly experience. And I could tell you something about what is happening in your brain stem or your spinal cord that causes sleep paralysis. And if you've experienced it, you might tell me that that totally misses the point of what it feels like to have that experience. But sleep paralysis is so common that every cultural tradition, every community has a story around sleep paralysis. There is a witch or an angry spirit or a creature that holds you, pins you down while you have this experience. And if you have experienced it, you might say that there is a truth to those descriptions as well to that that captures something about what feels like it's an out of body experience, or spiritual, or otherworldly, or totally overwhelming and consuming. So I think there's. There I so sort of that kind of subjective experience, that phenomenology of living in a body and experiencing kind of bodily symptoms, I think medicine does a really poor job sometimes of capturing. And I think there are many, many different kinds of language that can get it. What that phenomenology is that are not found in medical textbooks, but that are just as kind of precious or speak to just as much truth.

Going back to sort of some of the experiences of training in medicine and the things that you are taught. Another story you write about in your book is the history of the practice of Grand Rounds. And for those of you in the audience who aren't familiar, I would love if you could sort of paint a picture of what Grand Rounds once were and what's changed about this hospital ritual. And I'm really curious, as you talk about that, to hear sort of what do you think was gained and what was lost in that evolution and change of that practice.

So I think I especially now, as sort of we are thinking more in the world about, like, what things actually require a human body to be. Like what kinds of interactions actually require a human body to be a part of them. I feel like in medicine, I've thought a lot about kind of there's a ritual and a performative aspect to medicine. A lot of the. There, you know, I feel like medicine, you wear a special costume and you use these special tools, and at one time it was like the plague mask, and now it's this white coat and the stethoscope and the reflex hammer. And there is a. There really truly is kind of this performance, performative aspect to medicine. To the physical exam. It feels like we're like clergy and there's some sort of, like, sacrament to it, right? Like you're bending over someone and laying your hands on their body. There really is a ritual to it, and I think that's true across all of medicine. But I think neurology maybe has the strongest claim to this sort of ritual and performative aspect to medicine. Into the physical exam. So this, the kind of. The story of modern neurology goes back to this French hospital called the Salpetriere. If anyone here speaks French, please excuse my pronunciation for the next 10 minutes. But it was a hospital that was once a gunpowder factory, and that factory was repurposed into a women's asylum. And women would be held there if they were old or poor, if they got pregnant out of wedlock, or if they had an illness that was thought to be sort of like a burden to society. And they would live their whole lives there. And when they died, they would be autopsied and their brains would be studied. And we have, you know, we could, I think, have a whole. We could talk. We could have a whole entire conversation about, about what, what the significance of that is for sort of the provenance of medicine. But we have learned about a number of illnesses from, from the studies conducted at this hospital and the hospital, what the neurology service was run by this really charismatic doctor, Jean Martin Charcot, who we think of as the sort of the father of modern neurology. And he would. He had these very, very famous lessons where he would bring his patients onto a physical stage and an audience would come in to watch him examine patients. And he would put his patients in these really elaborate costumes, like with a feathered headdress so people could see from the back rows that someone's head was shaking. He would use props. So a woman with multiple sclerosis, he might give her a full glass of water to show the tremor of her hand, and he would talk through what he was witnessing. And this was a way of. So students and doctors in training would come to these events because they wanted to learn about medicine and they wanted to kind of watch. They wanted to see illness performed for them. Parisian civilians would come, actresses would come because they wanted to try and emulate this range of emotions that was expressed by these women who were being paraded on this stage. So there is the roots of what we do. There's like so much performance in it and there's this idea that, like, that performance is part of learning to be a doctor. And that tradition has continued in sort of quieter ways. So for many years, most departments and most hospitals across the country would have something called Grand Rounds, which was not quite as theatrical. There were no feathered headdresses. But a patient would come into an auditorium and a group of doctors would watch and someone would present that person's story. They would say, this is Ms. X. She's 49 years old, she has a history of three late term miscarriages and she is a heavy drinker. They would say something about this person's personal story. And then a senior physician, kind of in the vein of Charcot, would examine that person in front of this audience and try to divide the diagnosis from their exam and from probing questions in front of this audience. And I think people who sort of. That tradition has changed now. It's much more like a visiting speaker will come and speak to an auditorium of physicians with a PowerPoint lecture and people who mourn the loss of that tradition. Talk about this idea that in some ways a patient is at the heart of that exercise. There's a patient who's on the stage like a human being living in a body and experiencing an illness is on the stage being watched by all these doctors. I think the flip side of that is that I think probably the doctor is maybe at the heart of that exercise. There's this way in which we really lionize this idea of being smart enough to arrive at the diagnosis or being able to examine someone in such a way that you can know the answer. I think the question of who do people think is in that auditorium, think is the hero of that exercise? I think is. Is one that doctors don't always do a good job of fully kind of grappling with or contending with. But that's sort of the exercise, and that's kind of where what its origins come from.

Thank you so much for sharing that. I thought that was such an interesting story in history to read about in the book. Another one that sort of connected to me during reading is this theme of the power of language and sort of tied to how doctors shift the narrative, sort of either intentionally or unintentionally, about their patients when they speak about them and how the words that are used in medicine, so things like you talked about the words denies or complains or fails specifically sort of frame the patient's story and subtly shift how their experiences are perceived. A similar example, it made me think about in tech, we often talk about our users, which sort of felt like a similar reduction of this complex human on the other side of our products, sort of reducing them down to just the interaction that they have with this specific thing at the specific time, and only thinking about them in that way, whether intentionally or unintentionally. I'm really curious what you have learned and what you think we could learn from medicine's sort of ongoing struggle with vocabulary in this way.

Yes, I think it depends on whether you think language matters or whether it influences how we see one another or how we frame these interactions. But I think it goes a little bit back to this idea of who are we lionizing or who do these interactions? Who does medicine exist to serve? One of the examples that you listed, which I think it still blows my mind, is that one of the only moments where we use active language when we're talking about patients in medicine is when a drug, a medication, doesn't work for someone. So you hear doctors say something like, Ms. X failed this chemotherapy, or she's failed three rounds of chemotherapy, which is wild. Like, this person didn't fail the chemotherapy. This chemotherapy failed this person. But is really how. That's really the language that medicine uses to kind of talk about the work that we do and the people that we care for. And I think, you know, it really sort of, like, subtly, I think this idea of sort of like a. Like in. In a ritual, there's this. There's, like, someone who is empowered and who's, like, performing it, and there's someone who's sort of on the receiving end of it. And I think that this language kind of codifies that. That kind of chasm between the people, between the bodies that we're taking care of and. And kind of the. The people administering this care.

How do you personally navigate that in your practice?

So I hate medical jargon. So when I speak or when I write notes, I really try and avoid using anything that feels like it's an acronym or something that I can't fully explain the provenance of that phrase as much as possible. I just try and speak in the most simplest and narrative possible terms, I think. And I think a lot of it is sort of like. I think a lot of it is sort of a crutch. Like this idea of saying, like, that someone complains of a particular symptom, which is crazy. Like, they're experiencing something. They're not complaining about it, and they're in a hospital because the hospital exists to kind of serve someone who's experiencing those same symptoms. So I think just like, being as narrative and descriptive as possible and trying to avoid, like, jargon or specific terms that come from. That don't have a. That don't carry a lot of meaning, I think, is the way that I navigate it.

Yeah, I'm curious, too. Thinking back to your answers earlier about the sort of history of grand rounds and the difference between speaking sort of doctor to doctor versus doctor to patient, do you feel like it's important to carry through that ethos in a doctor to doctor setting as well?

I do, I think. I wonder if this is the same for all of you and the work that you do, But I think there's a way in which jargon can obscure how much you actually understand or how deeply you can actually explain something. And so especially when I. Especially with trainees or when I'm like, look, when I'm talking about kind of the. Trying to think about what kind of example I want to set for the kind of doctor that I want people I'm working with to be I think being descriptive rather than leaning on jargon, I think sometimes speaks to a much deeper understanding of something. It's a hard lesson for all of us, and I think it's something that I and many doctors still struggle with.

Yeah, I totally feel like I struggle with that all the time in our work as well. I don't know if anyone else resonates related to sort of some of the crossovers in experience. So I'm someone who works in AI. I suspect many of our audience members right now and viewers are also interacting with AI on a regular basis. I found it really fascinating throughout the book, your explorations on confabulation, particularly so hallucination, or more accurately, confabulation is such a big part of the world that I live in in the AI space. Dealing with large language models as well. And not just the naming of that, but the study and how we think about that is also very rooted in the history of neurology and the study of the brain. I would love if you could explain sort of what confabulation is in the human brain, what purpose it serves and what you think its existence might reveal about us as people.

Yes, confabulation is this really fascinating and perplexing symptom that many people experience when they have some sort of wound to their brain. What confabulation is, is it's your brain's desire to tell a story kind of beyond your conscious perception. So you have no idea that what you're telling is a story that's not rooted in reality. And that can happen after a number of different kinds of brain injuries. But probably the most common, the most common time that we see it is when someone has a problem of their memory. So when someone experiences some sort of amnesia and is missing details of their own life, or is missing details about how they ended up in the hospital or the. Or how they ended up ill, their brain will confabulate a story to fill in those gaps. And that confabulation can be something like. I often ask people who are struggling with their memory whether we've met before and how we've met. And I've gotten answers like, we were childhood sweethearts. We met, we saw each other at our high school reunion. I had a patient not too long ago who wore a helmet over his head because he had a skull surgery. And I asked him about the helmet, and he said, I'm wearing the helmet because I'm going to play in the big game later today. Like all of these things that sort of were from his Kind of composted from his personal story that. That found their way into these confabulations. So confabulation, it's shockingly common. It happens after a range of different kinds of neurologic injuries, from loss of vision to loss of language, to loss of memory to loss of strength. And it's this way of sort of filling in the gaps of what we don't understand about the world. And it's so interesting because I think. I think when I saw it for the first time, I was like, that's such a peculiar feature of neurologic illness that people will tell these stories. But confabulation is something that we do on a much smaller scale just as we move through the world. I think the world is like such a. There's so much sensory input, it's so chaotic. And to make sense of it, to really, like, navigate the world, you have to have some sort of heuristic for determining what is salient to you and what you can disregard. And I think a lot of that for humans is kind of a narrative or a story. So what we attend to and what we disregard, how we make sense of things that seem senseless, I think that applies to how we think about illness as well, is that we're often sort of searching for a story to make sense of it. And I think that's a form of confabulation. And, you know, the, The. The human. I think we've talked about this before, but I think of. I have. You said you shared that you think a lot of people complain that AI is a black box. And I think if there were ever a black box, it's the human brain. I don't think that we will ever fully understand how this mess of, like, chemistry and electricity gives rise to something like consciousness. The human brain is truly a black box. But I think the moments when we get closer to understanding something about how it works always come from seeing. Seeing a moment when it's glitching. So we understand something about language from seeing someone who's struggling with their language. That has told us something about how language is represented in the brain and how language is uniquely privileged in the brain compared to other sort of cognitive functions. And we've learned something about the human sort of impulsive storytelling from confabulation. So what unmasks it? Confabulation. There are many different sort of. I think we. Among many black box aspects of the human brain, I think we still have yet to fully understand what causes someone to confabulate. And it depends a Little bit on kind of what kind of confabulations they're experiencing. But part of it is that in the human brain, there's kind of the creative part of your brain that comes up with a story, and then there's the part of your brain that is sort of source checking and is saying, like, where did the story come from? Is it a thing that I imagined? Is it a thing that I dreamed? Is it a thing that I remembered? Is it a thing that I directly witnessed? And the idea is that maybe confabulation happens when someone is wounded, because that second part isn't working quite right. So the creative part is working just fine. But that part that says, actually this is a thing that I am uncertain of, that part isn't working. And so this, like, the sort of. The ability to kind of. To kind of acknowledge your own kind of uncertainty is part of what's broken when someone confabulates. And that's. That is really valuable information about how human brain is structured. Although it still is very much a black box. We're hopefully inching closer by being attentive to kind of glitches like confabulation.

Yeah, yeah. I'm curious, like, why. Why do you think those glitches have become so illuminating to people? Or like, what can we learn working in a related field about sort of like, how to learn from glitches or issues or mistakes as opposed to just trying to seek things? Something working perfectly all the time, like, what can we take away from that?

That's a fantastic question. I'll start by saying that I'm like, the worst kind of Luddite in that I'm, like, really poorly informed. So if I say anything wrong, sorry to apologize. So I think that sort of the thing that allows us to sort of start to pry open the black box is these glitches. Because to. If you were able to see that when someone has. For instance, like, there are certain kinds of problems of language that can affect our ability to. To just produce language or to just understand language or just to read, but not to write. And by understanding sort of what set of circumstances can create something so specific that tells you something about how the brain works when it's functioning well. So it's like a. Like a moment where you can kind of pry open that black box and see and something is illuminated about how that works when it's functioning. The fact that people confabulate, that tells us something about our impulse for storytelling. Even when we're not wounded or when we're not Confabulating. And I think it's interesting. I think people talk about, I feel like in the press there's this idea that AI confabulations or hallucinations are the reason that this particular technology is flawed or doesn't have a value. And to me, like, that's, I think the thing that makes it seem the most approximates the most, like the greatest humanity. Like the sense that like, it feels like an opportunity to understand something about how it's working, sort of what is glitching. And also I think there's a way in which I think we like want these technologies to be sort of more perfect than the human brain. But I also think that there has to be a degree of uncertainty that's just inherent in understanding or parsing the world that seems like a feature of knowledge rather than a feature of just the human brain. And so I think there's a. I think there's some. I imagine that they work very differently and what the lessons are that you can learn from those glitches are very different. But it really echoes what my experience has been as a neurologist.

Yeah, that was such an interesting sort of lens to look through this with. I will ask, I think, one more question and then we'll shift it over to questions in the room. So shifting gears a little bit to learning. You talked about sort of like the importance of learning about people's backstories and memoir. And this book is so much your story, as well as the story of neurology and sort of the history of medicine. I'm really curious to hear a little bit about your decision to work at Boston Medical center in particular. For our non local viewers. Boston Medical center is definitely a place with like a deep mission to serve underserved communities in particular. And so I'm really curious about how that speaks specific environment and the lives of the patients that you see there have shaped your perspectives.

So Boston Medical center is. This is just. It has a remarkable history. So it was founded as a Boston city hospital in, I think, I want to say the 1860s, in the middle of when Boston was being ravaged by a cholera epidemic. And at the time there were other hospitals in the city, but those hospitals were really specific about who they would take care of. So you could not get care at any of the hospitals in the city. If you had had a complication of pregnancy, if you had tuberculosis, if you had been born outside the country, if you were marginally housed or you didn't have stable housing, those are all disqualifying. You Couldn't get care anywhere else in the city. So this. The city sort of came together and decided. It turned out that as it turned out, cholera didn't care if you had a complication of pregnancy or if you had tuberculosis or if you had reliable housing. So it became really clear that there needed to be a hospital that was built with the idea of caring for everyone. And that was the Boston City Hospital. That's the hospital side of things. And then the medical school side of things was actually founded from what's called the New England Female Medical College, which was the first college to educate women as doctors in the United States. So it's this place that has this really, really kind of deep history completely in earnest. The hospital's motto is Exceptional care without exception. And it still is a place that cares for. It houses like a center for trauma, a center for addiction, a center for refugee health and human rights. It really is a place that exists and has always, since it was born, with the idea of caring for all comers. And I think if you're a person who thinks that bodies and healthcare are a universal human right, I think it's a hospital that really lives that value. So I think it's a very special place. I've worked at many hospitals and loved all of those hospitals, but I have never felt so proud as I do to work at Boston Medical Center. And then I think there's a way in which the stories that. That I think the stories that we have in neurology, you know, I think the stories that my patients experience are not ones that I often read in kind of like case reports or studies from. From other hospitals. And in. For my patients. Like, for instance, like, I recently cared for someone who had a particular kind of meningitis, and you would never be able to diagnose as meningitis unless you understood that he had traveled from Venezuela through South and Central America, had walked overland across the Darien Gap and crossed the Rio Grande Valley. And his meningitis was caused by a fungus, the spores of which live only along that sort of migration route and were kind of stirred up by his feet as he walked. And there's. There we would never. That's not a disease we would otherwise have tested for because it doesn't exist in Boston. But just the idea that, like, someone's story, their migration journey or their trauma can be entwined with their body in this really particular way, and we carry our stories with us in our bodies. I think that's true everywhere. But I think I see it really kind of keenly in my hospital.

Yeah, thank you. I'm going to turn it to the room for a bit and then I might squeeze in one or two more questions in our closing statement. But I want to make sure everyone in the room or on the dory, if anyone has a question, feel free to stand up and get at either mic. If anyone watching wants to add anything into the dory, feel free and we will take them as they come. Awesome. And I can, I can keep asking mine. I have many more if people need more time too. Awesome.

Okay.

Speaking of sort of more of your experience and the experience of medical students throughout history. I think those of us not in the medical field often see medical residency as sort of this almost like mythical trial by fire experience. And you have a really interesting thread in the book where you trace its modern history back from sort of both the innovations and personal demons of one particular person. Would love if you could tell us a little bit about that story and sort of how that person's legacy continues to shape young, young medical students lives for better and for worse today.

Yes, I would love to tell that story. I. So I trained the hospital. I trained at Johns Hopkins when I was in training, every fourth day I would work a 30 hour shift. So every fourth day I would come to the hospital in the morning and I would leave the following afternoon. And when I trained, that was considered like luxurious because in previous years that had been every third day or every second day and it was longer than 30 hours. So it's, it is sort of. And sort of while I was there, I learned kind of that the story of residency and medical training is really baked into the history of that hospital because of two men who sort of originated the idea of medical residency. So the first was William Osler, who was an internist and he originated the term resident because he required his trainees to live at the hospital full time for the entire eight year duration of their training. They were also called house staff because they were literally housed at the hospital. They weren't allowed to marry for that entire eight years. So he like cultivated this idea that that to be a doctor was to be like an ascetic, this like monk, like sort of dedication to your work, that this was the only thing that you would be doing and the only thing you would care deeply about for those eight years. And then the other physician who sort of originated this idea was a surgeon called William Halston. He has many, many legacies. He's sort of the father of cancer surgery.

He.

So he was really famously very Sort of unflinching and really kind of daring. He maybe did the first blood transfusion. He, he, his sister was hemorrhaging postpartum and he gave her his own blood. We'd never done blood transfusions before that. He famously operated on his own mother when he arrived at her house and found her septic on her dining table with, with, with, with gallstones. And he was really kind of famously someone who didn't seem to have normal human needs. So during a period of time when he was in New York, there are records of him working at six or seven different hospitals at the same time. He would go to one, he would operate, then he would go see patients at another, then he would teach medical students at the third, then he would go do trauma surgeries in the evening somewhere else and somehow manage to sort of have this 24 hour cycle. And he kind of wanted his trainees to exist in his own image. So he asked his trainees to work the same, keep the same hours as he did. He had this sort of pyramid model of training where a lot of people started and not that many people finished the training program, as you can imagine. And, and the idea of residency sort of came from the confluence of those two things. This sort of like aesthetic, kind of like monk like devotion, this idea that you should be a person who doesn't have the same needs as other mortals. The idea that you should not be like, you should really deny your humanity in order to be qualified to be a doctor. And we, it was not until years after he died that we learned that William Halstead had been a cocaine addict his entire life. And that was the reason he was able to work those hours without sleeping. We learned it in maybe 2014. And yet we still really line. We still view that as virtuous in our doctors in training. We still view it as virtuous to be able to deny your own needs and be able to function without sleep. This was a time when a lot of doctors were experimenting with a lot of anesthetics and maybe cocaine was the most effective of those. But, but it's so interesting that we haven't actually, we haven't progressed that far from that sort of like, even as we change the structure of residency programs that value that idea, that like, that somehow being able to deny your need for sleep or being able to sort of be this kind of like aesthetic person who has no other humanity is still something that we really value in doctors. So fascinating guy gave us a lot of many legacies.

Yeah, the book is juicy I'm telling you, there's like surprisingly juicy history that you have in here. So I'm going to sort of ping pong back and forth between the room and the dory and some of our continued questions, so. Oh, looks like we have a question in the room. Take it off.

I'm intrigued by the idea in the blurb about the talk about the gray area between sanity and insanity. And we'd love to hear a little of your perspective there.

Yeah, I think one of the things that I thought a lot about when I was writing this book is that I think in medicine, like we like to believe that our like diagnostic categories are sort of like objective truths or natural kinds even, but they're not. They're like man made and they're invented by sort of what we understand about medicine at a particular moment. And it's so interesting. I think there are many different ways to kind of, to grapple with that, but one is just to think about how the same experience or the same set of symptoms can be read differently in different places through different cultural lenses. So there's a really brilliant anthropologist, Tanya Lerman at Stanford, who has done a lot of work on voice hearing across cultures. And she did this great study where she looked at people who hear voices in California, in Ghana and in India and ask them what they heard and how they perceived that experience. And it turns out that the idea that hearing those voices was pathological was not universal. So it wasn't sort of universally true that everyone felt like this was an illness or even disruptive or painful or caused problems. Who the voices were like, whether they were a threatening stranger or a family member or an ancestor or a God also was super variable. So I think we have this idea that there's like an objective truth about like we have this, you know, we have a diagnostic category and it is a natural kind and it exists, it is a feature of bodies. But they're. These are all like subjective and they have kind of cultural boundaries that are a little bit wavy. And so I think there's a, I think there are a lot of experiences that don't fit neatly, are not like neatly or easily categorized as illness or the normal human experience. Because I think our bodies are much more complicated than that.

Thank you. I'm going to ask you a question from the dory as well. Then feel free again to come up and we'll ping pong back and forth from the dory. How easily do brain minds change in adulthood? Do they change? Are we the same person more or less from 30. Onward.

One of the. I think the most interesting things about how our brains develop and age and grow is that I think I sort of. I think I. You might assume that the ways that our brains grow is that they sort of become larger or they start to hold more, but it's actually the opposite. So before we're born, we have. So the. The number of connections in our brain actually starts to dwindle. So by the time we're at two, we lose a lot of the synapses and connections in our brain. And I think it has to do with what we were talking about earlier, this idea of how do you find, like, salience or meaning in the noise? So. So this process is sort of like pruning of neurons and connections happens in. It's sort of in, like, an accelerated timeline before we turn to. But it's continuing to happen throughout our lives. And it is. Part of what happens to the aging brain is that one of the things that happens is you're actually pruning your synapses and you're. And those connections are actually becoming.

You're.

You're losing some of those connections. And I think. I don't think that that's necessarily a. I think there are many kind of. There are many complexities to that. I don't think it's easy to say whether that's a good thing or a bad thing, because I think there's also a way in which being able to. Having much clearer sense of what is salient and losing some of the noise is maybe precious and maybe allows us to do things more efficiently as we get older, even as other things get harder. So our brains do change. They change not in the way that you might expect as we continue to age.

Yeah. What is the purpose of that sort of pruning process? Is it just, like, efficiency, or is there more to it than that?

Yeah, I mean, I think if you ask a lot of different neuroscientists, they would say many different things. But I really like the idea that it's really just this idea that in order to know what information to focus on and what experiences to hang on to. Our brains are not infinite processors, and we have to be able to lose some stuff in order to be able to find something that's meaningful or important or retain things that are meaningful. There are people who believe that that's one of the functions of sleep, is to help us to sort of, like, wash away the things that are no longer important or valuable. And I like that. But maybe it just fits with my Narrative about our brains.

Awesome. Thank you. Can take another from the room?

Yeah. So you mentioned that the brain and how it relates to consciousness is mostly a black box. We don't really understand. But I think the previous question also made me think about this. So in your perspective, how do you think the brain relates to consciousness or what a person is?

Yeah, that's a great question. That's a big question that I don't know, that I have a great answer to. But I guess the way that I would frame it is that I think there's this. I think we have this really sort of exquisite understanding of what neurons look like and the exact chemical signaling that happens. And then at the other end, we have all of this detailed understanding of sort of like cognitive psychology. And we know how people behave in certain situations, and we. And we have information about how people experience the world. But I feel like there's like a step in between those two things that is really hard to. That's really hard to. Like, there's a leap between those two things. It's really hard to make out.

Right.

Like, how do those experiences arise from this sort of massive chemicals in neurons? And I don't think I have a good answer to that. I don't think I have a good way of making that leap or to sort of like bridge that. That divide. But I think to me that feels like the. The sort of.

The.

That's. That's where the black box is, is sort of how we get from one to the other.

Awesome. Let's ask another from the Dorian, then maybe I'll throw one in from. From my sheet here. What are the top two or three things people can do to improve brain health?

So I am not an expert in brain health. I'm an expert in brain disease brains. But I. So. So I would say. So a couple of things.

So 1.

So I think one thing that we're just starting to sort of understand the significance of that probably this seems completely obvious to all of you in this room, But I think sleep is something that's so precious. It is one of very, very few things that everything does. Like all creatures, regardless of how many cells they have or kind of what their metabolism is, need something like sleep or something sort of like a rest period that's similar to sleep. It's incredibly precious. There's some. And it seems like a really kind of deep part of our evolutionary history. It is not just a human universal, but a species wide, across many, many species, a universal. And so I think it is something precious. I would Say, if you have the choice between 10 extra minutes of sleep and almost anything else, extra sleep maybe is the best thing you can do for your brain health. And let me think about what another. Another thing that I think is precious.

For your brain health.

I mean, I think the other thing I would say is. I feel like being open to some of this sort of gray area or open to this. The possibility that what you're experiencing is not sort of easily categorized. I think that's actually a really important part of brain health or existing in your body or. Or kind of like embracing the health or the idiosyncrasies of your own brain.

Okay, that's actually a perfect tie in to the question I was about to ask you, too. Really curious about the theme of sort of navigating illnesses that we have little to no understanding of, which is another thing that you wrote about a lot. This felt particularly urgent to me as someone who has personally navigated long Covid. And you draw a line from sort of historical mysteries like fever in maternity wards to clinicians today facing patients with poorly understood illnesses. Like during your time working on the front lines during the COVID pandemic, those early days when you're with a patient and you're armed with the knowledge that the history of medicine is sort of like, littered with these unintended consequences of trying to help and trying to do your best in the face of just a lack of knowledge. How do you deal with that? And how does that shape what actions you take or don't take?

I love that question. I think there's nothing as humbling for a doctor as reading medical literature from even five years ago, but especially 50 years ago, and being like, what were we thinking? Am I saying something so authoritatively today that someone five or 50 years from now is going to read and say, what was she thinking? And I think there's so, so many different, really lovely examples of that, of the ways that I think doctors are navigating uncertainty in much the same way that people who are experiencing illness are. And I think the example that I will share is one, because we're sitting here in Cambridge, I'll share a New England example, which is I. This is not in the book, but I. It was really fascinated with the history of tuberculosis. My family's from India, which is a place that has very much been shaped by tuberculosis for many reasons. But in New England, at a time when something like 1 in 3 people were dying of what was called at that time, consumption, this really bizarre disease that seemed to cluster in Homes and would cause people to waste away. There was this sort of kind of folklore that the thing that caused consumption was that a family member who had died was from beyond the grave, Sucking the life from their living relatives. And if you think about it, there's something that makes a little bit of sense about that, Right? Like, it clustered in families. People really seem to waste away. People would sort of lose their strength and their breath. It really seemed like there was some vampiric force that was sort of like, sucking the life out of people. And doctors at the time said, this is superstitious village nonsense. These are, like, villagers in Rhode island who have no clue what they're talking about. But at the exact same time, doctors were saying tuberculosis is a disease of wet lungs. Doctors were sending people to, like, the bottoms of caves or to. Or to, you know, to the ocean to breathe dry air to dry out their lungs. Because doctors were also telling stories about what tuberculosis was, how it worked. And their stories were kind of, like, shrouded in a more complicated language. But they were both doing the same thing, which was that they were confronted with this terrifying uncertainty that came with this disease, and they were trying to tell stories to make sense of it. They were trying to sort of explain this set of things that was really beyond comprehension. And I, in my practice, take care of people who have tuberculosis, and I still find it completely inscrutable. It is this wild disease that can lay dormant for decades, that can reactivate in any organ in the body, that kind of plays with our immune system in this really peculiar way. So I understand why it felt so difficult to kind of wrap. For anyone, to wrap their minds around. But I say that. To say that, like, I think, you know, I think it is. It sort of is really humbling to think about the fact that I think medicine was really just trying to tell stories to understand this illness, Just like the people who are experiencing it were. And I think the. The more that we can sort of embrace that there is this uncertainty and that we really are kind of doing the best. We're all humans doing the best with the tools that we have, which is kind of narrativizing around illness and bodies, I think the better we. The. The better we'll be able to serve people. Yeah.

Yeah. Thank you for answering that one. We have another one from our remote audience. Have you ever experienced. Experienced a situation where relying on just the objective truth would have led you to a different diagnosis than also taking into account the subjective?

Yeah, I mean, I think. I think this is especially true for Neurologic illness where I think someone's like phenomenology or someone's experience of a particular set of symptoms sometimes is the is sort of the. The is. Is sometimes the only. The only thing that you can really like, anchor on or go from. So. So an example of that is, is I often take care of people who have epilepsy or seizures and seizure. We used to think about seizures as this thing that we could see. So someone would have shaking of their body and would say, that's a seizure. But in the era of EEGs, we now know that seizures come from the kind of the overactivity of a particular community of neurons. And they can involve the whole brain or just part of the brain. But. But for someone who's experiencing them, seizures are like a phenomenology. It's something you experience in your body. And a seizure could be as subtle as sensation of deja vu. There are people who have seizures that are just a sensation of panic with no reason to be experiencing panic. And I think if you heard that, like, if you heard, oh, this person is coming to the hospital because they've experienced episodes of panic, I think just sort of like if you looked in your textbook, I don't know that it would, it would necessarily guide you to the answer of what sort of is happening in their brain that's causing it. But if you hear someone describe what they're experiencing and you hear that it happens exactly the same way every single time, and there's nothing in their environment that's provoking it, and it always seems to rise and fall exactly the same way, that tells you something about what's happening in their brain that I think the textbooks or the one line summary cannot get at. I do think there are many moments where the subjective experience of illness is where the answers lie.

Yeah. Thank you. We have another audience question from our online audience and we'll probably have time for one more question. So if there's any. If there's anyone brewing, now's your chance. So there was a recent study that showed reversal of Alzheimer's disease in mice due to microdosing of lithium. Lithium orotate. I am not a chemist. This seems like a very hopeful news. Can you say more about the possibility that this could eventually benefit humans?

So I'll start by saying that I'm sure that there are many people who are way more qualified to comment on this specific study than I am. I think the one thing I'll say has been really interesting. I think watching sort of the recent developments in I Think neurodegenerative diseases like Alzheimer's disease and other forms of dementia are a huge subject of focus for pharmaceutical companies and for scientists. And I think what's been really interesting is seeing that there is a. For diseases like Alzheimer's disease. It really, I think the reason that they're so terrifying and the reason that we are working so hard to try and treat and prevent them is because they feel like something that takes from you your identity or it takes from you who you are, it takes from you what you value. It takes from your. Your ability to recognize the people that you love. And it seems like actually in a lot of the, A lot of these studies, a lot of these pre clinical studies, there's a divide between how medications affect your brain chemistry or the structure of your brain and how they affect that like second level thing of whether you remember your loved ones or how you move through the grocery store. And there are a lot of medications that do the first one that haven't shown that they can actually do the second one, which is like keep you, you. I think so. So I will say I am now taking all news about reversal of Alzheimer's disease with a grain of salt because I think there's the question of whether you can fix, whether you can change the course of trajectory of this illness in the way that matters, which is not what's actually accumulating in the cells of your brain, but rather how you move through the world and how you relate to other people. I think that's often still an open question. I think I'm cautious of my optimism.

Yeah, just a follow up on that. I'm curious, are there any. Is that like a common pattern that you see in neurologic diseases and particularly like as we find cures for them or cures for them, that it sort of fixes the hardware issue but not the actual functional problems, or is that unique to degenerative diseases?

I think it's a great. I think it like speaks to one of the things that's really, that's really tough about the brain and diseases of the brain, which is that. But even sort of thinking about like what is a meaningful outcome, what is a meaningful recovery, what constitutes success, I feel like is so subjective. Like I, I'm often in the situation where, where someone has, for instance, they have a cardiac arrest and their brain doesn't receive oxygen for some period of time and the question becomes, are they going to recover? And what recover means or what a meaningful recovery is is so radically different depending on who you ask. And Some people even have a hard time putting their finger on what it is that constitutes a meaningful rec. Like very difficult because there's so much subjectivity to the part that actually matters, you know, which is like, you know, what is that? What does it mean to reverse those symptoms? What are the kinds of reversals that would feel meaningful for someone who's experiencing them? Yeah, yeah.

It's always comes back to again the human at the center of it and actually caring about them and their individual experience. Thank you. When we're in the room. Hello.

Hi, my name is April. I'm a software engineer here at Google and I don't have any like medical background myself, but my partner is a third year medical student so I've really like learned a lot about kind of medical training through him. I think like one challenge you touched on is the fact that the brain is kind of like a black box. There's a lot of unknowns. And I'm kind of curious, like, as a doctor who maybe like treats patients who have like neurodegenerative diseases with like no cures, how you kind of go about communicating with patients, kind of dealing with that uncertainty yourself if you've kind of found a method of kind of just being honest with yourself and the patient, but also seeking answers.

I think that's a great question. It's a really hard one that I still struggle with. I think uncertainty and ambiguity should be a huge part of how anyone practices medicine, especially in neurology. But I think in all of medicine and I think sort of treating uncertainty, approaching it with curiosity rather than with sort of make. Allowing to make you feel powerless, I think is really important. I'll say that when I. So when I was a third year medical student, I feel like everyone told me that I shouldn't become a neurologist because we had so many fewer treatments than we did diagnoses. And I don't think that's quite true anymore. I think we have a lot more treatment options than we, than we did when I was a third year medical student even. But I still like at that time I remember feeling like. I don't think I. I don't think that bothers me in the sense that I think that there's such a power in naming something or there's such a power in like someone experiencing something in their body and feeling like they're not sure if it's real or feeling like they're not sure what it means and being able to say, you know, like what you're experiencing is real. This is an experience that other people have had. This is something that tells us something about your brain or your spinal cord or your nervous system. I think a diagnosis can sometimes be almost like a prophecy. Like it tells you a little bit about what to expect and how you might want to live your life. And so I think there's like a huge power in that first step of hearing someone's symptoms or examining them and arriving at a thought about what might be going on, whether it's a neurodegenerative diagnosis or something else. And I think that has as much power as any medical treatment in some ways. I think just even being able to tell someone, give some information that will tell them how they want to live their life or how they want to move through the world, I think can be really powerful.

Thank you. Awesome. Thank you so much for taking the time to talk with us today. And thank you, everyone, both in person and remotely, for engaging in such interesting questions. I had a great time reading your book in prep for this and learning more about your experience and your thoughts on this space. I'll have you take us out on one last sort of hopeful, happy note, hopefully looking ahead in the next 10 to 20 years. What is the mystery about the brain that you're most excited for us to potentially solve or unlock?

This is a really hard question. I'll say. I think it's interesting. We talked a little bit about the language of medicine. So we still talk about neurologic diseases as being organic or functional. And organic diseases are ones where we can see the wound. So where that. That Parisian neurologist could dissect someone's brain and say, this is where the problem is. I can exactly see where the neurology uses the word lesion is. And functional ones are ones where you are having an experience and we don't have a lesion or a wound to explain them. And I think we. This is another situation where I think medicine sort of acts as if that is a natural distinction, but I think it really is the distinction between things we don't yet fully understand and things that we. That we have the technology to visualize and understand. So I don't know if we're going to come any closer to sort of understanding those functional symptoms any better. But I hope that at least in 10 to 20 years, we will acknowledge that it is a mystery and that it is. It's. That it's a failure of our own, of our insertive technologies in our own and our own understanding, rather than of any person who's experiencing those symptoms.

Thank you so much for such a wonderful talk. Thank you, everyone. Thank you so much.