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

Foreign. Hey everyone. Welcome to the Peter Attia Drive. I'm your host, Peter Attia. The Drive is a result of my hunger for optimizing performance, health, longevity, critical thinking, along with a few other obsessions along the way. I've spent the last several years working with some of the most successful, top performing individuals in the world, and this podcast is my attempt to synthesize what I've learned along the way to help you live a higher quality, more fulfilling life. If you enjoy this podcast, you can find more information on today's episode and other topics@peterattiamd.com. Hey everybody. Welcome to this week's episode of the Drive. I'd like to take a couple of minutes to talk about why we don't run ads on this podcast and why instead we've chosen to rely entirely on listener support. If you're listening to this, you probably already know, but the two things I care most about professionally are how to live longer and how to live better. I have a complete fascination and obsession with this topic. I practice it professionally, and I've seen firsthand how access to information is basically all people need to make better decisions and improve the quality of their lives. Curating and sharing this knowledge is not easy, and even before starting the podcast, that became clear to me. The sheer volume of material published in this space is overwhelming. I'm fortunate to have a great team that helps me continue learning and sharing this information with you. To take one example, our show notes are in a league of their own. In fact, we now have a full time person that is dedicated to producing those and the feedback has mirrored this. So all of this raises a natural question. How will we continue to fund the work necessary to support this? As you probably know, the tried and true way to do this is to sell ads and but after a lot of contemplation, that model just doesn't feel right to me for a few reasons. Now the first and most important of these is trust. I'm not sure how you could trust me if I'm telling you about something when you know I'm being paid by the company that makes it to tell you about it. Another reason selling ads doesn't feel right to me is because I just know myself. I have a really hard time advocating for something that I'm not absolutely nuts for. So if I don't feel that way about something, I don't know how I can talk about it enthusiastically. So instead of selling ads, I've chosen to do what a handful of others have proved can work over time and that is to create a subscriber support model for my audience. This keeps my relationship with you both simple and honest. If you value what I'm doing, you can become a member and support us at whatever level works for you. In exchange, you'll get the benefits above and beyond what's available for free. It's that simple. It's my goal to ensure that no matter what level you choose to support us at, you will get back more than you give. So, for example, members will receive full access to the exclusive show notes, including other things that we plan to build upon, such as the downloadable transcripts for each episode. These are useful beyond just the podcast, especially given the technical nature of many of our shows. Members also get exclusive access to listen to and participate in the regular Ask Me Anything episodes. That means asking questions directly into the AMA portal and also getting to hear these podcasts when they come out. Lastly, and this is something I'm really excited about, I want my supporters to get the best deals possible on the products that I love. And as I said, we're not taking ad dollars from anyone. But instead, what I'd like to do is work with companies who make the products that I already love and would already talk about for free and have them pass savings on to you. Again, the podcast will remain free to all, but my hope is that many of you will find enough value in one, the podcast itself, and two, the additional content, exclusive for members to support us at a level that makes sense for you. I want to thank you for taking a moment to listen to this. If you learn from and find value in the content I produce, please consider supporting us directly by signing up for a monthly subscription. My guest this week is Zubin Damania, aka ZDoggMD. Zubin and I have been friends for about 20 years and we talk about that actually at the outset. So how we met and things like that. We kind of lost touch for a few years, but then reconnected at TEDMED in 2013 when we both spoke. This is a kind of interesting episode in the sense that I wanted to interview him, but he wanted to interview me. So when I got to his studio in Vegas, which is where we did this, and his crew is there, we filmed it and actually ran it as a sort of a Facebook Live. And in the end it really, I think, comes across as a pretty equal balance of about a 5050 of just two dudes sitting there talking about this stuff. And it was really a mutual interview. Zubin, or as we call him, Zdogg, is kind of One of the most talented people I've ever met. I mean, not only is he talented as an amazing doc, but he's just musically gifted. He is comedically gifted, and he has put those things to an amazing use in what he does. So he has all the usual accolades. He trained at Berkeley, ucsf, Stanford, internal Medicine, and of course, that's where we met. And he went on to found something called Turntable Health in Las Vegas, which was part of this broader ambition of the urban revitalization in Las Vegas that was spearheaded by Tony Hsieh, who is the CEO of Zappos, and that's the guy who recruited Szubin there. This all started because Zubin was working as a hospitalist at Stanford in internal medicine, but he had this whole side gig of doing comedy and music, and it was that which Tony saw that made him think, hey, man, you got to do something a little bigger than just being an internist at Stanford. His videos are amazing, and we're going to link to a lot of them. In particular, Ain't the Way to Die, Lose Yourself in seven Years are my three favorites, but I've seen every one of them multiple times, and I've been following this for a long time. Many of these videos have gone viral, and I think in aggregate, he's got about half a billion views, views on Facebook and YouTube. And these are educating patients, educating providers, and kind of mercilessly creating a satire of our entire dysfunctional healthcare system. We do talk quite a bit about healthcare, and Zubin's given this much more thought than I have, but it was just so interesting to get into this stuff and we get into some really deep philosophy stuff. Basically, he just stumps me all day long with philosophical questions about consciousness and the mind and other things like that. I would say, overall, this is probably one of the most enjoyable discussions I've ever had with somebody in this sort of format. I've talked a lot about how the discussion I had with Jocko a few years ago was one of my favorite. I would put this up there as well in probably the top three discussions, just in terms of overall enjoyment. So the show notes will link to a bunch of really cool stuff, but you can also go to his site, ZDogg, and that's just two GS on the dog, maryland.com. so I'm really excited to introduce all of you to Zubin Damania.

We are live. What is up, Z Pack? It's your boy, ZDoggMD. I am live and direct out of Studio Z. You are not Gonna believe it, but we're doing something absolutely different. What's this big phallic symbol in my face? It's called a microphone. Okay, Learn about it. And I have it because I have a good friend that goes way back to my Stanford days. He is a physician, he's an engineer, he's done crazy stuff, worked with the world's top performing individuals to try to teach us not just how to live longer, but how to have a longer healthy life, a health span. He is one of my favorite people because he's uber smart. Hangs out with all kinds of hoity toity people like, you know, Tim Ferriss and Sam Harris and all these smarty pants intellectual dark web people. But more important than that, he's a bald off white Doctor. Welcome, Dr. Peter Attia.

Thank you so much for having me on this co hosted event today.

That's right. So what we're doing different now is we're co hosting this. You're in Vegas to give a talk. You have your own podcast called the Drive, which is a stunning deep dive into the nerdiest shit I've ever seen in my life. I love it like you're talking about. I heard Seyfried, Dr. Seyfried's one about how cancer may be a metabolic illness and how the mitochondria are abnormal. And you're like in his face going, well, just because they're morphologically abnormal doesn't mean that the function. Have you actually fractioned? What's your ideal trial? And I'm just going nerd, nerd, nerd, nerdgasm. But also you are even more than that. You're talking about how to maximize human potential in a way that's uniquely human. And that's what I love about you, ever since our Stanford days.

Well, speaking of those, let's retell that story. So I'll do this from the lens of how I would introduce you to my listeners, but I think your listeners will also be intrigued by this. So I was one year behind you in medical school. Now you went to ucsf, I went to Stanford. Is that correct?

That's right. It was a gang war type of deal.

That's right. This was back when the merger was trying to happen unsuccessfully.

That's right.

Pure animosity between the two best programs on the West Coast.

That's right. You guys thought you were all that because you were rich and we were ghetto as fudge.

But in the end of the day, you come to Stanford to do your residency in internal medicine. So you are now an intern in the internal medicine program. I'm a fourth year medical student. Yeah. And I had already decided I was going into surgery, so I had done the heavy lifting to begin that application process. So I'm doing internal medicine, but there's no pressure because Stanford is pass fail. And it's like, how can you fail the rotation? You know, it's not like I wasn't gonna show up, but I didn't have to like, be the smartest kid in the room. I didn't have to like impress the hell out of the residents. I was like, hey, I'm gonna be a surgeon. I might as well learn whatever things in medicine apply to taking care of surgical patients. So we show up on day one and you're the Internet. I don't remember who the second year was.

I don't either.

Yeah, the third year, I'm blanking on his name. But you called him Darth Vader because his fantasy, he said, was to walk. We can't name him now even if you remember, but he's described that his fantasy was to walk down the hall of the hospital with a cape because he was so smart and everyone would think he was Darth Vader.

I know exactly who.

You know who I'm talking about.

Oh, my God.

I remember his name now.

Malignant.

We're not. Yeah. We're not going to say his name.

We won't say it. Yeah.

Yeah.

Welcome to Stanford.

So I was kind of like, this guy seems like a douchebag. Meaning the chief resident pointing at me.

Because that also is true.

Yeah.

Yeah.

And the second year was a non personality. Was my recollection, like, just didn't. Like they were sort of there, but not there. And you were the intern and it was out of control. I could not imagine how much one could enjoy a rotation of internal medicine. I don't even remember where we were. Were we the va? Like, it was.

We were at the mothership.

We were at Sydney with the mothership.

You know, it's weird. I'm getting like this weird emotional reaction because I remember you so well. And the thing is. Look, look, look, dude, I've taken care of a lot of people. I've been through a lot of teams. There are very few people I remember. And I remember fucking Peter Attia. Coming up, medical student, fourth year. Cocky as hell. Because you were going into surgery. Did you already match?

No, I hadn't matched.

But you, in your mind, you.

I knew I wanted to go into general surgery. You knew.

And so on a medicine team, we've Already written you off as someone who doesn't matter to us because you're not.

Going down putting any energy into teaching me anything.

And then you sat down and did the entire monologue from Austin Powers, Dr. Evil and the Therapist, like, oh, my life is. I don't even remember it.

Yeah.

And you were bald at the time, or shaved head and had the finger here and did the whole thing. And I'm an intern, right? The only way I can cope with this shit is through comedy, through humor. Humor was my coping mechanism from the beginning. And this guy does this thing and you're a medical student, first of all, you have the balls to come up and do that thing, which in a hierarchical system like that already I'm like, this guy's my hero because I'm oppositional defiant. And then you nailed it perfectly. And I'm like, who is this guy?

So there's an interesting backstory to that. So my very, very first rotation was pediatrics because when I went to medical school, I thought I was going to be a pediatric oncologist.

Wow.

So I figured I better figure this out quick. And so I'm going to do pediatrics first. And this was the moment when I knew I couldn't be a pediatric oncologist, was when I realized I couldn't be a pediatrician. And I'm not saying that to upset the pediatricians because maybe it was just I couldn't be a Stanford pediatrician, but on about the fourth day of the rotation, there was like this really chubby, cute little baby in the nursery. You know, I forget, I forget what was wrong with, you know, dehydrated or something like that. And we were taking care of it and I just decided at that moment it made sense to walk down the hall and pretend I was fat bastard and talk about wanting to eat the baby. So I came out of the room and I was like, baby, get in my belly. And the whole rest of the night all I did was talk about the other, other white meat.

Oh, my God.

And I mean literally, not one of them, not one of them even smiled. They were mortified by my existence.

Humorless bastards. Forget about fat bastards. You know, it's so funny. See, this is why you and I get along. You're an introvert, I'm an extrovert. You're incredibly science minded, diligent, industrious. I'm the opposite. I'm lazy, I procrastinate, and I use smoke and mirrors to get any success I can and grasp onto it desperately. But the truth is we have a very similar disturbed sense of humor one time in hematology. So here I am, like, I'm a second year resident and the attending is a guy named Steve Coutray, really renowned guy. And we're on everybody's stress. It's young people who are dying, like, all over the place. And I had already built. You know what happens in medicine. You start building this brick wall around yourself so that you don't feel what's going on, because the minute you feel it, you're in the stairwell crying back and forth, and it's just morally distressing. So to cope with that, I built a wall. But then I started using humor. So Coutray, we had these really hard, sick service, and there was this creepy puppet that one of the patients had donated to F ground, which was our ench floor. And it was this weird hobo, like, had a little stick and these little things. You put your hand in its butt and you make it do stuff. And that sound, that came out wrong. It's a puppet.

I know what.

You know what I'm saying?

They have a very large anus, extremely loose sphincter tone.

Yeah, yeah. And so.

And no curvature in the colon. It's more of a mono. Like the GI tract basically goes the esophageal anal canal as well.

It's a straightened and shortened track. You know what? That always bothered me. That being said, rounds are happening. And Coutre goes, so, Damania, did you see, you know, Mr. Pickles in three? And I go, I didn't. I'm sorry. And you could see him just like, you know, this guy fucking sucks. And I go, but mini Z did. And I pull out the hobo clown. And he's like, the thing about this guy is, okay, he's feverile overnight. He's probably got some tumor lysis syndrome. And Coutre looks at me for a second and I'm thinking, I'm done. I'm fired. And he breaks into laughter with tears rolling down his face, and the whole team is laughing. And I'm like, you know what I found? My path, it is to try to bring some levity to situations that are disastrous. And that gave me hope because it could easily have gone the other way. I've been told things like, hey, you speak and then think, you should just reverse that. Or better yet, just think, an attending told me that at UCSF.

So when you and I took USMLE 2 so the final exam to graduate from medical school, we were about the last classes to do that before they switched to, like, live patient, actor interactions.

Is that right?

Yeah. Or we were very close. We were close to that because they.

I had just a scan trial.

That's right. Yeah. As did I. Yeah. But then they brought in, they said, you know, Stanford's gonna be one of the test sites for, you know, doing this whole thing. Because USMLE 2 is moving towards half the test being written and half the test being clinical with actor patients. You know, we were basically just being asked to do this so they could figure out the, you know, the kinks in the system. So for whatever reason, it was just too long a day. And I just wasn't really in the mood to deal with these actors and actresses who were annoying as hell to me. You know, you'd go in there and you sort of knew what was going on. You'd ask all the right questions, and then they'd give you this scathing feedback like they didn't even know what they were talking about. And it just bugged me. Right. But you can picture this, right?

Yeah. I don't know if you guys can hear me breathing angrily, but this is. I had the exact same experience. Keep going.

So we had to do nine of these in a full day. Each encounter took 30 minutes, 20 minutes to do the thing, 10 minutes to get the feedback. I do a really honest to good job for the first eight. I really. I'm trying as hard as I can. I'm doing the best I can. I'm taking my beatings. We're going into the last one and I just lose it. I can't do it. And so I pull the chart out of the medical thing and it says, you're seeing Mrs. Smith. And Mrs. Smith is here to talk about her daughter Susie, who is wetting the bed at night. That's all the information you have. So you got to go in and now play the pediatrician or whatever. So I walk in and I say, hello, Mrs. Smith. And she looks at me kind of funny and she says, hi. And I said, My name is Dr. Evil. I went to Evil medical school. And she's, okay, well, Susie is some. And she starts talking about Susie. And I said, I don't really want to hear about the details of Susie's life. Let me tell you about the details of my life. And then I do the entire monologue from Austin Powers.

They are quite inconsequential.

Ending with a Zoroastrian named Vilma ritualistically shaved my testicles.

And as a Zoroastrian, yeah, you can.

Appreciate close to home. And I Keep going. And then all of a sudden, the door, like, basically breaks down because they're videotaping this whole thing, which you knew. I knew that this was happening. And they get so pissed, they run and they go, this is over. This is absolutely done. It is totally inappropriate. What you just. And I said testicles. I said shorn testicles. That's a medical term. That's completely legitimate.

Did you tell them? Have you ever experienced shorn testicles? It's quite exhilarating.

I suggest you try it.

I suggest you try it.

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

That is the most amazing thing I've ever heard in my life. I'm so proud of you, Peter Attia, as your superior officer in school, because I thought that those patient actor things were the stupidest bullshit in the world. Okay? This is what they do. This is what they tell you. You know what? You need to have empathy. You need to be able to read people. You need to be able to see through lies and get to the heart of what's going on. So what do they do? They put you in a room with a professional liar. And when you see through it, when you see it for what it is, which is zeros and ones, you go, this person's faking it. I can't. How can I show empathy to someone who's pretending? You want me to pretend I can become a liar, too? And so I did the same thing. I went in the room, hands in my pockets, like this. The woman had fake bruises on her face. She was supposed to pretend to be abused. And my first reaction was, how dare you pretend? How dare you mock people who've actually been abused? You're doing a shitty job of it. You're not a great actress. And I'm being judged on how I pretend, right? Like, this is horrible. Give me a real patient. So I'm. So, did you pass?

Well, it didn't matter because it was right. It was just. We were being used as a trial site.

Oh, I see.

So the next day, I get a page. This is back when we used to carry those alphanumeric. Not even the alphanumeric pagers, just the straight numeric pager. And it's the dean's office. And I'm like, you've got to be freaking kidding me. It's like a month before graduation. I'm like. So I call and it's like, hi, this is Peter Attia returning a page. And they said, oh, Dean, so and so wants to speak with you wait a moment on the line, and I'm like, God damn it. So I just get all defensive. So he gets on the phone and he goes, hi, Peter. And I'm like, Dr. So and so, look, before you say it, I just want to say one thing. This was totally ridiculous. And I go off on like a four minute rant about how idiotic the whole process was. And he goes, he goes, well, look, I just want to say I watched it last night and I thought it was hilarious. And I really think you should question whether or not you should be at least incorporating some of that into your career. So I just wanted to call you to say good job, you know, And I was like, that is fantastic. That's like the highlight of my medical school.

There is hope in the universe. Peter Riz. I had a similar experience at UCSF when I did a graduation speech that actually launched my whole career as ZDoggMD because I later put it on YouTube. It's in my 1999 UCSF graduation speech. It's there, it's all captioned and everything. And I just went through it as I saw it and it was all just like, this is bullshit. This is bullshit. This is bullshit. This is why this is bullshit. It's about actually connecting with our patients. Isn't that. And the majority of the faculty behind me were just like stone faced for 90% of it and then finally start to crack. And you see Michael Bishop, who's like a Nobel Prize winner, finally, he's like. And afterwards they were like, that was very well done. But there was one guy who was like, that kid shouldn't be allowed to graduate. And actually was lobbying to have my graduation revoked for giving that speech. I mean, so this is the thing. It's a hierarchy. And I can tell you don't like hierarchies so much.

I probably have more respect for it.

Than you actually being a surgeon.

Yeah, I don't. I don't know. I feel like I'm not as. I don't bristle as much at it as probably some people. I mean, I would say for a surgical resident, I respected it much less than the other residents. And I definitely got into trouble on a few occasions as a result of it.

Yeah, yeah, yeah.

I've met people who completely have absolutely disregard for any hierarchy. And many of them go on, just do the most amazing things. So I always felt like I wish I had less respect for it.

Well, you know, it's a complex thing because I think certain personality types don't like to be in the middle or bottom of hierarchies. They either want to be on the top or they want to be off the hierarchy. It's hard for them to feel like other people are controlling them or they're beholden to others in the higher hierarchy. And they either have a tendency to dominate those underneath or to treat them as equals inappropriately, in which case the lower down and the hierarchy don't have the competence. And what they need is actually to be trained and lifted and supported. And instead it's like, why aren't you at the level that I'm asking you to be? And so it's interesting, it becomes tough in the higher echelons of performance and stuff. People.

I think the problem I had in residency was I really loved hierarchy when I could respect the person I was reporting to. So luckily I did my residency at a hospital where most of the residents were just exceptional. So it, for the most part was really easy to respect the hierarchy. But the problem was when I encountered somebody and I didn't think that they were good enough or smart enough or new enough, I wouldn't hesitate to just steamroll them. And that gets you into a lot of trouble.

I saw that in you when you were a medical student. I remember it. It was one of your characteristics that I actually respected a lot. Because again, if you, like you said, you kind of described our team pretty well. The person at the top was fairly narcissistic. The one in the middle was kind of a non entity. Then there was me, who was the class clown, and then there was you. And it speaks to our medical training in general that it really is about kissing the ring of the authority figure. So one day you will be the ring that's kissed. That's the majority of our training. The first two years, we're fed a bunch of information, 50% of which is wrong, but they don't tell us which 50%.

And then the 50% of the residual will be outdated by the time you finish.

Exactly. So it's 100% bullshit. And yet we're expected to kind of suck it all in and regurgitate it with respect for this hierarchy. And we don't ask questions, we don't step out of that. And you're right, you have to respect your authority figures, which is important when you trust and respect them. But when you're questioning things like why are we doing this? Why are we giving Lasix to this person? Or why, what's going on with this renal failure? Actually, what about the root cause of that? You start asking this question. No, no, no, no, no. That's when I was told, hey, you speak then think you should reverse that. They don't want to hear that from a medical student. And, you know, we had the short white coats and everything. You guys had the long white coats. It wasn't as hierarchical.

It was very unusual. Yeah. I didn't realize how quote, unquote special that was until I saw that there were many programs where even the interns were still in short white coats. And I didn't realize, like, what a big deal that was, like, how much obsessing went into the white coat thing. I feel like an idiot even just voicing this right now because I've never thought about this for, like, 20 years, but what a big deal that white coat is. And I feel bad. Maybe I should be more respectful of the white coat.

You know, when I came from ucsf, nobody wore a long white coat except for fellows and attendings. So even the residents wore short white coats. I think Hopkins was that way. They're just starting to change it. When I came to Stanford, I saw you wearing a long white coat, and my conditioned unconscious wanted to smack me.

Like, how I haven't earned it.

You haven't earned it. I haven't earned the long white coat I'm wearing as a R1, as an intern. It's such an interesting process. It's almost militaristic. It's a very military hierarchy. And the question is, is that good? Do we need that? I think some degree of organization hierarchy is important when people's lives are on the line. Same within the military, right?

Yeah.

You're friends with Jocko Willink and these guys. I mean, what would he say about this? I don't know.

I'd hate to speak for anybody, especially Jocko. But the challenge comes when you have to make a decision that is probably not the best decision for the patient, but it's the one that's coming down from the person just above you. And I always found the stickiest situations were. And I had an example. And I want to be very careful. I don't reveal too much because this was such a vivid example in my residency. But there was a time in my residency when I was an intern, and it was a small surgical service, so it was me and a chief resident only. So you didn't have all, like, the 17 layers. So it was, you know, you basically had attending, fellow, chief resident, intern. So there was only four people in the chain of command. And there was a situation that was, in my mind, clearly a Case of someone that needed to go to the operating room. I don't think you even needed to be a physician to know that this person needed to go to the operating room. I think if you walked into McDonald's and just polled 100 people there, 97 would say, yep, that's a surgical case.

Yeah. And the third would be like, I want extra.

The other three, I might miss some finer details. So I called the chief resident, and this was a weekend that I was on call, and I said to him, hey, I got this case, and, you know, blah, blah, blah, blah, blah, needs to go to the or. And he was like, just deal with it yourself. And I said, look, I know you're upset at me. I've already called you twice today. This was 8pm and I had already called him twice on the Sunday, and he had had to come in both times because of the injuries were so severe that I was calling him about that they had to be taken to the or. So he'd already been to the OR twice that day. It's a Sunday. He's pissed. It's his day off. So now I'm calling him at 8am or 8pm to say, this is a surgical case. He's saying, you fix it yourself. I'm saying, look, I technically could address this in the er, but that's not the best thing to do. And he was like, stop being such a fucking pussy. Huh. So this was your attending? No, no. This was the chief resident. This was the chief resident. Yes.

Yeah.

So, again, I don't want to get into details of it because it could kind of give away the identity of any of the people involved. In the end, I did deal with it in the er, and I dealt with it the best I could. Admitted the patient the next day. Everyone's rounding and they see the patient and they're like, God damn. How did this not go to the or? So what I realized in that moment, and I was very early in my internship, I mean, days into my internship, actually, what I realized was the mistake I made was I didn't call the attending directly.

Go right above.

Yeah. Again, it was so obvious that this chief resident was wrong. It's so obvious he was being a lazy sack of shit. So I should have just called the attending. Now, at the time, that wouldn't even occur to me. I mean, that's like, you can't break the chain of command. But I look back at that, and I view that as probably. Certainly one of probably my five biggest failures in residency was the weakness, the inability to break that chain of command and deal with the consequences of it, because there would have been consequences of that. Even though it was the right thing to do, and even though that patient would have gotten much better care, I would have paid an enormous price for that through the duration of my residency, at least in that era. And I don't know, I feel like in some ways I was just a coward, you know, or a deer in headlights. I just didn't know what to do. So I thought, okay, I'll do the best I can.

You know what? I want to dig into that because this story is at the center of what we're now calling burnout. And I don't think it's burnout. I think it's moral injury. And Talbot and Dean and others have written about this in STAT and other places. You were in a position where all the system was arrayed to make it very difficult for you to do the right thing for the patient. You knew it was the right thing. You knew the patient needed to have this done, and you knew that it would cause serious consequences to you to have it done. And you erred on the side of, okay, well, maybe the system is this way for a reason, and it'll be okay in the morning, and it may not have been. And then you had to live with the shame and the guilt of not having done something that was self destructive, that was not in your best interest to help this other person. And to this day, I can tell, sitting across the table from you, that this bothers you deeply. You're saying it's one of the five things.

It bothered me so much that for at least 12, 15 years after, I would contemplate asking one of my friends who was still at Hopkins. You know, by this point now, a few of my friends who had finished were still attendings at Hopkins. I had contemplated asking them to dig through the medical records to find out what happened to that patient, because I couldn't remember the patient's name, but I remembered the date. So I was going to say, hey, go back to this date and look at everyone that came in the ER on that day, and I will be able to figure out which this person is. I want to know what this person is doing today. And I kid you not, this is actually a really funny story. I mean, funny in this. This one twist. I know you're a huge fan of Dr. Oz, right?

Massive. Love him.

Yeah.

So glad you were on his show, by the way.

Right. So I was on that show and a little embarrassed, truthfully, because I Felt silly. And I didn't think it made sense for me to be on, but nevertheless, I was on. And I didn't know when it actually aired, but when it aired, I heard from the patient's mother, who was also there. And to make a very long story short, it reconnected me with the patient who was doing exceptionally well. And it was, you know, in a way, maybe it's wrong that I could alleviate some of the guilt by knowing that the patient turned out okay. But it was unbelievable because even this patient said they'd never watched this show before, this Dr. Oz show. They just happened to be in the waiting room, I don't know, getting their car fixed or something, and they saw it on TV and they were like, hey, I know that dude.

That patient recognized you across the years.

Yeah, this would have been 15 year Delta. And then connected with me through my blog or something like that.

Really, we have to let that sink in. That at the heart of all of this. And you're, you know, listen, you're an amazing scientist. Your podcast is unbelievable. Like, I listen to it, I'm enthralled by it because I'm also a huge nerd. But the fact is, that was a human connection that you made that also was a victim of a system that was so broken that it caused you moral distress that lasted for years and was only partially ameliorated by reconnecting with that human at the center of that. Now, let's take that that you suffered and scale it by a thousand times every single day. When we have to take care of patients, we know full well what needs to be done. We know where the fuck ups are and where things have gone wrong and where our system has failed and we have powerless. Not only powerless, if we do the right thing, we will lose money, we will lose time with our family. We'll be charting all night, and it still may not work for the patient.

Now, for my listeners who aren't as familiar with this stuff, help me understand what that means. So you trained in internal medicine when you finished at Stanford, what was the first job you took as an attending?

So I'll be honest with you, about year two of my residency, I wanted to do GI because I was always intellectually interested.

Your dad is a gastroenterologist, isn't he?

Actually a primary care doc who also trained in pulmonary. But I just, for some reason, I always love GI physiology, love hepatology. I love the way that digestion works and the mind, body, gut connection I thought was fascinating. Like, I loved irritable bowel syndrome, because I thought, how interesting that the mind can influence what we sense in our gut. We. When we get butterflies and that kind of thing. So second year, though, I did the rotation, had a terrible mentor. It was just scoping routinely, doing colonoscopies and EGTs, and it was horrible. The idea that that could scale for a career was mind numbing to me.

Because when I hear someone saying, I want to go into gi, I assume they mean they want to be a. You know, they want to do scopes, because that's the most lucrative part of gi, right? But you were more interested in like the medical part of gi.

I like the medical part of it. And even hepatology was a little too much. But I wanted a scope that was cool. That was video games in people's buttocks. Awesome, great. But I like talking to patients. I like the relationship and I like the physiology of it. Talking to people about their issues. Because abdominal pain, chronic abdominal pain, constipation, nausea, vomiting, a lot of times these are deeply connected to the mindset. And so that's what I loved. But then when I saw the scoping part of it, it was like, I hate this, I hate it. And this is most of how I make a living. It was repetitive, mindless to me. It didn't sit with me. Plus, I was starting to get disillusioned in general with medicine because most of what we did seemed like bullshit. Most of what we did either harmed people or just wasn't thought out. You know, it's half baked. And the thing is, that caused the kind of moral distress. So I was like, forget it. I was burned out. I was tired. So by third year, I remember my program director had to pull me in and he's like, you're a bad influence on the interns. It's one thing to be burned out and tired. It's another thing to model that for the younger. And it changed me totally. Then I became this great teacher and got focused on that as a way to have self worth.

And what were you doing to be at a bad influence? Sarcasm? Or like, had the humor gone too far? Like, what was it?

The humor got very dark. It became more of a wall than a coping mechanism. So it was more like, how can I mentally victimize everyone around me by throwing blame to build a wall around myself? The fact that I feel morally bereft doing this job, so, you know, calling patients gomers, you know, this slang that we're talking.

What does it stand for again?

It stands for get out of My er. And it comes from the book House of God.

Yes, yes.

And so I would use every verb.

I haven't heard that in, like, the longest time.

Because it's a horrible thing residents say.

Yeah, but we heard it all the time. I just had forgotten what it was.

Not only do you hear it all the time, I had conjugated every form of that verb. So it's like that guy's gomed out. He's in status gomaticus. You know, this guy's preparing to gom. He's like proto gome. He's got serious gomopathy, like every version of Gomer I could use. And it came from this black hole in my center where it was like, I'm a bad person, right? I'm a worthless poor, and that's burnout. But it's really moral injury. So because of that, I decided I was taking. I told our program director, Kelly Scoff. He knows this story I've told publicly. I said, kelly, I can't. No, I'm not gonna match. I'm not gonna do a fellowship and I'm not gonna practice medicine. I'm gonna go into tech. Cause I'm in the Silicon Valley. I'm gonna work for a couple startups and see what happens. And I did that for a year. And in that year, and I learned a lot about myself. I learned that without that stimulation of that deep relationship, like, money as a stimulus was never gonna cut it for me, which I wanted it to. Peter. I wanted to be rich. It couldn't happen. I was doing well. I was moving up in these companies. And then I just felt empty. So my buddy John offered, said, hey, there's this hospitalist gig at Stanford. You should take it. It's all your colleagues from residency. We're doing this cool stuff. It's great. And I said, I'll try it for a couple months. I was there for nine years, and that was the first real medical job. I was moonlighting, and I loved it, but this was it. And being able to spend time with patients when they're acutely sick in the worst day of their life, in the hospital, sitting with them, spending time. It was before the ehr. The electronic health record kind of destroyed our ability to make eye contact. And it was beautiful, man. I kept a diary because I was weird in those days. I was like 30, and I was like, I'm blessed. Like, who gets to do this? Like, I found my perfect niche. And it lasted probably four years before things started to change.

So then what changed four years into that nine year stint, I think what.

Changed was what's been changing in medicine across the board, which is the creep of medicine as business, medicine as assembly line, medicine as process to be improved, not medicine as deep human relationship. That's a sacred calling. So what ended up happening is EHR goes live productivity, we start to lose house resident support. So we're more. They're expecting us to just see a bunch of patients to generate revenue. And it's not so much about teaching, it's not so much about mentorship, it's not so much about a team. What I love about the hospital you go through, hey, Bob, how you doing? Social workers there, case managers there, we know everybody RTs and they're all, we're all supporting each other. It's not hierarchical. It's like whole archical, like everybody brings their thing. That started to disappear with the pressure of click, click, click. Then I was going home and charting at home. And then I had my daughter, my first daughter, in 2007. And that was a tipping point where I was like, I'm treating my daughter like, you know, my burnout is expressing in how I'm treating my daughter. And I can't spend time with her, I can't read her stories. At night. I'm thinking about clicking these boxes in epic and I haven't finished this note and did I remember to check the potassium on that guy? And I, you know, I'm the type of guy who can't just sign it out. I have to like, I own it too much. So it just got horrible and I started being nasty and like my relationships were suffering and, you know, what did.

Your wife think at the time?

So she was a radiologist, academic radiologist at Stanford. So she found a path that was really perfect for her. Introvert, very science minded, loved the team dynamic of it. She looked at me and was like, you're in a bad.

Did you guys meet at ucsf?

We met at Stanford as interns the year that I met you. She did all of medicine and then came to an epiphany. Don't like medicine. Parents were really into medicine, both were medical people. She's like, they didn't see radiology as a real doctor. You know, Chinese parents, it's a lot of pressure. So she's like, you know what, I'm not gonna specialize in pulmonary critical care. I'm gonna go back and do chest radiology and Zubin, you're gonna support me, by the way, for four years of more residency and fellowship. And I was like, all Right. And so when that table turned and I was miserable and depressed, she was the first to say, you know. Cause we had gotten this. I mean, that's another story. We started making videos, putting them online. And Toni Hsieh, the CEO of Zappos, reached out. But before that, she was like, what can we do for you? Do you wanna just stop working? I'll go up to full time. She was 80%. And you can just stop working. We won't have a ton of money, but in the Bay Area, you're poor no matter what you do. And I was like, I don't know, I don't know, I don't know.

And this is how long after 07.

This would have been? 08.

Okay, so your daughter's a year old, she's one.

And then by 09, what had happened was we went to visit. So Tony Hsieh went to Harvard with my wife and Tony Hsieh built Zappos and then sold it to Amazon for like a billion dollars and just wrote a book called Delivering Happiness, became this national sort of thought leader in the space. We went to visit him for Thanksgiving. He's having a bunch of friends over. So he does this thing that Tony does. You know, Tony as well. We all kind of roll in the same circles. And he kind of looks at me and he's like, so are you happy doing what you're doing as a doctor? It sounds really amazing. And I looked at him and I'm like, absolutely not. Absolutely not. And to see you living this life where you're doing what you love and you're financially successful and you're affecting people's lives and people come up to him in restaurants going, you changed my life with your book and this and that. I'm like, it was a mix of jealousy, like deep jealousy. Like, how can someone be so connected and me feel so isolated and self hatred.

Yeah. Because it wasn't the money. You certainly saw money everywhere in the Silicon Valley. I remember one of the things in Tony's book that I liked so much. They paid you to quit after a period of time, right? Was it three months in, three months.

In, and they give you 2,500 bucks to just go away, to just walk away.

Yeah, I love that.

And if you walked away, then you weren't really a good fit. They were happy to pay the money. That's the Zappos culture. And Tony, oh my God, it's amazing.

Brilliant.

Imagine if we did that in healthcare. Give somebody. It'd have to be like $100,000. Okay, quit now. And if you're still with it, it means that you're doing this because there's nothing else in the world you'd rather do. And that's what I tell medical students. You know, like, whoa, should I go into it? I don't know. If there's anything else you'd rather do, do it first. If there isn't, then this is your path. Because it is hard, but it is a sacred calling. And you'll feel it. And you'll feel it.

So you had that discussion over Thanksgiving with Tony, and then what?

I've never been so depressed in my life because I went back to Stanford. It's winter. You know how winter is in medicine wards? Every single old person with pneumonia tries to die in the hospital. It's gloomy. The residents are stressed. They're midway through. I'm supervising an intern who was a young lady who I remember was such a wonderful human being, but she was stressed and I was stressed. And we're looking at each other like, how do we help each other get through this? Because it was just she and I. Because they'd peeled back our support from a big team to just one intern, one attending. So I'm a uber mentor. I'm resident attending, second year sub I everybody in one. I would literally cry in the shower so that the wife wouldn't know that I was crying. And, you know, and it's funny. Cause I talked about some of this in the TED Talk where we met again. So super burned out. But Tony had. And this is why I think it's so important to have mentors that matter. Tony told me, so if you had one thing you could do that was in that visit, what would you do? And I'm like, dude, I did this speech for graduation. I felt so connected to the audience. I felt like I was revealing truth through humor that could help motivate people to change stuff. I would do that for a living. I would put these videos on YouTube, which was a new thing. But I can't because I'll lose my job and it's dumb and no one will watch. And he's like, you're wrong. Look at this guy, Vaynerchuk. He's like a wine salesman. He made a whole living out of this. Look at this guy who co founded Digg. What's his name?

Kevin Rose.

Kevin Rose. Kevin does this show and I watch the show and I'm like, that's funny and awesome. So part of my depression was, why can't I just get through this? Inertia to do this thing. And when I finally did, when I put my first video on YouTube on my birthday, basically in 2000, which one.

Was the first one?

The first one was Colon wars, and it was a parody of me talking about GI through the lens of Luke Skywalker going down the trench. So he's doing a colonoscopy and he's like, stay on target. I can't hold it. Stay on target. You can't do any more good back there. Wedge, pull up, pull up about this whole thing. And it got a bunch of views and people were like, that's nerdy as fuck. I like that. And that's when the depression started to lift. And then just on the side as this character ZDoggMD, which I created to try to make sure Stanford wouldn't fire me. And the thing is, they never even knew because they weren't on YouTube. And so it's more and more videos and more. And then we did one called Manhood in the Mirror, which was our first big music parody.

This is the first one I saw, right?

And it's good because I'm grabbing my crotch repeatedly, which is important for you to see, Peter. It's very important. And it was Michael Jackson's man in the Mirror, but it was about testicular self exam. I'm checking out my nad's in mirror. I feel my junk for lumps and stuff. Oh, and. And it gets a bunch of views. And people are playing it in these, like student health clinics on repeat. And they're saying, oh, kids are catching early testicular tumors. And I'm like, shit, am I responsible for over diagnosis now? Or people having their testicles removed that don't need to. And all this self blame again. But it woke me up.

So you were still at Stanford when you made that video full time? Okay, I didn't realize. I thought you had already left by then.

No. So two years at Stanford while making these videos full time. Until Tony saw the videos and was like, okay, here's a proposition. Unplug from that matrix, come to downtown Vegas. We're doing startups here, and I'm investing in some things. Do something that's gonna transform medicine that's about you and about the community. And that's when we imagine that conversation with my wife. Hey, you told me to follow my dreams, honey. So my dream is we quit this beautiful Bay Area lifestyle and we moved to downtown Las Vegas, which is currently a demilitarized zone, for this pipe dream of starting a clinic.

And it's a little warmer than Palo Alto in the summer.

Vaguely. Yeah, vaguely and very different.

And did she bristle or was she all in?

From the first moment, I was the one who bristled. I was like, that's dumb. I can't do that. And she was like, listen, this is your chance. You gave me a chance for four years to pursue what I cared about. Now's my chance to pay you back. We'll go, we'll give it a shot, and if it doesn't work, no problem, we'll come back and who cares? And if it does work, then great. So she was the one who pushed me. I mean, without being married to the right person, I think the biggest decision you can make in your life is who you partner with.

I mean, I agree completely. And my decision to leave medicine, which is a hard decision to make when you're two years left in your 200 year residency. And I was like, yeah, I don't want to do this anymore. Actually, my wife helped me see that because she said, you are so miserable. Why are you so miserable? And I gave her 12 reasons. She sat on it for a few days and then she said, I know you enough. We hadn't been married that long, maybe a year. And she said, but I know you enough to know that there's only two ways you're going to get better. You either have to fix those 12 things on that list or you have to leave. And I thought about that for a few days, probably for a few months actually, because this would have been the. Yeah, August of that year.

So when did you guys get married?

We got married in 04. So this is now summer of 05. So I'm really thinking this isn't for me, you know, reasons X, Y and Z like it would be. I mean, I loved the operating part. It was just there were too many things about the system I couldn't stand. So then I came to that really hard decision. But I thought her framework was the right framework, which was, it would be great to stay if I could fix all of these things, but I can't. So I probably need to go. And so that was the decision, to go. Now, I didn't know what go meant. I didn't know if it meant go into another specialty, leave medicine altogether, go into the lab full time. And because I had just come back from nih, where I had spent two years in the lab, so all of these options were spinning through my mind, which was, look, maybe I'll just get a PhD and just full time, do research, or go and do this or go and do this. I mean, it's funny. I found it recently. I found the document that I made. This is how nerdy I was. I put a table together in Word, and I had all of the things that I was considering doing with my life and the pros and the cons and the optionality triggers. And if you do this, it'll cut you out of this. But if you do this, you might be able to then pivot and do this. Like, it was this whole thing.

Wow. Engineer mindset. That's amazing. See, we're so different that way. Because I was like, let me throw some feces and see where it sticks. Oh, it sticks there. All right. I'm gonna leave medicine. So for you, it was thought out, but it was prompted by your wife in a way. Did you feel like you needed permission from your wife?

I think so, because people often say to me when they find out I left before finishing at Hopkins, they said, you must have really hated Hopkins. And the answer is, not at all.

All.

I freaking loved that place. In many ways, it was. It's hard to say, one of the best chapters of my life, because I feel like I've been really lucky. I think the only really shitty chapter of my life was college. But medical school was an incredible chapter. Residency was an incredible chapter. You know, work post residency was. All of these things have been very enjoyable. So, no, the reality of it is, like, I had amazing friends there who I am still incredibly close to, wonderful mentors. Obviously, like all hospitals there are, I think 20% of the surgeons at Hopkins you wouldn't let operate on your cat because they're absolute. I mean, assassins.

It's true everywhere.

Yeah, yeah, it's true everywhere. But you also were surrounded by some of the most skilled, gifted, remarkable surgeons. And the residents above me, meaning the people that I was trying to emulate, these chief residents and senior residents and the fellows. I mean. Oh, my God. I mean, some of them were just gods to me, and I still keep in touch with most of them. Right. Many of these people who were like, you know, my heroes are still my heroes in a way. I actually just ran into one in the Vons, like, very recently. She was my fellow on pediatric surgery when I was an intern, and she's now, you know, an attending in pediatric surgery in San Diego. And we bumped into each other, so. And she. Yeah, Vons of all.

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

I just can never remember it. So I mooch off my wife's phone number every time. That's what I do. Yeah.

Same thing.

In a way, I think I needed permission. I think my parents. Parents thought it was crazy.

You're Egyptian.

Yeah.

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

Yes. No, no. Super classic. My mom actually is completely supportive. So whatever I do, my mom is. I literally could be a garbage man and she would be delighted. But my father was very upset when I finished engineering, turned down my scholarships to do the PhDs in engineering, and then had to go back and do a postbac year to go to medical school. He was super upset about that.

Right, because you did that postbac where you got all the prereqs for medical school. What changed your mind from engineering?

It's a tough story to tell. It's hard for me to get into that.

Yeah.

Okay. Super emotional.

In a future maybe. Yeah. When we're both more woke.

Yeah.

Because it's tough. There are things I won't talk about, and it's. Because it's so personal and it's a thing that I'm still working through. We're constantly in this evolving thing, you know, and again, our identity as type A, kind of crazy, driven people. And you work with some of the top performers around the world and you do crazy shit like guys for my fans who don't know. Peter, this guy does shit that will blow your mind.

I don't do any shit. I don't do anything. But how many I have in the past, but I don't do anything now.

What's the longest swim you've ever done?

Probably 25 miles.

Oh, just 25 miles.

Yeah, but I mean, I can't believe if you dropped me five miles from shore today, I would pretty much die.

Yeah, but, you know, but because you're evolving to something different every minute, which we were talking even before this started, just a little bit about our mutual admiration for Sam Harris and his idea of the self and how it's an evolving, transient, almost illusory thing. But so is our identity the story we tell about ourselves?

Absolutely.

So the story of. I'm an engineer. No, I'm a doctor. No, I'm a consultant. What's your story now?

I mean, people who have listened to my podcast sort of know this, and I've gotten a little bit of grief for it. If ever given the choice, meaning if I'm at a party or if I'm somewhere where I'm asked what I do, I only have two answers. The first is, I'm a shepherd. And the second is I'm a race car driver. And the reason is usually the former. Nobody really asks you any more questions. Right. Like, I'm a shepherd. What do you mean?

Like, is this a religious thing?

Yeah, yeah, it's like, no, no, no. I mean, it's just like, you know, I tend to sheep and they're like, are there a lot of sheep in San Diego? Yeah, no, no, it depends. You have to go inland. But yeah, and then that's just my way of, like, I don't want to talk about it. And then with the race car thing, at first they think it's sexy, but then I explain that I'm on the formula 2000, like the formula Renault circuit, and I can just throw two or three sentences out and they already. The eyes glaze over. Nobody. Like, if you're not doing NASCAR or Formula 1, it's not like they have a follow up question. So it usually just gets me out of having to talk.

That's amazing. All I would be doing in that conversation, and we haven't caught up in a long time. Last time I talked to you, you were talking about installing a race car simulator in your house.

In fact, I rem. Was it that long ago? Yeah, I was actually driving back from the track.

That's right. Yeah, yeah, yeah, that's right. And you were so. I'd never heard the amount of passion in your voice. You were like, this thing is amazing. It's got all these buttons and like, my wife is a little pissed. But the thing is, it's like amazing and you gotta try this next time. And I'm like, who is this guy? So now you're actually driving on these circuits.

Yeah. But more importantly, it's just, to me, it's like I'm only interested in how well I drive versus myself. Like, I'm not, you know, this is not like something that's going to occupy much space in my life beyond just my own obsession with it. Like all the other things I obsess over. But the point is I don't have a narrative. I struggle with all of that stuff, you know, even when my kids are asking me now what I do. Like, because my daughter's 10, my son is four and a half, I have a younger son who obviously doesn't ask me anything. But yeah, I think they know I'm a doctor, I think they know that that's my job, but they don't have a clue what that means. And I just say, yeah, it means, you know, you take care of People. And my daughter then asks, what kind of doctor are you? And that's where I'm like, yeah, I don't. I mean, I just. I usually change the subject.

Yeah, I'm with you on that. You know, for you, I always see you as this kind of oscillating electron probability cloud wave that what you settle on at any minute can be on how you're observing yourself or what you're obsessed about at that moment. And it's always changing. So when people ask you, tell me your story, tell me your narrative, it's almost like when they ask me that, I get a little insulted. I'm like, you can't reduce the cloud that simply. It's more complex than that.

But I think that's true for everybody. And that's why I think maybe that's why I find that type of question difficult to answer and frustrating. And I think it's why, like, even today, I did it. The Uber driver who brought me, I came from a hotel over here, and really nice guy. I always love taking Uber in cities that I don't know, because really, the only two cities I spend, you know, a lot of time in is San Diego and New York and San Francisco. So if I'm in a city like Vegas, I'd love to like, hey, man, where are you from? Did you grow up here? You know, no. He'd been here 14 years, blah, blah, blah, blah, blah, blah, blah. So I'm asking him, like, 30 questions, so I now know his life story. And then he turns to me and he's like, well, what about you? Where are you from? And I'm like, God damn it. How do I get out of this? So I'm like, you know, I'm from San Diego. What are you doing in town? Business or work? Now, the reality is I'm kind of here to give this talk, but I was like, I'm just here to see a buddy. Yeah. Oh, you stay in her for the weekend? Nope, going home tomorrow. And it was like, you know, And I wasn't rude about it, but I think he could tell. What? This guy's a boring dude. Like, there's nothing else to ask. So I was like, I got to dodge the whole bullet.

Same thing. Because how do you. You have to tell? Almost like it's a huge, complicated unfolding.

And he didn't want that. I mean, like, there is no circumstance. Like, the other place where I will be equally dodgy is at, like, the parties of the parents at the school where you're with all the other Doctors and all that stuff. And this is my favorite thing to do is, like, I will spend an entire evening talking to a group of doctors and, like, learn everything about what they do and manage to not reveal one thing. They will think the entire night, this guy, you know, I'll be dressed like this, and they're all dressed nice, and, you know, they will think I'm a shepherd or a race car driver.

That is magical.

I actually want to hear about what they do. And truthfully, I think it's just selfish. I mean, if I'm going to be brutally honest, you know what it is? I don't learn shit when I'm talking right now. I'm not learning anything when the other person's talking. I get to learn. And I'm kind of selfish when it comes to desiring knowledge.

Yeah.

So I think the real reason I enjoy being in that setting and hearing what does that doctor do and what does she do and what does he do, is I'm soaking it up and I don't have to waste any of my time hearing myself say the same stupid thing.

And you and I both read this book, which I have. I just happen to have here. The Mind Illuminated. I was trying to understand myself better, understand meditation better, stop screwing around. Trying to meditate for five years and just being like, I can't seem to get.

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

Oh, really?

Yeah.

I discovered it just randomly on Amazon. Read it and was transformed in my practice because it was. Do you remember the Greatest American Hero? It was a show in the 80s with a guy, this guy Ralph, he's like an insurance broker or something. And these aliens come down, find him, give him this suit. That's a Superman type suit. And it gives him superpowers. And they give him the.

I actually do remember this.

Do you remember this? Believe it or not, I'm walking on air. And they give him the instruction manual to the suit. And they go, here's how you use this shit? And he's like, cool. And he reads it and these bad guys are coming. So he learns how to shrink himself down. He shrinks himself down with the suit. And then he gets himself grown again, forgets the fucking manual. And it's microscopic now, and it's gone. So he has to figure out how to use this powerful suit all by himself for the rest of the season. And that's where it's fun. Well, that's what it felt like with me. For meditation, trying to understand myself and my own what is my narrative and who am I and what's going on? Blindly scraping around, trying a little of Harris's meditation and doing a little headspace and doing a. Then I got this book and I'm like, it's the goddamn manual for nerds and for type A's who want to process. And part of what this thing talks about is this submind system, this idea that our mind is really like a boardroom where you're projecting stuff on a screen. And that's our conscious awareness. And what's doing the projecting are these subminds. There's a auditory submind, projecting sound, a visual submind projecting vision. And then there's a narrating submind that ties these things together, integrates them and projects them as this sort of integrated picture. And that's what tells our story at any given second. I am a race car driver and a shepherd, or I am a former burned out doc who's now trying to transform medicine, which is the lie I'm currently telling myself. And it's created like a beads on a string in these moments, these slices. The liberating thing about that is that at any moment your next slice could be something completely different. It's influenced by the momentum of the previous slices, but it is in itself an unknown and anything is possible.

So what got you curious to start exploring this?

You know what it was? It was moving to Las Vegas from.

The Bay Area, which was what year.

This would have been? 2012.

12.

Now I'm a type A, materialistic, high strung. I need a house and a car and keep up with the Joneses and my career and so on. That's how I'm conditioned. And I come here where people like Tony Hsieh are like, are you happy? Like, are you connected? There's this thing called community and relationship. And I'm like, these people are hippies. They don't know. They go to Burning Man. They have no fucking idea what they're talking about. And then I had an experience. Now look, I've done psychedelics in college, you know, lsd, psilocybin, mdma, those kind of things. They are transformative drugs. But when I was dabbling in them in those days, I didn't have an intent to change myself. Something crazy happened. I was up in Tony's place and he has a friend who we'll call the Sorceress, because that's what she called herself. She's this former fashion designer and she's like, hey, we're all hanging out. You want to smoke Some weed. And I was like, well, I haven't done this in months and months and months because I'm an upstanding doctor and a father and my kids are taken care of right now. Everybody's in bed. Sure. I ended up smoking a heroic dose, like a Terrence McKenna level heroic dose of weed because again, low tolerance, et cetera. And it turns out she is very adept as a guide and had known me for a few weeks now. And broke. She sat down with me. So this is what I see in you. I see a person who's this, this and this and this and this and this. And now you're here and you do these videos, but really you're trying to deny that that's an important part of who you are because your identity is a doctor. She goes, this whole thing basically breaks me down, destroys my ego, everything I thought I was dissolved. And then she started making.

And this is with marijuana, this is just with weed. It's so interesting. I've never liked marijuana. I actually can't stand it. I can't stand the way it makes me feel. So it's hard for me to imagine that that could happen because I don't view it as sort of one of those ego dissolving drugs. I guess for me, I just would always get paranoid, especially if it was sativa. I mean, that would just make me beyond paranoid.

So this was the most potent sativa you could imagine. Oh, God. And in my paranoia, which I also get, and I also don't love weed, in my paranoia came this paradoxical dissolution of ego as a protective mechanism. So, so interesting.

So you just, you might have gone to a place I'd never been to.

That's what it was. And I'd never been there. And with this guide who, you know, she's a Bikram yoga instructor, you know, something very spiritual about her. But in a strange way, I would have thought it was woo woo and forget it crazy. Says some very unscientific things. But as a guide for this triggered me to look at myself and go, what a worthless piece of shit I am. What a lying fraud and imposter that I am. And she starts noticing these things and what happened is a protective mechanism. To live with this thing I thought was myself was to dissolve that thing and realized that wasn't really me at all. Like the me is the awareness in which all this arises in moment to moment. And I can be something totally different the next day. And I should have gratitude for all these amazing connections and things that I have and I tell you. And I thought I told her at the time when I was super high, I said, I'm going to forget all this in the morning. But this is transformed. I was crying and all this shit. And the next morning I woke up and I remembered everything. The transformation was still there. And over the course of weeks, I had this glow. My wife was like, what happened? And I told her, I'm like, I've been changed. And she actually went and talked to this lady and was like, yeah, she's got something. And we're both hardcore scientist skeptics, right? And that change, it decayed over time. And so the ego reasserts itself. But I've never been the same. And that combined with living in the desert of Vegas, which is a blank slate, and being told, basically, reinvent yourself or go out of business, was a personal awakening for me. And since then, that got me interested. Then. And I listened. It sounds cheesy, but I listened to Eckhart Tolle's Power of Now. Just listening to the audiobook and listening to his voice. You know, there's nothing but now. And consciousness is this. And I'm like, okay, this is bullshit. And then about 20 minutes into it, I'm like, yeah, no, yeah, this is amazing. He's got some truth here. In all the woo, there's truth. And then I started down this path.

I mean, I have found this to be some of the most insightful, difficult material to digest. You know, you and I were joking about this before. A lot of things come easily to me in terms of understanding. I feel very blessed and privileged that, you know, whatever subject I needed to learn in school, like, if I decided I wanted to learn something, I could learn it kind of thing. When it comes to understanding consciousness, when it comes to understanding the nature of my mind, I feel like a complete moron. And you could argue, well, everybody struggles with that. But it's like, no, no. I feel like I'm three orders of magnitude below the average person in this regard. It's very difficult. And for me, like, the biggest breakthroughs have been catching the narrative, catching the self talk. That's like, that's a huge breakthrough for me. I didn't realize how much I talked to myself. That was a huge breakthrough. And also recognizing the transient nature of emotions, also just an incredible insight, very powerful insight for someone who's so prone to volatile emotions as I am, you know, that's funny.

So I just took a personality test. I scored off the charts in volatility and in withdrawal, which is another aspect of neuroticism. And I think. And again, I don't want to. I can't put myself in your mind. But kind of knowing you the way I do, the people who are very good at learning and are very good thinkers have these subminds that are very loud. They're always pitching you ideas. It's like being in an elevator with the most obnoxious fucking startup guy in Silicon Valley. Okay? This is the thing. It's gonna be called Dickly. And it's about taking dick pics and really democratizing them, including vaginas. And also because I think balls are important, they're often missed. And so anyways, that's my elevator pitch. Can I have $20 million? And he gets $20 million. It's like constantly. Along with the self narrative. So when you say I feel like a moron, I understand exactly what you're saying. Because being able to see clearly through the turbulence on the top of the water to the dick at the bottom, because that's really what it's a big dick with extra hairy balls. That's very hard. So meditation is one way. Psychedelics are a way to jumpstart it. I know you and Tim talked about this on the show, and I don't want to rehash all that, but I want to say that I think you guys are on the exact. All these paths converge, and it seems like pretty smart people are all saying the same thing, which is, we need to restart psychedelic research. Meditation is a crucial tool. I've kind of followed Tim's journey remotely. I've never met him, but he kind of takes the classic path that a striver type A takes in meditation, which is, first, I'm going to use this to help me perform better, Then I'm going to use it to quiet the demons. And ultimately what it is, you use it to actually understand and appreciate your mind and transform it so that your day to day actually all these defilements, these little voices and the emotional reactivity are uprooted permanently. And in this book, he talks about it having those inside experiences. It sounds very esoteric.

I found that book very difficult to read. Which is not to say it's not well written. I just. I think it, again, speaks to the problem. I mean, look, I had to read Waking up by Sam Harris, like, four times.

I did, too.

And I think I'm at the point where I understand the first third and the last third. I still don't understand the middle third of the book, Sam. It's just too hard for me. Like I just, I don't have the cpu, I don't have the neurons. There's something that I can't fully understand.

This is a huge problem. You know, we talk about the ineffability, the inability to describe these kind of experiences, and it's a huge problem. I found that the mind illuminated was the closest I got as a rationalist to understanding it. And even then, it's like shooting electrons off something and trying to reconstruct the image that this guy already ineffably feels he knows it. And it's taken me a lot of repetition. I think the point is we can't give up. I still don't entirely understand.

Yeah, you brought up swimming earlier. So I learned to swim as an adult. So I was about 31 and I decided relatively early in my flailing that like, I really want to do this thing. I want to swim these long marathons. And the amount that I had to put into doing that, the amount of hours I had to swim to catch up from being what I called an adult onset swimmer to being able to do this thing was a lot. And I used to sometimes get frustrated at swim practice because I couldn't swim as fast as half the people there. And you had to remind yourself they've been doing this since they were for these people have been on swim teams in high school, in college, blah blah, blah, blah, blah. There's a song by the Smiths where there's this line where Morrissey says, you just haven't earned it yet, baby. And I just love that line. That is my mantra. Every time I find myself getting sort of frustrated that I'm not good enough at something, I just say, you just haven't earned it yet, baby. You just have. These people have swum 20 times the number of hours you have. And similarly, when I find myself getting a little frustrated at my ability to understand consciousness. And I always think about Sam because he's just such an amazing teacher. I think, well, dude, you just haven't earned it yet, baby. Sam's been on this journey his whole life.

And Sam is probably in a similar boat to us in terms of he's a hyper rationalist. We use this metaphor that John Haidt uses the psychologist elfin and rider. So elephant is our limbic system, emotions unconscious. And then our rider is the cortex on top, that's conscious. And the thinker and the planner, our writers are hypertrophied, they're super big, but they're still fucking completely beholden to this totally dumb ass elephant that's like Pissed off, look up something online that backs me up. It's like, well, according to my data, this. And so Sam had to get through that by long retreats. And what I find is I'm in a position in my life now where by straight necessity to alleviate personal suffering. And that happened in 2012, where I just had this break where suddenly I see things differently. Sometimes it takes that a letting go, a relaxing. So something I hear in what you're describing concerns me in the sense that. And again, this is from my own experience that it's the striving to treat this like a pursuit, like swimming or anything that requires, like, you know, racing that will hinder. Ultimately you'll reach a wall where you can't release until you relax into it and let it go and surrender to it. And it sounds woo, woo, but I think there' so this morning I do an hour a day now using this. And I know Tim was Talking about like 10, 20 minutes a day and that's great to start, but what I find is there's a therapeutic threshold and I think it's around an hour. And it's hard to pitch that to people. But once you get into that mold, first you have to set that intention when you sit down. Like, this is what I'm doing in this sitting. And the intention creates a momentum of those mind moments that then drives you into the meditation. So you're not lost. When you get lost in thought, you remember the intention and you come back. But at about an hour, you're in a state where the noise actually quiets. And when noise appears, you recognize it and you ignore and you're floating on the breath and the body feels like this pulsing wave of energy and you realize, oh, this is all just experience happening in the present moment. And it's not even. I can't describe it. It's an insight that you have and then it vanishes about 20 minutes after you're done where you lose it, you're back in the world. But I'll tell you, if you keep repeating that, I suspect if we can maintain that even for five minutes a day, it's such a relief in human.

See, I think the benefit's even greater than five minutes a day. I mean, I think. So going back to the example you used about the psychedelics, there's a book that Sam recommended called Altered States or Altered Traits. I always get it mixed up. Yeah, yeah. The point it makes now, it's a book about meditation and it talks. I think it does a great job explaining that like Exercise. The purpose of the hour you spent in the gym this morning was not. Because there's something particularly insightful about moving a dumbbell from here to here, here to here, here to here, isolating this muscle and, you know, putting this thing on your back and moving it in this direction. And in other words, those are simply tools that we're using. There's a state that we create in that hour of exercise, but the goal is to give you traits that last for the other 23 hours. I would suspect you're getting a hell of a lot more than 20 minutes or 5 minutes of benefit thereafter. My guess is that kind of a meditative practice is infused into the other 23 hours of the day in how you react. I mean. Cause I don't even practice that long. And I feel the difference. I feel infinitely less aggressive. I feel infinitely more empathic. I'm a little jealous, actually. And I really feel like I need to up my game. No, I'm not saying that in a competitive way, but realizing there was. Cause I just had this discussion with Kevin Rose the other day, and he said the same thing, which is, you know, he has just totally upped his game, and he's going like 45 minutes a day. And he also mentioned that there's a real threshold you're getting over in terms of the practice and the settling of the mind.

And this is the thing. It is a threshold effect, because something does happen. People who've talked to me, they haven't talked to me in a long time are like, what happened to you? You're so much nicer. There's something edge that's been taken off again. You don't notice. One thing that he says in the Mind Illuminate is that if you practice meditation without somehow applying it in your daily life, it's like a bucket with no bottom. The stuff goes through. It's like a sieve. Whereas if you're starting to collect some of that mindfulness. And mindfulness is just simply a lack of reactivity, being able to go, oh, that's happening. Okay. Instead of making a choice. Tim said it best on your podcast. He said you become response able. So you're able to actually make a response instead of an autonomic knee jerk to your elephant.

All right, we just have to acknowledge we took a pee break. We probably forgot what we were talking about beforehand. And the last thing we were talking about was I was revisiting your dick pic joke. That was making me laugh so hard.

That's right. And I realized I didn't add taint into the mix because the taint is often neglected. You know, we had a joke, actually, when we were admitting patients when I was an attending at Stanford, the team would come to me and go, yeah, they're trying to. Surgeons are trying to admit this gallbladder to us even though we don't do operations. They're saying it's non surgical and this and that. I go, you know, this reminds me of when I worked on the taint transplant service. And they're like, what do you mean? You've never worked on taint transplant where you're taking donor taints and you're flying in and a homeless guy dies on the street and you excise the taint, you put it on ice, and you fly it off. And I would ask them, I say, listen, is this person in the hospital for anything other than their taint? If the answer is yes, it doesn't belong in our service. If this is for a taint issue and a taint issue only. I mean, I'm talking about taint the balls, taint the ass, the space between those two, then it's ours. It's a simple algorithm. And by the way, the graft versus host disease on a taint transplant, it can be devastating. It's devastating because both your balls and your anus are affected. And when they both go down, what do you have really? Can I pitch something to you? Because we were talking about meditation. Then I want to talk about what you do as a doctor, and you can ask me anything, you like it. But I want to pitch you this theory of consciousness and reality, and I want you to tell me as a smart person what you think. All right? Dr. Donald Hoffman is a professor of cognitive science and computer science at University of California, Irvine. He was on our show. He has posited this theory. And it starts with this basic idea, which is, do we see the world as it is, or are we seeing some fabrication that isn't even close to reality? And he actually was able to look at this evolutionarily. He studies visual perception and how people actually perceive stuff. And what he determined through lots of different studies and also different approaches in different fields was that organisms that see reality as it actually is go extinct. So if you see the matrix as zeros and ones, you go extinct. And the reason is it takes a lot of energy to actually see reality in all its complexity. And so the second proposition is, well, then maybe we just see part of reality, but it's still real. It's just not all of reality. And that's what most visual scientists propose. What he proposes is, based on his cognitive models and his computer models and his simulations, is that organisms that see any aspect of reality as it is go extinct in just a few generations, Whereas organisms that see reality as a fitness icon designed to help them reproduce, thrive. So in other words, there is no bottle of water here as such. There's no water, there's no atoms, there's no paper, there's none of that. This is a graphical user interface that I as a human have evolved to see to help me survive. I see something wet that I know that if I drink it, I will not die. So we have this shorthand hack in how we see the world. And over and over and over he gives examples of insects who will go extinct having sex with a beer bottle because it's perfectly hacked their interface to look like a female insect. And these male insects in Australia, these beetles will have sex with this bottle to the exclusion of beautiful females nearby because it is so perfect. This has been hacked in advertising with humans to make things look hyper appealing. Any McDonald's ad where they're opening the burger and you see the juicy cheese and all that. By the way, the vegans hate us, don't they? All that. That's designed to hack our interface. And his theory is the interface theory of perception, that every species sees reality through a series of evolved hacks that allow us to reproduce. And so here's the punchline of that. What is reality? Is there a reality? And what he argues is yes, there is. There is an objective reality. It's not. We're all not just making this up. Our visual cortex isn't just constructing it. It's not something where. And he's looked at the number of neurons in the visual cortex is way more than it takes to reconstruct an image, but just enough to construct an image. So we are constructing the world second to second in our minds every day. But the question is based on what? And if you look, he then digs into quantum mechanics and I read his manuscript, the book that he hasn't released yet. In Quantum Mechanics, they've pretty clearly established that there is no such thing as local realism. In other words, something doesn't exist until it's interacting with a conscious observer. It's a probability wave. So the moon maybe doesn't exist until conscious entities interface with it. But what is it that we're interfacing with? And this is what, when he described this in a TED talk, and then I read his stuff and I had him on the show, I was convinced it felt intuitively correct to me. I want to see how you feel. You may say it's bullshit. The world is actually nothing but consciousness, subdivided into things he calls conscious agents, which are little subdivisions of consciousness that sum up and break down. Kind of the way you can have a one bit conscious agent and all a conscious agent is, is it's able to. It's a simple mathematical function. And he has the formulas to kind of show this, how they interact with each other and how they sum up. The smallest one bit conscious agent is a Planck length thing, the smallest thing you can imagine that can have three things. It can perceive, it can decide, and it can act. And the currency of reality is experience. It's conscious experience from the tiniest levels all the way down, all the way to the largest structures that we have. And so when we try to explain the consciousness, the hard problem of consciousness, how does the brain, how does this three pounds of wet goo create the experience of me seeing Peter in his cool racing hat with his kind of sexy stubble, which I wish I had? Yeah, it's an icon, but I like it. I'm going to call it Micon because I want it. How does it create that experience? The smell of baking bread. And the answer is, we've been going about it wrong. We have to invoke a miracle in our current understanding. How do we go from atoms, neurons to experience? Well, at some point there's a jump that no one has been able to explain. You can wave hands. What he's saying is, how about you start with the miracle, which is everything is awareness and consciousness and matter and neurons are icons that we use in a species specific way to understand this vast network of social, this social network of consciousness interacting with itself. So when I see Peter, I see a sexy dude. But what is really there on your inside is this vast realm of experience and perception and awareness and thought and emotion that I don't see. What I see is my species specific hack that allows me to get through the world, allows me to reproduce, allows me to stay alive, and allows me to survive in a way, because we don't have enough processing power to see what I really think is there, which is this incredibly complex series of nested consciousness all interacting. And when you talk about books like this where they talk about subminds and meditation, what you're doing is you're taking your highest instantiation, which is the kind of aggregate of all these subminds, and you're looking and listening at those inner nested consciousnesses. Interacting with each other and you're also connecting to maybe the deeper connection between all of us as a higher consciousness. Sounds like woohoo. But in his formulas he actually shows how these things work mathematically and actually the formula reduces to the Heisenberg sort of formula for electron probability cloud. So it's really quite fascinating.

Can it be tested experimentally?

Right, so this is what he's working on now. You can computer model this stuff and the problem is it's as valid as any other model because it's hard to test. So the question is, how do you test that we're all awareness interacting with awareness.

Yeah, there's a famous. Actually I don't remember which physicist it was, I don't think it was Fermi, but. But a very famous physicist once said all models are wrong, some are useful.

That's right. And he himself says this is probably only partially correct because the idea is then, well, why would evolution even happen if conscious agents just exist and they're outside of time and space? It's really just an important piece of this. So we're wondering about time and space and are they real? Are they an actual thing? No, they are a species specific data compression algorithm that allow us to make sense of this social network and allow us to survive. So space and time are different for you and me? Well, we're similar because we have the same species presumably, although you're probably more evolved than me. But like a dog or a cat or a fruit fly, are all awareness interacting with other awareness. But the way they see the world in space and time is a totally different construct. And so all of it is constructed which transforms in my mind, let's say it's true. And we'll talk about how we can test it because I think we should brainstorm ways to test it. But I think it transforms how you think about mental illness. So what is mental illness? But in our reductionist materialist viewpoint, which we're very good as doctors at thinking because we've been conditioned to think that. And I think there's a lot of truth the way we do medicine now is we are really good at moving the icons around on the desktop. We know that a serotonin icon, when put into a human icon's bloodstream, does something to a subjective description of experience from that human subject in terms of depression. But what is really happening? We're like monkeys moving these icons around. But what's the transistors and the electrons that actually make it up? If the serotonin molecule is really a conscious agent That's a sum of little conscious agents. And it's interacting with our conscious agent that reshifts how we think about how these medicines work, how the mind body connection actually work.

What if that's not correct? What if the serotonin agent doesn't have the ability to perceive?

So if serotonin is actually electrons, if electrons are materially real, yeah.

What if serotonin is simply nothing more than atoms with all of its constituent elements, right? Electrons, protons, neutrons.

So if that's true, then it negates the entire model because it says something is materially real. This model says there is nothing real beyond awareness itself. And it creates reality on icons that allow it to evolve. And now this is difficult stuff to grasp. As scientists, which both of us are. You're much more than me because it goes against everything we trained, which is Big Bang happened somehow. Matter organized into complex structures through which consciousness emerged. We're saying consciousness was and subdivided into these smaller agents that combined into bigger agents and evolve over time into complex agents like ourselves that interact with other agents and social networks that probably form higher levels of consciousness. So you could actually posit what is God, but all these conscious agents at its highest instantiation in a way that it knows more than almost anything, because it's the sum of all these agents. Now, how do you test it? So if serotonin is a molecule, then yes, our reductionist approach is right and we should continue to hammer at it if it's wrong. We should still hammer at the reductionist approach because we're moving icons. So as Hoffman says, he says, just because the desktop trash icon on my computer desktop isn't literally a trash icon and I'm not dragging real documents into it, that doesn't mean I drag my life's work into it and hit delete. Just because I don't take it literally doesn't mean I don't take it seriously. So yeah, we take our icons seriously. We should know all about them. But we're going to hit a wall. And I think we're getting there in our understanding because until we understand what is the fundamental nature of reality, we're not going to be able to manipulate it in a way that reduces suffering, which I think is what we're trying to do. Right. When you talk about health span, you're talking about the longest possible life with the most enjoyment or happiness or fulfillment or whatever their individual's goal is. And to me, that's like a lack of suffering. No one wants to live to suffer unless you're a BDSM bondage person. And even that's not suffering because it's actually pleasure for them. So suffering is a mental construct. Pain is eternal. Suffering is optional because it's how we frame it. What do you think?

I don't know. It's hard for me to actually internalize that because, I mean, letting go of subatomic structures as sort of not being real, that would just require a lot more understanding on my part.

Let me say this. Subatomic structures are absolutely real, as icons. So in other words, they mean something, they're an image of something.

Yeah, I think trying to imagine that they have their own state of consciousness is, you know, it's not even for me to understand.

It's not even that. So, okay, let me dig into that a little bit because this is something that I have to think about a lot. That's a dualist belief. So in other words, the subatomic structure electron is an electron with some awareness. That's a belief called dualism. It means that there is matter and there's consciousness, and they're related. What Hoffman's saying, what I think I intuit from this is. And I could absolutely be wrong, and people get violently disagreeable to this idea. There's no electron at all. Electron is a conscious agent that we see as electron through our species specific interface. It's how we've evolved to see the world. We see it as. And we don't ever see electrons. We use equipment to intuit them.

But then how would we explain physical experiments that have independently validated the same construct?

Meaning?

So, for example, when Newton came along, he was the first to define a set of physical laws. And they held pretty well until the early part of the 20th century, when at one layer below the Newtonian understanding, there was a new layer of physical laws that had to be described. Many of these laws have been independently validated. And I would think that if it was all a hack, meaning if we were all creating our own construction, our own icons, it strikes me as improbable that we would be converging on the same descriptions, the same experimental identifications.

This is a great way to think about it, and here's how I would think about that. We have our hack, but it's based on reality. And reality is these conscious agents exchanging experience with each other. We see it as the laws of physics. We see it as an electron binding to this and this chemical reaction happening. And of course it will be validated because it's actually happening in the sense that these agents Are behaving relationally to each other in predictable, precise ways that we can measure and science can quantify.

But wait, but why would the electrons, the protons, behave in a predictable way when you and I can't behave in a predictable way?

Because we don't behave predictably, Peter. Because we are complex instantiations of multiple conscious agents that emerge a very high level of consciousness. So part of the reason you have these voices that are telling you you're an asshole and I have them is that we have. That are unconscious to us. Agents that are making decisions in the background that are feeding it up to our higher instantiation. It's very unpredictable. It's a complex system, the simplest systems. In other words, 1 bit, 2 bit, 12 bit, 100 bit conscious agents behave predictably because they have three actions. Perceive, decide, act. It might be that the 1 bit conscious agent can only have two perceptions, two actions. And so it sums up scientifically, mathematically, as absolute predictability.

But wait a second. If you collapse that to one and one, you could have a reductionist world if you had no choice. If all of the subparticles had no choice, it would become a semantic game.

Well, if none of the particles had.

A choice, meaning you always knew how they were going to behave.

Right, right, right. Well, then you have. It's the same as being materialist. It's saying they have no consciousness. So the definition of this is they have choice. And here's something that's even more interesting.

Which again, I just can't. So probabilistically, that just strikes me as impossible.

Yeah, right.

Because you couldn't have the order that we have in the universe if there was any choice to be made at that level. Again, I'm saying this as a guy who's bullshitting because he's hearing about this for the first time, but that's my initial reaction is I don't understand how you could preserve any order in the universe if there was any choice to be made in that regard.

Yeah, so what's interesting is when you look at actual quantum mechanics, there is uncertainty. At the quantum level, there is uncertainty, but there is a predictable predictability.

Yeah, but. Exactly. It's defined by a probability function.

Right.

But it collapses to something that's known once it's observed.

Correct. So what is observation but two conscious agents interacting and exchanging experience that then allows this particular conscious agent to settle into a particular choice. So to me, it's not exclusive of that having choice at the smallest level. Now, again, this is the simplest of choices.

Yeah, exactly.

And one thing you said was interesting to me because I struggle with this, which was if we all see things differently, as a hack, how can there be reality? How can there be objective, predictable, scientifically valid reality? Well, look at it this way. So he gives the example, which I think is very powerful of synesthetes. So people who have synesthesia, which is they experience the world very differently. They smell colors or they hear sights and you see colors when you hear sounds. And he gives examples of a guy who anytime he tastes mint in his hand, he feels a basket of ivy. And it turns out that guy is a synesthete. So his interface is a mutation. Something has changed in the way.

How do you know that without functional mri? Or is that the way that one.

Can validate that he's actually done some of that on these guys? It's interesting. And it's parts of the brain that light up with touch, light up when he's actually thinking about mint or something.

So you've basically just. You've disaligned it, for lack of a better word. The relationship between the external and internal sensory, you know, the cortex has basically been remapped.

There's some remapping now. I would argue that the cortex is an icon we use to actually consciousness interacting with itself. But imagine that person now is a mutation of some kind that interfaces with the world differently because he can feel mint. It turns out he's a glorious chef. So he has a career as a professional chef because he's able to take flavors and tactilely feel them. And to him it's real.

That's interesting.

It's like a basket. He's putting his hand in a basket of ivy. When he tastes something else, I forget what it was.

He would make a horrible surgeon. Could you imagine having to taste all of those body parts to be able. Because you rely on your feelings somehow.

It's like chilled monkey brains, Dr. Jones. It's true. So a surgeon would go extinct having that skill, but a chef would evolve. Now imagine evolution starts to put pressures on us where only the best chefs get laid and have sex and reproduce.

Now that that becomes the default. But see, to me that is totally explainable through Darwinian biology.

Right?

That is completely understandable.

So Darwin is essential for this theory as well. You have to. In fact, the core universal principles of Darwinism have nothing to do with DNA and molecules. They have to do with is something heritable, is there evolutionary pressure on it and those sort of things. And that works just as well with conscious agents. As it does with material stuff. So conscious agents can evolve over time to have perceptions that actually allow them to succeed in this social network where they're competing.

But, I mean. And again, forgive me for just not having a goddamn clue what you're talking about. Why is it that if that bottle is an icon, you can't make it lift up off the table by thinking about it?

Because in the social network of conscious agents that happen to be this way, that is not a perceptual decision or an action.

Why can't you override it?

Well, there are rules between how these things actually interact. In other words, it's not a free for all. It's not magical thinking. It's not like. Well, just because everything's awareness, I create the world. Like Deepak Chopra, he'll say something like, everything is consciousness, and so you can secrete, which is my way of using secret as a verb. You can secrete success and happiness and all that. Well, that's not true. That's magical thinking. What we're saying is. No. Have you seen the Big Lebowski?

Dude.

Dude. The dude abides.

Stop.

There are rules, dude, okay? This isn't fucking nom, all right? There are rules, and the rules are these things behave.

Just. One of the worst parts about trying to be health conscious is that you can't drink White Russians as liberally as the Big Lebowski.

Who says so? You say so.

I mean, the Kahlua is just. If you want a proper. I mean, now, you could drink a Caucasian.

Yes.

Right. Yes.

Just half and half.

Yeah. Which is a little cleaner. But if you want to do it right, you got to have the Kahlua in it. And between the vodka, the Kahlua, and the cream sugar. It's alcohol. But I've never craved a drink. I enjoy alcohol, but I've never craved it until the first time I saw the Big lebowski, which was. God, 25 years ago.

I'm in the same boat.

And I was like, I want to have one of those drinks, and I need to grow a mustache because I need to be able to lick that off.

So good. Oh, I just love it so much. We should have White Russians. And that gets me this thing.

Guys, could you. Is there any way you could fire up a White Russian?

Boys, right now, Boys, two White Russians. Throw a Black Russian in, too, just for the heck of it. We want to be equitable and one Caucasian. And one Caucasian. We initially reconnected over your work on nutrition and diet, and we had a patient in common. And so on and so forth. And you did a bunch of testing on me that really transformed how I think and know about myself. For example, I dabbled in ketosis. Yeah, I also dabbled in pacifism, not in nom. I dabbled in ketosis as well for probably eight months. You were in it for three years with one day exception. I understand. And I learned a lot because I learned that I make these very small, dense lipid particles that didn't seem healthy. And we ended up going to Mediterranean and I did a lot better. But the idea that a White Russian would. I couldn't do it was devastating to me. So it wasn't sustainable. How are you thinking about nutrition now? Because you have this patient panel, your functional medicine doc, which I want to talk about as well.

See, again, I squirm. Yeah. I don't know what to say. I don't even know what functional medicine is. I mean, I know what the definition is, but I don't know what I do. I don't know anything. I mean, I know what I know, but I don't know how to put a label on it. And I don't know what I'm all I'm interested in. I can define my objective. I can define the strategy and I can define the tactics, but other than that, I can't actually take an existing description and apply it to it. But the objective, which is the easiest part to state is I want to figure out a way. And I'll just use myself as an example, but I obviously would apply this to every patient. I want to figure out a way to live longer than I am otherwise on a trajectory to live, which means I have to delay the onset of the things that will kill me. And I want to improve the quality of my life, which I define rather simply as having three legs. One leg being cognition, the second leg being everything that has to do with the exoskeleton of my body. So the maintenance of muscle mass, the ability to move, I maintain mobility stability, which I actually think is much more important than mobility, but gets no attention. I can explain in a moment freedom from pain, sexual function, all of the things that people our age take for granted, but you stop taking for granted when you are in your 80s, in your 90s. Before we got started, we were looking at pictures of our kids playing instruments and stuff like that.

I mean, because we're gunners, man. How goes your kid, the drummer? Oh, it was pretty awesome, man. Well, mine's a virtue as a violinist.

How about you? Well, you know, but if you think about the way you were able to interact with your kids in your 40s. And now imagine, would you be able to reproduce that in your 80s? And so a lot of stuff you took for granted, right? Like could you lay down on the floor, play blocks or dolls or whatever, and stand up easily? Or is that like a debilitating activity? If your grandkid or great grandkid came running towards you, could you dip down into a goblet squat position and pick up a little 30 pound terror? So that sort of all is encompassed in this physical part. And then the third piece, which I don't have a great name for it or anything, but it's. And it's by far the hardest to impact as a physician, because I think the first two are a little bit more within the tools that we can apply. The third piece is this ability to be happy, as nebulous as that is, and to have what I describe as borrowing from a friend of mine, Paul Conti, who always explains what you call.

I know Paul, yeah.

Is just to have the highest degree of distress tolerance possible. And of course, mindfulness and meditation becomes the single most important tool to impact that. But there are other parts to that as well. Social support, sense of purpose, all these other things. And as you alluded to earlier, most people, if you took those things away from them, they wouldn't want to live one more minute. And there are exceptions to that rule. I mean, you look at Stephen Hawking, he had one of those three completely taken away, yet for all indications, lived a completely fulfilling life, and I'm sure wanted every additional day of life he could have had. But for many people, they want all of those things, especially if they at some point in time have had all of those things. So I guess the only way I describe myself, and this is why I generally like to be referred to as a Shepherd or a FR 2000 race car driver, is I'm a doc who's obsessed with that problem.

And I have to say, having experienced what you do from both a clinician as a patient side, seeing you with a patient and with me, you have a gift for this. This is something that very few people I've seen in medicine do, which is you look at the patient as a unique individual, you educate them in a way that sometimes is hard to understand. Actually, the same way when I'm talking about consciousness, we're all struggling with it sometimes some of the concepts that you talk about are so intuitive to us, but our patients look at us like we're crazy. But even then, this Idea that you can optimize a particular regimen to the goals of that unique patient is the foundation of what we call Health 3.0, which we tried in our clinic, Turntable health. And it is the same idea. And if we had clinicians like you surrounded with a team, do you do it all yourself or do you have a team?

Oh, no, no, I have a. A monstrosity of a team, actually.

Tell me about your team.

Yeah, so I have two, soon to be three people who are basically interacting with the patients on all of the logistics of what we do. We have a dietitian, soon to be another. Probably we need two health coach dietitians. What we're realizing is that the hard part is not. I mean, it is hard to figure out what is the optimal way for a person to eat, but there is a finite number of iterations you can make until you start to converge on it. So that's what we call the efficacy problem. By far the harder problem is the effectiveness problem. I'm a walking experiment of somebody who knows exactly what he functions best on. The problem is I just don't want to do it right. So I'm one of those guys who actually did incredibly well on a ketogenic diet. I mean, everything couldn't have gone any better. Now, whether I should have been on it indefinitely or cycled it or whatever, we don't know the answer to that question. The point is, I just didn't want to be on a ketogenic diet. I mean, I missed too many things. So now I take a totally different approach. I have a different framework around nutrition entirely that, you know, starts at one end with the sad, the standard American diet, and at the other end ends with complete caloric restriction. So water only, which obviously you can't do indefinitely. You should cycle that and then in between there are three other steps. And it's one thing to figure out how to optimize a person based on how they cycle between those layers, but, you know, like I said, the harder part is figuring out how to make that the default as opposed to something you have to work into. You know, I'm influenced a lot by Dick Thaler's work in Nudge, which is the easier you can make something for someone, the easier it's going to be to do and just figure out a way to make them opt out of good behaviors rather than opt in to good behaviors.

Nudge is very similar to Switch, which is by the Heath brothers, based on this elephant rider motif from John Haidt as well. And it's the same thing. You create a path for the elephant rider to walk. That is default good. You motivate the elephant by making them feel something like they want to change or they want to do this. And then you gently direct the writer, the rationalist, on how to make that change. And, you know, when I talk publicly too, I talk about this as a model of how we can do health 3.0 to influence change in our patient. I remember what you were asking us to do was very hard. You have to be motivated to want to do it. We happen to be. But let me ask a question. Like, are fat people fat because they just don't have the willpower that it's their fault that they're fat? Or is it that we just haven't cracked the hack for how to motivate people, make the system by default better, and find their optimal plan for them?

I mean, it's such a complicated question. There's something called the Dunning Kruger effect. I don't know if you're familiar with it.

Oh, anti vaxxers love this because they know a little.

Can we come back to vax?

Absolutely. Oh, can we?

Yeah. I actually lost a patient over this once.

Lost. Not died. Lost. Left.

Lost, left.

Yeah.

A patient of mine had some questions about not wanting to get his kids vaccinated and came to me, assuming that I would agree with him that he should not have his kids vaccinated. And I said, nope, you absolutely should get your kids vaccinated. And I said, look, here's the one deviation I made from the protocol. We waited six months to do the first panel instead of doing them on the the first day. But that was no rhyme or reason. That was just my intuition said, give the little bastards a break for six months. But, yeah, I can't imagine any reason why you wouldn't want to vaccinate your children. And he went loco. He was like, I expected more from you. I can't believe. Blah, blah, blah. I mean, he was pissed. That was it. Like, he left. I mean, he stopped. He didn't want to ever see me again.

So as someone who dabbles in the anti vax space a little bit, to the point where people are banging on this door, shouting obscenities at me during a live show with Paul Offit, I will say this. What you triggered was that person's elephant. So their unconscious was triggered in a way where their entire conception of the world, their ideas of liberty versus justice versus care versus harm, this moral palette that John Haidt talks about, which we can Talk about more later. But this idea that vaccines are a violation of the sanctity of the body, so you're putting toxins in the body. And the idea that he probably went to you thinking you were a little bit off the grid, that you're, you're looking at the unique person, therefore you're not gonna swallow the dogma, right? But the truth is, what he didn't realize is no, you swallow what works. And the things that have been shown to work are in fact vaccines and not a whole lot of other stuff until you really look at it and you look at supplements. You look at a lot of things, Peter, like stuff that would give standard American doctors or also sad. So you have the standard American diet and the standard American doctor or sad, the hives because you have taken yourself self experimented with with tons of supplements and you've drawn blood a million times. And you are the quantified person because you care about finding out truth for patients and also for yourself. But this idea that you triggered that person in a way that they made a moral judgment about you that was so far off their moral compass that they couldn't tolerate stomach the idea of seeing you. Until we recognize how people work, we'll never be able to connect with anti vaxxers that way because we can't imagine why people would think that way. And it's one thing to understand them, it's another thing to condone delusional and dangerous thinking in public forums like running into a theater and yelling fire. And that's what the hardcore professional anti vaxxers do. And our platform has zero quarter for that now. I just ban them, I ridicule them, I shame them, I drop F bombs on them. I will never stop until these professional anti vaxxers are stopped. However, the mother on the fence, the person who's like been conditioned by this stuff on the Internet, that's where it's obligate on us to be patient. But I think that's what happened with your patient.

Well, what's interesting is I'm not particularly equipped to delve into that. So I remember this discussion because my next step was, and it's been so long ago, God, I don't even, I don't even remember this. But I think, I mean, I don't remember all the details but I remember saying to him, look, there was this one paper that got made, this an issue, but you know it was retracted, right? Like you know that it wasn't retracted because the calculations were wrong. It was retracted because it was fraud.

Straight Fraud.

And do you realize that all of this sort of propaganda you're buying into emanated from something fraudulent, which was, I think a bit more of an intellectual approach? I don't think I had the resourcefulness or the insight at the time to take an emotional approach. Emotional might be the wrong word, but less of a. Let me just beat you down with more facts and explain to you why this is right. So my guess is he was pissed. Not only in the fact that I was obviously a not outside the box thinker but but maybe on some level he was just pissed that I probably talked to him like an idiot. I was dismissive of him. Right.

You really put your finger on something that we do in medicine a lot and I'm guilty of it. And that is speaking all to writer, trying to give them data when we haven't motivated elephant or understood elephant, unconscious motivation. And this guy, what I've started doing is sitting down and going, yeah, so why do vaccines bother you? Let's just take Wakefield and his study out of the equation. What is it about them that really bothers you? Well, they're forced on me. I don't like this idea of toxins in my body or I don't trust the government. I don't trust big Pharma. And I'm like, you know what, I don't either. I wouldn't let government run health care. I don't want fully socialized medicine. I think that's crazy. But I do think that the government does a lot of things that are good and things are much more complex. But let's talk about ways that maybe we can come to an understanding because we both want what's right for the kids. But it's very hard though because we get our own emotional. I get so angry, man. I've gotten triggered where I go on these expletive laced rants on my show. And you know what, here's the thing, Peter, you know this as well as I. It will get a shit ton of views when I lose my shit. And I'm like, fuck these anti vaxxers and everything and everything about them and it will go crazy because doctors will be like, that's what I've been wanting to say forever. Because my elephant is conditioned a certain way which is care versus harm. I want these children to live and not die of preventable disease. When you see a case of measles, you see whooping cough in the hospital, it will devastate you. And we're showing each other pictures of our kids. Like imagine one of our kids getting measles and you didn't vaccinate them. How am I gonna feel about you as a person, as a doctor? So that kind of thing, it's easy and it's seductive. I like to think of the emperor in his robes going, yes, unleash your anger and you will replace your father by my side. And just beams of flesh, like dark force energy coming out. But the truth is that is not gonna influence those people. And I've had to struggle with this because my platform reached a lot of people and I get a lot of criticism on both sides. You're being too much of a dick or you're not being enough of a dick. And it's like the truth is nuance and people hate nuance. And you know they hate it. And that's the thing about you. I remember you used to get really pissed when people would be like, so what are you eating now? What's your diet? And you're like, it changes and it's not my diet. Isn't your diet. And then you would say the diet. And then in the comments there'd be people like, I thought you were about ketones, man. You're a fraud. How dare you eat a molecule of carbohydrate? And they're super triggered because for them, this nutrition is a religion. And I've experienced that. We did a show about that documentary, what the Health. Have you heard about this thing?

Yeah, I've heard about it. I haven't seen it.

So there's a bunch of docs there spouting vegan propaganda, cherry picking studies and saying this is the only diet.

This is the thing.

I have no problem with vegan diet. The thing is, it's not the only thing.

Well, that's, you know the funny thing, it's funny you bring that up because that's the point I try to make. Is any diet that you do that's different from the sad, if you compare it to the sad, is amazing. You can't do worse than the sad.

The standard American diet, except eating more of it.

So the only. If you're over here on the left side of my framework, you're eating a standard American diet, which is this incredibly perfectly engineered ratio of just the right amount of refined carbohydrates, the right amount of sugars, the right amount of fats. It's like you couldn't come up with a better way to kill someone than that diet. And I'm not really into the conspiracy theory that that's deliberate. I mean, I think the harm is absolutely not an intended consequence. It's the palatability, it's the shelf life, it's the cost, it's the. All of these other things is the intended thing. It's basically driven by profitability. I mean, let's just call a spade a spade. As an unfortunate consequence, the drug kills the user. And that tends to be the case with good drugs. You know, eventually cigarettes are gonna kill you. If you drink too much, it's gonna kill you. If you eat too much sad, it's gonna kill you. So you're starting out here in SAD land, and then most people only realize one box on the framework, which is called dietary restriction, which is when you restrict certain elements of what you can eat.

Less sad.

Well, yeah, but it's take something out of SAD or reduce some element within sad. So you don't restrict when you eat, you don't restrict how much you eat, you just restrict certain elements of it. So it's an ad libitum diet that contains something or that is absent something in the sad.

Got it.

So a keto diet is a great example of dietary restriction, as is a paleo diet, as is a Mediterranean diet, as is a vegan diet diet, as is a vegetarian diet. These are all. They're all. So you think of all of the diets that people are out there talking about. They're basically talking about one little cluster of the state space in nutrition, which is dietary restriction. No one's talked about time restricted feeding, hypocaloric feeding, caloric restriction. So all of these guys are trying to nuke each other saying, my diet's the best. No, my diet's the best.

My diet's the best.

But what they're forgetting is they're all comparing it to sad. And guess what? You're all right. All of your diets are better than sad. I mean, that's like saying, like, my pancakes taste better than that dog shit over there. Yeah, I bet your pancakes will taste better than that dog shit too.

How dare you. My pancakes taste vastly worse than dog shit, by the way. That's a bumper sticker. My diet's better than sad. Like, that's. Yes, it is. So they're all at this reference point. That's dumb. All of them contain products and it's relevant.

It's just like, there's too much focus on this whole thing. And, you know, so when people say to me like, do you think a paleo diet's better than a vegan diet or vice versa, I'm like, it's kind of like an irrelevant question to me, truthfully. Like, if the alternative, if you're asking me my choice is, you know, I'm going vegan or I'm going back to my standard American diet. I'm like, you better stay vegan.

Yeah, right, yeah.

Please don't ever deviate from this one thing if it's keeping you away from being on the standard American diet.

Yeah. Well, you know, and for me, going from ketosis into kind of Mediterranean with intermittent fasting to now a feeding window of like once a day, I finally found a sweet spot where it's not only good for me, in other words, I feel better, my labs are good, but I can do it. And I enjoy that meal so much and it allows me to be with my family during the meal. We eat together and I cheat on the weekend because I'm with my family. So it worked for me personally. So this idea that I think obesity is something that's gonna take a multi pronged approach and fat shaming. I did a video where it was a short rant and it was called it's your fault your kid is obese. And my take was this, and I'd love your opinion on this. I said, listen, yeah, there are social determinants of health. Yeah, food deserts exist. Yeah, it's hard to afford good food. But if your kid, absent a medical cause, is obese, it is fucking your fault. It is entirely your fault as a parent because you control what goes in that child's mouth. I'm talking about young kids and they don't make decisions. They'll throw a fit and stuff. And yeah, you can negotiate with them, but if you're giving them a soda or a big thing of orange juice, something you gotta understand, you're just giving them a load of sugar, they're drinking their calories and then they're obese. That is on you. You need to educate yourself. You need to understand these simple things. And a ton of people were like, yeah, it's finally some doctor says what we're thinking. But then a lot of people push back and they're like, no, sometimes this is fully systemic. And you're asking somebody who has poor education to do this stuff. And I wonder where you stand on that. Am I wrong? Am I crazy?

I mean, truthfully, I don't spend much time thinking about this problem at all anymore. It has been probably three years since this was something that was in my crosshairs. And as is often my want, when I'm laser focused on something, it is generally to the exclusion of almost everything else. So while I think that what you're describing from an endpoint is imminently relevant, I don't have the data to speak to it. My intuition is that it is probably not as extreme as you are stating it. I think I have, over the years, become more and more. Empathic might be the wrong word, but maybe it is the right word. Probably just a little. You know, I look at my family, for example, right? So my father knows everything I've ever thought, taught, described. My father will not, for the life of him, take one bit of advice from me, medically or dietarily. Is it because he's not intelligent enough to. No. Is it because he can't afford to eat the way I suggest he would eat? No. There's some other reason there, and I don't know what it is, but I also don't know that it's his fault. I don't know how to think of it in those terms. It's certainly vexing to me, and it's probably one of the sort of few triggers that still, I have to be very conscious of not getting upset in that setting. But I just don't know. So in the example you gave, you, take those parents that are giving their kids whatever. I mean, do kids still drink regular soda? Is that still, or has that been generally curbed out of the system?

They still drink regular soda.

And not only that, it's on the decline, isn't it?

There are kids in this town that put the parents, put Dr. Pepper fully sugared in a bottle and give it to the kid, thinking it'll keep them quiet or it's healthy in some way.

So, I mean, I guess to me, it's just hard for me to say that that parent is at fault because they're not playing with the same template that you or I are playing with. So again, if I were obsessed with this problem, I would solely be interested in changing the environment. So what is it that's making you put diet pepper in that bottle? Is it because it's cheaper? Is it because it's there? Is it because I had a better shelf life? Is it because it tastes better and it shuts the kid up? Like, I want to understand why it's the diet pepper, and I want to figure out how it is you can put something that's not diet pepper in there. That would still check. What I consider sort of these four boxes of the. The default food environment.

That's a nanny state, Peter. People don't want you taxing sugar or Preventing it from being.

And again, I don't know that taxing is the right way to do it. I mean, one of the things that I had thought a lot about was an experiment that never got off the ground. So when I was still involved in this world, I used to have these sort of thought experiments and occasionally some of them become interesting ideas for actual experiments. I think this would have been one, but it would have been prohibitively expensive and I think logistically quite challenging. But it was to basically take two areas that were in reasonable proximity and similar to each other that were both, quote, unquote, food deserts, and do an experiment. So in the control group, you would give them an amount of money that was going to allow them to sort of buy whatever they want. But you wouldn't change the food environment or anything like that. So you just poured more fuel on whatever fire was there and in the treatment group. And you, by the way, have to do this as a crossover. So it's not a random assignment. You have to cross them over. In the treatment group, you would do a whole bunch of other stuff, which is you teach them how to cook, you give them the money, and oh, by the way, then you go into. This is the really hard part of the experiment. You go into the stores where they will buy all of their food and you price switch everything, position switch everything, and see if you can create a new default. So the Cocoa Puffs are no longer $2.99, they're like 12.99. But you know, the eggs and the avocado and you know, maybe the steel cut oats, like those are now super cheap. And by the way, they're the ones that are sitting in the front of the store with like the buy two for one right now. But the Cocoa Puffs, you can still buy them, they're just four times more. And you got to fricking find them. And you got to ask Sally where they are. And Sally probably won't even remember where they are. And they might not even be in stock. So it's like you totally change the food environment. And the fantasy I had was you ran these one year in parallel and then you crossed them.

And see, this is why it's so fucking hard to study nutrition, because that's what you would have to do.

Yeah, and I had done the math on how much this was gonna cost. I mean, there was a day when I used to think about this stuff so often that I sort of had what a budget for this would be. And it was in the grand scheme of Things not outrageous. I mean, it would be sort of 1/20 of the cost of developing a new drug, but still, you know, in the tens of millions of dollars.

So we'll never do it, because prevention, proactivity, looking at root causes, not something we do in American medicine. And, you know, when you were talking about giving people the tools, education, et cetera, teaching them to cook, that's what we did at Turntable. So we had a teaching kitchen in our facility. We had health coaches that would teach, you know, Winnie the Pooh how to cook in a food desert on a budget, without honey. And it worked. So these patients transformed their lives. And they would say, well, I really like the health coach. And I felt accountable to them, and they felt like they cared about me, and I didn't want to let either one of us down. And so this motivation component, the education component, and then going to the supermarket, what the coaches would do, look at their shopping list and go, yeah, you're fucking this up. So here's a simple thing. You know, shop in the periphery of the supermarket, et cetera. All these little hacks. So it got to the heart of this issue of, first of all, patients need to feel like we actually care, and they're being held accountable to some degree because we function in that way. If we're just left to our own device, like you and your dad, your dad's like, I'm not gonna listen to my son about this shit. And that's how. My dad is the same thing. I can give him advice. He'd be like, whatever. There's an emotional component to it, but humans are humans, and we're driven by these unconscious urges and processes. And until we are able to understand them, we can't hack them. And since it's all consciousness anyways, none of it matters. Let me ask you a question, though, relating to this free will. Do you think it's a real thing? Do you think humans actually make these choices?

Oh, boy. I mean, I would say this. If you asked me this question two years ago, I would have said absolutely 100% on the free will train all day long.

So people have free will.

Yeah, free will all day. I am now in a gray area where I'm starting to begin to understand the counter argument. What I love about the counter argument is it's another great empathogen. Do you know how much easier it is to go through life when you stop. Stop being a pompous piece of shit who thinks you're so good because of your own free will?

You just nailed what I was going to say, which is empathogen, which is an amazing word, something that generates empathy. When I came to the conclusion that free will was largely an illusion. But I have some nuance to that. But it was Sam Harris's book, Free will, and this idea that these thoughts and impulses bubble up from dark spaces that we cannot nail down. I made a decision. I made the decision. First of all, the state of I is a bit of an illusion, but let's say there is an I, a little guy behind our head pulling levers. How did he come to that choice? Well, it bubbled up from unconscious processes that we don't understand states and causes and conditions. And so, as a result, when somebody does something dumb in a way they could never have acted otherwise, the same person, molecule for molecule, could not have acted otherwise. And that's a tremendous sympathogen because it means instead of judging them and getting angry, you can say, let's see if we can perturb this neuronal storm to spin in a slightly more productive way for what their goals are.

And to clarify, I think one thing that someone listening to this might get confused by is that's not to say that there aren't consequences for the choices that are made. So if your absence of free will enabled you to decide you wanted to take a drink, have a couple white Russians, and drive home, and in the process, you hit somebody. Okay, maybe you didn't choose to do that or choose to make all of the decisions, the bad decisions that led you there, but there will be consequences for those actions.

Yes, absolutely. And this is what people who say, you don't think there's free will, then the whole criminal justice system.

Exactly. They're sort of confusing and confounding. Two issues.

They are because you murder someone, you made a choice to do it. You made a choice. Well, it wasn't free will. That's my argument, your honor. Sure. You're going to jail forever. Why? Because we need to make sure that others who also don't have free will have their subminds conditioned that if you commit murder, you go to jail forever or you die, depending on what state you're in. And whatever your beliefs are on the death penalty. And so as a result, that deterrent reconditions the unconscious that then allows different decisions to be made. So my feeling on free will is that it's actually much more nuanced. These subminds actually have their own free will, and they feed it up, and it's conditioned by our downward input. So what comes out is a consensus decision. And so in a way, yes, we are kind of in charge who we decide to be around. If I hang out with Peter Attia, I'm going to be better for it. If I hang out with Charles Manson, I'm probably going to come up with some shitty stupid ideas. If I fall into a Facebook hole where all I'm looking at is alt left or alt right or alt center, I'm going to miss. I'm going to be conditioned in a way that may be malproductive. So those things matter. There are consequences. We should hold them. So when I do the show about blaming, I say, it's your first fault that your kid is obese. My secret reason for doing that is not that I actually think they're to blame, it's that somebody will watch that and go, I never. Wait, what? I've been giving Dr. Pepper in the thing, like it's my fault. What do you mean? And they just. Something clicks and they go, wait. So I'm not supposed to do that. Okay, I'm gonna do something different. So it's a way of influencing. Now it may not work. So blame may not work. There's some data that it doesn't. And in looking at hospital errors, just culture is one of these blame free kind of scenarios. There's some data that people will hide and they won't come out and admit errors if they fear retribution. Whereas in an environment where we're trying to make the system better, it could change. So again, it's like gaming this bigger system.

Totally unrelated in medicine. Did you guys do Eminem all the time?

Okay, I was the presenting party in M and M at least once. And that's morbidity and mortality.

Yeah, yeah. So it's really funny. I remember the first. This is totally off topic, but just what you said about the coming out. One of the things I miss the most about being in an academic medical center is M and M. So the morbidity mortality conference. So might as well just explain and I assume it's the same in surgery as it is in medicine. What we would do is every Tuesday morning at 6am There was no exception to this rule. Like there was nothing that would get in the way of this conference. All of the surgeons, the residents, the fellows, the attendings, everybody would meet in a room and all of the complications. So the morbidities, pardon me, the mortality, the morbidities and then all of the deaths, the mortalities would be presented. And it was a very unemotional conference. So I would Stand up there. And I would say Mr. Smith was a 47 year old man who came to the emergency room on such and such a day, presenting of left lower quadrant pain, we suspected diverticulosis, blah blah, blah, blah, blah, blah, blah. Took him to the or did this, and then, oh, and by the way, he had a pulmonary embolism and died six days later. Okay. And so you just unemotionally present the facts and then comes the process. Okay, let's start with the basics. Was he on sub Q heparin? Was he up walking? Did he have a hypercoagulable state? Did you do this? Did you do this? Did you do this? And I've never been afraid of speaking in public, with maybe one exception. That was a very difficult conference to present at. But by the time you were presenting, that is, by the time you were senior enough to be the one to stand up there and present, you had seen the beauty of it and the benefit of it, which is it hurts. There's no denying it. I mean, it's a rectal exam without any lubrication, but there's benefit. You see this? And so I remember when I left medicine, the first place I went to was to work at this consulting firm, McKinsey and Company, which I loved. Another exceptional, fun chapter of my life. But I remember naively asking at one point, I'm like, why don't these companies do Eminem? And everyone's like, what do you mean? They eat M&MS. All the time. And I'm like, oh, no, no, sorry. I mean, morbidity, mortality. Why is it that there isn't a post hoc analysis of everything that goes wrong in a totally unemotional way that just. And the reason MM works is it's completely closed. There is no legal recourse, so there's no hiding. Nobody who's not a part of surgery is allowed in that room.

Yeah.

And that's sort of what enables it to be that way, which I enjoy. And look, if you're the, you know, if you're running a publicly traded company, you don't have that luxury.

And I had the same experience with Eminem. It was this horrible, painful. Going up there and going, this patient died because of a mistake that was made here. And then having to go through that and everybody looking at you and being like, so you did this? Did you think about this? I did, but I decided this. Do you feel like that was a correct decision? Well, obviously not. But coming out just like, okay, first of all, I'm glad that that, that I was able to talk about this because you don't think I've been beating myself up about this like I'm just a second year resident. Like, this is devastating to me. Like, I went into this to help people. My biggest fear is hurting people. And I hurt someone. And you come out so much stronger for it, even though you've been put through this wringer. And you're right, we don't do that. In other. It's a blame culture. Like, you get fired if you screw up. In a lot of businesses in the hospital, nurses often get fired if they make mistakes. And the truth is it ought to be a no blame culture. What was going on in that pillar dispensing system that allowed that medicine to be dispensed even though you erroneously typed it in wrong and it was a paralyzing agent instead of a sedative and the person died under torture in the CT scanner and you didn't check on them because there was no protocol saying they had to be monitored. Well, we need to fix that. Was there malicious intent? Was there recklessness? Was there substance abuse on the part of the nurse or the doctor? No. All right, well, now we need to talk about how can we prevent this from happening? And what is accountability? What does it mean in the setting of maybe free will not being entirely a real thing, but at the same time us having to behave like it is or else people won't. It won't condition people to do the right thing.

I love how we turn free will into Eminem. I never get to talk about Eminem.

This is why you and me need to do a show that no one will listen to. It's just you and me about stuff we care about, having been through it all. What do you care about, Peter? What are you interested in these days? What's driving you these days? And how can my experience? Because. Because what I've done is so different as well. And I can't categorize it. When people ask me, I want them just to stop talking because I'm like, I don't want to tell you this.

Yeah, you have a harder story.

I don't know that it's harder. It's just.

It's a more complicated narrative.

What do I say? I'm a professional clown? Because that's what my dad says. So you've become a professional clown, huh? At least you're putting some non on the table because otherwise it's just fatah fat. You're just wasting. You went to all the medical school and now what are you doing? You're just jacking off on the his camera. He doesn't even know what that means. He just hears me say it and he's like, oh, you're jacking off. I'm like, don't say that in mixed company. It's not something. So you're spending your time, but you're between San Diego and New York, you're doing all this cool stuff. You're talking with really smart people on your podcast. What's driving you right now?

Personally or professionally? Because there's a bit of a divide.

I want to go personally, actually. Okay, let's go professional first.

I would say professionally, I am really, really obsessed with the question of what is the appropriate dose of caloric restriction and the frequency and of the molecules that mimic that. So when you start to think about metformin, rapamycin especially, and complete caloric restriction. So I've really lost interest in much of the junior stuff that gets close to there. So I sort of view that as filler when you're not fasting.

Okay, let me interrupt for a second for my medical audience. A lot of them are going to have no fucking clue what you just said. So, rapamycin, metformin, caloric restriction. Operating on the principle that a lot of studies in animals, mammals, show that some form of caloric restriction increases longevity through a series of mechanisms. And there are molecules and receptors that might mimic or be at least partially responsible for the action of this caloric restriction in terms of promoting longevity. Rapamycin is one, metformin might be another. Yes, sorry, I just wanted to make sure I understood because I am dumb about this stuff.

Yeah, yeah, no, thank you for clarifying that. So molecules like metformin, which have a net effect of activating an enzyme called AMP kinase, which is a nutrient sensing enzyme. It mimics something that you see when you're being deprived of calories. Conversely, rapamycin inhibits something called the mechanistic target of rapamycin. They got very creative on the naming that mtor. MTOR would be a great superhero.

Sounds like a he man. Bad guy.

Absolutely.

Skeletor should have been an X Men. It should have been. Yeah.

So rapamycin inhibits that mtor, which is sort of the central nutrient sensor for amino acids. So again, when you inhibit mtor, you are mimicking deprivation of amino acids. And then of course, there's just the old fashioned way to do it, which is just. Just don't have anything but water. And that seems to work really well, provided you do it, in short, enough Periods of time. I mean, if you do it indefinitely, you arrive at a state called malnutrition and you die. But the problem is we don't have a clue what the optimal dose is. So if you treat caloric restriction like a drug, meaning don't eat for this long a period of time and then repeat that at this frequency, we don't know the answer to that question. Furthermore, we don't know, like, do you need to go all the way? Could you just eat 500 calories a day for a certain period of time and repeat that at a certain frequency? So you pretty quickly realize that it becomes an infinite problem. You have the number of calories you consume somewhere from zero to something not too big. The composition of those calories, if it's anything but zero, the duration at which you're exposed to that and the frequency with which you repeat it. And then, by the way, if you want to add a fourth variable, since we're talking quantum physics, add that whole three layer, three space onto the what you consume. When you're not doing that, the problem becomes ridiculous and it's unsolvable. That's an unsolvable problem. So what do you do when you're an engineer and you have an unsolvable problem? You take a guess at states that would be discrete enough that they're not too close to each other that they should overlap that much. And you would test them. So you would ask the question, well, if caloric restriction and, or rapamycin and or metformin extend life, what would be some of the readout states of that? So my obsession professionally is understanding those readout states and basically collaborating with and facilitating the funding of research to answer those questions. So there will be assays that need to be created to measure the readout states of that, including things like autophagy. So autophagy, as the name suggests, autophagy, self eating. That is generally regarded as probably the most important, though not the only mechanistic change that occurs under caloric restriction and administration of rapamycin.

Undertaking this line of research, as you said, is very complex. And what you're ultimately trying to figure out is really what is the best mix of variables.

Yeah, because I have a fasting routine that I literally pulled out of my ass. And I have patients that are doing slightly different ones or the same ones. And I have patients that aren't fasting at all because it's still a bit scary. And in the end, I just sort of want to be able to give a dose response. I want to be Able to say to a patient, look, if you want to go all in, this would be as reasonable or as aggressive a protocol as you might want to take take. But look, you could get 50% of the benefit of that doing this, and you could get 20% of the benefit doing this. And if you stack this with this, you can, you know, do X, Y and Z. So I have spent years experimenting on myself with this stuff, but the measurement tools that I have are too blunt to actually make any reasonable inference.

So you need a better study.

I need much better tools to measure what we care about.

So that's your passion now. And you also treat patients, trying to help them. Are you using these medications on patients?

Metformin? Yes. Rapamycin? No.

Right. Because rapamycin is a transplant rejection drug.

Yes. Now, rapamycin gets a bit of a bad rap. It's a much safer drug than people realize. Like, I would be less afraid of a patient taking rapamycin than ciprofloxacin.

Yeah, exactly. At the right dose.

Yeah, yeah, exactly. And at the right frequency. I mean, I wouldn't want to a patient taking rapamycin at the frequency that we gave it to a kidney transplant patient. But we certainly know enough now based on all of the literature out there, including literature in humans, dogs, et cetera, that rapamycin given at certain doses at certain frequencies actually enhances the immune system and improves many metrics of physiology. So if you talk about giving rapamycin at that dose versus giving Cipro for a bad uti, I'll take Rapa all day long. I mean, given how small my interaction is with patients, because I have so few of them, the fact that I've already known two patients who in the course of their life have had tendon injuries during the course of fluoroquinolones, I've become sort of paranoid about these antibiotics, which might be an overreaction, by the way.

I'm not sure it is, man, because we used to give them out like candy. You know, it was a moxie Cipro era when I was training and everybody with pneumonia got that kind of cause. It covered all kinds of shit. And then, you know what's interesting is we didn't see a lot of tendon stuff. It might be it was seen as an outpatient.

Well, I was just about to say the research I've looked into this is you have about a six month window of susceptibility to tendon injury following fluoroquinolone.

What we saw more often was a higher incidence of C. Diff C. Difficile. Bowel infection. In fact, I had a patient.

Have you done any songs on C. Diff?

Yes, it's called dawn of the Diff. And I took a lot of rapamycin so I could bust a rap about. Yeah, it was really dumb, it was one of our early songs. But it was all about how people will come asking with intent for cold antibiotics and go away with a debilitating bowel infection that could be fatal. And I had a patient who died of it coded in the CT scanner and had a huge pericolonic abscess from C. Diff. And I remember telling his son, who was a marathon runner that his dad had died. I was in the ICU and it was one of the most. I'll never forget it because the whole thing was iatrogenic, meaning it was caused by one error after another, one error after another. And this is one thing I wanna say because I think your listeners in particular, they're not all doctors and medical people. They may be scientists or people who care about this stuff. You don't understand how fucked up and terrible the hospital is as a place to be safe and taken care of. It is a disastrous zone of, of chaos, of infection, of errors, of poor system design, of lack of coordination and of expense that doesn't need to be done. And until we feel that emotionally in our elephant, we are going to continue to perpetuate a broken system. We have to wake up and realize even maybe we need AI to help coordinate our care. Maybe we need better technology, maybe we need better processes. But none of it's happening because our incentives are still fee for service, which is we get paid to do things to people. And in a hospital you can do a shit ton to people, the hospital gets paid, nobody's incentivized to make it safer. Even though we all have a story of someone who we love or we took care of, who died because of a medical error or got injured because of a medical error. So to me this has become a recent passion. So when I hear you talking about rapamycin I get excited because maybe we can keep people out of the hospital through the selective process.

Yeah, I think the thing about rapamycin that's so exciting is it doesn't just increase lifespan. I mean, if that's all it did, it wouldn't be that interesting because the US healthcare system's pretty good at increasing lifespan in the presence of deteriorating health span.

We can torture you in the ICU for years.

We could keep you alive for an extra year if Your aorta ruptures. If we're really willing to go all in.

Ecmo.

Yeah, exactly. Yeah. But it's the increase in health span that comes with it. Or stated more accurately, it's the reduction in the rate of health span decline.

That's interesting because it's always going to decline. You're never going to be able to do it. 90 what you did at.

That's right, that's right. My intention is to sort of understand what the 20 requirements are to be a kick ass 100 year old. So consider like a new Olympic sport is the centenarian decathlon. So you figure out what all those metrics are and then engineer your way back to what you need to be able to do at 40, 50, 60, 70, 80 to hit that target. So that's the second professional problem I'm obsessed with. So the first one is this whole thing around developing finer tools to probe the molecular places where we're going to see readout states on caloric restriction, Rapamycin, metformin, other agents that are CR memetics meaning drugs that mimic caloric restriction. And then the second completely independent obsession is codifying. What does the perfect training routine look like? That makes me at 100 the thing I have in my mind. In other words, that's why I don't actually care if I can swim 25 miles today. I don't care if I can ride my bike 200 miles, I don't care if I can deadlift 500 pounds anymore. None of those things matter to me anymore. Not that they weren't interesting and valuable and beneficial at one point in my life, but I don't think they matter enough to this centenarian decathlon.

That makes a lot of sense and it kind of brings it back to what your goals are and how you're changing over time. And we all. That's the thing. People expect something static of human beings. They expect us to be the same person we were here and here and here and here and here. And I think for me that's very uncomfortable because I think we evolve over time and our interests evolve. And I think medicine as an entity is a complex evolving organism. We treat it like some easy system or something. We can game or something. It's not. Do you have any thoughts on what you would do if you had a magic wand? How would you reform healthcare from a payment model? Have you ever thought about that stuff?

Stuff I have actually, but not in a very long time. I think my answers are conceptually quite simple, but practically almost impossible. So I'll start with a story. And I've actually given a talk on this once before. We were shooting the breeze here. I was explaining how much I hate giving talks. But one of the talks I gave was actually on this particular issue. It's the only time I've ever spoken about it. It's like 100 years ago. But I started with this example. So I had a friend who's an expat, so he's an American, but living in Saudi Arabia. Arabia. But he would always spend like June, July, August, September back in D.C. because obviously it's pretty hot in Riyadh that time of the year. And I remember him saying that. I don't even know how this came up. It was just like in the conversation that he left the air conditioning on for those four months and he just said it in a matter of passing. And I was like, whoa, whoa, whoa, dude, what do you mean you leave the air conditioning on for four months? He's like, well, if you didn't leave the air conditioning on when you come back and in October, like, it's going to be 120 degrees in your apartment. And I was like, yeah, but you'll turn the AC on and in like three hours it'll be 75 degrees. He's like, yeah, but that would take like three hours of being like balls hot. And I was like, dude, I'm struggling to understand the logic here. He goes, oh, you don't understand. Like, we don't pay for our energy in Saudi Arabia. I forget what the number was. It cost like $2 a month to, to keep my air conditioning on the whole summer. So for me, spending 8 bucks or 19 bucks or whatever it was to keep my air conditioning on all summer is totally worthwhile. And so we can listen to that in the United States and we can laugh our asses off at how ridiculous that is. And oh, those stupid governments subsidizing their people and that's the root of all evil in the Middle east and blah, blah, blah, blah, blah. And it's like, hey, dude, get off your high horse and take a look at the US Healthcare system. It's a long story, but I basically got a bunch of data to, to plot out what the P and L looked like of the US Healthcare system, which turned out to be much harder than I expected. This took all of my McKinsey ninja skills to get these data. And if you plotted basically where the dollars come in and who makes the decisions on where the dollars get spent, guess what? We're in Saudi Arabia, brother. The people who are driving the cost are not bearing the cost. And so it's not that dissimilar from you going to the Lexus dealer and knowing that you only have to pay 9% of the cost of whatever car you get. Do you really think that the parking lot that I'm looking at now would look as it does if people were only on the hook for 9% of the car that they got? No. So, fundamentally, if you want to fix the cost issue, you must be able to couple decision making to spend. You can't have those uncoupled, and they're currently uncoupled. But the other thing that is worth mentioning, and I'll get off my soapbox on healthcare, is there are two other legs of healthcare that often get confused with the third. So you have cost, you have access, and you have quality. And you don't get to move one without the others coming along. So you can't fix one independent. So the other thing that sort of frustrates me when people talk about healthcare, which is why I never talk about it. I view it like religion and politics. I just, I've decided I don't give a shit at all. I don't care what anybody thinks. I don't want anybody to know what I think. Although you've asked, so now you're stuck hearing what I think. But what bothers me is that when people talk about this, they talk about those three things like they're independent variables. Whereas the moment you decide, well, Canada's got the best healthcare system in the world because of X, Y and Z, it's like, no, no, no, that's actually not correct. You have to understand what Canada has optimized for. Canada has optimized for cost, they've optimized for quality to some extent, and they've optimized for access, but not in the immediate sense. So the difference is, in Canada, it's cheaper and you have X, Y and Z. But, like, if you want to go and you know, like things that you and I would take for granted, like if you tore your ACL or suspected you tore your ACL, you would have an MRI within 24 hours. Here, that's not going to happen in Canada unless you have the money to cross the border and get it done in the United States, you could easily wait six months for an MRI there, access to physicians. I mean, the stories are horrible. And I know this because my whole family's still there. So it's not just like, I'm sort of making this Stuff up. I mean, I'm seeing what they're going through. And yet there are still things that are amazing in Canada. Like when my father had an enormous operation there, I was totally impressed with his care. I mean, it was as good as care he would have received at a great U.S. hospital. And it didn't cost a penny. And that blows my mind because you don't need these sort of nonsense internal accounting system that we have in US Hospitals where like the cup that you collect your urine in is 78 bucks and you know, like that bag of IV saline over there is 100 bucks and all this kind of nonsense. So the short answer is if I could wave a magic wand on this system. As much as I hate to say it, on some level you have to have at least a blanket called a single payer system. I do believe that if you truly try to individually privatize this thing, you cannot get that silly decouple out. The second thing, and this is also very unpopular to say is I do think we as patients need more skin in the game. Now, of course, under the current pricing regime, that would be impossible, right? You couldn't allow patients to be exposed to more than the 9% that were already exposed to. And it's probably higher by now, by the way. Those are old data. You would probably know what the current exposure is. But because the prices are so inflated and so nonsensical and as you probably know, I mean, you obviously know this, but maybe the listeners don't. I mean, medical cost is the leading cause of personal bankruptcy. So the answer isn't patients need too much, spend more. They just need to own a greater share of the cost, which really means the total cost can't be a bullshit scam, which is sort of what it is right now. So as interesting and important as all of that stuff is, I never think about it.

I love it. Yeah. Here's my solution to this very complex problem and I don't think about it at all. You know what's funny? Everything you just said. I've been batting around this quite a bit because it's part of what I try to do. I have a solution that I'm going to pitch you real quick. I think it fulfills most of what you're saying because our plans again, converge like many things. It's strange when people think about these things independently and they converge. We've never talked about this. So my plan for fixing healthcare is this. First of all, you need to put patient skin in the game. And the way you do that Is you give them a personal health account up to about $2,500. If you're very poor, that can be subsidized by the government. What do you use that for? You use that for primary care services or out of pocket expenses.

So it's use it or lose it.

Use it. Well, it's use it or maybe it grows, maybe you keep it.

But it has to be used within healthcare so there's no incentive to not spend it.

Exactly. You wanna use it in healthcare. And the thing is you wanna use it for primary care. And the way you do primary care. Right, is the way we did Turntable Health, which is a flat membership fee for an unlimited all you can treat. Access to a relationship driven, preventative minded, team based healthcare that's technology enabled but not enslaved, that's evidence informed, but not evidence enslaved. You can look at the unique patient, you're not subject to metrics beyond the patient having outcomes that matter to them because otherwise they will take their money and they'll take their personal health account and they'll go somewhere else. So it's people competing with each other based on what they're providing to the patient. So you would be on that plan, they would use the money to pay you, et cetera. Once they reach that 2500, then it gets into deductible space. So at this point, if you're a rich person, that deductible may be $7500 or whatever it is for your family, which it is now. It's like that. Now if you're poor, it might be subsidized by either your employer or by the government to some degree, but your skin is still somewhat in the game. And so you're paying for that. Now once you reach the deductible, that's where the catastrophic Medicare kicks in. That is Medicare for all, but not in the single payer sense. It doesn't pay for everything. It's not like carte blanche fee for service. You get whatever you want. It's a catastrophic wraparound. If you go to the hospital, it will cover it after you paid your deductible, after you use your personal health account and it's given out and administered in the same way that Medicare Advantage is. In other words, different entities compete to be the most efficient with that money. So in other words, if a hospital system can actually keep you out of the hospital, it doesn't spend all the money, it gets to keep the shared savings. Something like that. So you have businesses competing, you have the government covering everybody, Nobody falls through the cracks. Hospitals compete, doctors compete, but everybody gets to practice the way they want. You get to choose your doctor and their skin in the game. And it doesn't bankrupt the country because you need maybe another 6% tax. And it's equitable, but not completely unfair. And I think that's how you do it. But at the center of it is prevention. Primary care as the engine that drives and that also ameliorates burnout. And then you focus on technology that actually enables that, quality science that actually enables that. And if you discover that there's a particular dosing of rapamycin and you have a clinic that does that, you're going to win the competition game and your science will disseminate and then other people will steal it and it'll elevate the game. So that's my theory.

I mean, it's very interesting. Obviously, I think a lot of that makes sense. The one thing that is very challenging in these systems, which are because there's a portion of what you're describing is almost captured.

Yes, right.

The challenge of these systems is, and this is why, as much as I would love to say this should all be done privately without the government, I think the one advantage the government has going for it, if it knows how to play its cards right, which unfortunately it doesn't always is it owns the patient life forever and therefore it is truly incentivized to participate in a capitated way. The challenge of privatizing this is the median tenure of a patient with a payer, be it an insurance company or their employee employer, is in the neighborhood of what, four or five years? Maybe less than that, actually. Yeah, maybe less than that. So if you have pre diabetes right now, the cost to normalize you, in fact, if you are a newly diagnosed type 2 diabetic today or you have NAFLD today, and I know I only own your life for three or four more years, I have zero incentive to spend one penny because the macrovascular and microvascular diseases that are going to destroy your life in 20 years, I'm going to be so long gone, I won't even know you, I won't even remember your name.

And actually this is a central piece of this, which is in this country we medicalize our social problems. So. So diabetes to a large extent in these very high utilizers is a social problem. It's poverty, it's lack of job security, it's inability to exercise because of danger in the community, these kind of things. It's adverse childhood experiences. So as a Result, if you start shunting money from healthcare into those social services like every other industrialized country does, you can actually squeeze down the overall cost. So that may ameliorate some of this, but I understand.

But that would have to be done centralized. There is no way any entity but the government's going to do that, is there?

I agree. I agree with you. I think that's the role for government. And people will disagree. Hardcore libertarians will disagree. I don't care. They can.

Well, here's the funny thing. I consider myself again, libertarian is such a broad term that it doesn't mean much because you have such extremes on that. But I actually found Michael Lewis's book, the Fifth Risk to be quite interesting.

I'll check it out.

I knew about half of it quite well. I actually knew a lot about what the DOE does and what. What the USDA does, but I didn't have much of a sense of what the Department of Commerce does. And his book is a very depressing book. So I don't want to get into the politics of the book. But absent all of the politics, if nothing else, whatever your political views are is simply an exercise in civics to understand what your government does, because we have a lot of examples of what they do poorly. I mean, and I'm as guilty of that as anybody. I could rattle off a hundred things that they are mindlessly incompetent at. I think Lewis does a great job explaining things that they are competent at, and in fact, so competent at that we don't realize how many close calls we have.

Right.

And he does that through going through what AG does, energy does, commerce does. It's a very quick read. I think I read it in a day and a half. It was a hard time putting it down. It was so good. A day and a half of busy work.

Right?

Yeah, yeah.

I mean, but this is why the center probably holds the truth in most cases. That's where I am, too. I think government has a role. Listen, people say, oh, get government out of healthcare. We can't have men in healthcare. They're already 50% of health care, Medicare, Medicaid, all this chip. They are a huge player.

Yeah, at least 50. More than that.

At least 50. So think of VA. Think about that. So now you're like, okay, well, how can we optimize them and don't let them break stuff that they have no business in, but then have them do what they really do well? And I think that some of that social support is something we do well. We don't have the political in this country, I think, to come together on that. But if we did, we'd stop putting the moral distress on us as caregivers because we feel terrible. We can't. It's a hamster wheel. You know, when I go round at the county, I did this week, every single patient there doesn't need to be there. They're all preventable. It's all social determinants. It's substance abuse, it's adverse childhood experiences, people who were abused sexually and otherwise. And that manifests as adult chronic disease. We know this. So this is a thing. I want to say one thing because I think my followers and yours will want to know how you're not scalable as a doctor. You do amazing things. But how are people going to find doctors like you, you that think so differently and are treating people in a way that is trying to maximize these outcomes that you talk about?

I mean, I think there are already sort of organizations that organize around this through functional medicine and things like that. I'm not being facetious. I probably get 250 emails a day. Now, obviously a number of those are directly work related patients, colleagues, whatever, but a very high number of those, which unfortunately I just can't respond to for the most part are through the blog or through the podcast or something saying, hey, Peter, I live in St. Louis and I've been listening to your podcast or reading this and I'm interested in the way you're thinking about metabolism or this or that or the other thing. My doctor kind of rejects everything you're talking about as I have 12 minutes to see him and it's basically refilling my blood pressure medication and that's it. Is there a doc in St. Louis that you know that you. And so the answer to these questions is inevitably and invariably, always. I don't. I just, you know, I don't know. Once in a blue moon I get asked that question and the person is asking it from a place that I know and I'm like, great. I used to always tell people about you in Vegas until they couldn't come and see you. So what we're actually doing is creating a Dr. Database on our site and we're making it a pain in the ass for the doctors to fill out because I want them to do some work, right? So it's like you got to come to the site, you got to answer a lot of questions and really get into the weeds on like, how much time do you spend each month learning about this subject or that subject or this subject, what is your process of re education? What is your philosophy on medicine? Because I think in about 2,500 words or less, and maybe we allocated a thousand words or whatever, I don't remember what it was, but we gave quite a bit of room for people to basically explain how they think about medicine. Because even though I can't do it in 30 seconds, if given three minutes, I could probably provide a reasonable overview. And then the goal is to basically figure out a way to get that to be a critical mass such that it now becomes just a sort of directory for patients. So someone can say, if my zip code is this, boom, pull up all doctors within 20 miles and then they'll be able to go and then read about those people. And obviously it's impossible for me to vet these physicians. So this in no way, shape or form means like endorsement. I'm putting an endorsement on this person. You know, Chris Kresser has done a bit of that through his work through. He can at least vouch for, you know, so and so has taken this course. But my hope is that given the hurdle of how much work goes into that, it's not just someone mindlessly saying, I'm a doc, I want another, you know, portal of referral. If it streamlines the process for patients by 50%, it's still valuable. I think it could be more valuable than that.

How can my fans help with this? These are all healthcare people, activist patients.

They should just go and sign up. So if you go to Peterattiamd.com, i don't look at my website enough to know, but I'm sure that somewhere on there it is physician network or something like that.

Right. It's not a porn site, so you have no business on it. Pretty much that's my criteria. Usually.

We'Ve touched on this briefly, but I don't think we've done it justice, which is your music videos are at once both incredibly funny and actually at times incredibly touching. Some of them are very moving and they're always entertaining. So rather than me, try to like describe six of your favorite videos. We're just going to link to all of them in our show notes so that people can see them. But every time I've asked you about it, either your modesty just downplays your process or you really are a savant. But I don't know how you actually do that. So can you just pick one and explain how you go from there's a very popular song out there to I have an idea that I would like, to parody to. I write the lyrics to. I make this video. You talk about that as though, like the same way I talk about making scrambled eggs.

Yeah.

It requires a little bit of work. You know, you don't want to get the shell in the bowl. Blah, blah, blah, blah.

So you want inside the Dr. Studio with ZDoggMD. You want to get into how I do this. And it's interesting because a lot of people.

Yes, exactly.

Exactly. So much of it is. It's like a creative process. Like, for example, when I see what you do and the way you dissect a paper, the way you think about science, it's inexplicable to me because my mind works very differently the way that I think about something. Let's use an example of. There's a song I did called Ain't the Way to Die.

Yes. Which is one of the. I would say, three of yours that I actually find very touching. Because as funny as it is, if you've been there and seen it, it's a tearjerker.

And I'm sure we'll link to it so people can see it. The idea was everything we do is try to be mission driven. So the why of what we're doing, and sometimes that's unconscious. We don't consciously go, oh, why are we doing this video? It's more like, what's the message we're trying to get now. When I was working full time at Stanford, one of the most painful things I saw was that people suffered and were tortured at the end of life because nobody had the balls to have a conversation and say, what is it you want when this happens? And be very specific. Like, talk to your loved ones. The loved ones will say, he never talked about it. He said he didn't want to be a vegetable. Or, the loved one's three states away and needs to come before any decisions are made. But they won't come for weeks because they think it's not urgent. But this person is on a ventilator, paralyzed, partially sedated, probably suffering, and didn't know that this was even a possibility. So it starts from that emotional place of, what do we want to do with this thing? Then you start to think, I want to do a song about this. What would be a fit for this? And this is kind of a bit of science. You're trying to fit this sort of peg in the right hole and figuring out what's the right emotional valence, what's the right lyrical structure. And you're going through. You're maybe Going through Spotify, flicking through. And then you see. And I saw Eminem. I'm like, I like Eminem. I mean, he's one of those guys that you can listen to. You don't love it, but it's so clever. You just go, that's clever. I admire that. But he did that piece with Rihanna about domestic abuse. You know, just gonna stand there and watch me burn. And you're like, that hits you right in the elephant, right in the emotional unconscious. Okay, we can motivate the elephant. And then later we'll think about the writer, how we direct them. So that made me feel something. It's about domestic abuse. Isn't domestic abuse the same as the institutional abuse that happens to our patients when we don't have this conversation? And then I really felt it. I was like, yeah, listen to the lyrics going. It writes itself. Then I sit down and I go through the lyrics and I create a spreadsheet. So this is kind of a Peter Attia approach. Yeah.

I did not expect this.

Yeah. This is where my scientist inside me comes out and I go, okay. These two, actually. So they'll sometimes help me with lyrics. They didn't help with this one, but my friend Harry did. He's a pediatrician.

Well, they didn't get me a White Russian either. And I'm still.

Because they're vexed. They're pieces of shit. Fade to black. Oh, he faded me to black. Actually, he faded Peter to black because Peter wants his White Russian instead. He got blacked out, which is another consequence of White Russians, the document. The nice thing about a Google spreadsheet is you have all the original lyrics here. And so this is the problem with. I get. You know how you get all these emails? I get that many emails, and they're all like, you should do a parody of OPP but make it about ecg. You down with ecg? Yeah. You know me. I'm like, okay, that's dumb. It has no point. And they often get the meter wrong. So they're saying, here are my lyrics, and the meter is totally off.

While we were talking earlier, we were looking at awesome vids of your daughters playing the violin. Are you musically trained?

So this is the funny thing. When I was in high school, we were talking about identity and self hatred. I wanted to fit in. I was a short little kid with a funny last name who was kind of chubby. So I always struggle with weight, an unhealthy relationship with food to this day. But I've somehow managed to do okay the way I Got by was I would try to find these crutches to help me fit in socially in the Central Valley of California, which is all white or all Hispanic. And here I am, this like Zoroastrian, Persian weird person. I had an Afro at that time.

Which I've seen photos.

You've seen photos. I used to pray, and I'm not even religious. I used to pray for my hair to fall out. Cause I hated my hair so much. And when it did, I was like, why, God, why? I was kidding. So awkward kids. So I picked up guitar as a way to try to impress ladies. Because I was like, you know what, everybody? You know, more than words. Which I eventually did a parody of, by the way, called More Than Warts about hpv. But the weird thing is I fell in love with the instrument because I always loved music. And Weird Al was always like a weird. Because I was a nerd. I loved Weird Al. And so I was just in love with this concept of parody. So I picked up a guitar, learned guitar. Then I went to UC Berkeley and had this delusion that I was gonna.

Be a rock star.

So I felt like, because Berkeley is.

I mean, generally going to the best school in the state. It's an obvious linear pathway to being a rock star.

It's a hundred one to one correlation. You're a scientist, Peter. Why are you asking these questions? Yeah, for me it was like, no brainer. I'll go to Berkeley just to please my parents. Because they want me to go to a real school. And it's not Stanford, so I don't have to spend all the tuition. Cause my dad was like, you know what? Berkeley is just as good and cheaper. I'm like, it's actually not, dad. Here's the secret. It's really cushy. Okay? It's really cushy. So all that being said, but I minored in music and I majored in molecular biology. Because I was like, pre med with the hedge. Then I'll be a rock star.

I like it.

And increasingly, it became clear that I didn't have this thing called talent. I didn't have enough drive and talent and ambition in that line of intelligence music to be famous. There were so many kids that were so much better than me. And I knew it. And the thing is, rather than beat myself up about it, I'm like, cool, I'll be a doctor who plays guitar on the side. And that's what ended up happening. And so I actually majored in. I did ethnomusicology. So it was like studying the music of Indonesia and all these different musical forms. And it turned out that was the perfect conditioning of my subminds, these little conscious agents to later, in my depths of burnout. All this music came back out, and the Weird Al component came through. So here I am as a professional Weird Al. Now I'm going, okay, here's my spreadsheet. On the left, I have the original lyrics to Eminem and their structure. And the right, I have a blank space. I come up with the title. And then I reach out to my friend Devin Moore, who's our audio engineer, who's just a genius. He's like a professional musician, and he just. We've met in Vegas, and he's like, this is how we do things. And I want to do your stuff because you suck at producing the songs, because I was doing it on GarageBand. So he creates the backing track, and he did that. In that case, he sends me the track. Then I have the feel of it. Then I'll sit there with the original. I'll listen to it, and I'll just start coming up with lyrics in my mind. I may have some notes. I need it to hit this point and this point and this point, and then I'll brainstorm. And usually this happens. My creative processes. I get on a treadmill or a StairMaster or I run. And that silences the monkey mind on top. So that the unconscious, which has been processing the stuff in the background starts to bubble up, these ideas. So these little clever phrases or little things that I remember from the ICU or a case that I remember bubbles up. And then I start to put it into the structure. So from open creativity to codified structure with parameters. So the nice thing is there's a parameter, there's a structure in the song already that I can't violate. So that bit of constraint allows me actually to excel at what I do. I need that constraint. If it's just open, I will fuck it up because it's too much possibility. And I'll mentally masturbate for hours, and it won't come out. So having that constraint is helpful. Then I put it in thing. Then I show it to friends. Then I go back. And then this is the thing. The rewriting process of lyrics is even more important than the initial writing. So it's going back, and that one word is just emotionally wrong or feels musically wrong. And you tweak it and tweak it and tweak it and get a thesaurus out. You go to rhyme zone and you find better Rhymes. And then you hone it. And when it's done, then I go into that studio, which is right there, which I won't say the name of it because it uses the R word, but it has TARDIS in it. It looks like a TARDIS from Doctor who, but it's not. Okay. It's a developmentally delayed Tardis and I record it and then Devin mixes it and then we put it in.

So put some time on that for me. From the moment you picked the Eminem song, what was the length of time from the idea I want to do a song on this topic to choosing the song?

Approximately a couple days.

Okay. I wanted to represent it.

Often it is.

Okay. And then from the moment you pick the song to strip the lyrics out, make the spreadsheet, do the runs, write the song. Is how long?

In this case it was about one or two weeks. In the shortest case, it's a day. I do it right then. And I have friends and they help me and the team here, Tom and Logan, in the longest. It's been a month where I'm just pounding my head on the shit and there's no time frame.

And do you ever, in that process, say, I picked the wrong song, I gotta go back?

Yes. Our history is littered with half completed projects where there's actually a track and it's just dumped. For example, we were gonna do Amy Winehouse rehab about skilled nursing homes.

Oh, interesting.

Doc tried to make me go to rehab. I won't go, go, go. Yes. I felt bad, But I got 12 cats at home, home, home the little old lady who won't go to sniff. That was dumb. And the more we tried to make it work, the less happy we were. Now then, we may come back to it, but. Yeah, so sometimes we just fail. But ain't the way to die. It just kind of started.

Oh, yeah, that's a.

And the more we realized, we got the sense of, you know, that sense of moral elevation you get in your chest where you feel something hit and it's. And it raises you in this way where you feel it expand. It sounds very woo woo, but it's a real human sensation. John Haidt and others have talked about the sense of moral elevation. Like, I've done something here. I've tapped into some ethos that will help people.

And recording a song like that is done in one day.

It depends. So that one we did over a couple of days. I went to Devin's studio actually, and we just kept banging it out and he would coach me. He'd sit there in the engineer space and be like, you know what? I'm not feeling anything with that. Try it. Maybe this. This way. And then we'll do like 30 takes.

Oh, my God.

And then he'll be like, that's it. I got goosebumps. That's it. That's it right there. How.

How does one do that? Like, if you said to me, can you repeat something six times? Like, I wouldn't. I would. This is the thing that's always amazed me about acting. I don't think I've appreciated it as much about singing. But, you know, if you've ever been on a set to actually watch a movie being made, and there's like a list actors, that. Which I've had the privilege of doing once or twice, I'm amazed that first of all, an entire day of shooting produces 60 to 90 seconds worth of a movie. That's how many times things are being done over and over and over again. And it's to watch the actors and actresses show up with the same level of emotion, the same emphasis, correcting, maybe whatever the director says to correct. I'm like, well, that's another great reason why I could never have done that for a living.

And these are professionals that are really good at that. Now, see, I'm an untrained amateur. I like to call myself a pro am because, you know, it's one of those things where I get paid a little bit here and there with ads and stuff, but really, I'm just, you know, it's for the love of the game. But the truth is, it's a craft for me. And the finished product matters so deeply to me that I cannot put out a stinky piece of shit. I've done it and I've regretted it. And sometimes I put out something I think is good. In retrospect, I think sometimes I think that's something that's crap. And it turns out being great but ain't the way to die was one of those things like, I can't fuck this up. So you do 20, 30 takes. And you'll see as they're all sitting there in logic, that's the program we use. And you just take, take, take, take, take, take, take. And what we'll do then is we'll comp. Sometimes we'll say, let's take the best of this first verse, best of that. And some people think that's cheating, but that's how most people do it.

Now, I didn't realize that would be thought of as cheating.

So some of the purists and the old school musicians say, well, no, you just got to go on and sing it, like. And that's how you do it. But that's not how anybody does it now, because you are trying to produce the best piece of art you can. And what's fascinating, actually, Peter, is, again, I'm not a trained musician. I don't sing. I don't rap. It's something that I had to figure out. I used to be really bad, and Devin would tell me, you really suck. Like, it takes 30 takes just to get it to sound good. Have you thought about taking voice lessons? And I'm like, don't insult me, dude. What's a. You can't train a voice. That's bullshit. It's stupid. And then I went and got voice lessons. Just. Just a few lessons. And then these CDs that I kept doing. And this is the thing, man. The voice, like anything, is a performance instrument. It's a muscle. And the vocal cords get stronger. Your control gets better. Your breath control gets better. So the way you breathe for singing is so different than the way you would normally talk or anything. And that helps when you do speaking, because you don't get hoarse. You warm up, right. You project better. So I'm a tiny little person who can project his damn voice.

Yeah. But you also, as a Zoroastrian, you come from the lineage of. Of the greatest singer of all time.

We are the Champions. Exactly. Freddie Mercury. Oh.

Oh, God.

Oh. And Zubin Mehta, who I was named after, is conductor. It's a musical lineage. Our people. My people call it Maze. Peter Attia. Do you remember that commercial? It was an old Mazzola commercial in the 80s, it was. They had a Native American guy in the headdress.

Yeah.

And he's sitting in a boat and he's eating corn, and he's like. My people call it maize, and it was like, mazzola, corn goodness. Anyway, so. So I trained my voice, and so now I have to do less takes, and I'm able to go live. So even though we do this art where we're cutting it up in the studio, when I have to perform Ain't the Way to Die Live, which I do 50 times a year when I do my live shows.

Oh, really?

Yeah. So I do that one. I do seven years. There's about 27 years old.

Oh, so you're hitting on all the killers. Like, seven Years is, I think, the most touching of them all.

Seven Years is my favorite. And Tom was the genius behind how To Tom and Logan back there. Genius of how to cinematographize that and the emotion of it. We're sitting in the edit, speaking of that. So the edit, there's.

Those were your kids.

Those are my kids. That's your clinic. It's my family, it's my wife, it's my dad. So it was a personal thing. And we're sitting in the edit on the apex where you're pushing in on my daughter. And it's like, you know, soon I'll be 60 years old. And it's a whole emotional piece. And we didn't feel it. We didn't feel it, we didn't feel it. And then we're like, how about this? Trim that one microsecond here. All of us are crying and we're like, okay, that's it, hit send. That's the thing, that's the process. And it's the same with the musical piece. So then once you do it, you may craft this thing here, but when you go and do it live, it takes on a whole new Persona. Cause you have this input and you're doing it in one take. And that's where I think the real artistry starts to try to have. I'm calling it artistry. I'm a fucking professional clown. But it feels like that on stage because you're seeing the synchronization of the audience with the message. People are crying, you're feeling this energy. And afterwards they'll tell you, this is how you made me feel during that. And I'm a 20 year veteran, I'm a 30 year nurse or I'm a 40 year RT or whatever it is. And that's what really gets you. So all of that is for this. That's the process. Then we'll put it out, then we'll brainstorm the video. Then we'll go beg our hospital to let us shoot. Extras are all real medical people. Nobody's paid. We'll go and do it. We'll rent the equipment, we'll get the crew and we'll do it.

And how long does it take you to shoot, say, those two videos there?

It's like a day.

Wow.

Because we don't have a choice. Cause we're operating in a real hospital with real patients running around. So we have to go to a wing where maybe they're not on overflow right now so we can do it. And they're kind enough to let us do it. And then maybe they'll kick us out because they haven't been.

You have extended the invitation to me so many times to be in a video. I just. I gotta take you up on one of these. I'll be the guy that just, like, walks by, and no one will even see me.

We're doing a parody of the Barenaked Ladies. One week. I don't know if I sent it to you. You remember that song? It's been one week.

Hang on a second. You don't realize this. I went to high school with the bare naked. You? Yeah. Their dad was our guidance counselor. The Cregan brothers, right? Andrew and Jim. Their dad was our guidance counselor.

Oh, my God.

Yeah.

So I saw them in 1991 in Berkeley in a small little club before they were famous. And I was like, these guys are gods, you know? This is me in grade nine, baby. Yeah. This. Oh, my gosh.

I notice it's grade nine, not ninth grade.

No, because it's Canada. It's grade nine.

Yeah.

So I always loved the Barenaked Ladies. One Week wasn't my favorite song, but I wanted to do a tribute for foreign medical graduates from India and South Asia. Like, my parents, both of them were doctors, and I'm like, one Sikh. We'll make it about doctors. And so this was one where it just. Right. Tom. We were just like, here are the lyrics. It took a second, and it was like, there's this one Sikh in the doctor's lounge, a Punjabi guy whose name no one can pronounce. Four Janes in emergency saying, get that corn dog away from Dr. Mukherjee. And when the rap comes up, it was like, you know, tikka masala, the desi chicken. You have a drumstick in. Watching Bollywood with no lights on. Check out Amir Khan. He does a slow mo run in this one, like Bobby Jindal. I'm trying to act white. That just ain't right because I always drive Camry. So we're shooting that in Texas next month, so you should come and be.

Where? What city?

In Victoria, Texas. This tiny town on the coast about an hour from Austin. I know you have homies in Austin. We're flying into Austin. We're renting all the equipment. We're going to this cardiology clinic that this Indian doctor couple runs. They heard the song, they're like, we want to be in it. Okay. Fat A fat. And so we're going to shoot it there. So you should come and be an extra on that.

All right, well, when we're off, Mike, I'll ask you for the details so that we don't let all the fans in the world know where we're going to be.

That's a great idea.

Yeah.

We don't want the anti vaxxers.

Anti vaxxers to show up.

Oh, to these poor people's clinic. Oh, that would be terrible. So that's more or less the process.

Well, I got to say, I mean, if nothing comes of this discussion other than a set of people who are not familiar with you, I. E. A subset of people who listen to me who don't yet know who you are, figure out who you are, that's worth everything. In fact, I almost feel bad that we took up all this time because what I could have just done is said today's podcast is going to be really short. It's just going to be me telling you, go check out all of Zubin's stuff because that's effectively the most important piece of this to me.

That's effectively what I'm gonna tell my followers, which is Peter Attia is doing brilliant work in this space that nobody else is doing and the people that are collaborating with him are amazing and you need to check him out. And also, he's my homie from way back and we don't give an F about a damn thing. That's one thing that separates us from some other so called doctors. All right? Am I right, brother?

It has been a lot of fun. This has been long overdue by about.

Two decades I think. So it's been a real pleasure, Peter, thanks so much.

Thanks for hosting me. And guys, despite the fact that you didn't bring me a White Russian, I still love you over there. You can find all of this information and more@peterattiamd.com podcast there you'll find the show notes, readings and links related to this episode. You can also find my blog@peterattiamd.com maybe the simplest thing to do is to sign up for my subjectively non lame once a week email where I'll update you on what I've been up to, the most, most interesting papers I've read, and all things related to longevity, science, performance, sleep, etc. On social, you can find me on Twitter, Instagram and Facebook, all with the id PeterAttiyamd. But usually Twitter is the best way to reach me to share your questions and comments. Now for the obligatory disclaimer. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional healthcare services, including the gift of of medical advice and note no doctor patient relationship is formed. The use of this information and the materials linked to the podcast is at the user's own risk. The content of this podcast is not intended to be a substitute for professional medical advice, diagnoses or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they have, and should seek the assistance of their healthcare professionals for any such conditions. Lastly, and perhaps most importantly, I take conflicts of interest very seriously. For all of my disclosures, the companies I invest in and or Advise, please visit peterattiamd.com about.