Atul Gawande

[0] Welcome, welcome, welcome, I'm Jack Shepherd.

[1] I'm Jack Shepherd.

[2] This is Monica Babin.

[3] Oh, yeah.

[4] It's not like a record going backwards?

[5] Well, experts on experts.

[6] That's what we got ahead of us today.

[7] A really interesting expert on a topic we generally avoid.

[8] Death.

[9] Now, Atoll Gwandae was recommended to us by Julia Louise Dreyfus.

[10] She said she had read a book called Being Mortal, Illness.

[11] medicine and what matters in the end.

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

[13] So we got to talk to a tool.

[14] And a tool is an American surgeon writer and public health researcher.

[15] He practices general and endocrine surgery at Brigham and Women's Hospital in Boston, Massachusetts.

[16] He graduated from Stanford, Oxford, Harvard, Rhodes Scholar, MacArthur fellow, you name it.

[17] He's done it.

[18] He's got four books.

[19] Complications, better, the checklist manifesto and being mortal.

[20] We loved a tool.

[21] We did.

[22] And we learned a lot from it.

[23] Yeah.

[24] He gives you a great framework for conversations that we all will have at some point.

[25] Have to have.

[26] So please enjoy a tool go one day.

[27] Wonderly plus subscribers can listen to Armchair expert early and add free right now.

[28] Join Wonderly Plus in the Wondry app or on Apple Podcasts.

[29] Or you can listen for free wherever you get your podcasts.

[30] we're intimidated to talk to you this doesn't happen very often but you just had too much stuff to learn about to be honest so shame on you can i ask you really quick because i don't want to get it wrong is it is it a toll or a toll it's a tool like a hammer you can imagine the jokes as i was crying a tool um you know you're someone that has come up on our show several times many of our guests are big fans of yours, enough so that we had to seek you out and beg you to do the show.

[31] So we're very grateful.

[32] I don't know if it got to you, but, you know, Julia Louise Dreyfus, who I, I worship.

[33] She's like a devotee of a tool.

[34] So there's a hilarious story behind that because she turned up on the show and I heard the podcast and then several of my friends are like, you got to reach out to her.

[35] She said she wanted to meet you.

[36] I'm like, come on.

[37] And then one friend, like, I know her agent, I'm going to ping them.

[38] Yeah.

[39] We talked today.

[40] Oh, that's amazing.

[41] We had a little Zoom date.

[42] Oh, wonderful.

[43] And it was amazing.

[44] It was amazing.

[45] We talked about our parents and we talked about a lot of what each other are going through at a similar age with kids who are now in their 20s and out of the house.

[46] And so it was great.

[47] And it was thanks to you.

[48] And she was.

[49] was just totally lovely, as you know.

[50] Yes.

[51] Now, your children are grown, but have you guys been quarantining together?

[52] That seems to be something that's happening.

[53] No, I have my eldest at 25 now is living in Berlin with his girlfriend.

[54] Wow.

[55] Wonderful.

[56] Which is a thing now for us to also understand.

[57] And then my middle child is in North Carolina where she's working.

[58] And my youngest is in Boston and has no interest in quarantining here.

[59] Okay, sure, sure.

[60] And now you're an Ohio native.

[61] You're a Buckeye, we could say.

[62] You're from the Midwest.

[63] Where are you from?

[64] Well, I'm from 25 miles northwest of Detroit.

[65] So right where the suburbs turn to corn.

[66] Okay.

[67] Yeah, so a big dose of hillbillies and then a big dose of folks who drove into Detroit to work.

[68] Well, Ohio and Michigan rivals, but very similar culture.

[69] I'm from a small town, Athens, Ohio, which is southeastern college town, but also the poorest county in Ohio.

[70] Oh, it is?

[71] Yeah.

[72] And so it's Appalachian Foothills and everything from hunger to poverty as part of the picture there, while also having some of my friends come from all of the kind of fancy colleges you can imagine.

[73] Did you read Hillbilly Elegy?

[74] I did.

[75] You did?

[76] Okay.

[77] I had a real argument with Hillbilly Elegy.

[78] Oh, my goodness.

[79] So I had a huge one.

[80] And Monica's very disappointed in it.

[81] And I would love to hear what yours is.

[82] Yeah.

[83] I actually, I wrote about it as well, which is that the hillbilly elegy, look, Chilicothe, Ohio is rival high school to one of mine.

[84] It is the area we grew up.

[85] And no question, J .D. Vance, who wrote this memoir of growing up in extremely poor circumstances, unlike me, parents of two doctors with the only Mercedes in town, you know, not the same story, right?

[86] right but but what i what i what i never had you never hear about his friends you never hear about who he dated and what that was like and that richness of the relationships beyond this family but but for him and this and how that changed him and affected him and you know so when i went back part of the premise of hillbill or the conclusion of hillbilly elegy is it's a cultural failure these are people who are stuck in their ways and are deteriorating the breakdown of the family, and they just got to pull themselves out of it.

[87] And, you know, the military and family values was what pulled him out, and this is what we need.

[88] And without ever getting into the ways in which in my county, you start with 30 % either uninsured or with inadequate health coverage.

[89] The larger picture that bothered me was that mix of I had friends who were unemployed for two and a half years and went through a lot and finally got a job at the waterworks working the midnight shift after all of that time and the ways in which you can get broken by the system and never have your shot and I grew up getting to see I was going to get my shot and yes I had an amazing family upbringing as well that kept me on a good course but it was also I was set up for success.

[90] And I could see from the beginning that some of my best friends were not.

[91] Okay.

[92] So what's so interesting is I don't think I was pinpointing what my issue was.

[93] To your point, I have a couple friends that there's no pull yourself up by your bootstraps.

[94] That's an insane proposition.

[95] Mom was dealing with a stepdad who's regularly tearing the house down in such a fashion that there's no way you could have prioritized schoolwork or learned anything.

[96] No one had their own bed to sleep in.

[97] This notion of, yeah, just kind of overcome that.

[98] I guess didn't ring ultra true to me and what I saw.

[99] At the core of this, in my high school, about half went to college and half didn't.

[100] And if you don't go to college, there is no middle class opportunity that's out there.

[101] And in the United States, 70 % of people don't go to college.

[102] And we don't have a solution for them.

[103] We don't have a future.

[104] We're offering to them than to say, well, why can't people get their act together?

[105] And yeah, because of the military and because of his family, he became one of the first, you know, he got to go to Yale and he got to get all these opportunities and move on.

[106] And absolutely.

[107] But that's not the pathway that can save everybody.

[108] Beyond single digit percentage people who, sure, get a trade job and then build their own company and become the one HVAC family who's rich as hell, even though they were from the dirt roads.

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

[110] And then on the personal level, my upbringing was a lot around the fact that as an immigrant family, not feeling like you could fit in and having great friends.

[111] But at the same time, like, yeah, I'd spent my teenage life wishing for a date and not getting one, right?

[112] Right, right.

[113] Or I have to imagine living in some fear of physical violence because you're other.

[114] And it's a town that's not afraid of a fist fight, right?

[115] Oh, I mean, everybody had a fear of physical violence in that town, right?

[116] Right.

[117] There were fights constantly out on the smoking patio.

[118] We were in the days where you had a smoking patio outside the cafeteria.

[119] Did you have a smoking patio at your high school growing up?

[120] Yeah.

[121] So it was basically, so I think I'm about 10.

[122] You're too young.

[123] Well, I'm 10 years younger than you.

[124] But my best friend, he got sent to an alternative high school where they just were like, you know what?

[125] Half the reason they're leaving is because they need to go smoke.

[126] So we're just going to let them smoke in school.

[127] So we were in the transition phase where like the more progressive angle.

[128] was like, well, let's just let them smoke and hopefully they'll stick around.

[129] So that was happening.

[130] And I think sometimes in the classroom.

[131] There were guns and there were knives and there were a lot of fights.

[132] And back then, people drank a lot compared to, I mean, kids today are so much better.

[133] Oh, my God.

[134] They're such better people than we were.

[135] Yeah.

[136] I mean, they're not having sex as much, which concerns me. But, you know, maybe that's part of being better.

[137] They aren't.

[138] You're exactly right.

[139] Most people don't, they don't really realize that, right?

[140] And that actually their interpersonal connections and the weakness of some of those is a thing to fear in some ways.

[141] I'm with you on that.

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

[143] So what I want that what I'm really tempted, which seems like low -hanging fruit, is if I look at your career, you're an Akana class.

[144] I have to imagine you're a little bit high on the.

[145] disagreeability, psychological profile, which again, yes, we're high on it and we value it.

[146] So just know that this is a compliment ultimately.

[147] Yeah, this is where my wife would burst out laughing.

[148] Okay, good.

[149] My problem is that I want everybody to like me. Her argument is I'm not tough enough and not a jerk enough.

[150] I'm pretty low on the disagreeability index, a barrier I generally work on.

[151] Okay.

[152] But could you be both?

[153] juicy, codependent and highly disagreeable?

[154] And that really just, that's the war that happens?

[155] It could be.

[156] I went into surgery as much because I loved how tough people were in surgery.

[157] The situation of surgery is in circumstances where people need to go to surgery.

[158] Often, you don't have all the data.

[159] The studies aren't great.

[160] You don't have all the information even in that moment in front of you and your skills are imperfect.

[161] You have complications and things can go very wrong.

[162] And yet going in there and being confident and taking your chances and living with the consequences is part of it, right?

[163] And then being prepared and owning responsibility.

[164] It is a very heavy, high on the responsibility culture kind of place and on owning failure and going to that next step.

[165] And I got in the operating room and you'd have these people who could dare to open up people's bodies and know they were imperfect and know that things could go wrong, have the confidence, and they could be jerks sometimes, right?

[166] Sometimes in ways that I've actually ended up fighting against in my career in surgery, which is, I don't think we need to destroy the people in the room and rip them apart.

[167] It actually makes for terrible results in surgery.

[168] So I can be an iconoclast in the sense that I want to push back and fix what's not working.

[169] But I wish I were tough enough to let people who disagree with me or angry with me not get to me. So as a result, I'm trying to win everybody in the room.

[170] And that's not always feasible a lot of the time.

[171] Well, minimally, it's antithetical to a surgeon.

[172] So we've interviewed a handful of surgeons.

[173] And I got to say, we feel very confident in stereotyping after those interviews.

[174] And again, it's something I've kind of defended, which is, I want a high level of air.

[175] I actually want someone to be overly confident and self -assured because what I don't want is doubt when things go haywire, as they do, right?

[176] You want someone with a real steady belief in their abilities, for better or worse, I'd argue.

[177] Now, you're already, you're breaking that mold and that I can already tell you're more empathetic and less narcissistic than what we like to see in our surgeons.

[178] Yeah, how dare you?

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

[180] You did not just get out of medical school.

[181] And I don't know what it's a product of.

[182] It could have been that you win a little later, right?

[183] You had some gap time where you got involved in the rest of the world.

[184] And that could be what it is.

[185] Or I was going to push this narrative that maybe growing up in Ohio is I have to imagine one of very few brown people.

[186] I think that's good fertile ground for, wow, should I accept the system I'm inheriting and do I want to perpetuate it?

[187] or do I have questions for the overall system?

[188] We can try to unpack that because I don't have the answer.

[189] Okay, okay.

[190] Our goal is for you to leave here with a mental diagnosis from two non -professionals.

[191] I get very disturbed by things that don't feel right and that are especially confusing to me. For example, in surgery, I became a person who really pushed back on the culture of arrogance and intimidating people.

[192] there is a difference between arrogance and self -confidence.

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

[194] You do.

[195] You have to make choices and you've got to forge ahead.

[196] But the ones who don't have humility that things can go wrong are the ones who then can't own it when things go wrong and learn from that.

[197] Right, right.

[198] And so it's not the confidence that you are perfect, which is a dangerous confidence.

[199] It's the confidence that you can handle it and that you're aiming for perfection, but you know you'll never completely achieve it.

[200] The best surgeons I know are ones that are able to have good judgment, make quick decisions in the face of uncertainty, and are generally right and own it when they're wrong.

[201] Some of the best politicians, I feel like, are those kinds of people that they are able to recognize things are uncertain.

[202] you have to make a choice, and then you've got to own it and live with it.

[203] Well, what's the saying, right?

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

[205] You don't want someone dithering.

[206] You know, Obama, the night that he sent the special forces out to kill Osama bin Laden, and his entire presidency's on the line, he happened to be at the White House correspondent's dinner that night.

[207] Yes, giving joke.

[208] Folks, being as funny as any of the comedians.

[209] Roasting Donald Trump at that very night.

[210] Regrettable, probably.

[211] Right, right?

[212] Which, of course, pissed him off.

[213] But being able to make the call, it wasn't arrogance.

[214] It was confidence.

[215] It was like I've done the best I can.

[216] And then I'm going to own and live with the consequences.

[217] And I'm going to hope everybody comes with me when I then say, well, this is my choice I made.

[218] and here's here's how now we deal with this consequence and where we are, right?

[219] I have to walk out in surgery.

[220] Look, I've got it down to like 97 % of the time it's going to go, as I hope, the 3 % I'm going to have made worse off.

[221] By the way, that seems like one of the highest percentages in surgery, right?

[222] I mean, in general, there's a sliding scale, right?

[223] Back operations, I don't know, they're like 50 % effective or?

[224] Yes, that's right.

[225] You can have their operations like colon surgery where 25 % will have some kind of a complication that you have to deal with.

[226] And then there's, you know, some of them are errors, some of them are not.

[227] But I have to be able to walk in when there is something that goes wrong and, you know, not say like, what, nothing went wrong.

[228] Look, this is what happened.

[229] This is our situation now.

[230] Here's what we can do.

[231] And this is how we can manage the situation.

[232] Nothing is ever going to always go work perfectly.

[233] Yeah.

[234] And so you have to be able to bring people along for the right.

[235] And that's what I felt like I got out of surgery, which was, I was not that guy.

[236] My favorite New Yorker cartoon, which I felt like defined me, was the gravestone that said, he kept his options open.

[237] And that was me. That is me. Kathleen, my wife, when we go out to pick a place to eat, she can't stand the process because it's like, I can't.

[238] There's so many options.

[239] Sure, sure.

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

[241] You would have thrived in communist Russia, where they really limited your options.

[242] There was no option fatigue.

[243] It was like, you want a dairy product?

[244] Here it is.

[245] That's right.

[246] Now, in your book, The Checkless Manifesto, you start co -opting or looking at other areas where organizations have been successful in creating systems that mitigate accidents and disaster.

[247] And I guess there's an openness there to even do that.

[248] Again, I think it's anti -arrogant to say, oh, some other disciplines have faced similar challenges with varying success.

[249] And I'm open to learning about that.

[250] What was the catalyst for you to explore that?

[251] The core of this started with recognizing when I wrote my first book, Complications, that was about needing to navigate the learning curve.

[252] Like, how do I have the right?

[253] to learn to operate on people right i'm doing all these things for the first time how do i even ask permission from you and half the time we're not really like you're at a teaching hospital uh you know ignore this person who's standing by the table here they're just here to help out yeah yeah and then you get comfortable you know like you climb the learning curve and you start getting better and better then you realize we still suck 97 percent of time it goes well three percent of time it doesn't And most of the time when it goes wrong, it's because of something we already knew how to do.

[254] It's not because we were ignorant about how to fix the problem.

[255] The majority of the time, it's a failure.

[256] And the approach to failure, I've been obsessed with failure my entire career.

[257] And part of what I loved about surgery is how high the stakes are.

[258] And the way we approach it is, well, we're going to teach you.

[259] You're going to go through school forever.

[260] You're going to do four years of medical school and then eight years of surgical training, which is what I did.

[261] Then you're going to be perfect.

[262] And the reality of that, and on the research side, I've done a bunch of research on this.

[263] I mean, we have over 150 ,000 people per year who die or are permanently disabled because of complications from surgery.

[264] I mean, it's five times the number of people die in car accidents.

[265] In the U .S. Just in the U .S. 150 ,000?

[266] Yeah.

[267] I mean, we do over 15 million operations a year, right?

[268] Oh, my gosh.

[269] So what is that 1 %?

[270] Yeah, it's about It's about 1 % have a major complication from inpatient hospital circuit, right?

[271] Big major operations and found that about more than half the time was avoidable with information we know.

[272] And those are all the people who went through all of that training and got that training.

[273] So then our usual reaction is, okay, well, then let's issue guidelines and rules.

[274] Here are the rules you have to follow.

[275] You have to do it better in the following ways.

[276] You know, it's just the natural need -jerk human thing.

[277] Once we discover, we, doctors aren't washing their hands enough.

[278] And therefore, we're getting all these infections in hospitals or people aren't wearing their masks, whatever you do.

[279] Like, we need some rules.

[280] And so then you get malpractice litigation and you get insurance requirements and all those things.

[281] And they kind of work, but they don't make you great.

[282] Can I ask something about that?

[283] Does it, in some ways in the ethical branch, train.

[284] Does it offload responsibility?

[285] So there is such, you know, as people know, we're a very litigious country and so much of our medical experience is driven by trying to head off potential litigation.

[286] So does that offload your own personal responsibility in some way as a physician where you're like, well, clearly this think tank that's trying to prevent losses will come up with the plan.

[287] And I should really just focus on this.

[288] Does that make any sense?

[289] like, oh, there's this huge organism that's supposed to be preventing me from making liable mistakes, so they'll probably think of it.

[290] I don't think so in the sense that I think day to day you feel responsible for the person in front of you, but there is this lingering thing in the back of your head like, well, I've certainly no moments when I'm aware that, boy, I could get sued for this.

[291] And the worst of medicine is when we then decide to change the way we practice because of it.

[292] Right.

[293] Defensive medicine definitely can occur where you're getting the CT scan, even though you don't think it needs to be done because, you know, you're worried you'll get sued.

[294] When you start playing that game, it does no good.

[295] I think the larger picture, though, is that the malpractice litigation, the whole idea that you can, whether it's punish people or reward people to do the right thing, ignores the fact that when things go badly, wrong, it's usually because you've been set up for failure.

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

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

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

[299] And you are you, you are novel in that you're saying, let's look at the system, right?

[300] This is such a kind of individually celebrated, individually punished pursuit, like all the glory, as you say, goes to the surgeon, and or all of the fallout.

[301] But let's look at that they are a part of a system and that the system needs an intentional design.

[302] And turning it into a tractable thing, right?

[303] The minute someone says, man, we should do something about the system.

[304] It feels like I just gave up.

[305] Totally.

[306] Totally.

[307] Yeah.

[308] Right.

[309] And so here what it was was saying, look, the oldest system that people have is a checklist for both makes up for the fact that I can't remember everything, right?

[310] You get an airplane to go through the checklist.

[311] But then also it's a team construct.

[312] We're all communicating together about what we're going to do and how we're going to deal with it.

[313] So the book is a story of deciding to bring that into my own operating room and then making it into a kind of global standard.

[314] And the checklist that we designed was simply.

[315] to say when we come in the operating room, we're all going to, you know, make sure everybody in the room knows each other.

[316] Make sure everybody understands what are the goals?

[317] What are we actually here to do today?

[318] What are the worries that anybody has about this person?

[319] What are the medical issues of the patient?

[320] It's like a one -minute huddle, like set and then go.

[321] And then there are about six or seven things that are easily forgotten, like, are we giving an antibiotic or not?

[322] And Are you operating on the right side of the patient?

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

[324] Yep, yep.

[325] That's right.

[326] But the powerful one actually turns out to be just people talking, the checklist saying, including the medical student, who's in the room, what's your name, what's your role here?

[327] Yeah.

[328] And then everybody owning, what are we attempting to accomplish?

[329] And we rolled that out, rolled it out in eight cities, two -minute checklist and cut the death rate by 47.

[330] percent.

[331] Monica, 47 percent.

[332] Oh, my God.

[333] It's huge, right?

[334] From just talking for two minutes.

[335] And getting people on the same page and saying, look, this operation can go wrong in a million ways.

[336] How do we get prepared by saying what could go wrong?

[337] What's anything people here can think of that could go wrong?

[338] And how are we prepared for even the unexpected by knowing who we are, what's available and being set?

[339] And then at the end of the case, going back around and saying, okay, anything that should be the plan for the next 24 hours.

[340] for this person.

[341] And it sounds so kindergarten, but we were not doing that.

[342] It was just assuming everybody knew what they were doing, and it dramatically cut the death rate.

[343] And so at this point now, this has been, this is 10th anniversary, actually, of the safe surgery checklist.

[344] It's now global standard.

[345] WHO's implemented.

[346] 75 % of the operating rooms are implemented.

[347] And I've got a nonprofit organizations we've stood up called Lifebox for getting it implemented in the low -income world.

[348] Because ironically, it's still got a long way to go in the low -income parts of the world.

[349] Well, I wish that were ironic.

[350] It seems pretty predictable.

[351] Sadly.

[352] I would imagine, and I'm sure you drilled down into all this, but I would imagine there's kind of unforeseen benefits of this.

[353] One just being, what you've also done in that moment has created a culture in this room, right?

[354] Whereby I've invited you to talk.

[355] I didn't invite you in a, you know, you can speak when I ask you a question.

[356] I've empowered you to bring up what you're seeing, which in essence is what the co -pilot in a cockpit does, right?

[357] I was hoping you got this idea from that Malcolm Gladwell chapter about Korean air because we listened to this one of the best podcasts of all time called Dr. Death.

[358] Did you hear that of the spinal cord surgeon?

[359] No. You must listen to it.

[360] To your point about learning on someone.

[361] It's a podcast.

[362] It's like a series.

[363] It's a series.

[364] It's absolutely the most horrific thing you could ever hear.

[365] And it sounds wonderful.

[366] It underprepared surgeon was basically released from residency having only done like 130 surgeries and they expect that number to be 3 ,000 and then you know lies his way through all these different situations and just injures untold people and again largely into this there were many of the surgical nurses that were saying I could see he was doing it wrong I could see what should have been done and did not feel empowered to raise a flag so that is the critical life -saving thing that we hijacked, basically smuggled into operating rooms because one of the best ways we could tell that people were using the checklist, we'd discovered because we'd have observers and operating rooms, all that, you know, many ways to try to figure out whether it's working or not.

[367] And the places where it was working, we found the best way was that if only one voice was talking at the beginning of an operation, then they weren't implementing the checklist.

[368] but if it turned out that people were speaking fairly equally, you heard the surgeon, you heard the anesthesiologist, you heard the nurse, then the culture was one where they really were a team and they were working together.

[369] The culture of surgery traditionally has been one where the biggest value was autonomy.

[370] The autonomy of the surgeon, what the surgeon says is what goes.

[371] You know, you call it the operating theater even in many places, right?

[372] It was the place where the surgeon came to perform.

[373] And the culture that this was trying to create was saying it's a place where there is humility to recognize anything could go wrong, where there is discipline in a belief that doing certain things the same way every time had real value.

[374] And there's teamwork where the voice of anybody in the room, it doesn't matter who they are, doesn't matter how much more experience or less experience they have, everybody's voice can matter.

[375] That's what saved fly.

[376] lives.

[377] And I love that Malcolm Gladwell chapter.

[378] Malcolm was the one who convinced me to write for the New Yorker.

[379] Oh, really?

[380] No shit in 1998.

[381] You've known him for that long?

[382] I've known him well before that.

[383] Before he started the Washington Post and before I ever wrote anything, he and another friend named Jacob Weisberg who started Slate convinced me to start writing.

[384] And then Malcolm sent me a note saying, hey, my editor's been following your writing on Slate magazine.

[385] And if you send him a letter, I'll bet he might like your ideas.

[386] I sent him.

[387] It was totally like connections, right?

[388] Oh, wow.

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

[390] Uh -huh.

[391] Incredibly valuable.

[392] I bet.

[393] Yeah, we're just, uh, we're in love with him.

[394] We're a little too in love with him.

[395] Yeah, our objectivity.

[396] I've heard your podcast with him.

[397] Okay.

[398] Yeah, yeah.

[399] I have the objectivities out the window.

[400] Whatever he says, I'm like, yeah, that's my new religion.

[401] Stay tuned for more armchair expert If you dare What's up guys?

[402] It's your girl Kiki And my podcast is back with a new season And let me tell you it's too good And I'm diving into the brains of entertainment's best and brightest Okay, every episode I bring on a friend And have a real conversation And I don't mean just friends I mean the likes of Amy Polar, Kel Mitchell, Vivica Fox, the list goes on So follow Oh, watch and listen to Baby.

[403] This is Kiki Palmer on the Wondery app or wherever you get your podcast.

[404] We've all been there.

[405] Turning to the internet to self -diagnose our inexplicable pains, debilitating body aches, sudden fevers, and strange rashes.

[406] Though our minds tend to spiral to worst -case scenarios, it's usually nothing, but for an unlucky few, these unsuspecting symptoms can start the clock ticking on a terrifying medical mystery.

[407] Like the unexplainable death of a retired firefighter.

[408] fighter, whose body was found at home by his son, except it looked like he had been cremated or the time when an entire town started jumping from buildings and seeing tigers on their ceilings.

[409] Hey listeners, it's Mr. Ballin here, and I'm here to tell you about my podcast.

[410] It's called Mr. Ballin's Medical Mysteries.

[411] Each terrifying true story will be sure to keep you up at night.

[412] Follow Mr. Ballin's Medical Mysteries wherever you get your podcasts.

[413] Prime members can listen early and ad -free on Amazon Music.

[414] Now, another topic that we have talked a ton about on here with a bunch of different great physicians and policymakers is this insanely difficult conversation that happens towards the end of life.

[415] And I'm pretty critical of it.

[416] I've now done it twice.

[417] I did it with my father and my stepfather.

[418] And I learned a bunch on the go around with my father that I applied to my stepfather.

[419] And it was really great.

[420] I think one of the big issues is recognizing right out of the gates, oh, this is their cancer.

[421] This is not my cancer.

[422] There would be decisions I would make, but they're not mine to make, even though it feels like I should have a big seat at the table, especially when I was the person with my father making all the decisions.

[423] But I really did learn.

[424] We had one fight over him eating a hamburger that was so regrettable, right?

[425] Like the guy should have eaten 26 hot food Sundays.

[426] We were at that point.

[427] but I was just locked into this no this is you know almost shaming him probably this is why you're in this situation here you go again and I just really regretted that like what you know there were that we were down to hours and I spent one or two of the hours berating him about a hamburger and um and then I was in a weird position where I worked with the prostate cancer foundation and so I had access to the clinical trials that could have potentially been miracle things for my stepfather and I got him in and he said ultimately I don't want to do this and I said cool I had no pushback.

[428] And I try to pass that on to people who are going through this.

[429] And I know you, you experienced it yourself.

[430] You said, you know, there's the conversation as people face the intellect.

[431] And you had it with the stepfather and the father.

[432] What was your goal that what were you hoping to get out of the conversation?

[433] What was the purpose in your mind?

[434] Well, I can tell you, and this, this has been unpopular, but it's very, it's just dead honest, which is from the second he called me, I thought, okay, I've been asked to come in and co -pilot this thing.

[435] I have the singular goal of getting him across the finish line with as little of the gnarly parts as possible.

[436] So I probably was already weighted to comfort over success.

[437] And part of it was my own life and having a job and having to fly back to Detroit.

[438] I selfishly was motivated by, I want to get this done peacefully.

[439] I'm not looking for a stretched out two -year version where he's miserable.

[440] So I already, you know, for numerous reasons, that's where I was at.

[441] Which makes a ton of sense, right?

[442] Here's what I think the goal is.

[443] The goal is, what is your father, my patient, my mother's, what are their priorities?

[444] And I can't believe I had to write a whole book to figure this out because I wasn't, I was never asking patients that question, right?

[445] I mean, I interviewed over 200 patients and scores of clinicians about how do you have this conversation.

[446] What I realized was the ones who are really successful, I just had a different goal.

[447] They realized people have priorities in the life besides just living longer.

[448] Yeah.

[449] Those priorities are different from person to person and also different for you as you change and go through what you're going to go through.

[450] And your only way to learn people's priorities is to ask them.

[451] Yeah.

[452] What are your priorities besides just living longer?

[453] I don't think there's a contradiction, as it turns out, there's not between your goals for your length of life and your goals for your quality of life, because getting clear about the priorities you want to serve around your quality of life, ironically, helps people live at least as long, if not longer, as well as better.

[454] And when you don't ask people what their priorities are, no surprise, the result is suffering.

[455] Right.

[456] You know, like I interviewed a woman with severe Alzheimer's disease who'd reach the stage where, you know, she could have difficulty swallowing.

[457] And she had a medically ordered liquid -only diet.

[458] And she'd be caught by the nurses stealing cookies from her neighbors and hoarding them.

[459] Good for her.

[460] And they need them.

[461] Good for her.

[462] Yeah.

[463] And so they take them away and she'd get ridden up.

[464] Oh, my gosh.

[465] contact the family like you know this is dangerous and you just want to say let her eat the damn cookies right right she is telling you what her priorities are and this one source of joy and you can talk to the family who the proxy and say like you know I think I think she's telling us what her priorities are what do you know about her what do you understand about her have you had this conversation would she want this taken away for the small risk and the real risk that she could choke on the cookie.

[466] Uh -huh.

[467] So in the same way as you're having the conversation with your dad, maybe it was that he was willing to not be comfortable.

[468] He was willing maybe to say, you know what, I want to get every shot I can at more time, even at the cost of pain.

[469] Uh -huh.

[470] Or he might say, you know what?

[471] I'm now in pain.

[472] My priorities have just changed.

[473] Yeah, yeah, yeah.

[474] And some of the questions that you end up asking that I found really powerful are, what are your fears for the future?

[475] What are your hopes if your health worsens?

[476] But then also, like, what's the minimum quality of life you'd find acceptable?

[477] It's become my favorite thing to just talk about.

[478] Like, for you guys, what would the minimum quality of life be acceptable?

[479] For me, as long as my brain is working and I can talk with you, I can communicate with you and share memories and have those stories, I could be quadriplegic.

[480] I could be paralyzed, but if my brain is not working, let me go.

[481] My wife, her view is, I'm God's creature.

[482] If I'm experiencing joy, I don't care if my brain works.

[483] If I'm experiencing joy, keep me going.

[484] And if I'm not experiencing joy, if I cannot experience joy, let me go.

[485] That's a pretty sizable burden to put on to you to evaluate someone's happiness, especially if they've lost kind of cognitive ability to check in with you.

[486] I mean, you're putting a lot of weight on a smile.

[487] Let's hope that's not gas.

[488] But I do feel like, I actually feel like it took a lot of burden away.

[489] But I'm curious for you.

[490] So what's the minimum quality of your life?

[491] Well, let me let Monica go first because I'm a hog.

[492] It's hard because I definitely, my grandfather's so old right now.

[493] And he like barely remembers my mom or, you know, he'll sometimes remember her, sometimes not.

[494] He's just sitting.

[495] And he was a professor of biology.

[496] And he was always talking.

[497] He's the smartest person I've ever.

[498] known.

[499] Well, second, yeah.

[500] Well, first.

[501] And to see him there, unable to contribute to a conversation.

[502] I talked to one professor who said, if I can eat chocolate ice cream and watch football on television, that would be good enough for me. And his family was blown away.

[503] They're like, we didn't even know you watched football.

[504] Yeah, they even cared about it.

[505] Yeah.

[506] Like, I can't, how can that be true?

[507] First of all, we've got to order a television package with football on it.

[508] Because despite you're loving it, we don't have it.

[509] But so that might be true for him, but how about for you?

[510] Well, that's what I was going to say is this is where it gets really, really tricky because you're projecting so much of your own.

[511] But that's what I'm saying.

[512] When I see it, I think I don't want that.

[513] I don't want to be sitting in a room with my family and not be able to contribute or not just be sitting.

[514] You love cookies too.

[515] I do love cookies.

[516] God, but would I be able to taste them?

[517] Yeah, yeah, yeah.

[518] You can taste them.

[519] Well.

[520] So eating food, that might be really important to you.

[521] My dad, when he came towards the end, radiation took away his taste.

[522] And that really took away one of his joys.

[523] Yeah.

[524] Can I tell you that to me as I was evaluating?

[525] I took him out to this restaurant with great, great effort, had to get him in a wheelchair, the whole nine, get a pass out of the hospital.

[526] Got him his favorite gold brick Sunday.

[527] And he just stared at it smiling.

[528] And I was like, okay, well, I know my dad.

[529] It was a real, you know, canary in the coal.

[530] mind moment where I'm like, we've transitioned into another phase.

[531] What do you think?

[532] I'm with you, Atul.

[533] I want to be able to talk.

[534] If I can talk with my kids and look at them, I feel like I would be good.

[535] But I will say now having, and you've gone through this many more times, people's own priorities evolve throughout the process.

[536] So my stepfather, who was an electrical engineer, very, very bright, did not want to get to a point where he mentally wasn't as sharp and that was a big moment for him he wouldn't want to be around for that and also had a plan they lived in Oregon to do euthanized assisted which would have been great full intention to do it and then all of a sudden as we got to this point where he would have had to gone to the place to prove competency we passed that window and we were left then when he did say I'm ready with a new problem on her hand so I was like well hmm best laid plans I know he didn't want to end up in this situation I didn't think we'd be in this situation, but here we are.

[537] Yeah.

[538] So they evolve, right?

[539] And as the co -pilot, you're like, okay, this wasn't the game plan, but I got to stay flexible.

[540] But what you think right now is this.

[541] This is joy.

[542] This is purpose.

[543] Yes.

[544] Yes.

[545] And what makes what life worth living?

[546] Mm -hmm.

[547] And I'll just say that there's this cultural expectation that you are weak or cowardly if you don't want to fight cancer.

[548] And that came to really piss me off.

[549] It's, It's antithetical to something in AA that has been the greatest gift I've been given in AA, which is like acceptance is the answer to all my problems.

[550] And in general, I find that to be largely true.

[551] Once you've figured out what options you can exploit, when they're done or the ones you want to exploit, I feel like there shouldn't be shame in surrendering.

[552] Well, there's a lot of discussion in the oncology world and most of my surgical practices and cancer surgery, that we just want to get rid of this whole fight metaphor thing.

[553] I hate it.

[554] Whether it's fighting or surrender, it is a journey with this cancer.

[555] We have a lot we can do.

[556] But ultimately, if we're doing our job right, it's around, you know, what are your goals?

[557] What are you willing to give up for the sake of more time?

[558] Yeah.

[559] And what are you not willing to give up?

[560] The other way you can describe it is, okay, let's fight.

[561] What are we fighting for?

[562] Are we fighting for your ability to be at home every day and go for a walk and see your friends?

[563] Or are we fighting to make the disease shrink on this scan?

[564] Have you had to give your patient's permission?

[565] Like, you're not a coward.

[566] You're not weak if you don't want to spend the last three months of your life with intravenous harsh chemicals flying your body.

[567] What I used to do was getting arguments like that with people and it never felt very successful.

[568] Like you don't have to do this and then they'd get all, you know, the natural reaction to that is, well, you know, what are you trying to kill me?

[569] Like, are you telling me something?

[570] Instead, it's sort of like, well, you'd let me know before was you really did not want to be in a situation where you couldn't live at home anymore.

[571] And if we do this, you're not going to be able to live at home anymore.

[572] So has that changed?

[573] And then it's not about are you being tough?

[574] Are you not being tough?

[575] It's just what matters to you.

[576] And it isn't about who you are.

[577] It's, you know, what kind of image you have of yourself?

[578] It's just about what do you want?

[579] This is tough.

[580] Can I be critical of one component of it that I see?

[581] No, you can't.

[582] It wasn't that perfectly reasonable.

[583] Come on.

[584] No, but one systemic issue that I, again, having gone through it twice, that seems like it puts people in a very challenging situation is declaring hospice.

[585] So if you haven't gone through this at home, first of all, we'll all go through this.

[586] This is another frustration of mine is like the notion that you can avoid having this conversation, no, this is the singular conversation you are guaranteed to have in your life.

[587] You know, if you're lucky, you don't get hit by a train or something.

[588] But the declaration of hospice, as I understand it, and maybe I have it wrong.

[589] But basically, the doctors are always waiting for you to declare hospice.

[590] And that's now, we'll move you to your house.

[591] We're going to now have the new goal of making everything comfortable as possible, and we are no longer fighting.

[592] Now, what's tricky about that is there's, so you're basically signing off your right for any medical treatment, right?

[593] And this can get tricky because there are things that this happened to my stepdad, which is we had declared hospice.

[594] My mom hears from the bedroom, huh?

[595] You're going to want to see this.

[596] She comes into the bedroom, his test.

[597] which had become the size of cantaloupe had split and one of the veins had severed and it's literally spraying blood on the ceiling of the room.

[598] But we're in hospice.

[599] So what do you do?

[600] Like, do you let them bleed out of this?

[601] You know, as it turned out, they made an exception and they sewed that part of them back up.

[602] But there was one of these tricky situations where it's like, you kind of want to reserve the right to get your husband's ball sack, which is spurting blood under the ceiling, addressed, but you're not asking that goes through chemo again.

[603] And there seems to be a little appetite for some hybrid of the situation.

[604] What are your thoughts on that?

[605] You've put your finger on something I've actually been very critical of, the idea that it's either or, right?

[606] Uh -huh.

[607] You know, how, this is not a fight for your quality of life versus quantity of life, and you've got to pick.

[608] So, for example, the state of Massachusetts, all of the insurers now allow you to go into hospice without giving up your doctors.

[609] and without giving up your medical care, and you can do it at 12 months before the end of life.

[610] The goal is that you have options for people because it leads to people not going into hospice in the first place.

[611] And invariably what happens when you do go into hospice is then you end up saying, you know what, I'm so glad to be able to be kept comfortable at home.

[612] I can see I'm not getting any benefit from the chemotherapy, but I'm just getting sicker because of everything.

[613] And I'm feeling better.

[614] And lo and behold, a lot of the time when you are not taking that chemotherapy in the last couple months of life, you're actually living longer and doing better.

[615] So that in the, in private insurance right now, a lot of different companies have made the shift.

[616] We haven't persuaded Medicare yet, which is, of course, the most important insurer to make the shift.

[617] But it doesn't save money.

[618] It doesn't improve the outcome.

[619] I got to imagine there's some counterintuitive outcomes, which are like for our example, we would have probably declared it sooner.

[620] He was happier at home.

[621] He wanted less services.

[622] It actually saves money because people then having gotten the option to get good care for their pain and their needs at home, which weren't being addressed at the hospital, end up appropriately deciding to stop chemo and on average living depending on whether it's lung cancer, pancreatic cancer, whatever, anywhere from six to 12 weeks longer on average with lower costs.

[623] So it's win -win all the way around.

[624] But it comes from being able to say we're going to have a conversation about your goals.

[625] Yeah.

[626] What's important here?

[627] My other issue with it, and this sounds anything but emotional or compassionate, which is I have another issue just objectively with spending maybe 60 % of someone's life.

[628] medical expenses in the last three months.

[629] It just doesn't seem like a super sustainable approach when we're already having other issues.

[630] And this person said, well, we tried to address that with Obamacare and then the right labeled it as death panels.

[631] And all the death panel was was us way before you're in the situation saying, hey, let's commit some time to thinking about this inevitable scenario you'll find yourself in.

[632] And let's make some decisions with your current self that's not going through the biggest crisis of your life.

[633] You're absolutely right.

[634] There's two things I sort of come away, I want to say about that.

[635] Number one is it's true we spend a disproportionate amount of our medical spending on the last three months of life.

[636] And it would be perfect if you knew when the last three months of life were, because then we could, you know, we could change that.

[637] I've done some work showing that about 9 % of the population will have surgery on their very last few days of life.

[638] Wow.

[639] You know that undergoing surgery, you don't have time to recover from it.

[640] You're getting all the pain, all of the invasion, and none of the benefit.

[641] But we don't know when that moment is.

[642] And so that's why that other part, which is the conversation ahead of time about what you're willing to go through and what you're not willing to go through for the sake of more time, the main value, it seems to show, is that having that conversation earlier means that you're making subsequent decisions sooner because you started to think about it.

[643] Right.

[644] And you've started to ask, you know, where is my line in the sand?

[645] And you've gotten to experiment with that a fair amount.

[646] We did a study at the Dana Fabric Cancer Institute where we randomized training, half of the clinicians in having these conversations.

[647] They would have these conversations on average at five months before the end of life rather than five weeks because it's just a conversation you have with anybody.

[648] The trigger was, would you be surprised that this person died in the next year?

[649] And if you would not be surprised, that group absolutely had to have this conversation.

[650] Uh -huh.

[651] And about half of them died and half of them didn't die.

[652] But, you know, clearly, this is the conversation you need to have if you wouldn't be surprised.

[653] And then that group had the conversation five months earlier, and they ended up with having half the level of depression, half the level of anxiety, same survival rate.

[654] Wow.

[655] Another study along the way has shown that people typically because they've done this thinking, will on their own stop their chemotherapy and again no reduction in survival and lung cancer was a 25 % increase in survival.

[656] So, you know, the last thing I'll say is we're past the death panel and that is the best news we've got, which is this is bipartisan support for this now.

[657] Republicans are not labeling this death panels.

[658] I feel like we have another leap to make.

[659] We finally made it so having these conversations are, you know, like mom and apple pie.

[660] It's all great, Right.

[661] It actually needs to be a scandal that we don't have these conversations and you come to the end of your life, right?

[662] It is such a worse experience.

[663] Three quarters of people who are seriously ill never have this conversation with either family or their clinicians.

[664] And everybody's uncomfortable.

[665] But I think when you understand, it's not about like, are you going to give it up at the end?

[666] Like, you need to surrender at the end.

[667] No, this is about like, what are we here for?

[668] What are we fighting for?

[669] What do you need me to do for you?

[670] Yeah.

[671] And what do you need me to not do for you?

[672] Where is your line in the sand?

[673] Is it challenging knowing that you must deal with the full spectrum, right?

[674] So we watched your frontline episode that was about your book.

[675] And what I was immediately just confronted with is like, it's not unlike the job I think we asked police to do, which is not to say I'm not very critical of the police and the systemic issues.

[676] But also, okay, these people have to deal.

[677] deal with every problem we've kicked down the road virtually right they're dealing with it real time and i would just say to expect you all to to learn everything you need to learn in medical school and in your surgical residency and to be at the forefront of all of that and then be some master communicator that can navigate how to help people how to not trigger people how to not talk down to people.

[678] That could be its own specialty.

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

[680] Actually, that's totally misplaced.

[681] It is part of the job that I should understand, what am I doing this operation for?

[682] And it doesn't have to be the end of life.

[683] You know, my mother underwent a knee replacement.

[684] And I never asked her, like, what are you hoping to get out of the new replacement?

[685] She was an avid tennis player.

[686] I was thinking maybe she wants to play tennis again.

[687] She was at the point where she needed a wheelchair in the airport.

[688] She only did enough rehab that the pain went away and then would still take the freaking wheelchair at the airport.

[689] She was like, I like getting the ride.

[690] There we go.

[691] And the orthopedic surgeon would want her to get, you know, let's get more physical therapy, but she wasn't really with the program.

[692] And the reason was her goal was, I just want to get rid of the pain.

[693] Right.

[694] Whereas another person, they want to run a marathon.

[695] And I should be able to be good at finding out, you know, lawyers are good at this, right?

[696] What is your goal?

[697] And then how do I help you achieve that goal?

[698] And we get to bring this huge armamentarium and 20 % of the American economy to you.

[699] And let's deploy that in ways that actually serves some meaningful function rather than, you know, with back surgery, where you have the majority of people undergoing it who still have just as much pain and, just as limited ability to walk and no reduction in disability rates, like, what are we accomplishing here when we're doing that?

[700] So I think this is not too much to ask.

[701] It's a basic skill.

[702] And if you can't learn to have these basic conversations, I think it goes all the way back to how we pick people for medical school.

[703] The skills are not just about the technical stuff.

[704] The big skill is helping people achieve their goals and why we think organic chemistry in your freshman year in college is the right why is that our weed out mechanism yeah it seems like we just we just picked the wrong people yes you know that's our screen for whether you should be an empathetic yeah successful human being and navigating complex problems with people oh i i couldn't agree more now i think the patient largely gets off of all the blame so I'm infected with a self -help program that doesn't tolerate a lot of horseshit.

[705] So when I imagine myself being you, I think it would be so hard because I only have had the experience where someone comes in.

[706] We go, look, there's these 12 steps.

[707] If you work them, this percentage gets it.

[708] Well, I don't like those two steps.

[709] And it's like, cool.

[710] Go do 10 and see how it works out.

[711] I know how it works out.

[712] I can't co -sign on your delusion.

[713] Now, you can go do whatever the fuck you want.

[714] But I'm telling you, if the 10 ,000 people I've seen try to get sober, here's where I know works.

[715] It would be so hard for me to go along with what is ultimately sometimes people's delusions.

[716] How do you handle that?

[717] I guess you have a different priority.

[718] Well, I think it also depends on the field that you go into because some people, you know, I think in primary care you're navigating this all the time with people as they confront or don't confront what they're dealing with.

[719] For me, I have people coming in and they've got a problem.

[720] Right.

[721] They have a new cancer or they have a tumor or they have something going on.

[722] And then, you know, the choices, do you want to deal with it or not?

[723] What's the goal that you want to have?

[724] And it's actually relatively straightforward.

[725] I will have, for example, people who will come in and they've got an operable cancer, but it's a cancer.

[726] And then they will say, you know what?

[727] I think I'm going to do a herbal therapy.

[728] I know this Chinese herbalist and we're going to do that.

[729] And what I say to them, it doesn't bother me at all.

[730] My big thing is I'm just worried about them.

[731] Right.

[732] And so I'll just say, you have to make your own choices, but I'm really worried about you.

[733] So can I ask you to come back in three months?

[734] And let's see if this gets bigger or not.

[735] Right.

[736] And just will you come back?

[737] And when you browbeat them, yeah, they're not coming back and they're not going back to anybody.

[738] And I have seen people who died because of that.

[739] and just, you know, offering a hand, pull them along.

[740] And that's what you're doing with him, right?

[741] You didn't tell them, well, you can either do the 12 steps or you're gone.

[742] No, yeah, you're free to do however you want, yeah.

[743] Yeah, you can say, look, do the 10 steps.

[744] We'll be with you.

[745] And I'm worried about you.

[746] Yeah.

[747] But also with sobriety, there's a clear checkmark.

[748] Like, did you drink or did you not drink?

[749] You know, it's different, like you said with your mom, where the goal is just no pain, but for somebody else or even like for you looking at your mom.

[750] mom, you might be like, you're not doing enough or I want you to be able to play tennis or whatever.

[751] So I do think also so much of this is about the people around the person at the end of life or in the middle of making those decisions because even what I did earlier, it's like you're just projecting what you want for them or what you would want for yourself.

[752] And I think there's guilt.

[753] Like, I don't think my grandfather could ever tell any of his children, you got to let me go now.

[754] Like, he just couldn't do it, but that's really on the children who aren't letting him.

[755] Yeah, and we're never asking in the first place.

[756] Yeah, well, because probably they don't want to know the answer.

[757] Okay, two more things.

[758] Can I ask one?

[759] Yes, yes, yes, yes.

[760] Are you chewing tobacco?

[761] Yeah, yeah, yeah.

[762] God, that is so Midwestern.

[763] I grew up.

[764] I knew when I put it in, you were going to say something, too.

[765] And I was like, you know what?

[766] I have an excuse.

[767] I'm quitting September 1st on my sobriety dates.

[768] But please, tell me, yeah.

[769] All right.

[770] All right.

[771] You should.

[772] You should.

[773] But it does remind me being home, you know, like I tried happy days in fifth grade and like, ugh, I was throwing up afterwards.

[774] Oh, my God.

[775] Kill me. Well, I'm also reading the emperor of all maladies, which is a great companion piece of dipping.

[776] I got to say, I'll be packing one and listening to it and going, look at this.

[777] I'm creating lots of cell division on my on my gums and I know it.

[778] Increased cell division.

[779] Stay tuned for more.

[780] armchair expert if you dare back to the responsibility of the patient and again you're just you're very generous and kind and I admire it I think it says a lot about your integrity we know I don't know what the number is monocle fact check it but the number is somewhere in the 70 to 80 percent range that physical therapy results in success like physical therapy works it works in overwhelming majority of people who try it and then surgery just doesn't in many of the surgeries you'd get to deal with a physical therapy issue.

[781] And by the way, I've gotten surgeries.

[782] I've gotten several of them.

[783] You know, we're fucking lazy too.

[784] The patient's lazy, but we're so pissed at this system.

[785] And yet we won't do physical therapy.

[786] We won't watch our diet.

[787] I'm dipping.

[788] You know, is there any frustration on y 'all's end?

[789] Well, I mean, it's not just patient of forgiving.

[790] I mean, like, I don't eat right.

[791] I don't exercise.

[792] Like, we're human beings.

[793] And part of that is navigating risk and learning how you deal with that.

[794] But on some of those things as well, I think we make it brutally hard to do the right thing.

[795] You can yell at people about not doing their physical therapy, but then you have a $5 ,000 deductible and you have no idea what the cost is and they're not going to tell you.

[796] You don't know who to go to.

[797] In order to find out, you got to make another appointment with your doctor so they can tell you where to go.

[798] You probably have to take time off work that you don't have.

[799] Right.

[800] This, again, is that sort of that hierarchy I talked about.

[801] Like, we can teach you the right thing to do.

[802] And then when you don't do the right thing, then we can, like, yell at you about it and punish you.

[803] And, you know, like, we should take your insurance away because why are we paying for Dax's head and neck cancer surgery after he's been doing all of this dip in?

[804] There we go.

[805] It's personal now.

[806] Keep going.

[807] Keep going.

[808] And then, look, you understand the risk.

[809] And people still do plenty of stuff to take risk.

[810] And we should make it easy when you're ready to do the right thing.

[811] Example of the physical therapy.

[812] We know that if you have a severe, terrible back pain, most people get rooted to visiting a surgeon as the first step.

[813] But there are clinics where the first thing that happens is they will get you a physical therapy appointment within 48 hours.

[814] Right.

[815] And within six weeks, and you never see the surgeon unless there is a neurological issue or the pain gets worse.

[816] or isn't improving after six weeks.

[817] And in 90 % by six weeks, it has gotten better.

[818] But it needed to make it so, yeah, I could call up, hey, here's what's going on.

[819] You've gotten an appointment.

[820] Yeah.

[821] Here's your way in.

[822] And then if that doesn't work that you know, you will be rooted right to the surgeon who can help you figure out what you're going to do next.

[823] Yeah, that's genius.

[824] Ideally, you go into that appointment and they go great.

[825] So now I'm walking you over to this room and you're going to learn these four stretches.

[826] and we're going to keep on the other thing, but like, yeah, if it's right there, if you make it that easy, your odds of success have to go up.

[827] Completely.

[828] We've made it incredibly easy to go get a surgeon's appointment, a scan, and a $60 ,000 operation.

[829] It made it incredibly difficult to get in the door to the right physical therapist within 24 hours that could address that issue.

[830] That's true.

[831] There's also an unavoidable incentive structure within the system.

[832] that you find yourself in.

[833] So my father largely offloaded all the decisions to me. Now, we did go through chemo.

[834] I really am grateful that I had a friend who's an ER doctor here in L .A. And I called her and she just said right out of the gate, she's like, look, small cell carcinoma.

[835] That's a rap.

[836] There's no, you're not going to find some miracle thing.

[837] You're not going to call the president and get to go see some doctor.

[838] Like, this is on a three to six month timeline and that's that.

[839] I'm like, thank you for telling me that.

[840] That's what I needed to know.

[841] And so we did chemo.

[842] That was mostly to appease him.

[843] I don't think I would have chose that for him.

[844] But at the final stages, man, an oncologist comes on and says that the brain tumor is of such a size that he wants to do radiation.

[845] And I say to my dad, you know, here's what's on the table.

[846] I don't think you should do this.

[847] And he said, I want to do it.

[848] And I wasn't willing to fight him.

[849] And he had radiation.

[850] It happened in the last week of his life.

[851] It had a very profound effect on his cognitive ability.

[852] So all we did is knock down his cognitive abilities.

[853] And I said to the oncologist, I said, is it worse to die of brain cancer than this small cell?

[854] Is there a hierarchy that I should be trying to avoid?

[855] And he kind of, and I didn't buy it, he was like, well, brain cancer is a particularly brutal way to go.

[856] And then at the end of the day, I was just like, I don't feel great that this person's incentivized cell radiation.

[857] I don't know why we've linked their incentives to this product.

[858] I'm not super comfortable with that.

[859] Yeah, I mean, clinicians are really uncomfortable discussing prognosis.

[860] And part of it is the idea that you're supposed to give a crystal ball like, well, you've got six months.

[861] But the way your friend talked about it, you know, basically what you really want to do is give them best case, worst case.

[862] And my dad, who had, you know, a tumor in his brain, stem, and spinal cord, and it had progressed the same point that you're talking about, you know, when the discussion came for, radiation therapy didn't work and then getting to chemotherapy, which was just getting the first start of the therapy with steroids was making it miserable.

[863] There was never discussion.

[864] I had to force an oncologist like, what's the best case with the chemotherapy and what's the worst case with the chemotherapy?

[865] And what's the most likely that you think?

[866] And it's actually a framework that a colleague at the University of Wisconsin created called best case, worst case, right?

[867] Give me the best case, worst case with the treatment.

[868] And then give me the best case, worst case without the treatment.

[869] And when they finally did that, they said, well, the chemotherapy, the range of survival is like the shortest I've seen is three months, the longest I've seen is three years, if you do nothing.

[870] And my dad was just, you know, he thought, because it's such a slow growing to me, he thought he thought he had a lot longer than that.

[871] So that was incredibly valuable, just knowing that.

[872] But then second, I said, okay, so now what is it if you get the treatment?

[873] Oh, it's still three months to three years.

[874] But, you know, the tumor will shrink and you might, you might feel better.

[875] oh well you know maybe it'll shift a little bit towards the the three years rather than the three months there are all these complications from it and maybe towards the end you feel better and my dad looked at that and said no that doesn't seem like a good deal to me right but but no one was framing it correct no one is naturally laying this out in a way that you can make that choice like that and that makes it much simpler yeah do you think part of that is the doctor has some hope that like they themselves will be the doctor that that is the one to get the person to 10 years?

[876] Or like, is there some arrogance in that too?

[877] I've always chalked that up to just being myopic.

[878] Like they have a singular goal of beating this cell.

[879] Exactly.

[880] I think Dax, you got it, that you are fighting the disease.

[881] And if I see it shrinking, I feel I've got some victory here.

[882] And I presume they're going to be feeling and doing better.

[883] But I don't necessarily have the big picture.

[884] I don't know what's going on at home.

[885] I get 15 minutes in the office where I get to see them.

[886] Oh, it looks good.

[887] Connecting with me. But, you know, I'm not really getting the whole picture.

[888] And so it becomes myopic.

[889] Whereas if I'm able to say, oh, well, you tell me chocolate ice cream and football on television, are you still getting the chocolate ice cream and watch football on television?

[890] Do you still enjoy them?

[891] Is that still what matters to you?

[892] Now we have a real conversation there's a couple cheats i think i'm a critical of of humans i think we have a real hang up about evaluating the quality of a life by its duration and i i've looked at many lives that ended shorter than i would want that have been to me ones i'd pick over ones that went 110 years and you know it's a relevant question why do you think someone like julia louise dreyfus loves you so much what do you think she got out of being mortal that people seem to get that you think is such an emotional, that she would feel that emotionally connected to you?

[893] That's awesome that you would say it that way.

[894] What she said was simply that on one level, it gave her a playbook for this very unknown thing.

[895] And it gave her a sense of control and she needed to figure out a sense of control.

[896] As she said on the podcast and said to me, she did ask the kinds of questions we were talking about didn't completely necessarily get the answers she expected or the ones that she thought were necessarily wise choices.

[897] But she got to understand where she was coming from and then feel like she knew where she stood and could make choice about where she's going to push where she wasn't going to push.

[898] And it just gave her a playbook.

[899] And I think there's comfort in that.

[900] I agree.

[901] Well, I have children.

[902] You have children.

[903] Even if you're presenting them with two shitty options.

[904] Just the notion that they're going to get to pick the less shitty option is hugely empowering.

[905] Yeah.

[906] And you're not going for the fake option, right?

[907] It's the situation we're in with coronavirus.

[908] We have enormous numbers of people in denial about how and just not wanting to have a conversation about how shitty this all is.

[909] Yeah.

[910] And then here are the tough choices.

[911] and let's not just keep pretending it's going to disappear, right?

[912] Maybe it magically will, but let's have a conversation about what seems to be right in front of us right now and then actually do something.

[913] But that's, you know, just like people who can be seriously ill, you are dealing with people who are in denial and don't necessarily want to talk about it.

[914] And things have to get worse before they get better.

[915] But you open the door and then they become willing to talk about it.

[916] I see the country moving that way, right?

[917] We suddenly have 85 % of the country now willing to wear a mask.

[918] We have 10 % or 15 % who are going to be absolutely crazy and put the rest of us at risk.

[919] And we might have to be saying, too bad, you can endanger me at work or in my school.

[920] We don't have any rights in this country that allow you to endanger other people as part of your rights.

[921] We just don't.

[922] There's some illusion that that somehow exists.

[923] But there's not one I can think of in the Bill of Rights that's like you can hurt other people.

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

[925] They may not be completely rational.

[926] They may be in denial.

[927] They may be unwilling to deal with what's in front of you.

[928] And there isn't control.

[929] Ultimately, the book gives you some sense of the playbook, but it's a playbook maybe for dealing with the fact that you're not really in control.

[930] Yeah.

[931] Well, I think your work is amazing.

[932] I'm excited for whatever you write next because you're clearly drawn to some kind of bigger picture looking at the system you're in, but trying to look at it in its totality, which again is hard to do.

[933] You've got to make time for that type of analysis.

[934] It's an admirable quality you have.

[935] Well, I don't think it's admirable or I happen to, I get very uncomfortable as soon as I'm seeing things from only one perspective and seeing it from inside the bubble and then getting outside and trying to see what it looks like.

[936] Well, we hope you'll come back and talk to us because what an asset.

[937] you are someone I would love to continue to talk to you so just really quick you don't think it's super productive to be calling it the the who -wan virus of all the things that seem like a waste of time these people who are trying to blame someone for a virus seems like the least productive certainly not not solving the question of whether we're going to get rid of this thing yeah a thousand percent well a tool pleasure to talk to you and I hope we get to talk to you again.

[938] And I hope you and Ms. Dreyfus somehow have some lasting friendship.

[939] I'm envious.

[940] She didn't ask for my email after the interview.

[941] Dax and Monica, this is awesome.

[942] Thank you.

[943] Thank you so much.

[944] Good luck in the rest of your Zooms.

[945] Okay.

[946] All right.

[947] And now my favorite part of the show, the fact check with my soulmate Monica Padman.

[948] Round two, foo.

[949] Are there any of my accents that you like that you like you would maybe request um any impersonations or anything that you enjoy that i do i like when you do owen okay listen okay i don't know how many times i can say i like all of them just not when you're next to me no just not when you can't stop it i'll take any of them in a short well not any not the racist ones but the the impressions i'll take in a small does any time you want to give them.

[950] But the problem is you just can't stop and it's uncomfortable.

[951] Well, there's two issues afoot.

[952] One is I have impulse control issues, clearly.

[953] Clearly.

[954] Part two is I'm not an impressionist.

[955] So it takes me about 20 sentences before I remember how to do it.

[956] Okay.

[957] And then I finally find it.

[958] It's a minute and a half later, but now I want to do it because I finally found it.

[959] I understand that.

[960] Like if I was just great at them and could do them when you click your fingers, it would probably go better.

[961] All right.

[962] I mean, I think you're underestimating yourself.

[963] I think you sound pretty much the exact same 10 minutes in than you do when you start.

[964] How's an asshole like Baum get such a great kitchen?

[965] Yeah, see?

[966] You did it.

[967] But that's the one line I always, that's how I set myself up for Owen.

[968] Yeah.

[969] I have that one line and then I launch into.

[970] I don't know.

[971] Why your crows like multi -step problems?

[972] That same crow is back.

[973] He's in the tree today.

[974] Oh, my God.

[975] Guys, we have like a harbinger of good fortune.

[976] There is an enormous crow that now lives on the roof of the new house that we've yet to move into.

[977] But now I see it residing in the oak tree.

[978] And now we're obsessed with him because crows can do eight -step problems.

[979] They're the smartest bird.

[980] Yeah.

[981] Well, not math problems, but they can do set pieces.

[982] It's like they got to open a box.

[983] They get a key.

[984] They take the key over to here.

[985] Then they screw it in.

[986] Wow, this is just fucking.

[987] Unfortunately, that was from our last episode.

[988] Oh, shit.

[989] Two fact checks in a row.

[990] We're going hot and fast.

[991] Yeah, things are getting muddy.

[992] Oh, there's two crows.

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

[994] The crows can do a lot of problems, and I think we're going to ask it to do a few problems.

[995] Well, this was the funniest moment.

[996] I saw it out the window a couple days ago, and I said, oh, my God, Monica, look at that size of that crow.

[997] And then she was like, ooh, and, you know, they look scary.

[998] And then I go, those are my favorite birds.

[999] She goes, really?

[1000] I go, yeah, they're so smart.

[1001] They can do an eight -step problem.

[1002] And she goes, solve a problem.

[1003] Solve a problem.

[1004] You were yelling at the bird, solve a problem for us.

[1005] Maybe he can answer my email.

[1006] That's also from the other fact check.

[1007] Oops.

[1008] And all you got to do is pay him with like one kernel of corn.

[1009] That's what they get after the eight steps.

[1010] Well, I don't know what it is, but it's something really insignificant.

[1011] You would not do the eight steps to get the reward.

[1012] So sometimes this would cost us virtually nothing.

[1013] If we had to do chores that we needed done and it did eight of them and then we gave it a kernel of corn.

[1014] Hmm.

[1015] Let's have him do like our sound engineering.

[1016] No, I can fly away at any time.

[1017] Yeah, it has agency.

[1018] It's just not a living wage.

[1019] It's not?

[1020] I think it is a living wage in crow.

[1021] One kernel of corn?

[1022] Because that's how they live by eating corn.

[1023] I think they're eating a mammal up there.

[1024] Ew, really?

[1025] Yeah, yeah.

[1026] Lean over.

[1027] There's two of them and they're like tearing something apart.

[1028] This is awesome and creepy.

[1029] So far I'm loving the fact that there's now two crows nesting at the house.

[1030] At what point do you think it'd get super terrifying?

[1031] Like what amount, you don't see on that big branch of the oak tree right there?

[1032] Oh, man. They're moving around right now.

[1033] I'm too full.

[1034] I'm too full from lunch.

[1035] You went from too hungry and borderline grumpy to not you're too full.

[1036] And also borderline grumpy.

[1037] Okay, I'll be scared when there's four crows.

[1038] I think you're right.

[1039] Three's good.

[1040] Four's like, wait, are there 20 coming?

[1041] And it's like there's something dead.

[1042] What would you assess, like, how many crows would it take to kill me?

[1043] To kill you?

[1044] Are you bound?

[1045] Are you bound?

[1046] No, I'm able -bodied, and I have all my faculties about me, and they come for me. And are they stabbing?

[1047] I could beat the shit out of four crows.

[1048] Yeah.

[1049] So what is the number do you think that I'd get overwhelmed?

[1050] If this wouldn't raise red flags from PETA, I would love to do a pay -per -view event where we find out.

[1051] And we put like a, unleash a hundred crows in me in an atrium, I guess.

[1052] We've had a lot of fact checks lately that have involved animals do.

[1053] doing unconventional things, i .e. the snake up.

[1054] Oh, sure, sure, sure.

[1055] So the crows, I think you, I think you could withstand.

[1056] They're big, though, huh?

[1057] They are big.

[1058] They're big.

[1059] They're bigger than a Yorkie.

[1060] Okay.

[1061] And they've got talons.

[1062] They've got a real strong beak.

[1063] And they're clever.

[1064] Okay, then I'm going to say 30.

[1065] I'd fucking kick 30 crow's asses.

[1066] Yeah, yeah, yeah, yeah.

[1067] Not if some of it.

[1068] I would have to be, like, they'd have to black out the sun because there was so many of them that I couldn't see and it was dark.

[1069] And then one of them would have to get lucky and hit my carotic artery or my femoral artery.

[1070] First, they just pluck out your eyes and then they can do whatever they want to you.

[1071] Great point.

[1072] You're right if they went for the eyes.

[1073] Yeah.

[1074] Is that what happened in Edgar Allen Poe, the Raven, knock, knock, knocking at my chamber door.

[1075] Do you remember that poem?

[1076] Of course.

[1077] I don't actually remember if the eyes got plucked.

[1078] And the beating heart gave it away.

[1079] He was under the boards.

[1080] I feel like they plucked.

[1081] his eyes out.

[1082] God, now I have to look up the rain.

[1083] No, you don't.

[1084] Continue on with your thing.

[1085] This doesn't need answering right now.

[1086] Or are you going to go to Wikipedia?

[1087] Once upon a midnight dreary, while I pondered weak and weary.

[1088] Let's see how long it is.

[1089] It's pretty long.

[1090] It's too long.

[1091] Get to the bottom and just see if he's got his eyes plucked out.

[1092] Holy fuck, that's long.

[1093] Remember never more, never more?

[1094] It does kill him, I think.

[1095] Well, his beating Heart gives away his location, I think, as I recall.

[1096] What's the last paragraph?

[1097] Spoiler alert, if you've never read The Raven by Edgar Allan Poe, plug your ears.

[1098] What is going on over there?

[1099] Are you having a seizure?

[1100] What if I was?

[1101] Last week, you scratch your tongue.

[1102] This week, you're ever in a seizure.

[1103] That is a type of seizure.

[1104] I think those are Petit Mall.

[1105] I have grand mal.

[1106] Petit Lacour.

[1107] What are those?

[1108] yummy cookies.

[1109] Petit la la liqueur.

[1110] They're like really fancy cookies in the grocery store and their little grand crackers with a nice piece of chocolate over and a little stamp like a Dutch boy.

[1111] Petit alacour's or some shit.

[1112] I used to love them.

[1113] I don't know that.

[1114] Okay.

[1115] Take thy beak from out my heart and take thy form from off my door.

[1116] Quoth the raven, never more.

[1117] And the raven never flitting, still a sitting, still a sitting on the pallid bust of palace just above.

[1118] my chamber door and his eyes have all the seeming of a demons that is dreaming and the lamplight o 'er him streaming throws his shadows on the floor and my soul from out that shadow that lies floating on the floor shall be lifted never more never more yeah so we don't really know i think the hard let me glance at that i want to see what voice i would enact for this and the raven never flitting Still is sitting, still is sitting on the pallid bust of palace just above my chamber door.

[1119] And his eyes have all the seeming of a demons that is dreaming.

[1120] I don't know.

[1121] That was good.

[1122] That was good.

[1123] That was good.

[1124] That felt like I was transported.

[1125] We need cordy in here to read that properly.

[1126] Yeah, we do.

[1127] Okay, a tool.

[1128] Oh, man, did I like a tool?

[1129] I loved his message and just we don't talk about it.

[1130] about these things, me and you, but also just the people.

[1131] People don't like to talk about end of life, of course.

[1132] And unfortunately, it's important.

[1133] Even calling it end of life, that feels like a euphemism, right?

[1134] Like an attempt to get us to talk about it to call it end of life.

[1135] Instead of death.

[1136] Yeah.

[1137] Okay.

[1138] So he said Athens is the poorest county in Ohio.

[1139] 32 %, well, this was in 2014, but 32 % of Athens County residents were living in poverty.

[1140] Below the poverty line.

[1141] Yeah.

[1142] Okay, he says 70 % of people don't go to college.

[1143] I think that's what he said.

[1144] Maybe I misunderstood and he said, do go.

[1145] No. He said don't, right?

[1146] Yeah.

[1147] Okay.

[1148] So the percentage of students enrolling in college in the fall immediately following high school completion was 69 .8 % in 2016.

[1149] So it's actually the opposite.

[1150] Okay.

[1151] But I have to imagine the amount of people who finish college versus enroll in one community class is at best half.

[1152] Yeah, probably.

[1153] Which would put that at 30%.

[1154] Probably.

[1155] Which would put it at 70, don't get a college degree.

[1156] Okay.

[1157] That's true.

[1158] Don't get a college degree, though, is different than don't go.

[1159] But going to a class in college doesn't get you anything career -wise or economic.

[1160] You're right.

[1161] But we don't know that.

[1162] Okay, so I'm sorry, I do have to check this.

[1163] Okay, great.

[1164] I'll watch The Crows.

[1165] Percentage.

[1166] Remember the movie The Crow?

[1167] I never saw it.

[1168] How should I phrase it?

[1169] What percentage of Americans have college degrees?

[1170] Percentage of U .S. citizens have college degrees?

[1171] Keep showing me this dumb map of states' percentage of population.

[1172] That's Wikipedia.

[1173] That's Wikipedia.

[1174] Okay, the census in 2017.

[1175] 33%.

[1176] It was so fast.

[1177] Look at this.

[1178] You're too full.

[1179] No, I'm not.

[1180] Your fullness is starting.

[1181] Why?

[1182] Why'd this happen?

[1183] But look at 34 % of U .S. born Americans have a four -year college degree.

[1184] That rate is similar to the 33 % of those born in other countries.

[1185] 34 % of U .S. born Americans have a four -year degree.

[1186] The rate is similar to the 33 % of those born in other countries.

[1187] Okay, but look, so you didn't get this chart?

[1188] I don't, no, and that is not a helpful chart.

[1189] I don't know why you're now forcing me to read your chart that didn't get you an answer.

[1190] I am trying to compare what happened here versus what happened there.

[1191] Well, my search was what percentage of Americans graduate from college?

[1192] That was my search.

[1193] And read your search?

[1194] You just wrote percentage of Americans with college degrees.

[1195] So we had different searches.

[1196] But I asked you, what should I type?

[1197] You told me to type that.

[1198] Wow.

[1199] Yes.

[1200] And then look, I do see her 34%.

[1201] I just hadn't gotten there yet because I was looking at my chart.

[1202] You were very formixed with that chart.

[1203] So I guess what you meant to say was thank you.

[1204] And I will say to that, you're welcome.

[1205] Not thank you.

[1206] I was starting to read U .S. Census.

[1207] I was about to read the 2010 Census in its entirety.

[1208] No. Oh, my God.

[1209] I quit.

[1210] Why are you quitting because you're too full?

[1211] Yeah.

[1212] Oh, boy.

[1213] Oh, boy.

[1214] Why don't you go make a poody and fucking get it over it?

[1215] Okay.

[1216] Oh, shit.

[1217] I texted a...

[1218] Oh, my God.

[1219] I texted a fact to Allison.

[1220] She hasn't responded.

[1221] Fuck, we got to do another search.

[1222] Okay.

[1223] I'm the guy.

[1224] All right.

[1225] I'm on point today.

[1226] You said that 70...

[1227] Let me go to Wikipedia.

[1228] Hold on.

[1229] Let me open it up.

[1230] You said that 70 to 80 % of physical therapy works is effective.

[1231] Yes, yes.

[1232] Let's see if that's true.

[1233] How effective is physical?

[1234] I don't think you're going to get what you want on that okay how about this oh I got a great search I got a great search listen to this what percentage of the time is physical therapy effective question mark now erase all this other crap I wrote oh boy see you're no faster than me I'm doing really good I'm doing a really good okay almost there okay what percentage of, oh, I need physical.

[1235] Oh, wow.

[1236] This is...

[1237] Physical.

[1238] Let's get physical therapy.

[1239] I want to get physical.

[1240] What does it say?

[1241] Nine truths about physical therapy patients, often misunderstood by Dana.

[1242] You know, I know like 100 physical therapist is this embarrassing that none of them have responded.

[1243] What is the success rate of physical therapy?

[1244] Oh, that's specifically just for spine, I found 52%.

[1245] I bet it is going to have to be by body part or orthopedic versus.

[1246] Yeah, yeah.

[1247] So there's no way to know.

[1248] And that's probably why Allison didn't respond to it.

[1249] Intriguing physical therapy, statistics, and facts.

[1250] We're not going to find this out yet.

[1251] We're not going to.

[1252] It's okay.

[1253] But talk to any doctor, they'll tell you.

[1254] It's highly, highly effective, much more effective than most surgeries.

[1255] It's very highly effective.

[1256] I know many.

[1257] If any armchairs need a wreck, I know one in California.

[1258] I know two in North Carolina.

[1259] I know one in Atlanta.

[1260] I'm sorry, I know two in Atlanta.

[1261] Oh, my gosh.

[1262] So I have you covered.

[1263] Okay, great.

[1264] So just reach out to Monica and get connected with a great PT.

[1265] Don't send me any more emails.

[1266] That's from the last fact check.

[1267] Okay.

[1268] All right.

[1269] Well, that's all, and I'm full.

[1270] Okay, great.

[1271] That's not all.

[1272] There's one thing I wanted to say because it's been cut out of an episode and I wanted to just address this quickly.

[1273] So some people were upset that I had quoted Lewis Farrakhan when we were interviewing Leslie Odom Jr. And the point I was making was that I had seen some footage of him making some points in the 90s.

[1274] And when I had seen it in the 90s, it seemed very radical.

[1275] And my point was now that I'm hearing it, I recognize that he was completely right on the topic at the time he was discussing, which was redlining, steering black folks away, generational wealth, all these things.

[1276] Several people then wrote that I shouldn't be promoting an anti -Semite.

[1277] So, yes, I am not saying we should build a Louis Farrakhan monument.

[1278] I think he was anti -Semitic.

[1279] I think he was a very flawed person.

[1280] The only thing I was saying was that his take on why black people are systematically oppressed is very, very relevant still some 30 years later.

[1281] And he was speaking many truths on that topic.

[1282] And that's where I'll leave it.

[1283] I'm not condoning any other points he made other than that.

[1284] I guess I'll add we did remove it.

[1285] Which I didn't agree with, but I trust you more than I trust me. We removed it because without hearing this part of it, it could be mistaken and we don't want to be misunderstood.

[1286] And because we weren't explicit about there's other parts that we don't agree with that are pretty extreme, we just decided to cut it out.

[1287] but if you had heard it, this is...

[1288] Also, if you're now hearing this and you love Louis Farrakhan and you want to explain to me why he wasn't anti -Semitic, I'm done with this topic.

[1289] I'm going to have this.

[1290] So this is where this topic ends.

[1291] Yeah.

[1292] If there's another rebuttal.

[1293] I love you guys.

[1294] But we love you guys.

[1295] We love you so much.

[1296] Peace.

[1297] Follow Armchair Expert on the Wondry app, Amazon music, or wherever you get your podcasts.

[1298] You can listen to every episode of Armchair Expert early and add free right now by joining Wondry Plus in the Wondry app or on Apple Podcasts.

[1299] Before you go, tell us about yourself by completing a short survey at Wondry .com slash survey.