Atul Gawande is an American surgeon, writer, and public health researcher. He practices general and endocrine surgery at Brigham and Women's Hospital in Boston, Massachusetts. Dax and Atul discuss the personalities of surgeons and the use of checklists to remedy the complexity of their responsibilities. Dax tells a scary hospice story and the two discuss how you determine your priorities as you reach the later stages of life. In the fact check, Monica & Dax discuss training crows to do complex tasks.
This is an unofficial transcript meant for reference. Accuracy is not guaranteed.
Welcome, welcome one arm direct armed shepherd. This is money. Well, there's gonna be a record going backwards. Yeah my mom mom german. Where experts on expert that That's what we got ahead of us today really interesting expert on a topic. We, early avoid Jeff now to one day was recommended: do us by Julia Louie Dreyfus. She said she had read a book called being mortal illness medicine in what matters in the end, and she said that was her favorite book on the topic. So we got to talk to a tool and a tool as an american surgeon, writer and public health researchers practices general in endurance surgery at bring em in women's hospital in Boston Mass, chooses. He graduated from Stanford Oxford, Harvard Road scholar, Macarthur Fella, you name it he's done and he's got for books, complications better the check,
this manifesto in being mortal we loved, but to a dead end. We learned a lot from it yeah he gives you a great framework for conversations that we all will have at some point have Have so please enjoy a to go one day. We are support my master class with master class. You can learn from the world's best minds anytime anywhere in your own pace. You can learn cookin from Gordon Ramsay, improve your beat making skills from timberland come on or learn writing from Malcolm Gladwell, with over eighty five classes from a range of world class instructors. That thing you always wanted to do is closer than you think. Now a recently watched the Gladwell one is there anything he puts his fingers on that doesn't turned gold. That's my question. That's a good question answers now, so they have access to Malcolm's, mind on writing. What an opportunity master class is accessible on your phone web or smart tv offering classes on a wide variety of topics. Hundreds of
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as a tool. You know you're someone there has come up on our shows several times. Many of our gas are big fans of yours enough, so that we had to seek you out in beg you to do to show serenely we're very grateful. I don't know I've got to you, but you know Julia Louie drivers who I worship, Ellie she's a good devoted of a tool to serve as a whole, a story behind, because she turn up on the show- and I heard the podcast and then several of my friendship, you gotta, reject, or she said she wanted me to my come on and then one friendly. I know her agent I'm gonna ping. We talk today saying we that little zoom date. Oh wonderful,
and it was amazing. It was amazing, wait, wait. We talked about our parents and we talked about a lot of what each other are going through at a similar age with kids. You are now in their twenties, not at a house, and so it was great and it was thanks to you and she was just totally lovely. As you know. Yes, now, your children are ground, but have you guys been quarantining together? That seems to be something that's happening, now I have my eldest at twenty. Five now is a living in Berlin with his girlfriend Why? Which is a thing now for Africa and then my middle child is in North Carolina, where she's working, and my youngest is in Boston and has no interest in quarantining here.
And now you're in Ohio Native you're, a buck guy. We could say you ve, no enormous, where you from at one from twenty five miles: North West Detroit, so right where the suburbs turned to a corn, yes, a big dose of hillbillies and then a big dose of folks who drove in Detroit to work. A melting pot, Ohio in Michigan rivals, but very similar culture, I'm from a small town, Athens, Ohio, witches, southeastern college town, but also the poorest county in Ohio. Oh, it is yet, and so it's Appalachian foothills and everything. From hunger to poverty as part of the picture there, while also having some my friends come from all of the kind of fancy as you can imagine, did you read hillbilly ology I did you did ok. I had a real argument with
Bela Ology Monica very disappointed in it, and I would love to hear what yours is here Actually, I wrote about it as well, which is that the heel Billy Ology, look till I got the Ohio is rival high school. To want a mind, it is the area we grew up and no question jade events who wrote this memoir of growing up in extremely poor circumstances. Unlike me, of two doctors with the only Mercedes in town, but not the same story right register, but but what I want, I never had you never hear about his friends, you never hear about who we dated and what that was like and that richness of the relationships beyond this family, but but for him. And how that change them. In fact it- and you know so when I went back part of the premises held the earthen. Fusion of hillbilly geology. Is it's a cultural failure? These are people who are,
stuck in their ways and are cheer rating. The breakdown of the family and they just gotta pull themselves out of it, and you know the military and an family values was wet, pulled him out, and this is what we need and without ever getting into the ways in which, in my county, you start with thirty percent, either uninsured or with inadequate health coverage. The larger picture that bothered me was that mix of I had friends who are 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 the sea I was gonna. My shot and yes, I had an amazing family upbringing as well. That kept me on a good course.
But it was also I was set up for success and yeah see from the beginning them somebody s, friends, we're ok. So what so interesting, as I dont think I was pinpointing what my issue was to your point. I have a couple friends that there's no pull yourself up by your bootstraps. That's an insane proposition Mom was dealing with a step dead whose regularly tearing the house down in such a fashion that there's no way you could have prioritized schoolwork or learned anything? No one had their own bed to sleep in this notion of yeah. Just can overcome that I guess didn't ring, Your true too, to me and what I saw at the core of this in my high school, about half, went to college and half didn't, and if you don't go to college, there is no middle class opportunity, that's out there and in the United States seventy percent of people don't go to college and we don't have a solution for them. We now have it. We have a future where offering to them, then to say well, why can people get
act together and yeah, because the military, because his family, he became one of the first thing he got to go to yell and you got to get all these opportunities and move on an absolutely. But that's not the pathway that can save everybody beyond single digit percentage. People who sure get a trade job and then build their own company and become the one atrium see family whose riches hell, even though they were, from the dirt roads yeah, it's just not a high percentage endeavor and then on the personal level. My upbringing was, was a lot around. The fact that, as an immigrant families, not feeling like you could fit in and having great friends but at the same time like yeah, I've spent my teenage life wishing for a date, not anyone or right right or apt, imagine living in some fear of physical violence, because your other and it's a town
it's not afraid of a fistfight right. Oh, I mean everybody had of Europe's Escobar allowance in that found right here, right right, rumour fights constantly out on the smoking patio we we were the days where you had a smoking patio and outside the capture. I did you have a smoking patio, your high school growing up it s out, so it was basic. So I think I'm about Romania and one ten years younger than knew about it, but my best friend he gets into an alternative high school where they just were like. You know what half the reason they're leaving this, because they need to go smoke, somebody's gonna, let them smoking also we were in the transition phase, where, like the more progressive angle, is like well, let's let em smoke and hopefully the stick around. So that was happening and I think sometimes in the key s room, they were guns and they were knives and there are a lot of bites and back then people drink a lot compared to having kids today or so much better. Oh, my god, there such better people, then we were yeah. I mean they're, not having sex.
Much which concerns me. But you know, maybe that's part of me in better looking those say: aren't yearnings accurate, most people don't meet. You don't really realise that right and that actually there interpersonal connections and the weakness of some of those is a thing to fear. In some ways, I'm with you Now one of my favorite things adduced know very little about a person and then make a very sweeping psychological care generalization self 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 economy class, have to imagine you're a little bit high on the disagree, ability psychological profile, which again yes were higher than we value it. So just know that this is a compliment, ultimately zoo, where my wife would burst out laughing. My problem is that I want everybody to like me. It is I'm not tough enough and not a jerk enough,
I'm pretty low on the disagree, ability index barrier right. I generally work on ok, but could you revolve juicy codependent an highly disagree? that really just that's the war that happens it could be. I went the surgery as much because I loved how tough people were in surgery. The situation of surgery is in circumstances where people need to go to surgery often you don't have all the data. The studies are great. You don't have all the from even at that moment in front of you, and your skills are imperfect. You have complicate some things can go very wrong and yet going in there and being confident and taking her chances and living with the consequences is part of right and then being prepared and owning responsibility. It is a very heavy high on the responsibility culture kind of place and on
owning failure and going to the next step, and God got in the operating room. You'd have these people who could dare to open up people's bodies and no they were imperfect and know that things to go wrong, have the confidence and they could be jerks times, right in 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 read them apart actually makes for a terrible salts and surgery. So I can be an iconoclasts in the sense that I want to push back and fix, what's not working, but I wish I were tough enough to lead people who disagree with me or angry with me, not get to me so as result I'm trying to win everybody in the room and that's not always feasible have time or minimally. Its antithetical do
surgeon. So we ve interviewed a handful of surgeons and I gotta say we feel very competently stereotyping. After those interviews and again it I've kind of defended, which is I want, high level of arrogance I actually want someone to be overly confident and self assured, because what I dont want is doubt when things Oh hey wire, as they do right. You want someone with a real, steady belief in that in their abilities for better or worse I'd, art now, you're, already you're breaking them all and then I can already tell your more empathetic and lessen our says nothing about what we like to see in our surgeons. By a how dare you where I come up with this economy class label, I want to give you is you you did not just inherit your system right, you did not just get out of medical school, and I dont know what it Product could have been that you'd. You went a little later right. You had some gap time where you got involved in the rest of the world than that. That could be what it is, or I was gonna push this narrative that may
be growing up in Ohio. Is I have to imagine one a very few brown people? I think that's good fertile ground for wow. Should I accept the system inheriting and do I wanna perpetuated or do I have questions for the over system. We can try to contact out, because I dont have not always where you to leave here with it with a mental diagnosis, is further to ban professionals. I get very disturbed by things that don't feel right and better especially, can fusing to me, for example, in surgery I became a personally pushed back on the culture of arrogance and intimidating people, there is a difference between arrogance and self confidence. Oh please tell me so I can stand the right side of it you do you have to make choices and he got a forge ahead, but the ones who don't have humility that things can go wrong, are the ones who
I can only when things go wrong and learn from their rights Ryan. So it's not the confidence of that. You are perfect, which is a dangerous confidence. It's the confidence that you can handle it and that your aiming for perfection, but you know you'll, never completely achieve it right. The best surgeons, I know, are ones that are able to have good judgment. Make quick decisions in the face of ants certainty and are generally right and own it. When they're wrong some of the best politicians. I feel like her those kinds of people that yeah they are able to recognise things are uncertain you have to make a choice and then you got on it and live with it. What what's the Seine right? They say like you, you make the best choice with the best information available, and sometimes that's in. Vision, you know, want some endeavouring in Obama the night that he sent the special forces out too.
Kill us on a bin and his entire presidencies on the line having to be at the White House corresponded dinner. That night, yes Giving jokes, if a is funny as any other comedians roasting well from the a very night regrettable, probably right which across pissed off but being able to make the call. It wasn't arrogance. It was confidence. It was like I've done the best. I can and then I'm gonna own and live with the consequences and I'm gonna hope ever but he comes with me when I then say well. This is my choice I made and yours how we deal with this consequence and where we are right, I have to walk out in surgery. Look
got it down to like ninety seven percent of time it's going to go, as I hope, the three percent I'm going to have made worse off and by the way that seems like one of the highest percentages in surgery. Right I mean in general, there's a sliding scale right back operations. I don't know they're like fifty percent effective or yes, do you. You can have their operations like colon surgery where twenty percent while have some kind of a complication they have to deal with, and then there's you know, some of them are errors. Some of them are not, but I have. Build a walk in when there is something that goes wrong and you know I'd say like what nuthin went wrong look. This is what happened This is our situation now, here's what we can do is how we can manage the situation. Nothing's ever gonna always go work perfectly, and so, and so you have to be. To bring people on the right and that's what I felt like I got out of surgery, which was I was not there my favorite New Yorker virtue, in which I thought
defined me was the gravestone that said he kept his options. Open, that was made, but isn't carefully my wife when we go out to pick a place to eat. She can't stand the process because his life of so many hours and search and surgery pushed me to be more decisive and pushed back. Where things don't seem right, you would have thriving communist Russia, where they really limit your options, sillery. No, because we want a dairy product here. It is now in your book. The checklist manifesto use start
CO opt in or looking at other areas where organizations have been successful in creating systems that mitigate accidents in disaster- and I guess, there's an openness there to even do that. Again, I think its anti arrogant to say of some other disciplines have faced similar challenges and some were varying success and I'm opened to learning about that owes the catalyst for you to explore that the core of this started with recognising when I wrote my first book complications that was about needing to navigate the learning curve like how do I have the right to learn to hopper it on people right rising. All these things for the first time haven't even ask permission from you and half the time were, not really, like you're the teaching hospital. You know This person, steady by the table here there.
Dear to help out there, and then you get comfortable here like you climb the learning curve and you started, and better and better. Then you realize we still sock ninety seven percent time. It goes well three percent of time it doesn't and most when it gets wrong. It's because of some we already knew how to do it's, not because we were ignorant about how to the problem, the majority of the time. It's a failure and the approach to failure. I've been obsessed with failure. My entire career and part of what I love. That surgery is house how high the stakes and with the wind the approaches while working to teach you where you know you're gonna go through school for ever you're gonna do for years, ethical school and then eight years, a surgical training which what I did then you're gonna be perfect reality of that research. I've done a bunch research on this and we have over a hundred, and fifty thousand people per
here who dire are permanently disabled because a complication from surgery minus five times the number of people contracts in the? U S, just as you all my hundred and fifty thousand, yeah me we do. We do over If ten million operations ear right, o my guy, so it is that one percent- yes about as I want to have a major complication- will from impatient hospitals right, big, big major and found that about more than half the time avoidable, with information we now, those are all the people who went through all of that training got battery then our usual reaction is okay. Well, then, let's is you guidelines and rules here are the rules you have to follow, you have to do better in the following way. You know it's just the naturally knee jerk human thing. Once we discovered we, doctors are washing their hands enough and therefore getting all these infections and hospitals or people are wearing their masks nor everyday life,
we need some rules, and so no, then you get an outbreak for the geisha and you get insurance requirements and all those things and any kind of work, but they don't make you great cannot. Can I ask something about that? Does it in some ways in the in the ethical brain? Does it offload responsibility? So there is such a you know. As people now, our very litigious country and so much of our medical experiences driven by trying to head off potential litigation Does it does that off load your own personal responsibility in some way, as a physician, we're like will clearly this think tank that trying to prevent losses? Wilt will come up with the plan, and I should really just focus on this as it make any sense, like others, is huge organs that was the year prevented me from making liable mistakes. So they'll, probably think of it. I don't know,
think so, in the sense that I think data day, you feel responsible for the person in front of you, but there is this lingering thing in the back your head like well, I certainly no moments. When I'm aware that boy I could get sued for this and in the way of medicine is when we then decide to change the way we practice because of it right, defence of medicine definitely occur where you're getting the city scan, even though you don't think it needs to be done, because you know you're worried you'll get see when you start playing that game. It does no good. I think the larger picture I was at the malpractice litigation the whole idea that you can, whether its punish people or reward people to do the right thing and ignores the that, when things go badly wrong, it's used because you ve been set up for failure. It's because the system never worked right in the first place and so that
the idea behind an entire but on a checklist, is the idea that places the work. The best the ones that get beyond fighting over, whether those malpractice lawsuits or not and starting What can we learn from all the things I went wrong and then make this system makes it easy to do the right thing right. We make it really hard to get the right thing done, because we're never fixing the system around us in New York, your novel in that year saying: oh, let's look at the system right with this is such a kind of individually celebrated individually punished. Pursue like all the glory, as you say, goes the surgeon and or all of the fall out. But let's look at that. They are a part of a system and that this, system needs an intentional design turning it into a tractable thing right. The many someone says We should do so about the system it feels like I just gave out I totally yap right and so here there was was saying what
but all the system that people have is a checklist proposed makes up fact that I can't remember everything right. You got an airplane, they got you a check list, but then also the team contract we're all communicating together about what we're and to do and how we can deal with its of the book of the story of the adding to bring that into my own operating room and then making it into a kind of global standard, and the checklist that we designed was. Simply to say when we come in the operating room, we're in it. You know make sure when interim room knows each other make sure everybody understands what are they all when we actually here to do today what the worries and anybody has about this person, one of the medical issues of the patient. It's like at one minute huddle. Like say: and then go and then thereabout, six or seven things that are easily forgotten, like we giving an antibiotic or not, and are you getting at an untimely, his blood available operating on the right side of the patient,
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, yup, that's but the power, for one actually turns out to be just people talking the checklist sang, including them a student who, in the room, what's your name? What's your role here there and then everybody owning? What are we attempting accomplished and We were all that our world it out, made cities too minute trackless and cut the death rate by forty seven percent. Why Monica forty seven percent MIKE S huge reference, looking for two minutes and getting people on the same page and saying: look this duration from wrong in a million ways? How do we get prepared by saying what could go wrong? What's anything people here can think of that could go wrong and how are we prepared, for even the unexpected. By now HU, we are what's available and and being set, and then, at the end of the case, going background and saying: ok, anything, That should be the plan for the next twenty four hours for this person and it
I'm so kindergarten, but we were not doing. It was just assuming everybody knew what they were doing and it at a dramatically caught the death and so at this point now, there's been that's it. Tenth anniversary actually of the safe surgery. Checklist is now global standard Debbie I chose implemented. Seventy five percent, the operating winds are implemented and I've got a non profit organisations. We stood up called Life box, getting it implemented in low income world, because, ironically, it's still got lost let it go and the low income parts of the world. Why sour ironic. It seems pretty predictable sab I would imagine in- and I'm sure you drill down into all this, but I would imagine there's kind of unforeseen benefits of this one just being what you've also done in that moment is created a culture in this this room right, whereby I've invited you to talk. I didn't invite you in a you know: you can speak when I ask you a question Ivan powered you to bring up what you're scene, which, in essence, is what the co pilot in a cockpit does right. I was hoping you got
idea from that Malcolm Gladwell chapter about Korean Harry, because we listen to this one- the best progress of all time called doktor death here that of the spinal cord surgeon now lets you must listen to it. Your point about learning on Anselmo hijacked, ragged series, it's a series, it's absolutely the most horrific thing you could ever here sounds. Wonderful, underprepared surgeon was basically release from residency. Having only kill you know done, make a hundred and thirty surgeries and they expect outnumbered entering housing air, and then you know lies his way through all these different situations in just injures untold people and again largely into this. There are many of the surgical nurses that were saying I could. See he was doing it wrong. I could see what should have been done and did not feel empowered to raise a flag. So that is the credit. All lifesaving thing that we hijacked. Basically,
smuggled into operating rooms, because one of the best ways we can- how the people were used in the checklist we discovered cost have observers and operating rooms. Alek in many ways try to forgot whether its working or not and the places where you it was working. We found the best way that if only one voice was talking at the beginning, duration. Then they weren't implementing the trackless, but if it turned out that people worked speaking fair, equally you heard the surgeon you heard the anesthesiologist. You heard the nurse, then the culture, was one the where they really were a team and there were working together, the culture of sir, We traditionally has been one where that the just value was autonomy. Autonomy of the surgeon? What the surgeon says is what goes here? You call it the operating Theodore. Even in many places, writer was the place where that surgeon came to perform, and the culture that this was trying to great was
hey it's a place where there is humility to recognize any, and could go wrong where there discipline in the belief that doing so things the same way. Every time had real value and there's teamwork, where the voice of anybody in the room. It doesn't matter who they are, does matter, how much more experience or less experience they have everybody's voice can matter. That's what save lives yeah, and I love that Malcolm Gladwell chapter Malcolm, was wanted convinced me to write for the new Yorker. No! Ninety. Ninety eight, you ve known him for that long item well before that before he started the one imposed and before I ever wrote anything he and their friend, got named Jacob Weisberger started slight convinced me to start writing and then Malcolm Sonnino, saying hey my There has been following your writing and on slate magazine and that
If you saw him a letter, I'll bet he might like your idea. So I sent him. It was totally like connections right how well he has always been incredibly generally about he's one of a small group of people where I will share my rough drafted, each broken, let them written the part incredibly valuable. I bet a yet where workers lower and loving her, who are a little too in love with me. Our objective and I've heard your pod chest with him. I have about objective, it is out the window, whatever he says on my yeah. That's my new religion stay to arm chair there. We are supported by sleep number is more
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now another topic that we have talked a ton about on here with a bunch of different great physicians and policy makers. Is this insanely difficult conversation that happens towards the end of life, and I'm pretty critical of about have now done it twice. I did it with my father and my stepfather, and I learned a bunch on the go round with my father that I applied to my stepfather and it, and it was really great. I think one of the big issues is recognizing right out of the gates of this. Is there cancer? This is not my cancer, the b 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 out
decisions, but but I really did learn. We had one fight over him eating a hamburger that I so regrettable. Right like I think I should have eaten the twenty six hot fudge sundaes. We are at that point, but I was just locked into this. No, this is often shaming him? Probably this is why we are in this situation. Here you go again and I just really granted that, like what you know what they were, that we were down to ours and I spent one or two of the hours berating him about a hamburger and then and then in a weird position where I work with the prostate Cancer Foundation, and so I had access to the clinical trials that could potentially been mere things for my stepfather and I got a man and he said ultimately, I don't want to do this and I say: go they had no push back and I try to pass it on a people who are going through this, and I know you you experiences
yourself. You said you know, there's the conversation as people face intellect and you had it with the step farther and farther. What was your goal, that what will we hoping to get out of the conversation? What was the purpose in your mind? What I can tell you in this this is then unpopular, but its very edge is dead on us, which is from the second call me, I thought. Ok, I've been asked to come in and co pilot thing? I have the singular goal of getting them across the finish line with his little of the gnarly parts is possible, so I brought but he was already waited to comfort over success and
prove it was my own life and having a job and I'm going to fly back to Detroit. I selfishly was motivated by I want to get this done peacefully and I'm not looking for a stretched out two year version where he's miserable. So I already you know for numerous reasons. That's where I was at, which makes a ton of sense right. Here's what I think the goal- The goal is: what is your father, my patient, my mother's? What are their priorities, and I can't believe I had a right, a whole book The figure this out? As I wasn't, I was never asking patients that question right, I'm an interview over two hundred patients and scores of clinicians about how do you, this conversation when I realized was the ones who really successful. I just had a different goal. They realized people. Our priorities in the life decides.
Living longer. Yeah. Those priorities are different from person to person and also different for you. As you change and go through you're gonna go through, and you're only way to learn people's priorities is to ask them now. What are your plans he's besides just living longer, I dont think there's a contradiction as it turns out, there's not between your goals for your length of life, in your goals, for quality of life because get clear about the priorities you want to serve around your quality of life. Ironically helps people live at least as long as no longer as well as better and when you don't ask, people what their priorities are? No surprise, the result is suffering right. You know, like I interviewed a woman with Severe Alzheimer's disease. Who'd reached the stage where you know she could have difficulties
following, and she had a medically ordered liquid, only diet and she'd be caught by the nurses, stealing cookies from her neighbours and hurting her, and so they did take them away and she got written up contact the family. Like you know, this is dangerous. I want to say one of the main cookies right right, she's telling you but her priorities are and this one source of joy and you can talk to the family, 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? but the small risk and the real risk that to choke on the cookie. Aha. So in the same way as you're having a conversation with your dad. Maybe it was that, willing to not be comfortable.
Here. We are willing, maybe to say you know what I wanna get every. I can and more time, even at the cost of pain or might say you know what I am now in pain. My priority suggestion de I and some of the questions that you at the end up asking that I found really powerful are. What are your fears for the future when your hopes, if your health worsens then also like. What's the minimum quality of life you'd find acceptable has become my favorite things just talk about like for you, guys. What would the minimum colleague life be, except for me Long as my brain is working, and I can talk with you, I can communicate with you sure, memories and and have those stories I could be quadriplegic. I could be paralysed, but I, but if my brain is not working, let me go out my wife. Her view is. I'm dots creature. If I am experiencing joy, I don't care if my brain works
experiencing joy, keep me going and if I'm not experience in joy? If I cannot experience joy, let me go that's a pretty sizeable burden, what Andy you evaluating ones have been, especially if the law is kind of cognitive ability to deal with the army a lot of weight on a smile, let's hope that's not gap, but I do feel I feel like it. It took a lot of burden away, but I'm curious for you. So what's the matter Call you live. Let me live. Monica gophers has again it's her, because I definitely my grandfather's so old right now and you like barely remembers my Mom are you know, he'll sometimes remember, sometimes not he's just sitting- and he was a professor of biology, and he was always talking. Is that he's the smartest person I've ever known certain well version
Athens to see him there unable to contribute. To a conversation. I talk to one professor who said if I can eat chocolate, I screamed the watch football untenable, now be good enough for me, and his family was blown away there like I would even, though you watched for sharing hereby like I can't, but how can I first of all we got order television package with football? Is by your loving it. We don't have it but so that might be true for him, but have for you that's all I can say this word- gets really really you because you're you're projecting some of our own. But that's what I'm saying when I see it. I think I don't want that. I dont want to be today in a room with my family and not be able to contribute or not now our jalopy sitting of cookies tie what are those learning about the whole time, but what I be able to take them yea you can talk well
so what so leading food that might be really important EU my dad came towards the end radiation took away his taste and that really took way one of his joy yeah. Can I say that me as I was evaluating. I took him out to this restaurant with great great effort. Get him in a wheelchair, the whole nine get a pass out of the hospital got him his favorite goal, brick Sunday and he just stared at smiling, and I can see why No, my dad was a real Vietnam Canary in the coal mine moment were like we ve transitioned into another phase. When do you think I'm with you or to all? I want to be able to talk. If I can talk with my kids and look at them, I feel like I would be good, but but I will say now having a new, through this many more times our peoples priorities evolve throughout the process. So my stepfather, who is another
trickle engineer, very very bright did not want to get to a point where he mentally wasn't a sharp and that was Big moment for him, he wouldn't want to be around for that and also had a plan. They lived in Oregon to do euthanize desisted, which would have it grateful intention to do it and then all of a sudden is we got to this point where he would have had to gone to the place to prove competency. We pass window and we were left then, when he did say I'm ready with a new problem on our hands saws. I welcome 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 so they have of right in your and as the co pilot year like okay. This was in the game plan, but I gotta stay flexible.
But when you think right now is this. This is this is joy, MRS Garabin, yeah and wet. What makes what life worth living not just state of theirs is cultural expectation that you are weak or cowardly. If you dont want to fight cancer- and it came really pissed me off its antithetical. Do something in a that has been the greatest gift. I've been given an aim, which is like acceptances the answer to all my problems and in general that I find that to be largely true. Once you ve figured out what what options you can exploit and when that, when they are done, are the ones you wanna exploit? I feel like there should be shame and in surrendering well There's a lot of discussion in down calls you Weldon most of mice, surgical practices and cancer surgery that we just want to get rid of this whole fight.
The fourth thing? I hate it, whether its fighting or surrender it it is a journey with this cancer. We have a lot we can do but ultimately, if we're doing our job right, it's around. You know what are your goals? What are you willing to give up? For the sake of more time? and you not willing to give up the other way you ve been to describe. It is ok, let's, by what are we fighting for, gliding for your ability to be at home every day and go for a walk and see your friends or we fighting to make the disease shrink on this scale. Have you had to give your patients permission like you're, not a coward, you're, not weak. If you dont want to spend the last three months earlier life with intravenous harsh, chemicals for everybody. What what I used to do is get in arguments like that with people and never felt very successful, like you don't have to
thus in then they get all Vienna, be the naturally that as well, you know. But what are you trying to tell me you why are you telling me something? Instead, it sort of like well, Let me know before: was you re We did not want to be in a situation where you couldn't live at home anymore, and if we do this, you're not, can build live at home anymore, so has changed yeah and then it's not about. Are you being tough? Are you not being tough? It's what you just what matters to you and it isn't about who you are you know what kind of image you have yourself it's just by. What do you want? This is tat. Can I be critical of one component of it that I it's yet he now you can't stand it wasn't a perfectly reasonable, come on number one systemic issue that I again having gone through a twice that seems like it puts people in and in a very challenging
situation is declaring hospice serve if we haven't gone through this at home. First of all will all go through this. This is another frustration of minors, like that. The notion that you can avoid having this conversation. No, this is the singular conversation you or are you Aren t you have in your life. You know if your luck has been data, your light on get hit by a train or something but but the declaration of hospice. As I understand it, maybe I have it wrong, but basically the doctors always waiting for you, too, Claire Hospice, and that that's not what movie to your house we're going to we're going to now have the new goal of making everything comfortable as possible, and we are no longer fighting know it's tricky about that is there so you're, basically signing off your right for any medical treatment right in this can get tricky, because there are things that this happened, my stepped out, which is we declared House ass, my wife, my mom ears from the bedroom Han you're gonna.
See this. She comes into the bedroom, his testicles, which become the size of cantaloupe, had split in one of the veins and severed in its literally rainwater, failure of the room. But were not possible. So what do you do like the deal? Let em bleed out of this, as it turned out that date they made an exception and eight they so that part of him back button. There was one of these tricky situation. Where's, like you kind of want to reserve the right to get your husband's ball sandwiches spurting blood under the ceiling address. But you're, not asking a goes your chemo again in this. To be a little appetite for some hybrid of the situation. What are your thoughts on that you put your finger on Sunday. I ve actually been very critical of the idea that it's either or right MA am you know how This is not a fight for your quality of life versus quantity of life. Then you gotta pick so, for example, the state, a master
it's all of the insurers. Now allow you to go and a hospice without giving up your doctors without giving up your medical care, and you can do it at twelve months before the end of laugh. The goal is that you have options for people because it leads to people not going into hospice in the first place and really what happens when you do go and a hospice is then you and I'm saying you know what I'm so glad to be able to be kept comfortable at home I can see I'm not getting any benefit from the chemotherapy, but I'm just getting sick or because of everything, and I'm feeling better and lo and behold the lot of the time when you are not take that chemotherapy in the last couple mental life you're your ass living longer and doing better, so that in the in private insurance right now, a lot of different companies have made this
We haven't persuaded Medicare yet, which is, of course, the most important, ensure to make the shift, but it doesnt save money. It doesn't improve the outcome that got imagine there's some countered intuitive outcomes which are like for art ample. We would apply declared it sooner. He would he was happy or at home I he wanted less services. It actually saves money, because people then have and got the option that get good care further pain and their needs at home, which warrant being addressed at the hospital and up appropriately deciding to stop chemo and on average living depending on whether its lung cancer pancreatic cancer, whatever anywhere from sixty of weeks longer on average, with lower costs it it's win, went all the way around, but it
from being able to say we are going to have a conversation about your goals, yeah what's important year, my other issues in the sounds anything but emotional or or compassionate, which is. I have another issue. Just subjectively was spending, maybe sixty percent of someone's lifetime medical expenses in the last three, my just doesn't seem like a super sustainable approach when we are already having other issues and this person said well, we tried to address that with a bomb care and then the right label, that is death panels and all the death panel was was us way before you're in this situation. Saying hey, let's commit some time to thinking about this inevitable scenario. You'll find yourself in and let's make some decisions with your current self. That's not going through the biggest crisis of your life
you're actually read those two things out sort of wanted to say about that number. One is its true: we spend a disproportionate amount of our medical spending on the last three months. A life would be perfect. If you knew when the last three months of life work is, then we can. You know we could change that. Done some work showing that about nine percent of the population will have surgery. On their very last few days of life and out you know that under surgery, you don't have time to recover from it you're getting all the pain, all of the invasion and none of the benefit. But but we don't know one that moment is that's it. 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 further through, for the sake of more time, the main value it seems to show. Is that having a conversation earlier means that you are making subsequent decision sooner because you started to think about it right and you ve started to ask
Well, you know, where is my line in the sand and you ve gone to experiment with that, a fair man We we a the data further cancerous to where we randomize training half of the clinicians, and having these conversations they would have these conversations on average of five months before the end of life, rather than five weeks because it's just a conversation have with anybody the trigger was, would you be surprised? This person died in the next year and if you would not be surprised that group absolutely had to have this conversation, about half of them died and have them didn't die, but Clearly, this is the conversation you too have you wouldn't be surprised, and then that group had the conversation five months earlier and they ended up with having half the love of depression, half the level of anxiety same survival rate, while Another study along the way, as shown the people typically because they ve done this thinking
well on their own, stop their chemotherapy and again no reduction in Serbia, holiday. Lung cancer was a twenty five percent increase in survival, so You know the lasting I'll say as we pass the death penalty, that is, that the best needs review which is. This is bipartisan. Support for this now, that was not labeling, this death panels. Feel like we have another week to make we. Finally, so having these conversations, are you know, like Mama Apple pie, it's all great right. It actually needs to be a scandal that we don't have these conversations, and you come to the end of your life right It is such a worse experience through hundreds of people who seriously ill never have this conversation with either family or their clinicians and everybody's uncomfortable, but when you understand it's not about like, are you going to give it up at the like you need to surrender the notice about like what are we here? For what are you
fighting for what do you need me to do for you there, and what do you need me to do for you where's your line in the sand? Is it challenging knowing that you must deal with the full spectrum right? So we watch your frontline episode. That was about your book in what I was immediately just confronted with his like, like it's not unlike the job, I think we ass police to do, which is not the same, not put a very critical of the police in the systemic issues, but also ok world. These we love to deal with every problem. We ve kick down the road virtually right, their dealing with real time, and I would just say to expect you all to learn everything you need to learn in medical school.
And inured surgical residency and to be at the forefront of all of that and then be some Masur communicator that can navigate how to help people how to not trigger people. How did not talk down a people this is that could be its own specialty, the interactions that you have with your patients on the hardest topic under the sun. You know it's a lot to ask your helps to do that, I think the action that totally misplaced. It is part of the job that I should understand. What am I doing this operation when it doesn't have to be the end of life? You know my mother underwent a new replacement and I know, asked her like what are you hope get out of new replacement. She was a tennis player out. Information wants to play tennis again, she was the point where she needed a wheelchair and the airport. She we did enough rehab that the pain went away and they would still take the friction wheelchair the apple. Just like I like getting the right in Europe
exertion would want or to get. You know, let's get more physical therapy, but she was a really with the programme and the reason was her goal was I just want to get rid of the paint right whereas another person they want to america- and I should be able to be good at find now? You know. Lawyers are good at this right. What is goal and then how to how do I help you achieve that goal you get to bring this huge arms in terrorism and toys percent of the american economy to you and let deploy that in ways that actually serve some meaningful function, rather than you know with that. Surgery where you have the majority of people undergoing it, who still have just as much pain and justice, when inability or walk and no reduction in disability rights like what are we accomplishing here, when one we're doing that. So I think this is not too much to ask it to basic skills and if you can't learn to have these basic conversations, I think again,
all the way back to how we pick people for medical school that skills are not just about the the technical staff. The big skill is helping people achieve their goals and why we think organic chemistry in your freshman year in college is the right one why is that our weed out mechanism, the advertising we just we just picked the wrong people, be ass. Any of that screen for whether you should be an apathetic yeah. Successful human being and navigating complex problems with people I couldn't even more now. I think the patient largely gets off of all the blame. So I'm infected if a self help program that doesn't tolerate a lot of horse shit. So when I age and myself being you, I think it would be so hard because I only have had the experience were. Someone comes in. We go. Look there's these twelve steps. If you work on this post,
It gets it. Why don't like those? Two steps? Incite cool go: do TAN and see how it works out. I know how it works out. I can't co sign on your delusion. Now you can go. Do whatever the fuck you want, but I'm telling you of the ten thousand people. I've seen try to get sober, here's. Why works. It would be so hard for me to go along with what is ultimately sometimes people's delusions. How do you handle that? I guess you have a different priority. Well, I think it also depends on the field that you go in because some people, you know, I think, in primary carrier, navigating this all the time with people as they confront or don't confront what to deal with For me, I have people coming in and they ve got a problem right. They have a new cancer or the Heaven a tumor, or they have something going on, and then you know the choices. Do you want to do
was that are not what's the goal that you want to have, and it's actually relatively straightforward. I will have, for example, people who come in and they ve got a an cancer, but it's a cancer and then they will say you know I think I'm gonna do a verbal therapy. I know this chinese herbalist and we're gonna we're going to do that and what I say to them. It doesn't bother me and all my big thing is I'm just about them right? It's all just say you have to make your own. Since, but I'm really worried about you. So can I ask you to come back in three months and let's see if this gets bigger amount brand? Just will you come back and when you browbeaten yet they're not come back, and then I got back to anybody I have seen people who died because an interest you know offering a hand on long enough you're doing within where you didn't tell him.
You can either do the twelve steps. Are you're gone, no yeah, you're, afraid of two. However, you are young, you can say, look do the ten steps will be with you and I'm worried about you also sobriety bears a clear check mark like did you drink or did you not drink? You know at its different, like you, so with your mom, where the goal is just no pain, but for somebody else or even like for you, looking at your mommy might be like you're not doing enough, for I want you to be able to play tennis or whatever. So I do think also so much of this is about the people around the person at the end of life or in the middle of making those decisions, because I even what I did earlier think you're just projecting what you want for them or what you would want for yourself and I think, there's guilt like I don't think my grandfather could ever tell any of his children
you gotta. Let me go now. I just couldn't do it, but that's really on the children who are letting them beyond on never whenever asking him the first but yeah we'll could probably it. I want to know the answer. Ok do more things that can ask one. Yes, yes, yes, yes, are you chewing tobacco? yeah yeah yeah, God that is so midwestern didn't. You were going to say something to, and I was like you know what I have. I have an excuse, I'm quitting September first on my sub today's badly? Please around me yeah, alright, alright beauty should you should but it does Romania being home. You know, like I tried happy days and fifth grade and like throwing up at me also reading the the emperor of all maladies, which is a great companion, peace dipping, I gotta say, attacking one in listening to a guy, and later this I'm creating a lot of cell division. Am I am I gonna oil internally elder vision
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W H, Opie dot com and enter Dax at check out to save fifteen percent sleep. Well, a cover vaster in train, smarter optimize, your performance with whoop back to the responsibility, the patient and again you're, just your very generous in kind, and I admire it. I think it's it says about your integrity. We know, I don't know what the number is. Monaco fact check it, but the number is somewhere in the seventy to eighty percent range. The physical therapy results in success like physical therapy work.
Works in over while mean majority of people who try it and then surgery, just doesn't in many of the searchers you'd, get to deal with the physical therapy as you and by the way I've gotten surgeries have gotten several of them. You know we're fuckin lazy too, that the patient's lazy, but we're so pissed at this system, and yet we won't do physical therapy. We won't watch our diet, I'm dipping you know he's, are any frustration, yells and Well, I mean it's not just patient for giving them like I'd. Only right, I don't I says, might like where human beings and part of that is now. I getting Riskin learning how to deal with that, but on some of those things as well, I think we may get brutally hard to do the right thing. You can yell people about not doing their physical therapy, but then you have it
five thousand dollar deductible, and you have no idea what the cost is and they're not going to tell you you don't know who to go to. To find out. You gotta make another point with your doktor, so they can tell you where to go. She private take time off work that you don't have right this again. That sort of that hierarchy talked about like we can teach the right thing to do, and then, when you don't you, the right thing, then we can like yellow you about it and punish you, and you know like we, should take your insurance away. Because why are we paying for Dax's had neck cancer surgery he's been another debate very Emerson right now and then look you understand. The risks and people still do plenty stuff to take risks and we should make it easy when you're ready to do the right thing examples of physical therapy. We know that If you have a severe terrible back pain, most people get rooted too
visiting a surgeon is the first step, but there are clinics where the first thing that happens as they will get you a physical therapy. Appointment within forty hours right and within six weeks, and you never. The surgeon. Unless there is a neurological issue or the pain gets worse or isn't improving after six weeks and in ninety percent by six weeks it has gotten, but but I needed to make it so yeah I could call and here's what's going on, you gonna blame yeah. Here's your way in and then, if that doesn't work that you know you will be rooted right through the surgeon who can help you figure out what you're gonna do next year that she's? Ideally you go into that appointment and great. So now, I'm walking over to this room and you're going to learn these for stretches and we're going to keep on the other thing, but like yeah, if it's right there, if you make it that easy, your odds of success have to go up.
Completely. We ve made it incredibly easy to go, get it surgeons, appointment, a scan, Andy Sixty thousand dollar operation. You made an increase, a very difficult to get in the door to the right physical therapist. In twenty four hours that could address at if that's true theirs an unavoidable incentive structure within the system that you find yourself in so my father largely off loaded all the decisions to me now we did go through chemo. I really am grateful that
I had a friend who's, an er doctor here in LA and I called her and she just said right out the gate cycle. Small cell carcinoma. That's a wrap, there's no you're not going to find some miracle thing: you're, not going to call the president and get to go see. Some doctor like this is on a three to six months timeline, and that's that I'm like thank you for telling me that that's what I needed to know, and so we did came out. That was mostly to appease him. I I don't think I would have chose that for him, but at the at the final stages, man we get. It just comes on and says that the brain tumors of such a size that he wants to do radiation, and I say to my dad you know here is on the table. I dont think you should do this and he said I want to do it and I wasn't willing to fight them and down he had a radiation, it was happened in the last week of his life. It had a very profound effect on his cognitive abilities.
We did has knocked down his cognitive abilities and, I said to down count, as I said, is it worse to die of brain cancer than the small? So is there a hierarchy that I should be trying to avoid any he kind of, and I didn't bite is like well. Brain cancer is a particularly brutal way to go, and then, at the end of the day or just like, I don't feel good this person's incentivize cell radiation? I dont know why we ve linked to their incentives to this product. I'm not super comfortable with that yeah. I mean conditions, are really uncomfortable. Discussing prognosis and part of it is the idea that you're supposed to give a crystal ball like you well yet, six months, the way your friend talked about it you know. Basically what you really want to do is give them best case worst case and my dad, who had you know a tumor in his brain, stem and spinal cord and had progressed the same point that you're talking about. You know when the discussion came for radiation,
We didn't work and then getting too chemotherapy which was just getting the first start of the therapy was steroids, was making them. RO there was never discussion. I had to force in cows like what's the best case with the chemotherapy and what's the worst case with the chemotherapy. What's the most likely that you think you know it's actually a framework that colleague at the university of constant credit best case worse case right gimme, the best case worst case with the treatment and then give me the best gets worse case without the treatment when they finally did that they said, while the chemotherapy the range survival is like the shortest, I've seen as three months the longest I've seems three years. If you do nothing and my dad was, you know she thought because you such a slow going to me that the value lot longer ass. I was incredibly valuable. Just knowing that. But then second, I said Ok, so now what is? If you get the treatment, I would still three months to three year, but you know the tumor shrinking. You might, he might feel better well, maybe it'll shift a little bit towards the door
three years, rather than the three months there. All these applications from it and maybe towards the end. You feel better and my dad looked at that and said No, it doesn't seem like a good deal to making arrived, but but no one was framework. Groundwater is naturally laying this out in a way that you can make that choice, and that makes it much simpler. Be out. Do you think part of that is The doktor has some hope that, like they themselves will be the doctor that that is the one to get the person to ten years or like is there some arrogance, that too I've always chalked up to just be myopic like they have a singular goal of beating the cell exact. I think that you gotta But you are fighting the disease and if I see a shrinking, I feel I've got some victory and I presume they're gonna be feeling in doing better battle necessarily have the big picture. I don't know what's going on at home, I get fifty
minutes in the office where I could see them very looks good connecting with me, but you know, I'm not really getting the whole picture, and so it becomes myopic whereas, if I'm able to say oh well, you Tommy Me Chocolate ice cream football on. Are you, we're getting the chalk and watch football on television joy them. That's that matters to you. Now we have a real conversation, there's a couple cheats. I think, I'm a critical of humans. I think we have a real up about evaluating the quality of life by its duration? And I looked at many lives that ended shorter than I would want that have been to me ones. I pick over ones that when honoured ten years- and you know it's a relevant question, why do you think someone like Julia. Louise Dreyfus loves you so much what
She got out of being mortal that people seem to get that. You think is such an emotional outta that she would feel that emotionally connected to you. That's all that you'd say that with what she said was simply that level, it gave her a play book for this very unknown thing and it gave her a centre all and she needed to figure out since it control ass. She sat on the podcast and said to me. She did. I ask the kinds of questions. We're talking about, didn't completely necessarily get the answer she expected or the ones that chief thought were necessarily, wise choices, but she got to understand where is coming from and then feel like she knew where she stood and
big choice about where she's gonna push where she wasn't going to push, and it just gave her a paper. Yet I think, there's comfort. In there I agree a boy of children. You have children, even if your presenting them to shitty options, just the notion that they're gonna get to pick the less shitty option. Is hugely empowering yeah we're not going for the fake option right. The situation wherein in with corona virus, we have enormous numbers of people in denial about how and just not one. In our conversation about How should this all is the out and then you're the tough choices and, let's not just keep pretending. It's gonna disappear, right? There may be a magically well, but let's have a look at the conversation about what seems to be right in front of us right now and then actually do something bad. But but that's you know, just like people, who can be seriously ill. You are dealing with
well who are in denial and don't necessarily want to talk about it, and things have to get worse for they get better, but you in the door and then the become only time I see the country moving that way. Right, yes, suddenly have eighty five percent of the country. How willing or a mass we have ten percent or fifteen percent. Who are gonna? Be absolutely crazy and put the rest of us at risk, and we might have to be saying too bad you can endanger me at work or in we don't have any rights in this country that allow you to endanger other people's party or rights. We use down, there's some illusion that that somehow exist, but it when there is not one I can think of in the bill of rights that site you can hurt. Other people Anne and that, in the same way, dealing with a family member, whose going through illness, they may not be completely rationally be a mile, they may be unwilling to deal with what's in front of you and there isn't control the item
we. The book gives you some sense of the play book, but it's a play book may be for dealing with the fact that you're not really uncontrolled, yeah well I think your work is amazing. I M excited for whatever you write MAX, because your clearly drawn to some some kind of bigger picture. Looking at this this demirel in but trying to look at it in its totality, which again is hearted. Do you gotta make time for that type of analysis? It's an admirable quality. You have well, I don't think it admirable, run out. It happened it I get a very uncomfortable as soon as I'm seeing things from only one perspective, then seeing it from sighed the bubble and then getting outside and trying to see what it looks like a well. We hope you'll come back and talk to us because what an asset you are someone I would love to continue to talk. So just really quick, you don't think it's super productive to be calling.
The who want virus of all the things that they make a wasted. Time he's a momentary, nothing why I don't think I'm going for a virus seems like the least productive, certainly not not solving the question of whether we're gonna get rid of listening. He hath thousand percent well a tool pleasure to talk to you, and I hope we get to talk to you again, and I hope by you in and now Miss Drive is somehow have some lasting friendship and envious. She didn't they demands for my email after the equipment, that's a market. This is awesome. Thank you, Yankees lacking the rest year, your zooms. Ok, my favorite part of the show the fact check, with my soul maiden Monica got round to food. Are there any of my accents that you like that, you like you, would maybe request on any impersonation serene. That you enjoy, that I do
you do oh in ogre, listen. I know how many times I answered. I like all of them does not winning next him now, just not when you can't stop it I'll. Take any of them in a shop will not any not the racist ones, but the impressions I'll take in a small doze any time you want to give them, but that the problem is you just can't stop and its uncomfortable others to issues of foot one is I have impulse control issues clearly, Clare Part who is I'm not an impression is so it takes me about twenty sentence before I remember how to do it and then I finally and it is a minute and a half later, but now I want to do it because I finally found it I understand like if I rate at them and could do them. When you click your fingers, they would probably go better her. I mean, I think, you're under estimating yourself. I think you sound pretty much the exact same ten minutes and then you do when you ve STAR generals, worn bomb infringement,
kitchen we'll see you do not have the one line. I wait. That's how I set myself up for our air. I have that one one and then I launch into I don't know why you Quarles, like Maltese, stop problems that same crow is bad he's in the treated all my guide, their guys. We have like a harbinger of good fortune. There is an enormous crow that now lives on the roof of the new house that we have yet to move into, but now I see residing in the oak tree and now our obsessed with him, because crows can do a step problems though the smallest barons yeah, and will not math really oh dig into surpluses. They had opened a box, they get a key, they take you over to here than they screwed it and why this is fucking. Unfortunately, that was from our last apple, so used to fabric that around one hundred thousand things again muddy. Others too grows there's a We have crows living at the house. The crows can do a lot of problems and I think we're gonna ask it to do. If you
While this was the funniest moment, as sought out the window a couple days ago, I said only Monica look at the size of that crow dementias. And you know they looked scared, and then I got those are my: a bird. You really go you're, so smart. They can you ain't that problem and she goes solemn problems Who is your yelling at the bird, solve a problem boy? Maybe now- that's island than the other fact chattels. Then all you gotta do pain, would like one corner of corn will they get a failure that wine or know what it is, but is something really insignificant? You would not due date, steps to get the reward systems, What causes virtually nothing if we had to produce chores that we need done and it did. Of them and then we gave it a colonel of corn Let's have a visa waiver renowned engineering nor can fly away, It has agency. This is what has not a living wage. It's not. I think it is a living, age in crow, one kernel of corn, but that's how they live vague eating core. I think there
in a mammal up there really yeah yeah good lean over there to him in there like Terran some apart. This is awesome, creepy so far loving the fact that there is now to crows nesting at the house at what point do you think it gets super terrifying like what amount you don't see on that big branch of the tree, where their me they're moving around renew until four. To a girl from long given from to Hungary and borderline graphics in return for not a word. Allied grubby, ok, I'll, be scared. When there's four crows, I think you're right three is good for, like we are there, twenty coming and it's like, there's something dad. What would you assess like how many crows would it take to kill me to kill you I ll be bound now norodom able bodied, and I have all my my faculties about me and they come for me.
Not only damage or I could beat the shit out of four criteria? So what is the number? Do you think that I'd get overwhelmed? If this would raise red flags from Peter? I would love to do a paper you have where we find out and we put like I can't the unleash a hundred grows in me. In a tree I mean we ve had a lot of fact checks. Lately there had evolved animals doing unconventional things. I e the snake smash for sure sure. So the crowds, I think you I think you can withstand- then thou high our big big, their bigger than a your key I've had neither they ve got to ones they ve got a real, strong beak and their clever, ok phenomena, say thirty, but fuck kit, thirty crozier yeah yeah fine summer. I They have to be like they'd have to black out the sun, because there were so many of them that I couldn't see and it was dark.
In a minute and then one of them would have to get lucky in hit my carotid artery or my fee. More artery, first stages pluck out here eyes women men and do whatever they want. You great point you're right. If they went for the eyes, is that what happened in EDGAR, Allan POE, the Raven knock knock knocking them. Chamber Dorothy. Remember that pass. I dont action remember if their eyes got plugged in, I have beating heart gave away was under the boards, the I feel like they plucked his eyes out after like no. Down, continue on with your thing. This isn't need answering right now. Are you gonna go to one we're gonna, be here once upon a midnight query. While I pondered weaken weary This is money wants to get to the bottom and to see if he's goes eyes plucked the holy fuck. That's remember. Never more and ever more minutes kill him. I think. Will his beating heart gives away his location? I think, as I recall, what the last pair
F, spoiler. If you ve, never read the raven by EDGAR, Allan POE plug your ears. What is going on over there? You have, Caesar whenever I was, that is less, you scratch your tongue. Must we uranos seizure? That is a type of Caesar. I think those are petty, more I've, grand petite le coeur, where those yummy cookies petite le coeur, the like really France cookies in the grocery store in their little guy last piece of chocolate over in a little stamp. Like a dutch boy petite, I look, there are some ice or our ok, take thy beak from out my heart and take thy form from off my door, quoth the raven, never more than the raven ever fleeting, still sitting still sitting on the pallid bust, a palace just above my chamber, door and his eyes have all the seeming of a deal
means that is dreaming and the lamp light or him streaming throws his shadows on the floor and my soul from out that shadow that lies floating on the floor shall be lifted. Never So we don't really know, I think the heart and the raven never flitting, still sitting still is sitting on the pallid bust of Pallas I chamber door and his eyes have all the seeming over demons. That is dreaming. I was good and closed her good that felt like I was transported. We need Cordery, and here to we are ok, a tool. Oh man did I like a tool, I loved his message, and just we don't talk about these think me a new, but also just the people. They don't like to talk about end of life. Of course
unfortunately its importance even calling it and a life that feels like a euphemism right like an attempt to get us, it can happen to call it and of life. Said a death yeah. Ok, so he said Athens is the poorest county in Ohio, thirty two percent- or this was in two thousand fourteen, but thirty, two percent of Athens, county residents were living in poverty below the poverty line. Yeah, ok, he's a seventy percent of people. Don't go to college, I think that's what he said. Maybe I misunderstood he said do go now. He said dot, radio, okay, so the percentage of students and rolling in college in the fall immediately following Highschool completion was sixty nine point. Eight percent in two thousand steam, so it's actually the opposite. Ok, but I have to imagine the amount of people who finnish college verses and in one community class is
Madagascar, half yeah, probably would put that at thirty percent. Probably measures, seventy don't get a college degree. Ok, that's should don't get a college degree is, I think, that's what are you well, but going to a class in college doesn't get you anything career wise or I am a clear I, but we don't know that. Ok, so I'm sorry, I do have to check that my group will watch the crows. Her son. Remember the movie chrome, I never sigh I shall raise it. What percentage of Americans have college degrees percentage of? U S? Citizens have college degree, keep tremulous dumb map of states percentage of population, one percent as Haiti is gradually from college. Ok, the census in two thousand.
Represent yourself ass when it is you're too. For the rule of law, reform is a wide. This happen, but look at thirty four percent of U S born Americans have a four year college degree. That rate is similar to the thirty three percent of those born in other countries. Thirty, four percent of U S born Americans have a four year degree It is similar to the thirty three percent of those born in other countries. Ok, bullets, So you didn't get this chart. I dont know if that is not a helpful chart. I dont know why you're out forcing me to read your try, didn't give you an answer. I am trying to compare what happened here verses, what happened? well. My search was what percentage of Americans graduate from college. That was my search and read your search. You just rope:
senator of Americans with college degree after we had different searches- and I ask you: why should I type media hype? Well, yes, and then what I do. See or thirty four percent doesn't hadn't gotten their necks of looking at my char, you were very for mixed with that charter so you, I guess what you mine. I was. I thank you and I. Say too that you're welcome. Not thank you. I lived. I was starting to redo essences. I was about to read: the two thousand ten census in its entirety now why couldn't you do for the boy lying omega podium for over it? Ok, oh shit. I texts on my head, fixed it back Two Alison she hasn't response. Are we gonna do another search ogre,
I'm the guy? I am I'm point today. You said that seven Loader Wikipedia whole over me open. You said that seventy to eighty percent of physical therapy works is effective. Yes, yes, let's see, if that's true power fact of his physical therapy. I don't think you're gonna go anyone about this, but I got a great search. I got a great social service. What percentage of the time is physical therapy effect, question mark now, a race. All this other crap, I rely on play, see ya, know fazender, I'm really I'm doing or really almost hair poke percentage of or need physical, this physical. Let's get physical therapy, I forget his name,
truths about physical, fair patients often misunderstood by deal. You know, I know like a hundred physical therapist S, embarrassing that none of them are responding. What is the success rate of physical? Very specifically just spine. I found ok ready to pursue a bet. It is I'm gonna have to be by body part or Peter version, so there's no way and now and that's how they wound. Indian responded, intriguing, physical therapy statistics and fax we're not going to find so you're not gonna. It don't have a better Danny Doktor they'll tell you it's highly highly effective, much more effective than most surgeries. It's very highly effective. I know many. If any armchairs need a rack I know one in California, I know too and North Carolina, I know
one in atlanta- I'm sorry, I know too in Atlanta movement, so I have you covered ok, great reach out to Monica and get connected with a great pity. Don't semi anymore amounts, as from the last backtrack poker or I well, then, all in all a great deal, that's not all. There is one thing I want to say because it's been cut out of an episode and I rang I wanted to just addressed this quickly, so some people were upset that I have quoted Louis Fair Con when we were interviewing Leslie. Junior and the point I was he was that I had seen some footage of him making some point in the nineties and when I had seen it in the nineties, it seemed very radical. Point was now that I'm hearing it I real. I recognise that he was completely right on the topic at the time he was discussing, which was I'd lining steering black folks away generational wealth, all these things. Several people then wrote that I shouldn't be promoting
an anti semite, so yes, I am not so We should build a Louis Farrakhan monument. I think he was anti semitic. I think he was a very flawed person, the only thing I was saying was that his take on why black people are systematically oppressed is very, very relevant still some thirty years and he was speaking many truth on that topic and that's it. I'll leave it? I'm not condoning any other points he made other than that I guess I add we did remove their, which I do not agree with her. I trust you more I trust me. We removed it because without hearing this part of it, it could be missed. Stake in and we don't want to be misunderstood and because we weren't explicit about there's other parts that we don't agree with, that are pretty extreme. We just decided to cut it out, but if you had heard it also, if your now hearing this new love, Louis You want to explain to me why wasn't anti semitic
I'm done with this topic on an air of this is this is where this dump again there's. Another rebuttal are we to lobby? We love you so much. Peace.
Transcript generated on 2020-08-13.